Exploring Common Hip Ligament Injuries

Ligaments are connective tissue structures that connect bone to bone. They help provide stability for joints such as the hip. There are four main hip ligaments that help to keep the hip in its natural socket. If these ligaments are injured, then they may cause pain directly.

Most often, they cause the hip to become unstable, leading to more stress and injury to other parts of the hip such as the labrum, cartilage, and/or bone.

Different Ligaments in the Hip

The hip joint is a ball and socket joint formed by the femoral head (the ball at the top of the hip bone) and the acetabulum (the socket). It is surrounded by a thick articular capsule that is made up of four ligaments (the iliofemoral, ischiofemoral, pubofemoral ligaments, and ligamentum teres).

• Iliofemoral ligament: This ligament is in the front and on top of the hip capsule and is the strongest ligament in the body. It attaches to the femur and the anterior inferior iliac spine (AIIS). It is sometimes called the Y ligament of Bigelow due to its inverted Y shape. It supports standing posture and limits extension of the hip. 
• Pubofemoral ligament: The pubofemoral ligament is in the front of the hip and is attached from the femur to the pubic bone. It is the weakest hip ligament, and it limits external rotation (rotating outward). 
• Ischiofemoral ligament: The ischiofemoral ligament is in the back of the hip. It attaches to the back of the greater trochanter to the ischium. It prevents excessive hip flexion and internal rotation. 
• Ligamentum teres: This ligament is deep within the hip joint. It is attached to the inner ball of the femur (called the fovea) and the deep inferior (lower) part of the acetabulum and another ligament called the transverse acetabular ligament. 
  
  The ligamentum teres is a secondary stabilizer that prevents the hip from coming out of the socket. There is a strong association of ligamentum teres injuries and labral tears.¹

Causes of Injuries in the Hip Ligaments

In a hip hyperextension injury, the iliofemoral ligament can be injured. In excess external rotation, the pubofemoral ligament can be injured. In a hyperflexion injury, the ischiofemoral ligament can be injured. These injuries are generally caused in one of the following ways:

Trauma

Trauma such as a motor vehicle accident, fall, or direct blow to the hip can damage the ligaments.

Repetitive Microtrauma

This means repeated stress from activity being done with poor form, muscle and postural asymmetries, or excess force.

 Latrogenic

This means a medical procedure caused an injury. The hip capsular ligaments can often be injured during a hip surgery such as arthroscopy, as a great amount of traction has to be applied to the hip joint in order to open it to allow access for the camera and surgical instruments.

Genetic Hypermobility or Connective Tissue Disorders

These are inherited issues that make all the body’s ligaments loose or weaker than a normal person’s ligaments. These are more prone to injury and arthritis due to excess movement in the joints.

Symptoms of Hip Ligament Injuries

The symptoms of hip ligament injuries include:

• Loud “pop” upon injury
• Bruising
• Inability to bear weight on the injured hip
• Poor or limited movement in the joint
• Pain with activity
• Pain with excess stretching of the joint
• Clicking sensation with movement
• Hip weakness

Diagnosis of Hip Ligament Injuries

Diagnosis of hip ligament injuries can be difficult and these injuries are often missed or under diagnosed. The diagnosis requires referral to an orthopedic specialist such as a physical medicine and rehabilitation (PMR) doctor, sports medicine doctor, pain doctor or orthopedic surgeon.

The doctor will take a detailed history that would give clues to potential injury. They will then perform a detailed physical examination, testing the range of motion of the hip, looking for tender areas, performing specialized tests that stress the joint, labrum and ligaments, and they will also examine other associated body parts that may contribute to the problem.

Hip X-rays may be taken to look for bony deformities, fractures, arthritis, or signs of abnormal hip shape (dysplasia).

A hip MRI can show the soft tissues in better detail to reveal injuries to the bone, cartilage, labrum, ligamentum teres or signs of hip capsule injury, such as leakage of fluid from the joint.

Conventional Treatments

Typically, the first line of treatment for hip ligament injuries would be conservative. At home, patients can avoid aggravating activities, use heat or ice, or briefly take over-the-counter pain medications as needed. Conventional treatments may include:

Physical Therapy

After seeing a specialist and obtaining a diagnosis, physical therapy typically should be the first recommendation. Good physical therapy can help correct postural and biomechanical factors that may be leading to more stress on the hip. 

It can help to mobilize the hip for improved range of motion and nutrient delivery, and it can help strengthen the muscle around the hip to provide more stability.

Steroid Injection

When physical therapy fails, a steroid injection is often recommended to help with pain. While this may help with pain in the hip joint, it does nothing to help to fix the damaged ligaments. In fact, steroids can actually cause damage to cartilage and ligaments and impair healing.²

Furthermore, if hip surgery were required in the future, steroids increase the risks of surgical complications and infection.³ For these reasons, most patients should avoid these injections.

Surgery

If physical therapy has failed after one to two months, patients would generally be left to deal with the dysfunction. The only other option would be surgery. Surgery for hip capsular ligament repair is newer and rare, so should only be performed in the most severe cases.

Ligamentum teres repair can also be done but again this is a difficult and invasive surgery with significant recovery times. Long-term results are unknown, as these surgeries are not well studied.

Regenerative Medicine for Injured Hip Ligaments

In lieu of invasive surgery, there are now novel regenerative medicine treatments that can help hip ligaments heal with much less invasive injections that help to facilitate healing.

At the Centeno-Schultz Clinic, we specialize in treating orthopedic problems such as hip ligament injuries with substances that help the body self-heal, called orthobiologics. Many of these orthobiologic techniques have been invented by doctors from the Centeno-Schultz Clinic.

Dr. Pitts invented a technique to accurately and safely inject the difficult to reach ligamentum teres. The image below shows this combined ultrasound and fluoroscopic (X-ray guided) injection from the textbook for which Dr. Pitts served as primary editor and author.

The two most common orthobiologics used for hip ligament tears are PRP and bone marrow concentrate containing stem cells.

• PRP (platelet rich plasma): This involves obtaining blood from a vein in a simple blood draw, centrifuging (spinning) that blood to separate the components, then isolating and concentrating the platelets. 
  
  At the Centeno Schultz Clinic, the healing agents from your own blood are concentrated and customized to each patient’s individual issue to promote your body’s natural ability to heal. PRP has growth factors that help stimulate soft tissue healing, similar to what happens when you heal from a cut on your skin.
  
  PRP works well for mild hip ligament injuries.

• BMAC (bone marrow aspirate concentrate): BMAC contains stem cells and is obtained by taking bone marrow from the iliac crest (hip bone) in a safe and comfortable way. The bone marrow is processed similarly to PRP, to concentrate the cells in the marrow. 
  
  Those stem cells aid in healing as they contain stem cells, the most powerful healing cells. BMAC is used for more severe ligament tears.
  
  In addition to using PRP or BMAC to help heal the hip ligaments, we also look for associated injuries with the hip cartilage, labrum, tendons, and bones that we can also treat and help heal.

Recovery from Hip Injuries is Possible

Don’t avoid the diagnosis of a hip ligament injury. Now there are safe and effective treatments that can help you stay active and avoid surgery.

At the Centeno-Schultz Clinic, we are specialists and pioneers of regenerative medicine. We offer patients the most advanced treatments for hip problems, including ligament tears. We can even treat the ligamentum teres that are often underdiagnosed and difficult to treat.

We want you to know there is help for you to recover from hip ligament and other orthopedic problems, so you can continue the activities you love without drugs or surgery. 

There’s hope for even the most serious hip ligament injuries. Learn more about our alternatives to hip surgery.

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Christopher J. Centeno, MD

Christopher J. Centeno, M.D. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics. He is board-certified in physical medicine and rehabilitation with a subspecialty of pain medicine through The American Board of Physical Medicine and Rehabilitation. Dr. Centeno is one of the few physicians in the world with extensive experience in the culture expansion of and clinical use of adult bone marrow concentrate to treat orthopedic injuries. His clinic incorporates a variety of revolutionary pain management techniques to bring its broad patient base relief and results. Dr. Centeno treats patients from all over the US who…

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John Schultz, MD

John R. Schultz M.D. is a national expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate for orthopedic injuries. He is board certified in Anesthesiology and Pain Medicine and underwent fellowship training in both. Dr. Schultz has extensive experience with same day as well as culture expanded bone marrow concentrate and sees patients at the CSC Broomfield, Colorado Clinic, as well the Regenexx Clinic in Grand Cayman. Dr. Schultz emphasis is on the evaluation and treatment of thoracic and cervical disc, facet, nerve, and ligament injuries including the non-surgical treatment of Craniocervical instability (CCI). Dr. Schultz trained at George Washington School of…

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John Pitts, M.D.

Dr. Pitts is originally from Chicago, IL but is a medical graduate of Vanderbilt School of Medicine in Nashville, TN. After Vanderbilt, he completed a residency in Physical Medicine and Rehabilitation (PM&R) at Emory University in Atlanta, GA. The focus of PM&R is the restoration of function and quality of life. In residency, he gained much experience in musculoskeletal medicine, rehabilitation, spine, and sports medicine along with some regenerative medicine. He also gained significant experience in fluoroscopically guided spinal procedures and peripheral injections. However, Dr. Pitts wanted to broaden his skills and treatment options beyond the current typical standards of care.

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Jason Markle, D.O.

Post-residency, Dr. Markle was selected to the Interventional Orthopedic Fellowship program at the Centeno-Schultz Clinic. During his fellowship, he gained significant experience in the new field of Interventional Orthopedics and regenerative medicine, honing his skills in advanced injection techniques into the spine and joints treating patients with autologous, bone marrow concentrate and platelet solutions. Dr. Markle then accepted a full-time attending physician position at the Centeno-Schultz Clinic, where he both treats patients and trains Interventional Orthopedics fellows. Dr. Markle is an active member of the Interventional Orthopedic Foundation and serves as a course instructor, where he trains physicians from around the world.

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Brandon T. Money, D.O., M.S.

Dr. Money is an Indiana native who now proudly calls Colorado home. He attended medical school at Kansas City University and then returned to Indiana to complete a Physical Medicine and Rehabilitation residency program at Indiana University, where he was trained on non-surgical methods to improve health and function as well as rehabilitative care following trauma, stroke, spinal cord injury, brain injury, etc. Dr. Money has been following the ideology behind Centeno-Schultz Clinic and Regenexx since he was in medical school, as he believed there had to be a better way to care for patients than the status quo. The human body has incredible healing capabilities…

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Other Resources for Hip Ligament Injuries

References:

1. Christopher M. Larson, Editorial Commentary: Ligamentum Teres Tears and Femoroacetabular Impingement: Complex Coexistence of Impingement and Instability, Arthroscopy: The Journal of Arthroscopic & Related Surgery, Volume 32, Issue 7, 2016, Pages 1298-1299,ISSN 0749-8063 https://doi.org/10.1016/j.arthro.2016.05.003.(https://www.sciencedirect.com/science/article/pii/S0749806316302286)
2. McAlindon TE, LaValley MP, Harvey WF, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA.2017;317(19):1967–1975. doi: 10.1001/jama.2017.5283), (Wang BL, Sun W, Shi ZC, et al. Decreased proliferation of mesenchymal stem cells in corticosteroid-induced osteonecrosis of femoral head. Orthopedics. 2008;31(5):444. doi:10.3928/01477447-20080501-33
3. Ravi B, Escott BG, Wasserstein D, Croxford R, Hollands S, Paterson JM, Kreder HJ, Hawker GA. Intraarticular hip injection and early revision surgery following total hip arthroplasty: a retrospective cohort study. Arthritis Rheumatol. 2015 Jan;67(1):162-8. doi: 10.1002/art.38886