Transcription:
Treating Hip Injuries

Melanie Cole (Host):  Are there certain sports or activities where hip injuries would be more likely and be more common?  What are those most common hip injuries and how do you prevent them?  That’s the most important thing. My guest today is Dr. Winston Gwathmey. He’s an orthopedic surgeon with UVA whose specialties include arthroscopic hip surgery and sports medicine. Welcome to the show, Dr. Gwathmey. Tell us a little bit about sports or activities where our hips seem to be more at risk for injuries.

Dr. Winston Gwathmey (Guest):  Thank you. The hip is sort of the new frontier of sports medicine in that injuries that, 20 years ago were really unrecognized or we just really didn’t understand the pathology behind it, we are starting to recognize a lot more often now. To be honest, it’s sort of an exciting topic to discuss. So, your question about what sports predispose you to injury, really any sport where you’re moving at a high speed, pivoting, changing direction, where you are loading the joint, the hip can be at risk. I think that what athletes need to understand is that sports that may injuries, there’s also elements of the human body that may predispose injury as well. I think it’s an important concept to understand when you are dealing with hip injuries.

Melanie:   Well, we are even seeing more of these which we never would have seen in younger people. As soccer becomes more prevalent and these, as you say, the stopping and turning, and those kinds of sports are becoming more common. People are playing weekend soccer and injuring their hips. What about the things that don’t involve sports?  Things that we could do that would injure our hips that are just functional things every day.

Dr. Gwathmey:   I think I need to back track just a touch and that it’s not that the hip injuries are more common now; I think we are starting to recognize sort of what’s causing them. It’s a combination of two things really that make it pretty simple. One is the way you’re shaped and two, is what you expose your hip to. The normal hip is pretty tolerant to most activities but there are certain elements to the way the pelvis might be shaped that might make you at risk for having a hip injury with sports or even with just routine activities. What I mean by that is, sometimes the ball and socket of the hip joint just don’t fit together that well and it’s either a developmental things or it’s sort of built into your genetics--sort of the same reason why some people go on to have arthritis and some people don’t. I think that what we are starting to recognize is, there are certain elements of the skeletal morphology that might make you at risk for having hip injuries.

Melanie:   When do we know that it’s actually a strain or an injury?  When would we go see a doctor?

Dr. Gwathmey:   So, normally hip injuries will be pain localizable to the groin. The hip joint is actually directly in the groin. It’s not out in the side. It’s not really in the back. Most people who have hip injuries recognize discomfort in the groin and it’s usually worse with the loading the hip. So, if you are putting impact onto the hip or when you are sitting for a long period of time with your hip flexed, sometimes you will feel some discomfort. Sometimes standing up from a long car trip, you’ll feel pain from the hip or sometimes when you’re playing a specific sport and you to a certain twist or turn, you’ll feel that pain. That’s when really we start thinking more and more about the hip joint as being part of the problem.

Melanie:   What do you do about it?  What’s the first line of defense?  Icing the hip or resting? You know, you think about the knees are easier, but what do you do about the hip?

Dr. Gwathmey:   The hip, like you say, the knee is right there, the hip is deep down within the body so even putting a bag of ice on it, it takes a while for that cold to get down to the hip joint. I think rest really is the first thing I would try. Just try to calm things down. Ice is very helpful for some of the inflammation that might be around the hip. Anti-inflammatories are always very helpful because there’s usually an inflammatory component to it.  Hip pain that’s real localizable to the groin that doesn’t get better after a couple of weeks, you probably ought to at least see somebody to try to make sure that you don’t have something more sinister going on.  

Melanie:   What if you do?  When you go see a doctor, what is it you’re going to do?  Can an x-ray show things or do you have to have an MRI?

Dr. Gwathmey:   I think that’s a very good question. I think, and this is sort of my gestalt, if you will, that the x-ray is really the gold standard for diagnosing hip pathology. What I mean by that is, going back to what I said previously, is that the way that your body and your pelvis is shaped is very important when you’re trying to understand hip injuries. There’s a term that’s kind of a complicated term. It’s called femoroacetabular impingement or FAI. The femur is the thigh bone, acetabular is the socket and, basically, it’s when the ball and the socket don’t fit together that great. That’s recognized really on x-ray really to be honest. You can see sort of the way the ball and the socket is shaped and see if there’s going to be a risk factor for having a hip injury. Let’s just say that you do have that shape to your pelvis, an MRI can be very helpful to make sure the labrum, which is basically the seal, the lip around the hip joint, the cartilage, the soft surface of the hip, to see if there’s damage there or the muscles around the hip.

Melanie:   I’m even hearing about some younger people requiring hip replacements, Dr. Gwathmey. When does it come to that and especially we hear about that in our older patients all the time. Hip replacement being one of the easier to recover from, certainly more than a shoulder or a knee, but when does it come with the younger people to something so drastic?

Dr. Gwathmey:   So, let me tell you, my goal--my specialty--is to avoid hip replacement. I’m a hip preservation specialist so I try to do everything I possibly can to prevent the progression of arthritis, to address injuries in a minimally invasive manner to avoid the ultimate salvage which is the hip replacement. All that being said, a hip replacement is an outstanding surgery. It has got probably the best positive track record of any orthopedic surgery that we offer but it is metal inside the body.  If you can maintain your own anatomy and your own tissue, you’re a lot better off in the long run. So, what I would try to do is recognize the pathology that might predispose you to having arthritis and do what I can to either correct it or at least ameliorate it to a point where you can put off getting a hip replacement much, much later in your life.

Melanie:   Dr. Gwathmey, when I hear people complain of hip pain and right away they want to do something about it or, as you say, look into replacement, sometimes there’s a simple solution. As a hip preservationist, how important do you think shoes or heel lift or orthotics play that role if we find out our hips are uneven or something’s going on in our spine that’s causing pain that we think is in our hips. How important do you think it is?

Dr. Gwathmey:   My first line for all hips is trying to address the environment in which the hip is. So, whether it be a misbalance of the pelvic stabilizers, whether there be a spine issue like you’re saying, whether it be shoe wear, limb length discrepancy, a lot of times I’ll start with a therapy routine to try to get a functional assessment. So, a therapist can take a look at you and see how you walk, see if there is something just in the way you do things that might put your hip at risk. That really is a first line for all people with hip problems just to make sure that you correct what can be corrected before you go forward with something like surgery. To be honest, most people get better without surgery. As far as hip preservation,  that’s where I come in and I do arthroscopic surgery of the hip and so if the therapy doesn’t work or if there’s pathology that can’t be addressed from an external standpoint, that’s where I come in and do what I can do to try to make the hip feel better.

Melanie:   I agree completely and I see so many people and have myself had hip problems that were solved very simply with a better pair of shoes or an orthotic or a heel lift. So, these kinds of solutions are something that people really can look to. What role do you think that exercise plays in keeping those good strong hip muscles?  What are your favorite exercises to recommend to people to strengthen up their pelvis and all around their hip muscles?

Dr. Gwathmey:   I start with the core, typically. I think the core is really where the foundation for the entire gait cycle, the way your hips move, the spinal stabilizers, the pelvic stabilizers and things like that. The hip abductors and adductors are very critical as far as keeping the pelvis balanced. But, again, you have to have your range of motion first before you can imagine strengthening stuff so I work on symmetry. Whatever’s going on good with the hip that’s working, I try to make the bad hip match that one.

Melanie:   That’s great information. In just the last minute, why should patients that are suffering from hip pain come to see you at UVA for their care?

Dr. Gwathmey:   Again, I am a surgeon that specializes in arthroscopic hip surgery. So, let’s just say that all the stuff we throw at your hip, it’s still not getting any better and we get an MRI and you have a labral tear or you have FAI--this impingement thing that we’re talking about--what I can do and what I think that sort of sets me apart as a surgeon is, I can address those elements with a video camera and two tiny holes in your hip. Now, it sounds simple but it’s actually a very challenging procedure and it’s actually pretty challenging to come back from but it is a technique that we can utilize here that gives a minimally invasive approach to hip pathology. So, I do think that there is a role for trying to do everything we can to get the hip better without surgery but when it comes to surgery, I think I can provide a pretty good tool bag as far as things that I can do to help the hip.

Melanie:   Thank you so much. You’re listening to UVA Health Systems Radio. For more information you can go to uvahealth.com. That’s uvahealth.com. This is Melanie Cole. Thanks so much for listening.