HIP AND GROIN

PAIN

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SYMPTOMS

Most frequently, the pain that arises from the hip joint is felt in the groin or on the siteof the hip. When the joint is inflamed the pain could have a very sharp quality. In the chronic condition the pain is dispersed over larger area and is felt as dull and achy.

CAUSES

Hip pain disorders unless arising from trauma are mostly a combination of improper development of hip and pelvis bones and disturbance of walking mechanics.

DIFFERENTIAL DIAGNOSIS

Differential diagnosis is based on clinical examination and radiology such as x-ray, ultrasound or MRI. Most common hip conditions include: labral tears, FAI (femoroacetabular impingement), degenerative hip disease (hip arthritis), degenerative hip tendon disorders and hip bursitis.

Frequently, pain in the joint on the back or side of the hip is referred from muscles or joints in the spine. Pain arising from spinal nerve compressions at L2 - L3, L3 – L4 can refer to the hip and groin area. Spinal joint restrictions from the upper lumbar or lower thoracic areas can refer to pain in the hip and groin. Occasionally femoral, illiohypogastrioc and illioinguinal nerves can be impinged.

Anatomy

DIAGNOSIS

Correction of biomechanics towards normality improves energy consumption. As, in principle, normal function rather than normal anatomy is the goal, biomechanics and muscle function need to be understood in normal and pathological situations. (R.Brunner and E. Rutz et al, 2013)

At NYDNR we use a thorough clinical exam from both structural and functional perspective. We use diagnostic ultrasonography to visualize hip joint, tendons and bursas. We use sophisticated video gait (walking) analysis to define function of hip and its relationship to other joints in kinetic chain during walking.

Due to a very intricate anatomy and function the hip and groin area the disease of hip and groin can be very confusing and puzzling to physicians and therapist who don't specialize in this field. Most patient wonder around from doctor to doctor until; they find the right diagnosis and then wonder from therapist to therapist until they find relief.

Dr.Kalika has gone through preceptorship program with the European surgeon who revolutionized the field of hip arthroscopy as well as with prof. Kolar of Prague school who created most advanced non invasive protocol of rehabilitative care for intra and extrarticular pathology in the hip joint. With the help of gait analysis, diagnostic ultrasonography and evidence based expertise we are able to provide precise diagnosis and create successful individualized treatment for those patience who feel lost with their hip complain.We can get you back to walking and doing your favorite fitness activity.

Variety of recent research publications proved that early hip arthroscopy for FAI or Labral tear can be beneficial. The success of hip arthoscopy is dependent on proper patient selection based on the patient's history and diagnosis.( Byrd et al, 2007) . However, in our experience and experience of many other researchers with post hip arthroscopy patients proper selection does not only depend on structural factors ,but on functional state of the patient prior to surgery. At NYDNRehab we employ the most advanced functional testing utilizing our CAREN (computer assister rehabilitation environment) and gait analysis technology. Based on this data we can either help you avoid surgery or institute a targeted prehab program to prepare you for optimal surgical outcome. So of the top NYC surgeons refer their pre-surgical patients for consultation with us.

TREATMENT ADVANTAGE
at NYDNRehab

Our integrative approach and top notch technology allows us achieve excellent results with treating variety of hip conditions. We use extracorporeal shockwave technology to regenerate degenerated or damaged tendons and overused muscles. Computer-Assisted Rehabilitation Environment (CAREN) can detect problems arising from asymmetrical weight-bearing with the assistance of force-plate and motion-capture analysis, along with a feedback/feed-forward facilitation retraining that is unique among newest sports rehabilitation treatments. Last but not least, is our legendary DNS (Dynamic Neuromuscular Stabilization) therapy, which has become the hallmark of hip treatment standard in the industry.

Groin pain in adductor tendinopathy
in 25 year old professional soccer player

CONDITIONS TREATED
at NYDNRehab

- Hip labrum tears
- FAI ( femoral-acetabular impingement)
- Hip arthritis
- Hip bursitis
- Groin pain
- Hip snapping conditions such as coxa saltans
- Hip pain in runners and various athletes
- Hip tendinitis and tendinoses
- Post-surgical hip rehabilitation
- Myofascial hip conditions

Testimonial

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phone: 1-866-311-5889
e-mail: info@nydnrehab.com
address: 130 West 42 Street, Suite 1055, New York, NY 10036

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 anatomy of the hip joint; joint capsule is not damaged.

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 CAREN (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 CAREN is most unique in the field of modern rehabilitation. Please check out our pages for the CAREN (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

References

  • Byrd JW. Hip arthroscopy in the athlete N Am J Sports Phys Ther. 2007 Nov;2(4):217-30. https://www.ncbi.nlm.nih.gov/pubmed/?term=Byrd%20JT%5BAuthor%5D&cauthor=true&cauthor_uid=21509141
  • J Child Orthop. 2013 Nov; 7(5): 367–371. Published online 2013 Sep 15. doi: 10.1007/s11832-013-0508-5 PMCID: PMC3838524 Biomechanics and muscle function during gait
  • R. Brunner and E. Rutz https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3838524/
  • Movement Pattern Training To Improve Function in People With Chronic Hip Joint Pain: A Feasibility Randomized Clinic Trial (PDF Download Available). Available from: https://www.researchgate.net/publication/301669227_Movement_Pattern_Training_To_Improve_Function_in_People_With_Chronic_Hip_Joint_Pain_A_Feasibility_Randomized_Clinic_Trial [accessed Aug 14, 2017].

Srikanth VK1, Fryer JL, Zhai G, Winzenberg TM, Hosmer D, Jones G.

  • A meta-analysis of sex differences prevalence, incidence and severity of osteoarthritis.  https://www.ncbi.nlm.nih.gov/pubmed/15978850

DNS Therapy / oblique sit