Hip Labral Q&A: Hip or Pelvic Pain – The Chicken or the Egg?


Hip Labral Q&A: Hip or Pelvic Pain: The Chicken or the Egg? Not familiar with HLI? Read my recent post on Four “Must Know” tips for identifying HLI

Overview: Rehab is necessary for HLI

Hip labral injury (HLI) is a relatively new diagnosis in the last 10 years of orthopaedic and rehabilitative care. However, just because HLI is a new diagnosis doesn’t mean the injury is new. In fact, HLI is posited to be responsible for the premature aging and osteoarthritis of the hip joint and pelvis that leads to hip replacements. HLI is also a major source of hip pain, with groin pain being the most common subjective complaint.

However, groin pain is not the only complaint that is associated with HLI. Pelvic pain commonly goes hand-in-hand with hip pain.

What does this mean for rehab pros?

If you see anyone with a pelvis, you need to know how to differentially diagnose hip and pelvic dysfunction.

What does this mean for patients?

If you have hip or pelvic pain you should be evaluated by an HLI specialist, which can be a PT, surgeon, or osteopath who has received additional training on managing HLI. It is critical that you see someone who specializes in HLI. If HLI or other hip or pelvic injury is suspected, it is important that you follow up with a physical therapist who has had advanced training in HLI rehab for the best chance of recovery.

Hip or Pelvic Pain: The Chicken or the Egg?

However, there is a larger question looming here – one that I field quite often. That is – how do we know if a patient’s pain is coming from the hip or pelvis? The answer to that question can sometimes seem like a “chicken and egg” type of conundrum. Here is an example from a 9 month post-op HLI patient and pediatric PT in the eastern US:

Hi Ginger, What’s your opinion on pelvic floor PT after hip scope. Think it’s helpful?

Ginger: Absolutely – if there is a pelvic issue (and typically there is) – what’s your struggle? What is making you ask, “is it hip or pelvic pain?”

Patient: Adductor pain. My PT said adductors attach there. How do you know if there’s a pelvic issue? My PT thinks since I have adductor pain and psoas pain I should try pelvic floor PT. Your thoughts?

G: I would highly recommend seeing a trained pelvic rehab pro for an internal and external exam. You would need to check everything from the puborectalis to the ischiocavernosus and all the way out to the obturator internus and the fascia it implicates. In other words, a trained pelvic rehab pro would assess 2 triangular-shaped areas, the urogenital triangle and anal triangle, as well as global and local stabilizers and fascia that are typically implicated in HLI. The key word here is – the pelvis is almost ALWAYS implicated in HLI and should be checked whether or not you have surgery.

P: So an exam will tell if you need pelvic PT? Is an exam the only way to tell? 

G: Yes. A trained pelvic rehab pro would be able to discern if an issue existed, rather quickly, with an assessment. For someone who may be very uncomfortable with the idea of an internal assessment, such as those with past sexual or birth trauma, I recommend starting with an external exam of the hip and pelvis and then progress to internal only when necessary. Also, explaining exactly what the exam entails, including using a pelvic model or other illustrations that show the internal muscles to be assessed, can be incredibly helpful and encouraging for the patient. 

P: External exam? What does that involve?

G: I have a 6-point differential diagnosis exam for the pelvis that covers all extraarticular pelvic and hip issues which covers more than 30 diagnostic points. I do teach that in my HLI course, so it’s a little lengthy to discuss here. It takes me 2 days to teach it in the CE. If an internal assessment of the pelvic floor is needed, it involves examining those 2 triangles I mentioned earlier. As a HLI specialist though, you would also need to examine related hip stabilizers and fascia, including viscera.

After the conversation, the patient went on to see a trained pelvic PT in her area that was also completing her Professional Yoga Therapist (PYT) certification in my program.

Here is her response:

P: I met with the pelvic PT, PYT today! She is really nice and really good! She thinks much of my pain is from faulty neuromuscular patterning. I didn’t realize that poor NM function could cause so much pain!

G: Yes, definitely. Unfortunately, women with HLI also have to deal with another common phenomenon, which is increased pain just before their cycle begins.

P: Yes, I do have that happen. My groin pain is awful and I am in tears from pain. Ironically, tomorrow I am due to get my period.

I find the premenstrual cycle pain (usually 1-5 days before the cycle begins) is a common phenomenon with many women with HLI (operative and non-operative), which is an area that needs more attention in research. Some women say it feels like they have retorn their labrum, and as a result, they get fearful – which affects not just their physical functioning but their psychoemotional and social well-being.

They limit activity which can exacerbate faulty neuromuscular patterning and deconditioning and result in increased pain from faulty structural support. Their realm of social activity and self-efficacy can suffer, which is also not good for long-term well-being.

Additionally, sleep can be interrupted with HLI and pelvic pain, which can dysregulate the HPA (hypothalamic pituitary adrenal) Axis and cause further problems with issues like pain centralization, cortisol dysregulation, and digestion. A recent study correlated vulvodynia and FAI (femoracetabular impingement), a type of hip impingement commonly found with HLI. The study found that those women who received early surgical intervention received the most relief from vulvodynia, while those who had a longer duration of pain did not experience the same level of improvement. Read my post about FAI and new discoveries in hip impingement

The take-home message is that early intervention for HLI is absolutely critical for the best long-term prognosis, and that pelvic pain, which can include anything from vulvodynia, dyspareunia, interstitial cystitis, non-relaxing pelvic floor/myalgia, pudendal neuralgia or entrapment, athletic pubalgia, and/or continence issues, although a common occurrence with HLI, is not normal and should be addressed by a trained pelvic rehab professional.

Want more? Read my post about Hip Labrum Tear Risk: Why Early Care is Critical , is absolutely necessary for the best long-term prognosis.

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