Hip joint is surrounded by muscles that attach around this joint. Thus, gluteus medius, tensor fascia latae(TFL), sartorius muscle and anterior right muscle attach to the ilium bone, while psoas muscle originates in the spine with a distal attachment on the thighbone.
Tendinitis means the inflammation of a tendon, most often caused by repetitive or excessive stress on the tendon and “exhaustion” thereof.
When tendons are too exhausted, the sheath that surrounds them becomes swollen, leading to specific symptoms.
Most often, the area is painful and warmer, with local swelling and sometimes redness.
Joint mobilization leads to pain in the tendon concerned, which is moderately alleviated by rest.
We will review some types of tendinitis that are more common in the hip.
Gluteus medius tendinitis
This tendinitis presents itself essentially as a pain in the external buttock and slightly in its rear side. This pain is exacerbated when climbing stairs, especially first steps and after prolonged sitting position.
True overwork tendinitis of this muscle is quite rare and is exhibited by individuals who have intense activities (walking or sports) or limping people as a result of pelvic problems (arthrosis, total hip replacement, limb inequality).
Diagnosis is mostly clinical and confirmed by palpation of the tendon at rest or during a contraction of the muscle in question. A complementary set of tests is sometimes necessary to confirm the diagnosis (ultrasound, MRI, hip scintigraphy) or to make a differential diagnosis with other pathologies (osteoarthritis of the hip, joint impingement, lumbar sciatica, tendon rupture, osteitis, ….).
Tensor fascia latae (TFL) (moved hip)
This is a tendon that attaches to the iliac crest and puts pressure on the fascia, which is the external part of the thigh. This long tendon attaches to the external anterior tibia, and passes over the two bony prominences of the hip (the greater trochanter) and knee (external femoral condyle).
At knee level, we are talking about a syndrome called windshield wiper syndrome and this tendinitis is seen most commonly in runners.
In the hip, if feel more like a spring or a sensation of rubbing, a crunch felt on the outside of the joint. This noise can be heard and perceived during hip flexion – extension and corresponds to the passing of this tendinous strip above the bone surface of the greater trochanter. It is felt especially during the active mobilization of the hip; diagnosis is rather clinical, but a dynamic ultrasound may reveal tendinous crossing over the trochanter.
On the outside of the hip, bone relief is upholstered with a small bag filled with a liquid that acts as a sliding surface. Its function is to avoid friction between the bone (in the external part of the proximal femur, trochanter) and soft tissue (in this case the external part of gluteus maximus). Sometimes this serous bursa may become inflamed and give what we call a bursitis. In the hip, the most common is the pertrochanteric bursitis.
This explains the pain to the outside of the hip; patients cannot sleep well on the affected side. This pain is aggravated by excessive walking; climbing of stairs is difficult. Sometimes this pain can occur after prolonged sitting. Additional examinations are necessary to support this diagnosis (ultrasound, MRI, hip scintigraphy). Thus, before the diagnosis of pertrochanteric bursitis, pain from other causes must be excluded: osteoarthritis of the hip, femoral head necrosis, tendinitis…
Psoas muscle is a muscle that performs hip flexion on the abdomen. It originates on the inside of the thigh near the groin crease. This tendinitis is mostly seen in athletes who make repetitive movements with kicks, running, jumping. It is a sign of tendon fatigue (by excessive use).
Tendinitis has already been describe in many sports such as football, rugby, swimming, especially sprints, and jumps in length or height….
This tendinitis may be due to a conflict with the front of the hip prosthesis in patients who carry a full prosthesis. Patients complain of pain in the internal hip enhanced by its flexing. Pain is felt in case of a foot lifting test, with the leg stretched in slight external rotation, from 30° degrees.
The diagnosis is confirmed by complementary examinations, such as ultrasound, MRI, scintigraphy. A diagnosis should exclude pain with other origins: osteoarthritis of the hip, tendinous tears, tendonitis of the abductor muscles, pubalgia, adductor damage, etc.
Treatment follows several steps:
- In a first phase, kinesiotherapy is preferred. This must be adapted to each type of tendinitis. Hip joint will be under rest and any sporting activity involving the hip joint is interrupted. Kinesiotherapy sessions should be accompanied by physical therapy sessions (ionization, shock waves, electrotherapy,….). Ice is recommended, as well as pain management with anti-inflammatory drugs and classic painkillers.
- Then we can consider corticoid infiltrations; moreover infiltration of corticoids mixed with an anaesthetic can be a diagnostic test.
- If pain is still present despite well-managed medical treatment, we can consider a medical approach depending on the type of pathology and aetiological factors (hip displacement, a conflict between the prosthesis and psoas tendon, a repetitive chronic bursitis…). Surgical indications are discussed on a case by case basis.
In terms of hip pain, tendinitis occupies a special place. The diagnosis should be confirmed by additional tests; treatment requires a multidisciplinary cooperation (general practitioner, orthopaedic surgeon, sports doctors, physical therapist, homoeopath, and osteopath).