FIX HIP PAIN F O R GOOD IDENTIFY IT, TREAT IT, AND MAKE SURE IT NEVER COMES BACK Jason Suarez Jason

RUNNERSWORLD.COM 45 INJURY No_ 1 MUSCLE STRAINS AND TENDINOPATHY

These account for about a third “You can of all hip pain in runners. Strains, or pulls, often occur in the top of the hamstrings, the iliopsoas, the rectus femoris, and the adduc- tors, while the gluteal tendons are have prime targets for chronic damage and inflammation. Both are gen- erally a function of muscle imbal- ances, which are typically caused by a lack of side-to-side training. “If [these muscles] are weak, they surgery are constantly doing a tug of war, under load, while contracting,” says American Physical Therapy Association spokesperson Robert Gillanders, PT, DPT. That tug is ex- acerbated by big jumps in training or stop volume or intensity. SPOT IT > Muscle strains and ten- dinopathy both cause moderately sharp localized pain, swelling, weakness, and stiffness, says Jan- et Hamilton, CSCS, an exercise .” physiologist with Running Strong in Atlanta. They typically develop slowly, but if you trip on the trail, He actually put it in slightly gentler terms, but to trim down the bone and repair the labrum, muscle and tendon tears can hap- those were the options my orthopedist gave me last have increased as much as 25-fold over the last pen in a second, causing strong, summer. Nearly a year earlier, I had started feeling decade, particularly among athletes in their 20s piercing pain as well as bruising. sharp, stabbing pains in my groin. During runs, the and 30s. Olympians Emily Infeld and pain sporadically went nuclear, and my leg would both had procedures to address impingements TREAT IT > Ice for 10 minutes, give out. Even walking, I needed frequent breaks. and torn labrums before hitting 30. several times a day, and limit ac- I took six months’ rest from running and focused The rise in hip repairs is due in part to doctors tivity until your symptoms sub- on gentle resistance training to strengthen my getting better at diagnosing and treating hip side, then ease back into normal- hips and core. When that didn’t help, I did three problems. “Our understanding of hip pathology distance runs. Mild muscle strains months of physical therapy. But the pain worsened, has improved dramatically over the past several can take three to six weeks to morphing into a dull, almost constant ache in the years,” says Shane J. Nho, MD, director of the Hip fully heal, tendons can take six base of my left butt cheek. Preservation Center at Rush University Medical weeks to several months. Avoid An MRI in September showed that I had femoro- Center in Chicago, and my surgeon. But, he adds, “IT WAS SURPRISING, LIKE nonsteroidal anti-inflammatories acetabular impingement (FAI), a deformity in the running is by nature repetitive, high impact, and (like ibuprofen) if possible, since hip joint that causes the bones to rub against each significantly loads the hips. Genetics may also inflammation actually prompts other. I had also torn the labrum, the cartilage that make some runners more susceptible to injury. WOW, I USED TO BE ABLE healing, Hamilton says. Significant lines and protects the hip socket. That’s when my With that greater understanding of the hips tears require surgery. orthopedist gave me my ultimatum. also come significantly better recoveries—as in, TO RUN 100 MILES A My case is hardly unique. Sports medicine phy- you don’t have to stop running. Take racer Sybil PREVENT IT > Strength-train at least sicians are seeing a dramatic rise in the number Shapiro, who had her hip replaced at age 39. Two WEEK AND JUST LIFTING twice a week with an emphasis on of young (I’m 33), otherwise healthy athletes years later, she’s setting masters PRs, which bodes eccentric lower-body exercises developing hip pain. A quarter of runners ages well for all of us with aching hips. On my own path MY LEG UP TO GET OUT OF (like slowing the lowering phase 26 to 50 reported strained hip muscles in a 2019 to recovery, I spoke with leading experts and dug of your squats to three or four sec- survey. And research suggests that running is one into the research to figure out exactly what you BED IS REALLY PAINFUL.” onds) to improve your muscles’ and of the most common sports associated with hip need to know about how to identify, treat, and tendons’ ability to lengthen under and groin pain in women. Rates of hip arthros- even prevent the most common hip injuries in  2008 Olympic Marathon, tension without pulling apart.

copy, the keyhole procedure I ended up having runners.—K. Aleisha Fetters, CSCS Luis Sinco/Los Angeles Times via Getty Images 2009 hip flexor and groin muscle strain

46 RUNNERSWORLD.COM RUNNERSWORLD.COM 47 “THE IMPINGEMENT FOLLOW THESE grass, sand, track, pool) can strength- INJURY ITSELF NEVER FELT TOO TRAINING RULES OSTEOARTHRITIS en the supporting muscles without ex- TO STRENGTHEN No_ 3 cessively loading the joint and causing BAD, BUT IT CAUSED HIPS—AND THE pain and further joint damage, says MUSCLES THAT “Wear and tear” arthritis is less com- Paul Sorace, MS, CSCS, a fellow of IMBALANCES. I HAD SURROUND THEM mon in active marathoners than it is in the American College of Sports Med- the general population, according to icine. Even a softer shock-absorbing SOME REALLY WEIRD research from the Rothman Orthopae- insole can help. dic Institute (loading the joint may im- To further head off hip pain and ADDUCTOR ISSUES—IT MOVE TO THE SIDE prove its health by strengthening the eventual replacement, many doctors surrounding muscles). But in runners offer injections such as steroids, or HIP Performing lateral and with structural hip abnormalities such regenerative treatments. In platelet- FELT LIKE LIGHTNING external-rotation hip exercises strengthens as FAI, osteoarthritis in the hip can rich plasma (PRP) therapy, doctors BOLTS GOING UP AND the gluteus medius and crop up as early as age 40, says Peter inject your own blood, minus the red ANATOMY minimus—the muscles Moley, MD, a physiatrist with New blood cells, into the joint. In stem DOWN MY LEG that stabilize your hips as York’s Hospital for Special Surgery. cell therapy, they use cells from your The hip is the largest you bound from one foot 101 to the other, says Gilland- bone marrow. Some patients experi- weight-bearing joint in your DURING LONG RUNS. ers. These muscles are SPOT IT > Joint stiffness; poor range ence improvement with these thera- body; when you run, it can often weak in runners. of motion; and at least three months pies, but more research is needed to absorb three to six times your AARON BRAUN  Retired pro of deep, aching pain after sitting or prove their effectiveness—and to get body weight, says Scott Pa- runner and cross-country coach at Sacramento State, hip impinge- running or at the end of the day are insurance to chip in, says Harrison luska, MD, a sports medicine ment diagnosis in 2015 WORK YOUR CORE common symptoms, says Paluska. Youmans, MD, a sports medicine specialist at the University of Your core is a complex X-rays can confirm suspected arthritis. specialist with Orlando Health. Illinois at Urbana-Champaign. series of deep muscles The first step in protecting around your trunk and TREAT IT > Most flare-ups will abate PREVENT IT > Treating any existing hip the joint? Understanding it. pelvis that provides with RICE. In the long run, low-impact injuries or imbalances is key. Try to stability when running. Weakness in this system strength-training, and switching to maintain a healthy weight to further can throw off trunk softer running surfaces (treadmill, reduce stress on the hip joint. positioning, stressing the 1. FEMUR 4. HIP ADDUCTORS hip joint and overworking The “ball” of the ball-and- These muscles run along certain muscle groups, socket hip joint, your femur the inside of your leg, from such as the hip flexors attaches to many of the the groin to just above the and abductors, says “I WISH I WOULD hip’s strongest muscles and knee. When you’re running, Scott McAfee, PT, DPT, absorbs impact with each they pull your thighs a physical therapist with foot strike. It should glide toward each other to help MovementX and the HAVE LISTENED TO easily in the hip socket, but control your leg swing. Formula Running Center running’s repetitive nature in Arlington, Virginia. can contribute to bone 5. ILIOTIBIAL BAND Increasing your core THE PEOPLE AROUND deformities (such as FAI)— A thick tract of fascia, or exercises—such as dead- as well as muscular im- connective tissue, that bugs, planks, and hollow ME A LITTLE BIT balances—and can cause runs along the outside of holds—in your routine painful irritation on the the leg. When you run, is also vital. To improve femur’s bony protrusions. muscles in the hip add ten- core activation when MORE AND BELIEVED sion on the IT band to keep running and optimize 2. LABRUM your hip and knee moving your overall mechanics, The rubbery cartiliage in sync. he recommends altering THAT REST IS OKAY. lining the acetabulum, the your upper body so deep circular socket in the 6. HIP EXTENSORS that you’re leaning slight- IT’S TOUGH.” pelvis. The labrum makes When running, these back-

ly forward, up to n) the joint strong and stable, of-the-hip muscles (includ- 10 degrees.  and helps the femur glide ing the gluteus maximus 2004 Olympian in more easily. If the femur and hamstrings) allow you INJURY the 1500m, osteitis pubis pinches against the labrum to drive forward. from a 2004 fall (which it often does, No_ 2 though it may not cause 7. HIP ABDUCTORS pain), the protective tissue The gluteus medius, mini- Femoroacetab- SPOT IT > Start with the FADIR test: Lie flat on therapy can curb discomfort. PT can also deter- can tear, increasing the risk mus, and tensor fasciae HIP IMPINGEMENT ular impinge- your back, draw your knee toward your chest, mine a safe range of motion to avoid pinched for pain (especially when latae are among your ment (FAI) is a gently press your knee across your body, then positions when running or cross-training. In running) and arthritis. most important hip injury mismatch in the rotate your foot as far out and away as possi- some cases, surgery is needed. fighters. They stabilize 3. HIP FLEXORS the pelvis, keep the knees shape of the femur (ball) and the acetabulum ble. A pinch in the front of your hip is a sign of This muscle group (it from caving in, and prevent (socket), which causes them to beat up the possible impingement, but you’ll need an MRI PREVENT IT > FAI is believed to be partially includes the quads and the hip drop. But they’re also joint’s protective cartilage (labrum) and, over from an orthopedist to confirm. genetic. But core and hip strength work like iliopsoas) brings the leg among the most neglected time, contribute to degenerative osteoarthritis. monster walks, single-leg deadlifts, and dead- forward for each stride. muscles in runners. FAI is a leading cause of hip pain for athletes TREAT IT > Correcting muscle weaknesses and bugs will give your body more control and power in their 20s and 30s. abnormal movement patterns through physical to protect the hip and help prevent injury. Rabbitwolf Creative (Braun); Stu Forster/Getty Images (Tollefso

48 RUNNERSWORLD.COM RUNNERSWORLD.COM 49 “I FELT LIKE “I TRIED RESTING FOR THREE MONTHS AND I HAD PULLED MY RECEIVED LOTS OF MANUAL TREATMENTS, LIKE CHIRO HIP FLEXOR AND AND MASSAGE, NONE OF WHICH SEEMED TO HELP. I TRIED COULDN’T PULL MY INJURY A CORTISONE INJECTION, WHICH ALSO DIDN’T OFFER LEG UP. I WOULD No_ 5 BURSITIS RELIEF. IT WASN’T UNTIL I STARTED DOING START TO RUN AND More than a dozen little fluid- filled sacs, called bursae, are HIP FLEXOR STRENGTHENING EXERCISES TO STRENGTHEN THEN I FELT LIKE a cushion between your hip bones and neighboring soft THE AREA THAT I BEGAN TO GET RELIEF. AFTER A FEW MY LEG WAS tissues. Repetitive motion, along with muscle imbalances WEEKS OF STRENGTHENING I WAS ABLE TO RESUME TRAINING, DRAGGING.” or poor form, can inflame any one of them. Issues most EMILY INFELD  AND GRADUALLY THE PAIN DISAPPEARED.” 2015 World Championships often arise at the side of the Bronze Medalist in the 10K, hip, and are four times more RYAN HALL  2008 and 2012 Olympic Marathons, 2013 hip bursitis 2017 labral tear common in women, says Paluska. The iliopsoas bursa (the front of the hip) is an- other prime target for inflam- mation.

SPOT IT > Inflamed bursae ache, feel warm and tender to touch, and get angrier with hill running or sprint- ing. The most common diag- nostic method: injecting the bursa that’s suspected to be inflamed with numbing lido- For a workout caine. If the pain goes away, that protects hips from injury —or helps there’s your answer. MRIs you come back stronger are a less invasive but more from one—visit time- and cost-intensive tool. RUNNERSWORLD .COM/HIPS-FIX TREAT IT > Visit a physical therapist who specializes in running to see if strength deficits, faulty running gait, l) inadequate balance, or all of the above are to blame INJURY for the inflammation. When No_ 4 paired with corrective exer- A torn labrum is most may hear a clicking as the loose labrum moves cises, RICE and injections can LABRAL TEAR commonly caused by over bone, says Youmans. help ease inflammation. In FAI in younger runners, stubborn cases, surgeons can as it places them at a TREAT IT > Start with rest and physical therapy remove the swollen bursa. It higher risk for injury or increased wear and that includes strengthening the hip and core will grow back after several tear, says Kristin Morrison PT, DPT, COMT, my (fire hydrants, stir-the-pots), Nho says. Steroid months. therapist at IMPACT Physical Therapy in Chica- injections can curb the pain; if they don’t, you go. Hip dysplasia, a genetic condition in which may need surgery. PREVENT IT > Strengthen your the hip socket is too shallow to fully cover the hips in all planes of motion femur, can also tear the labrum. PREVENT IT > Warm up the muscles protecting with single-leg deadlifts, the joint with monster walks, single-leg bridges, monster walks, high-knee SPOT IT > Labral tears can cause sharp or dull deadlifts, and clamshells to help reduce midrun raises, fire hydrants, and lying REST DAYS? TAKE REST MONTHS Taking two to three months off from running (it doesn’t have to be all at once) each year can do wonders groin pain and a limited range of motion. You grinding. inner-thigh lifts. for your hips, according to Paluska. Spend that time focusing on strength-training, swimming, yoga, climbing, or other forms of cross-training to address some of the repetition and muscle imbalances that are often caused by running. David Jaewon Oh (Infield); Jonathan Moore/Getty Images for ASICS (Hal

50 RUNNERSWORLD.COM “I’M OF THE OPINION THAT STRAIGHT REST WON’T HELP BECAUSE IF YOU TAILOR YOUR INTENSITY DON’T FIX THE UNDERLYING PROBLEM, Speedwork and hill- work require the hips YOU’RE JUST GOING TO KEEP RUNNING to exert and absorb greater forces, which can contribute to pain, INTO THAT PROBLEM. A BIG THING says Hamilton. Your high-intensity train- FOR ME WAS FINDING A VERY GOOD ing—anything at 5K pace or faster—should INJURY account for no more PHYSICAL THERAPIST THAT than 7 percent of your No_ 6 total weekly mileage. UNDERSTOOD BIOMECHANICS. HE’S If you’re training at 10K STRESS FRACTURE to marathon pace, your hard miles can count for GOING TO HELP YOU MOVE THROUGH about 15 to 20 percent About two-thirds of hip stress of your training. YOUR OWN WEAKNESSES TO HELP fractures in runners are caused by excessive mileage, PREVENT A PROBLEM AGAIN.” and the injury is significantly more common in women. Be-  Second at 2020 Olympic Marathon Trials, cause stress fractures develop 2016 and 2017 sacral stress fractures slowly, they can take a long time to diagnose; untreated, they may develop into full breaks.

HIP-SAVING GEAR SPOT IT > Pain is usually sharp when walking, running, or 1 2 3 4 jumping, and may feel dull the rest of the day. “It is not ALTERG ANTI-GRAVITY GLUTE LOOP HYPERVOLT GAME READY GRPRO 2.1 uncommon for it to present TREADMILL Resistance bands help Used between manual and SYSTEM WITH HIP WRAP G (AlterG; Courtesy (Hypervolt); Trevor Raab (Seidel); Suarez Jason symptoms at rest and at Using NASA technology and challenge and isolate the physical therapy sessions, this Combining compression night,” says Moley. You’ll need a pressurized, waist-height air gluteus medius and minimus. massage gun increases blood- with cold therapy, this an X-ray and likely an MRI to chamber, this treadmill can This one from top glute expert flow and releases tight glutes machine speeds injury recov- confirm a stress fracture. reduce your body weight by Bret Contreras, PhD, CSCS, is and hamstrings. As Nho’s current ery, reduces swelling, and up to 80 percent so you can made from a thick elasticized research is showing, hip pain can help you avoid taking TREAT IT > Rest for four to six run without overloading a fabric that doesn’t rip, fold, or can cause the other healthy hip pain medications. weeks and do low-impact ex- compromised joint. When bunch up. $20 to work overtime. Do not use on $2,800 to buy, $420 for ercise like cycling and swim- scouting out physical therapists inflamed or strained tissue or a 4-week rental ming for another four to six. for an injury that requires a suspected stress fractures. $349 Then ease back into walking long hiatus from weight-bearing and running, Hamilton says. exercise and running, look for a clinic with an AlterG. PREVENT IT > Ramp up your mileage or intensity gradually, sticking with a “no more than 10 percent increase per week” rule. A bone-mineral density lute Loop, Game Ready) Game Loop, lute test can help determine if you need improved nutrition (more calcium and vitamin D) or medications to reduce your risk of breaks.

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