Muscle Medicine: The Revolutionary Approach to Maintaining, Strengthening, and Repairing Your Muscles and Joints (32 page)

Looking at the hip as an integrated system of muscle, joint, and bone has, over the past decade, changed the way the top specialists diagnose and treat it. Two questions in particular troubled doctors. Why were so many well-conditioned athletes straining or tearing their abdominal and adductor (inner-thigh) muscles, the so-called sports hernia? Why were so many older people losing their hip function to osteoarthritis and needing hip replacement surgery? One’s a muscle problem, one’s a bone problem, and yet there was an emerging common link: what happens inside the hip joint. A recently appreciated source of hip pain is called femoroacetabular impingement. The ball of the femur can’t move around properly because of bony bumps on the femoral ball, or friction against the hip socket. This alters the way the body’s entire midsection moves, straining the abdominal and the adductor muscles, making them vulnerable to tearing. Over time, an impinged hip can tear the supporting labrum, which can lead to bone-on-bone friction, then to arthritis, which can eventually result in a hip replacement.

IMMEDIATE TREATMENT/WHEN TO SEE A DOCTOR

The hip is a sturdy joint, so if you feel a sudden pop or experience the onset of sudden severe pain, it could be something serious such as a tendon or a labrum tear. See a doctor sooner rather than later. It usually takes a severe trauma such as a high-speed car accident to dislocate the hip (where the femur comes out of the hip socket), so if that happens, you’ll find yourself in the emergency room anyway. As with any joint problem, check for any signs of infection—redness, heat or fever, pain not connected to changes in activity. If there are any, see a doctor immediately. When the dire possibilities have been ruled out, you can assume you’ve got some kind of soft-tissue damage, usually a muscle or joint strain or sprain. The normal rules of RICE apply: Rest (keep weight off the area); Ice it; keep inflammation down with Compression (a compression bandage or bike shorts, which can contain the ice); and Elevation (bring the affected area above the level of your heart). It’s your call whether you want to seek out a doctor or muscle therapist right away, but if you still can’t put weight on your leg after one or two weeks, it’s time.

Combining the most advanced orthopedic surgical procedures with the most effective manual therapeutic techniques, we have created a state-of-the-art approach for dealing with the entire range of hip problems. These include the problems that require surgery (and receive muscle work before and after), and the ones that can successfully be treated, and self-treated, by working on the muscles only—no scalpel or arthroscope required.

WHAT GOES WRONG, AND HOW TO FIX IT

Mostly Muscular

Groin Pain

Amy is a successful, disciplined Manhattan woman in her early thirties who works in the financial industry. She takes her running seriously. But for the past several months, she’s been bothered by groin pain when she runs. She tried to run through

COMMON PROBLEMS AND CULPRITS

The iliopsoas and the rectus femoris are two muscles that flex the hip exclusively, bringing the thigh up toward the torso. The rectus femoris is a big, visible muscle that gives definition to the front of the thigh. But the ropy iliopsoas (actually, three muscles that merge: the psoas major and minor and the iliacus; see page 197), buried deep in the pelvic region, is the more common troublemaker. The psoas major originates on the lower third of the spine and runs from the front of the spine to just inside the top of the femur, or thighbone, in the groin area. If it tightens up, it can painfully press against the hip capsule, which protects the hip joint, causing front-of-the-hip pain. If the iliopsoas fatigues and shuts down, it forces the rectus femoris to overwork, causing front-of-the-hip thigh soreness and irritation. Or it can shorten and pull the spinal column forward, forcing the back muscles to constantly pull back to keep the spine straight. The result: lower-back spasm and pain.

The seven adductor muscles of the inner thigh bring the leg toward the center of the body and also help with stabilization. The kind of lateral motion demanded by such sports as soccer, tennis, basketball, and hockey is tough on the body’s lower half. Not only are the adductors prone to strain and tear (so-called groin pulls), causing soreness in the groin area, but a major abdominal muscle, the rectus abdominis, can strain at the same time. Then you’ve got a more serious, harder-to-heal, and still not entirely understood condition called athletic pubalgia (or sports hernia).

Two versatile muscles that run along the outside of the hip, the gluteus medius and minimus, abduct the leg, that is, they bring the leg out to the side of the body. They too can become strained, causing soreness in the outer-hip area and symptoms that can mimic sciatica. A small neighboring muscle that helps externally rotate the hip, the piriformis, can entrap the sciatic nerve and send pain shooting down the posterior leg. Besides piriformis syndrome, and pseudo-sciatica from the glutes, a number of other less common and often hard-to-diagnose nerve entrapment syndromes in the hip area can deliver pain and numbness to the groin and legs.

The large muscles that cross the hip and the knee from behind are easier to assess. The gluteus maximus is the muscle that gives the buttock its rounded shape. It helps to attach the pelvis to the femur. The hamstrings run down the back of the thigh, connecting the pelvis to the femur and lower leg bones. Together, the gluteus maximus and the hamstrings pull the upper and lower leg backward, the power stroke that assists walking
and running. The gluteus maximus is quite resilient and hard to tear. The worst you’re likely to get is sore if you overdo running or cycling up hills. That’s not the case with the hamstrings, which are probably strained more often than any other muscle group in the body. The hamstrings provide a decelerating force, stopping the hip from over-flexing during the gait cycle, by balancing and controlling the forward pull of the quads. This decelerating force, which involves contraction and lengthening at the same time, is stressful to the muscles fibers and can often result in injury.

the pain, but it only got worse. She went to her internist, who diagnosed a groin pull and sent her to a physical therapist, who helped her to strengthen her core muscles. But that only caused the pain to flare up. Then the internist ordered an MRI of her lumbar spine, which showed a slight bulge in one of the spinal disks, so he sent her to a neurosurgeon. The neurosurgeon didn’t think the bulge was all that interesting, so he sent her back to physical therapy to strengthen her back muscles. Finally, the groin pain lessened, and desperate to get back to her running routine, Amy returned to the Central Park Reservoir track. Before she’d finished her first lap, that familiar aching pain returned to her inner thigh.

When you strain a muscle once, the odds are you’ve simply overdone it. You’ve asked the muscle to fire too hard or too fast. (RICE should take care of the problem.) When a muscle or a group of muscles strain repeatedly, your body is trying to tell you something. Something about the way the muscles, joints, and bones mesh in movement is setting you up for pain. It could be a problem with your form— something you can change, such as the way you carry your arms or which part of the foot you land on. Or it could be “biomechanical,” for instance, the way your hip rotates or your foot turns in when you run.

Amy had something more than a garden-variety groin pull. Both her abdominal and adductor (inner thigh) muscles were severely irritated and fatigued. In the elite male athletes that Dr. Kelly often studies and treats, this syndrome is called athletic pubalgia (or, popularly, the sports hernia), and femoral acetabular impingement, or hip impingement, is an increasingly recognized reason those muscles are under such strain. But Amy’s hip didn’t look that bad. The problem is that normal running motion creates extra twisting forces in the hip joint when the leg strikes the ground. This occurrence is not as common in men, but women generally have a
wider pelvis, creating a greater angle of the femur (in sports medicine lingo, they have a wider “Q angle”), and that puts the abdominal muscles and hip joint under greater tension. For a significant number of women joggers, the abs and the adductors have to work overtime to stabilize the lower back and the hips. The result can be the disabling groin pain that sent Amy on her medical merry-go-round.

So the treatment emphasis was to manually release tension in the abdominals and these two muscle groups of the hip, the adductors and the abductors. (Recall that the abductors primarily bring the leg out to the side; the adductors bring the leg in toward the midline.) After several sessions, the muscle fibers had relaxed and normal blood flow had returned to the area, speeding the body’s natural healing. Amy was able to resume running. With the muscle damage repaired, she was able to go through a successful course of physical therapy. Strengthening her core muscles is the best assurance the problem won’t return.

Front-of-the-Hip Pain: Hip Flexor Tendinitis

Joe, thirty, was a solid power forward on his high school basketball team, and although he wasn’t powerful (or tall or quick) enough to make his college team, he played intramural ball and then rec league hoops when he went to work on Wall Street. One winter, the normally hearty Joe began to suffer twinges of hip pain as he ran up and down the court. At first, only the running irritated the hip, but after a few weeks he felt a jolt of pain in the left hip when he got out of bed in the morning. If he sat too long at work, he had to walk off that achy, cramped feeling. Joe’s orthopedist ruled out joint injury and sent him to a physical therapist to address the hip tendinitis. At first, the PT “modalities”—whirlpool, ultrasound, and electrical stimulation—calmed down the inflamed area. But then he felt a familiar tightness when he tried to strengthen the leg on the exercise bike, and a return to the basketball court brought back the old pain.

Joe’s story illustrates the importance of the “kinetic chain,” the linkage of muscles and joints that allows us to move. When one important link in the chain is damaged, the body has to compensate, and invariably the trouble is passed up or down the line. In Joe’s case, the bad link is the iliopsoas group, the muscles buried deep in the pelvic region that pull the thigh up and out. Joe’s iliopsoas was so fatigued from his sudden increase in activity, it had practically shut down, shifting the burden of flexing the hip to the rectus femoris, a long muscle that runs
down the thigh from the hip bone to the knee. In turn, this thigh muscle became so overwhelmed, it tightened up, tugging against the tendon that attaches it to the hip bone. The problem inflamed the surrounding tissues and hobbled Joe on the basketball court.

Manually treating Joe, Dr. DeStefano worked on the iliopsoas and the rectus femoris and a couple of smaller muscles that help out with hip flexion, in addition to chiropractic treatments. But just as important, he worked with Joe to get at the root of the breakdown. Joe’s overall muscular fitness had been in decline since college and had taken a steep dive two years before when he and his wife had a child. Joe still had the self-image of an athlete and enough “game” to be a threat on the court. But without the conditioning base provided by constant physical activity, his muscles had lost the strength and resilience they needed to handle the stress of Joe’s jumping from a sedentary lifestyle to his winter regimen of basketball two nights a week. His setup at work did him no favors either. He was always swiveling to the left to answer his phone, which, over time, had tightened up one side of his lumbar spine, an imbalance that contributed to his psoas woes.

After the hip flexors had healed—and the desk was rearranged—Joe went to a talented physical therapist for a couple of weeks of targeted flexibility and strength work. Subsequently, Joe teamed up with a good personal trainer, building enough gym time and all-around conditioning into his busy schedule so that he could hit the basketball court without its hitting back.