When the Hips Are Down

May 2, 2004
Outside Magazine
Outside magazine, January 1996

When the Hips Are Down

...even a simple stroll is a trial. How to keep the big ball-and-sockets rolling through the snow.
By Dana Sullivan

The hips are the postal workers of the human body: They'll diligently do their mundane yet essential duty year after year, unheralded and unnoticed--until one of them becomes "disgruntled," with disastrous results. Your hips are the strongest and most stable joints you've got. But take them too much for granted, and they'll become the joints most likely to put you out of commission. And if something's apt to snap, this is the season for it. The repetitive-motion nature of sports like skiing and snowshoeing, combined with the increased resistance of slogging through snow, makes winter particularly hazardous to the hips.

When the hips are ailing, a mere promenade around the block can be as taxing as a marathon. "Consider the hips the body's suspension system, and you begin to understand their importance," says Dr. P. Z. Pearce, a family and sports medicine specialist at Rockwood Clinic in Spokane, Washington, and team physician for the U.S. Triathlon Federation. "They're the hinges that connect the lower body to the trunk and, along with the pelvis, accommodate for the uneven terrain your feet constantly encounter." Without the rotational ability of these ball-and-socket joints, your ankles, knees, and spine would be forced to absorb the shock waves that rumble through you with every step. And just like the suspension on your car, the equal and opposite malady is also there: Throw your body out of whack anywhere, your suspension system becomes skewed, and your hips have to work overtime to compensate for the imbalance. "Too often, athletes and doctors alike dismiss pain in the hip area as simple groin strain," says Dr. Lyle Micheli, director of sports medicine at Children's Hospital in Boston and author of The Sports Medicine Bible (HarperPerennial). "But pain in the hips that lasts for more than a few days is worth investigating, because if it goes unchecked, it often becomes chronic." That's tough, since it's nearly impossible to give these joints total rest.

It's their fairly encased ball-and-socket construction that makes the hips impervious to most of the impact our athletic activities force on them. It takes significant trauma--a rock-climbing fall or cycling crash, for example--to fracture or dislocate a hip. Yet two of the most prevalent hip ailments, iliotibial band syndrome and trochanteric bursitis, are caused by plain old overuse, particularly common when your hips are struggling to correct an imbalance elsewhere in the upper or lower body. "The usual overuse-injury suspects are nordic skiing and running, since the lower extremities take a constant pounding on a hard surface," says Micheli, "and sports like alpine skiing and cycling, which require repetitive contraction of the powerful muscle-tendon units in the hips." So if you're going to put your hips through repetitive motions, better prepare them.

Loosen the Strings
Iliotibial band syndrome (ITB) is a bane that Pearce has all too much experience with outside the examining room. Ten years ago, the triathlete significantly upped his training mileage to prepare for the Hawaii Ironman. One day, intense, stabbing pain on the outside of his left knee preempted a long training run after only five miles. The diagnosis: One of the long, thick tendons that runs from the outer rim of the pelvis down the side of the thigh to the tibia, anchoring muscle to bone along the way, was the source of his problem. "The iliotibial bands are like bowstrings," Pearce explains. "Every time you bend and straighten your legs, the bows snap across the hipbones." If they're strung too tightly, the iliotibial bands can rub against bones, ligaments, and even other tendons in the hips. The resulting irritation causes pain and swelling.

Nordic skiers and runners seem to suffer from ITB more than other athletes, says Pearce, because all the force of their movements is absorbed one leg at a time, putting extra tension on the tendons in the thighs and hips. Running on sloped surfaces exacerbates the problem, as does a sudden increase in training distances. Cyclists, alpine skiers, rowers, and any athletes whose sports require continual hip flexion and extension are also at risk. "Though it's one of the most common sports medicine problems, ITB is also one of the most underdiagnosed," says Pearce. "It can manifest itself as pain in four places between the hip and the knee: under the pelvis, outside the boniest part of the hip, at the outside of the knee, or right where the tendon attaches to the tibia."

Fortunately, says Pearce, there are a few simple things you can do to reduce your chances of getting ITB. First, to ensure that your legs are of similar length, you may need heel lifts. (See "The Orthotics Option.") "If one leg is even a quarter of an inch shorter than the other," says Pearce, "it can eventually cause enough pain that it hurts to walk." Second, start stretching and strengthening your hips. (See "Tuning Your Body's Suspension," page 76.) The more flexible and fit they are, the less likely they'll be to rub against and irritate the surrounding tissue and bone.

Turns out that a minor leg-length difference was keeping Pearce out of the Ironman; custom orthotics and regular doses of hip work solved it. These days, the 43-year-old competes in one or two Ironmans annually, cycles 150 miles a week, runs about 45, and swims four or five, and he hasn't had a hip-related setback since his initial problem.

Spare the Bursae
If there's a dull ache and a snapping sound coming from the outside of your hips when you run or ride, the cause could be trochanteric bursitis. "Repetitive forward motion can cause the wide band of muscle that passes over the greater trochanters--the bony protrusions that we know as hipbones--to irritate the fluid-filled sacs called bursae that are actually there to help reduce friction between tissue," says Micheli. When the bursae become irritated and inflamed, pain sets in. That gruesome noise is the sound of iliotibial bands snapping over the greater trochanter.

Once again, it's runners who are particularly susceptible, and overpronators--Micheli estimates that one-third of the population pronates excessively--are sitting ducks if they don't take some preventive measures. Pronation causes the leg to collapse inward and pull on the pelvic structure, increasing the friction against the bursae. "If your car is out of alignment, your tires bear the brunt of the problem and quickly wear in an atypical way," says Dr. Timothy Moore, an exercise physiologist and fitness consultant at Exercise Science Inc. in Greenbelt, Maryland. "Likewise, if your hips are out of alignment, the muscles and the tendons in the pelvis grate on the bursae." Because rehab for trochanteric bursitis can be a long, losing process, Moore can't say enough about prevention. His preemptive solution to tronchanteric bursitis involves the same steps as Pearce's program for preventing ITB: alignment, stretching, and strengthening. As a last resort, your physician will probably recommend steroid injections and a sharply restricted training schedule.

Thankfully, most athletes should never have to worry about rehabilitating a hip--provided the joints get the recognition they deserve. In fact, as far as Pearce knows, a hip-overuse injury has never prematurely ended an athletic career.

Dana Sullivan wrote about preventing back injuries in the April Bodywork column.

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