Dr. Miller: When hip pain is not arthritis pain. I'm Dr. Tom Miller and I'm here with Dr. Steve Aoki. He's a professor of orthopedic surgery here at the University of Utah, in the Department of Orthopedics. Steve, hip pain isn't always due to arthritis. If that's the case, what can it be due to?
Hip Pain Causes
Dr. Aoki: So it's interesting when I went through my training ten years ago, often times we didn't quite know what . . . we'd have these young adults come in that had hip pain. They'd have this radiating pain right in their groin region. We'd look at them, we'd look at their films, and we wouldn't see any arthritis, and we'd say, "You strained your groin" or "You pulled a muscle," and we'd send them out.
I think that what probably happened over time was they'd get disappointed, and wouldn't have a good answer, they'd go see someone else, and everyone kept telling them, "No, it's a pulled muscle or it's a groin injury," and they just weren't able to get back to their activity. So what's interesting, it's surprising that we took so long to kind of understand the young adult hip pain problems, but what we've realized . . .
Dr. Miller: Do you think that's because it just did not show up on an x-ray, like arthritis shows up?
Dr. Aoki: No, it actually, once you start looking at the films and the radiographs a little bit closer, you start looking at shape issues, and we've noticed that bone shape, whether it be the ball or the socket side of your hip joint, that the shape of the joint plays a big role in what we understand . . .
Dr. Miller: So joints are like individuals. They're different from one person to the next.
FAI: Femoroacetabular Impingement or Hip Impingement
Dr. Aoki: Sure. Everyone's built a little bit differently, exactly, and that shape of your hip joint plays a role in different causes of groin pain and hip pain. So what we've gotten to understand is a concept of what we call "femoral-acetabular impingement," or "hip impingement," where the ball and the socket get a pinching with activity and range of motion.
I would think of it somewhat where there's a mismatch between the ball and the socket, where if you have a cup that's round and you have a ball that maybe didn't form quite as round as we'd ideally like it, as you do activity you twist, pivot, you squat, you force the area of the ball that's not round into that round socket, and it starts to pinch. Over time that repetitive pinching can cause discomfort and start causing hip pain.
Dr. Miller: Are there certain activities that bring this out, that precipitate this more than others?
Dr. Aoki: Yes, so what we've noticed is that in general, athletes tend to have more discomfort and shape issues in their hip joint, and that's probably a combination of the way that their hip joint formed and the shape of their joint on top of their increased activity with competitive sports.
Dr. Miller: Would it be more running, or basketball, or . . .
Dr. Aoki: It tends to me more cutting, twisting, pivoting, deep squatting type of activities. So what happens, most likely what happens and what we think is going on is that, when you are going through those early teenage years, the growth plate around that hip joint is still open, and with stress to that growth plate, we can see kind of a stimulation of extra bone in that area around that growth plate which makes the ball so that it's not as round as it ideally should be.
Physical Therapy for Hip Pain
Dr. Miller: How common is the physical therapy to solve the problem for most athletes?
Dr. Aoki: I think it can be helpful for some people. I don't think it's one of those parts of our process that I see people get better with the pinching type pain, the deep squatting groin pain. But treating the muscular pain can be helpful, and if I can get you to a point, regardless of what's going on in your hip joint, if I can get you comfortable where you say, "It's reasonable and I can do the things that I want and it's more comfortable and I can tolerate the pain," to me that's worth sitting on it for a little while and not rushing into something surgical.
Dr. Miller: When that person finds that the pain is not getting better, or their function is not where they want it to be, what are the next steps?
Dr. Aoki: So if we've given it a chance at non-operative treatment, which includes activity modification within reason, maybe anti-inflammatories, maybe a course of physical therapy, but time if it's not getting better, then continuing with the workup of looking at the shape of the joint, maybe getting an MRI plus or minus a CT scan to look at the shape of the bones of the joint.
Then if we're not getting any better with non-operative measures, potentially considering something surgical where we go in and we scope the hip, and we reshape the hip joint and we repair the tissue that potentially is torn.
Dr. Miller: So you use, when you say "a scope," you mean a little device making a small incision?
Dr. Aoki: Yeah, a small incision.
Dr. Miller: No large incisions?
Dr. Aoki: Two or three incisions about the size of a button shirt hole, and then we go into the joint and we evaluate the cartilage, clean it up, repair the tissue if it's torn and unstable, and then I think a big part of this whole process is reshaping the joint, taking the ball of the joint and making it rounder so that it doesn't pinch as much into the socket side of the joint.
Dr. Miller: Now as an operator, how hard is that to do? It sounds like sculpture.
Dr. Aoki: Yeah, it's a little bit. I think a lot of what we do with orthopedics is like a jigsaw puzzle. We take broken bones and we piece it back together and it's like a jigsaw puzzle. I would look at what we do from the standpoint of hip arthroscopy and femoral-acetabular impingement, we're doing a reshaping. It's almost more like pottery. You're reshaping it and you're trying to get it to be round and ideally a shape that doesn't pinch.
Dr. Miller: That sounds like quite an art.
Dr. Aoki: I think so.
Dr. Miller: So after that surgery, then talk about the recovery.
Hip Arthroscopy Recovery
Dr. Aoki: Yeah, recovery after it's an outpatient same-day surgery so you go home the same day. I typically put people on crutches for a few weeks, typically around four weeks where you're gradually increasing your walking and putting a little bit more weight on there as you start to tolerate. I get you started in physical therapy after a couple of weeks, mainly to have some guidance and have them work on just motion and some gentle exercises, get you on the stationary bike. I really reserve those first three months of this whole process to just get more comfortable with your daily routine, the things in life you have to do.
I typically think of that after three month process as being getting or starting to do more of the things you want to do in life, some jogging, some lighter change of direction activities. I'm not necessarily releasing you to full activity until about that four to six month mark, and at that point it's really dependent on how comfortable you are. Everyone's always a little bit different as far as how quickly they recover, and some people just don't feel ready yet at the four to six month mark. But pain's a pretty good guide.
Dr. Miller: So prior to surgery you have this detailed discussion with them about what to expect after surgery. It's not launching back into their activities that they want to do. It's a steady process.
Dr. Aoki: It's a steady process.
Dr. Miller: They're involved in that.
Dr. Aoki: Yeah, and hopefully the surgery itself is not something that you feel laid up and you feel like you're laying in bed and six months later you're ready to go. This is a gradual process of continuing to increase your activities, you're getting on the stationary bike pretty quickly, you're increasing your strengthening as you go along, as you get more comfortable. So this is not a surgery that hopefully you feel laid up or you feel like you're not able to do some function.
updated: May 20, 2020
originally published: October 25, 2016
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