When we look at the hip, we can see a very complex structure but this complexity also has a simple side as well. Because of the complexity, we unfortunately see quite a bit of injuries. Unfortunately, this year, I've seen my fair share of hip injuries. Within the first 6 weeks of the fall season, I have seen: sports hernia, osteitis pubis, internal snapping hip syndrome, adductor strain, ASIS apophysitis, gluteal medius strain and various other back problems that I think stem from the hip issues. Unfortunately, I did not see any of these atheletes in our athletic development/injury prevention program with the exception of one and he insisted on playing about 30 games of lacrosse while going through his rehab program for an adductor strain from the previous sports season. What I have become very good at is understanding the hip and many of the issues that affect it, so I will go through a little overview of some of the injuries commonly seen as well as the though process that I use in post rehab and injury prevention situations involving the hip.
NOTE: THIS INFORMATION IS FOR EDUCATIONAL PURPOSES ONLY. IF YOU ARE EXPERIENCING ANY PAIN OR DISCOMFORT, YOU ARE ADVISED TO CONSULT A PHYSICIAN IMMEDIATLY. THIS IS NOT A SUBSTITUE FOR A MEDICAL CONSULTATION.
HIP AND GROIN INJURIES:
The hip is truly a marvelous structure that is a source of power, stability and moblity in the body. However, this trifecta also has a very delicate balance. Any hyper or hypo conditions in the hip and soft tissues can cause a litany of issues.
In the research article in AJOSM "Hip and Groin Injuries in the Athlete" by Anderson, Strickland and Warren, they categorized some of common disorders of the hip in the following manner:
Acute Onset
- Muscle Strains
- Contusions (hip pointer)
- Hip Dislocations and Subluxations
- Avulsions and Apophyseal Injuries
- Acetabular labral tears and loose bodies
- Proximal femur fractures
- Sports hernias and athletic publagia
- Osteitis Pubis
- Bursitis
- Snapping Hip Syndrome
- Stress Syndrome
- Osteoarthritis
- Lumbar Spine abnormalities
- Compression neuropathies
Short story: I went to a party last weekend of a college friend. It was really nice to see some people I have not seen in such a long time. We really picked up where we left off with partying and such. Toward the end of the night, a few of my friends were getting a little more boisterious than normal. They were carrying on, standing on furniture, screaming, etc, bascially causing a big ruccous. I thought to myself "These guys really are getting it done with the partying." Well, I looked around a bit more and I saw another of my college buddies in the group pretty sober but laughing like crazy, and I thought thatwas a bit weird given his illustrious party background, so I went over to chat with him. Come to find out that my buddy had a really crappy week and he needed to just laugh so he decided to start feeding the drinking boys more and more alcohol than maybe they should have been taking in. He told me that if he started to see their cups or beers at about half, he'd go get them another and tell them to drink up fast so that the next one wouldn't get warm. Wow! I found the troublemaker! My buddy had been pretty much shooving alcohol down their throats all night and these guys started making a lot of noise. So we had discovered who the troublemakers and the noisemakers were. Well, decided to leave the drunkards be and engaged the troublemaker in some good conversation so he would not want to give our buddies drinks. It worked. The noisemakers soon started sober up, the troublemaker was able to laugh and chat a bit more and the house was left in good shape.
I think the first thing to understand is that no injury happens in a vaccum, meaning that there something caused this disorder. From there, we can start our biomechanical investigation of the injury. With many disorders, it's easy to spot the NOISEMAKERS. They are the muscle strains, osteitis pubis, labral tears, etc and those can be managed. However, if we can look a little further for that TROUBLEMAKER, we can find the source, hopefully calm it down and work at preventing the injury again.
As we look through our glasses of Applied Functional Science and Principles of Function, the picture can become a little clearer. With injuries like the hip contusions (hip pointers), that's going to be easier to understand as that injury is generally caused by a concussive force at the hip to the bone. However, this injury can also damage the surrounding soft tissues, so it's imperative that we understand the healing process of soft tissue as well as our principles of function so that we can facilitate an succesful healing environment.
However, with the other acute onset disorders, even though they are "acute" as far as the pain may go, it seems that are not acute traumatic injuries. In my experience, the muscle strains, unless there was some kind of trip or fall associated with it, has been building. Muscles are reactive soft tissue along with the tendons, ligaments etc because of the movement sensory nerves or PROPRIOCEPTORS. Here's one of the of ways I go about looking at the muscle strains:
- Principles: 3-D, Driven by gravity, mass, momentum and ground reaction forces
- Strategy: Identify the joint relative joint motion and relevant muscles involved in 3 planes and then assess for any 3-D lack of ROM of the foot/ankle, and thoracic spine as well as the hip. Overworked/strained muscle has "left the building". Can the rest of the body assist so that the "noisemaker" can not have to work so hard?
- Technique: Soft tissue assessment and passive range of motion on plinth. Tri-planar hip assessment in an upright function. (video to follow). If we find any 3-D lack of ROM with the tests, that then becomes the exercise. Good place to start is also the foot and ankle complex? Is there enough subtalar joint motion? Callous patterns? Are the foot and ankle "feeding" the body with the ground reaction forces to start to activate muscles in 3 planes of motion so that it can properly load to explode? Hip flexion/extension, abbuction/adduction, internal/external rotation? Proper thoracic spine mechanics for Type I (lateral flexion/opposite side rotation) and Type II (lateral flexion/same side rotattion). Type III (flexion or extension/lateral flexion/same-opp side rotation)
As the athlete, a proper training and conditioning program that focusing on both enhancement and injury prevention is something you should invest your time and energy into.
One of the first things we give our athletes is the 3-D kneeling matrix followed by the 3-D lunge matrix. It's a one-two combo of stretching and strengthening. Next, we give our athletes a dynamic warm up to do. This is so important as this warm-up addresses many of the movements of body with a focus on the hips. (Videos to follow). The great thing about the dynamic warm-up is that it can be also used as a short workout tweaking the load, speed, and angulations. I typically will use this as workout if I'm running short of time.
CONCLUSION:
As we look at the hip and some dysfunctions, we see that as complex as the hip is, there is a simplicity there as well; however, we have to allow ourselves to step back and take a look at the total picture. NOISEMAKERS are usually easy to spot. The TROUBLEMAKERS are where its start to get interesting. If you are looking at hip only, you may be missing out on the troublemakers like the foot/ankle and thoracic spine. After looking at those probable suspects and everything is clear, then return back to the hip and see what is going on. Don't miss the forest for the trees.
As always, I hope this info helps. If you have any questions or comments, please feel free to leave them in the COMMENTS section.
Happy Monday!
Will
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