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Hip pain, groin pain, post-surgical pain
Athletes rush to hip arthroscopy to get back to the game – wait!
Hip and groin injuries can quickly debilitate athletes while threatening to end a career. An athlete is often fast-tracked to get an MRI and arthroscopic surgery once this type of sports injury occurs. Others may spend months or years on pain medications while undergoing numerous rounds of physical therapy. Neither of these options is ideal for an athlete given that they only slowly get an athlete back to sport, if at all. One very successful alternative to surgery and pain medication for hip and groin pain is Prolotherapy.
Prolotherapists agree that surgery should be avoided at all costs. Research continues to prove the poor long-term effects of surgery for sports injuries. A 2012 article in Arthroscopy noted: “Instability after hip arthroscopy is due to a number of factors, including excessive rim trimming, capsulotomy, overzealous labral resection, or inadequate labral repair. This report emphasizes the importance of the ligamentum teres and small disruptions of the capsule in patients with mild dysplasia.”1
And another sports medicine journal noted difficulty in diagnosing pain after hip resurfacing, stating, “”Determining the etiology of persistent groin pain after hip resurfacing arthroplasty (HRA) can be very challenging, even for the experienced surgeon. Thirty-three [percent of patients surveryed were found to be suffering from snapping-hip syndrome (iliopsoas tendinitis.)”2
And finally, hip surgery runs the risk of not returning to pre-surgery shape: “Thirty-two percent of patients (studied) previously undergone athletic pubalgia surgery…No patient returned to his previous level of competition after isolated AP surgery. Thirty-nine percent had athletic pubalgia symptoms that resolved with Femoroacetabular impingement surgery alone. Of the 38 patients, 36 returned to their previous level of play; all 12 patients with combined AP and FAI surgery returned to professional competition on average 6 months after arthroscopic surgery.”3
Causes of Hip and Groin Pain
Oftentimes athletes receive the diagnosis of pubalgia or simply “groin pain” involving the pelvis. The pelvis consists of three paired bones: the ilium, ischium, and pubis that interconnect and form the innominate bones, meeting anteriorly at the pubic symphysis and posteriorly at the sacrum. The front midline joint is called the pubic symphysis joint and the back midline joint is the sacroiliac joint. These are the two joints of the pelvis.
In a Prolotherapist’s opinion, the most common cause of pubalgia, or groin pain, is pubic symphysis diathesis or injury to the pubic symphysis itself. Traditional orthopedics teaches that the most common cause of groin pain is a strain injury to the muscles of the groin region. Muscle strains heal very quickly and only in rare cases do not heal at all. They do cause some of the chronic groin pain problems in athletes, but not all. Therefore groin and hip pain in an athlete is commonly misdiagnosed. To properly treat pubalgia, Prolotherapy must be administered to the pubic symphysis and/or sacroiliac joint(s) to strengthen the cartilage of the joint and thereby eliminating pain.
Abdominal Wall Abnormalities
One etiology that is often overlooked in the evaluation of groin pain is an incompetent abdominal wall in the groin. In these cases of groin pain there is no palpable hernia and no other etiology for the groin pain. In such cases, what are sometimes found are microscopic tears of the internal oblique muscle in the area of the muscle that attaches to the superior pubic symphysis.
The tendency in patients with groin pain due to abdominal wall abnormalities is a history of inguinal pain that worsens with strenuous activity, especially activity stressing the abdominal muscles, such as sit-ups. On physical examination there is tenderness of the pubic tubercle and a positive jump sign is elicited. Prolotherapy, in this instance, to the muscle attachments onto the pubic symphysis is often curative. All of the other muscle attachments to the groin area, including the rectus femoris, gracilis, rectus abdominis, and adductor group, can all be treated with Prolotherapy if there is tenderness and reproduction of the athlete’s pain upon palpation of the area where the muscle attaches to the bone. If a positive jump sign is elicited, the diagnosis is made and Prolotherapy is given to the weakened fibro-osseous junction.
Simply put, femoroacetabular impingement or FAI is a condition where there is too much friction in the hip and this “bone-on-bone” causes damage in the joint. Of the two types of FAI is the “cam-type” where the femoral head-neck junction is abnormal and the “pincher-type” FAI is where the acetabulum shape or its configuration within the pelvis is abnormal. The head of the femur meets with the pelvis at the acetabulum. Some people have both types of FAI. Both cause injuries to the labral area because of repetitive impingement stress. They either cause labrum degeneration or labrum tears.
Both types progress to hip labral and cartilage damage and therefore can cause premature hip osteoarthritis. For the person who desires a conservative approach, Prolotherapy is recommended. Prolotherapy inside the joint, as well as around the structures of the joint causing some or all of the pain is what I typically do. What most patients may not realize is the cartilage has no nerve endings, so pain in a joint originates from some other structure(s) than cartilage. This is another reason that just getting injections inside the joint does not make much sense. Hackett-Hemwall dextrose Prolotherapy, along with other proliferants, addresses all the pain-producing structures. It typically works well with FAI, along with the other conditions causing premature hip osteoarthritis. Again we use this along with an exercise program that we prescribe geared at stimulating joint health.
Like other causes of premature hip osteoarthritis, sometimes surgical procedures are needed. The operative procedures are designed to address the adverse mechanical effects of impingement and hopefully address the reasons for it. Sometimes a combination of Prolotherapy and surgery is required.
Snapping Hip Syndrome
Snapping Hip Syndrome is a clinical entity that causes pain and snapping in the hip joint. There are several known causes, the most common being the iliotibial band snapping over the greater trochanter (at the top of the thigh bone). It can also be caused by snapping of the iliopsoas tendon over the iliopectineal line (in general the pubic area of the hip bone), the iliofemoral ligaments over the femoral head (where the thigh bone connects to the hip bone), as well as other places on the hip bone. The gluteal muscles can also make a snapping sound as they go over the greater trochanter. The psoas tendon can also cause snapping hip as it passes over the hip joint, producing pain with hip flexion. The question to ask is why is this happening?
The psoas tendon is in the front of the hip joint, the gluteal muscles are over the hip joint, and the iliotibial band (tensor fascia lata) is on the side of the hip joint, yet all of these structures are considered part of the problem? We don’t think so.
It is easier to explain Snapping Hip Syndrome as one hip problem versus three separate muscle problems. Hip joint ligament weakness causes excessive movement of the hip joint and thus the greater trochanter, since they are connected. This excessive movement of the greater trochanter encroaches on the iliotibial band or gluteal muscles, causing a snapping sound. If the lax hip joint moved forward it would encroach on the psoas muscle, causing hip snapping with movement of this muscle (hip flexion). This hip ligament laxity also explains the dramatic results seen with treating Snapping Hip Syndrome with Prolotherapy. Prolotherapy is the treatment of choice for Snapping Hip Syndrome because it gets at the root cause of the problem, which is hip ligament laxity. Prolotherapy to the posterior hip capsule and ischiofemoral ligaments generally resolves the problem if the condition involves snapping of the iliotibial band or gluteal muscles, because posterior hip laxity is involved in these conditions. In psoas-muscle-related Snapping Hip Syndrome, the hip joint is moving anteriorly, encroaching on the muscle. Prolotherapy to the anterior hip ligaments, namely the iliofemoral ligament, will tighten the joint and stop the anterior protrusion of the hip. Prolotherapy is extremely effective at permanently resolving Snapping Hip Syndrome because it repairs the underlying etiology of the problem, hip ligament laxity.
1. Mei-Dan O, McConkey MO, Brick M. Catastrophic failure of hip arthroscopy due to iatrogenic instability: can partial division of the ligamentum teres and iliofemoral ligament cause subluxation? Arthroscopy. 2012 Mar;28(3):440-5. Epub 2012 Feb 1.
2. Pattyn C, Verdonk R, Audenaert E. Hip arthroscopy in patients with painful hip following resurfacing arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2011 Sep;19(9):1514-20. Epub 2011 Mar 16.
3. Hammoud S, Bedi A, Magennis E, Meyers WC, Kelly BT. High Incidence of Athletic Pubalgia Symptoms in Professional Athletes With Symptomatic Femoroacetabular Impingement. Arthroscopy. 2012 May 18. [Epub ahead of print]