Polodoc: Unhappy Hip

Dr.med. Andreas Krüger is a Swiss board orthopaedic and trauma surgeon in Zurich, who specialises in knee and shoulder surgery. Andi is a second generation of tournament doctors for equine sports, known as Polodoc since 2013

Unhappy Hip

Sudden pain & no idea about the trigger?

Photograph courtesy by MTR Spa Shockwave application with Swiss DolorClast® EVO Blue on the point of pain where the tendons insert on the bone to trigger regeneration

Introduction

In the evening you go to bed and in the morning you stand up and walking feels like you slept on a bed of needles. Immense pain in the gluteal area and thigh with no idea what the reason is for it. Mostly pain in the joints results from overuse or wear over time, with a constant increase of impairment. Nevertheless subclinical inflammation of the insertion of hip muscle can result in a calcification of the intersection between these two materials (bone – tendon interface). The inflammatory pain can be immense with massive reduction in mobility and loading. Tendinitis is most often caused by repetitive, minor impact on the affected area, or from a sudden, more serious injury.

Pain can be so limiting that riding is not possible at all.

Symptoms

In the intimal phase, a sore muscle feeling can be present. Secondly a sharp, disabling pain can limit the free range of motion with very localized area of discomfort. Mostly rotational movements trigger these sensations. Patients usually try resting in a comfortable position in slight elevation and external rotation.

Grain of rice shaped calcification as a sign of inflammation of the gluteus mdius tendon

Anatomy

The hip is built by the femur bone with its ball like head and the acetabulum, which is a cup shape. The cup is surrounded by a soft sealing tissue, which forms a capsule and joint lip. Muscle around the hip bone is in a circumferential position forming a cuff so that movement in all directions is possible. In between the tendon and bone intersection, soft tissue in the form of a bursa, is positioned to minimize friction in this area.

Diagnostics

Clinical signs

A clinical examination will highlight joint pain through passively moving the hip. The outer side of the hip, where the soft tissue of the bursa is placed above the insertion of hip muscles, is a typical spot where pain is localised. Local reddening and pseudo infection signs like reddening or swelling and pressure tenderness can be present. Elevated infection parameter like CRP and white blood count is possible but can also be misleading.

X-ray (flouroscopic) guided punction/infiltration of the hip under sterile conditions executed by PD Saupe in the Radiology of Hirslanden Klinik. With the help of laser light, exact needle placement is possible.

Radiology

Alteration of the bursa or inflamed tendon tissue can be pictured well with ultrasound examination. X-ray and additional MRI of the hip can help to better understand unclear clinical symptoms and can help to rule out possible pre-existing conditions of the joint. Calcifications can be detected best in X-rays. Mostly small round or triangular deposits are visible in the insertion area of the tendon.

Therapeutic treatment

In an initial phase, anti-inflammatory drug treatment is recommended. In the first instance, non-steroid drugs like oral Ibuprofen is recommended. Additional high dose intake of Vitamin C and Zinc can prove beneficial. Dermal patches can be administered on the painful area with warming or cooling ingredients. Physical rest in a comfortable position is also recommended. In cases where the acute phase is not reacting to the initial treatment, a secondary infiltration of antiinflammatory drugs to the affected area is favourable. These infiltrations should be executed guided with the use of ultrasound or X-ray technology. If the full treatment armamentarium is administered in the early stage, quick recovery is very likely. In longer lasting cases, a well-dosed shockwave treatment can boost recovery. Concomitant Physiotherapy is always favourable. In rare cases where high grade partial tears of the hip abductors’ tendons have occured a surgical intervention should be considered.

For more information on Polodoc contact Andreas Krüger at drmedkrueger@gmail.com or www.polodoc.ch