Hip and Groin Pain

Hip pain is a very a frequent musculoskeletal complaint that affects all age groups. Most frequently it occurs due to structural and functional misalignments in the hip joint itself or in combination with neighboring articular structures suffering from compensatory overuse, muscle strains, tendinosis, hip bursitis, femoral acetabular impingement (FAI), labrum tears and finally damage to the hip joint cartilage.

Normal Hip Joint Anatomy

Hip joint is the deepest and the biggest joint in the human body. The increased depth of this joint in combination with its perfectly round shape provides most stability while allowing great degree of mobility in multiple directions and in different planes simultaneously.
This joint is second to shoulder joint in its versatility and motion complexity. Just like the shoulder joint, the hip joint is, in evolutionary terms, the newest structure of the body and developed to accommodate the need for vertical locomotion. Joints versatile mobility is what makes it so susceptible to injuries of its extra-articular structures (ligaments, tendons, muscles and fascial tissue).
Joint is frequently affected later in life due to the structural misalignments occurring at the early stage of life because of the abnormal bone formation. These are not so infrequent as the scientific community thought before.
In adult stages of life hip misalignment usually occurs due to ever increasing demand for the weight bearing stability. Also many sporting and fitness activities cause hip joint pain by nature of excessive movement produces through the hip joint. Most frequently it occurs in: soccer, hockey, figure skating, martial arts, ballet and yoga.
It has been recently established that even a little misalignment or any deviation of the anatomical structure of the joint can lead to the development of the degenerative hip disease.
The following is a list of the predisposing factors:

• Congenital hip dysplasia
• Prominent femoral head-neck junction
• Elliptical femoral head
• Femoroacetabular anteversion
• Femoroacetabular retroversion
• Coxa valga
• Coxa Varum
• Coxa profunda
• Protrusio acetabulum

Why Hip Joint Dysfunction Does not Readily Convert into Pain and the Diagnosis of Degenerative Hip Disease Is Almost Always too Late?

Even though, radiological examination of the hip joint is used to confirm the diagnosis of degenerative joint disease, it cannot predict or define the degree of dysfunction or pain with which the patient is affected. For example, radiological examination in-patient without symptoms may discover moderate to severe degree of degeneration, while patients with minimal degenerative changes in the joint can be in extreme pain and disability. Therefore, the relationship of degree of degeneration to degree of disability is not predictable. This is due to multiple extrarticular and regional factor involved in hip pain syndromes.
Due to unique anatomical shape of the hip joint and its proximity to other joints of the lumbopelvic region, its movement dysfunction is initially well compensated by the structures located above and below the ailing area. This compensatory freedom of movement in the state of the dysfunction is notable however by the excessive movement (hypermobility). The joint might stay unaffected for a long time under these conditions until stresses created by inefficient repetitive hypermobility build up, eventually compromising the stability of the entire lumbopelvic region.
Another reason for the hip joint pain syndrome symptomatology delay is because stiffness of the dysfunctional hip joint elements and tissues is greater than the stiffness of the knee and the lumbopelvic joints. In the compensatory effort, the main burden of the hip movement is transferred to the less-affected articular structures of the region. This brings loading and shearing forces exerted by powerful contractions of long levered muscles of the upper leg to the knee and lumbo-pelvic joints.
And for these forces neither the knee nor lumbo-pelvic joints have been designed. Consequently tremendous new stresses exerted on the compensating structures will wear them out first. Therefore the dysfunction of the hip joint will initially cause pain in the neighboring joints long before the joint itself shows any pathology symptoms.
This is exactly why so many problems are discovered only when pain appears. Unfortunately, when that is the case, radiological images of the joint already show some degree of degeneration (hip arthrosis), which usually means eventual hip replacement.

Risk Factors and Prevalence

The risk factors of developing chronic hip pain are divided into local and systemic .The local factors are: sports specific activity, trauma, occupation, surgery and  obesity while the systemic risk factors are: age, gender, ethnicity, nutrition, anatomical variations and systemic diseases. Women, not only have a possibility to develop OA more often than men, but also with a more severe form ( Srikanth et al, 2015) .

The New Approach to Diagnostics and Treatment of the Hip Pain

With advancements in radiological, arthroscopic and functional clinical examination methodology of the hip, a new model of the joint disease has been established. This model enables doctors and practitioners to diagnose hip joint pain and dysfunction at a very early stage. The early diagnosis allows commencing the treatment at the stage when hip joint degeneration has not yet set in and is therefore reversible. For those patients who already have developed some early signs of degeneration, further progression can be arrested or significantly slowed down. Unfortunately, this recent scientific development, has not reached the majority of clinicians or therapists yet.

What Are the Early Signs of Hip Joint Disease?

The most distinct early sign of the hip joint dysfunction is not the pain but the abnormal movement in the joint area. Unfortunately you cannot see movement abnormality on X-ray or any other radiological examination. Abnormality can manifest itself in the variety of ways. This movement could be limited, excessive or imprecise. The patient however rarely notices these developments, as the compensation will be provided by other articular structures in the lumbo-pelvic region.Hip joint pain may occur in seemingly unrelated areas causing patients to look for medical advice. Unfortunately the vast majority of the doctors rely solely on the MRI and other imaging diagnostic procedures and movement examination of the hip joint is rarely, if ever, conducted on the patient complaining, for example, of the low back pain.
Another very frequent complaint is pain radiating down the thigh known as sciatica. In almost every case of the true sciatica it is the abnormal movement of the joint that either is the cause or one of the causes of the shooting pain down the leg.

What Are the Conditions, Which Affect Various Areas of the Hip?

True hip joint pain and pain in the groin area:

• Hip Osteoarthritis
• Labrum Tear
• FAI (Femoroacetabular Impringement)
• Avascular Necrosis also known as Asceptic Necrosis
• Iliopsoas Bursitis or Tendonosis
• Groin Pull
• Adductor Tendinosis
• Hip Fracture
• Hip Stress Fracture
• Direct local pain or pain irradiating into the side of the hip:
• Greater Trochanteric pain syndrome (GTPS) (Bursitis or Tendinosis)
• Piriformis Syndrome
• Obturator Syndrome
• Gluteus Medius Syndrome
• Pelvic Floor Myalgia
• Posterior Hip Pain
• Gluteal Bursitis
• Hamstring Tendinosis
• Hamstring Ruptures

Hip Pain Treatment at the Dynamic Neuromuscular Rehabilitation Midtown Manhattan

We maintain that successful hip pain treatment depends on the diagnostic precision.
Because of the limited ability of medical imaging to reveal all causes of the joint problem, we conduct computerized Gait (walking) analysis with highly advanced technological equipment. Our Gait (walking) analysis Lab is the first outpatient facility in NYC providing these types of services. The various data acquired through Gait analysis allows very precise diagnosis of movement pattern dysfunction in the hip joint and pelvis. Rehabilitation to address abnormal movement patterns and muscle weakness may help to restore joint precision and dynamic stability, reduce excessive stresses, and allow healing of injured tissues.( Marcie Harris-Hayes et al, 2016)
We use diagnostic ultrasonography and X-ray imagery to analyze the integrity of the tissues around the hip joint as well as to rule out bone anomalies and anatomical misalignments. If, however, these procedures fail to explain patients symptoms we may opt to ordering the MRI or CT scan study.
The most precise imaging diagnosis of early hip disease at this time is CT-scan. However, the specific CT-scan has an enormous dose of radiation. It should not be used initially, unless surgery is considered. The newest ultrasonography methods of diagnosis combined with X-ray and MRI and good clinical examination should be sufficient to establish proper diagnosis and treatment plan.
Based on Gait analysis data and clinical examination our pain treatment focuses on elimination of the faulty movements and rebuilding strength and coordination of the hip, lumbo-pelvic area . We also use some of our Gait lab equipment for feedback training of precise hip movement. We
use combination of DNS method, Shirley Saharmann method, Chris Power’s hip strategy method as well as video and force plates’ feed-back training. Our extensive rehabilitation program integrates the aforementioned methods with various manual techniques. If the integrity of the tendons or the muscle tissues is affected, we combine our rehabilitation protocols with biological treatment. Extracorporeal shockwave therapy is used to regenerate damaged tendons and muscles. Frequently hip problems arise due to asymmetrical weight bearing. Our C.A.R.E.N (computer assisted rehabilitation environment) therapy is breakthrough rehabilitation technology available for the first time in NYC (please review our slide presentation) is able to detect this with its innovative force plate and motion capture analysis. The feedback/feed forward treatment by C.A.R.E.N is most unique in the field of modern rehabilitation. Please check out our pages for the C.A.R.E.N (computer assisted rehabilitation environment), running gait lab, the alter-g treadmill, and shockwave therapy to see how these technologies can help you.
Our extensive rehabilitation program integrates the aforementioned methods with various manual techniques. If the integrity of the tendons or the muscle tissues is affected, we combine our rehabilitation protocols with biological regenerative treatment such as ESWT( Extracorporeal shockwave therapy ).
ESWT is used to regenerate damaged tendons and muscles.

PREVENTING HIP PAIN AND HIP INJURY

• Always warm up your pelvic and hip muscles before exercising
• Establish ergonomically correct workstation
• Learn how to bend though your hips not through your low back
• Learn how to relax your pelvic floor muscles while seating
• Maintain an active and adequate core musculature
• Maintain good range of motion through your ankles
• Put it all together in simple weight bearing exercises
• Train balance and weight transfer