Hip Flexor Pain and Why it’s so Tricky to Treat.

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I had a friend in the clinic the other day, who is also a client.

 He was having hip pain.

A doctor friend we share sent him to my clinic to see if I could help him out with the pain he was having and help him out with a comprehensive diagnosis.

The doctor was sure it was a sciatic issue, the old school type version.. “piriformis syndrome.”

Now you guys that have been in my clinic before know that hips are my baby.   I feel very good at my Diagnostics and my treatments, especially the hips. We go the extra mile here to keep it Cutting Edge and much of what we diagnose and treat is different than classical presentation.

The idea of not stretching the tight muscles on the backside and things like glute activation and hamstring activation, has been around for about a decade but still hasn’t trickled into mainstream therapies.  These treatments are legit despite Tiger Wood’s memes making fun of his “Glute Activation” before a Major Tournament years ago. Yep, I remember when everyone was making fun of him. I guess it never occurred to the populace that perhaps Tiger Woods, the most famous athlete, and highest endorsement earner had a future-thinking doctor and staff that was 5 years ahead of the curve.

Now, No self-respecting doctor or therapist would dare laugh at this. It’s all we talk about for 100s of conditions.

Back to my patient:

I went through the exam and evaluation and presented my evidence for why I thought this and that.   I worked this patient up and despite me thinking it would take two to three visits, he actually left the office feeling nearly 100% better.

My diagnosis?   Low-grade bursitis with hip Mis-position,  or more properly termed lack of proper movement.  His hip flexors, the anterior hip muscles, were tied up and tight because they were short and adhered to each other,  consequently causing the backside muscles of the butt and hamstring to be tight because they were elongated and overstretched.

I know, that’s a mouthful.

Any of you that have been to my clinic or read any of my articles on Muscle Recovery or seen any of my rehab videos… you get it.    My diagnoses are long and quite descriptive but on the same hand are rarely scary or quipped, and typically not something simple enough that you can Google it and get a one-word answer on treatment. -Basically, it’s -, this guy who has a bunch of little things that are compounding on each other and making his life miserable. None of the things are serious, but if treatment is done for any one of his problems the issue will not get better.

The resolution of his issue takes Chiropractic or rehabilitative napalm.   Each and everything needs to be done, and it needs to be done in the proper order.  

 The analogy I use when teaching lectures for this type of issue is that it is like a little kid’s bike lock.   All the numbers can be put in but if it’s not done in the correct order the bike lock will not open ie any of these treatments can be done but if they are not all done together and in the correct order you don’t get better.

So I worked this guy over… in my typical fashion, I explained it all.  I made it all very simple to understand by explanation.

Simple explanations need explanation.  That’s what makes it simple.

Now, this patient is a nurse and works alongside our doctor friend doing surgeries each morning.

The next day when he came back to work, the doctor asked him how he was doing and what he thought was going on and the patient explained it.

The doctor scoffed and told him I was full of s*** and that it was a simple piriformis syndrome and he should do the figure 4 stretch at home.  Basically, the opposite of what I explained over 20 minutes. But it was simple and easy to digest. It took 5 seconds, not 20 minutes. And…he’s a “real” doctor.

So the patient did what this guy told him to do.    And the pain returned immediately.

This leads me to this particular write-up.

The trouble with the hip is, They are complicated.

There are a lot of moving parts and a lot of attachments and because of the attachment points of the hip flexors and the glute muscles, this area is perhaps the most important part of the body to have to work correctly.   Calling something by a simple name and then giving it a simple stretch isn’t going to work. Just ask your friends, the marathoners, and triathletes. Every one of these guys has had either a hip issue, a knee issue, IT band issue, a back issue, or their running is just off the mark. They’ll never stop talking about it. You just want to enjoy a beer at the BBQ and you get cornered by Todd over there pummeling you with his groin problem and then showing you his ass…Todd actually wants you to feel his strained glutes?   WTF TODD? Back off!

Most of them will also swear that their specific stretch or Release Technique or chiropractor or foam roller or whatever magic potion they have is the answer and will 100% relieve their condition and restore their Mobility in….say 8 months to a year.

It is so much simpler than that.   8 months to a year is for crazy people –  let’s start to get a hold of this issue and make the fix much faster.

Typically three to four treatments and approximately six minutes of rehab are done every day for about 2 weeks for most cases.

Let’s dissect this case and see if it makes sense.

The patient presents with right hip pain with running or sitting or changes in position.

The pain is along the backside of the patient’s hip bone where the butt and hip come together.

Now I live in Texas.  Until I moved here, I had always assumed the “hip” was the anatomical hip – where your hand would be if you put your hand in your front pockets.    In Texas, for some reason, often times the hip is thought of as where your hand would be if you put your hand in the back pocket. Your pelvis or butt… someone explain this to me – I have no idea.   But in my clinic, I do need to clarify.

For this case, I really don’t care what hip you want to use because you can have pain with this similar issue practically anywhere in your lower body.

A good doctor or therapist should be at least half – a good detective first.   Use Sherlock Holmes, or Hercule Poroit’s skills to look for Clues to unravel the mystery of this patient’s problem and solve the caper.

So, at this part of the patient visit, I start asking questions looking for Clues.

Does the pain get worse with activity?

Does it hurt to go upstairs?

Does Advil or Aleve or a steroid pack seem to make the issue better?  

Does it feel better if you rest?

I also check his range of motion,  his muscle tension, his reflexes, and other medical stats such as blood pressure, heart rate Etc – all the typical doctor stuff.

Because anti-inflammatories greatly affected his issue and made it better AND a previous steroid pack over seven days nearly completely resolved the issue for about a month –  I can say with relative certainty that he has some sort of inflammatory issue. His clues gave me the information to make this educated guess. Anti-Inflammatories worked, it must be inflamed.  

Inflammation in the hip is typically bursitis,  although there could be other factors going on such as a spur or something serious such as a tumor or condition called AVN.

In this case, I had an x-ray and we could all but rule out a tumor and AVN.

So great… he has bursitis.   I get a gold star for solving the mystery and getting a test question correct.    But a diagnosis alone doesn’t help this patient at all. He came to me for a diagnosis AND treatment so let’s continue.

When I test his range of motion, he has virtually no internal hip rotation which would suggest that his hip is in fact jammed upward in the socket a bit.    Because of this, or possibly due to this, he has the muscle spasm on the front side contracted, his hip flexors and quad.   The muscles on the backside, his butt, are longer than they should be because the hip is rotated internally and can’t go any further.

Visualize the ball of the hip is positioned in a corkscrew fashion, UP AND IN.

The little fat pads that are between the ball of the hip and the cup of the hip are named the bursae.   And inflammation is called itis. Added together bursa + itis or bursitis.

Because the hip is jammed up in there- every step this guy takes,  especially activity which has multiple fast STEPS, would cause multiple irritation to the bursa.    In a case like this, I really don’t care which came first the Bursa irritation because the hip is off or the muscle imbalance causing it all…it’s a chicken or the egg type argument.   They all work together to create a cycle of misery and make correcting the issue with one treatment nearly impossible.

Remember,  this guy took a steroid pack,  which is an anti-inflammatory, and his pain all but disappeared.    The inflammation was gone and therefore the pain was gone as well. But nothing was done with the steroid treatment to actually fix the issue.  It just gave us some info…some clues.

His hip was still jammed up,  the muscles were still out of balance,  and as soon as the anti-inflammatories were out of his system- the cycle continued and the pain came right back.

Hopefully, this description makes it quite easy to see how it typical musculoskeletal issue has a lot of other parts associated with it.

If all I do is give this guy a stretch,  it’s really not much of a different treatment than just giving him a steroid pack.    It’s only addressing one part of the larger complex. His cycle of pain can’t be broken because we’re not doing enough to disrupt the cycle.

How would I fix an issue like this? bursitis/ sciatic/ hip mobility/ muscle imbalance issue?

By attacking all aspects.

Let’s get the inflammation off the hot bursa,  move the hip into a better position so there isn’t any grinding which would reactivate the bursa irritation, and balance the muscle so the patient was less apt to start the cycle over again. I would like to give this guy some rehab-type exercises to basically stretch or down-regulate the tight muscles on the front side of the hip,  and turn on or upregulate the weak stressed muscles on the backside.

I mean it’s a full paragraph,  but a pretty basic and easy Treatment if it is explained to you in full.

It just took a little explanation and now you are all damn near experts at the hip.  Hey Todd, take this! POW!

Now, the mind-blowing part – the SportsdocDC, I actually CARE part.

The entire idea of this article is not to treat your hip, your shoulder, or your sore back but to understand that simple answers for complex issues seldom work.  

I would argue that in fact, simple answers and simple treatments create more trouble because we no longer have good Clues. We have Misinformation and bad information because we try half-ass approaches to issues in our life and then think that these approaches didn’t work.  This happens in life – with almost all of our simple one-answer decisions. Diets that do or don’t work, financial plans, workouts, health, relationships, movie choices, whatever. It takes a little more thought.

So back to my hip guy for a second. What happens to my patient when he gives up on treatment because he has two doctors basically telling him two different things and it’s confusing?   He decides to do nothing. Six months later he still has the issue. He now decides to get an MRI. The MRI is done to his lower back, not his hip when he was having the issue, but to his back because he relates to his new doctor that none of the hip work he had tried had had any results.   Note: by this time it’s typically his 5th or 6th doctor.

Anatomically, the nerves from the lower discs in the lower back travel into the hip.    So maybe the discs are screwed up, and the nerves are being irritated and that’s why he has hip issues.

This train of thought happens every day.   Thousands of times.

Sure enough, the MRI reveals low-grade disc issues most often called disc degeneration.

aha more clues,  the Brainy doctor/ Scotland Yard Inspector incorrectly claims, “This must be where his issue is coming from!”

The trouble is, this particular patient was 61 years old.   I would argue that 95% of people over 30 years old probably have a low-grade disc issue evident on MRI.   Usually, It’s not a big deal. When the discs are actively injured, often called a hot disc, or in years bygone a “slipped disc”,  the issues are nearly unbearable and cause tremendous pain.

But when the issue is resolved and the inflammation is gone there really isn’t a disc issue anymore despite there still being disc findings on MRI.

So what just happened?    We went down the wrong path.  We obtained new information,  but information not so much related to this case.   It’s evident, but probably not causative. In the detective books, it’s like a known bad guy living next door, but he wasn’t the killer.

In our story, Treatment down the wrong path begins.   Our hero starts treating his simple hip issue as a low back disc issue.   As a betting man, I would say the chance for success of treating his hip issue with low back disc protocol is pretty low.    On any given timeline, however, the human body will self-correct and he will start to feel a little bit better.

All along, having a pretty simple fix in his back pocket – which SHOULD have been saving him time money, and months of misery.

I mean he was nearly 100% out of pain in 1 visit in my clinic yet chose to not pursue this path because it was uncommon.

This entire site is not so much supposed to be “Doctor Chad’s clinical case studies”   although I like doing this stuff if you want more just ask.

No, this is but an analogy for things that may be a bit mixed up in our lives.    Hopefully, you liked learning about the hip but the take-home point is, in LIFE, get better information. Test what works and what doesn’t work in your life.   Try multiple approaches at the same time. Take expert advice and opinions and make decisions based on how those opinions and advice work for you… or…. don’t work for you.

But Above All Else,  try not to look for simple easy -push-button- magic- pill- fixes for the things that are messed up in your life.

Most often all it’s going to take are small easy steps from multiple angles.   As my last patient stated, that happened to have the same hip issue, “I knew it was all connected.”

Bingo.   Life is more like a spider web of interconnection than a straight linear line.  “It’s” always connected, no matter what “It,” we’re discussing.

My second point:

Just fixing the pain isn’t fixing the problem.   The steroid pack made my patient’s pain completely disappear.    The problem was still there, however.

In life often times we disregard the problem for the quick fix,  The feel-good, and the cheap Buzz.

Tackle the problems. It’s nearly always easier that way.   Or better stated, It’s the same amount of effort to fix it as not to fix it.

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