Treatment Options for Hip Pain - Rush University Medical Center

Treatment Options for Hip and Groin 

Pain 

S HANE J . N HO, M D , M S 

A ssistant Pro f essor 

D ivision o f S p o rts M edicine, Healthy Hip 

Pro g ram, R ush U niversity M edical C enter, 

M idwest Orthopaedics a t R U S H 

C h icago, IL

A B O U T M E : 

B O R N I N C H I C A G O S U B U R B S 

N O R T H W E S T E R N U N I V E R S I T Y ‘ 9 8 

R U S H U N I V E R S I T Y 

Introduction 

M D , R U S H M E D I C A L C O L L E G E ‘ 0 3 

M S , T H E G R A D U A T E C O L L E G E ’ 0 3 

O R T H O P E D I C S U R G I C A L R E S I D E N C Y , 

H O S P I T A L F O R S P E C I A L S U R G E R Y ’ 0 8

Introduction 

F E L L O W S H I P , S P O R T S M E D I C I N E , R U S H 

nho54456 

U N I V E R S I T Y M E D I C A L C E N T E R 

• Healthy Hip Program: Charles A. Bush-Joseph, MD; 

Walter A. Virkus, MD; Jorge O. Galante, MD 

H E R O D I C U S T R A V E L L I N G F E L L O W S H I P 

I N H I P A R T H R O S C O P Y & H I P J O I N T 

P R E S E R V A T I O N 

• Michael Leunig, MD @ Schulthess Klinik, Zurich, 

Switzerland 

• Marc J. Philippon, MD @ Steadman Hawkins Clinic, 

Vail, Colorado 

• J.W. Thomas Byrd, MD @ Nashville Sports Medicine 

and Orthopaedic Center, Nashville, Tennessee 

• Bryan T. Kelly, MD @ Hospital for Special Surgery

Pic of Sisters 

QuickTime and a 

TIFF (Uncompressed) decompressor 

are needed to see this picture.

Hip in the News 

A-Rod 

2008 2009

Fig. 1 The projected number of primary total hip arthroplasty (THA) and total knee 

arthroplasty (TKA) procedures in the United States from 2005 to 2030. 

Kurtz S. et.al. J Bone Joint Surg 2007:89:780-785 

174% Growth in Demand for THA

� Why Now? 

� Combination of several 

factors 

� Media coverage 

� Success of the Total Hip 

Replacement 

� Hip arthroscopy has been 

performed since 1990s � 

technique evolved 

� Improved understanding of 

hip pathology 

� Femoro-Acetabular 

Impingement 

Hip in the News

What Is Hip Pain?

Causes of Hip 

or Groin Pain 

Burnett, Clohisy 

et al. JBJS 2006 

•Average time 

from injury to 

accurate 

diagnosis 21 

months 

•Average of 3.3 

providers seen 

before definitive 

treatment 

� Anterior Hip Pain 

� Muscle strains 

� Contusion (hip pointer) 

� Avulsions and apophyseal injuries 

� Hip dislocation/subluxation 

� Acetabular labral tears and loose bodies 

� Proximal femur fractures 

� Osteitis pubis 

� Iliopsoas bursitis 

� Stress syndrome 

� SCFE 

� Perthes disease 

� Developmental dysplasia 

� Osteoarthritis 

� Inflammatory Arthritis 

� Avascular Necrosis 

� Femoro-acetabular Impingement 

� Lateral Hip Pain: 

� Greater trochanteric bursisits 

� Gluteus medius/minimus tear 

� ITB syndrome 

� Meralgia paresthetica 

� Posterior Hip Pain 

� Lumbar spine abnormalities 

� Compression neuropathies 

� Piriformis syndrome 

� SI joint pathology 

� Other Causes of Hip Pain: 

� Abdominal (sports hernias and athletic pubalgia, inguinal hernias, 

appendicitis) 

� Gynecologic (ovarian cysts, PID, pregnancy) 

� Urologic (testicular, scrotal) 

� Genitourinary (kidney stone, nephritis)

Other Possible Causes of Hip Pain 

� 5 main sources: 

� GI 

� GU 

� Athletic pubalgia, inguinal 

hernias, appendicitis 

� Kidney stone, nephritis 

� Gyn 

� Ovarian cysts, PID, pregnancy 

� Neurological 

� Musculoskeletal 

� Psychological

� Acute 

� Sudden onset, sharp rise, and 

short course 

� Often assoc with autonomic 

response (n/v, diaphoresis, etc) or 

signs of inflammation (f/c, 

leukocytosis) 

� Chronic: 

� >6 mos duration 

� Causes functional disability 

or necessitates treatment 

� 10-20% of women in US are 

affected 

� ~10% of all gyn visits due to this 

� 12-19% of hysterectomies 

performed for chronic pelvic pain 

� Cyclic 

� Associated with menstrual cycle 

Hip vs. Pelvic Pain 

� Pain 

� Pain / ache in vagina or 

rectum 

� Pressure sensation 

� Abdominal tenderness 

� Rebound or guarding 

� Associated symptoms: 

related to menses, 

intercourse, urine, 

incontinence 

� Cramping 

� Bloating

� Do I have hip pain? 

� Hip pain characteristics 

� „C‟ sign 

� Groin 

� Worse with start-up activities, 

prolonged sitting (chair or car), 

prolonged activity or sports, uphill, 

putting on shoes/socks, getting in and 

out of car 

� Can be ATYPICAL! 

� Mechanism 

� Acute event: fall or trauma 

� Insidious 

� Associated symptoms 

� Mechanical symptoms : catching or 

locking 

� Snapping 

� Instability 

� Stiffness 

Patient Presentation

� Gait 

� Active / Passive ROM & 

strength of both hips 

� Limited IR 

� Hypermobile 

� Lateral pain with 

palpation 

� Abductor weakness 

� Impingement sign: pain 

with flexion/internal 

rotation 

� FABER test 

� Evaluation for athletic 

pubalgia 

Physical Exam

Imaging Studies 

Radiographic Appearance of Hips 

Impingement (Deep)NormalDysplasia (Shallow)

Who Gets Hip Pain & Why? 

� Abnormal anatomy: 

“normal” use 

� Normal anatomy: 

abnormal use exceeds 

tolerance of joint 

structures 

� Acute injury 

� Chronic abuse/overuse 

(occupational, 

recreational) 

• Combination: abnormal 

anatomy and abnormal 

use

1. NSAID 

� Oral 

Non-Surgical Treatment 

Options 

� Local delivery: Voltaren gel or Flector patches 

2. GLUCOSAMINE & 

CHONDROITIN 

3. PHYSICAL THERAPY 

� Active Release Therapy 

4. INJECTIONS 

� Intra-articular 

� Selective

Glucosamine & Chondroitin

Corticosteroid Injections 

26 RCT Cortisone vs Placebo 

Cortisone for pain at 2 weeks 

No difference at 4 weeks (Bellamy 2006)

� Intra-articular Injection 

� Positive Test 

� 90% accuracy of 

determining intraarticular 

etiology of hip 

pain 

� Patients with intraarticular 

pathology have 

improved outcomes with 

arthroscopy 

� Selective Injections 

� Trochanteric, SI joint, 

Spine 

Byrd & Jones. AJSM 2004. 

Injections

Physical Therapy / Active Release Therapy 

� First line treatment: to 

address neuromuscular 

imbalances around the hip 

� Tight muscle groups: 

stretching, deep tissue 

massage / ART, foam rolling 

� Flexors 

� Abductors / ITB 

� Adductors 

� Rotators 

� Strengthening

Common Causes of Hip Pain

� Internal Snapping Hip – 

Iliopsoas Tendon 

Why Does My Hip Snap? 

� External Snapping Hip – 

Iliotibial Band

Psoas Tendonitis & Labral Tears

Snapping Psoas 

� 20-40 yrs 

� Females > Males 

� Audible & 

PAINFUL Snap 

� Reproducible with 

specific movements 

� Activity 

Modification 

� PT / ART 

� Topical Patches 

� Injections 

� Surgery

Arthroscopy

Arthroscopy

� Underlying diagnosis? 

� Determine the underlying 

diagnosis 

� FAI 

� Iliopsoas 

� Dysplasia 

or other deformities 

� OA 

What is a hip labral tear? 

� Treatment?

Normal 

CAM 

Femoro-Acetabular 

Impingement 

Pincer 

Combined

Normal 

CAM 


Impingement 

Pincer 

Combined

Impingement of 

Acetabular labrum

Delamination of 

Cartilage

Delamination of 

Cartilage

Normal 

CAM 


Impingement 

Pincer 

Combined

PINCER Type 

Pincer Impingement-Mechanism

Mechanical Damage 

Contracoup 

Injury

Impingement of 

Acetabular Rim 

Contracoup 

Injury

Tearing of Labrum 

Contracoup 

injury

FAI 

� 20-40 yrs 

� Males & Females 

� Pain with 

hyperflexion / 

rotation 

� Stiffness 

� Activity 

Modification 

� PT 


� Surgery

Arthroscopy 

•Central Compartment

Arthroscopy 

•Peripheral 

Compartment

FAI Outcomes 

Open Surgery Arthroscopy 

� Treatment of FAI 

� Open Surgical Dislocation 

� Hip Arthroscopy 

� Philippon et al. JPO 2008 

� MHHS 90 

� Larson et al. Arth 2008 

� MHHS 94.3 

� Patient Selection is Critical 

(Philippon et al. JBJS Br 

2009) 

� Poor prognostic factors: < 2mm 

joint space, amount of cartilage 

injury 

� Good prognostic factors: labral 

repair, pre-op MHHS

Greater Trochanteric 

Bursitis (Rotator Cuff 

Tears of the Hip, 

Trochanteric Bursitis) 

� 40-60 yrs 

� Females > Males 

� Tendinopathy � 

gluteus tears 

� Pain over 

trochanter 

� Night pain 

� Weakness 

� PT 


� Surgery

Peritrochanteric Space Bursectomy 

Gluteus Tendons Intact Massive, Chronic Tears

Gluteus Medius Repair

Rotator Cuff Tears of the Hip 

� Voos et al. AJSM 2009 

� 10 Patients with persistent lateral hip pain and weakness 

refractory to conservative treatment 

� Hip Arthroscopy with Trochanteric Bursectomy and Repair of 

Gluteus Medius Tears 

� Mean Follow-Up 25 months 

� All Patients with complete pain resolution 

� Significant improvement in clinical outcome scores 

� MHHS 94 

� HOS 93 

� No Complications

Osteoarthritis 

18 yr old male 35 yr old male 44 yr old female

Summary 

� Hip arthroscopy is in 

its infancy but growing 

at a very fast pace 

� FAI may cause OA 

� Risk of OA related to 

overuse & abnormal 

anatomy 

Hip Pain

Summary 

� Hip and groin pain can 

be disabling and 

significantly affect a 

patient‟s quality of life 

� Difficult diagnosis 

� Many possible diagnoses 

� Lack of awareness from 

HCP and patients 

� Evaluated by a hip 

specialist 

Hip Pain

Treatment Options for Hip Pain - Rush University Medical Center

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