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 hamstring muscles originate at the ischial tuberosity (or the bone where you sit.) The medial hamstrings, semitendinosus and semimembranosis, attach to the inside of the knee on the tibia (lower leg bone.) This attachment is referred to as the pes enserines. The lateral hamstring (biceps femoris,) attaches to the outside of the knee complex at the lateral aspect of the fibula (lower leg bones.) 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.
Symptoms of Hamstring Tendinitis or Tear
- 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.
Treatment of Hip Tendinitis
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 Therapy Interventions
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.
Physical Therapy Interventions
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.