The Spinal Column
HIP BURSITIS by Dr. Margaret Perez
So many of my patients come to me with pain on the side of their hip, or on the side of their thigh.  It’s usually caused by hip bursitis. 

  • Sharp burning pain at the top of your thigh radiating   to the hip and sometimes to the buttock
  • The pain is worse with sleeping on the sore side
  • Bursitis is inflammation of a small jelly-like sac that acts as a cushion between the leg bone and the overlying muscles of your buttocks and legs. WHAT ARE MY RISK FACTORS?
    • Repetitive stress (overuse) injury. This can occur when running, stair climbing, bicycling, or standing for long periods of time.
    • A hip injury to the side of your hip usually when falling.   
    • Spine disease. This includes scoliosis, arthritis of the lumbar (lower) spine, and other spine problems.
    • Leg-length inequality. When one leg is shorter than the other.


    • At Home- Remember that this is an inflammatory problem so initially use ice, NOT HEAT! You may also be helped with anti inflammatory medication if your stomach can tolerate it.   
    • At Our Office- Ultrasound therapy, red and infrared laser, massage and low range interferential current.
    • Later At Home- Roll the joint (Ha! before you think this is some kind of drug ad, look at the picture below) with a foam roller or a rolling pin. 
A Crucial Read for Saving Your Back! 

A Crucial Read for Saving Your Back! 

Meet Paul McCartney at Outside Lands Festival in SF for learning about Greenpeace’s Save The Arctic campaign on The Urgency Network

Meet Paul McCartney at Outside Lands Festival in SF for learning about Greenpeace’s Save The Arctic campaign on The Urgency Network

Don’t fall down the stairs while running with scissors.
This section is devoted to avoiding injuries.  Here is some practical advice. 

The best way to sleep is on your back.

This prevents neck and back pain. It reduces acid reflux, and minimizes wrinkles. The downside, it increase snoring. But hey you are getting your sleep so who cares?  
You should have a small pillow under your knees if you suffer from low back pain. I am not a big fan of expensive pillows. Start with one that supports your head and neck without propping your head up too much.

The next best is sleeping on your side

This is better than stomach sleeping in preventing neck and back pain. It reduces snoring and is the best position during pregnancy. For this you should have a thick pillow (not a curved cervical pillow). 

The last is sleeping on your stomach

It rates evenly with sleeping on train tracks as far as spinal health is concerned.

  Nest issue will be setting up your work place.


These are good for most conditions, but are especially good for shoulder bursitis.  Shoulder bursitis is that pesky pain you get when you try to reach behind you. The pain is usually in the upper arm. At this office I use cold laser, ultrasound and mobilization to reduce joint swelling and place the shoulder to its proper position. You can help yourself with these exercises

I hope you find this helpful. 

What is the Quadratus Lumborum? Nope, it’s not a Harry Potter Spell.

What is the Quadratus Lumborum?

TheQuadratus Lumborum is a muscle whose job is to stabilize the pelvis and lumbar spine. As you can see from the drawing below it starts at the ilium (pelvis rim) and travels to the transverse processes (the side of the vertebrae) of the upper four lumbar vertebrae and also goes to the twelfth rib

What is the treatment of Quadratus Lumborum Syndrome?

  1. Trigger point work for the areas shown above

  2. Balancing exercises to increase erector spinae neurologic control.

  3. Progressive stretching of the quadratus lumborum. This is done side-lying with the sore side up. A folded towel is placed under the waist (increasing number of towels are used as the patient progresses). While the patient maintains a strict side-lying posture the top leg is extended backwards and down into a stretch and the top arm increases the stretch by reaching overhead. See picture above.

  4. Strengthening of the larger oblique muscles (after the multifidus is working correctly)

  5. Supported modalities such as cold laser, ultrasound, interferential current, massage


We all agree that sleeping on your stomach is bad for your neck and low back.  But what about side sleeping?  It turns out that the naswer may lay on how you place your head on the pillow rather than on what pillow you use.

The reason why we like to  have patients sleep on their backs is that it forces the head to move back, which is the opposite of the forward head posture that most people assume all day long.  Sleeping on you back can help to restore the normal cervical curves. 

If you place your head slightly back on the pillow while you are sleeping on your side (instead of tucking your chin in) you can also restore the normal curve and negate the daily stress of the forward neck posture.   Of course also make sure that the pillow is high enough to keep your head level with your chest and not drooping down or being cranked up.  Questions? email me at



This should be called a pain in the butt!!  It is caused by the piriformis muscle tendon choking the sciatic nerve, and causing pain in the buttock and the leg.  

Treatment of piriformis syndrome at this office includes ultrasound to loosen the affected muscle and manual therapy to release the muscle, Finally we educate the patient in a proper home stretch and exercise program 



By Margaret Perez, D.C.

 There are several different causes of thigh pain. A good examination will determine the cause of the pain to determine the treatment area.  If your thigh pain is caused by a hip, buttock or low back problem, then treating the thigh will not get you better.  The goal is to find the source of pain, then treat the source.  


This pain is located in the back of the leg.  If it is above the knee it usually is the sign of a minor nerve root irritation. When it goes beyond the knee it is a sign of a more serious problem, likely a herniated disc. Don’t worry, this can still resolve with a short course of conservative care.  Pain that is from the sciatic nerve ususally starts in the low back and is worse with sneezing or coughing.  


Sneezing and coughing increases low back pain


Sciatica is caused by disc material placing either mechanical pressure or chemical irritation to the underlying nerve root.

Treatment is based on relieving the pressure in the low back.  This can include physical therapy modalities and traction or manipulation.    

Herniated Disk

A Herniated Disk




Femoroacetabular Impingement (FAI)

Femoroacetabular Impingement (FAI)


(AKA: Femoral Acetabular Impingement)


What is it?


Femoroacetabular impingement or FAI is a condition of too much friction in the hip joint.  Basically, the ball (femoral head) and socket (acetabulum) rub abnormally creating damage to the hip joint.  The damage can occur to the articular cartilage (smooth white surface of the ball or socket) or the labral cartilage (soft tissue bumper of the socket).


FAI generally occurs as two forms: Cam and Pincer.  The Cam form (Cam comes from the Dutch word meaning “cog”) describes the femoral head and neck relationship as aspherical or not perfectly round.  This loss of roundness contributes to abnormal contact between the head and socket.  The Pincer form (Pincer comes from the French word meaning “to pinch”) describes the situation where the socket or acetabulum has too much coverage of the ball or femoral head.  This over-coverage typically exists along the front-top rim of the socket (acetabulum) and results in the labral cartilage being “pinched” between the rim of the socket and the anterior femoral head-neck junction.  The Pincer form of the impingement is typically secondary to “retroversion”, a turning back of the socket, or “profunda”, a socket that is too deep.  Most of the time, the Cam and Pincer forms exist together.


FAI is associated with cartilage damage, labral tears, early hip arthritis, hyperlaxity, sports hernias, and low back pain.


FAI is common in high level athletes, but also occurs in active individuals.



Femoroacetabular (FAI) Impingement Forms

Lavigne et al. 2004

Normal Hip     CAM Hip

Pincer Hip      Mixed Hip




How is it diagnosed?


The diagnosis can be straightforward or a diagnosis of exclusion.  Most patients can be diagnosed with a good history, physical exam, and plain x-ray films.  A patient’s history will generally involve complaints of hip pain (front, side, or back) and loss of hip motion.  The physical exam will generally confirm the patient’s history and eliminate other causes of hip pain.  The plain x-ray films are used to determine the shape of the ball and socket as well as assess the amount of joint space in the hip.  Less joint space is generally associated with more arthritis.


Often an MRI of the hip is used to confirm a labral tear or damage to the joint surface.  The MRI is most helpful in eliminating certain causes of non FAI hip pain including avascular necrosis (dead bone) and tumors.




What studies should my doctor order?


In most cases, a Supine AP Pelvis view and a Hip Cross Table Lateral View are sufficient.  The Pelvis view should be taken so that the coccyx projects 1.5 cm above the symphysis pubis.  The Lateral view should be made with the lower extremity internally rotated 15 degrees.  As the x-ray films are the most important part of the diagnosis, they should be no older than six months and of good quality.


An MRI should be ordered as a left or right hip study with intraarticular gadolinium (contrast dye in the joint) and a pain test.  The pain test typically involves placing a local anesthetic inside the hip joint with the contrast dye.  Using the pain test helps assess whether the pain is coming from inside the hip joint.



Can back pain be a sign of FAI?


Yes.  While the cause is not well understood, patients with FAI often complain of low back pain.  This pain is often localized to the SI (sacroiliac joint on back of pelvis), the buttock, or greater trochanter (side of hip).  FAI pain typically does not go beyond the level of the knee.



What other diagnoses might be confused with FAI?


Hip Dysplasia (Adult Form)


Lumbar Spine Pain (Low Back Pain)


Lumbar Radiculopathy (Low Back Pinched Nerve, Low Back Facet Disease)


Sacroiliitis (SI Pain/Dysfunction, back of pelvis)


Trochanteric Bursitis (Outside Hip Pain)


Piriformis Syndrome (Back of Hip Pain)


Psychosomatic Pain Disorder (Stress Related Illness)


Iliopsoas Tendinitis/Tendonitis/Tendinosis (Hip Flexor Inflammation)


Groin Pull (Adductor Strain)


Sports Hernia (abdominal muscle strain)


Iliac Apophysitis (Front of Pelvis Pain)


Quadriceps Hernia/Strain (Thigh Muscle Pull)


Chronic Pain Syndromes




With what activities is FAI associated?


Some common activities


Ice Hockey


Horseback Riding




Football (American)














Field Hockey




Bike Riding/Cycling


Martial Arts


Deep squatting activities such as power lifting


Rowing Sports (Kayaking, Sculling/Rowing)


Car riding (deep seated position)




Why does it occur?


No one knows if FAI is a condition that begins at birth (congenital) or develops during periods of growth (acquired).  It is likely a combination of one’s genetics and environment.




How did I get it?


Some experts believe that significant athletic activity before skeletal maturity increases the risk of FAI, but no one truly knows.  Significant contact sports (i.e., football) are associated with Cam impingement.




Do I have arthritis if I have FAI?


Both plain film x-rays and MRI scans are an incomplete view of the cartilage inside the hip joint.  It is possible and common to have good joint space on plain x-ray films and no signs of arthritis on MRI and still have significant loss of cartilage within the hip.




Do I have FAI if my hip MRI was read as “Normal”?


At times, an MRI will be read as “Normal” but the clinical history, physical exam, and plain x-ray films indicate FAI.  In this situation, further investigation with an arthroscopic surgery may be needed.




My doctor told me that I have hip dysplasia, is this FAI?


Hip dysplasia (adult form) and FAI are two separate theories to account for degenerative hip disease and hip pain. Hip dysplasia is basically a hip condition where, most commonly, the socket (acetabular) coverage of the hip ball (femoral head) is insufficient or “too shallow”. Ultimately, the contact forces within a dysplastic hip joint are more concentrated than in a non-dysplastic hip joint with sufficient socket (acetabular) coverage of the hip ball (femoral head). Hip dysplasia is associated with tearing of the labral and articular cartilages. In some circumstances, adult hip dysplasia may be present with FAI.




What is an Alpha angle?


The Alpha angle refers to a measurement taken of the hip ball (femoral head and neck junction) to determine how much Cam impingement exists.  The larger the Alpha angle, the larger the Cam impingement lesion.  The Alpha angle is most accurate when obtained from a special MRI scan that controls for hip rotation.  An alpha angle is not essential to the diagnosis of FAI.




My doctor recommended a CT scan of my hip to evaluate for FAI, should I follow this recommendation?


A CT or CAT scan is often helpful in understanding the anatomy of the bones of the hip joint, but not essential to the diagnosis of FAI.  One should balance the large amount of radiation to the pelvis/reproductive region with the amount of information obtained.  This concern of  additional radiation is especially important when 3-D CT scans are performed.




My doctor recommended an MRI with IV contrast  [dGEMERIC MRI study] instead of  contrast in the hip joint (MRI Arthrogram) to evaluate for FAI, should I follow this recommendation?


An MRI scan with IV contrast [dGEMERIC] is an experimental study used to understand the condition of the hip joint cartilage.  It is not essential to the diagnosis of FAI.




My diagnosis was made after many years of hip pain, is that common?


Many physicians have heard of a hip labral tear but have not heard of FAI.




I’ve been treated for a labral tear with a hip arthroscopy.  Could I have FAI, too?


Hip labral tears are associated with FAI.  If you have had your labral tear treated and are still having pain, you may have unrecognized FAI.  This FAI may accelerate the loss of hip cartilage leading to further degeneration.  Labral debridement is not the same as labral repair.




Can my other hip be involved as well?


Yes, it is possible for both hips to have FAI.




I don’t have any pain, what should I do?


Some patients with FAI complain of stiffness and loss of hip range of motion without any significant pain.  Progressive loss of motion in the hip can be associated with ongoing FAI.  Speak to your physician about your options.




My doctor says that FAI doesn’t exist, why?


Currently, three different opinions exist regarding hip pain and hip problems.  The first is that all hip problems are generally mild and should be managed with nonoperative choices such as injections, therapy or rest.  If there is severe hip arthritis, a total hip replacement is considered.  The second is that hip problems often involve labral tears and that these tears can be treated by cutting out the torn tissue– usually with an arthroscopy.  The third is that hip problems often involve labral tears and that these tears are often secondary to abnormal hip biomechanics such as the labrum getting caught by friction between the bone of the ball (femoral head) and the bone of the socket (acetabulum)- the condition of FAI.  This third approach often leads to surgical treatment of the bone and soft tissue problems of FAI.




What type of doctor can treat it?


If one has a diagnosis of FAI or suspects FAI, one should be evaluated by an orthopaedic hip specialist.  Your physician should have experience with either open surgical hip dislocation or hip arthroscopy.




What are my treatment options?


Nonoperative management of FAI is possible; however, it involves a change in lifestyle from active to less active and a commitment to maintaining hip strength. Nonoperative management may not change the underlying abnormal hip biomechanics of FAI.


Operative management of FAI can be addressed via hip arthroscopy or open surgery.  In hip arthroscopy, the hip is distracted and an arthroscope is used to make an assessment of the hip joint and treat damage that is found through two to four 1 cm incisions.  Often, all of the components of FAI such as the labral tear, damaged cartilage, and friction between the ball and socket can be treated through the arthroscope.  Repair of a torn labrum as well as stimulating new cartilage growth (microfracture) are often possible with the arthroscopic approach.  A hip arthroscopy involving labral debridement (no repair) and no bony decompression usually takes less than one hour.  A hip arthroscopy involving labral/cartilage repair and FAI decompression may take between two and four hours, depending on the amount of work performed. Care must be taken to avoid damage to the hip’s blood supply (the retinacular vessels) during the osteoplasty procedure.


The open surgical hip dislocation involves an incision (approximately 6 to 10 inches), an osteotomy or bone cutting of the upper thigh bone, and dislocation of the ball from the socket exposing all parts of the joint.  This exposure allows treatment of labral tears and abnormal contact between the ball and socket while protecting the blood supply to the hip.  The open approach can typically be done in a few hours.  The open approach is not generally recommended in older patients or in patients with significant hip degeneration.


Recovery time from most FAI surgical procedures is about 4 months to full, unrestricted activity.  Your postoperative activity level will depend on your surgeon’s recommendation, the type of surgery performed, and the condition of the hip joint at the time of surgery. Revision FAI surgery may involve a significantly longer recovery.




What are the central, peripheral, and lateral compartments of the hip?


During a hip arthroscopy, the surgeon should visualize two compartments or spaces of the hip joint.  The first space is the central compartment.  The central compartment is composed of the surfaces of the ball (femoral head) and the socket (acetabulum) as well as the soft tissues (i.e., labrum).  Procedures performed within the central compartment include treatment of the cartilage and labrum.  The peripheral compartment is the remainder of the hip joint and refers to the area along the junction of the femoral head (ball) and femoral neck.  Procedures performed within the peripheral compartment include treatment of bone spurs and the joint capsule.  Both the central and peripheral compartments are within the hip joint capsule making them accessible with the arthroscope. The lateral or peritrochanteric compartment lies outside of the hip joint. The surgeon may enter the lateral compartment with the arthroscope to evaluate and treat disorders such as hip muscle/tendon tears, snapping hips, and hip inflammation (bursitis).




What are the main risks of FAI treatment?


Complications from FAI hip surgery are uncommon but include the following:


DVT (blood clot)




Hip Instability & Dislocation


Femoral neck fracture


AVN of the femoral head (dead bone)


Heterotopic ossification (abnormal bone formation in soft tissues)


Nerve injury (Sciatic, LFCN, Pudendal)


Nonunion (open surgical dislocation only)






How long can I wait before seeking treatment?


Typically, FAI that produces symptoms should be evaluated for surgical treatment.  A delay in FAI treatment may compromise the cartilage of the hip.




Can I be treated with an injection of medicine or good physical therapy?


Generally, FAI is a chronic condition that does not typically respond to hip injections or physical therapy over the long term.  That being said, a good physical therapy program focusing on hip strengthening instead of stretching may be beneficial.  In fact, the stretching associated with yoga may make the symptoms worse.




Can I just wait a few years and have a total hip replacement?


Yes.  The postoperative rehabilitation of a total hip replacement (total hip arthroplasty) is significantly less than an FAI procedure; however, the lifespan of the replacement hip is shorter in younger patients.  The same is true for a hip resurfacing type of procedure such as the Birmingham Hip Resurfacing Arthroplasty.  Both the resurfacing arthroplasty and the total hip arthroplasty involve amputation of the diseased joint surfaces and replacement with man-made materials (i.e., metal, plastic, ceramic) which are subject to wear.  The wear results in joint debris which may shorten the life of the replacement. Finally, the use of metal-on-metal hip bearings is controversial in women of childbearing age.



Margaret Perez: A Look Into The Office! (by DrMargaretPerez)