Posted on Wed May 1, 2019
Mr Arjuna Imbuldeniya explores some of the most common problems leading to hip pain in runners, and explains the best ways in which we can work together to manage them.
It was great running weather on Sunday 28th April for Virgin’s 2019 London Marathon, and, as always at this time of year, it seemed that the nation was gripped by marathon fever!
Whether already planning next year’s London effort to smash a PB, chasing that elusive qualifying time for the Boston race or simply having been motivated to get outdoors and move a bit more this summer, it is likely that we will see increasing numbers of people starting to run or increasing their training intensity.
But what can we do for patients who hit a stumbling block in the form of hip pain associated with their running?
Although there are several bursae around the hip (the gluteus medius, iliopsoas, ischial and trochanteric bursae), by far the most common form of hip bursitis is trochanteric bursitis.
Trochanteric bursitis is a frequently-overlooked cause of hip pain in young adults – particularly in runners – which can be caused either by trauma (for example a fall directly on to the lateral hip) or by the repetitive friction occurring during running.
Patients who overpronate are more likely to develop trochanteric bursitis as their gait involves inward turning of the knee and in turn an increased angle at the hip, whilst weakness of the hip girdle muscles can also be an exacerbating factor.
Patients typically present with pain and tenderness over the lateral aspect of their hip and buttock, and report pain whilst lying on the affected side in bed and which is exacerbated by rising from a seated position or whilst climbing stairs.
X-rays can be useful in the early investigation of patients with likely trochanteric bursitis to help exclude the presence of a bony spur which may have triggered the inflammation, but in general initial management involves taking anti-inflammatory medication, topical ice application and resting the area until the inflammation has resolved.
The condition is usually self-limiting, although patients should be made aware that this usually takes at least 2-3 months to heal.
In addition to routine stretching and strengthening exercises, a good physiotherapy regimen will be able to target any existing muscle imbalances which have contributed to the development of bursitis, although this should be built up slowly to allow the inflammation to settle in the first instance. Referral to an orthotist may also be beneficial in selected patients who have poor foot biomechanics as a contributory factor.
However, if a patient requires to get back to high levels of activity quickly, or their symptoms have not improved with more conservative measures, this would be an appropriate point at which to refer them to an orthopaedic specialist for consideration of further imaging modalities (MRI) to help confirm the diagnosis, or for targeted injection therapy to manage the symptoms.
If a bony spur has been identified, the opinion of an orthopaedic surgeon should also be sought as surgical intervention may be required to eradicate symptoms.
‘Injection therapy’ actually comprises different treatments options which can be injected directly into the affected bursa. Most commonly used – and recommended by NICE – are corticosteroids, which act within a few days to reduce inflammation and have been proven through numerous randomised control trials to improve clinical outcomes for a large proportion of patients in the short term (around 3 months).
This provides symptomatic relief and can also enable patients to progress further with their strengthening exercises. However, the evidence suggests that the effect is short-lived, and because of the risk of tendon weakness associated with repeated steroid injection it is recommended that patients have a maximum of 3 injections into one area, at least 6 weeks apart. This means that if a patient’s trochanteric bursitis has not resolved after this, other options may need to be considered.
Platelet-rich plasma (PRP) is a newer addition in the management of trochanteric bursitis. This technique involves drawing blood from the patient and spinning the sample in a centrifuge to obtain a sample of plasma with high concentrations (5-10 times the usual level) of platelets, which are desirable for their high concentration of growth factors which may help to stimulate repair.
This PRP is then injected directly into the affected area – activated platelets release bioactive proteins which recruit other repair factors, stimulate them to repair damaged tissue and promote angiogenesis. The entire healing process in PRP treatment is around 6 weeks, although some patients require a repeat injection at around 4 weeks.
Because it is a newer technology, research is still ongoing to determine the true effectiveness of PRP for trochanteric bursitis; current results are equivocal. However, many patients attest to the success of their PRP treatment.
Should a patient have failed to improve after trying all management options discussed above, they may be suitable for open surgical debridement of the inflamed bursa by an orthopaedic surgeon.
Stress fractures are relatively common in runners and joggers, and usually involve the metatarsals or tibia. They are caused by the repetitive loading of the feet and legs during running, whilst various running styles can play a contributing role – for example, over-striding with a definite heel-strike may increase your chances of a tibial stress fracture whilst running with a forefoot-strike can overload the foot and lead to metatarsal stress fractures. Diagnosis is by X-ray, DEXA bone scan or MRI.
Alterations in nutrition, running style and work on rebalancing muscles to improve patients’ biomechanics can all play their role in preventing further stress fractures, but once affected an individual’s only choice is complete rest for around 6-8 weeks whilst the fracture heals, aided by analgesia, ice and splinting if required.
However, there is one important ‘special case’ to consider in terms of stress fractures in runners in which prompt diagnosis is key, and this is the femoral neck stress fracture.
Stress fractures of the femoral neck are, by contrast to those in the lower legs and feet, relatively uncommon (accounting for around 1% of all stress fractures), but occur more often in runners than other groups due to repetitive loading of the femoral neck.
This injury should therefore be considered with a high index of clinical suspicion in athletes who present with insidious onset of exertional groin or anterior thigh pain and pain at the extremes of movement during examination.
Patients often provide a history of an increase in training intensity or overuse, and describe the pain as worse during high-impact activities and best following periods of activity cessation.
Fractures can occur either on the inferomedial femoral neck at the site of compressive stress or on the superolateral neck at the site of tensile stress during weight-bearing. Repetitive loading of the femoral neck leads to microscopic fracture formation (known as ‘crack initiation’), whilst continued loading stresses do not permit a healing response to occur and instead lead to ‘crack propagation’.
The clinical signs and symptoms – as described – are non-specific, and diagnosis is further complicated by the fact that initial radiographs often appear normal. In fact, Johansson et al reported an average diagnostic delay of 14 weeks for patients with femoral neck stress fractures.
The major concern with delayed diagnosis in these injuries is the potential for the fracture to displace, which significantly worsens outcomes for the patient and leads to a reduction in activity levels along with a 30% risk of avascular necrosis – elite athletes will not be able to return to their prior level of function should they sustain a displaced fracture.
Therefore, prompt diagnosis and management are key to maintaining patients’ activity levels and optimising their outcomes.
The imaging modality of choice for diagnosis is MRI, which is both sensitive and specific in identifying stress fractures and can detect early changes. Therefore, in patients where there is clinical suspicion of a femoral neck stress fracture and initial radiographs appear normal, referral to an orthopaedic surgeon should be made early in order to facilitate appropriate investigation and avoid diagnostic delay.
Features suggestive of a stress fracture on subsequent x-rays may include linear lucency or cortical changes – both AP pelvis and lateral hip views should be obtained.
Management of patients with femoral neck stress fractures is predominantly non-operative, with provision of crutches and a period of non-weightbearing and activity restriction.
However, those who sustain a displacement of the stress fracture will require surgical intervention (either fixation or replacement, dependent on the presence of avascular necrosis), and where there are large stress fractures on the tensile side or fatigue lines >50% of the width of the femoral neck, fixation with cannulated screws may also be indicated.
To help prevent the consequences discussed following diagnosis, patients should be followed-up regularly to be monitored for fracture displacement.
Athletes who participate in repetitive twisting or pivoting activities – such as hockey, football or long-distance running – can be at risk of developing a tear in the labrum, the rim of cartilage which lines the rim of the hip joint. The chances of this are increased in individuals who also have underlying structural abnormalities, such as femoro-acetabular impingement, and of course such tears can also be traumatic (sustained during injury to, or dislocation of, the hip joint).
Although many labral tears are asymptomatic, some can be debilitating and can limit range of movement and participation in running and other activities. Patients often complain of pain or stiffness in the hip, groin, buttocks or radiating to the knee, a reduced range of movement at the hip joint and sensations of clicking, locking or catching in the joint itself.
Although x-rays can be useful in the initial stages of investigation to identify pre-existing structural abnormalities or concurrent bony injuries, the labrum itself can only be visualised on MRI.
Labral tears are best visualised by a specialised type of MRI known as an MR Arthrogram, during which radio-opaque dye is injected into the hip joint and the images examined for evidence of leaking of this dye through a potential tear. However, the introduction of 3T MRI scanners, which are more detailed, may allow tears to be visualised without the need for invasive dye injection and the potential for adverse reactions.
If you suspect a labral tear in a patient, it is therefore useful to refer them to an orthopaedic hip specialist – ideally one specialising in young adult hip problems – early, in order to obtain a proper diagnosis and to tailor management appropriately.
Treatment options vary with symptom severity. Some patients recover well with a few weeks’ conservative management, whilst others will ultimately require open or arthroscopic surgery to repair or remove the torn piece of cartilage. A course of targeted physiotherapy to strengthen the surrounding muscles, increase range of motion at the hip joint and analyse movements in order to retrain movements and offload the hip can often go a long way to alleviating the symptoms associated with labral tears.
Again, injection of corticosteroids directly into the hip joint – usually performed under image-guidance by hip surgeons or radiologists – may be useful in providing some relief, and can also play a diagnostic role in localising the problem to the hip joint itself as opposed to the surrounding soft tissues.
Injection of hyaluronic acid into the hip joint can also help with symptoms. Hyaluronic acid treatment is known as viscosupplementation as the substance is naturally found in human joints. It is an essential lubricant and shock absorber for the hip as it is our largest weighbearing joint.
The results of the recent UK FASHIoN Trial – a large, multi-centre, assessor-blinded randomised control trial comparing hip arthroscopy to conservative management (personalised, progressive, supervised hip physiotherapy) in patients with hip impingement – were published in the Lancet in 2018; its results support both management options in improving patients’ quality of life, but found hip arthroscopy to be superior in achieving clinical improvement.
Specifically for runners, the wider literature currently supports a moderately high midterm return-to-running rate for patients undergoing hip arthroscopy, as well as high patient-reported outcomes and a low complication rate (Chen et al, 2019).
Should patients opt for non-operative management or continue to train unaware of their labral tear, there is a risk that they could develop hip osteoarthritis due to the loss of the protective function and stabilisation provided by the labrum.
Should patients develop early-onset degenerative changes secondary to an untreated labral tear, they should – in addition to their physiotherapy and input from other specialists – be referred on to a hip specialist orthopaedic consultant for assessment of their further management.
Options may include injection therapy (corticosteroids, hyaluronic acid, stem-cells – although more common in treatment knee osteoarthritis – or PRP, as discussed above) or joint replacement surgery once the patient reaches a symptomatic threshold.
We offer affordable diagnostic imaging in London’s world-renowned Harley Street medical district. If you or a patient need a scan, we’re an efficient, affordable and quick option, with private MRI scans from £200, Ultrasound from £250, X-ray from £40 and DEXA from £65.
Mr Arjuna Imbuldeniya
ICE ORTHO West London Hip and Knee Clinic
Secretary: Annie McKirdy
Tel: 0207 859 4016 / 07784141294
The London Clinic (5 Devonshire Place, Marylebone W1G 6HL; 0203 797 0297)
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