Hip pain, even when mild, can be debilitating. Imagine the number of steps you take throughout the day. Now imagine the amount of force that is applied to the hip with every step, stair, forward bend, and squat. As a weight-bearing joint, the hip has a tremendous responsibility in the body. It must not only be strong enough to accept the load placed upon it by our daily activities, but also assist in stabilizing the lower extremity and pelvis during walking. Additionally, the hip interacts with the muscles and body regions around it, which can make pinpointing the exact cause of hip pain very difficult. Here are some common causes and symptoms of hip pain:
Greater Trochanteric Pain Syndrome
One of the more frequent diagnoses given to patients complaining of lateral hip pain is trochanteric bursitis, which is more accurately described as Greater Trochanteric Pain Syndrome. This essentially describes inflammation of the bursa in the hip. The bursa is a shock-absorbing structure located on the upper, outer side of the femur (hip bone) in-between the gluteus medius and gluteus minimus muscles. The bursa can become inflamed and painful through overuse, injury, or often through no specific identifiable cause. Symptoms include pain in the outer hip region with walking and tenderness in the upper part of the femur. Individuals may also complain of an inability to lay on the affected side, which may interfere with sleep. It occurs most commonly in women 40-60 years of age. Greater Trochanteric Pain syndrome has also been shown to be associated with leg length discrepancy, ITB dysfunction, and weak hip or core strength.
Greater Trochanteric Pain Syndrome is commonly misdiagnosed, and frequently over-diagnosed in the medical community. There are numerous possible diagnoses for lateral hip pain, and mismanagement may lead to chronic lateral hip pain and high medical costs spent treating something else than the actual cause of the patient’s symptoms. Individuals may be labeled ‘malingerers’ by the health care system and report seeing many different specialists throughout the years. Part of the reason why this may occur is due to the fact that bursitis rarely occurs as an isolated condition (meaning a problem elsewhere leads towards trochanteric bursitis, and failure to treat that distant area will likely lead towards a high recurrence rate of symptoms (see previous blog on Regional Interdependence). More often, however, lateral hip pain is the result of another pathology, often an issue with the gluteal muscles or lumbar spine. A 2001 study by Bird et al. found that only 8% of individuals with a diagnosis of Greater Trochanteric Pain Syndrome had actual inflammation of the bursa visible on an MRI, while nearly all of them had evidence of gluteal muscle tendinopathy. More interestingly, there were no cases of bursal inflammation without evidence of gluteal muscle tendinopathy.
Pain on the outside of the hip is commonly caused by irritation of the gluteus medius muscle at its insertion on the trochanter of the femur. Overuse of the tendon, combined with faulty movement patterns, can result in compromise of the integrity of the tendon and manifest as pain. Over time this can result in degenerative changes in the tendon’s collagen. Patients often report having recently increased their fitness activity (especially walking), and complain of pain when striding on the affected leg, laying on the affected side, sitting or when crossing their leg in sitting. Objective tests may reveal pain and weakness with active hip abduction, and patients commonly have a positive Trendelenburg sign in single-leg stance, which is a dropping of the opposite hip when standing on one leg. There is also pain to palpation of the tendon at the insertion of the tendon onto the femur, and pain to stretch the affected muscles.
Lumbar Spine Pain
Another potential cause of hip pain is the lumbar spine, specifically between the spinal segments of L4/5. While the low back is the pain source, pain may or may not also be felt in the low back. In some cases pain will manifest elsewhere in the body, and one of the more common places for the low back to refer pain to is the lateral hip region. In these circumstances the hip is not the cause of pain, as there is no definitive muscular or bony compromise in the hip that would result in the actual hip symptoms. Regional interdependence also plays a role with this presentation, as issues with the hip (i.e. hip stiffness due to hip osteoarthritis) places adverse stresses on the low back and can lead towards low back pain which refers pain to the lateral hip. In this case, treatment aimed at the lumbar spine will successfully diminish the lateral hip pain, while treatment of the hip joint concomitantly to improve mobility and strength will assist in long-term management to prevent recurrence.
The hip is a complicated region of the body to treat, requiring a thorough understanding of the numerous structures which it interacts with in order to obtain an accurate diagnosis for the lateral hip pain. A physical therapy evaluation by a skilled practitioner consists of not only figuring out what structure is painful, but also why it is painful, and provide you with a plan of care to assist with long-term self-management of symptoms.
At Life’s Work Physical Therapy, we pride ourselves on the ability to differential diagnosis patients suffering from lateral hip pain. Once a diagnosis is made, we begin to correct the movement dysfunctions and compensations that result in the painful symptoms. If you are struggling with hip pain, contact us today to schedule your evaluation. Our expert clinicians are excited to help you find the answers you are looking for, and work with you towards a successful recovery.