Anterior Hip Pain with Wil Seto

Mark: Hi, it's Mark from TLR. I'm here with Wil Seto of Insync Physio in Vancouver, and they also have an office in Burnaby, BC, Canada. Multi award winning best physiotherapists in both locations, multi award-winning best physiotherapist in each location. And of course, today, we're going to talk about hip interior hip pain. What's interior hip pain?

Wil: Yeah. So anterior hip pain, which is pain in the front of the hip. And this is actually a quite common syndrome and dysfunction in the hip. So basically there's many causes of it. When we look at some of that comes in to the clinic that it has anterior, which is a hip pain, it can be caused by like bursitis. So bursitis is basically when you have an inflammation of the bursa SAC in the front of the hip. 

And then another common cause of that, it can be basically an overuse thing in the hip flexors of the hip. So that's more commonly called a hip flexor tendinopathy. So tendinopathy being that it's been more of a kind of a long-term thing. And so those are the two most common causes of hip pain that we see from, especially people who are really active in sports. You know, we treat a lot of sports injuries at our clinic and people were just generally active like hikers, bikers and doing a lot of field sports. 

So the other part of you know, aspect of anterior hip pain that doesn't really get looked at too much is it's something that's kind of more related to the bone and the structure of it. And so the terminology of this is called an FAI, which is femoroacetabular impingement. So basically what that is is there's a bony anomaly happening there, in one of the two bones causing impingement in that joint. And there's specific limitations associated with that on a clinical level when you assess it.

But all in all, when you either look at whether it's an FAI or if it's like a bursitis, overuse tendinopathy or even something that's more wear and tear where it could be a bit arthritic. There's usually a lot of imbalances in terms of the muscle structure around the hip. So a lot of weaknesses and a lot of stuff that's just too tight and not allowing the actual hip joint to basically move properly and optimally. 

Mark: So how do you diagnose that? 

Wil: Well, so with the bony part of it is, you know, like it's, through specific ranges and limitation, but you ultimately need to have some scans and imaging done, and that's usually not related to trauma. So it can develop sort of when you're growing in the bones and in terms of how the structure of the bone start to then get maybe a little bit thicker in certain parts of the femur or the pelvis. And then so when you look at other injuries like, so I'll give you an example. 

I had a woman that came into our clinic who went on a five day hike at the West Coast Trail. And she's also a rock climber too. So she does a lot of like, you know sort of fluxion movements where their hips and then she bikes a lot. So anyway, she went on this five day hike and then two days into it she started getting anterior hip pain. And so it's funny because she was attributing that specifically to the hike, but knowing her and the fact that she was so active. You know, this was all set up to happen before. And the other interesting thing is that as I was assessing her, I realized that she had other stuff going on too.

So it wasn't just like in her hip joint that she was having all these imbalances, but her sacroiliac joint, which is basically an adjacent joint to the hip, was really, really stiff. And you know, just in digging a little bit more about her history, she had like a snowboarding accident many, many years ago and just landed on her bum and she couldn't walk for a couple of days. And it was one of these things that she didn't even really think anything of, but I was just like probing about, have you actually injured that hip or anything like that before? Oh yeah, now that I think about it. Yeah, I used to snowboard and I had fell on it really hard once and I couldn't walk for a day or two and then she was fine. 

It turns out that after I worked on mobilizing that sacroiliac joint, that hip area adjacent to the actual hip you know, her limitation and her hip pain was completely gone. But what still remained though, was a lot of the weakness and a lot of the tightnesses in her hip flexors. So she's been having this sort of a issue with this adjacent hip proper issue with the sacroiliac joint. That then I think started building up with all these imbalances and she's very active to begin with, but a lot of her activities involve hip flection and her hip flexor muscles, even after mobilizing and getting that sacroiliac joint moving was so tight that she didn't even have neutral range into hip extension. And that was actually one of her biggest things that she was complaining about too, is that hip extension was painful, but hip flection was painful too, but after we mobilized it, you know, her movement wasn't painful anymore, but she was just stiff.

So basically what we had to do then after mobilizing the areas that were stiff, we had to actually start to loosen those muscles around there that were also really tight and binding. Because what happens and then it just causes this sort of vice grip in the joint still. And like you're still not getting optimal movement in actual hip joint.

And then as a result, because she's always used to those muscles being tight and other muscles were just super, one specifically like interior iliocapsularis, which is a muscle in the front of the hip. And then her gluteus medius, which is basically the butt muscles. And gave her some exercises start off with, but she was like, miraculously got off the table, I can walk after one session. But it doesn't end there because then the muscle imbalances need to be addressed. 

Mark: What's a typical course of treatment? How long has it take in a more normal situation to get more pain-free? 

Wil: Yeah, so anywhere between you know, depending on the kind of injury, if it's an acute injury, it can take a little longer anywhere between like four to six weeks. If it's like an acute strain in the hip flexor or maybe longer. If it's a bursitis, those things can settle down pretty quickly, but then it's really now addressing the imbalances. Because the thing is like with this client, she wants to get back to doing all of her sports and her activities. And, you know, they're at a recreational level, but she's operating not at an optimal way of moving her hip and she has to relearn how to use those muscles. And so our job is to help facilitate that and make sure that the range of motion in the adjacent segments and the joints are actually moving properly, continuing to move properly and to basically reinforce that optimal movement pattern.

Mark: Cool. You mentioned, like you had a second client who was having this kind of interior hip pain. Yeah. 

Wil: Anterior hip it. Yeah. So this person, we actually suspect that might have a little bit more of what I mentioned earlier, FAI, femoroacetabular impingement syndrome. He had no trauma. I mean, no trauma that he can recall. And he's young, like 30, I think he's 30 something, really active guy really fit, likes to ski, but like pretty adamant, no trauma, he's always been really careful and stuff. Just serve development with chronic hip pain and also I think part of his history, like he hasn't been really good at stretching and working on recovery and stuff like that.

But the thing is, as I started to test him, he had all the symptoms and all the clinical signs of femoroacetabular impingement and those ranges and those loss of ranges and the weaknesses too.  I think that's one of the biggest thing is that he developed this imbalance and so we want to try and work on fixing that. Ultimately I kinda told him, like we think it's this, we can only really know, like if we get some imaging, but that's really up to you. You haven't had any trauma.

And so he has been in a few sessions to see us and it's interesting because when he works on his exercises, he gets really good. He's pretty consistent, but then he goes in bouts where he'll go hard on mountain biking, he'll be a bit more sore for a few days. So it's really interesting, like how the muscle imbalance does play a really big factor, but then at the same time, you know, if it continues on and it's ongoing, then you want to address that a little bit more.

And one of the things that we did was we did some things to actually address the limitation of the actual hip joint proper. That actually helped a little bit, but it was obviously, if it's going to be something more structural and bone, then that's not going to really be a solution because it's going to keep pinching in on the cartilage and then causing a continued stress and strain and aggravation.

 If that's the case, then that'd be where I'd be wanting to refer them back to the family doctor and saying, yeah, let's get some imaging done. And let's just see. I know you haven't had any trauma and I know you're operating at a high level of like your sports and activities, but if you want more information and data on what's going on, then let's take a closer look at this.

Mark: Yes. Taking care of it sooner rather than later, if it's something like you don't want, like a cyst growing or arthritis, et cetera, whatever they possibly can do. 

Wil: Yeah exactly when it persists like that, and it just doesn't seem to get fully better. 

So, if you want some help with your hip pain, anterior, posterior, medial, I don't care where it is the guys to see are Insync Physio in Vancouver. You can reach them in Vancouver at 604-566-9716. Or you can book online@insyncphysio.com. They also have a Burnaby office. You can reach them at 604-298-4878. Same story. You can book online insyncphysio.com. Thanks a lot Wil. 

Thanks Mark.