Hip Injuries

Q. My daughter has played competitive tennis for ten years, about four months ago she complained of right hip pain after a hard match. We tried physical therapy with no results and we saw a second orthopedists who diagnosed her with sacro-illiac rotation. We have been seeing a chiropractor with somewhat better results.

It is no longer a goal to get my daughter back on the court but to just get her to be pain free. Do you have any suggestions for me? Do you know of any one who specializes in this treatment. Any suggestions would be greatly appreciated.

A. Regarding your daughter, injury to the lower back and sacro-illiac region is a common occurrence in high performance players.

Typically, the best treatment involves decreasing the initial pain and inflammation, and then most importantly, developing a comprehensive program of core stability training to support the lower back and pelvis through specific exercises and stretching. This program initially must be set up by a knowledgeable sports physical therapist and continue to be carried out to ensure that optimal stability is provided by these muscles.

The chiropractor may be placing the lumbar spine and sacro-illiac segments into proper alignment, hence the better recent result, however, if your daughter is rather hyper mobile or extremely flexible in these areas, this treatment alone without the proper core stability training would likely not completely address the problem. Core stability training is a very important part of treatment and prevention of sacro-illiac and lumbar spine injury.

Q. I'm curious about common hip injuries associated with hitting an open stance forehand or backhand. Or actually, what I am really interested in is hip injuries due to poor technique on ground strokes (such as opening up too soon, pulling off a shot). Also, what can adult players do to counter this as far as conditioning goes (since it might take awhile to get the form right!).

A. Unfortunately, most tennis injuries are multifaceted so there are few easy answers to injury questions. There are no studies that statistically link open stance tennis strokes with higher rates of certain injuries at the hip joint. Most tennis players could benefit from strengthening hip musculature in all directions (flexion/extension and abduction/adduction). Most players should also stretch the muscles around the hip in all directions too. One recent study of tennis professionals found an association between flexibility losses of hip internal rotation of the lead leg and lower back flexibility.

Hip flexors are muscles on the front of your hip and thigh that help you quickly swing the leg forward as you run about the court. For most players strength is not the issue but flexibility. If your knee is strong a good stretch is to bend your knee and grab your foot behind you and gently pull your leg backward. More advanced stretches are splits (rear leg) or elevating your leg behind you and placing the top of your foot on a short bench/fence.

One of the hip flexors (rectus femoris) crosses both the hip and knee joints, so combinations of hip extension with and without knee extension will allow you to focus stretching on this superficial muscle or the deeper hip flexors in the pelvis/lower back. To reduce the risk of painful hip flexors one should both strengthen these muscles away from the court and stretch them to maintain their flexibility.

Q. If you had to identify one area of the body that you would want to make sure had sufficient strength, what would it be and how would you strengthen that body part to reduce injury risk?

A. From a biomechanical perspective, there is a lot of trunk muscle activity in the tennis strokes, all tennis strokes. There is a lot of abdominal muscle activity. Many people call this the core and it is a popular theme in strength and conditioning these days. There basically is a channeling of energy from the lower body to the upper body through the core. The core musculature also protects the spine from getting out of position where it would get hurt. What tends to happen is that players have strong abdominal muscles, naturally, from hitting their strokes and tight and over-stressed lower back muscles - although these show a lot of activity in tennis strokes as well. I would encourage a player to develop strength and flexibility for the trunk musculature.

Hip and trunk is by far the #1 area. If you have a player who comes to you and says "I want to improve my serve velocity, what rotator cuff exercises can I do?" You would give them an "F". You would give them an "A" if they asked you "What exercises should I do for my hip and trunk to allow me to have good stability and generate the needed force?"

If there is one single area you want to have flexibility, it would be at the shoulder - in internal rotation. This is one area where we know that decreased flexibility has a direct correlation to injuries in the shoulder and decreased performance. The High Performance Profile does a good job at assessing this. You have to have good internal rotation to get effective long axis rotation. You have to make sure that is maximized.

Q. I play every day, sometimes 1 1/2 hours on ball machine. The right hip sometimes develops a pain. Could it be from hitting forehands with open stance, after 500 hits on the machine? I am 81 and in good health and love this game. Is there an exercise, or medicine or prayer, as I would go nuts to give it up?

A. First off, congratulations on your health and your love for the game of tennis. You serve as an inspiration and an example that tennis truly is a lifetime sport.

To answer your question, I think it is definitely possible that the pain you are experiencing in your hip is the result of overuse. You say you are hitting 500 open stance forehands every day. That means you are loading that hip and putting essentially the same stresses on it each time you hit the ball. That is a lot of repetitive stress, and you can probably see how that could damage the structures in your hip. Overuse injuries occur over time.

Every time a stress is applied to a tendon, or ligament, or another structure in the body a small amount of damage occurs. This is not enough to cause an injury, but over time, these small micro-tears build up and lead to pain and inflammation.

One suggestion would be to mix things up a bit – play with a partner or have the ball machine alternately feed to your forehand and backhand. At least then you will be moving and hitting different shots – some likely will still be open stance forehands but you also will likely hit some with semi-open or square stances. As for strengthening, there are some exercises you can do to build strength in your legs.

Some examples of exercises you can use are found on the Player Development website – there is an article on Strength and Conditioning for Injury Prevention under the Sport Science – Strength and Conditioning heading on the left side of the page.

I also recommend you get an exam by a physician and/or orthopedist as your doctor will be able to tell you more accurately what is going on in your hip.

Q. How do you deal with a hip flexor injury? I have stretches and stuff but after two and half months still feel I cannot move side to side enough to play tennis.

A. Great question! With a hip flexor injury, as with many musculoskeletal injuries, the healing process is based upon three stages of healing. These stages include the acute inflammatory phase, the intermediate (repair) phase, and the advanced (remodeling) phase. Although it has been two and a half months, your muscle remains in the advanced remodeling phase. This phase typically begins three weeks after injury and can last up to six months. During this period, the scar tissue that was formed during the repair phase undergoes remodeling and becomes stronger. Therefore it is necessary to continue treatment and rehabilitation of the hip flexor. This includes ice post practice, flexibility training, and strengthening of the hip region.

Since the hip flexor plays a large role in the movement of the anterior (front) leg during tennis it is important to have full strength before returning to play. The atrophy or weakness that occurs during injury will cause other muscles of your leg to compensate. In your case, difficulty with side to side movement may be caused by the stress placed on the side and back of your leg which is compensating to take the load for the weakness in the hip flexor. For this reason, it is important to strengthen the entire hip. This includes the front, side, and back of the leg. More specifically, be sure to strengthen the quadriceps, hamstring muscle group, hip abductors (iliotibial band) and hip adductors.

In order to allow your body to continue healing and prevent further injury, be sure to perform a proper warm-up and cool down each time you play. The warm up should include dynamic stretching exercises such as straight leg marching and carioca. This will help you increase body temperature and allow your muscles to work more efficiently. After you finish playing cool down with light jogging or biking and static stretching. Both the warm-up and cool down should be done for 10-15 minutes.

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