Lateral Hip Pain? Time to Stop Blaming the Poor Bursa…

Lateral hip pain is a very common occurrence amongst the general population and even more-so for middle-aged women, who demonstrate a 4x higher prevalence then men. In fact, literature has found that 23.5% of women over the age of 50 indicate having persistent lateral hip pain (15% unilateral and 8.5% bilateral)1.

Pain in this region can be caused by various anatomical and neurovascular structures, from the sacroiliac joint to referral from the lumbar spine. However, among these potential structures, the greater trochanteric bursa has historically been to blame2,3 and is likely the most common source…

Or is it?

The beginning of the end for Trochanteric Bursitis started with a study conducted by Bird and colleagues in 20014. With the hypothesis that gluteus medius tendinopathy was the prevailing underlying pathology in lateral hip pain, they evaluated 24 patients via magnetic resonance imaging. The results very much fell in line with their hypothesis as 45.8% had a gluteus medius tear, 62.5% had gluteus medius tendinopathy, and only 8.3% presented with trochanteric bursal distension.

A 2007 study conducted by Silva and colleagues5 set out to further understand whether this persistent lateral hip pain can actually be blamed on an inflamed trochanteric bursa. This prospective, case-controlled, blinded study attempted to determine the histopathologic features of patients with greater trochanteric bursitis versus asymptomatic control subjects. Bursal specimens were obtained following each subject undergoing total hip arthroplasty on the involved hip. Two different blinded surgical pathologists evaluated the samples and found no signs of acute or chronic inflammation in the control or greater trochanteric bursitis groups. Unfortunately, this study had a few significant limitations. One being that it was an extremely small sample size (6 subjects) and the other being that all subjects were undergoing a THA on the involved hip.

Similar to the original article in 2007, Board and colleagues also compared pathohistolgical composition of the trochanteric bursa in individuals undergoing ipsilateral THA. However, this study was performed on a much larger scale with 100 subjects included (50 with greater trochanteric pain and 50 without pain in this region). Once again, this study found no evidence of acute or chronic inflammation in the 100 included subjects, however 20% of subjects in the ‘trochanteric bursitis’ group demonstrated thinning of the gluteus medius tendon6.

This led the authors to conclude…

It is perhaps best to view any involvement of the trochanteric bursae within Greater Trochanteric Pain Syndrome as a secondary event with the inciting initial pathology stemming from either involvement of the ilio-tibial band or from the ‘abductor cuff’ of the hip that is the gluteus medius and minimus tendons — Board et al., 2014

And to continue beating a dead horse, another study demonstrated more confirmatory findings. Long and colleagues7 more recently published a much larger study trying to answer the same question. This retrospective review of musculoskeletal sonographic findings of 877 patients with greater trochanteric pain demonstrated very similar results. Of the included subjects, 700 (79.8%) did not have trochanteric bursitis on ultrasound. The most commonly involved pathological conditions were gluteal tendinosis (438; 49.9%) and a thickened iliotibial band (250; 28.5%).

What’s in a name?

Lateral hip pain… Trochanteric Bursitis… Greater Trochanteric Pain Syndrome (GTPS).

Why does it matter what we call pain localized to the greater trochanteric region? When we think “-itis”, understandably we jump to the conclusion that this an inflammatory disorder and more specifically an inflammatory condition of the bursa in the case of trochanteric bursitis. This then leads to interventions that act to decrease inflammation of the involved structures. These conservative interventions likely start at NSAIDs and end at cortisone injections prior to the eventual progression to surgical interventions. When we look at the interventions studied in the case of GTPS, there is an overwhelming predominance of anti-inflammatory procedures. A systematic review of conservative treatment for GTPS included 8 studies (696 patients). Of these 8 studies, 6 investigated cortisone injections, 2 on extracorpal shockwave therapy, 1 on orthotics, and 1 on ‘home training’8.

That is right, there has yet to be a study looking at activity modification or physical therapy in the treatment of greater trochanteric pain syndrome (however there are two large studies currently underway). And the one study looking at ‘home training’ left A LOT to be desired. This lack of understanding related to the underlying pathology in GTPS has led to an over-reliance on anti-inflammatory interventions in the literature and in clinical practice.

Now that we have all but eliminated trochanteric bursitis from contention, maybe we can finally determine the best way to treat this complex condition…

References:

1. Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. 2007; 88(8): 988-992. doi:10.1016/j.apmr.2007.04.014.
2. Stegemann H. Die chirurgische Bedeutung paraartikularer Kalka-blagerungen. Arch Klin Chir. 1923; 125: 718-738.
3. Ege Rasmussen KJ, Fano N. Trochanteric bursitis: treatment by corticosteroid injection. Scand J Rheumatol. 1985;14:417–420.
4. Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis & Rheumatism. 2001;44(9):2138-2145. doi:10.1002/1529-0131(200109)44:9<2138::AID-ART367>3.0.CO;2-M.
5. Silva F, Adams T, Feinstein J, Arroyo RA. Trochanteric bursitis: refuting the myth of inflammation. J Clin Rheumatol. 2008; 14(2): 82-86. doi:10.1097/RHU.0b013e31816b4471.
6. Board TN, Hughes SJ, Freemont AJ. Trochanteric bursitis: the last great misnomer. Hip Int. 2014; 24(6): 610-615. doi:10.5301/hipint.5000154.
7. Long SS, Surrey DE, Nazarian LN. Sonography of Greater Trochanteric Pain Syndrome and the Rarity of Primary Bursitis. American Journal of Roentgenology. 2013; 201(5): 1083-1086. doi:10.2214/AJR.12.10038.
8. Barratt PA, Brookes N, Newson A. Conservative treatments for greater trochanteric pain syndrome: a systematic review. British Journal of Sports Medicine. 2016. doi:10.1136/bjsports-2015-095858.

Early Sport Specialization…

Growing up and playing competitive hockey, my goal was always to obtain a college scholarship and maybe, just maybe make it to that next level. So, I did what any other talented young athlete would do, listen to well-meaning coaches and scouts and focus all of my energy on MY sport at a young age. I thoroughly enjoyed playing hockey and was happy to play 2 hours, 5 times a week year-round…

My story of early specialization is all too common in competitive athletics. A recent study by Post and colleagues found that the vast majority of division 1 athletes that specialize early do so because…

The most common reason cited by athletes for choosing to specialize in their college sport was enjoying that sport the most. The second and third most frequent selections were having an opportunity to earn a scholarship to play in college and being the best at that sport, respectively. Only 9.9% (n = 34) of athletes cited parental influence as the most important factor in their decision to specialize in their college sport. — Post et al., 2017

All of these reasons make perfect sense, but do athletes who specialize early actually have more success than multi-sport athletes?

According to the same study, the prevalence of highly specialized athletes (year round training of > 8 months per year, chose a single main sport, and quit all sports to focus on a single sport) increased significantly from freshman (16.9%) to senior year (41.1%) of high school. In a separate study, amongst high school athletes, 29.5% classified themselves as one-sport athletes and 36.4% were considered highly specialized in their chosen sport. Based on this information, there does not seem to be a significant difference between division 1 athletes and the general high school athlete population with regards to specialization.

Furthermore, approximately 90% of 2016 and 2017 NFL draft picks played multiple sports during high school. In agreement with this trend, 100% of 2016 national college football award winners, including all 5 Heisman Trophy finalists, were not highly specialized or single-sport athletes in high school. And looking closer at the two teams who played in Super Bowl LI, approximately 87% of the players on both teams were multi-sport athletes in high school. The current evidence does not necessarily look favorable for the highly specialized athlete.

More importantly, how does early specialization impact risk of injury?

In order to be successful, you need to be healthy and the literature once again does not give favor to specialization. Athletes with high competition volume, who participated in a club sport, or who were highly specialized had 2.08 times greater odds of reporting a previous lower extremity injury than those with low competition volume, 1.50 times greater odds than no club sport participation, and 2.58 times greater odds in comparison to low specialization. Building upon this information, another study found that highly specialized athletes were more likely to report a previous injury of any kind or an overuse injury in the previous year compared with athletes in the low specialization group. Athletes who played their primary sport more than 8 months of the year were 1.68 times more likely to report an upper extremity overuse injury or 1.66 times more likely to sustain a lower extremity overuse injury. When looking at serious overuse injuries, highly specialized athletes were 2.38 times more likely than multi-sport athletes.

When looking closer at ice hockey, one of the most common areas of injury tends to revolve around the hip/pelvic region. Being that highly specialized athletes are 2.74 times more likely to sustain an overuse injury to this region, this should be an area of specific concern… 

Femoroacetabular Impingement Syndrome (FAIS) is an abnormal growth of bone localized to the femoral neck and/or acetabular rim. In the case of Cam morphology (increased bone growth on femoral neck), the prevalence significantly increases in ice hockey players as they age. Even when compared to a similar group of athletes (skiers), the ice hockey group showed a consistent increase in prevalence as age increases. While this altered morphology may not result in a painful condition, as a recent study showed prevalence of FAIS in 68% of ice hockey players with only 22% demonstrating symptoms. This increased prevalence of altered hip/pelvic morphology speaks to the repetitive nature of the sport (especially among goaltenders) and may predispose them to hip/groin pathology as their career progresses.

Moving to the psychological impact of sport specialization, there is also evidence to support increased levels of drop out in those highly specialized athletes.

Among ice hockey players, those who began off-ice training earlier and those that invested a larger number of hours training at a younger age were more likely to drop-out of their sport. This study showed that hockey players started playing at 5 years old and the athletes that ended up dropping out began off-ice training at 11.75 years old in comparison to 13.8 years old in those who continued playing. Additionally, those that continued playing their sport invested an average of 6.8 hours to off-ice training versus 107 hours per year in the drop out group.

Dropout can occur for any number of reasons spanning from psychological to physical factors. Studies looking into reasoning behind burnout in competitive tennis players found burned-out players had less input into training and sport-related decisions and practiced fewer days with decreased motivation. While sport specialization has not necessarily been linked to burnout, the underlying stressors related to the early and highly specialized athlete mimic those reasons for dropout.

Knowing the negative impact of early and high specialization in one sport, what can we as athletes, coaches, parents, and healthcare providers do? 

  1. Take a break. Actually take the off-season off and find another sport or passion during this time.
  2. Develop overall athleticism. There is a reason multi-sport athletes are generally more successful at higher levels. They have been exposed to different movements and stresses that their primary sport does not provide them.
  3. Listen to your body and your mind. Are you feeling burnt out or are you suffering from a nagging injury? Take the time to have these factors addressed… See a physical therapist, see a sports psychologist, or see the appropriate medical professional.
  4. HAVE FUN. Sports are meant to be a positive influence on your life, not a drain on you physically and mentally.

We as a culture need to make a change in how youth and competitive sports are positioned. The highly specialized athlete is not necessarily more successful, is more likely to sustain an overuse or serious injury, and demonstrates the psychological profile of those that drop-out of their sport. We need to embrace the need for varying experiences and movement activities. The literature is fairly definitive and we need to push our children, athletes, and coaches to focus on the enjoying their athletic career and on developing overall athleticism during this timeframe.

References:

1. Bell DR, Post EG, Trigsted SM, Hetzel S, McGuine TA, Brooks MA. Prevalence of Sport Specialization in High School Athletics: A 1-Year Observational Study. Am J Sports Med. 2016;44(6):1469-1474. doi:10.1177/0363546516629943.
2. Brunner R, Maffiuletti NA, Casartelli NC, et al. Prevalence and Functional Consequences of Femoroacetabular Impingement in Young Male Ice Hockey Players. Am J Sports Med. 2015;44(1):46-53. doi:10.1177/0363546515607000.
3. Fabricant PD, Lakomkin N, Sugimoto D, Tepolt FA, Stracciolini A, Kocher MS. Youth sports specialization and musculoskeletal injury: a systematic review of the literature. The Physician and Sportsmedicine. 2016;44(3):257-262. doi:10.1080/00913847.2016.1177476.
4. Feeley BT, Agel J, LaPrade RF. When Is It Too Early for Single Sport Specialization? Am J Sports Med. 2016;44(1):234-241. doi:10.1177/0363546515576899.
5. Gould D, Tuffey S, Udry E, Loehr JE. Burnout in competitive junior tennis players: III. Individual differences in the burnout experience. Sport Psychol. 1997;11:257-276.
6. Gould D, Tuffey S, Udry E, Loehr JE. Burnout in competitive junior tennis players: II. Qualitative analysis. Sport Psychol. 1996;10:341-366.
7. Gould D, Udry E, Tuffey S, Loehr JE. Burnout in competitive junior tennis players: I. A quantitative psychological assessment. Sport Psychol. 1996;10:322- 340.
8. Jayanthi NA, LaBella CR, Fischer D, Pasulka J, Dugas LR. Sports-specialized intensive training and the risk of injury in young athletes: a clinical case-control study. Am J Sports Med. 2015;43(4):794-801. doi:10.1177/0363546514567298.
9. Myer GD, Jayanthi N, Difiori JP, et al. Sport Specialization, Part I: Does Early Sports Specialization Increase Negative Outcomes and Reduce the Opportunity for Success in Young Athletes? Sports Health: A Multidisciplinary Approach. 2015;7(5):437-442. doi:10.1177/1941738115598747.
10. Myer GD, Jayanthi N, Difiori JP, et al. Sports Specialization, Part II: Alternative Solutions to Early Sport Specialization in Youth Athletes. Sports Health: A Multidisciplinary Approach. 2016;8(1):65-73. doi:10.1177/1941738115614811.
11. Pasulka J, Jayanthi N, McCann A, Dugas LR, LaBella C. Specialization patterns across various youth sports and relationship to injury risk. The Physician and Sportsmedicine. April 2017:1-9. doi:10.1080/00913847.2017.1313077.
12. Philippon MJ, Ho CP, Briggs KK, Stull J, LaPrade RF. Prevalence of Increased Alpha Angles as a Measure of Cam-Type Femoroacetabular Impingement in Youth Ice Hockey Players. American Journal of Sports Medicine. April 2013. doi:10.1177/0363546513483448.
13. Post EG, Bell DR, Trigsted SM, et al. Association of Competition Volume, Club Sports, and Sport Specialization With Sex and Lower Extremity Injury History in High School Athletes. Sports Health: A Multidisciplinary Approach. 2017;34:1941738117714160. doi:10.1177/1941738117714160.
14. Post EG, Thein-Nissenbaum JM, Stiffler MR, et al. High School Sport Specialization Patterns of Current Division I Athletes. Sports Health: A Multidisciplinary Approach. 2017;9(2):148-153. doi:10.1177/1941738116675455.
15. Post EG, Trigsted SM, Riekena JW, et al. The Association of Sport Specialization and Training Volume With Injury History in Youth Athletes. Am J Sports Med. 2017;45(6):1405-1412. doi:10.1177/0363546517690848.
16. Wall M, Côté J. Developmental activities that lead to dropout and investment in sport. Physical Education & Sport Pedagogy. 2007;12(1):77-87. doi:10.1080/17408980601060358.

Exercise Testing… What is it and why do I care?

Many trainers, let alone clients, do not fully understand the importance or purpose behind exercise testing. Many clients wonder, “why do I care what my body fat percentage or VO2max is?” These values, among others, allow a well-informed trainer to create an individualized and effective exercise program. Without knowing these parameters, a trainer is playing a guessing game trying to determine what their client needs, which can lead to missing a key area of potential improvement. Goal setting, both long-term and short-term, is nearly impossible without knowing where your client is starting and where they can reasonably progress in a given period of time. If a trainer makes the assumption that their client can look like they did in high school without taking into consideration their current fitness level, it can be a recipe for disappointment. These testing procedures also allow the client to see their progress over time, which is both a major motivational tool for the client and it gives the trainer the opportunity to see what is and is not working. If you can see your improvements aesthetically, internally, and quantitatively, you should be more inclined to stick with an exercise program.

So, what’s involved in the testing?

This is far from an all inclusive reference, but is meant to be more of a brief overview of the basics that should be involved. Other tests may be included or excluded based on the client’s preliminary goals (athletic performance, weight loss, muscular strength, ect.).

1. Resting Vital Signs

Included in this section are primarily resting measures of cardiovascular function. This typically includes resting heart rate and blood pressure. Heart rate is measured by palpating the radial artery and counting the number of beats felt during a one minute time frame. This can be used to identify abnormal heart rhythm or excess/diminished pumping of the heart. Blood pressure refers to the pressure exerted on the blood vessel walls during contraction/pumping (systolic) and rest/filling (diastolic) of the heart. This is the determining factor in diagnosing hypertension, which increases the risks of several serious conditions (stroke, retinopathy, heart disease, diabetes, ect.). Hypertension is defined as a systolic BP > 140 mmHg and/or a diastolic BP > 90 mmHg. These two assessments are typically the most simple to obtain, but their importance in determining an individual’s cardiovascular fitness and health cannot be overlooked.

2. Body Composition

Body weight, BMI (Body Mass Index), girth measures (hip and waist), and percent body fat are all components of a thorough body composition assessment. BMI is determined by comparing an individual’s body weight with their height. While this is a viable option for categorizing large groups of people, it is not a valid option for determining the composition of one individual because it does not take into consideration muscle mass or bone structure. For example, someone can have a body fat percentage of 5%, but be classified as obese because of their increased body weight due to muscle mass. The primary purpose for recording girth measurements is to determine an individual’s waist to hip ratio, which shows the proportion of body fat distributed in the abdomen. The greater the amount of relative body fat distributed in the upper body leads to a greater likelihood of developing hypertension, metabolic syndrome, type 2 diabetes, dyslipidemia, and coronary artery disease. The most telling measurement for body composition is percentage of body fat because it takes into consideration all aspects of an individual’s physical makeup. In general, the most practical way to determine body fat percentage is the use of skin fold calipers. This is because the proportion of sub-cutaneous (directly below the skin) fat directly correlates with total body fat.

3. Cardiovascular Fitness

Testing procedures will typically involve the use of a treadmill (walking or running), stationary bike, or step testing. The determination for mode of testing will be based on the client’s comfort with a specific activity, musculoskeletal limitations, or what is most readily available to the trainer. Regardless of the specific test, the purpose remains the same, to determine the maximal oxygen uptake of the client (VO2max). This measure is calculated by finding the relationship between a client’s heart rate and the specific workload at which it was elicited. This value represents an individual’s ability to utilize oxygen during exercise and is the “gold standard” for determining an individual’s cardiorespiratory endurance. This value can be obtained directly in a clinical graded exercise test that most accurately measures the physiological responses of the individual’s body. The direct measurement of maximal oxygen uptake is based on the equation VO2max = Q(A-VO2 diff). Q refers to cardiac output, which is the total amount of blood pumped through the body in one minute. While A-VO2 is the difference between arterial and venous oxygen content. While the direct measurement is the more accurate, it is not always practical due to the excessive cost and time requirement for client and patient alike. In most cases, a trainer will elect to use a field test to predict their client’s cardiovascular fitness. These tests can include running a predetermined distance/time at the client’s own pace or using a submaximal graded exercise test, which increases the intensity or speed at consistent intervals.

4. Muscular Endurance and Strength

Muscular endurance refers to an individual’s ability to lift a predetermined amount of weight as many times as possible while maintaining proper form and rhythm. This is typically achieved by performing as many push-ups, sit-ups, or repetitions of a specific weight for bench press or leg press. Whereas, muscular strength is the ability of an individual to lift the maximal amount of weight that they can for a predetermined number of repetitions, which is often called their one repetition max (1-RM). This value can be predicted using various equations/tables if an individual cannot physically handle the stress of a 1-RM test or adequate weights/equipment are not available. Both endurance and strength values are used to determine areas of weakness and in order to predict proper load for their resistance training program. This is typically determined based on a percentage of their 1-RM and is the most accurate prediction of proper training load. While determining the proper load based on 1-RM is not a perfect science, it does eliminate a lot of the trial and error involved in finding the appropriate weight for resistance training exercises.

5. Flexibility

Flexibility is an often-neglected area of an individual’s exercise program, however its importance cannot go unnoticed. Flexibility is an individual’s ability to move a joint through its complete range of motion (ROM). When one thinks of this measure, they typically are drawn to the vision of a ballet dancer or hockey goaltender, however it also has implications in everyone’s activities of daily living. Limited ROM can predispose an individual to musculoskeletal injury and disability with even the most simple of everyday tasks. Regardless of age or starting point, anyone can improve or maintain their flexibility with a safe and effective stretching routine. Base-line measures can show areas of impairment and needs for improvement, which allows for the creation of the most appropriate program.

Typical measures included in most flexibility testing include both the sit and reach for an assessment of general flexibility and goniometric measure for a more joint specific test. Both of these measures should be used for a thorough appraisal of flexibility.

The use of an exercise testing regimen gives both personal trainer and client a snapshot into all aspects of an individual’s physical fitness. By having this information in hand, a trainer and client can sit down and most efficiently improve any areas that may be deficient. Also, when routinely reassessing these measures, you can see first hand the progress that you are making during your exercise program. All of these measures are highly modifiable with proper exercise programming and nutritional counseling regardless of age, sex, or baseline level. When you can see a numerical value to work towards, it gives you more confidence and a sense of pride once your goal is achieved.

References:

1. Ehrman JK. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2010.
2. Thompson W. ACSM’s Guidelines for Exercise Testing and Prescription. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2010.
3. Reynolds M, Gordon T, and Robergs R. Prediction of One Repetition Maximum Strength from Multiple Repitition Maximum Testing and Anthropometry. Journal of Strength and Conditioning Research, 2006, 20(3), 584–592.
4. Wilmore JH, Girandola RN, Moody DL. Validity of skinfold and girth assessment for predicting alterations in body composition. Journal of Applied Physiology, 1970, 29 (3), 313-317.