The Hip Joint – Do You Really Need It Replaced?

I would like to start this month’s column off with a personal note.

In the August issue of the Townsend Newsletter, I wrote about Rotator Cuff Shoulder injuries. I had one of these injuries. About three years ago, I injured my shoulder. I was demonstrating some gym equipment for a writer, so I was doing very light weights. A day later, my shoulder was extremely painful and I could barely move it. It was not this one incident that caused it. Rather, like most joint injuries, it was a compilation of years of doing athletics. That one day was just the straw that broke the camel’s back. At that time, I was unaware of the risk/benefits of an MRI. So after a week of not being able to lift or move my shoulder and being in extreme pain, I had an MRI. As soon as the films were on the screen, the radiologist called me into his office. The radiologist I went to is an expert in musculo-skeletal MRIs who I know very well and trust his opinions. He said that there was nothing more to do and that I needed to go find a surgeon as I had torn two out of my four rotator cuff tendons and my labrum. I just said thanks, but no thanks. I instead had Comprehensive Prolotherapy done on my shoulder. I am happy to say that this past August 24, 2013, I finished my third Ironman Triathlon which included a 2.4 mile swim, a 112 mile bike and a 26.2 mile swim. All that with a shoulder that I was told to have surgically repaired or risk not moving it again. Prolo works! Now on to this month’s column.

The hip is one of the largest weight-bearing joints in the body. It is a ball and socket joint that is used on a daily basis since it is involved with walking, sitting and standing. It is a very useful and functional joint. The hip ligaments and tendons are subject to enormous forces during activities of daily living and also during sports activities. Unfortunately it takes a lot of wear and tear and can be weakened by many things. It is also one of the most ‘popular” joints in the body to have surgery on or be totally replaced. According to the Centers for Disease Control and Prevention (CDC), 332,000 total hip replacements are performed in the United States each year. This does not include partial hip replacements and other hip surgeries which have been estimated to be close to 10 million! More on this later in the article.

Anatomy

The hip consists of two main parts: the socket (acetabulum), which is a cup-shaped socket in the pelvis where the ball fits. The ball is the top part of the femur (femoral head) which is the top part of the upper thigh bone, the longest bone in the body. The top of the shaft of the femur as two has two eminences (bumps): the great and lesser trochanters, where many muscle tendons attach The hip joint is normally very sturdy because of the fit between the femoral head and acetabulum as well as strong ligaments and tendons at the joint which provide it with stability.

The most notable ligaments which help stabilize the hip joint are:
1) Iliofemoral ligament, which connects the pelvis to the femur at the front of the joint. It keeps the hip from hyper-extension; 2) Pubofemoral ligament, which attaches the most forward part of the pelvis known as the pubis to the femur 3) Ischiofemoral ligament, which attaches to the ischium (the lowest part of the pelvis) and between the two trochanters of the femur.

The various muscle tendons which attach to or cover the hip joint generate the hip’s movement. The important ones are:
1) The gluteals, which are the muscles in your buttocks. There are three of them: the gluteus maximus, the gluteus medius and the gluteus minimus. They attach to back of the pelvis and insert into the greater trochanter of the femur. 2) The four quadricep muscles (vastus lateralis, medialis, intermedius and rectus femoris), which are located at the front of the upper leg (the femur). All four tendons attach to the top of the tibia (lower leg bone). The rectus femoris originates at the front of the ilium, which a part of the pelvis. The three other quads attach around the greater trochanter of the femur and just below it. 3) The Ilio-Psoas is the primary hip flexor muscle. The three parts of the iliopsoas attach to the lower part of the spine and pelvis, then cross the joint and insert into the lesser trochanter of the femur. 4) The hamstrings are three muscles at the back of the thigh. All three attach to the lowest part of the pelvis. 5) The groin or adductor (pulls your leg inward) muscles attach to the pubis and run down the inside of the thigh.

The hip, like many joints in the body, is surrounded by a capsule. The joint capsule is a thick ligamentous structure surrounding the entire joint. Inside the capsule, the surfaces of the hip joint are covered by a thin tissue called the synovial membrane. This membrane nourishes and lubricates the joint. The hip also has a labrum, which is a circular layer of cartilage that surrounds the outer part of the acetabulum making the socket deeper to provide more stability for the joint. Labrum tears are not an uncommon hip injury.

Hip Injuries

Arthritis, or Osteoarthritis, is the most frequent disorder associated with hip problems or pain. Arthritis afflicts most of us as we age, steadily wearing away the smooth and resilient cartilage that caps the ends of our long bones and is essential to normal joint function. Arthritis is a catch-all word, since all it really means is that the joint (arth) is inflamed (itis). What causes this pain is another story. This is most likely weakened, torn or damaged ligaments, tendons or cartilage. In most cases, this does not happen suddenly. The pain may suddenly appear, but it usually develops over time and is the result of an accumulation of over usage, injuries or everyday wear and tear. A few other forms of arthritis can cause hip pain as well, including rheumatoid arthritis, traumatic arthritis and gouty arthritis. Other conditions associated with hip pain include bursitis, muscle cramps, hip fracture, stress fractures of the femoral neck or pelvis, avascular necrosis, joint infection and congenital defects such as congenital dislocation (CDH) and congenital hip dysphasia. In addition one may have a ligament injury or weakness in one part of the body that causes pain in another part, which is called referred pain. The sacroiliac and pubic symphysis areas are often overlooked because some physicians are not familiar with the ligament referral patterns from the lower back and pubic symphysis. When examining a patient for hip pain, all related areas including the knees, the feet and the lower back must also be considered. Hip motion is affected by all these areas. A complete examination of someone with hip problems or pain should include evaluating all these areas and can indicate whether an MRI is appropriate. Only then, if deemed necessary, should you have an MRI.

Several years ago, a 64 year old woman came to see me for her left hip pain. After a thorough examination, I determined that she would be an excellent candidate for Prolotherapy. With only five treatments, her left hip was pain free and she had full range of motion. She was able to continue her daily routine of walking, dancing, bowling and more. Two years later she appeared in my office and this time she had a set of x-rays with her. She said her primary care physician convinced her to have them, although he did not really examine her. She explained that her right hip was bothering her (the last time it was her left hip). The left hip, which I previously treated, had no pain. I examined her and determined that ligament and tendon laxity was the cause of her problems and that Prolotherapy would be very beneficial for her. After this, I looked at the x-rays. I never look at the x-ray or MRI before I take a thorough history from a patient and then do a comprehensive physical exam. This allows me to establish my own opinion of the problem instead of letting the radiological results influence it. When I looked at her x-rays, the left side which had no pain, had radiological changes. The right side, which was bothering her, was read as normal. She said “If I showed this to a surgeon, he would want to operate on the pain free side!” After treating her for five treatments, she was pain free on the right side

Treatments

Usually anti-inflammatory medicines are prescribed. When that fails to resolve the problem, one is given cortisone injections. Most of the time, these drugs may provide only temporary relief, while doing nothing to correct the underlying condition causing the pain. In fact, in the long run, these medications do more damage than good. The next step is usually surgery. Surgery has to be one of the most common treatments that is suggested for dysfunctional hip joints. The most common hip surgery is total or partial replacement. Unfortunately there are many side effects associated with hip replacement surgery. Some of the more common complications of hip surgery are: Blood clot, Misalignment of implants, Dislocation, Leg length differential, Infection, Implant loosening, Fracture, Allergic reactions and more. Roughly three percent (that is almost 10,000) of patients who undergo total hip replacement surgery require critical care services (intensive care unit) before they are discharged from the hospital, according to an analysis of roughly half a million patients in the journal Anesthesiology. Plus with approximately 332,000 total hip replacements being done every year, if only 10% of all the surgeries fail outright, that would mean over 33,000 complete failures per year. Many times, hip surgery and joint replacement makes the problem worse, because it never corrects the true underlying problem which can be weakened, torn or damaged ligaments and tendons either in or around the hip joint or in another associated area.

Remember that surgery can always be done- but never un-done!
Comprehensive Prolotherapy (dextrose, PRP and Bone Marrow-Stem Cell) are techniques that address the cause of a problem and not just the effect. They stimulate ligament, tendon and cartilage repair. Most people have chronic and/or acute pain because of problems with these structures. The instability of these weakened areas causes a joint to lose its stability. The joint begins to ache and decrease its range of motion. As the joint bones ‘bump’ into each other, the joint forms spurs and bony overgrowths which is termed arthritis. If you just give pain medicines, you are treating the effect and not the cause. If you have surgery, many times the cause is not addressed. Plus if one takes something out (changes the structure) you will affect function and accelerate deterioration and instability. That is why a regenerative/proliferative technique like Prolotherapy is usually the best choice for your joint. Plus if cartilage is worn away, Bone Marrow/Stem Cell Prolotherapy can cause it to regenerate.

I am not anti-surgery but I am against unnecessary orthopedic surgeries that may sometimes cause more problems than they resolve. I believe that many times non-surgical procedures should be tried before one has surgery. There are some cases where only surgery will help. This I do not deny. If you get an opinion from a surgeon, you should also get one from an experienced Prolotherapist. If one is deemed a candidate for Prolotherapy, you will have a greater than 85-90% chance of success. And if does not fully resolve the problem, you should at least likely have some significant improvement. Certainly you will not be worse off.

One last patient story before I sign off. About 3 years ago, a 35yo woman came to my office. She had been in a bicycle accident two years prior. She was using a cane to walk, limping quite noticeably and in pain. She was an extremely healthy and fit woman outside of her hip problem. Prior to the accident, she was a fitness competitor and triathlete. She also was, and still is, a personal trainer. After a thorough history and exam, I looked at her x-rays. After that I told her that I might be able to help her, but maybe only about 50% – 60%. At this point I said she had better consult with an orthopedic surgeon too. After she stopped crying she told me that she had seen two surgeons already and they both said only surgery would help. She even considered going to Europe for hip re-surfacing. She said she needed to think this all over and left. About three weeks later, she came back to my office and said that she had now read a lot about the procedures that I do and understood them better. She wanted to give these non-surgical approaches (Comprehensive Prolotherapy) a chance before having surgery. I treated her with dextrose Prolotherapy initially and she started to improve. After several treatments, we decided to also use PRP Prolotherapy along with the dextrose Prolotherapy. I am extremely pleased to say that at this time she is over 80% pain free, able to work out with her clients, ride a bicycle, swim, do squat exercises, and can even climb stairs without any discomfort. She thanks me every time I see her. To see her testimony, please go to my website, www.DrFields.com.Look for the link for testimonials (and then video testimonials) and she is the second one up there (Nanette) or search for hip.

The bottom line: If you give your body a chance, it can heal itself in unbelievable ways. This woman was extremely fit and healthy and took all the supplements we recommended, which helped her healing process. But most importantly, she believed in this process and wanted to get better without surgery. These are two essential ingredients in natural healing. This allowed her own body to respond at its best to the treatment with Prolotherapy to allow her hip to Regenerate/Proliferate itself.

As I have always said, Prolo First- Surgery Last!

Peter A. Fields, MD, DC
The Athletic Doc® and 3X Ironman Triathlete.