Hip and groin pain Archives • Page 2 of 7 • Sports Injury

Hip FAI – top 3 best ways for fast…

Femoroacetabular impingement, or “FAI”, causes a sharp pain in the hip, most commonly in the front of the hip or groin. It can come on suddenly and may not necessarily have an obvious mechanism of injury.

You may be more prone to FAI with bony changes around the hip. Bony bumps can form on the pelvis or femur side of the joint. These bumps get compressed when the joint moves to the end of its range, causing FAI.

A simple x-ray is commonly performed to screen for these bumps however this is often not useful. You may have the bumps without FAI, and vice versa, so it doesn’t confirm the diagnosis. And surgery is very rarely required to correct the bumps, so knowing that they’re present doesn’t change management.

People often feel the FAI pain as groin pain, anterior (front) hip pain or deep buttock pain. The symptoms are flared when the leg moves in a combination of flexion (forward), internal rotation (twisting inwards) and adduction (tilting inwards).

These movements can occur with simple tasks such as doing up a shoelace, climbing stairs or getting out of a car. This may also occur while running uphill or on tired legs or during pivoting in field sports such as football.

MY TOP 3 DO’S FOR A FAST FAI FIX

Once accurately diagnosed, anti inflammatory meds usually have a significant effect within a few days
- It’s important to cease or pause the meds after a week or so. If the pain returns to the same intensity within a day, the meds are unlikely to be a solution for the injury. They’re just subduing it without resolving the reaction completely.
Imaging isn’t typically required unless the pain is persistent, recurrent or extremely strong
- An MRI can be useful to confirm the diagnosis and screen for other pathologies like labral tears or bone stress injuries. The findings can also be used to guide the location of a cortisone injection if recommended
- Doctors often refer for screening x-rays but these have little clinical value in guiding management
Exercises to improve hip strength and control must be done in safe positions, avoiding deep or unstable positions
- Full depth squats or deadlifts will build strength but can compress the injury, worsening the condition
- Staying in upper ranges and avoiding unstable movements (such as lunges) is recommended
- Stretching is not useful, despite the “tight” feeling around the hip, as it often adds to the compression

MY TOP 3 DON’T (BOTHER)…

If you find a bony bump or labral tear on imaging, it doesn’t automatically mean you’ve found the culprit
- Both of these findings are present in people without FAI pain too
- X-ray is unable to differentiate between old or unrelated findings and findings that are causing symptoms
- MRI has the benefit of showing which structures are currently reactive, which can help to determine if a bump or labral tear is involved in the current presentation
People often mistaken FAI for chronic hip flexor tightness or soreness after exercise
- Stretching is the usual response to the feeling of tightness and can inadvertently make FAI worse
- Stretching pulls on the sensitive and inflamed soft tissues, which can cause further irritation
- You’ll often hear FAI sufferers remark that they can’t feel the hip flexor stretch in the targeted muscle
As an acute (sudden onset) injury, FAI can feel like a pulled hip flexor or groin muscle
- You can differentiated FAI from strained muscles as FAI recovers quickly and responds well to anti inflammatory meds
- Another key feature to differentiate is that muscle injuries usually have a sore area found when you poke around. FAI is too deep to have any palpable soreness

WHAT ELSE MIGHT BE CAUSING YOUR HIP PAIN?

Hip labral tear
- This injury is almost impossible to differentiate from FAI except for a painful click (only present in labral tears, not FAI)
- Labral tears are on the same continuum as FAI and are both precursors to hip osteoarthritis
- Differentiating between FAI and labral tears is often unnecessary as the management plan for each condition is almost identical
Hip flexor muscle strain or tear
- This injury is very similar in presentation to FAI – they both start suddenly, generate pain in the front of the hip and don’t like movements that bring the knee towards the chest
- With hip flexor strains, there’s often an area that’s sore to push on. By comparison, FAI doesn’t have any palpable soreness
Lower back pain
- Back pain can refer to a number of areas, including the front of the hip
- It’s difficult to determine whether the back is causing anterior hip pain as there’s often concurrent back pain with FAI sufferers
Hip osteoarthritis
- Hip OA is on the same continuum as FAI – that is, FAI is a precursor to the changes that lead to hip arthritis
- Hip osteoarthritis usually feels worse after prolonged rest or sleep but loosens up with activity. Conversely, FAI can loosen up slightly with activity but deteriorates with aggravating activities
Psoas (hip flexor) bursitis
- This injury is an inflammatory reaction around a small pad in front of the hip and comes on slowly over a period of days or weeks, not suddenly like FAI
- Unlike FAI, it’s painful to push on the sensitive area with Psoas bursitis
Inguinal hernia
- This injury causes pain higher up in the lower abdominal area, although it can refer a dull ache to the groin
- The pain is rarely sharp with a hernia, although it does linger after it’s stirred up
- With an inguinal hernia, it’s painful to cough
Lower abdominal strain
- Similar to inguinal hernia but with a more easily identified cause, this injury occurs after abdominal overload or excessive stretch
- The pain is higher up compared to FAI and doesn’t refer past the skin creases in the front of the hips
Inguinal ligament strain or tear
- This injury can occur suddenly or over time and causes pain on or just above the skin creases in front of the hips
- There is usually a sore area to press on with inguinal ligament strains
- Inguinal ligament strains share many of the same aggravating activities with FAI and may be confused based on their presentation

Gluteal tendinopathy – symptoms, causes & answers

Gluteal tendinopathy symptoms include pain on the lateral (outside) aspect of the hip, often felt during exercise or walking. Pain can also be felt when lying on either side or on standing after prolonged sitting.

This tendon condition can occur on its own but is more commonly seen in conjunction with other conditions, such as hip osteoarthritis and trochanteric bursitis.

It tends to be linked closely with reduced strength and as such, it is more prevalent with older age groups. The strength deficit leads to poor control of hip rotation, which in turn tightens and overloads the Gluteal tendon.

Symptoms of gluteal tendinopathy

Symptoms of gluteal tendinopathy can be varied but there are some common elements. Pain on the outside of the hip is by far the most common complaint.

Symptoms can also include a dull constant ache or a painful snapping sensation in the same area but won’t include pins & needles or numbness – these are more likely to be associated with spinal nerve compromise or Lateral Femoral Cutaneous Nerve injuries.

Pain from gluteal tendinopathy is aggravated by running, walking (particularly walking downstairs) and side lying in bed. But it can also be stirred up by activities such as swimming due to the kicking action.

What causes gluteal tendinopathy?

The direct cause of gluteal tendinopathy is an overload of forces on the tendon. This can come from too much prolonged loading (like a very long day of hiking) but is more commonly associated with repeated spikes in loading (from a combination of rapid stretch and “shock loading” from poor muscle control).

When the muscle becomes fatigued, or leg stability is compromised, the leg rotates inwards quickly on landing. This causes a sudden pull on the tendon, which in turn creates an acute inflammatory reaction.

Over time, this reaction accrues and begins to cause pain. And that’s where the downwards spiral begins…

The ability to maintain strength in the hip muscles becomes limited by pain inhibition of muscles in the area. Basically the brain won’t fully activate the muscles if it thinks that will cause pain, so the pain “inhibits” muscle function.

That inhibited muscle function means that the rotation on landing is even more rapid and poorly controlled, creating a more significant reaction on the tendon. And so the cycle continues….

What is the best treatment for gluteal tendinopathy?

The biggest issue with making progress and fixing gluteal tendinopathy is trying to break the cycle of pain and inhibition.

Anti inflammatory meds can help make early progress by reducing pain and improve muscle recruitment during exercises. That can allow you to begin to rebuild strength around the hip.

If you’re sensitive to meds or who prefer to avoid them, you can relieve symptoms with a non-medicated heat rub (eg. Dencorub) which can be quite effective at blocking out pain and improving muscle function.

You’ll need to select strength work that doesn’t cause pain and can be performed with good technique. My preferences are, in no particular order:

Double leg hip thrust or hip bridge
Sustained wall sit
Sumo deadlift
Pallof press, on single or double leg
Crab walk with ankle band

These exercise can build strength in safe positions while avoiding symptoms. Exercises to avoid, due to their likelihood of irritating the tendon, include:

Lunges
Single leg squats
Step up or down
Any hopping or jumping (particularly during the earthly phase of rehab)

Running can still be an option but it’ll be safer if you can break it up into a run:walk format. Run until BEFORE the pain starts, then take a walk to avoid accruing fatigue, then run again and repeat. The run time is case-specific but the walk can typically be 2-4 minutes (shorter timeframe for more experienced runners).

Don’t get caught out by these myths

This condition resolves completely in almost every case although it can be quite stubborn and slow to resolve. Don’t get frustrated and return to full loading prematurely. Just be patient.

A cortisone injection may seem like a quick fix but it’ll only be successful if the underlying cause has been found and fixed (such as a single bout of overload, like an ultramarathon). It can be helpful to start your exercise program without pain but it’s a limited window to attack your exercises, not a cute in itself.

Supportive shoes and/or orthotics can be helpful for some but they’re not a guaranteed solution for all. They’ll only be successful if poor rotational control of the leg is the major factor in your causative biomechanics. If it’s a result of the pain and pain inhibition cycle, it’ll only provide limited relief.