The Challenges of Hip Pain in the Triathlete

By Todd Shatynski, MD | Nov. 14, 2019, 12:05 p.m. (ET)

man stretching in grass

While not as common as knee or shoulder pain, triathletes frequently experience pain in the hip.  Structures around the hip are responsible for an estimated 20-30% of injuries in cyclists and runners. Hip pain is a complex problem that often requires significant skill and time for the clinician to sort out – the average time from symptom manifestation to definitive diagnosis is 21 months, with athletes visiting an average of 3.3 healthcare providers before diagnosis. Multiple different problems can manifest with similar presentations.  As a result, hip pain can cause more mental and psychological stress to the athlete than other injuries. 

In order to determine the source of hip pain, one must understand the complex anatomy of the hip which consists of several overlapping structures that can all cause pain. The hip bones create a deep, stable, ball-and-socket joint with smooth cartilage lining both the surface of the femoral head (ball) and the acetabulum (socket).  The ball and socket are further stabilized by a rim of cartilage around the edge of the socket called the labrum. The joint is supported by the hip flexor muscles and connecting tendons in the front, in the back and side (lateral) by the hip abductors, and in the groin (medial) by the hip adductors.  These muscles are covered in fascia (like the skin of a sausage) and the tendons are lubricated by small bags of fluid call bursae. 

Determining the source of the pain begins with a thorough history and a physical examination by a skilled clinician. The presentation of intra-articular and extra-articular hip problems are often quite similar, so obtaining sufficient information is essential to try to determine what tissue is the actual source of the pain.  X-ray, ultrasound and MRI can be vital tools for identifying anatomic factors predisposing hip pain and possible sources of pain. However, imaging studies need to be correlated with symptoms.  Studies show conditions seen on an MRI are present in nearly 70% of active individuals who have no complaints of hip pain!  

Hip joint injection can also be an extremely helpful diagnostic tool.  If the pain resolves after an injection, even temporarily, the clinician can be more confident that the pain is intra-articular.  Because the hip is a deep joint and is located next to large blood vessels and nerves, it is necessary to visualize the joint and guide the injection.  Historically, guidance has been via x-ray, but with the advancement of the musculoskeletal ultrasound, current standard of care is ultrasound guided injections. These can be done outside of the hospital, do not require radiation, and allow visualization of the soft tissue structures such as the joint capsule (see ultrasound). 

Causes of hip pain vary from intra-articular to extra-articular and problems that do not originate at the hip but cause pain to radiate there.  Intra-articular problems often result in groin pain that may radiate to the thigh but can also present as posterior pain. These include tears of the labrum which can be caused by a congenitally misshapen ball and socket. While treatment may include surgical consideration, long term study of these surgeries has not yet been completed.  

On the other hand, studies have shown that there are a large number of asymptomatic athletes who have the impingement morphology on x-ray.  Thus, most sports medicine clinicians believe that conservative treatment should be tried first with physical therapy. If the condition of the joint has degraded with thinning or irregularity of the cartilage, then it has already developed wear-and-tear osteoarthritis. In these cases, minimally invasive surgery to correct the impingement or labral tear is less effective, especially in athletes over the age of 50, but running has not been definitively shown to cause arthritis.

Extra-articular hip problems often present similarly to intra-articular problems.  Previously termed “sports hernia,” athletic pubalgia (groin pain from sports) can be hip joint derived but is frequently caused by extra-articular sources and thus can include a multitude of symptoms and structures. Acute inflammation of the tendon (tendinitis) or chronic wear-and-tear of the tendon (tendinosis) can cause pain that worsens with exercise. Often times these pains can be accompanied by snapping or clicking which is usually the tendon or bursa slipping over a boney prominence. Treatments usually involve rehabilitation.

Initially conservative with focused physical therapy, treatment often needs earlier intervention geared towards releasing myofascial trigger points and decompression of nerve entrapments.  Ultrasound imaging that helps guide needle placement and inject fluid around the nerve to free it from adhesions or to provide therapeutic medications is an excellent treatment option for entrapped nerves.

Further complicating the diagnostic challenge, hip and groin pain can also come from conditions that are not in the hip at all. Stress fractures in the femur or pelvis can result in vague pain. While most typically heal fully with simple rest from impact exercise, there are a few that are high risk for a bad outcome and should never be ignored — the lumbar spine and sacroiliac joint, inguinal hernias and pelvic organ problems can result in hip pain that acts like a hip joint or tendon problem. 

When a triathlete experiences hip or groin pain that is affecting training, the first step is to decide if a training error caused the condition. Sometimes a bike fit, swim kick technique change, or running gait adjustment can be quite helpful. If not, start by ceasing or reducing the element of training that is causing the pain – cut down on the time spent kicking in the water by using a pull buoy, stay out of the aerobars, or reduce running mileage and speedwork. If the pain continues, you should seek a medical opinion from a sports medicine physician, orthopedist, chiropractor or a physical therapist.  If the reduced training and relative rest combined with physical therapy is ineffective in improving the situation, it may be time to discuss interventions that include minimally invasive injections or surgery.

While there are congenital conditions that are out of your control, there are certainly things you can do to reduce your risk and keep your training as healthy and effective as possible.  With so much of our lives spent sitting, we develop tight hip flexors. Combining this excessive sitting with all of the forward cycling and running in triathlon, this imbalance worsens.  Tight hip flexors inhibit the hip abductors (muscles that move the hip out laterally) and fundamentally makes them weaker. Studies have shown that these imbalances with flexibility and strength prompt injury in the hip and thus treatment must include their rehabilitation. Cross training with activities that counteract the forward motion of running and the extreme hip flexion of the aero position, like multidirectional sports, trail running, and yoga, can be especially helpful. 

Despite our best efforts, however, hip injuries are common. Most conditions have contributions from multiple structures and are best treated with conservative treatments including focused physical therapy and possibly medication or injection for diagnostic and therapeutic purposes. Most of the conditions can be treated without surgery. If athletes listen closely to their bodies and are willing to temporarily deviate from their training plans, they can often recover from the problem and get back out on the course as soon as possible. 

ultrasound guided injection

Author: Todd S. Shatynski, MD, CAQSM is a sports medicine physician at Capital Region Orthopaedics (https://www.theboneandjointcenter.com/experts/todd-shatynski-md) and faculty with the sports medicine fellowship at Albany Medical Center in Albany, NY.  He is a team physician with University at Albany and with Triathlon Australia and also is an elite-level triathlete himself, having qualified and completed Ironman World Championships in Kona, Hawaii.

Series Editor: Andrew Getzin, MD is the head team physician for USA triathlon.  He is a USAT level 1 coach, many year USAT age-group All-American and has qualified and competed in Kona.  He is a fellow of the American College of Sports Medicine.  Dr. Getzin is the medical director of Cayuga Medical Center Sports Medicine and Athletic Performance in Ithaca, NY, www.cayugamed.org/sportsmedicine and the director of their shortness of breath in the athlete clinic, www.cayugamed.org/sob.