Background and Etiology
The hip joint is one of the largest joints in the body. It is composed of one osseous (bony) joint. The hip is built for weight bearing and movement in several different planes. The stability of the hip joint comes from the joint design, capsule, ligaments, muscle and a cartilaginous tissue called the labrum. There are several groups of muscles and tendons that attach near, and control, the hip.
A tendon is the cord-like part of the muscle that attaches muscle to bone. Hip tendinitis is the irritation, inflammation and swelling of tendons around the hip. The most common tendons affected are the psoas/hip flexor, rectus femoris/quadriceps, hamstring, and gluteus medius/buttock.
The psoas muscle is the primary hip flexor of the body. It runs from the pelvis and attaches to the lesser tuberosity of the femur (leg bone) which is located in the groin area. Tendinitis is common in individuals who participate in activities like up-hill running, jumping and rowing.
Common causes of psoas hip flexor tendinitis include:
- Overuse injuries are common in individuals who participate in activities like basketball, rowing, running, volleyball and soccer. Particularly sports that require running with hyperextension of the hip.
- Weakness of the hip flexor muscle that places increased stress on the psoas tendon
- A rapid increase in the frequency or intensity of training.
- Hip flexor tightness that makes the psoas muscle more susceptible to injury during repetitive activity.
- Pain and tenderness of the groin area
- Swelling over the patella tendon
- Difficulty and pain with jumping, running, stairs, squatting or kneeling activities
- Achiness and stiffness in the front of the knee below the patella after exertion or exercise.
- Pain and weakness with resistance of the quadriceps muscle.
The function of the hamstrings is to bend the knee and extend or straighten the hip. They play a critical role in performing walking, running, jumping and kicking motions.
Common causes of hamstring tendinitis include:
- Repetitive activities such as running, jumping or kicking.
- Sudden and frequent deceleration, acceleration or stopping and starting activities that may occur in sporting activities.
- A rapid increase in frequency or intensity of activity, exercise or training.
- Doing too much too quickly when it comes to exercise or activity.
- Improper running technique or training on hard surfaces
- Weakness of the hamstring muscle creating increased stress on the hamstring tendons
- Poor pelvic alignment
- Obesity placing increased stress on the hamstring tendons.
- Pain and tenderness on the inside or medial aspect of the knee or lower buttock area where the hamstring tendons attach to the tibia.
- Swelling or bruising of the hamstring muscle or lower buttock on either side of the knee where the hamstring tendons attach.
- Stiffness and achiness of the posterior knee when at rest following intense activity of the hamstring muscles.
- Pain following activities like running, jumping or kicking.
- Weakness and pain on resisted testing of the hamstring muscles.
Adductor or Groin Strain
The adductor muscles originate from the pubic area of the pelvis and can insert on the tibia (lower leg bone) along the medial knee. The most commonly injured adductor is the adductor longus.
Common causes of adductor or groin strains may include:
- Individuals who participate in hockey, ice skating, football, soccer or track and field are more susceptible to groin or adductor injuries.
- Sudden deceleration or strong eccentric (lengthening) contractions of the muscles.
- Weak adductors, poor off-season conditioning and inadequate warm up or stretching increase the risk of an adductor strain.
- Sudden pain in the groin or medial leg sometimes associated with a pop.
- Pain on palpation of the muscle with possible swelling and bruising.
- Loss of motion at the hip joint
- Weakness of the adductor muscles
- Difficulty putting weight on the affected leg. Crutches may be necessary to move around.
- If not cared for properly this may become a more chronic situation.
Gluteus Medius Tendinitis
The gluteus medius muscle abducts or moves the leg away from the body. It originates on the iliac crest of the ilium (pelvis) and runs to the greater trochanter of the femur. Tendinitis of this muscle can often be confused with greater trochanter bursitis.
- A sudden fall onto the hip.
- Repetitive or overuse activities, prolonged sitting or certain sporting activities.
- It is common in middle aged women who suddenly increased their activity level such as participating in an aggressive walking or running program.
- Weakness of the gluteus medius muscle is secondary to another hip or leg injury.
- Pain along the lateral hip with standing, walking, going up or down stairs and getting out of a chair.
- Pain on palpation of the gluteus medius muscle.
- Weakness of the gluteus medius or when abducting the hip
- A visible limp or antalgic gait (trendelenberg) a perceivable change in walking pattern when weight bearing on the affected side of the hip.
Rectus Femoris/Quadriceps Tendinitis or Strain
The rectus femoris muscle is the only quadriceps muscle that crosses both the hip and knee. The muscle originates from the pelvis at the ASIS and AIIS and joins the other quadriceps muscles at the quadriceps tendon of the knee.
- Injury may be the result of over use especially in sporting activities.
- Sudden motions that require “explosive” stress like bursting into a sprint
- Forceful kicking activities
- Sudden sharp pain in the muscle. Injury is often felt at the mid belly.
- Bruising may be present at the site of the injury.
- Pain on palpation of the injured area
- Difficulty straightening the knee
- Pain with ambulation (movement) in the thigh.
- Proper rehabilitation is important to avoid re-injury
Iliotibial Band Tendinitis or Friction Syndrome
The Iliotibial band is a fibrous band of tissue that stabilizes the knee and hip during walking, standing and running activities. Iliotibial band tendinitis is often referred to as Iliotibial Band Friction Syndrome. There is a bursa below the iliotibial band that helps the band glide over the lateral femoral condyle of the femur (leg bone). When this bursa is inflamed the iliotibial band does not glide smoothly and it becomes irritated.
Common causes of Iliotibial band tendinitis or friction syndrome include:
- An overuse injury, which is common in people who suddenly increase their level of activity. This is especially true for runners, cyclists or rowers who suddenly increase their mileage during training.
- Individuals with poor alignment in their legs and feet, like pronation or flat feet, and people who are bowlegged may be prone to iliotibial band tendinitis.
- Uneven leg length.
- Repetitive flexion (bending) and extension (straightening) of the knee.
- Excessive tightness of the iliotibial band.
- Excessive downhill running
- Tenderness and pain localized over the lateral knee (lateral femoral condyle). In severe cases, the pain may radiate down to the calf and up the thigh.
- Pain with running, cycling or rowing. Runners will experience more pain when running downhill.
- Cyclists may experience more pain if positioning their feet in a toes-in position.
- Noticeable pain when going up and down stairs.
- Pain with repeated flexion (bending) and extension (straightening) of the knee.
Treatment of hip tendinitis will depend on the severity of the condition. When treating acute hip tendinitis the principles of RICE (rest, ice, compression and elevation) should be initiated.
- Rest: avoid the activities that produce the pain (jumping, running, going up or down stairs, kneeling and squatting.)
- Ice: apply ice to the tendon or area of inflammation. It is one of the fastest ways to reduce swelling, pain and inflammation. Apply it right away and then at intervals for about 20 minutes at a time. Do not apply ice directly to the skin.
- Compression: such as an ace bandage to help take stress off the injured muscle may be useful. When using ice, apply light compression. This is especially helpful if swelling is present.
- Elevation: elevate the area to help reduce swelling.
- Crutches for ambulation or moving around may be necessary in the case of ruptures or significant injuries of the rectus, hamstrings or adductors.
Mild: In mild cases rest, ice and medication may be enough to reduce the pain. Once the pain is reduced, physical therapy is recommended to develop a series of stretching and strengthening exercises to prevent reoccurrence of the injury. Return to activity should be gradual to prevent a flare up of symptoms.
Moderate to Severe: If the problem persists, consulting with your health care provider should be the next step. Your physician and/or physical therapist will perform a thorough evaluation to determine what tendon(s) is involved, the severity of the condition, and the best course of treatment.
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals.
Your physical therapist will perform a thorough evaluation to assess and determine the following:
- Tendon: a series of tests will be performed to determine which tendon is involved.
- Strength: resisted testing is performed to determine if there is associated weakness or strength imbalances
- Flexibility: tight muscles can contribute to poor mechanics and weakness creating imbalances and making the hip more susceptible to tendinitis.
- Technique: Often it is the way we perform motions (run, jump, cycle or row) that may cause a problem. Discuss and observe the activities you participate in, that may have started the problem to improve technique.
- Training: review your training program and any sudden changes that may have precipitated or caused the present condition.
- Alignment or footwear: a physical therapist will assess your leg lengths, foot mechanics and alignment to see if there are any imbalances. Checking for appropriate footwear is a crucial part of balancing the stresses applied to your legs and body.
Physical therapy for hip tendinitis must remain conservative at the onset to avoid aggravating the condition. Emphasis will be on rest, reducing the inflammation and increasing the blood circulation for healing. Once the initial inflammation has been reduced, a program of stretching and strengthening will be initiated to restore flexibility to the muscles involved and improve strength to reduce stress on the tendons and the hip. Taping or strapping to rest and reduce the stress placed on the tendon and promote healing may be necessary. Your therapist is trained in these specific taping techniques.
Common Physical Therapy interventions in the treatment of Hip Tendinitis include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to improve alignment, mobility and range of motion of the knee and hip. Use of mobilization techniques also help to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen muscles of the knee and lower extremity to support, stabilize and decrease the stresses place on the bursa and tendons of the hip joint.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, running, kneeling, squatting and jumping) of the involved lower extremity to reduce stress on the bursa and tendons in daily activities. Taping, strapping or bracing may be useful to rest the tendon and promote healing.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain and inflammation of the involved tendon and bursa.
- A home program that includes strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
Avoiding the activities that produce the pain or stress the involved tendon is the first line of treatment.
- RICE: Rest, Ice, Compression Elevation should be used to reduce the stress on the bursa.
- NSAIDS (Non steroidal anti-inflammatory drugs) to reduce pain and inflammation.
- Injection of steroids may be necessary to reduce inflammation of the involved tendon
- Immobilization, strapping or bracing may be beneficial to rest the tendon and promote healing.
In general patients respond well to conservative treatment of hip tendinitis. It is important that once the pain and inflammation is reduced, and motion and strength are restored, the patient gradually returns to full activities. Instruction in daily activities or sport performance is helpful for reducing a reoccurrence of tendinitis. In most cases, full return to activity will take from 2-6 weeks depending on the severity of the tendinitis. As a preventive measure individuals should:
- Warm Up: warming up prior to physical activity is important in preparing the muscles and tendons for the work required of them. A 5-10 minute warm-up elevates the body temperature, increases the circulation to the muscles and tendons and raises the heart rate. Elevating your body temperature and increasing the circulation will also make the muscles and tendons more pliable for stretching.
- Stretching: stretching regularly in addition to before and after activity will reduce the chances of developing tendinitis. Stretching will also improve and maintain the elasticity and flexibility of muscles and tendons. Hold stretches for 20 seconds and do not bounce. Remember, as tendons get older they lose flexibility. It is part of the aging process.
- Strength: performing a regular strength program will keep muscles strong enough to absorb the stresses placed on them. Just running or playing a sport does not prepare your muscles for the impact forces involved in these activities. Remember, as people age they naturally get weaker.
- Training: avoid sudden increases in your training program. Gradually progress your training program to avoid injury.
- Foot Wear: in weight bearing or impact activities proper footwear is crucial to reduce and distribute forces properly.