From strains and sprains to fractures and breaks, NYU Langone Orthopedics experts explore the variety of reasons athletes may suffer from hip pain.
Dr. Laith Jazrawi and Dr. Guillem Lomas explore the various reasons that athletes may suffer from hip pains. From overuse to fractures to sports hernias, we'll take a closer look at the symptoms and solutions to hip pain.
Narrator: SiriusXM presents an NYU Langone Orthopedics podcast. Orthopedics is just very important to the population in this country. Its ability to restore patient function. Problems related to cartilage, to someone who has more advanced forms of arthritis. Getting people back to their activities and the things that they like to do. Featuring NYU's experts in the field of Orthopedics trying to figure out that problem before it even is a problem. Problems with solutions. Well beyond physical therapy, to conservative pain management, to surgery. The best medical minds now come together. Applying all of our minds to solve these problems. We're here to get people feeling better so they can get back to their lives. And that's really what we try and accomplish. These are the Bone Whisperers.
Dr. Laith Jazrawi: This is Laith Jazrawi, Chief of Sports Medicine here at NYU Langone Health. You're on the Bone Whisperers podcast and I'm here with Dr. Guillem Lomas, associate professor of Orthopedics here at NYU School of Medicine and team physician for the New Jersey Devils hockey club. And we have the pleasure of having him - he's a hip specialist. And we're going to talk about the many causes or many reasons for hip pain in athletes. Exciting topic. Hip is very popular now. It's almost like during our residency, the only thing that we were doing for the hip was either replacing it, fixing a fracture, or doing some procedure on a pediatric patient. But this whole advent of hip arthroscopy, which came in the 90s and has certainly been strong, continuing now, has been pretty incredible. But I guess the ultimate reason people come in with hip pain into the office, I always like to go through, well, what are the potential causes of hip pain in an athlete? And Guillem, what's the number one reason for an athlete, the cause of an athlete's hip pain? I guess that's the – just diving right into it.
Dr. Guillem Lomas: Well, first of all, great to be here and thanks for inviting me. And you're right. We've started to understand so much more about the hip. And it's interesting, I think part of it is correlated with our ability to scope the hip, to actually look inside. And the reason for that is for a long time, you're right, it was very kind of, uh, essential treatment that we would do, fractures, et cetera. And the reason the hip was so challenging to assess for other kinds of injuries that we did understand better, you know, in the shoulder and the knee, is that it's really, really hard to get to. Because it's multi layered it's got a lot of layers over it. It has a lot of big neurovascular bundles, so nerves, arteries, veins that go around the joint. And it is challenging to make a diagnosis. And so when you say, what's the most common reason, you know, someone comes in for hip problem, Honestly, the answer is, uh, it depends. Cause it depends where they're complaining of pain. Because when somebody says hip pain, that could mean they're groin, it could mean the side, it could mean their buttock that could be radiating down their thigh, down their leg, up their back. And we actually know that the hip joint itself can produce what's called atypical pain. So pain that we would not expect the joint to produce in up to 15 to 30% of cases. So that means someone showing up to your office with low back pain. Well, turns out it's the hip, right? And so you have to do a really thorough workup, uh, physical exam, and the appropriate imaging to identify the culprit. But when we talk about what I tend to see in the office, most often when someone shows up and it says on the little blurb, you know, right, hip pain, it's probably something involving the ball and socket joint of the hip. And ball and socket of the hip, you know, the body is very consistent, and it's the way that it constructs its joints. There's usually cartilage on both sides, and then there's some form of padding or cushioning in the shoulder, it's the labrum, and then knee, it's the meniscus. Well, the hip has another labrum, and that's basically this cartilage O ring. It's sort of like a gummy worm that surrounds the socket, and that can get torn, usually related to patients' anatomy but also could be torn traumatically. And so that's oftentimes the thing that I see in the office. But again, hip pain could also mean a hamstring injury, right? You can have a hamstring injury off the sit bone in the back of the pelvis, the ischial tuberosity. And that can, you know, that presents his butt pain, but that's kind of in that hip area. So, I mean, just an example of something else that a lot of times will come into the office and initially just described as hip pain.
Dr. Laith Jazrawi: One of the things I want to ask you, and this will get you right into another topic, which you see in athletes with hip problems - Patient athletes they have varying degrees of flexibility of their hips, right? Some can sit Indian style very easily. Others can, you know, some have more internal rotation, others have more external rotation. So the issue is, well, if the hip joint, a ball and socket joint, why do some people can sit very easy in Indian style and others can't. That may not be a very PC statement, but sort of, you know, where they're crossing.
Dr. Guillem Lomas: No mean you meant from, uh, from Southeast Asia. Yes, yeah. Yes, yeah. So great question. Right. And the hip is challenging also in that respect. And you know, I think this is where it shares some common elements with the shoulder. So there is overlap in the concept. So mobility, very multifactorial parameter to measure, and it has to do with first of all the anatomy of the joint. So sometimes the ball and socket joint is not perfectly spherical. And so we have some patients who have something, we've got a nickname for it, FAI. It's an acronym, it basically stands for femoroacetabular impingement, which just means femur, the ball, acetabulum is the socket and they have impingement. So it's hip impingement. And ideally the ball is a ball. It is perfectly spherical. But in a lot of people, actually 10 to 20% of the population at large, the ball's not perfectly round and it's a little square shaped almost. And so when you go to flex your hip over thousands and millions of gait cycles and of flexing the hip cycles, you can start to erode that edge of the rim of the socket because the ball is not perfectly round. And so then it can cause the labrum tear we're talking about now, that can be also implicated in lack of mobility. So that's one reason that you might not have a lot of mobility. Also your baseline joint elasticity, your ligament elasticity, we call it ligamentous laxity. Some people have rubber bands, other people have more ropey kind of ligaments. If you have those stretchy ligaments, you're going to be able to overcome even an anatomy that's not perfectly round and get good, uh, mobility. If your ligaments are like burlap, they're really tight, like, you know, like ropes like mine are, uh, you could have a perfectly spherical hip, but you may not get the mobility that you need. And then we were talking about layers - superimpose on that, the muscles and the tendons and those can get tight. And so there you have another potential reason for tightness. So you really have to go down the line and uh, again, lack of mobility is generally undesirable. I mean there's a spectrum where it's okay to not be the most flexible person, but when it gets really too stiff, then you start seeing compensations occurring at other parts of the body. So the low back may start to get stressed because you're sort of trying to get your back into what's called lordosis to stay upright. If your hip flexors are a little tight and your hips are just kind of tight, and then you can, you know, also have issues with the hamstrings, et cetera. So there's a wide spectrum of reasons why people are tight. But in general, we do want to try to optimize mobility as much as we can.
Dr. Laith Jazrawi: I think we're here now doing this podcast, we're approaching November. We're here in New York City. That typically means marathon time here. And I'm seeing a lot of patients in my office with hip pain. And, uh, at least for me, that's always stress fracture until proven otherwise.
Dr. Guillem Lomas: Oh, yeah. Especially marathon season.
Dr. Laith Jazrawi: Marathon season. Can you get into that? Discuss that a little bit? You know, what's the workup for that? Uh, are you getting an MRI and everyone with hip pain who's a runner? Um, and just your approach. What do you tell these patients if they end up having a stress fracture?
Dr. Guillem Lomas: Well, I love that you're already concerned about it, right? Suspicious about it, because that's one of the conditions that I call the great pretender. That and radiculopathy, basically a pinched nerve in the back. Those are conditions like a stress fracture in the hip - that can present in so many different ways. It doesn't just present with groin pain. It could be side pain, it could be sort of buttock pain. And you really have to have a high index of suspicion and get the right imaging, because if you let that patient continue running, that stress fracture can turn into a complete fracture. So, yeah, stress fracture is basically an overload problem. The bone in our bodies, it's an incredible tissue. It regenerates. It's regenerating all the time. It's basically breaking down and building itself back up. But if we overload it so much that it can't build itself up, at some point it can fail. And usually it starts to fail in this kind of stress reaction way where the tiny little - most bones are sort of like a pipe on the outside. So they've got really thick bone on the outside that inside, we call it spongy bone. It's not really like sponge. It's not soft, but It's a little like, uh, coral, like it's got these small little spicules. Those can get tiny microscopic cracks in them. So the pipe stuff is still okay, bone is still okay, but the inside has got little cracks. And those can propagate if you don't let the bone heal and let it rest. So it's very important to get MRIs is typically the study that we get for those. We start off with X rays, a lot of times these stress fractures are not visible on X rays, then we get an MRI and the MRI shows it, and then we can shut these patients down. And unfortunately, you know, most of the time that means no more marathon for them. But one interesting point, and I'm curious about how you recommend, like, if you identify the stress fracture, what you recommend. You know, there's this concept of joint reaction forces, meaning, like if you lift your leg, you know, if you're listening to the podcast now, you lift your leg, the forces across your hip are greater than body weight just because of the leverage. Because you're basically jacking that leg up and it's pushing on the hip joint. What's your recommendation for weight bearing when you see these patients with and you get an MRI that shows a stress fracture?
Dr. Laith Jazrawi: The tendency on these patients is to make them non weight bearing, so there's no weight. But especially with hip, we know that just like you said, just lifting up the leg and holding the leg up puts a lot of joint reaction force there. And you can argue whether it's concentric, sort of this well-distributed force. So my thing is always, okay, you can put your toes down in balance. And I think that's a fair way where at least their muscles are sort of firing but not lifting up the hip. And I think, you know, that's a more common sense approach to managing these, you know, patients.
Dr. Guillem Lomas: I do the exact same thing.
Dr. Laith Jazrawi: For the audience. I mean, there are indications where it's not only taking the weight off, but there are certain fracture patterns, stress fracture patterns that require screw fixation because they're at risk for progressing and getting worse, despite being non weight bearing or what we call toe touch weight bearing. And I think it's important. I mean, and those are things that you've got to get, if you're having hip pain and you're a runner, you've got to get to see your orthopedic surgeon and figure out whether it's stress fracture or not.
Dr. Guillem Lomas: Exactly. And again, as all of these things are you know, you start to dig a little bit, and it becomes more complex. So we know, especially in women, there can be a concern for something called relative energy deficiency syndrome, or REDS, and that's where sometimes there's nutritional deficits that can predispose to stress fractures. Again, it's that idea of the bone doesn't have the resources to build itself up from how it's broken down. And so sometimes, you know, eating disorders or restrictive eating can lead to that. And, you know, we look for some hormonal imbalances and things like that. But, yeah, certainly stress fractures, like you said, sometimes, despite all of our best intentions, they're just not healing or they're in a part of the bone that's at risk for fully fracturing off. So in those cases, we'll do surgery.
Dr. Laith Jazrawi: Yeah, I do like your approach. I mean, there's a bucket full of things these things could be - hip pain in an athlete, we could probably rattle off 30 different things that it could be. The question is, how do you get to that place where you can figure out the diagnosis? Obviously, you're asking questions, you're getting history, the location of the pain, and then the appropriate imaging or, you know, study that we get to confirm what we think it is. And whether it's X rays, MRI. And I'm getting into another topic, which we see in athletes, and it's becoming very popular, and I wanted you to talk about that a little, is this concept of a sports hernia. I think a lot of people kind of think they know what a hernia is. They think belly, and they think, what does that have to do with the hip? There may be someone out there would go, well, I had a hernia, and it was in my testicle, so that's close to the hip. But what's a sports hernia? And, you know, why has it become all of a sudden so popular?
Dr. Guillem Lomas: Yeah, well, first of all, shame on you for using the word sports hernia, because we decided, I don't know, you didn't get the memo. You weren't at the meeting. We decided we're not calling it that anymore. No, it's funny, you know, you go of these meetings where we talk about hip injuries in athletes, and there has been this push away from calling it a sports hernia, but the fact is, it's a catchy term, so it sort of remained. Probably what we call it most now is something called athletic pubalgia, which in my opinion, is a silly term. It's sort of like, uh, when we call, you know, anterior knee pain, like, we diagnose people with pain in front of their knee. It's like, yeah, that's what I came to see you for, pain in front of my knee. So athletic pubalgia just means pubic pain in an athlete, all right, big deal. But what you're getting at is, and there's a little, like, everything, right, where there's smoke, there's fire. There's a reason why it was called that. So a normal hernia is a defect in some kind of wall of fascia or muscle. So it's a hole, basically. And most people are familiar with something like an inguinal hernia, where there's a little defect down in their abdominal wall, and then some of the abdominal contents start to pooch through. And, you know, now we fix those. You can either repair them or you can put a mesh that blocks the hole. So that's a normal hernia. When people talk about a sports hernia, what they're talking about is an injury around the pubic bone area. And that is a very, that is like, you know, when we talk about core muscle injuries, like, that is the nexus of core muscle injuries. That is where everything attaches. So basically, your adductor tendons attached on the bottom of the pubic bone, and your abs, your rectus abdominis muscle attaches on the top part of the pubic bone, and they actually converge at the front part. And that's the part that can sometimes get injured. And that's why the term hernia was used, because it is sort of an injury to “fascia”. We use this term aponeurosis, which is a fancy term, but it's basically just very thick tissue that connects both of those tendons to the bone. But it's not a hole. It's not like there's a hole that's created - it detaches from the pubic bone. And you can have more of it being the adductor that's one of the groin tendons. Or you could have more of it being the ab. The rectus abdominis as like the six pack, eight pack that we have all of us. But either way, there's a detachment. And so it can be one or the other or both. And you see this very commonly in sports that require a lot of explosiveness and torque. So athletes moving very quickly from side to side, soccer, football, hockey, rugby, those are sports where there's just a lot of explosiveness that's coming from the core. And certainly you know, in hockey, just seeing a lot of hockey players covering the Devils, it's something we have to contend with every single year. Sometimes it doesn't need surgery, but very common in hockey because they're sort of, like, pushing off and they're straightening their body. So they're, it's a very common theme in sports injuries. Their muscles are contracting as they're lengthening, which sounds kind of paradoxical, but it's like if you grab a weight and you lower weight, you know, your biceps muscle is contracting because you're lowering it slowly, but it's lengthening that puts the most stress on tendons and muscles. And so we tend to see that in sports where you have a lot of that explosiveness.
Dr. Laith Jazrawi: So when you talk about fixing these sports hernias, it sounds like some of them don't need surgery, but some of them do. And are you putting a mesh there? You talked about meshing or closing the hole, but there's not a hole here. So is it just repairing it back to the bone? Is that the surgery?
Dr. Guillem Lomas: Yeah. Well, so it's interesting. This is a really curious diagnosis that has essentially - a lot of times in medicine, there will be two specialties that sort of, like, overlap. We'll say whimsically, there's a turf war between, you know, different specialties that do the same procedure. So say, you know, cardiologists and cardiothoracic surgeons, right - they both might do, you know, angios something like that. Well, what's funny about this is this is like the redheaded stepchild. Like, this is the unwanted procedure where both general surgeons who do hernia surgery don't really do this surgery because it's more of, like, a muscle tendon thing. And they don't do that. They just fix holes. And orthopedists don't do it because it's right near the spermatic cord, where there's a lot of nerves that go to the testicles on the penis or the vagina. And we're just not used to being in that area, so we don't do it. And so it's created a little bit of a void. And into that vacuum there have entered very specialized, oftentimes general surgeons. And there are some orthopedic surgeons who do it as well, but very specialized people. So, in fact, there are very few people in general. Like, if you go to a typical orthopedic surgeon, they're not going to do sports hernia surgery. And if you go to a typical general surgeon, they're not going to do sports hernia surgery. So to answer your question, sometimes we do use mesh for the part that's closer to the abs, sometimes we repair it. And I would say it really depends on the person in general. What I have seen is more direct repairs of the rectus abdominis, so that's the ab muscles. And for the adductor, sometimes we release them, sometimes we repair them. And it really depends on the kind of tear that it is. But a lot of times you repair everything without any kind of anchors in the bone. So you basically just sew everything back up to itself and to the lining of the bone there, which is called the periosteum, which there it's very thick, so it can actually take stitches and hold them.
Dr. Laith Jazrawi: So we've gone through sports hernias, we've gone through stress fractures. You spoke a little about bony abnormalities which can be shaved off or smoothed out. You talked about labral repairs where we can fix this torn people sometimes, you know, think of it as a meniscus of the hip where you could fix them. You could even put a new one in there where you're doing a labral reconstruction. What else do you see that's common in hip athletes or have I hit on everything or touched on everything?
Dr. Guillem Lomas: Yeah, I mean, those are the big boys. I mean, that's probably the ones that are most common. But one thing that we do see a fair amount of, and again, especially in these like explosive sports where people kick or sprint, and a lot of times in younger athletes, we see avulsion fracture. So that's basically where a tendon that's attached to the hip, usually very hip joint, pulls off. And sometimes the tendon just tears on its own and it rips off, but other times it pulls a little piece of bone with it. And either way, muscles, all they know how to do is contract. So they'll tend to pull either the torn tendon or the tendon with the bone piece away from its attachment site. And depending on how severe, how far away it's pulled, we treat these operatively or non-operatively. So when it's just an injury and everything is kind of where it needs to be, body does a great job of healing around the hip. Hip has a lot of really good blood supply. But in instances where it's sort of pulled off, it's almost like a spring, it just like rips it off. And you know, you could have tendons that are 6, 7, 8 centimeters away from their original attachment site. So the ones that are the most common for these are hip flexor injuries. So something like the, your rectus different kind of rectus is your rectus femoris, so one of your quad tendons that attaches right on top of the hip. So we see that in kickers, soccer players, you can see the hamstring pop off. So again, either just the tendon or with bone. And then there are some that we see more commonly in athletes that are not skeletally mature. So slightly open growth plates. And so for example, at the top of the pelvis, there's this structure called the anterior superior iliac spine. It's where this muscle called the sartorius attaches and that can pull that off. Or there's a another hip flexor called the iliopsoas that can pull off a piece of the femur when it tears. So these are just different things. And most of the time we can treat a lot of these without surgery. But if they are too far from where they need to be, then we have to treat them operatively.
Dr. Laith Jazrawi: The most common thing, right, in terms of - while it's not near the hip, you can get a mid-hammy, you know, strain sprain or even tear. Those typically don't require surgery. They're part of this complex of pain in and around the hip. But athletes come in often with hammy injuries that we have to sort of treat non-operatively. But the ones that are ruptured or detached from the bone at the sit bone or the ischium that we call it, if you rupture a certain amount of those tendons could to require surgery.
Dr. Guillem Lomas: Yeah. And you know, it's interesting, as time has gone on, we've started to identify some of those injuries that are not off the bone that probably do better with surgery, if we're talking about an athlete who needs to get back to kind of a, you know, very high level of activity, don't have to be professional, but just someone who wants to, you know, play a sport at a high level. An example would be one of the hamstring muscles is called the biceps femoris. So just like we have a biceps in arm, we have one in the leg and there's a special kind of tear that happens further down. So you would say it's close to the belly and it's called a T type injury. It has to do with where the two heads that that muscle has what we call two heads. So two sort of bellies and where they join, it can tear. And those ones, if you don't fix them, can end up being recurrent. Like they can keep happening over and over and over again. Doesn't matter how much the athlete rests and rehabs. So for some of those, if they're really torn, we would actually operate on them if someone's going to get back to sprinting or jumping sports.
Dr. Laith Jazrawi: And what's the, as we kind of wrap up here, what's the most unique hip injury that presented in an athlete into your office?
Dr. Guillem Lomas: Yeah, I mean, there's, there's probably a few. I mean, one thing we didn't talk about is a condition called avascular necrosis, which is where the bone in the head of the femur, the ball actually dies. And sometimes it happens for no reason at all. So I've had some athletes present with that, where they didn't have a reason for their pain anywhere else. And that's what it was. And there was no real reason for that to happen. That is something that's more common in someone who takes medications like, for example, steroids, not anabolic steroids, but cortisone or prednisone. Yeah, I mean, I would say some of the ones that are interesting are when people have had old injuries and they've just tolerated them. Like they've just dealt with them for years, and now it's like 10 or 15 years later and they show up and like some of these evulsion fractures and, uh, you know, they've turned into these stalactites of bone. And they've just been totally dealing with the fact that their hip lost, you know, 50% of its range of motion. And they've got this massive wad of bone that's basically bridging from where they broke it off to the tendon that's left. And those are actually fairly satisfying to treat because if you take that off, they suddenly get their mobility back. But sometimes we do have to, you know, they've lost so much tendon there that you actually have to reconstruct some of the tendon. Those are probably there. You know, cartilage injuries in the joint, those are always very challenging, like potholes on the cartilage.
Dr. Laith Jazrawi: I think as a team physician, you need to be prepared for everything. And as a good doctor, you need to think about all possibilities. And, you know, when you get down to the very basics, you try to figure these things out. And we're pretty good. You know, you're a hip specialist, you know that there are certain things that can happen. And there are other things that are these bizarro things or strange things, whether they're infections, tumors, cancers, things like that. That. Yeah, you didn't expect that in that person. That's, you know.
Dr. Guillem Lomas: No, and that's a great point. Right, because sometimes it's in an athlete, but the issue has nothing to do with the sport. So like you said, you know, a tumor or just something that's completely unrelated to their activity, but it showed up while they were playing. So they present it to you and said, yeah, when I play soccer, I get this pain, but it turns out it to d be something that needs to be managed.
Dr. Laith Jazrawi: I think as we wrap up, I think one of the things that we see a lot in these, especially football, maybe even hockey, are these hip fracture dislocations. And there have been famous athletes, one was Bo Jackson had a devastating, almost career ending where he fractured, dislocated his hip, required hip replacement, ended up playing on that hip replacement as a professional baseball player, and then wore that down as well. So there are cases where patients get, you know, these injuries to their hip joint where they get a fractured dislocation that you need to manage as a team doc.
Dr. Guillem Lomas: Totally. And yeah, I mean, those are definitely injuries that still occur today. This year there have been a couple of football players with those, uh, dislocations. You know, one thing that is interesting is we sort of separate athletes from hip replacements and of any kind. And more recently, we've seen the occurrence of something called a hip resurfacing, which is - it's a hip replacement, but it's basically a hip replacement where you put a metal socket on the cup side and then you basically put a cap - just like you put a cap on your tooth - you put a cap on the femur so you don't put a stem down the hollow part of the femur. And so it's called a hip resurfacing. And there are a few NHL players now actively playing with hip resurfacings. Andy Murray, famously in tennis, came back with the hip resurfacing. So, look, I think they're kind of the exception that proved the rule, like, most people aren't going back to elite sports with a hip replacement or resurfacing, but it's actually speaks to just how advanced we've gotten in terms of managing hip issues, that this can actually happen. So you could be in your 30s and need a hip procedure that actually replaces the joint and still continue playing at an elite level.
Dr. Laith Jazrawi: That was great. And we're going to wrap up this podcast on hip injuries and athletes. I want to thank Dr. Lomas for giving us his expert opinion. He's Associate professor at NYU School of Medicine and team Physician for the New Jersey Devils Hockey Club. And I'm Laith Jazrawi, Chief of Sports Medicine here at NYU Langone Health, as well as Professor, Orthopedic Surgery, NYU School of Medicine. Thank you.
Narrator: The Bone Whisperers is a co production of NYU Langone Health and SiriusXM. The podcast is produced by Scott Uhing, sound design by Sam Doyle. SiriusXM's executive producer is Beth Ameen and senior operations manager is Emily Anton. Narration and additional sound design by Michael Luce. Don't miss a single episode of the Bone Whisperers and subscribe for free wherever you listen to podcasts. To hear more from the world renowned doctors at NYU Langone Health, tune into Doctor radio on SiriusXM Channel 110 or listen anytime on the SiriusXM app. For the Bone Whisperers podcast, I'm Michael Luce. Join us next time for the latest advances in orthopedics on the Bone Whisperers.