CASE REVIEW
Management of Hip Pain in a 25-Year- Old
Female Runner
Scott Cheatham, PT, DPT, OCS, ATC, CSCS • California State University Dominguez Hills
E
stimates of the prevalence of running
injuries range from 37% to 56%, with the
majority of injuries affecting the lower
extremity.1 The recurrence of running injuries
has been reported to be as high as 70%, with
about 20% to 70% of all running-related injuries leading to a medical consultation.1 Risk
factors for running-related injuries have not
been conclusively established,2,3 but recent
research suggests that
novice runners may
possess elevated injury
Key Points
risk with a high body
Recent research suggests that novice
mass index (BMI), hisrunners have elevated risk for injury, partory of prior injury, lack
ticularly those who have previously been
of prior running experiinjured and who have a high BMI.
ence, or lack of prior
participation in a sport
The regional interdependence approach
that involves axial loadmay help the clinician identify impairments
ing of the spine and
in remote body regions that contribute to
lower extremities.4
the primary source of pain.
The most common
injuries associated with
running include patellofemoral pain syndrome, iliotibial band friction syndrome,
Achilles tendinosis, medial tibial stress syndrome, and plantar fasciitis.5,6 Such injuries
tend to have clear clinical presentations,
which support the accurate diagnosis of a
given condition; however, accurate diagnosis of the cause of acute or chronic hip
pain in runners can be challenging. Up to
60% of patients who ultimately undergo
hip arthroscopy are initially misdiagnosed.7
A search of the literature identified two case
reports that described rehabilitation following arthroscopic hip surgery,8,9 one case
report of nonoperative rehabilitation for hip
arthrosis10 and one case series describing the
nonoperative rehabilitation of patients with a
hip labrum tears.11 No published reports were
found pertaining to female recreational runners with acute or chronic hip pain.
The purpose of this case report is to
describe the rehabilitation program for a
25-year-old female recreational runner who
had a 4-year history of left hip pain using the
principles of regional-interdependence (RI).12
The term RI refers to a broader examination
approach that has the goal of identifying
unrelated impairments in remote bodily
regions that may contribute to the primary
source of pain. 12 This approach can be
applied to both the examination and rehabilitation of patients.
Case Report
A 25-year-old female recreational runner
(i.e., 10 to 20 miles per week) who had a
combined endomorphic-mesomorphic body
structure (Mass: 58.96 kg; Height: 165.1cm;
BMI: 21.6) presented with recurrent hip pain.
She reported a history of ankle arthroscopic
surgery for excision of a nonunion distal
fibular fracture of the left fibula. Postsurgery
physical therapy was deemed successful,
which allowed return to pain-free physical
© 2013 Human Kinetics - IJATT 18(1), pp. 15-20
international journal of Athletic Therapy & training
january 2013  15
activity that included running and resistance exercises.
Nine months later, the patient suffered a recurrence
of left hip pain with no known precipitating event.
She sought evaluation by an orthopedic surgeon for
symptoms of anterior hip pain, occasional clicking
and popping, and pain with internal rotation of the
hip joint. Radiographs and an MR arthrogram were
negative for any soft-tissue or bony abnormalities. The
patient was diagnosed as having a hip flexor strain,
and she continued her regular exercise program. For
the next 3 years, the patient continued to have intermittent left hip pain, which was exacerbated by a fall
from a mountain bike. The patient was evaluated by
her primary care physician for complaints of anterior
hip pain after the traumatic event. The physician
diagnosed the patient as having sustained an acute
aggravation of chronic left hip pain and referred her
to physical therapy.
At the initial visit, the patient completed the Lower
Extremity Functional Scale (LEFS) to document her
functional abilities.13,14 The minimal detectable change
and minimal clinically important difference for the
LEFS is 9 points.13 The patient LEFS score was 76%
(61/80 possible points). She reported the greatest difficulty with usual hobbies, recreational or sporting
activities, squatting, and sitting greater than 1 hour.
The patient reported a pain level of 3/1015 during athletic activity (e.g., yoga), squatting, prolonged sitting
(> 1 hour), and rotational hip motions. Her pain was
decreased to 2/10 pain with medication. The patient
reported the location of pain to be in the anterior
hip area. She demonstrated the “C-sign” (Figure 1)
by cupping her hands in a c-shape above the greater
trochanter, which has been reported as a common
pattern of hip pain.16
A general postural screen in a standing position
revealed an anteriorly tilted pelvis and a mild degree of
right trunk shift. Observation of gait revealed decreased
left hip motion (i.e., decreased step length) and a lateral
weight shift during the stance phase on the left foot.17
The patient’s hip, knee, and ankle ROM were tested
both actively and passively. Bilateral measurements
were within normal limits and symmetrical, with the
exception of the left hip. Passive ROM measurements
of the left hip were 90° flexion, 25° internal rotation
(painful), 30° external rotation, 25° abduction, 10°
adduction, and 0° extension.
Manual muscle testing identified strength deficits
in both the left hip and ankle compared to the right
side (Table 1). Ober’s test (i.e., iliotibial band tight16  january 2013
Figure 1 C-sign.
Table 1. Muscle
Performance Testing
Muscle Groups Tested
Right
Left
Hip flexors
5/5
3/5
Hip extensors
5/5
3+/5
Hip abductors
5/5
3+/5
Hip adductors
5/5
3+/5
Hip external rotators
5/5
3+/5
Hip internal rotators
5/5
3+/5
Knee extensors
5/5
5/5
Knee flexors
5/5
4/5
Ankle dorsiflexors
5/5
4/5
Ankle plantarflexors
5/5
4/5
Ankle inverters
5/5
4/5
Ankle everters
5/5
4/5
ness), 90/90 hamstring test (i.e., hamstring tightness),
Thomas test (i.e., hip flexor tightness), and Ely’s test
(i.e., rectus femoris tightness) were all interpreted as
positive for the left extremity. The Ober’s test and
90/90 hamstring test were interpreted as positive for
the right extremity.
Tenderness elicited by palpation of the left hip
musculature was assessed on a 0-4 scale (Table 2).18
international journal of Athletic Therapy & training
Table 2. Palpable Tenderness
Rating Scale
Grade
Definition
0
No tenderness
1
Mild tenderness without grimace of flinch
2
Moderate tenderness plus grimace or flinch
3
Severe tenderness plus marked flinch or withdrawal
4
Unbearable tenderness, patient withdraws with
light touch
Palpation elicited moderate tenderness along the left
iliopsoas tendon, tensor fascia lata, hip abductors,
and hip external rotators. A contralateral assessment
did not elicit any pain. Postural stability was assessed
by a 30-second single-limb balance test in a barefoot
condition.19 Postural stability on the left extremity was
poorer than that for the right extremity, both with eyes
open and eyes closed. The Flexion-Adduction-Internal
Rotation (FADIR) test was interpreted as positive for
the presence of femoral-acetabular impingement (FAI),
which reproduced the patient’s anterior hip pain.
The examination results included poor posture, gait
alteration, limited left hip joint ROM, and muscle tightness in the region of the left hip joint, general weakness
of the left hip and lower leg musculature compared to
that of the right extremity, palpable tenderness in the
anterior and lateral hip musculature, and a positive
FADIR test.
The patient attended rehabilitation sessions two
times per week for four weeks. A description of the
patient’s rehabilitation program is provided in Table 3
(Figures 2 and 3 are referenced in Table 3). She was
discharged after completion of the four-week physical
therapy program with a 0/10 pain level for activities
of daily living (i.e., sitting), weight training, and sports
activity (i.e., jogging). Her LEFS score at discharge was
100% (80/80 possible points). The left hip joint demonstrated full pain-free ROM, normal muscle extensibility (with the exception of mild hip flexor tightness),
normal strength (5/5), and adequate neuromuscular
control during performance of single-leg exercises,
multidirectional activity, and light treadmill jogging.
Compensatory movements at the hip, knee, and ankle
joints were minimal. At one month after discharge from
physical therapy, the patient reported pain-free jogging
and gym activity, with no recurrence of hip pain.
international journal of Athletic Therapy & training
Figure 2 Single leg squat on TRX©
Discussion
The outcome for this case report was consistent with
the findings of Snyder et al.,20 who reported that
resistance training of the hip musculature improved
lower extremity biomechanics during running.
Similar findings have been reported for runners with
patellofemoral pain syndrome21 and iliotibial band
syndrome. 22
A unique aspect of the reported case report was
the existence of both proximal and distal influences on
the patient’s lower extremity function, which required
an RI approach to the rehabilitation process. Research
has clearly demonstrated that both proximal and distal
factors can influence lower kinetic chain kinematics
in runners.23,24 Thus, the patient’s combined lumbopelvic-hip and lower leg impairments may have created
dysfunction affecting the entire kinetic chain of the left
lower extremity.12
The patient presented combined abnormalities that
were consistent with the Pelvic Cross Syndrome (PCS)
described by Janda.25 PCS is a condition that is characterized by “overactive” muscles, which may include
the rectus femoris, iliopsoas, and thoraco-lumbar
extensors, and “underactive” (i.e., inhibited) muscles,
which may include the abdominals, gluteus minimus,
medius, and maximus.25 For the case reported, the
patient presented with overactive anterior musculature,
january 2013  17
Table 3. Rehabilitation Program
Timeline
Rehabilitation Program
Focus: restore muscular symmetry across the hip and pelvis; begin strengthening of the abdominal core
and left ankle.
Strengthening/Balance: core strengthening (e.g., abdominal bracing) and ankle exercises (e.g., resistance
bands). Single limb balance activity on a stable surface.
Manual Therapy/Stretching: soft tissue management of the surrounding hip musculature with emphasis
Week #1
on the iliopsoas, rectus femoris, iliotibial band complex, and hamstrings. Graded joint mobilization using
a belt for general distraction of the hip. Static stretching focusing on the iliopsoas, quadriceps, gluteals, hip
external rotators, hamstrings, and Iliotibial band complex.
Cardiovascular/ROM: stationary biking for up to 20 minutes with light to moderate resistance.
Home Program: stretching, core strengthening, ankle strengthening, and stationary biking.
Focus: begin basic strengthening, functional movements, and progress core strengthening.
Strengthening/Balance: Sidelying hip abduction, clams, double leg bridges, and leg press. Core strengthening and balance activity were progressed with the addition of planks and single leg stance on the foam
pad.
Manual Therapy/Stretching: soft tissue management continued with emphasis on the illiopsoas and rectus
Week #2
femoris. Joint mobilization included graded anterior to posterior glides and long-axis distraction. Stretching
activities continued with the addition of self-myofascial release with the foam roll.
Cardiovascular: stationary biking for up to 20 minutes with light to moderate resistance.
Home Program: Week I activity with the addition of the foam roll and cardiovascular conditioning with the
elliptical trainer.
*Formal reassessment conducted between week #2 & #3
ROM: pain free left hip internal rotation of 35 degrees (10 degree increase)
Reassessment MMT: all hip & knee manual muscle tests were graded a 4/5.
Special Testing: FADIR test of the left hip was negative (no pain)
Function: Poor eccentric control with lunge, single leg squat, and multidirectional toe touching.
Focus: continue strengthening and introduce functional movements.
Strengthening/Balance: continuation of basic stretching, self-myofascial release, core and lower extremity
strengthening with the addition of closed kinetic chain (CKC) functional activity. CKC exercises including
lunges, side-steps, and single leg squats. Balance was further progressed with activity on the BOSU® trainer.
Manual Therapy/Stretching: continuation of soft tissue management of the hip musculature and graded
joint mobilization to maintain joint mobility. Stretching activities continued with the addition of self-myofascial release with the foam roll.
Cardiovascular: cardiovascular activity was progressed with light treadmill jogging.
Home Program: week I and week II activity with the addition of CKC activity and light treadmill jogging.
Week #3
Strengthening/Balance: sports specific activity including multidirectional agility drills (e.g., ladder drills),
and movements on the TRX® suspension training system including single leg squats (Figure 2) and side
lunges (Figure 3a, 3b). Advanced balance activity was introduced including single leg balance and bilateral
squats on air filled discs.
Manual Therapy/Stretching: continuation of soft tissue and joint mobilization as needed to maintain
adequate soft tissue and joint mobility. Dynamic warm-ups were introduced prior to activity and stretching
and foam roll techniques were continued after physical activity.
Cardiovascular: progressive jogging on the treadmill and outdoor track.
Home Program: week II-week IV activity
Focus: return to pain free running and gym activity.
Strengthening/Balance: sports specific activity including multidirectional agility drills (e.g. ladder drills),
and movements on the TRX® suspension training system including single leg squats (Figure 2 ) and side
lunges (Figure 3a, 3b). Advanced balance activity was introduced including single leg balance and bilateral
squats on air filled discs.
Week #4
Manual Therapy/Stretching: continuation of soft tissue and joint mobilization as needed to maintain
adequate soft tissue and joint mobility. Dynamic warm-ups were introduced prior to activity and stretching
and foam roll techniques were continued after physical activity.
Cardiovascular: progressive jogging on the treadmill and outdoor track.
Home Program: week II-week IV activity
18  january 2013
international journal of Athletic Therapy & training
(a)
(b)
Figure 3a, 3b Side lunges on TRX©.
which included the iliopsoas and rectus femoris, and
underactive posterior musculature, which included the
gluteus maximus.
The patient’s rehabilitation program incorporated
strengthening exercises that were selected to correct
the identified muscle imbalance. Sherriton26 emphasized the “Law of Reciprocal Inhibition” as a means
to address muscle imbalance, which employs the
principle that agonist contraction promotes relaxation
of antagonist muscles. Thus, a primary focus of the
patient’s rehabilitation was reduction of hypertonicity
and restoration of normal extensibility of the illiopsoas
(overactive), and improvement of strength in the gluteal
muscles (underactive). To address the residual impairment of lower leg strength and ankle function from the
earlier fibula fracture and surgical procedure, restoration of optimal ankle strength and postural balance
were emphasized. Research has demonstrated that
poor hip kinematics and impaired postural stability
can be associated with a history of ankle sprains.27,28
The FADIR test has been reported to have excellent
sensitivity (0.91 to 1.0) and positive predictive value
(0.65 to 1.0).29 Despite the previous negative finding of
an MR arthrogram, the patient demonstrated a positive
FADIR test during the initial physical therapy examination. Hypertonicity and tightness of the anterior
hip musculature can elicit symptoms that are similar
international journal of Athletic Therapy & training
to those of FAI. After two weeks of rehabilitation, the
patient’s FADIR test was negative.
Summary
This report describes the successful management of
chronic hip pain in a young female runner whose case
demonstrated regional interdependence. The information presented in this report may help guide clinicians
in the development of effective rehabilitation programs
for similar cases. 
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Scott Cheatham is an adjunct faculty in the Division of Kinesiology at
California State University Dominguez Hills.
Lindsey E. Eberman, PhD, ATC, LAT, Indiana State University, is the
report editor for this article.
international journal of Athletic Therapy & training