Every day we receive emails asking if stem cell therapy can be effective in treating hip osteoarthritis and in helping to avoid a hip replacement surgery. The answer is yes in many cases, however the first step is getting to an accurate diagnosis.
Hip pain can be a challenging area to treat for the patient who has long-term chronic pain. This is because the “hip” is often confused with other parts of the body. The hip could be the back of the pelvis where the ligaments attach themselves to vertebrae, or it could be the on the side where there is a lump on the femur (the curve of the hip). The hip has even been described as the muscles in the front thigh that connect to the pelvis. The pain caused in these areas of the “hip” may just be issues lying in the hip joint or the ligaments that attach the hip to the pelvis.
One of the more signficiant problems in successfuly treating the hip is getting an accurate diagnosis
The medical literature clearly points out that “MRI of the hip presents technical difficulties seldom encountered when imaging other joints. The imager is responsible for surrounding bony and soft tissue structures susceptible to many maladies that can mimic hip pain related to an intra-articular derangement.” 1 Here the MRI can confuse the issue and lead to an unnecessary surgery.
Hip pain is common, and its causes are many, although not all come from the joint but can masquerade as hip pain. The confusuion can be so signficiant that in one case history, doctors reported on a 64-year-old woman with a painful total hip replacement.
She suffered of excruciating pain after the implantation of a cementless total hip replacement and revision because of recurrent hip dislocations.
Walking was limited to short distances using two crutches. The work-up at this time included the usual diagnoses and remained unsuccessful. No loosening, infection or malposition of the prosthesis could be found, and she had no neurologic deficits in her operated leg. An MRI showed a tight scar surrounding the sciatic nerve.2
So here as in many cases, the surgery caused more pain
The medical literature is filled with similiar cases and makes it clear to pint out that hip replacemnt is an ELECTIVE surgery. “Total hip replacement has been indicated as the surgical intervention with greatest improvement in pain and physical function. However some patients continue to experience hip pain after elective surgery….The “hip region” constitutes the groin, buttock, upper lateral thigh, greater trochanteric area, and the iliac crest. Pain originating from various sources and not directly linked to the replacement may be perceived here and includes the lumbosacral spine, referred pain from abdominal organs and soft tissue sources such as trochanteric bursitis, tendinitis, hip abductor dysfunction, and inguinal hernia. An accurate assessment of the pain cause is extremely difficult to construct and a complete differential diagnosis is fundamental.”3
Again we are back to the hip diagnosis as one of the most important elements in teh success of stem cell therapy in the treatment of hip osteoarthritis.
Pyriformis Syndrome, mentioned above, may cause pain in the buttocks, lower back, or down the leg. Your hip has some very powerful muscles. Among them is the piriformis, which is in the back of the hip and helps rotate the leg outwards. The sciatic nerve is just underneath it; in some people, the nerve is impinged under the piriformis muscle. When the muscle contracts, it acts like a pincer on the nerve, which causes the discomfort. 4
Greater trochanteric Bursitis
Greater trochanteric Bursitis & Ischial bursitis: The hip joint and the large muscles that cover it are protected by several bursal sacs. There is also a small amount of fluid contained in the hip joint. Each bursa produces lubricating fluid and functions to reduce pressure and friction around the joint. These bursa sacs can become irritated from injury, excessive pressure, and overuse. Inflammation of a bursa is called bursitis.
Hip tendonitis or tears
Hip tendonitis or tears: Tendinitis occurs when a muscle is overused and pulls on the tendon that attaches it to the bone. In your hip, tendons perform an important role by keeping strong muscles attached to the femur (thigh bone) as your legs move. One kind of tendinitis that occurs as a result of overuse is called iliacus tendinitis or iliopsoas tendinitis. The iliac muscle, which starts at your hip bone, and the psoas muscle, which starts in your lower spine, are used when lifting the leg toward the chest to keep you stable. They come together in a tendon at the top of the femur, and that is the point where tendinitis occurs.
Diagnosing Hip Pain by being a doctor not a machine
In February 2012, research was presented at the American Orthopaedic Society for Sports Medicine’s (AOSSM) Specialty Day meeting that suggested that when doctors treat people with hip pain, “physicians should not replace clinical observation with the use of magnetic resonance images (MRI).” The research stated that when MRIs were performed on volunteers WITHOUT hip pain – 73% showed abnormal finds.
Sometimes it is a herniated disc that can refer pain to the area of the hip, or a mixture of some, or all of the above, depending on the patient’s condition. So, a very complete examination of all of these areas with my hands must be made to determine the hip pain source. I can’t depend on an X-Ray or MRI to tell me where to do the PRP or Prolotherapy treatment.
A patient came in to our clinic with right hip pain. The pain started one year earlier. It got worse with walking and radiated down to his right knee and toes. He experienced occasional numbness and tingling in those same areas. He felt his legs were getting fatigued with walking. He was taking Percocet for pain. Due to the pain and fatigue, he needed assistance and started using crutches to ambulate.
Although the patient came presenting with hip pain, we found on examination that the pain was in his low back. An x-ray of his right hip showed narrowing of the joint with some degenerative change. He also had pain with lateral abduction and hip flexion. There was tenderness around his right greater trochanter. In regards to his lower back, he had tenderness on the right iliolumbar ligaments, sacroiliac ligaments and the upper gluteal attachments on the pelvis. An MRI of his lumbar spine showed a 7mm bulge at L4-L5 with central canal narrowing, 2mm bulge at L3-L4, and a 5mm disc bulge at L2-L3.
We started him on injections to his low back in the area of his right pelvis and right greater trochanteric bursa. After the first set of injections, he had immediate relief in his lower back and leg. There was still some pain but it was much improved. The following week after discontinuing the Percocet, we injected him again. He no longer needed to use crutches to get around. He was feeling 75% better and had no pain after his third week of treatment. There was no tenderness to palpation in his greater trochanter, iliolumbar ligaments, SI ligaments or gluteal area.
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1. Zoga AC, Morrison WB. Technical considerations in MR imaging of the hip. Magn Reson Imaging Clin N Am. 2005 Nov;13(4):617-34, v.
3. Wettstein M, Garofalo R, Mouhsine E. Painful total hip replacement due to sciatic nerve entrapment in scar tissue and lipoma. Musculoskelet Surg. 2010 Nov;94(2):77-80. Epub 2010 May 22.
4. Ferrata P, Carta S, Fortina M, Scipio D, Riva A, Di Giacinto S. Painful hip arthroplasty: definition. Clin Cases Miner Bone Metab. 2011 May;8(2):19-22.
5. Kabataş S, Gümüş B, Yilmaz C, Caner H. CT-guided corticosteroid injection as a therapeutic management for the pyriformis syndrome: case report. Turk Neurosurg. 2008 Jul;18(3):307-10.