Avulsion fractures – muscles to the thigh can pull off their bony insertions on the hip and pelvis, often with a fragment of bone attached

 Stress fractures –hairline fractures of the hip due to repetitive overloading of the bone, typically caused by training errors ; may lead to complete fracture if not treated

Trochanteric bursitis– pain in the outside aspect of the hip, caused by tightness of the iliotibial band (ITB)

 Snapping Hip– loud popping from internal or external areas of the hip; usually painless; aggravated by repetitive hip flexion and external rotation

 Avascular necrosis – loss of blood supply to the ball of the hip joint; leads to collapse of the joint and early arthritis

 Labral tear– tears in the cartilaginous rim of the socket (acetabulum); may be caused by injury or repetitive compression

 Femoral Acetabular Impingment (FAI)– abnormal spurs of the socket, femoral neck or both, causing impingement and tears of the labrum (cartilage)

Localizing the pain can often be difficult.  True pain emanating from the hip joint typically involves the groin area, but some people also have pain referred to the outer hip area or buttock.  The pain may radiate down the thigh or into the lower back.  There may be associated clicking, or even a loud pop may be present.  Usually, a careful exam can detect he source of pain, which can usually be treated with activity modification, stretching, and exercise or physical therapy.  But what can be done when those modalities don’t help?

First, a detailed history and exam can help detect the source of the pain.  Overall limb alignment can reveal problems with pelvic imbalance, over-rotation of the hips, and flatfoot deformities.  Training histories can help detect stress fractures.  Loss of rotation in the hip suggests a problem stems from the joint space.  X-rays may show avulsion fractures, calcium deposits, stress fractures, congenital deformities, or arthritis.  An MRI may be necessary, and can show cartilage injuries, labral tears (the rim of the socket), loose bone fragments, or torn tendons. 

Depending on the diagnosis, most hip pain can be treated conservatively.  Occasionally, a cortisone injection can help stop inflammation.  Diagnostic injections in the joint can differentiate pain from within and outside the joint.  Surgery may entail an arthroscopy to repair a labral tear or shave down a spur, drilling holes in bone to stimulate blood flow, or releasing a tendon to relieve pain.

If your symptoms persist despite modifying your routine and allowing for rest, an examination by a specialist may be needed.  Often a complete evaluation, including x-rays and occasionally an MRI, may be necessary to rule out a more serious injury.

When pain strikes, don’t ignore it.  Try to determine what errors in training may have led to the discomfort…Are your muscles tight?  Light stretching before running, especially of the quadriceps, hamstrings, and Achilles tendon, can help prevent muscle strains.  Do you have a muscle imbalance or weakness?  Strengthening the muscles that support the kneecap is critical to minimizing knee pain.  Are your shoes old and worn?  Proper footwear is also very important.  Dedicate a pair of shoes specifically for running, and change to a new pair after 6 months or 500 miles of distance.  A properly-fitted pair of shoes will address alignment issues such as overpronation, and an arch support or orthotic can help as well.  If you do develop pain when running, try cross-training with another activity until the pain resolves.  Lower impact activities, such as biking, swimming or use of an elliptical machine will still give an aerobic workout without aggravating the areas of pain.  Anti-inflammatory medications can help with recovery, however, should not be used to mask pain.  Do you push yourself too aggressively, never taking a break?  Sometimes, all that is needed is a short period of rest to allow overused muscles to recover.

If your symptoms persist despite modifying your routine and allowing for rest, an examination by a specialist may be needed.  Often a complete evaluation, including x-rays and occasionally an MRI, may be necessary to rule out a more serious injury.  Most of the time, however, a few modifications and specific exercises may be all that is needed to return to running again.

Common Running Complaints:

Patellofemoral syndrome – pain in the front of the knee, due to excessive pressure across the kneecap and the groove it tracks against; may be aggravated in those with flatfeet or instability of the kneecap

Shin Splints – pain in the front of the shin bone (tibia), caused by improper training on a hard surface

Iliotibial band (ITB) syndrome – pain in the outside aspect of the knee, caused by friction of a tendon in the thigh against a prominent bone in the knee; caused by sudden increase in training

Stress fracture – localized pain in the lower leg or ankle, caused by repetitive overuse; may go on to a complete fracture if not treated

Achilles tendinitis – pain in the back of the ankle that worsens when pushing off, due to tight Achilles tendon

Plantar fasciitis – pain in the bottom of the heel; can be caused by stiff shoes or tight Achilles tendon

Overpronation– malalignment of the forefoot or heel when running, causing the foot to rotate inward; may lead to knee pain

Try warming up with a light jog first, then do intervals of fast/slow running or jogging/walking.  Cool down with a walk, then do some light stretches to keep from getting tight.  Try it on your next vacation.  Make sure you hydrate appropriately, and preferably run in the morning hours before the sun gets too hot — your endurance will be greater when your core body temperature is cooler.

This study was very strange to me.  I competed in both basketball and track & field in high school, as well as track in college.  I was ranked #2 in the state for 400m hurdles in high school, and #5 in the ACC in college.  Although I never quite had that cut-throat edge (which may have helped me to excel even more than I did), I considered myself as having a drive to win, as well as to excel personally.  I was not depressed, nor did I feel any more lonely than other high school kids trying to find their way in life.  The other girls on my team were also competitive, so we had social relationships with each other, and the sport created bonds of friendship we wouldn’t otherwise have had.

The study suggests that motivation to win is typical and socially expected of males, which may be one way of explaining the differences found in the study.  I believe it has recently become more socially expected of females, especially as they become more involved in sports at a younger age.  The drive to win is natural, and should not be discouraged in girls.  Because of previous social expectations, however, we need to pay more attention to their welfare, which may be overlooked in settings where male athletes outnumber the females.  There is still a higher risk of injury, which increases as the level of competition increases.  Focusing on conditioning, strength training, and balancing/core exercises is essential to helping young girls maintain a competitive level of athleticism while decreasing the risk of injury.  Should an injury occur, early recognition and proper orthopedic intervention can often keep them in the game for a long time to come.

Cartilage defect

Cartilage cells implanted with overlying biologic patch

This procedure involves 2 surgeries:  one to biopsy the normal cartilage cells, and a second procedure to implant them into the defect.  It is best used for large defects (at least 2cm in diameter), or after failing another type of cartilage repair procedure.

The recovery can be long, so this procedure is not for everyone.  Weightbearing is usually restricted for up to 3 months.  A strict rehabilitation protocol is followed, and may take up to 18 months before return to competitive sports activities.

The size of the defect dictates how many plugs are used.  Smaller defects work best, using only a single plug.  Unfortunately, the more plugs that are required, the higher the risk for donor site morbidity (problems in the normal area of the knee).  In addition, since the plugs are round, when more than one is used, the gaps between them fill with fibrocartilage.  Fibrocartilage is similar to scar tissue, and is stiffer and less efficient than normal hyaline cartilage.  When a larger defect is encountered, a better option is using cadaver tissue, knows as an Allograft OATS Procedure.  This allows for a single large plug to be obtained, with no additional morbidity to he patient.

Allograft OATS

Some weight can typically be applied immediately after surgery, followed by early range of motion.  Return to sports activities can usually be achieved within 3-6 months.

Completed OATS Transplantation

This procedure can help to repair a focal cartilage defect in the knee, minimizing joint dysfunction, and potentially prevent the onset of early arthritis.

1.  Microfracture- drilling multiple holes in the defect to prompt filling in of fibrocartilage; good for smaller defects

2.  Osteochondral transfer (OATS) – taking a plug of bone and cartilage from one part of the knee, and transferring it into the defect; good for small or medium defects

3.  Allograft OATS – for larger defects, cadaver bone and cartilage can be used instead of your own tissue

4.  Autologous Chondrocyte Implantation (ACI) – a staged procedure, where normal cartilage cells are harvested from the knee, then grown in a lab to “clone” them into a cluster of new cells to be implanted into the defect; good for large defects

5.  DeNovo NT Graft – the newest technique, where juvenile cartilage cells from a cadaver are implanted to the defect, and held in place with a fibrin glue; good for medium or large defects

All of the above techniques have strengths and weaknesses, and are not indicated for every defect.  None of the procedures works for treatment of cartilage damage due to generalized arthritis.  An MRI is the best study to look at the size and depth of the defect, to determine if repair is a possible option.  Once that has been determined, a discussion can be made to determine which treatment option is best for you.