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PATIENT HIP RELATED QUESTIONS

Join Dr Liew in answering your questions. Post a comment on the Facebook Post specific for this page, and Dr Liew will read, and answer most questions on here. The current segment is focussing on Hip Pain and Hip Arthritis and Sports injuries of the Hip. Please note that sensitive medical information will not be disclosed on this page. This area will be used for general questions that can be used to help others that may have the same questions as you.

Calcified Tendon in hip. Can this be rectified with surgery?

I have a calcified tendon in my left hip.Can this be rectified with surgery? I believe my calcified shouder tendons were “needled” during prior shoulder surgery. Do you do this procedure?

Thank you for your query. The first thing to determine is where the tendon is, and what symptoms it is causing. Generally calcifications around the hip occur in the gluteal tendons. These are comprised of two tendons, called the Gluteus Minimus and Gluteus Medius. These are the abductors of your leg (such as in lifting your leg out to the side).

When you have small tears in a tendon, then your body can cause these areas to heal with small areas of bone. Sometimes it can occur spontaneously, as is often the case in the shoulder. These an be quite painful, and can be treated with needling. In the hip, needling of the calcium deposits is a lot less commonly performed. In general, the cause of the pain (if you have bad pain) should be identified. This is often the bursa. We would try to investigate the cause thoroughly first with either an ultrasound, MRI or both, and determine if your pain is actually just soft tissue, or if it involves bone as well. Once this is determined, then treatment with a small injection with steroid can often do the trick if it is the most common cause for your pain, which is an inflamed bursa.

You may not require any surgery at all, as this type of disorder can often be managed non operatively. If surgery is required, this can be performed open or arthroscopic (key hole), depending on the underlying pathology. If a tendon repair is required, generally an open approach is warranted. If it is for the bursa and bone underneath, then arthroscopic can be performed.

I hope this answers most of your queries.

Work accident causing knee injury. Hip bursitis and new groin pain.

As a result from a work accident left knee injury n nerve damage. I have bursitis in my left hip and in the last 4 years I have left groin pain and left side of back muscles are tight in constant pain and discomfort. I exercise daily and do exercises to maintain movement in muscles and nerve stretches. However the pain in my groin, hip and back are starting to impact that plus day to day activities.

Thank you for your message on Facebook. It sounds like a few things were damaged during your accident. If we focus firstly on your hip pain, there seems to be two problems here.

  1. Trochanteric bursitis (The usual one) causes pain on the side of the hip. Its usually worse when walking up and down hills and when lying directly on your side. The first steps to treatment are usually physiotherapy, and then corticosteroid injections. I addressed some of the treatments for this in an earlier message. The other kind of bursitis is posts bursitis – this can cause groin pain, but is far less common.
  2. Groin pain can be caused by a few things, and some of those are not from your hip joint. This includes the inguinal ligament, hernias, and genitourinary issues. If these have been ruled out, then the hip joint should be investigated. This includes plain X-rays, possibly an Ultrasound looking for posts bursitis, and then an MRI. For me, an MRI is probably the most useful tool.

MRI: An MRI uses a magnetic field to image a part of the body. That part of the body needs to remain very still, or the image isn’t clear. This scan takes around 30-60 minutes to perform, so needs to be booked in advance. The benefit of the scan is that is does not cause any radiation (Like an Xray or CT scan) and can show soft tissue very well. X-rays generally have little radiation, but some CT scans can have a fair bit. Radiation is cumulative over your life time, so we limit CT scans unless necessary. The MRI can show how bad your bursitis is, and can also look at your hip joint to see if there is any major osteoarthritis there causing your groin pain.

If you are still able to exercise, this is a good sign. Depending on your age, and limitations, the treatment options will vary. A good start is to start taking some baseline medications which are anti-inflammatory in nature. Glucosamine (capsules) and Fish oil (liquid) can be useful in decreasing inflammation naturally. In 30% of people, they do not create a good response, so I tell my patients to trial them for 3 months, and if there is no difference, to stop them.

A lot of your pain may be related to something happening in your knee or back, so a careful examination and series of investigations would be the best start, in determining what to do. I hope this helps.

15yo with PVNS in the hip joint.

Hi Dr Liew, my 15 y.o. daughter has recently been diagnosed with a P.V.N.S. on/in her hip – which is not going to be removed at this time – but instead monitored. I am wanting to know about pain relief – would a gel like Voltaren help?

Thanks for your query. A bit of general information before I address your specific question:

PVNS stands for Pigmented VilloNodular Synovitis and is an excessive growth of the synovium. It can either be in one spot or through the entire joint. This is called Localised or Diffuse. The localised form has a great prognosis with a low recurrence rate when treated surgically, but the diffuse form (More Common) has a recurrence rate of 46% after surgical management. PVNS can affect any joint, but the Knee is the most common.

We don’t actually know why PVNS occurs. Some theories suggest that it is due to trauma and the resulting bleeding into the joint, but we see a lot of trauma that doesn’t result in PVNS, so we believe there is something more here. Some of the current literature suggests that it is a neoplastic process (Where the cells grow abnormally), but very very few cases go on to produce tumour cells. Currently, there has been no conclusive evidence to suggests the cause.

When PVNS is within a joint, left untreated, it continues to cause pain and discomfort. The localised version as above, is probably on a spectrum as the mildest cases, with the diffuse (more common) being at the other end of the spectrum. The diffuse ones are much harder to treat due to their much higher recurrence rate. The usual age for developing PVNS is between 20-30yo and affects both males and females equally.

To diagnose PVNS, the best imaging modality is an MRI (Magnetic Resonance Imaging). This is non invasive and can be quite specific for PVNS. It can also help to distinguish between localised and diffuse PVNS.

Management

  • Radiation therapy: Results have been mixed as there are complications associated with radiation such as skin reactions, joint stiffness and transformation of the PVNS to something more sinister. Newer modalities such as intra-articular radiation unfortunately hasn’t resulted in better results overall, with studies showing minimal differences.
  • Arthroscopy (Key hole) total synovectomy: This is the most used method today, and requires a thorough synovectomy, or else recurrence rates increase. In most studies, localised PVNS gets a lot better with arthroscopy treatment. In diffuse PVNS, arthroscopy can be a relatively length procedure, and when is it like your daughters (hip), the length of the procedure matters, as we do not want to keep patients under hip traction for too long, to avoid damaging other structures. Appropriate equipment is required, and the procedure length should be kept as short as possible, whilst trying to get all of the PVNS within the joint.
  • Open surgical excision: This is more important for the knee, where an open approach is much easier. In the hip, access to the hip is much more difficult, without a large incision, and other complications, so arthroscopy approaches are preferred.
  • Your question relates mostly to the Voltaren Gel. Unfortunately, this Gel tends not to penetrate deep enough to access the joint, so its use is quite limited. The gel can help to make the joint feel better, but it certainly will not affect the underlying disease process (inflammation). I would recommend using it only for symptomatic improvement. It will not help the underlying pathology.
  • Joint Replacement: Although your daughter is far too young to require this, this is the end result of long standing PVNS, and once performed, the results are good. This would only be suitable once you are aged 50+ minimum.

Long answer, but there is a lot to go through with PVNS. I hope this helps to answer your question.

Injury from running with 3 Slipped Discs and a til in the hip

Hi … I had an injury from running and now I have three slipped disc and a tilt in the hip. Always in pain. I do the usual like core excercises to keep the muscles strong but would like to run again..any tips would be great. Thank you

Thank you for your query. A little bit more information is probably required for a full answer here as I am not sure what kind of injury you had whilst running. Unless you have a fall, or acute injury, it would be relatively uncommon to slip your discs in your back from running, so I am assuming you’ve had some kind of fall, or twisting injury or similar.

In reference to your hip, the tilt might be coming from your back. As your spine changes, you pelvis changes with it. The pelvis is trying to make things level in your legs, and can accomodate for all of the differences with lower back stiffness and pain, and leg length discrepancies. It sounds like you’ve been doing a good job of maintaining your core muscles, which is extremely important for back related pain, as it stabilises your spine.

If you have nerve roots that are being pinched in your back, then there are a few things that can be done. I am not a spinal specialist, but the following general principles apply:

  • Obtain an MRI to see what the exact issues are with your spine. Is there a pinched nerve, or disc fragment pushing on your spinal cord or similar. Is there any sign of instability between the vertebral bodies.
  • Generally an injection is attempted first, to decrease inflammation around your nerve roots, or inflamed joints in your back. This is with local anaesthetic and steroid.
  • If these fail, then a microdiscectomy is a good choice if you have a disc fragment in a place that is irritating nerve roots or similar. A spinal surgeon can look at this and see if you are suitable.

As far as you hip goes, if this is just a function of what’s happening in your spine, then it should improve once your spine is taken care of. If there is a separate issue with your hip, then a physical examination and baseline investigations starting with Hip X-rays, and then potentially an MRI of your hip would be useful.

I hope this helps somewhat – more information is probably required to work out who the best person for you to see would be: either an orthopaedic surgeon or a spinal surgeon.

Vehicle accident with Broken Femur helped by a steroid injection to the hip

I had a vehicle accident in 2006 and broke my left femur, my right shoulder was dislocated and torn labrum (shoulder reconstruction and 10 years later requires complete replacement at only 46?), but now have constant issues with my right hip/leg & limp. My left leg is only 2 cm shorter, which I’m told is minimal, but every time I get up from sitting it seems to hitch and I have agony through front of pelvis and up to hip… A costo cortico steroid ? In the hip seems to help… But i don’t understand what is causing it?

Sorry to hear about your accident, and the subsequent injuries. Leg length discrepancies are important to realise and to measure accurately. Often there are significant inaccuracies in how we measure leg lengths which makes the treatment of them harder, as we chase the goal of equalising each leg. Your pelvis and lower spine can play a big part in the perceived leg length discrepancy. To start with to accurately measure leg lengths:

  • Both legs need to be exactly in the same plane and position whilst being measured.
  • Your pelvis and spine need to be equal, flat and not tilted.
  • The person measuring your leg lengths should be able to account for any other deformities in your spine, knee or ankles.
  • Ultimately, an Xray can help, but a “CT Scanogram” can be the most useful measure.

Remember, if you have a deformity in your knee etc, it can make any of the above inaccurate. What really matters is what the underlying cause of your actual or perceived leg length discrepancy. 2cm is a lot. We do know that 90% of the general population have up to 1cm difference in leg lengths, which is usually clinically insignificant. Once you get above 1cm, then people tend to notice. This can cause your pelvis or back to start taking more strain.

Once accurately measured, a shoe raise may help. This is, of course, after the underlying problem has been addressed. If you have bad osteoarthritis from trauma, this can result in a shortened leg. Fracturing your femur will also alter the length of your leg, and perhaps your femur has healed in a shortened way. If the joint is not affected, this is a good start.

If the steroid helps, then this suggests that your hip joint is affected in some way. This could be from the labrum or due to post traumatic arthritis. A baseline Xray and possibly an MRI would be the most useful first investigations to determine exactly what is happening.

In your situation, I believe the first most appropriate step would be to see your GP, have your leg lengths measured with a CT scanogram, and then organise baseline plain X-rays of your hip, and then to see an Orthopaedic Surgeon to determine if an MRI will be required.

I hope this helps.

 

Bursitis in Hip following Spinal Fusion

I have bursitis in my right hip following a spinal fusion. Cortisone and physiotherapy hasn’t helped. Do you have any further suggestions? Thank you.

Bursitis can be two forms usually. Trochanteric Bursitis is the most common form and Psoas bursitis is the other. Usually a spinal fusion will not be the direct cause of your bursitis. Bursitis develops due to multiple reasons, but some of those reasons include:

  • Gluteal muscle tears
  • Overuse
  • Pelvic tilt
  • Post Total Hip Replacement surgery
  • Trauma

When you have trochanteric bursitis, the pain is on the outer aspect (Lateral side) of the hip.

The standard treatment for Trochanteric Bursitis is steroid injections to the bursa, and physiotherapy, as you have already had. The physiotherapy should focus on pelvic stabilisation, and strengthening of gluteal muscles. If this fails, then there are only a few other options.

  • Anti-inflammatory medications can work: such as Nurofen, Mobic, Voltaren, Celebrex. This acts generally, to decrease inflammation, but can have some issues with gut irritation. So discuss this with your doctor first.
  • Extra-corporeal shockwave therapy. This is performed at a radiology unit and is where a specific wave of energy is pulse through the hip. This has been shown to be successful in reducing the pain associated with bursitis in lots of different situations, like in the shoulder, hip, as well as in other irritating conditions like plantar fasciitis. Because it is non invasive, then it is a good next step, as no cuts on the skin are required. Generally 3 treatments are required, with the maximal response being about 6 weeks after.
  • If all of the non operative measures fail, then surgery can be contemplated. Open or Arthroscopic approaches are available. If there is just bursitis, and the underlying muscles are intact, then the arthroscopic approach is best. This only requires two small cuts on the side of the hip, and the bursa is removed, the bone is shaped and the surrounding tissues are shaped to decrease the chance of recurrence. If there are tendon tears causing the bursitis, then an open approach and muscle reconstruction is best.

The overall success rate of all of these these treatments is only about 50-65%, so each one should be attempted, before progressing to the next step.

I hope this helps your situation.

27 with Perthes disease of the hip

My son is 27 and had Perthes disease aged 9. 
He was in slings and springs for 2 weeks and then in a wheel chair and on crutches for 2 years, doing hydrotherapy 3 times a week until his ball joint had regrown as he lost 75% of his femoral epiphysis. But it has grown back more of a mushroom shape and sometimes is a bit like a square peg in a round hole scenario. He has some arthritis in it and has been told recently by an Adelaide specialist, that he’ll eventually need a hip replacement from 40 onwards. He’s now given up sport and we’re wondering, with all the new treatments with hip replacement, is 40 still the earliest age for a hip replacement

Thanks for sending through your query. Perthes (Legg-Calve-Perthes disease) is a childhood hip condition of unknown cause that causes a permanent deformity of the femoral head and therefore the acetabulum (ball and cup). We don’t actually really know why it occurs, but current evidence suggests that a disruption of blood supply to the femoral head (ball) is the key even associated with the development of the disease. It is most commonly seen in children aged 5-8yo and is much more common in males with a ratio of M:F of 5:1. There are numerous grades of Perthes disease, based on the Xray findings with patients with a mushroom shaped head having a 58% change of having an osteoarthritic joint at 40 years. This can get worse if the head is flat and not the same shape as the cup, as the rate of osteoarthritis rises to 78%.

It is actually a better prognosis if your child develops Perthes earlier, with the best result being in those who develop Perthes at aged < 6yo. For those children > 8yo, fewer went on to have hip joints that were as good as those who developed it earlier.

A small number of adolescent and young adults will degenerate their hips significantly, and there are then 2 choices.

  • Total hip replacement
  • Arthrodesis (fusion of the hip)

Both are more technically demanding due to deformity and often, due to previous surgery to the hip that can further deform the hip joint. Generally speaking, hip fusions are less commonly performed because of new methods of fixation of prostheses and new bearing surfaces. Generally speaking, fusions are considered in patients who have a very high activity level, male, and have significant pain and reduction in motion. These patients should not have any lower back issues, as fusion can make this worse.

Hip replacements have certainly come a long way, and the goals of surgery are to prevent muscle injury, dislocation, and be friendly for future revision operations, which would be applicable for your son at his age of 27. If he is having a considerable loss of quality of life, then a hip replacement may be suitable. Current methods do seem to have excellent results, and whilst hip replacements are generally reserved for those over 55yo, despite his age, he may go on to require this at an earlier age than 55yo.

A lot to think about, but I hope this helps somewhat in giving you some options.

Pain running down lower back to buttock

Hi, i have pain that runs from left side of lower my lower back down through left buttock, sometimes feels like a tendon or something is trapped, i have a bursar in the left hip, what do you think?

Thanks for your question – The first part of your description sounds like sciatica. This is where you have irritation of the sciatic nerve. The first course of treatment for this is stretching with a qualified physiotherapist, followed by some anti-inflammatories. Generally speaking, things settle with conservative measures. If you have nerve related pain, an MRI of your lumbar spine might be useful to see if you have a bulging disc or lower spine issues, causing your pain.

The bursa in your hip can be one of two bursts (Generally). The first and most common one is the trochanteric bursa. The second is the posts bursa. The trochanteric bursa lies on the side of your hip. I answered a similar question earlier regarding bursa types so please see below.

The trapped tendon sensation is usually due to the inflammation of the tissue around your nerve of tendons. In the button, there would be few tendons that can cause true trapping.

I would suggest in the first instance, to see a good physiotherapist, to see if some stretching will help to settle your symptoms. If your bursal pain is the predominant feature, then an injection with local anaesthetic and steroid would be a good starting point.

I hope this helps.

46yo with Cauliflowering around the hip joint

Hi …im 46 years old played football for 30 years…5 years ago i had scans done and collyflowering was present around my hip ball…i can hardly walk around my street block ..400m aporox…can you help me

Thanks for your message. From what you describe, you have hip arthritis. When full thickness cartilage loss happens within any joint, the body starts making little bony growths around the bones of the joint called Osteophytes. These can be large growths on the side of the head of the ball (Femoral head) or on the edges of the socket. When they are present, they cause you to have quite restricted range of movement of the joint. You might be finding that tying your shoes and socks, getting in and out of a car, and clipping your toe nails is becoming harder and harder.

Mobility is extremely important, and 400m is quite a short distance, especially for someone as young as you. Whilst we generally try to hold off on performing total hip replacements on people under the age of 55 due to research suggesting that the rate of revision surgery increases at a larger rate when you are younger than 55, sometimes we have to perform surgery to give our patients back quality of life.

To start with, managing the discomfort is the first priority, to maintain your mobility. The following medications can help:

  • Panadol Osteo: Long lasting panadol that is taken 3 times per day. This is safe to take over a long period, unless you have liver problems.
  • Glucosamine (capsules) and Fish oil (liquid): Research performed 5-10 years ago showed a significant improvement in pain relief for patients with arthritis who took both Glucosamine and Fish oil. The study suggested that about 2/3rds of people have a good response to these remedies, however 1/3rd did not. I advise my patients to trial these for 3 months, and if there is no noticeable difference, to stop taking them. There is always conflicting research on most things, as you can imagine, and some studies show no difference. My advice is to give them a shot, as they do not generally cause any negative side effects.
  • Anti-inflammatories: Nurofen, Mobic, Celebrex and Voltaren are some of the more common ones. They target inflammation which is a key part of the pain that you experience when you have arthritis. They have some gastrointestinal issues too (gut irritation) which can be quite bad for some patients, and not at all for others. A short course of 2-3 days, followed by a 2-3 day break is a good starting regimen.

I would suggest you obtain updated X-rays to see how bad your hip is, and whether or not you are down to bone on bone yet. If your quality of life is severely affected, then speaking to your general practitioner is a good start to see if you have maximised your non operative management.

I hope this helps.

 

Extensive Hip Labral tear

I have a fairly extensive Labral tear in right hip, and just had cortisone injected. Not a sport injury. If I walk the amount I did before it locked up, the top and outside of femur just ache so much. Will surgery fix this?

The labrum is a soft tissue structure around the socket (Acetabulum) of your hip. It supports the hip, and creates a boundary for the cartilage, and holds joint fluid in to create a very stable joint. A labral tear usually occurs when your hip is moved into an extreme position, in an awkward or overly aggressive way. The usual group of people that sustain acute labral tears are Football Players, Dancers, and Netballers.

You’ve mentioned that your hip injury was not sports related. The labrum also degenerates with hip arthritis which might be the cause of your labral tear.

The first investigation is an Xray to see if the shape of your bone predisposes you to having a labral tear. This is called femoroacetabular impingement and the theory suggests that this causes early onset arthritis. If caught early, a Hip Arthroscopy can reshape the joint to decrease the risk. I would guess that you’ve had an MRI, as you know that you have a labral tear. An MRI is the best investigation to confirm what you have inside the hip.

Surgery to repair or selectively debride (remove) the labrum can be performed via keyhole surgery. This is performed under a general anaesthetic, on a specialised traction table. The hip joint can be visualised with small cameras and instruments that allow us to repair or selectively debride the labrum. If this is the only finding inside the hip, then this surgery can be very successful. If your hip is arthritic, then a hip arthroscopy may not make a difference.

I hope this answers some of your queries.

Ball Joint (Femoral Head) that has totally disintegrated

dr-chien-wen-liew-hip-arthritis-example

I’m a nurse like my friend above julia. I’m 50 and hv been limping for several months while working. I adventurally went too . Yes I need hip replacement . I hv been on waiting list and even wth my recent fall which I was left byself for 5 hrs before my daughter heard me. Too my suprise the ball joint had totally disintegrated . But still hv too wait another 4 too 5 months! I’ve gone from a runner gym junkie too a depressed grumpy women. Not allowed too work. So yes I’m 50 and will need it redone when the joint wears out

Thanks for your query. Your X-rays certainly look like your right hip is certainly unusually worn out. What I am seeing is not a typical osteoarthritis. This looks more in keeping with something like Avascular Necrosis (Where the blood supply of the femoral head (ball) dies and the hip disintegrates, or Infection of the joint. There are a few other rarer causes too, but in the first instance, some further investigation of your bloods, and an aspirate of the hip is probably the best course of action to take before embarking on any major joint surgery. You are very young, and generally, patients who have hip replacements older than 55 years old, tend to have a lower revision rate by a fair margin, over those younger than 55yo.

If there is infection of your joint, you may have been quite ill at some point. It is very important to ensure that your hip is free from infection before putting in a prosthesis, as there is a lot of downside to putting a hip replacement in around an infection area.

I know that you haven’t asked any specific question, but I hope this goes to give you a little more information about your right hip.

How long do hip replacements last?

How do you know when your time is Actually up after having a actually hip replaced
Titanium and ceramic done 8 years ago. They said a life span of 30 years but how do you actually know? Does it just fall apart lol

Thanks for your question which I am sure is one on many people’s minds. I previously wrote a little bit about how long Knee replacements last, which can be found here. Hip replacements do last a long time (Knees and Hips are almost the same). Current research from the Australian Registry, which tracks almost all joint replacements in Australia has been running for 15 years now. Recent data suggests that about 93% of all Hip and Knee replacements survive at 14 years. Meaning that 7% have been revised.

Revisions happen for many reasons. This includes: Loosening of the components, Infection, Dislocation, fracture etc. The younger you are, the higher the chance of a revision operation.

Whilst this data exists only to 14-15 years in Australia, around the world, current data suggests that hip replacements at around 20-25 years have a survival rate of about 80%.

There is no defined moment when your hip replacement will stop working. Ceramic is a good option, which is what I use for all my patients as it has the potential to be one of the most inert, and long lasting bearing surfaces around. But all bearing surfaces do well overall. If you start experiencing any change in your hip function, then you should have it checked. Generally, I see all my Total Hip Replacement patients at 2 weeks, 3 months, 1 year, 5 years, and then every 5 years after that (indefinitely) to monitor how the hip replacement is looking in the bones. There is theory that due to the Direct Anterior Approach not requiring any detachment of muscles for its use, when or if a revision is required, it can be simpler, as the tissues around the hip have never been violated. Lets hope you will not require a revision operation though!

I hope this helps to answer your question.

Pelvis Separated due to Pregnancy

My pelvis separated with my 3 pregnancies. I had an X-ray done a few years ago and it shows it is still separated. I have pain in my hips and pelvis after standing for long periods, walking, during the night from sleeping on my hips (side sleeper) and when I wake up in the morning. Is there anything I can do about it? It has been suggested to me I may need my pelvis pinned.

When you are pregnant, hormones are released which relax the ligaments around the pelvis to allow a child’s head to exit during birth. Whilst I am certainly not an expert in this specific issue, I can give you some general advice. Usually the pubic symphysis only allows a very small amount of movement (around 1mm), which can dilate to several centimetres. Usually the two bones are separated by about 5mm. Anything over 10mm as an adult is considered abnormal. Sometimes, there can be no symptoms even when they are dilated.

Standing X-rays of the Pelvis can show the widening, and anything over 1cm is abnormal and suggests an abnormal ligament at the front of the pelvis; whilst over 2cm suggests that the ligaments at the back of your pelvis are disrupted including the ones at the front.

Generally, conservative treatment is the mainstay of treatment, and you can trial a period in a pelvic binder. I have never done this personally, however it is certainly described. Anti-inflammatory medication and core exercises with a qualified physiotherapist would be added on as well.

In some cases, where pain and dysfunction are a large problem, and if it does not improve with a brace, and conservative measures, plating can be considered. This would be the last resort, and certainly the other options are more suitable to try first, given the potential complications from any pelvic surgery.

I hope this helps.

Left Groin pain after pump class

Hi, I was doing a squat at pump class in January and as I came up I felt a pain in my left groin. I have had a MRI and ultra-sound which haven’t shown anything. I have been seeing a Physio for 6 months and doing prescribed exercises, they think it it an adductor problem. I have constant pain in my groin at the attachment point, pain gets worse after running, core exercises and after walking. Any help would be great as to where to from here. Thanks 

Thanks for your question. Groin pain can be from many origins. Sometimes they are from muscles attached to the bone, tendons being inflamed, arthritis in the hip or a hip labral tear. They can also be caused by other, non musculoskeletal things, like lower abdominal discomfort, or genitourinary problems.

From a musculoskeletal perspective, the following are causes of groin pain:

  • Psoas Bursitis
  • Adductor tendonitis
  • Pubic Symphasitis
  • Rectus Femoris inflammation (Abdominal muscle)
  • Hip Arthritis
  • Hip Labral tearing
  • Capsulitis of the hip joint.

It can be difficult to determine without a close examination, and supporting investigations. If it is worse on core exercises, like sit ups, and is in the groin, it could be Psoas Bursitis. The Psoas muscle attaches from the spine to a small area on the thigh bone (femur). its principle function is to flex the hip.

The determine where the problem is, a series of ultrasound guided injections over time can be performed to try to localise where the problem is. Alternatively, a bone scan can be performed to see if there is any increased uptake in the area.

I hope this helps to answer your question.

Bursitis that doesn't get better with cortisone

 I have bursitis in my left hip, and I have had cortisone but it’s hasn’t worked, is this something that could be operated on and removed?

Thanks for your question. I am guessing that you have Trochanteric Bursitis, which is located on the side of your hip. These usually make it more difficult to walk up and down hills, stairs, and can irritate you when lying on your side. This is different to a Psoas Bursitis which is located more in the groin.

Trochanteric Bursitis is a nuisance condition which can be very limiting. It can sometimes be difficult to treat. Generally, the mainstay of treatment is non operative management comprising of:

  1. Physiotherapy: To strengthen the Gluteals and Core muscles, thereby stabilising the pelvis and decreasing pelvic tilt as a factor in the development of trochanteric bursitis.
  2. Cortisone injections under ultrasound guidance.
  3. Extracorporeal Shock Wave Therapy: Current research shows about a 60% chance of success. This is where a special signal is pulsed through the skin into the area, and stimulates healing of the tissue. It requires no cuts to the skin. 3 treatments are generally required, with a maximal effect around 6 weeks after the last treatment.

If surgery is required, the first step is to ensure that there is no other pathology causing issues, such as a major gluteal muscle tear. An MRI is the most sensitive in picking up issues here although an ultrasound can help. The gluteal muscles in question are comprised of the Gluteus Minimus and the Gluteus Medius (Bigger and more important one). If this is torn, then generally an open approach is preferred to repair the tendon whilst removing the bursa.

To remove the bursa only, keyhole surgery can be performed. This is an arthroscopy. This requires two small cuts on the skin, and a special device is used to remove the bursa.

Sometimes, removal of the bursa does not work, and this type of surgery has a success rate around 50-60%. It should only be attempted once all other measures have been exhausted.

I hope this answers your question.

Clicky Hips

What do “clicky” hips mean? Not painful but just feel the need to let them “pop” and feel more comfortable afterwards. They “pop” when I extend my leg

Great question. Clicking around any joint is due to several reasons. It can be from a tendon flicking past a piece of tissue, such as bone. It can also be caused by pockets or air shifting around joints, or loose bodies that are inside the joint. In other circumstances, clicking can be a very negative thing, and when painful, clicking should be investigated.

When people talk about Clicky Hips – it is often related to newborns. This is when a paediatrician or general practitioner manipulates a baby’s hip in a specific direction under a small force to see if the hip is a little unstable. If this occurs, a click is felt, and suggests that you might have Hip Dysplasia. As a new born, hip dysplasia is managed with casting or splints. Untreated, it can go onto abnormal development of the socket (acetabulum) which may result in difficulties as the child develops, and later in life. A major advance in recent times has been the change in how babies are swaddled. Keeping their legs together is not a good position for their hips, and they should have them in the frogleg position. Click this link www.healthyhipsaustralia.org.au to learn more about dysplasia of the hip.

For adults with clicking around the hip, unless it is painful, then it is usually not a problem. The relief is usually felt as the tendon finds a better position for itself when it is near a bone or other harder substance. Generally though, continuous clicking for the sake of clicking can cause irritation of the tendon, which is to be avoided. It is more common in runners and sports people. Here is a link that might explain what you are feeling: www.runnersworld.com

I hope this answers your question.

Muscle Strains causing Hip Pain

I have hip pain which began when I strained a muscle, it’s right down the buttock, I’ve had physio which relaxed the muscle but it still aches and seemed to hurt toward the front over the bone. My bone density has decreased also, I’m 54, any ideas? Is it arthritis starting, the physio thought the muscle could be scarred from the original injury 2 years ago but would this cause intense pain?

Thank you for your question. Muscles strains around the hip can cause pain in various spots. Generally, unless you have torn your muscle from the bone 2 years ago, it would be unlikely that this is continuing to cause intense pain. There may be multiple other causes for your pain.

  • Bursitis: the pain may be related to an inflamed bursa surrounding the torn tissue, or aggravated from underlying muscle weakness, or an abnormal gait. There are a few bursa around the hip joint, but the most common are on the side (Trochanteric Bursa) or the front (Psoas Bursa).
  • To work out if you have arthritis, a proper physical examination and baseline Hip X-rays are required. Common symptoms of hip arthritis include: Pain at night; Difficulties reaching your shoes and socks; Difficulty getting in and out of a car; Pain that improves with anti-inflammatories; Limitations in the distance you can weight bear.
  • Pain in the buttock that runs down the back of the leg is often due to sciatica. This causes a nerve type pain to radiate down the back of your leg and is due to sciatic nerve irritation from several different causes. Physiotherapy to stretch the nerve safely and anti-inflammatories are the mainstay of treatment here.
  • Often your physiotherapist will be able to determine what might be going on. If not, your GP should have an idea of whether your condition is serious, or warrants further investigation.

I hope this helps somewhat to answer your question.

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Dr Chien-Wen Liew

Dr Chien-Wen Liew

Orthopaedic Surgeon

Consulting from:

NORTH: Nuriootpa, Barossa Valley

NORTH EAST: North Eastern Community Hospital

SOUTH: Morphett Vale

EAST: Burnside Hospital

WEST: Health @ Hindmarsh

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