Hip Pain Cartilage Injuries with Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physio in Vancouver. He's the head clinician, the expert, the guy many time voted best physiotherapist in Vancouver. Of course his clinic has also been voted the best physiotherapy clinic a number of times. And we're gonna talk about hip pain today. How you doing Wil? 

Wil: Hey, I'm doing well, thanks Mark. Yeah, hip pain. More specifically cartilage related type of hip pain. 

Mark: So what kind of symptoms, I mean, it's pain in your hip, but how would you know that it's the cartilage versus arthritis or a growth in your hip or, or? 

Wil: Yeah, no, those are good questions. So the technical term, when we talk about the cartilage in the hip we refer to it as the labrum. So quite often, if you get an injury or a tear in the cartilage of your hip, we call it a labral tear. And you're right about like how do you know that it's not like a tumor because it could be right. And that's one of the causes and actually. 

I'm glad that you actually brought that up because we had a patient that came in to see one of our physios, this is a while back now, a few years ago. And he was having hip pain that just wouldn't go away. And these are the kind of things you wanna look for, like there was no trauma and he didn't do any sports or any exercise in particular that brought this on. And I remember one of our physios who was treating him, you know, was telling me about him. And he brought me in to kind of take a look at it and and I was like, yeah, like, this is interesting. It's strange. Because there was no real mechanism of injury, number one. And when I say that, there was no trauma and there was no like acute trauma and there was no like repetitive type of trauma and there was no incident. And so we said, you know, go see your doctor and get some scans and get it checked out.

So he did that and it turned out that he ended up having a tumor, the size of a baseball in his hip. And so I'm glad that you brought that up. So it could be that, but I mean that was very rare, like that happens probably less than 1% of all hip pain and these type of cartilage type of errors that we see.

But that's what we thought it was initially because it was acting a lot like a cartilage tear, like a labral tear. And you know, we get the classic symptoms of it catching and clicking but you can imagine finding a tumor the size of the baseball, of course, things are gonna pinch in there. You know, of course things are gonna not move right in there. 

So some of the other symptoms, if there is more of a tear in the labrum, that cartilage portion, then there'd be specific movements that cause it like if you ended up getting in a car accident. And that can cause sort of the shearing force and you're already in this you know, flex position or something like that, and it can damage sort of the back top side versus the posterior superior portion of that labrum. Or if you're in a hyperflex position, if you're just doing a lot of stair climbing and for some reason the stats show that the Asian population tend to have a lot more of that.

I don't know if it's because you know, they tend to squat more or something like that. So doesn't have to be an acute trauma. It can mean it's sort of this repetitive thing. And so they found that they have more of that tearing on that posterior superior side. But then they also found that the highest incidences seem to be related to kind of more in the anterior superior, which is on the front top part of that hip labrum. And so anything that involves twisting compression, in terms of the mechanism of an injury. 

So on a repetitive and on longer sort of chronic scale and maybe even things like, okay, let's say I do a lot of training and I suddenly add stairs to it. And then I just start to feel a little bit of a low grade ache and that builds. So it can start up as a small injury, a small tear and start to build into a bigger tear and then escalating into a bigger one and then causes a lot more symptoms and eventually dysfunction where you can't even walk. And so you experience pain whenever you try to run and even walk and even just standing. And even bringing up your knee in hip flexion, try to put on your pants, put on your socks. 

We have a couple physios that are seeing a couple of patients that have that exact problem right now. An older gentleman that came in, very active, likes to swim. Took some time off. Didn't feel comfortable going in the pool during this whole pandemic. It's been a long stretch. Went back in January for the first time in like, you know, year and a half or whatever. And started swimming four days a week. And it was actually kind of a funny injury. He tried to, you know, prop himself out of the pool, like mantling pulling out of the pool and put his right hip into this hyper hip flexion and tried to get himself outta the pool with his leg up. Felt a little tweak. He thought he just pulled the muscle kind of went away. 

So this is sort of how it starts. It went away and then he tried to do the same thing again the following week. And then it got worse and felt even sharper. And then it started clicking more. We haven't sent them in for scans yet, but our physio team sees a lot of this.

And what ends up happening is that you know, for quite a majority of them, there's stuff going on in the labrum, at the cartilage area. That's usually the presentation. There's some kind of trauma, whether it's like an acute type of trauma or some kind of micro trauma or repetitive type of trauma. 

And another cause is if you have like, so related to trauma, let's say you injure the hip and you don't injure the cartilage and you have a hyper mobility. So there's all the laxity in there. Or maybe a little bit of laxity. And because of that, then it's more unstable. And then the hip joint, so you have sort of like, it's a ball and socket, and so what ends up happening is that ball portion, because more unstable, then as you twist and turn in a ball and socket type of joint, then it can cause some injury in that hip, if it's more unstable. 

If there's a lot of multiple imbalances, like we were talking before then yeah you add that to the mix. Then that can cause more compression. And then you go to try and get into the range that you're used to for flexion or extension. Then you will tear that labrum. 

So there's also certain conditions that you're born with. Let's say you have what's called, like when you're a child, you have certain diseases in the hip where it's just more lack or congenital hip dysplasia where you know, when you're born, your hip kind of gets dislocated and gets put back in. That can be something of an issue that can cause a type of labral tears.

But there's also like the degeneration component, like as you get older, it's just tends to wear a little bit more and you're more prone to having it wear out. If you have other preexisting injuries to maybe your back or, you know, things that are related to the function of your hip.

Obviously we know how the back is really connected with that hip. So if you've had, you know, certain back issues or certain back conditions and that can affect the hip and usually the symptoms are right in your hip joints from the front. We call that the anterior right to the lateral, and it feels like it's deep inside and it feels like there could be like a locking and catching type of pain. And it can be from like a constant diffuse ache to a sharper type of pain sensation in there. And usually that will progress a little bit more as that degeneration occurs more and more. 

Mark: So what kind of things do you do to diagnose this? 

Wil: Well, it's kind of tough to actually say that it's a labral tear, but we can always say that it's like probability that it is. And there's certain things that we do in our examination procedures to look at it's the probability is likely that it's this, based on these different tests that we're doing. And quite often people will think, oh, like when they have this especially in the initial stages, that they might have pulled the hip muscle.

And so we obviously wanna rule out any of the muscles if they've been sprained. And then we also check out whether or not if there's a hyper mobility or instability natural joint. Because like I said earlier, like that laxity and that hyper mobility can play a factor in this.

And then sometimes there's like, there's a condition called Ehlers Danlos syndrome where you're just sort of locked through all the ligaments in your body and not just ligaments, but through other parts of your body that can also lead to issues with the labrum. And some people have gone on living into like, you know, their fourth or fifth decade of their life, not knowing that even had Ehlers Danlos syndrome. So it can be mild to more severe.

And so these are things that you do specific testing, you go back to the doctor, but you know, it's sort of these genetic markers that you look for that can add to that. So these are all things to consider. 

Mark: And how bad does it get to be before you are, or when's it the best course of action, is to refer someone to the doctor for scans and whatever treatment the medical doctor might provide. 

Wil: Yeah. So basically, we are seeing patients sort of like first line. So what that means is that we see them before they've even gone to the doctor, quite often. We have about like 25% of the patients that will see a doctor first because you know, they're not really sure. And they go to their family physicians who they trust. But usually we see them first and we'll diagnose it or we'll look at what's going on based on the tests.

And then we wanna treat that. And we wanna treat it, especially if we think it's an orthopedic thing. If there's other sort of signs that if it's really obvious, like, oh, that sounds like it might be something more going on on that initial assessment. Then we will refer you back to see your doctor and to get more testing done. Because I think that it's important to work with your family physician to really solve and get at the root cause of your aches and pains of what's going on in your hip. Because there could be more going on. 

Even though we may be suspecting that it could be like a possible labral thing, but if there's other things going on, like there's unrelenting pain. And pain that's like a 10 outta 10 without any relief with any kind of positioning or movements, you know like there should be some kind of relief, if it's biomechanical issue. Unless it was just a fresh injury. 

So those are really sort of warning signs right away like if it was like a gradual thing, like there was no true mechanism of injury. But they're having this 10 outta 10 or 12 outta 10 pain. That's a huge warning sign that something else might be going on. And especially like, there's no lead up to this. 

Mark: And let's say it's not that bad, and so you're moving forward with treatment. What is a typical course of treatment? 

Wil: Yeah, really addressing if there's a hyper mobility or instability, stabilizing the joint. And that also means that looking at okay, well what's imbalanced. Because usually if there's instability, there's also an imbalance in the muscles, but let's say if there's no instability, we wanna look at what's not working properly.

So we want to start to address the movement to function. So quite often the hip flexors are super tight and not functioning properly and they're not allowing the extension mechanism to work properly. But it becomes a bit of a dilemma because let's say like I was saying earlier that it's the anterior top portion, which is the anterior superior portion of that cartilage that usually gets damaged.

And usually what happens is, it's a hyperextension compression type of injury. But then quite often you need to activate those muscles in that range. Like your glutes, because they're not activating properly. So then what happens is we gotta start to address the movement function of it. So we have to look at how do we get your hip moving better without aggravating it?

Because even the act of getting it moving, if we produce pain, that's gonna shut everything down because pain will also cause things to not work properly. Swelling will also cause things not to work properly. So we wanna address those things. We wanna settle it down, if it's acute. Take the swelling down. Do whatever it takes for that part of it.

And then now we wanna start addressing okay, the mobility issues. And then we can start addressing the strength issues and then kind of doing that together maybe. And then the functional mobility. So now we've gotta work on the core aspect in getting what is overactivated and what is underactivated.

And then part of that is addressing, okay, well can we walk on this now? Can we go upstairs? Can we even just put on your pants? Can we even put on your socks first thing in the morning? So those kinds of things.

Mark: Does it change when someone's had a hip replacement?

Wil: So that's a good question because slightly different. It does change because there's a lot of positions that you want to avoid. And when you have a hip replacement you essentially have like automatic instability. And so usually with the hip replacement, the cartilage is all worn out. So there is no cartilage. And so you're not really looking at rehabilitating the hip with respect to a torn cartilage that you're trying to maintain and keep intact. Cause now there's basically no cartilage there. And now you're just replacing it with a total new hip or partial hip or whatever you decide to choose. And now you're looking at strengthening and trying to maximize function and avoiding certain positions and letting the postoperative part of it heal first.

Mark: So if you're having hip pain, the guys to see are Insync Physio. You can reach them on their website at insyncphysio.com. You can book for either office. You can call the Cambie office at (604) 566-9716. Or the North Burnaby office, you can reach them at (604) 298-4878. Get in there, find out what's going on with your hip, and if there's more going on, then they can look after it, they'll refer you to your doctor. Or they'll get you started on the path of recovery and get your hip working properly again. Thanks Wil.

Wil: Yeah, you bet, Mark.