Hip Pain: To run or not to run???
History: Last fall I began training for my first marathon with the Marathon Nation plans. In early October I began feeling some pain in my left hip. Upon the recommendation from a friend (20+ marathons under her belt), I sought out a chiro who aligned my hips-- apparently they were out of whack. (Note: The doc has been vetted and approved by my friend’s father who was a chiro, and he is on staff with the women’s pro basketball team in my city—so I assume he knows athletic women’s bodies). He thought perhaps I had a slight laberal tear in my hip, but wanted to be conservative in treating. He recommended a couple of adjustments each week, some rolfing, ice baths, lots of core work, and no trail running or hills. Pain at most was about a 4-5 on a scale of 10---did not get worse, but was constant.
In early Jan, the pain seemed to go away. I ran the marathon Jan 15th and the hip felt fine—no issues (except for the stomach, but that’s a different story). I took a couple weeks off from running and have slowly been easing back into over the last 2 weeks.
The problem is, now when I try to run, the pain is back. I saw him again this week and asked if it was time for an MRI. He re-evaluated, my hips are misaligned (again) and thinks perhaps it’s not a tear, but rather some bursitis and/or tendonitis. He wants to take the same approach as last time as it seemed to work. He said the dreaded "C" word again (core), and upped the frequency to 5x per week.
Current Situation:
Week 2 of OS plan; Light running but its painful---2-3 on a scale of 10 (definitely feel it on hills); Does not hurt when I bike; Sadly, core work for the last month has been minimal 
My question is:
What do I do?
Do I keep running (per the plan) and follow his recommendations for a few weeks and see how it does?
OR
Not run for a few weeks but keep biking?
OR
Get a second opinion immediately?
Any thoughts would be greatly appreciated!!
Thanks
Dana
Comments
As a runner who has been managing a hip labral tear for several years, I can say that it is possible for some to continue to train and run with a labral tear, but it has taken me quite a bit of time to figure out the tips and tricks that have helped me.
A few questions come to mind, in no particular order
What types of core work have you been doing? (specific exercises)
Are you doing any yoga?
Has your doc done a Faber test to rule out a labral tear?
What kind of shoe do you run in?
What does the pain feel like?
Have any other MD's or PT's evaluated your hip?
I have been struggling with a labral tear, torn glut med. and GT bursitis, all on the right side. I did ART and got a cortisone shot to the bursa just prior to IMWI last year and except for the sprint I did 2 weeks later, I took off from running until the end of Oct. During that time I had an MRI, which led to the diagnosis. I started TRX 2x week and have been doing that since Nov. It was really evident once I started TRX how lopsided I was. The Doc said to not do the things that hurt, i.e speed work and hills, so I have been working on endurance. I would suggest you get an MRI and go from there after the diagnosis. Treatment can be determine after a dx and can depend on what your race schedule is.
Good luck
Mary
Hi Mike--
Core: None for the last few weeks
, but prior to that mostly planks (front, side and back), and some pelvic tilts to try and access the lower abdominal (the one that you feel when you cough). My TRX is getting hung this weekend, and I'll be starting that routine!!
Yoga: started (back) doing it a few weeks before the marathon, and have been at least 1x each week. I will say that when I started back I was significantly less flexible than when I had been going before. Note: Fall 2010 I was marathon training as well, and attending yoga 2x per week. I felt great and had no hip issues. I made it to week 12 of that training program, and had to have some unexpected surgery (non-sports related).
Faber test: I googled this and (non-MD) husband helped me. I have unusally flexible hips, and this did not hurt. My knee can almost touch the ground (many yoga poses to stretch the hips do nothing for me). I felt tightness in the inner thigh and could feel where I am experiencing pain, but it did not hurt.
Shoes: Saucony Kinvara---I rotate between 2 different pairs
Pain: it feels deep in the hip and burns. When it is sore and I sit for too long, it starts to throb.
No one else has evaluated my pain-----except for me, with the help of Web MD. I will say that the rolfer spent a lot of time on my aductors (he described them as spongey), and when he worked on my psoas I wanted to cry and curse and punch him.
Thanks
Dana
Hi Mary--
Thanks for the info.
We recently moved, and my TRX is being installed this weekend. I was pretty religious about it last year, and it was amazing how much core strength I was able to build. And you are absolutely right---It does not hide imbalances.
I absolutely feel pain the most on hills, but oddly, faster running makes it feel better!!! The slow stuff seems to aggravate it most.
My gut tells me to get the MRI, so I just need to make that happen!!
I'll keep you posted!!
Dana
You should seriously consider a stress fracture specifically of the femoral neck before you continue any additional impact activities (running). This could be a disaster in the making. Sorry to get you worked up.
My current job has me taking care of both Army and Marine trainees. Stress fractures are very common and are usually not a big deal but stress injuries of the hip can be disastrous and are preventable.
You family physician should at a minimum perform an x-ray. If the x-ray is negative either a bone scan or MRI should be performed. A bone scan will not assist in diagnosing a labral tear; however, it is very specific and will show increased tracer uptake if an area of your body is under additional stress. An MRI would allow you to evaluate for both a tear or stress injury. You would have to have an arthrogram of your hip in addition to the MRI to evaluate for a tear. This is when a needle is introduced to your joint so that die/contrast is injected to help identify the presence of a tear…OUCH.
Your chiropractor is likely very good at what he does and is correct in telling you additional core work is needed .
Labral injuries typically cause discomfort on hill or at least my patients seem to complain of. It may also hurt when running slow because your posture is more vertical and feet remain on the ground longer increasing the ground force reaction to your body possibly contributing to a stress reaction…injury…fracture.
If you have the means I would follow your gut.
WORST CASE SCENARIO BUT PREVENTABLE
Sample X-Ray: you can see it is very difficult to see.
Sample bone scan below
Sample MRI below
The picture below is likely from a car accident on elder; however, I've seen the same injury with young health adults from running.
Jamison--
YIKES!!!! But thank you for the info---stress fracture is not something that had yet been mentioned. I'll be working today to get myself in for further examination!!
Dana
Sorry to be a little obnoxious about it, but I really do see the injury very frequently. Everyone tends to "blow-off" stress fractures because they sound like such a minor injury. I probably see 5 a week and unfortunately 4 breaks like the pictures above last year. I describe to patients, "it is like bending a #2 school pencil. You'll hear it start to crack and then it traumatically snaps." If you progressed properly your pain is likely something else, but it isn't worth taking the chance. I'm an Army Physician Assistant who is currently working with sports related injuries and this a major focus that the DoD is working on improving.
WOW!! Those bolts look like something you'd pick up in the bolt section at Home Depot!
Saw chiro again the is morning, he did several tests (including the Faber = negative). He's still thinking tendentious and/or bursitus. Asked me not to run for awhile, and I said fine--until Thursday when I see him again, then maybe we could revisit the topic.
I also made an appt with the Sports Medicine clinic at the hospital for next week.
Gonna hit the TRX and start re-building core strength in the mean time.
Thx
Dana
Faber's and Patrick's test certainly have their own limitations. Your body regardless of what is wrong sounds like it is asking you for a break. Sometimes Chiro can increase the mobility of a joint that does not necessarily need to be.
You can continue to make running gains by not running. Consider after some time off getting on the elliptical. If you want to make it a little more fun and your body will tolerate it. Perform a threshold test and make some temporary workouts of different intesity and try to calulate your Training Stress Score (TSS). Do the same to running in the pool. Anything to keep you interested and avoiding becoming discouraged.
We always tend to increase our activity in other sports when we can no longer work on a specific one (running). Stress is stress, decrease all your training volume or as we are learning your TSS. Healthcare providers only have jobs because of people's expectations. I always joke that I can entertain you while your body heals itself.
I certainly understand your frustrations. This is the 3rd time I hurt my calf (usually in March). I think I know why but that is a different forum. You don't walk around and punch yourself in the face because it hurts and you look stupid. If it hurts don't do it.
When is your 1st race?
Keep us up-to-date.
Ortho said I may not need surgery, but its best to get the info. His preference would be to have me off it for awhile (no running), work on my biomechanics, strength (including the dreaded c-word: core), chiro, PT, rolfing, whatever else helps---let's be conservative (unless surgeon completely disagrees!!) and see how it goes.
I've cancelled my half marathon in 10 weeks, and pushed out my A race from July to Sept.
I guess its time to get in the pool and on the saddle!!!
Thanks
Dana
YES please share.
My preference would be to aggressively manage it without surgery---and I think it can be done. I started feeling better about 4 weeks pre marathon and had no hip issues during the run. It wasn't until a few weeks after the marathon (when I started running again) that it started hurting again. By that time my hips were way out of alignment again---so obviously I'm doing something to upset it!!!
I did get out and test it today---3 easy miles on a flat, soft surface. Pain did not increase and after I was done hip actually felt better. I did do 75 minutes of yoga pre-run, so maybe it was really well loosened up and that helped?? Feels a little sore this evening, but northing more than normal (2-3 on a scale of 10).
Any advice/tips would be appreciated (especially because I can't get into the surgeon for several weeks!!!)
Thx
Dana
Findings:
There is a deep cleft filled with contrast between the superior labrum and the bony acetabulum. A sulci can occur in this location. However, the depth of the cleft and apparent displacement of the labrum raises suspicion for partial detachement of the superior labrum. The adjacent bone is unremarkable. The cartilage is preserved.
The posterior labrum is unremarkable.
The morphology of the acetabulum and femoral neck is normal without evidence of femoral acetabular impingement.
Bone marrow signal is unremarkable.
There is no evidence of trochanteric bursitis.
Impression: Possible partial detachement of the superior labrum.
Ortho's orders: no impact activities and if it hurts--STOP!!!
Now it's a wait and see what the surgeon has to say when I see him in May.
Looks like my tri season might be a year of relays with me swimming and biking!!!!
Dana
Thoughts on managing a labral tear:
Shoe selection: see this thread. For me, the magic has happened when I stopped using shoes with more than 10mm drop from heel to toe height (calculations available on runningwarehouse.com)
PT: Went through 6-8 weeks of pretty vigorous PT. Lots of strengthening of the core through bridges and planks, along with a bunch of other work (band walks, mountain climbers, etc). If your doc prescribes PT, go and do it.
Flexibility: my sports med doc gave me some of the best advice on flexibility. lack of flexibility isn't the problem here, and it probably helps some. Even though the pain can often feel like something that needs to be "stretched out", resist the temptation to get into lots of pigeon poses and other stretches that severely flex the hip (knee to chest). All it's really going to do is to aggravate the tear.
Pain management: avoid NSAIDs like the plague.
Of course, that's nearly impossible to do. But the spirit is, don't do anything that makes the hip hurt in THAT way. If it hurts, stop. This is one sort of pain where there's literally ZERO benefit to pushing through it. I've walked in the occasional run rather than keep going knowing that I've tweaked something.
Quad-dominance: this is totally anecdotal, but I believe that a lot of athletes who run with a labral tear for months/years (in my case, about 5 years) develop what my PT referred to as a "quad-dominant motor pattern". In other words, you learn use your quads to do a lot of things that your glutes should be doing (both are able to extend the hip, but the glutes are good at it, and the quads stink at it). Think about it like this. If you want to extend your hip, your glutes should be able to do that work. But, if you put your foot on the ground, you can use your quad to 'lever' your thigh bone over the knee, which kinda-sorta accomplishes the same thing. This is a terrible motor pattern, and one that requires a lot of glute strengthening and neuromuscular re-training to break. I'm not sure I have the best recommendation for this (I'm in the process of re-education now), but it's worth discussing with your PT or doc.
I'll see what else I can come up with tonight, and add to this thread.
Thanks Mike for all your insight.
Right now I'm trying to stay positive and be excited about building strength in my core, swim and bike, BUT I am also terribly upset about this turn of events. I had lots of fun running events planned this year, and who knows if I'll be able to do any of them!!!
The docs that I see work with the Seattle Storm. 2 of the key players had labrum issues---1 played through it, 1 had surgery. So I trust them and know it can be managed. I will also check out the blog you mentioned. And of course, I'll keep watching your successes as inspiration!!!
Cheers
Dana
One other thought I had last night. I have pretty much eliminated most of the things that aggravate the tear, which means that I'm reasonably pain-free most of the time (a lovely way to live!!!). I do have restrictions on range of motion with my left leg, but it's something I've learned to accept.
Two things that I've learned aggravate it (and I have to consciously focus on NOT doing) are below
1) external rotation (think bent knee, rotating the knee out, foot in) with a flexed hip. For example, getting into a car, I need to lift up my foot by flexing the hip, and then externally rotate the hip to get the foot in. There are ways I can do this without elliciting any pain, and ways that cause significant pain. Some days, when I've been on my feet all day long, I'll find that I have to use my left arm to help lift my leg into the car, in order to avoid causing myself any pain. This is also the position of a number of stretches for glutes, piriformis, etc, which I've basically given up.
2) seated positions that 'push' the femur into the anterior portion of the hip socket. When I sit on a chair, I typically sit near the edge, on my sit bones. If I don't, I often find myself sitting in ways that cause upwards force on the middle of my femur (thigh bone), which invariably causes pain. Examples include: sitting on a chair and tucking my feet way back underneath the chair, so that there's pressure on my hamstrings, or, sitting in a booth at a restaurant that slopes down towards the back, so that my knees end up higher than my hips. Virtually guaranteed to get me limping.
You may not have the same triggers, but it's worth paying close attention to what you were doing immediately before any time your hip flares up, and then find the commonalities. Eliminating the constant hip flare-ups goes a long way towards improving mental health around the whole thing.
To give you some hope, in training for Philly marathon this past fall, I strung together several weeks in a row of 40+ miles per week, one or two of 50+. Almost all of it was pain-free (like I said, I don't run if it hurts).
Dana, hopefully surgery is not in your future. Keep us updated.
Mary
#3 did take additional imaging, spent lots of time looking at my MRI, spent the most time actually talking with me and explaining what was happening. He is also considered to be the #1 guy in the area (which is why it took me so long to get in and see him).
So now I am totally confused and overwhelmed---it does not make sense to me why the first two did not mention hip replacement as eventual outcome.
Have any of you heard this is a potential?
I'm still hunting for answers!!
Thanks
Dana
Impingement (or Femoral Acetabluar Impingement, FAI), is a controversial topic. Lots of info on the Internet. Basically, the hip joint isn't as open as it 'should' be, leading to the femur (thighbone) hitting the acetabulum (hip socket) in a narrower range of motion than normal. Two basic types, cam and pincer (best to look at pictures to see the difference). Often associated with labral tears, but certainly not always.
Nobody can say for sure that impingement will or won't lead to some type of degeneration requiring hip replacement. There are conflicting studies, some suggesting that impingement in and of itself is a problem, as eventually, all the pressing of the femur into the acetabulum will cause labral tears and/or arthritis. Others suggest that many people live asymptomatically with FAI, and therefore it cannot be the 'cause' of these things.
There are also conflicting results of impingement surgery. Basically, they're going to go in there and shave off some of the 'extra' bone to give your hip a full range of motion. Recovery can take a while, and some report great results. Others haven't had the same level of success. It would also be wise to check with your insurance policy, as some insurance companies still consider surgery for FAI experimental, and do not cover it.
A couple of things to consider. How is the pain these days? How have you been keeping up with the core routine? Is the current level of discomfort, or something slightly reduced, something you think you could live with? I have a bias towards attempting all non-surgical options before going for surgery. But that's a personal thing.
Also, remember this. One of the sources of the pain is that your hips physically cannot go as far as other people's. You should not be able to do a split! Flexibility (or lack thereof) is not your problem, and working on stretching to improve range of motion may very well be aggravating your hip. Find ways to stretch that do not cause any pain or discomfort in the hip, either during or after. Stick with tried and true stretches for quad, hamstring, and hip flexor. Don't do things like the pigeon pose in yoga, that puts your leg in extreme flexion. That will almost certainly put too much pressure on your hip capsule, and cause you to be in pain either then or later in the day.
Thanks MIke, once again, for your insights.
From what I understand, I have both cam and pincer, and possibly a cyst on the femur where its rubbing on the acetabulum.
I have been keeping up with my core and PT, and while my pain is not increasing in number (2-3) it has become constant. I have switched chiros to one that does ART as well, and he is focusing more on that and less on spine/hip adjustments. MOTHER OF GAWD it hurts---each session I laugh and cry and curse and throw punches, but after the sessions I feel better. Chiro says he's not surprised I am having more soreness and doesnt think its a bad thing (as long as the pain number does not go up). He says he's doing a lot of work in there and its bound to be sore.
I also had a gait analysis done---shocking results (not): I'm a straight leg heel-striker. So when I hit the ground, all that pressure and force is radiating up my leg and into my hip joint. Also, my glutes and hammies are not even part of the process--(as you suggested) I'm all quads. My upper body also torques quite severly to the right, putting additional pressure in my left hip. Wish I would have done this prior to marathon training!!!
I went ahead and schedueld the surgery, but its not until end of September (that was the soonest he could do it). I see this as a good thing because I can use these next 5 months continue with conservative management to see how I progress. And I can also use this time to collect more information. To that end, I have also sent all my recods and imaging to Dr. Marc Phillipon at the Steadman Clinic---you probably know he is considered to be the leading expert in the country (if not the world). If I'm not mistaken, he also operated on TJ Tollekson (as well as many other high profile professional athletes).
As I learn more, I'll update.
Thanks for being a sounding board!!
Dana
Thanks for all the tips and posting. Dana, I hope all goes well for you. You mentioned that your glutes and hammies are not part of the process.. I was told that my glutes are not activated when I run as well.
I took Mikes advise and got a pair of Brooks (can't remember the name). They have a 4 mm drop instead of the 10mm I was used to. They are very light but still seem to have some stability compared to the others I tried on. I have run with them several time and have absolutely no hip pain during or after running but now my hammy on the left is incredibly tight and my glutes appear to be firing as I now have pain there. I am also having some low back pain on the left as well. I imagine this is from the ham tightness. I anticipate this will disappear the more I run and get used to the "new" way of running. I have been keeping up with core training on my own as I have not time for TRX anymore.
Thoughts?
I sent my records and images to Dr Phllipon at the Steadman Clinic. My understanding is that he is regarded as the expert.
They are recommending surgery to shave off they excess bone (pincer impingement) and reattach the labrum (as opposed to cutting it off; this maintains the suction for a fixed seal on the head of the joint).
If I opt to do nothing (outside of PT and ART), I run the risk of articular cartilage damage to the surface of the bone. If I take the do-nothing approach, they recommend imaging every 6 months to monitor the space in the joint for progression and further deterioration.
We also talked about injections--steroids and PRP. Steroids are a diagnostic tool to help determine that the pain is in fact in the joint, and could ease the pain. PRP, in theory, promotes healing of the labrum, but does not address the impingement issue.
The soonest I could get on his surgery schedule would be January.
So, obviously I think this news sucks, and now I just have to decide what to do. I have been running (in Kinvaras with a 4mm drop) a little over the last few weeks, in fact did a hilly 12k yesterday and it only felt a little tight. The 4 hour car ride home seemed to aggravate it more!!!
My thoughts right now are continue with the ART, PT, core, and gait improvement. Also, try the PRP injection. If I all these elements get me to a good place, and no progression in the joint space, then forego surgery. I appreciate you guys as a sounding board!!
Dana