Self Help Series: Lateral Hip Pain

‍‍Self Help Series:  Lateral Hip Pain

Anna Staehli Wiser, DPT, FAAOMPT

The hip is a ball-and-socket joint, and it is one of the largest and most stable joints in the human body. It plays a crucial role in supporting the weight of the body and facilitating various movements, including walking and running. The socket or acetabulum sits within the pelvis, and the ball is the proximal end of the thigh bone or femoral head.  The muscles around this joint are very important for providing stability through the hip and pelvis during standing and walking activities.  Injury to the gluteal muscles, primarily the gluteus medius, can cause major disruption to the stability of the hip which can then lead to alterations in walking mechanics as well as pain in the lower back and knee.  

Although there are many types of hip-related pain disorders, lateral hip pain due to gluteal tendon impairment  is one of the most common types of hip pain and is commonly referred to as greater trochanteric pain syndrome, trochanteric bursitis,  or gluteal tendinopathy.  The trochanteric bursa is a fluid-filled sac located near the greater trochanter of the femur, which is the bony prominence on the outer side of the hip. Bursae are small, synovial fluid-filled sacs that act as cushions between bones, tendons, and muscles, reducing friction and allowing smooth movement of these structures.

When there is gluteal weakness or poor mechanics at the knee or ankle, the femur translates into adduction and internal rotation which then causes increased tension over the greater trochanter and can lead to inflammation in and around the bursa.  This is why trochanteric bursitis and gluteal tendinopathy generally go hand in hand1. Gluteal tendinopathy is the most common cause of lateral hip pain2 and is most common in the middle aged population (age 40-60) and especially in post menopausal females3.  

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Why do the gluteal muscles become weak in the first place?  Muscle weakness can occur anywhere in the body due to various reasons - usually lack of adequate use.  Many times injuries occur when a person places demands on the body when the body is not properly conditioned for the task it is being asked to perform - for example, going for long walks on the beach while on vacation. When the muscles are placed under a load that they cannot handle, then micro-tears can occur - usually at the enthesis (where the muscle transitions to tendon and attaches to the bone)4.  If the injury is detected early enough (at the first sign of soreness), then usually the body can repair itself in a few days with proper rest.  However, if proper rest does not take place, then the injury can become worse and turn into a chronic, nagging problem.  Also, there are scenarios where the body is slow to recover and needs more rest, such as with advanced age, poor nutrition, or menopause in women.  

Weakness and pain in the lateral hip leads to altered standing and movement mechanics, which can then cause the lateral hip pain to spread into the lower back, lateral thigh, and knee.  

Although muscle weakness is a major cause of lateral hip injury, it is not the only cause.  Many times there can be structural issues at the foot/ ankle complex or knee that will affect the mechanics of the hip.  When the femur translates toward the midline (adduction), a scenario is created where the gluteal tendons become over-stretched and more load is placed over the trochanteric bursa causing risk of injury because of an improper length -tension relationship between the tendon and muscles.  

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In mild cases of lateral hip pain, self treatment can be effective.  Self treatment for any injury starts with rest - giving the body a chance to heal by avoiding painful activities for a week or two. Sleeping with a pillow between the knees, avoiding lying for prolonged periods on the painful hip, prolonged sitting, or sitting with legs crossed are all strategies to reduce irritability of the soft tissues around the lateral hip.  Stretching out the piriformis and hip flexors, foam rolling the iliotibial band and long muscles of the thigh, trigger point release around the hip with a small ball, proper footwear, and light strengthening of the hip muscles can also be helpful strategies in self treatment.  Watch the video to learn more.

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When lateral hip pain becomes chronic, it can be difficult to get over it without help.  Rest alone many times will not be enough because there may be changes in the tendon structure, such as collagen disorganization, increased vascularity, and alterations in the extracellular matrix, all of which inhibit the body’s ability to heal itself properly5,6.  Although muscle weakness is the underlying cause, it is many times very difficult to start a strengthening program when the muscle tissue is in an unhealthy and weakened state, and any kind of exercise is painful.  

So how can the vicious cycle of pain and weakness be broken?  This is when physical therapy is needed.  Deep tissue massage and dry needling (dry needling is the use of acupuncture needles to thread into the impaired tissue and generate a healing response) can be very effective in cleaning out unhealthy tissue and facilitating fibroblast proliferation and  the regeneration of a new and vibrant collagen matrix7,8.  Once this process starts to happen and pain is well controlled, then the application of a graded progressive exercise program9 to properly load the tissue will rebuild the integrity and strength that the gluteal muscles need in order to be fully rehabilitated.  Also if there are structural issues at the knee, ankle or foot, they need to be addressed with hands-on therapy, proper footwear, orthotics, and specific exercises.  

Many times in chronic cases of lateral hip pain, the lower back has become involved as well due to altered standing and walking mechanics.  Osteopractic physical therapy can also address the lower back issues with spinal manipulation, massage, and dry needling.  Although spinal manipulation is traditionally thought of as done exclusively by chiropractors, osteopractic physical therapists and osteopathic physicians are also trained in this technique.  

If you are having persisting lateral hip pain despite trying the self help ideas listed above, fear not -  Dr. Anna Staehli Wiser is here to help!

 Electrical Dry Needling for lateral hip pain

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References:

1. Kagan A 2nd. Rotator cuff tears of the hip. Clin Orthop Relat Res. 1999;(368):135-140.

2. Grimaldi A, Fearon A. Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management. J Orthop Sports Phys Ther. 2015;45(11):910-922.

3. Lespasio MJ. Lateral Hip Pain: Relation to Greater Trochanteric Pain Syndrome. Perm J. 2022;26(2):83-88.

4. Govaert LHM, van Dijk CN, Zeegers AVCM, Albers GHR. Endoscopic bursectomy and iliotibial tract release as a treatment for refractory greater trochanteric pain syndrome: a new endoscopic approach with early results. Arthrosc Tech. 2012;1(2):e161-e164.

5. Kaux JF, Forthomme B, Goff CL, Crielaard JM, Croisier JL. Current opinions on tendinopathy. J Sports Sci Med. 2011;10(2):238-253.

6. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409-416.

7. Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014;19(4):252-265.

8. Stoychev V, Finestone AS, Kalichman L. Dry Needling as a Treatment Modality for Tendinopathy: a Narrative Review. Curr Rev Musculoskelet Med. 2020;13(1):133-140.

9. Ladurner A, Fitzpatrick J, O’Donnell JM. Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation. Orthop J Sports Med. 2021;9(7):23259671211016850.