Hip stress fracture – how to spot it &…

• Hip stress fractures can present as a vague but persistent hip, buttock or groin pain
• They are more common in females and most prevalent in endurance sports such as distance running
• The pain is often confused with gluteal tendinopathy or chronic gluteal muscle fatigue or strains due to its common aggravating factors and symptoms

TIPS

• One of the most telling symptoms with a hip stress fracture is the lingering ache for more than 24 hours after exercise
• Imaging is vital to confirm the presence and location of the fracture. One particular location of stress fracture, on the upper side of the neck of femur (joining section between the shaft and ball of the femur) is prone to progression to complete fracture. For this location, we take all weight off the leg with crutches or even a wheelchair to allow it to heal
• Identify the causative loading pattern as soon as possible. This is often a loss of hip joint range or strength but this must be assessed early. Both weakness and stiffness will be present after a week or two of reduced activity and may not be related to your cause

MYTHS

• Hip stress fractures don’t generate huge amounts of pain. The pain can be quite mild and often leads to the assumption that it isn’t painful enough to be fractured
• Anti-inflammatories (such as Nurofen or Voltaren) will completely relieve the pain from a stress fracture. This allows people to continue exercising but prevents the bone from healing itself effectively, making the fracture worse
• Hip stress fractures don’t require big weekly distances or excessive body weight. They’re quite common in average to slight builds and at regular to low weekly running distances

WHAT ELSE COULD IT BE?

• Deep hip muscle fatigue
• Gluteal tendinopathy
• Lower back pain, referring pain across the hip
• Hip osteoarthritis
• Hip labral tears

Deep hip rotator overload – buttock & hip pain

Deep hip rotator overload causes a diffuse deep hip muscle pain, felt centrally in the buttock.

Pain in the buttocks and hip often peaks the day after exercise. It causes pain on stretching (eg. sitting) and activation (eg. squats, walking upstairs). Combining stretch and activation is usually the most provocative so hip pain when squatting deep is usually noted.

Aside from hip pain when squatting deep, there can be hip pain after running (as the fatigued muscles tighten) and hip pain when sleeping (due to sore deep hip rotators being stretched in side lying).

It is caused by excessive fatigue of one or more of the six small hip muscles that sit underneath the gluteal group (larger hip abductor muscles).

These small muscles rotate the hip laterally (outwards, referred to as “external rotation”) and assist with hip joint stability.

Why do deep hip rotators cause so much hip muscle pain?

The answer is what makes them vulnerable and so very effective. These muscles are short, which means they aren’t able to stretch very far.

They’re also small. That doesn’t matter when they work together but leaves them prone to overload if one is working harder than the rest.

So if one of the group is overloaded relative to the others, it spells trouble.

Piriformis is the most prone to overload and pain. It’s also implicated in some forms of Sciatica.

As the individual muscle accrues too much fatigue, a reaction within the muscle is initiated that results in deep hip pain and some muscle shortening (although the shortening is only temporary).

Remembering that these muscles don’t have a lot of length to begin with. The shortness causes additional restriction and further overwork, as the muscle activates to try and resist excessive stretch.

This creates a cycle of hip muscle pain and overload that can last for weeks. Running can feel good as it stretches it out, but it also adds fatigue. So you’ll feel hip pain after running.

You decide to rest, but laying on your side puts stretching pressure on the muscles. So you get hip pain when sleeping.

It’s a frustrating cycle that feels like you can’t escape.

So how do you treat it?

Stretching can be effective ONLY if it’s gentle and comfortable! As the muscles involved are very short, they go from mild stretch to over-stretched very quickly.

Vigorous stretching causes a protective activation of the muscle, the body’s natural defence to overstretch. This means that the harder you stretch, the harder the muscle fights back and the more fatigue you’ll generate.

A trigger point ball is more effective than a foam roller as the muscles are positioned in a bony recess in the pelvis. That makes them hard to access with the broader surface of a roller.

This is one of those injuries that you can actually “run it out“, kinda. Slow easy running can help restore normal muscle length. But you have to be careful not to add to the overload with further fatigue.

Overloading the muscles or generating fatigue will make it worse but gentle exercise including easy yoga and walking can help gently stretch the muscles and relieve soreness.

Avoid these approaches as they’ll slow your recovery

Trigger point pressures shouldn’t be painful – harder pressure isn’t better (see our point above on vigorous stretching and how your body responds to pressures it thinks might be damaging).

Firm pressure can be uncomfortable but if you perceive it as pain, the protective response from the brain is to activate and tighten the muscle to avoid damage. So it’ll actually have the opposite effect and worsens the issue.

Strength exercises are not a solution for muscles that are already overloaded.

We can always be stronger but strengthening these muscles while they’re fatigued and sore will only worsen the pain and extend your recovery.

You can perform gentle exercises of the area with lighter loads or less range of motion around the hip. Here’s an example:

Ice and heat are not effective. The muscles are too deep to be affected by the thermal effects of ice and heat. So the best they can do is distract you from the pain in buttocks and hip – and for that you may as well use a heat cream like Dencorub or Tiger Balm.

Be wary of these conditions that can mimic hip muscle pain

Bone stress – this can cause deep hip “muscle” pain similar to sacral and hip bone stress injuries, although those injuries behave differently in response to loading.

Low back pain – lumbar pain can refer into the buttock and may worsen after exercise.

Sciatica – Sciatic nerve irritations may be felt in the buttock but commonly progress to pain spreading down the leg.

Muscle tear – a pulled hip muscle can occur with the same overload but it’s often associated with sharp pain on initial loading.