Healing and Rehabbing Hip Flexor Tendinosis

Tendon strains and ruptures are common athletic injuries that can be painful and slow to heal. Because tendons attach muscle to bone, they undergo a great deal of stress during physical activity. When resistive force loads overcome the tendons’ capacity to effectively move the bone as the muscle shortens, the tendon may be torn or damaged. In some extreme instances, a tendon can be completely torn away from the bone, doing irreparable damage.

During sports and physical activitiew, the tendons of the hip flexor muscles work to stabilize the hip and pelvic regions as large force loads are transferred between the upper and lower body. Due to the vast number of structures throughout the hip and pelvic region, hip and groin pain can be difficult to accurately diagnose.

Tendons are tough collagen-based structures that are continuous with the muscles they anchor. Tendon tissue is denser and tougher than muscle tissue, with less elasticity and limited vascularity. Denser tissue coupled with fewer blood vessels means reduced circulation to damaged tendons, restricting the amount of oxygen and nutrients available to facilitate the healing process.

Tendon pain of any sort was once universally referred to as tendinitis, which literally means Inflammation of the tendon tissue, a short-term condition caused by overuse. Long-term structural damage to the tendon involving tissue degradation at the cellular level without inflammation is clinically referred to as tendinosis. The condition is believed to be caused by micro-tears in the tendon tissue that reduce tendon tensile strength, increasing the risk of injury and tendon ruptures.

Tendinosis is frequently misdiagnosed as tendonitis, leading to ineffective treatment approaches and delayed healing.

Your hip flexors are a group of muscles that allow you to raise your knees toward your trunk as you bend your hip. They also serve as stabilizers when you lift your trunk from a supine position, as when performing a sit-up. Because load transfers between the upper and lower body during sports and physical activities and intense and dynamic, the tendons of the hip flexor muscles are subjected to enormous strain.

There are several muscles that contribute to hip flexion:

Rectus Femoris: One of the powerful quadriceps muscles, the rectus femoris crosses over two joints, contributing to both knee extension and hip flexion.

IIllicacus and Psoas (the illiopsoas). Both deep pelvic floor muscles, the Illicacus and psoas connect the low back to the front of the pelvis, providing stability for the pelvis during load transfer, and contributing to hip flexion.

Tensor Fascia Lata: Located in the upper hip region, this long taut muscle attaches to the Iliotiblial (IT) band, and functions as a hip abductor, internal rotator, and a hip flexor.

iIiocapsularis: A small muscle buried deep in the pelvis, the iIiocapsularis helps to stabilize the head of the femur in its pelvic socket and contributes to hip flexion.

Sartorius: The longest muscle in the human body, the sartorius is a long thin muscle that originates at the anterior superior iliac spine (ASIS) and descends at an angle across the front of the thigh, toward the medial edge of the knee, attaching at the inner edge of the tibia. The roles of the sartorius include hip flexion, abduction and external rotation, as well as knee flexion.

Diagram caption: Multiple muscles work together to flex the hip during walking, running and other movements involved in a broad range of sports and physical activities.

In addition to muscles and tendons, the pelvic region is a complex intersection of bones, nerves and ligaments, and it also houses the reproductive and other vital organs. There is also a great amount of fascia in the pelvic region, thin bands of elastic tissue that surround other structures to keep everything in place. Fascia can sometimes stick or adhere to other structures, and fascial adhesions can also be a source of hip and groin pain.

Hip flexor pain can be either acute, arising from trauma, or chronic, becoming worse over time. Common symptoms of hip flexor tendinosis include:

• Pain at the front of the hip or in the groin
• Pain while walking or climbing stairs
• Pain when lifting the knees toward the chest
• Altered gait or limping due to hip or groin pain
• Muscle spasms around the hip and groin region

In most cases, tendinosis of the hip flexors begins as a microscopic tendon tear, gradually increasing in size with repetitive hip flexion. Pain increases gradually over time as the tear worsens. Hip flexor tendinosis is common in sports like cycling, running, swimming, baseball and golf due to repetitive overuse of the hip flexors.

Diagnosis of Hip Flexor tendinosis begins with a medical history and physical exam. The practitioner will evaluate for hip range of motion and palpate for areas of pain and tenderness. Xray or MRI may be conducted to rule out other causes of hip and groin pain, like fractures, SI joint dysfunction or other possible causes.

At NYDNRehab, we use high-resolution diagnostic ultrasonography to examine the hip and pelvic region in real time. Ultrasonography enables us to scan the entire length of soft tissues and neural bodies with the patient in motion, to pinpoint the exact site of injury. Ultrasound imaging is quick, inexpensive and painless. Because images are provided instantaneously in real time, there is no wait time for laboratory results, so we can begin treatment immediately after accurate diagnosis.

In addition to ultrasonography, we will evaluate your hip flexor strength and range of motion, and perform gait analysis and jumping diagnostics tests to identify mechanical deficiencies that may be contributing to hip flexor pain and injury.

Our diagnostic analysis may include evaluation of:

• Ground reaction forces
• Joint angles
• Compensation patterns
• Coordination of movement

Our end goal is not only to heal damaged tissues and eliminate pain, but also to identify and correct any contributing underlying causes of your hip flexor pain and injury.

Traditional treatment for hip flexor pain often involves rest, ice and pain management, often with NSAIDs (non-steroidal anti-inflammatory drugs) and corticosteroids. Because traditional practitioners are often unable to distinguish between tendonitis and tendinosis, conventional treatments often fall short of resolving hip flexor tendinosis.

At NYDNRehab, your healing journey begins with an accurate diagnosis that precisely identifies the locus and degree of injury. Some of our treatment approaches for tendinosis include:

• ESWT (extracorporeal shock wave therapy) to stimulate cell biogenesis and speed healing
• Injection therapies, including PRP (platelet rich plasma) or Prolotherapy to stimulate and accelerate tendon healing
• Eccentric muscle strengthening exercises
• Range of motion exercises
• BFRT (blood flow restriction training) to promote strength with minimal load
• Biofeedback motor control training to improve hip flexor function and eliminate movement errors