Lateral Hip Pain
Have you got a niggling pain in the side of your hip? Has it recently started, or maybe been bothering you for quite some time, maybe months or years. Did you find that corticosteroid injections provided some relief but the pain came back, or you experienced no relief at all? Keep on reading to find out what may be the true cause of your lateral hip pain and for some tips and tricks as how to beat it.
Pain felt on the side of the hip is often diagnosed as trochanteric bursitis. What is a bursa? It is a fluid filled sac that is designed to help with friction, they are all throughout our body between tendon and bone to help things slide and glide. Bursitis is when the bursa becomes inflamed, irritated and swells. people will receive corticosteroid injection for this, but this will not always completely resolve the pain.
Despite the fact that you ultrasound imaging may show inflammation of the bursa, it has now been discovered that trochanteric bursitis most likely happens secondary to gluteus medius tendinopathy.
Read about what a tendinopathy is here.
When we refer to gluteal tendinopathy we are talking about where the tendon of the gluteus medius and/or the gluteus minimus tendons insert on the greater trochanter, an area on the side of your thigh bone. Gluteal tendinopathy has a 4:1 female to male ratio and occurs more commonly post menopause. Other risk factors include leg length discrepancy, low pack pain and knee pain.
Gluteal tendinopathy may present a pain with prolonged standing, getting up out of a chair, walking or stair climbing. It may be worse in the morning. Night pain can occur when lying on the affected or unaffected side (1).
But what is it about these movements and activities that can aggravate a tendon to the point of tendinopathy? Compression. The main cause of lateral hip pain is compression of gluteus medius/minimus tendons and potentially the underlying bursa. This compression occurs from repeat postures that compress the lateral structures and from being unable to hold postures which support the lateral structures. When compression occurs again and again, with no time for the tendon to rest and healt disrepair and potentially degeneration are the result. For a quick read about gluteal tendinopathy click here.
Diagnosis predicts prognosis – so it is important to know at what stage of the tendinopathy you are at. If the condition has not been present for long and has followed a sudden increase in training or change in daily activity (eg you move house to somewhere with stairs etc), you may be in more of a reactive stage of the tendinopathy. This will most likely resolve quicker compared to someone who has been dealing with lateral hip pain for months or years, and their tendon has potentially traversed into the degenerative stage of tendinopathy. This patient will require more time to overcome their hip pain. When it comes to imaging, X Ray can be used to look at the bony integrity of the hip (OA can sometimes present as lateral hip pain or can co-exist with gluteus medius tendinopathy), ultra sound scan can look at the integrity of the tendon and see if there is enlargement or inflammation of the bursa. MRI can also be used to assess (2).
Once you have your specific diagnosis, rehabilitation must begin.
The beginning of rehabilitation focuses on controlling load on the tendon. This means avoiding aggravating positions and activities that compress the tendon.
Things to avoid/reduce
- standing in a position of hanging on one hip
- sitting with one leg crossed over the other
- sitting in low chairs or couches
- stretching lateral structures of the leg (eg ITB, TFL, lateral quadriceps – stretching increases compression)
- sitting with knees wide and feet together
Things to do
- use manual techniques to loosen lateral structures eg massage (this avoids compression)
- foam rolling tight muscles of leg (avoid going over bony prominences and aggravating irritated structures)
- sleep with a pillow between the knees
- use a mattress protector to make the bed more soft
- strengthen the hip stabilising muscles
- decrease body weight if applicable
Avoiding or reducing activates that aggravate your pain are a great place to start. But the fact of life is that there is going to be times you cross your legs or side in a deep chair. The true key to overcoming your gluteal tendinopathy is addressing that factor that caused compression to be a problem in the first place – and this comes down to hip strengthening and stabilising (3).
Initial strengthening exercises that do not compress the painful structures
these include
- wall push
- standing abduction on reformers
- galileo
It is important to listen to your physiotherapist during rehabilitation – exercise prescription is key. You need to find a balance where the tendon is being challenged enough to initiate healing, but not too much to lead into disrepair. It is important to gradually build exercises up. Tendon can take up to 2 days to react after adding new exercises so it is important to listen to your body as you add new exercises and activities into daily life.
As your tendon becomes less irritated, your physiotherapist will progress your hip stabilisation exercises. Some of these include
- Fire hydrants
- Side bridge scissor kick
What about corticosteroid injection? Research shows that some people respond very well to 1-2 injections. The injection is more likely to be successful is guided by ultrasound rather than based on point tenderness. As discussed, it is now understood that the pain is more likely due to the tendon and the bursa is a secondary thing, so although the cortisone may provide some relief it does not treat the underlying cause (4).
Emily Georgopolous (APAM)
Physiotherapist
References
(1) Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg. 2009;108(5):1662-1670. doi:10.1213/ ane.0b013e31819d6562.
(2) Cook JL1, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009 Jun;43(6):409-16. doi: 10.1136/bjsm.2008.051193.
(3) Grimaldi,A. (2015) LATERAL HIP PAIN: MECHANISMS AND MANAGEMENT Published in In Touch Magazine. Accessed from http://dralisongrimaldi.com/publications-2/lateral-hip-pain-mechanisms-and-management/
(4) Del Buono A, Papalia R, Khanduja V, Denaro V, Maffulli N. Management of the greater trochanteric pain syndrome: a systematic review. Br Med Bull. 2012;102(115-131). doi:10.1093/bmb/ldr038.
