Hip Injuries and Tears
The hip is an important joint that helps us walk, run and jump. The ball-and-socket joint in the hip is formed between the round end of the femur (thighbone) and the cup-shaped socket of the acetabulum (part of the hip bone). Joint stability in the hip region is achieved through the labrum (a strong fibrous cartilage), which covers the acetabulum and seals it, and ligaments (tissue connecting bone to bone) and tendons (tissue connecting muscle to bone) that encase the hip and control the hip movements.
Snapping hip syndrome is a condition in which you hear or feel a snapping sound in the hip while swinging your legs, running, walking or while getting up from the chair. Movement of the muscles or tendons over a bony protrusion in the hip region gives rise to the snapping sound, which can occur in the back, front or side of the hip. It is usually painless and harmless, but may be accompanied with pain and weakness in some. People who are involved in sports or dance where they must repeatedly bend are most vulnerable and it may affect their performance. Sometimes, the syndrome can lead to bursitis, a painful swelling of the fluid-filled sacs called bursae that cushion the hip joint.
The most common cause of snapping hip syndrome is tightness in the muscles and tendons surrounding the hip. Sometimes, a loose piece of cartilage, a cartilage tear or pieces of broken cartilage or bone in the joint space can lead to the snapping sound. This may also lock the hip causing disability along with the pain. However, this is less common.
The doctor will discuss your medical history and symptoms with you, and will conduct a physical examination to detect the exact cause of snapping. You may be asked to reproduce the snapping sound by moving your hip in different directions. Imaging tests may be ordered by your doctor to rule out bone and joint problems.
Rest and modification of activities may be suggested initially by your doctor followed by conservative therapeutic options. The therapeutic strategies for snapping hip include:
A few home remedies can be followed if you experience minor snapping hip pain, which include:
- Applying ice to the affected area
- Using NSAIDs to reduce discomfort
- Avoiding repetitive hip movements by changing your activities
Consult your doctor if the discomfort persists even after following the home remedies.
Your doctor may teach you certain exercises to strengthen and stretch the musculature surrounding the hip. You may be guided by a physical therapist. Tendon stretching exercises such as iliotibial band stretch and piriformis stretch will be indicated depending on the type of snapping you experience.
Your doctor may recommend a corticosteroid to be injected into the bursa to reduce the pain and inflammation in the hip joint in case you have hip bursitis.
Surgery is recommended when conservative approaches do not have an effect in resolving the snapping hip syndrome (which is rare). The type of surgery will depend on the factors that cause snapping hip. Surgical procedures include:
- Hip arthroscopy: This procedure is usually used to remove or repair the torn labrum. Your surgeon will insert an arthroscope (small camera) into your hip joint so that minute surgical instruments can be guided with the help of images displayed on a large screen. Very small cuts are required for this procedure due to the presence of a small arthroscope and surgical instruments.
- Open procedure: The open surgery can help your surgeon to gain better access to the hip problem. An open incision of several centimeters will be made to resolve the issue of snapping hip.
Your surgeon will discuss the best surgical option depending on your situation.
Femoroacetabular impingement (FAI) is a condition where there is too much friction in the hip joint from bony irregularities causing pain and decreased range of hip motion. The femoral head and acetabulum rub against each other creating damage and pain to the hip joint. The damage can occur to the articular cartilage (the smooth white surface of the ball or socket) or the labral tissue (the lining of the edge of the socket) during normal movement of the hip. The articular cartilage or labral tissue can fray or tear after repeated friction. Over time, more cartilage and labrum is lost until eventually the femur bone and acetabulum bone impact on one other. Bone on bone friction is commonly referred to as Osteoarthritis.
FAI impingement generally occurs as two forms: Cam and Pincer.
CAM Impingement: The Cam form of impingement is when the femoral head and neck are not perfectly round, most commonly due to excess bone that has formed. This lack of roundness and excess bone causes abnormal contact between the surfaces.
PINCER Impingement: The Pincer form of impingement is when the socket or acetabulum rim has overgrown and is too deep. It covers too much of the femoral head resulting in the labral cartilage being pinched. The Pincer form of impingement may also be caused when the hip socket is abnormally angled backwards causing abnormal impact between the femoral head and the rim of the acetabulum.
Most diagnoses of FAI include a combination of the Cam and Pincer forms.
Symptoms of FAI
Symptoms of femoroacetabular impingement can include the following:
- Groin pain associated with hip activity
- Complaints of pain in the front, side or back of the hip
- Pain may be described as a dull ache or sharp pain
- Patients may complain of a locking, clicking, or catching sensation in the hip
- Pain often occurs to the inner hip or groin area after prolonged sitting or walking
- Difficulty walking uphill
- Restricted hip movement
- Low back pain
- Pain in the buttocks or outer thigh area
A risk factor is something that is likely to increase a person’s chance of developing a disease or condition. Risk factors for developing femoroacetabular impingement may include the following:
- Athletes such as football players, weight lifters, and hockey players
- Heavy laborers
- Repetitive hip flexion
- Congenital hip dislocation
- Anatomical abnormalities of the femoral head or angle of the hip
- Legg-Calves-Perthes disease: a form of arthritis in children where blood supply to bone is impaired causing bone breakdown.
- Trauma to the hip
- Inflammatory arthritis
Hip conditions should be evaluated by an orthopaedic hip surgeon for proper diagnosis and treatment.
- Medical History
- Physical Examination
- Diagnostic studies including X-rays, MRI scans and CT Scan
Conservative treatment options refer to management of the problem without surgery. Nonsurgical management of FAI will probably not change the underlying abnormal biomechanics of the hip causing the FAI but may offer pain relief and improved mobility.
Conservative treatment measures
- Activity Modification and Limitations
- Anti-inflammatory Medications
- Physical Therapy
- Injection of steroid and analgesic into the hip joint
- Hip arthroscopy to repair femoroacetabular impingement is indicated when conservative treatment measures fail to provide relief to the patient.
Avascular necrosis, also called osteonecrosis is a condition in which bone death occurs because of inadequate blood supply to it. Lack of blood flow may occur when there is a fracture in the bone or a joint dislocation that may damage nearby blood vessels. Chronic use of high doses of steroid medications and heavy alcohol consumption are the two main risk factors of avascular necrosis. Initially, small breaks appear in the bone that may eventually collapse. Hip joint is most commonly affected; however, the knee and shoulder may also be involved.
The symptoms appear suddenly if it’s a result of an injury. In other situations, the pain and stiffness may gradually appear over a period. Typically, avascular necrosis causes pain and restricted range of motion in the joint affected. Your doctor will diagnose the condition using imaging tests such as X-rays, MRI scan and bone scan that help rule out other causes of joint pain.
The treatment for avascular necrosis aims at preventing further loss of bone and it depends on the bone damage that has occurred already. Conservative treatment would reverse early stages of avascular necrosis whereas surgical treatment may be required in more advanced stages.
- Medications: Non-steroidal anti-inflammatory drugs (NSAID’S) may be prescribed that help control your pain and swelling
- Rest: Restriction of physical activities and use of crutches to decrease weight bearing on your joints may be beneficial
- Exercises: Regular exercises that improve your range of motion may be done
- Electrical stimulation: Electric currents promote new bone growth. They can be applied directly to the area of damage or through electrodes fixed on skin. It helps replace the damaged bone
- Core decompression: During this procedure, a portion of the inner layer of the bone is removed to relieve the pressure inside the bone. This decreases the pain and allows growth of new blood vessels thereby stimulates new bone growth
- Bone transplant: A healthy bone from harvested from other part of your body is grafted into the affected area.
- Bone reshaping (osteotomy): This procedure is done in advanced stages and involves reshaping of the bone which is done to decrease the stress placed over the affected bone.
- Joint replacement: Joint replacement surgery is done as a last resort when the bone has collapsed needing artificial replacement
Hip Labral Tear
A hip labral tear is an injury to the labrum, the cartilage that surrounds the outside rim of your hip joint socket. The hip joint is a ball and socket joint in which the head of the femur is the ball and the pelvic acetabulum forms the socket. The labrum helps to deepen the socket and provide stability to the joint. It also acts as a cushion and enables smooth movements of the joint.
A tear in the labrum of the hip can result from traumatic injury, such as a motor vehicle accident or from participating in sports such as football, soccer, basketball, and snow skiing. These sports are associated with sudden changes of direction and twisting movements that can cause pain in the hip. Repetitive movements and weight bearing activities over time can lead to joint wear and tear that can ultimately result in a hip labral tear. Degenerative changes to the hip joint in older patients can also lead to a labral tear.
Many patients with a hip labral tear do not have symptoms. However, some patients may experience pain in the hip or groin area, a catching or locking sensation in the hip joint, or significant restriction in hip movement.
Your doctor will order certain tests to determine the cause of your hip pain.
X-rays of the hip allow your physician to rule out other possible conditions such as fractures or structural abnormalities.
Magnetic resonance imaging (MRI) may also be used to evaluate the labrum. An injection of contrast material into the hip joint space at the time of the MRI can help show the labral tears much clearer.
Injection of local anesthetic into the joint space is sometimes performed to confirm the location of the pain. If the injection completely relieves your pain, it is likely that the cause of the problem is located inside the hip joint.
Treatment for a hip labral tear will vary depending on the severity of the condition. People with a minor labral tear recover within a few weeks with the help of non-surgical treatments.
Conservative treatments include:
- Medications: Anti-inflammatory medications can be helpful in relieving pain and reducing inflammation associated with labral tears. Your doctor may also recommend cortisone injections to alleviate the pain associated with a hip labral tear.
- Physical therapy: Physical therapy that helps to improve hip range of motion, strength, and stability are also recommended.
However, severe cases may require arthroscopic surgery to remove or repair the torn portion of the labrum.
Hip arthroscopy, also referred to as keyhole surgery or minimally invasive surgery, is a surgical procedure in which an arthroscope, a narrow tube with a tiny camera on the end, is used to assess and repair damage to the hip.
The surgery is performed with the patient under general, spinal or local anesthesia.
Your surgeon will make 2 or3 small incisions around the hip joint area. The arthroscope is inserted into the hip joint through one of the incisions to view the labral tear. The camera attached to the arthroscope displays the image of the joint on the monitor. A sterile solution will be pumped into the joint to have a clear view and room to work. Through the other incisions specially designed instruments are inserted. Your surgeon repairs the torn tissue by sewing it back together or removes the torn piece all together, depending upon the cause and extent of the tear. After the completion of the procedure, the arthroscope and instruments are removed and the incisions are closed.
Post- Operative Care
Following the surgery, you will be given instructions on caring for your incisions, activities to avoid and exercises to perform for a fast recovery and a successful outcome. Physical therapy will be recommended by your doctor to restore your strength and mobility. Your doctor will also prescribe pain medications to keep you comfortable.
Risks and Complications
Possible risks and complications specific to arthroscopic hip surgery include:
- Deep vein thrombosis(DVT)
- Blood vessel or nerve damage
- Hemarthrosis (bleeding inside the joint)
- Failure to relieve pain
Chondral Lesions or Injuries
The hip joint is one of the largest weight-bearing joints in the body, formed by the thigh bone or femur and the acetabulum of the pelvis. It is a ball and socket joint with the head of the femur as the ball and the pelvic acetabulum forming the socket. The joint surface is covered by a smooth articular cartilage which acts as a cushion and enables smooth movements of the joint. A chondral injury refers to an injury of the articular cartilage, covering the joint.
Chondral injuries can result from various hip conditions such as labral tears, loose bodies, posterior dislocation, slipped capital femoral epiphysis (SCFE), dysplasia, osteonecrosis, and degenerative arthritis.
Articular cartilage covering the hip joint can also be damaged by a direct blow to the outer part of the thigh. Femoroacetabular impingement or FAI can also cause chondral injuries. This is a condition characterized by excessive friction in the hip joint causing pain and decreased range of motion. The femoral head and acetabulum rub against each other eventually causing damage to the cartilage.
Most patients with chondral injuries experience severe pain in the hip or groin, a locking sensation in the hip joint, and significant restriction in hip movement. In some patients, physical examination may also reveal a noticeable limp.
Diagnosis of chondral injuries involves a thorough medical history and physical examination by your doctor. In addition to this, X-rays and MRI scans are also useful in diagnosing these types of injuries. However, arthroscopy is the most accurate way of diagnosing, evaluating, and managing chondral injuries.
The management of chondral injuries depends on the severity of the injury and includes non- surgical and surgical modalities of treatment. Non-surgical treatment includes a healthy diet, regular exercise and avoidance of aggravating activities.
Arthroscopic surgery is performed to treat chondral injuries when non-surgical options are ineffective and pain persists.
Hip arthroscopy, also referred to as keyhole surgery or minimally invasive surgery, is a surgical procedure employing an arthroscope, a narrow tube with a tiny camera attached on the end, to assess the damage to the hip. Your surgeon makes 2 to 3 small incisions around the hip joint. The arthroscope is inserted through one of the incisions and the camera attached to the arthroscope helps visualize the joint, on a monitor. A sterile solution is pumped into the joint to clear the view and increase the space for surgery. Specially designed instruments are inserted through the other incisions. During the surgery, any loose fragments, small pieces of bone and cartilage floating within the joint are removed. After the completion of the procedure, the arthroscope is removed and incisions are closed.
Other arthroscopic surgeries that may be recommended to manage chondral injuries include:
Microfracture surgery: This technique to treat chondral injuries involves stimulating the formation of new articular cartilage by drilling numerous tiny holes in the bone underneath the damaged cartilage. This results in the formation of blood clots within the damaged cartilage, which stimulates the growth of new cartilage known as fibrocartilage. Although, the fibrocartilage formed is different from the normal hyaline cartilage, it can provide significant improvement in the symptoms.
Autologous Cartilage Implantation (ACI): In this procedure the cartilage, harvested from the patient or a cadaver, is cultured and later implanted over the damaged area of the joint.
Matrix-induced Autologous Chondrocyte Implantation (MACI): This technique employs cultured chondrocytes (the cells which produce the cartilage) to repair the articular cartilage damage. These chondrocytes are inserted onto a layer of collagen which is then implanted over the damaged area of the joint.
Post- Operative Care
Following the surgery, your doctor will instruct you on the care of your incision, activities to be avoided and exercise programs to hasten recovery. Physical therapy will be recommended to restore strength and mobility to the hip joint. You may also be prescribed medications to relieve pain.
Risks and Complications
Possible risks and complications specific to arthroscopic hip surgery include:
- Deep vein thrombosis(DVT)
- Blood vessel or nerve damage
- Hemarthrosis (bleeding inside the joint)
- Failure to relieve pain
A chondral injury is damage to the articular cartilage covering the bones of the joints resulting in pain, swelling and impaired function. Unlike other tissues, cartilage does not have its own blood supply, and therefore requires longer time to heal. The management of chondral injuries depends on the severity of the injury and includes non- surgical and surgical modalities of treatment.
The hip plays an important role in supporting the upper body weight while standing, walking and running, and hip stability is crucial for these functions. The femur (thigh bone) and acetabulum (hip bone) join to form the hip joint, while the labrum (tissue rim that seals the hip joint) and the ligaments lining the hip capsule maintain the stability of the hip. Injury or damage to these structures can lead to a condition called hip instability. Hip instability happens when the hip joint becomes unstable causing various symptoms.
The most common symptoms of hip instability include
- Giving away of the hip
- Producing a clicking sound
Hip instability can be traumatic or atraumatic. Traumatic instability can be caused by injuries from sports or motor vehicle accidents. These injuries can damage the bony structures, labrum, and cartilage of the hip joint and can form loose bodies. It can range from severe dislocation to a simple subluxation (partial displacement) of the hip joint. Atraumatic instability can be caused by overuse or developmental/congenital abnormalities of the hip joint.
Conditions that can cause hip instability include:
- Labral and ligament tears
- Hip dysplasia (misaligned hip joint bones)
- Femoro acetabular impingement (abnormally shaped hip joint bones)
- Tears to the ligamentum teres
Your doctor will diagnosis hip instability based on your medical history and physical examination. Imaging studies such as plain X-rays, MRI, and MRI arthography (use of a contrast agent) may also be ordered to confirm instability. Your doctor may also perform hip instability tests such as posterior impingement or dial test; both of which involve simple range of motion exercises.
Your doctor may start you off on a conservative/non-operative treatment approach such as protected weight bearing (crutch, cane, or wheelchair) and referral to a physical therapist for exercises. A physical therapist will instruct on special exercises, focused on improving your strength, balance, and flexibility.
When conservative options fail to resolve your symptoms or if you have large fractures, you may be recommended to undergo surgical management. Surgery can be arthroscopic (minimally invasive) or open depending on your condition. Most of the common causes for hip instability, such as damage to the hip capsule and ligaments surrounding the joint, and labral tears can be rectified arthroscopically. Your doctor will be the best person to address your concerns and help you overcome your instability.
Loose bodies are small loose fragments of cartilage or a bone that float around the joint. The loose bodies can cause pain, swelling, locking and catching of the joint. Loose bodies occur if there is bleeding within the joint, death of tissues lining the joints associated with tuberculosis, osteoarthritis, and rheumatoid arthritis. Other causes include fractures, trauma, bone and cartilage inflammation, and benign tumors of the synovial membrane.
Loose bodies are commonly found in individuals who participate in sports since they are more susceptible to fractures and other sports injuries.
Often X-ray helps in diagnosing loose bodies. However, small loose bodies which contain little fragments of bone or no bone may not be visible on an X-ray. In such cases, other diagnostic tests such as CT scan or arthrography, MRI scan and ultrasound may be performed to locate the loose body. For small loose bodies your doctor may prescribe anti-inflammatory medications to relieve pain and swelling. However, any loose body that is causing the symptoms are removed.
The loose bodies are removed by arthroscopic procedure. Surgery is performed depending on the location and the size of the loose bodies.
- A suction tip is used to withdraw the loose body or is held with a small needle and grasped with a surgical instrument called as grasper.
- If loose bodies are present in the joint space, a special instrument, called mechanical burr or a resector is used to break the loose bodies. The broken pieces will be easily degraded by the body by means of a mechanism called enzyme degradation.
- Large loose bodies which are caused by fractures, inflammation of bone and cartilage (osteocartilaginous loose bodies) are reduced and fixed to the position using screws or pin.
- If the loose body is caused by benign tumor of the synovial membrane, a procedure called partial synovectomy may be done. It involves removal of part of the synovium.
- Arthrotomy is a surgical procedure that employs an open technique in which incisions are made into the joint and the loose body is removed.
Following surgery, rehabilitation program may be needed to control pain and restore function and strength to the involved joint.
Hip Abductor Tears
Hip abductors are a major group of muscles found in the buttocks. It includes the gluteus maximus, gluteus medius, gluteus minimus, and tensor fascia lata muscles.
The Gluteus medius arises at the top of the pelvic bone and runs to attach on the outer side of the thighbone or femur. The muscle controls side-to-side movement of the hip and stabilizes hip movement.
Gluteus medius tear is a condition characterized by severe strain of the gluteus medius muscle that results in partial or complete rupture of the muscle. It is also referred to as rotator cuff tear of the hip.
The tear or rupture of the gluteus medius muscle is commonly seen in runners and athletes involved in high-impact sports such as soccer or basketball due to sudden bursts of activity or poor flexibility of the gluteus muscle. Any traumatic or overuse injury, or degenerative changes may lead to partial or complete tear of the gluteus muscle.
The symptoms include pain and tenderness over the lateral aspect of the hip which may aggravate with activities such as running, climbing stairs, prolonged sitting or walking, and lying on the affected side of the hip. One of the main symptoms of gluteus medius tear is the presence of Trendelenburg sign - dropping of the pelvis towards the unaffected side by being unable to bear weight on the affected limb.
The diagnosis of gluteus medius tear is based on physical examination of the patient, followed by palpation of the affected muscle, testing muscle power and assessing walking pattern or gait of the patient. Certain special tests such as single-leg squat test or a positive Trendelenburg sign confirm the diagnosis of gluteus medius tear. Sometimes, MRI or ultrasound may be helpful to show the pathological changes of the muscle.
The aim of treatment is to restore the normal function of the gluteus medius tendon.
- Immediately following the rupture of the tendon, RICE therapy is advised which involves:
- Rest your hip by refraining from activities until it is healed.
- Apply ice to your hip to reduce pain and inflammation caused by injury.
- Compression with an ACE bandage helps to reduce tenderness and swelling.
- Elevation involves keeping the affected hip raised above your heart to minimize swelling.
- Medications such as non-steroidal anti-inflammatory drugs (NSAIDs) or steroid injections may be given to reduce the pain and inflammation.
- Assistive devices such as a cane or crutch may be used temporarily to facilitate pain free ambulation.
- Your surgeon may recommend physical therapy to strengthen the muscles and increase stability of the hip.
- Surgical treatment may be recommended to repair a complete, full-thickness gluteus medius tear. The rupture can be repaired arthroscopically to help restore the strength and function of the gluteus medius.
Untreated cases of gluteus medius tear may result in gait disturbance and disability.