Lateral Hip Pain
Many people suffer with pain on the side of their hip. This is a relatively common condition, and can vary from discomfort at night, to severe pain, requiring a wheelchair and morphine pain relief. People with this condition can limp, and their hip muscles get tired easily. It can be more difficult to take weight on one leg – which can affect balance.
Pain or discomfort is usually felt around the bony prominence at the side of the hip (the trochanter). This can be associated with a click or clunk.
The pain often then travels or radiates down the side of the leg, or up into the buttock.
It can affect all age ranges. It effects many people -from those who are sporty to sedentary people..
It can be difficult to identify why each person suffers from it and therefore how to treat it.
It used to be commonly alled 'Trochanteric Bursitis', as some patients develop a sac of fluid around the trochanter called a bursa. It is now called Greater Trochanteric Pain Syndrome or GTPS.
Common Causes of GTPS (Greater Trochanteric Pain Syndromes)
GTPS is usually a symptom of another condition or problem including,
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Muscle imbalance / Posture
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Muscle tears / tendon problems
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Injury
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Surgery
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Repetitive actions
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Pain , e.g back or sacro-iliac joint pain
As you can see from the box, this GTPS pain is usually because of another problem. There can be many causes, that the patient may not even be aware of.
It might be that you were limping because of a painful knee or ankle, or had back pain from an old mattress.
Jan's Story
Jan had suffered with back pain for many years. When it was bad, her back would go into spasm, and she would limp. She then found it difficult to lie on her left side, as she was developing GTPS. It was getting more and more difficult to sleep
Jan went to her GP, who diagnosed 'Trochanteric Bursitis' and gave her a steroid injection around her trochanter. Whilst initially very painful, this helped for about 4 weeks, then the pain came back.
Jan then went to a phsyiotherapist, who treated her back pain and hip pain succussfully.
What's happening to me?
Greater Trochanter
This image, looking from behind, shows the fascia lata and iliotibial tract. (image credit: GoGraph /Eraxion)
The Tensor fascia lata muscle starts at the front of the pelvic crest, and comes down and backwards towards the trochanter.
The muscle then merges into a tough layer or fascia (iliotibial band) that comes down the side of the thigh, to insert onto the top of the tibia.
Sometimes it will get tighter, which can put pressure on the trochanter, the bony protruberence at the outer edge of the hip.
This tightness can start off a vicious cycle, where the tightness causes pain, which can then cause more tightness, which then causes more pain etc.
Hip abductor tendon problems (Rotator cuff disease of the hip)
The hip abductor muscles, Gluteus medius and minimus, start on the side of the pelvis and act on the trochanter. The muscles connect to the bone with tendons. They are essentially under the Fascia Lata. Their main function is to stabilise the pelvis when walking / getting up from a chair, as well as rotating the leg , and moving the leg away from the midline.
Every day, these muscles and tendons cope with repeated stress. If you stand on one leg, its hip abductor muscles have to contract with about three times the force of your weight, just to keep the pelvis steady. This force dramatically increases with running / exercise.
Wear and tear commonly affect these tendons. Usually, the body can heal minor knocks / sprains if the tendon is rested / looked after. However, people will often walk through or ignore the initial phases of the tendon injury. Sometimes other injuries mean that it is impossible to rest. Sometimes people will continue to try and run on the injury. If the body is not able to heal the tendon, it can become inflamed and weak.
All tendons are alive, and need oxygen / nutrients, as well as circulation to remove waste products. These are pumped through a network of tiny blood vessels called capillaries. The tendon relies on regular contraction and relaxation to pump these substances into and out of the tendon to keep it healthy.
If someone has chronic back or sacro-iliac joint pain, then the hip abductor muscles often go into spasms / cramps.
When the muscle is in spasm, the tendon’s capillaries are clamped shut, and the tendon cannot get nutrition / excrete its waste products. The tendon cells can die, which then makes more inflammation.
Inflamed tissue swells, putting more pressure on the capillaries. When the pressure blocks the capillaries, the cells do not get enough nutrients, and they die.
Chronic pain often results in tighter muscles and tendons, which compounds the problem further.
Therefore, once a tendon starts getting inflamed, it enters a vicious cycle, that can be very difficult to break.
This cycle can result in an inflamed painful tendon, which will eventually tear.
As these tendons and muscles are next to the Fascia lata, they are sometimes confused with ‘Trochanteric Bursitis’.
If steroid is injected around a diseased tendon, it will often make the tendon worse.
Treatment of Hip Abductor Tendon inflammation
The first stage is rest and gentle stretches. Use simple measures to try and stop muscle spasm, e.g. hot baths / ice / wheat packs etc. Avoid overdoing exercise. Listen to your body if it is telling you to rest.
Physiotherapy is the mainstay of treatment. Regular movement and stretching will increase the healing. Avoid exercises that cause pain. Acupuncture can alleviate spasm
Try to make the healing environment of the tendon as good as possible. There is some evidence that anti-inflammatory drugs such as ibuprofen can aggravate tendon injuries, and so a long course is not recommended. Smoking / nicotine will affect the healing ability of your tendon – try and stop smoking.
Biological injections. There are a range of injections that may help healing of the tendon. Mr Stott has been using either blood or PRP (Platelet -Rich Plasma) injections around these tendons for over 5 years – with great results for the appropriate patient. Unfortunately, PRP is not available as an NHS therapy yet in hips, although NICE have approved its use in elbows and knees.
When a tendon is injured, its natural healing cycle starts with bleeding, and the development of a blood clot around the damaged tendon. Platelets are one of the constituents of blood, and they activate as part of the clotting process. They release signals to attract other cells to start healing the tendon to start the healing process.This effect can be mimicked by injecting platelets or blood around the damaged tendon.PRP is obtained by taking a sample of blood, and concentrating the platelets.If this fails, stem cell therapy or surgery can be discussed.
Surgery. A range of surgery is offered, from simple cleaning out of the inflamed tendon (debridement) through tendon repairs and grafting of the damaged area – see rotator cuff tears of the hip, to muscle transfers. Mr Stott regularly recieves referrals from other orthopaedic surgeons, from local hospitals and other trusts. Surgery is not usually considered until someone has had a good course of physical therapy.