Muscle Medicine: The Revolutionary Approach to Maintaining, Strengthening, and Repairing Your Muscles and Joints (33 page)

Back-of-the-Hip Pain: Hamstrings and Gluteals

Sue, forty, is an executive secretary from New Jersey who never cared much for sports and was happy to do without. But with her weight and her cholesterol numbers steadily creeping upward, her doctor advised her to go on an exercise program. Sue got a gung ho trainer who gave her an aggressive routine of “clamshell” exercises when she told him she wanted more definition in her butt. She was delighted with the results until her butt muscles developed a persistent ache that wouldn’t go away even after a few days off from the gym. Instead, the pain traveled partway down the back of her thigh. So much for trying to get in shape, she figured, and returned to the couch.

The muscles behind the hip, the gluteus maximus, which wraps around the buttocks, and the hamstrings, which run down the back of the thighs, are power-houses.
They look bulging and impressive as they power a sprinter or a football running back. But as Sue discovered, the two smaller muscles in the glute family, the gluteus medius and minimus, can be more sensitive and troublesome. Located on the outside of the hip, they’re sometimes referred to as the abductors, because they bring the leg out to the side (or abduct). The glute exercises that Sue was assigned can stress these abductors if the intensity is ramped up too quickly. The same thing can happen in yoga or gymnastics. Not only do the muscles become sore and painful, but they can create a condition called pseudo-sciatica, which sends pain down the back of the leg. A little muscle that helps rotate the hip, the piriformis, is actually the most common culprit when it comes to entrapping the sciatic nerve. Piriformis syndrome is a classic “referred pain” syndrome in which the source of the pain (the entrapped sciatic nerve) is sometimes somewhere other than where the pain is felt. When attention is focused on the structures of the lumbar spine, which can cause similar symptoms, or true sciatica, these other conditions are sometimes overlooked.

Don’t sit in a position where your hips are lower than your knees, either sunk down in a cushy chair or with your legs propped up on a support higher than the chair.

Don’t cross your legs. Crossing your legs in a figure 4 position exerts a “twisting out” pressure on the hip. Crossing one thigh over the other exerts a “twisting in” pressure. Both are bad.

Sleeping on your side is, for most people, the healthiest position. Slide a pillow between your knees to relieve the pressure on the hip from the top leg pressing down. This is especially helpful for women with wider Q angles.

If you know you have hip weakness or vulnerability, avoid extreme ranges of movement while symptomatic, as in dance, yoga, or extreme stretching.

When Sue’s glutes, hamstrings, and hip rotator muscles were manually released, her symptoms resolved. The answer was clear: the butt, not the back, was to blame. Sue returned to an exercise program, this time under the guidance of a personal trainer who subscribed to a “slow and steady” philosophy.

We should add that abductor muscles aren’t a problem only for the exercise novice. Running gives runners toned muscles in the front of the thigh (quadriceps) and the back (hamstrings). But if runners or
joggers don’t do anything besides run for exercise, their abductor muscles on the outside of the hip may be so out of balance that they struggle to keep the pelvis level as the legs turn over in the running stride. The stride is therefore less efficient and can lead to injury.

Muscle or Joint?

Groin Pain: Sports Hernia/Hip Impingement

Jane, thirty, is a businesswoman in New Jersey and a promising recreational marathoner. But after her second marathon, she felt as if she weren’t the same runner. She had a constant dull ache in her groin area and a propensity to pull a groin muscle every time she stepped up her training. She fit the pattern for sports hernia or athletic pubalgia. Dr. DeStefano would manually treat her abdominal and adductor muscles and win her relief from the pain for a while, then she’d strain another muscle. That suggested that the root problem was the joint, not the muscles. Sure enough, Dr. Kelly ordered an MRI that revealed that her hip joint was too tight and the ring of cartilage that supports it, the labrum, had torn. He made the necessary surgical repairs, and Dr. DeStefano worked on the muscles before and after the operation to speed recovery. Several weeks after the procedure, the hip joint and the muscles that drive it were sufficiently healed that Jane could start physical therapy to build up her core strength and flexibility.

Conventional medical wisdom has held that the hip was something to be pinned together when elderly women fell, or to be replaced if and when the cartilage inside wore out during the senior years. For the rest of us, the ball-in-socket joint was viewed as a model of sturdy stability, of medical interest mostly when it was on the receiving end of trauma, such as when dislocated in a car accident or severely injured playing sports.

Dr. Kelly is one of an elite group of doctors specializing in hip dysfunction who realize that the hip is a lot more delicate than anyone has given it credit for. In the most common bad-news scenario, the hip joint is “impinged”—the ball of the femur doesn’t have its full normal range of motion inside the socket—which then forces the pelvic joint in the center of the midsection to compensate with extra movement. The major abdominal muscle (the rectus abdominis) and the adductors that cross over the front of the pelvis get irritated by this movement and grow tight and

PROTECT YOUR LABRUM

When you get out of your car seat after a long drive, or your theater seat at the end of the movie, do your hips feels tight, achy, crampy? Perhaps the hip joint is “impinged” (suffers from an irritating, diminished range of motion), or a tear of the labrum could be part of the problem. Have an orthopedist check it out. In the meantime, back off of any strenuous activity at the first sign of hip pain. The labrum can be injured in accidents as well. Here’s one common scenario: a car passenger rests his or her knees against the dashboard, and even a modest crash impact does the rest. When the hips are flexed at ninety degrees, the impact against the dashboard could tear the labrum.

painful. That’s why Jane kept straining those core muscles, a syndrome that, as we mentioned before, doctors now call athletic pubalgia. In more serious cases such as hers, the orthopedist must repair the hip itself, cutting away some bone or the rim of the socket, to allow the joint to move more freely, and sewing up the hip’s cartilage support, the labrum, which often gets torn by the pressures generated by that impinged hip.

It’s a complex anatomy lesson, but it’s important. The latest research suggests that this impingement/labral-tear combo is a time bomb inside the hip. It’s a major cause for degeneration inside the joint, which over time often develops into osteoarthritis, and the need for hip replacement surgery.

Groin Pain: Psoas Impingement

Kathy, forty-two, is an executive with a New York media company who works hard and works out hard. She hikes, swims, cycles, you name it. But increasingly she’s slowed down by groin pain, originally diagnosed as a simple groin pull. Because the pain is chronic and severe, Dr. Kelly suspects joint damage. He discovers that the source of the pain is actually muscular, the ropy iliopsoas, which runs from spine to thigh. It’s now so tight, it’s painfully pressing against the hip capsule along the way.

Dr. Kelly could surgically trim off some of the width of the psoas tendon, allowing for greater stretch and relieving the pressure on the hip. But by collaborating with Dr. DeStefano, he has the luxury of keeping the surgical option in reserve. Dr.
DeStefano does intensive manual work to break up the tension in the muscle, and after ten sessions Kathy is pain-free and back to hiking in Harriman State Park and hitting her weekly mileage marks on her bike.

As we’ve said quite a few times, our medical system tends to undervalue muscle damage in its eagerness to explain how pain and suffering is caused by structural problems inside the joints. Kathy’s case is one example of a muscle disorder contributing to joint damage. Her case was resolved by working directly on the muscles. In more severe cases, when the tight iliopsoas tendon actually snaps against the hip capsule, surgery may be required to fix the situation.

Kathy’s problem—a problem for a lot of us with demanding office jobs—is that she sits at her desk working long hours without taking regular walking and stretching breaks. Evolution hasn’t designed us to be such good sitters. When the iliopsoas doesn’t get a chance to do its primary job—flex the hip—it tightens up. Kathy is a regular exerciser, which is a good thing, but because she doesn’t warm up before running, she irritated an already tight muscle. Even in less dramatic cases when the psoas isn’t directly interfering with the hip, it still often refers pain from the hip to the groin area or the lower back.

Outer (Lateral) Hip Pain/Bursitis

The abductor muscles—the gluteus medius and minimus—have the nonstop job of stabilizing the pelvis. (They’re the muscles that Sue strained with her clamshell exercises.) In middle age, playing two or three sets of tennis, formerly no big deal, can trigger pain in the outer-hip area. For the elderly, simply walking can bring on the pain. In both cases, the deconditioned abductors have fatigued, throwing off the position of the pelvis and the mechanics of moving, and maybe even irritating the protective bursa sac. (The major hip bursa lies outside the joint, near the protruding top part of the femur or thighbone called the greater trochanter, hence the name
trochanteric bursitis
.)

The standard treatment is rest and an anti-inflammatory injection if necessary. But once again, addressing the underlying muscle problem, either with manual therapy or surgery, depending on the severity of the damage, is changing the treatment landscape. Manual therapy to relieve muscle tightness along the iliotibial band, the long tendon that runs down the outside of the thigh, can relieve pressure on the bursa. (More about the iliotibial band in the next chapter.)

Leading hip surgeons have discovered that surgically repairing badly torn gluteus tendons is the key to solving what had been regarded as the toughest bursitis cases.

Joint/Orthopedic

Hip Impingement

You’ll notice we put hip impingement in two categories: Muscle or Joint? and here in Joint/Orthopedic. In the case of Jane the marathoner, we had to tease out the muscle and joint issues to figure out that the compromised hip joint was at the root of her problems. But with a lot of the athletes Dr. Kelly sees—soccer, hockey, lacrosse players—there is no medical mystery. The friction in the impinged joint can tear the supporting cartilage and the labrum, increase instability and improper movement, and lead to pain. Surgery to reshape the hip socket and repair the labrum solves the problem, if it’s caught in time. If not, bone grinding against bone inside the joint can lead to osteoarthritis and, ultimately, the need for joint replacement surgery.

Osteoarthritis

Marilyn is a fifty-year-old Manhattan corporate executive who came to Dr. Kelly with lower-back pain and limited mobility in both hips. She was overweight and