Persistent hip pain. (The Clinic).

I am a 43-year-old runner with pain on the top right side of my thigh just below where it meets the hip. I've had this problem for about a year. I ran the Chicago Marathon and the Twin Cities Marathon without problems. However, about a month after Twin Cities the pain began without any obvious cause since I'd cut my mileage to about 25 miles a week at the time. The pain gradually worsened until I could no longer run without pain. After about four weeks of rest I gradually began to run again, but I have not been able to run more than about nine miles per week without the pain coming back. Cross training with a bicycle, recumbent bike, and even deep-water running all seem to aggravate the problem. The pain is worse when I'm driving a car.

A physician diagnosed the condition as trochanteric tendinitis/bursitis, but despite a steroid injection in the region of the greater trochanter and ultrasonic therapy, I still have pain. Do you have any suggestions?

Greg Thorgaard

Ottumwa, IA

At times, what appears to be an iliotibial band problem or trochanteric bursitis may in fact represent some other type of underlying condition. This could include a primary problem with the hip joint, stress fracture, or possibly even pain referred from the lower back. An MRI of the lower back, as well as the hip, might prove helpful.

If, in fact, your problem is trochanteric bursitis, the condition is often associated with tightness and inflexibility of the iliotibial band, which is a soft tissue structure traveling from the outer aspect of the hip along the outer thigh toward the knee. Even without experiencing pain in the thigh or knee, as in a typical iliotibial band syndrome, a tight or contracted iliotibial band can often result in pain at the region of the trochanter. There is a fluid-filled sac, or a bursa that overlies the trochanter, which can become inflamed.

It is possible that the second marathon may have mechanically overloaded these structures. You may also have had a subtle injury that had gone unrecognized. Frequently, iliotibial band problems are associated with bio-mechanical dysfunction, either around the hip girdle, including weakness of the hip abductors and extensors, or possibly even more distally, an inflexibility of the calf and Achilles, as well as problems with hyperpronation.

Try eliminating all activities for a more extended period, to see if you can bring this problem under some control. At the same time, I would strongly recommend starting a comprehensive physical therapy program to assess your gait and to provide you with specific stretching and strengthening exercises. It is possible that simple iliotibial band stretches may be enough to help eliminate this problem.

Stuart M. Weinstein, M.D.

Seattle, WA