Hip Sprain: Causes, Symptoms, Treatment, Exercises

Pelvis is formed by 3 pelvic bones known as pubic, ischium and ileus. Ileus is also known as hip bone. Pelvis supports hip joint. Hip joint is a ball and socket synovial joint. Hip joint is formed by ball shaped head of femur and concave shaped socket of acetabulum. Head of femur fits into socket of acetabulum to form the hip joint. Multiple ligaments, joint capsule and tendons are attached to hip joint and prevents separation of two bone during activities and at rest.

The inner surface of acetabulum is covered by thin tough cartilage. The joint capsule lies underneath ligament and covers outer surface of neck of femur and acetabulum. Ligaments and tendons are formed by tough fibrous tissue. The joint is also supported by muscles. The thin space of joint between head of femur and acetabulum is filled with synovial fluid. Synovial fluid acts like lubricants when head of femur rotates and moves over the cartilage surface of acetabulum. The joint is also known as synovial joint. The head of the femur moves over the surface of cartilaginous acetabulum.

The ligaments are stretched during hip joint movement. The hip joint movements are flexion, extension, adduction (leg is moved towards midline), abduction (leg is moved away from body) and rotation.^[1]

A hip sprain is a condition that occurs due to stretching or tearing of ligaments that support the hip joint. Occasionally, tear may extend and involve joint capsule as well as injury of tendon. The hip sprain causes mild to moderate pain at rest and severe pain with activities. ^[2]The diagnosis of hip sprain depends on detailed history taking, examination and radiological studies. Radiological studies are performed to rule out conditions like fracture, dislocation and tear of muscle or tendon.

The hip joint movements are assisted by flexor, extensor, abductor and adductor muscles. Two ends of muscle continue as tendon. Tendons are attached to acetabulum and neck of femur adjacent to ligaments. Hip sprain occurs when ligaments supporting hip joints are over stretched or torn. Hip ligamental tear may be simultaneously associated with tendon separation or tear. Large hip ligamental tear resulting in hip sprain may cause bleeding from surrounding ruptured blood vessels. Bleeding may be significant or negligible. Significant bleeding is observed if individual is taking blood thinning medications.^[3]

The hip sprains is broadly classified into three types depending on the extent of injury and anatomical damages. Each type of hip sprain has particular signs and symptoms. The severity of symptoms and sign of hip sprain signifies the status of the injury. The severity of a hip sprain is classified as follows-

• First degree hip sprain is considered as mild trauma
• Second degree hip sprain is considered as moderate trauma;
• Third degree hip sprain is considered as severe trauma.

First degree hip sprain is referred as a minor hip sprain that is cause by minor microscopic tear or separation of ligament. First degree hip sprain heals up in few weeks with appropriate rest and pain medications.

Second degree hip sprain is referred to as a moderate type of hip sprain. Second degree hip sprain is caused by significant partial tear or injury of single ligament or multiple microscopic or partial tear of more than one ligament. The injury is quite severe than the first degree hip sprain. Second degree hip sprain is also caused by partial separation of single or multiple ligaments. Second degree hip sprain heals up in about two months.

Third degree hip sprain is also known as severe sprain. Third degree hip sprain involves complete tear of single ligament or multiple partial tear of several ligaments. Surgery may be required to repair complete torn ligament or attached separated ligament to neck of femur or hip bone.^[4]

Old injury, old age and inappropriate warm up before exercise are few of the common risk factors that increases the chances of hip sprain.

1. Age- Elderly individual suffering with arthritis is at higher risk developing hip sprain.
2. Old Injury- Old injury often forms scar tissue during healing. Scarred ligaments may snap and partially tear during strenuous activities, fall or abnormal twist and turn of lower leg.
3. Inappropriate Warm Up- Healthy individual and trained athlete should warm up prior to strenuous activities to prevent ligamental injury.
4. Malnourishment- Lack protein and vitamin weakens the internal tissue like ligaments and tendon. In such cases strenuous activities causes hip sprain.
5. Osteoporosis– Osteoporosis makes a bone brittle as well as attachment of tendon and ligament loose. The ligament tears or separates from attachment when the hip joint is stretched or when there is abnormal twist and turn.

1. Inflammatory Joint Diseases- Chronic arthritis like rheumatoid arthritis causes inflammation and thickening of joint capsule as well as ligaments. Patient suffering with rheumatoid arthritis may develop second or third degree hip sprain following a trip and fall accident. Osteoarthritis causes joint deformity because of inflammation and swelling of cartilages and surrounding bone. The anatomical changes of cartilage and bones also loosen the contact between ligament and bones. Elderly patient suffering with osteoarthritis often complain of sudden increase of pain lasting several weeks because of hip sprain.^[5]
2. Domestic Fall- Tripping on carpet or uneven sleeper surface causes loss of balance and fall. The sudden twist and turn of hip joint causes stretching of ligaments of hip joint. Most of hip sprain following domestic fall are of first or second degree hip sprain that often gets better in 2 to 4 weeks.
3. Contact sports– Contact sports include sports like football, soccer, basketball, wrestling and rugby. Contact sports causes accelerated direct impact of hip joint leading to hip sprain. The direct impact occurs when two players collide against each other or player fall on ground or gets slammed on ground. The injury is caused by either direct hit over the hip joint or slamming the body predominantly hip joint over the even or uneven surface. Such impact over hip joint causes second or third degree hip sprain. Occasional Hip Joint Dislocation Or Fracture may be associated with third degree hip sprain. The direct impact occurs when two plays collide against each other or player fall on ground or slammed on ground. The injury is caused by either direct hit over the hip joint or slamming the body, predominantly the hip joint, over the even or uneven surface. Such impact over hip joint causes second or third degree hip sprain. Occasional hip joint dislocation or fracture may be associated with third degree hip sprain.^[6]
4. Repeated Action- Long distance running or cycling causes moderate strenuous repeated hip joint movement. Occasional uncoordinated hip joint movement can cause twist and turn of hip joint resulting in stretching of ligament. In most cases such stretching causes first or second degree hip sprain.
5. Work Accident– Second or third degree hip sprain is often observed following work accident. Second or third degree hip sprain may be caused by fall resulting in hip joint impact on ground or hard object. Work accident may involve direct impact of moving object over the hip joint. The long working hours in a standing position causes fatigue of leg muscles. Individual may trip and fall If work involves frequent use of lower leg like going up and down the steps.

The detailed history of diseases and trauma is taken prior to examination. Careful physical examination is performed to diagnose hip sprain. Physical examination involves checking active and passive hip joint movement, placing pressure on the affected areas of the injury to identify pain, bruising, swelling and tenderness. The patient may be asked to perform certain movements for determining muscle strength, stability of the joint, range of motion limitations, and finding out the reason for decrease and increase of pain.

Pain- Pain caused by hip sprain is experienced over the groin at the front side of the hip joint. Pain is experienced while moving the leg in the backward direction or leg rotation. Mild pain or no pain is experienced at rest if the injury is first degree hip sprain. Patient suffering with first or second degree hip sprain may develop severe pain during repeated strenuous activities. Third degree hip sprain causes severe pain at rest as well as with activities. In most cases individual avoids all activities if injury has caused third degree sprain.

Tenderness and Leg Movement- Fracture and dislocation is ruled out If individual can move the legs in all direction with mild to severe pain. Tenderness is described as sudden increased pain when joint is examined. Tenderness when lasts for short period of time after examination suggest first or second degree hip sprain. Tenderness lasting for prolonged period after hip joint examination suggest possible third degree hip sprain.

Restricted Hip Joint Movement- Most patient after third degree hip sprain refuse to move leg during examination. Patients are afraid of inducing severe hip pain while there is no pain at rest. Patient are also afraid that mild to moderate pain at rest may turn into severe continuous pain after hip joint movement. Such pain may last for prolonged period. Such refusal of voluntary movement of hip joint is often misdiagnosed as hip joint fracture or dislocation until such condition is ruled out with MRI or CT scan.

Muscle Spasm– Third degree hip sprain may cause muscle spasm. Muscle spasm is observed in muscles supporting hip joint. Muscle spasm is triggered either because of muscle injuries or opposing muscles like flexor and extensor working simultaneously all the time to prevent joint movements.

Swelling and Bruising- Swelling and bruising is seen over the groin in few patient suffering with third degree hip sprain. The blood may slowly spread from joint to surrounding soft tissue and skin. Bruising is purple discoloration of skin suggesting presence of blood under the skin. Moderate to severe bleeding following third degree hip sprain may cause skin discoloration and bruising.

Radiological studies- X-Ray, CT scan and MRI are the radiological studies performed if patient is complaining of groin or hip joint pain. The radiological tests are useful to rule out fracture and dislocation of hip joint. Selective and targeted MRI of the soft tissue around hip joint may show hematoma (blood clot) and soft tissue swelling. MRI or CT scan does not show specific injury, swelling or tear.

Ultrasound study- Ultrasound study is a diagnostic imaging study. Ultrasound is a high frequency sound waves. The sound echoes off the soft tissue and bones. Ultrasound probe passes ultrasound through the tissue and creates the computer assisted image. The images observed are of tendon, muscles, joint, blood vessels and internal organs. Ultrasound shows the images of the tendon and muscles and in certain instances detail of ligaments.

Medications: Medications are prescribed depending upon the type of injury. First and second degree hip sprain is treated with physical therapy, NSAIDs and muscle relaxants. Third degree hip sprain is treated with rest, physical, opioids, muscle relaxants and surgery.

Rest and Ambulation- Patient is advised to take a rest to avoid activities that may increase hip pain. Activities in most cases increases pain and often patient avoids activities. Patient is advised to use cane during ambulation when mild pain is caused by first degree hip sprain. Second and third degree hip sprain causes severe pain and patient may have to use crutches or wheel chair for ambulation.

Cold therapy– Cold therapy involves application of ice compression. The ice compression is performed by pressing ice bag or frozen object over the groin or back of hip joint. Immediately following injury, cold therapy helps to reduce the bleeding and swelling.

Leg Elevation- Leg elevation prevents tissue swelling and improves direction of blood flow. Leg elevating helps and reduces pain.

Physical therapy– Physical therapy includes massage, heat therapy and ultrasound treatment. Physical therapy helps to improve range of motion and stretching of joint. Physical therapy also includes supervised strengthening exercises of muscles that support hip joint movements.

Non-steroidal anti-inflammatory drugs (NSAIDs)- Non-steroidal anti-inflammatory medications not only help in relieving pain, but also reduces swelling and inflammation.

Opioids– Pain caused by third degree hip sprain does not respond to conservative treatment like cold therapy, rest, leg elevation, as well as NSAID. Such severe sprained hip pain is treated with opioids for 2 to 3 weeks.

Surgery- Surgery to treat hip sprain is performed to repair hip joint ligaments that are separated from its attachment or completely torn. Surgery is also performed to repair associated injuries like tendon rupture, hip dislocation or hip fracture.

Rehabilitation Program- Rehabilitation includes physical therapy and occupational therapy. Rehabilitation program is targeted to improve muscle strength and educate the patient to manage domestic essential activities.^[7]

Hip Sprain Exercises- Individuals with strong leg muscles are less prone to repeat hip sprain and recover faster. Thus, post recovery, patient should perform following exercises to prevent recurrent hip sprain and also improving functions of hip joint muscles. Appropriate stretching not helps in increasing hip joint flexibility.

Exercises to prevent re-injury and strengthen weaker muscles. However, there are various kinds of exercises and physical therapy that help in preventing or treating hip sprain. Following exercises should be performed after the recovery from hip sprain injury.

1. 1. Rotation Hip Flexor Exercise- This exercise for hip sprain is performed by lying down straight on the floor in supine position. Place both the arms spread perpendicular to the body. Keep palms flat on the floor. Now slowly bend upper body to the right side and bring left leg heel over the right knee. Roll the left heel down the leg while knee is supported by right hand. Repeat the exercise 5 times and the do the same on other side. The exercise can be repeated 5 to 10 times each side.

1. 1. Kneeling Hip Flexor Exercise- This exercise is performed for hip flexors. Hip flexors are group of several muscles. Bend the right knee at 90 0 so right leg below the knee lies flat on ground. Same time bend left leg at hip and knee joint, while left feet stays flat over the ground. Now move the left hip forward and backward 10 time. Repeat the same exercise on the other side.

1. 1. Hyper-flexion Hip Flexor Exercise- This exercise for hip sprain is performed while upper body lies supine on a bench. Both legs are kept beyond the edge of the bed rested on ground. Now gently pull the left leg, flex at hip and knee joint. Simultaneously hyper-flex the left leg at hip and knee joint. Count up to 10 and then bring the left leg back to original position so feet rest on ground. Repeat the exercise on the other side. Repeat the exercise 10 times on each side.

1. 1. Standing Iliotibial Band Stretch for Hip Sprain – This exercise for hip sprain is performed by standing straight and crossing the left leg behind the right foot. Now reach overhead with the right arm and lean to the left until a pain-free stretch is felt in the right hip. Hold the position for few seconds and release. Repeat the same exercise on the other side.

Pain caused by hip sprain may last for 6 to 10 weeks. The pain and healing of first degree hip sprain lasts for 4 to 6 weeks. Second degree hip sprain gets better in 6 to 8 weeks. The third degree hip sprain takes longest to recover. Healing of ligament may take 8 to 12 weeks. During the healing period, pain continues. Intensity of pain in the hip caused due to hip sprain gets better with time.

Depending on the cause, you can begin to exercise between 6 to 10 weeks following initial pain and injury. If you experience increased hip pain immediately following exercise lasting more than 2 to 4 hours, you should consult your physician or visit ER. The diagnosis of the hip pain in such cases should be re-evaluated.

Hip pain lasting more than 3 to 5 days should be evaluated by physician and radiological studies are recommended.

References:

Also Read:

• Post Traumatic Osteoarthritis of the Hip Joint: Causes, Signs, Treatment, Exercises
• Q&A: Hip Joint Pain Treatment Approach and Options–Everything You Need To Know
• Hip Joint Rheumatoid Arthritis: Causes, Signs, Symptoms, Treatment
• Hip Joint Septic Arthritis: Causes, Symptoms, Treatment, PT, Surgery
• Hip Joint Psoriatic Arthritis: Causes, Symptoms, Treatment, PT, Surgery
• Enthesopathy of Hip: Causes, Symptoms, Treatment