Prolotherapy for hip instability

This article will explore the problems patients have in making a decision in their treatment of chronic hip pain.

  • One course of treatment is the conservative care treatment, this is painkillers, medications, physical therapy, cortisone injections until such time as a hip replacement procedure is warranted.
  • Another course of treatment is the actual hip replacement procedure. There are many patients who have great success with this treatment. Ironically we see many of them in our office looking for alternatives to hip replacement for their other hip. Why? The typical response is, “I don’t want to go through all that again.”
  • The third course of action is regenerative medicine. We call this Comprehensive Prolotherapy in our office. The treatment may include stem cell therapy, Platelet Rich Plasma Therapy, dextrose Prolotherapy or a combination of these treatments. This will be explained in the article below.

For someone in chronic pain, in this case from degenerative hip disease, I know you will spend hours in front of a computer searching information, I hope this article will offer you some insights and answers in helping to understand, manage and making decisions in regard to your chronic hip pain.

Chronic hip instability is it caused by hip arthroscopic surgery?

If you search the medical literature looking for research on hip instability, you will find dozens of new articles on hip instability after total hip replacement and hip arthroscopic surgery. You find very few on the role of ligament injury and damage before a hip surgery. Yet it is pain and lack of motion caused by hip instability that sends patients to these hip surgeries. Based on the literature, one could get the idea, that hip instability can only be cured with surgery. This article will not come to that conclusion.

Hip instability to you means grabbing for a chair, railing or anything you can hold unto. Medical research acknowledges this problems but seemingly in disproportionate awareness to patients before hip replacement and patient after hip replacement. The focus in research is on the patients after hip replacement.

Here is an example of the type of research that discusses hip instability, it is a recent study from the journal Knee surgery, sports traumatology, arthroscopy.

“The increasing use of hip arthroscopy has led to further development in our understanding of hip anatomy and potential post-operative complications. Iatrogenic (surgery causing) gross hip instability following hip arthroscopy is a concerning complication described in recent orthopaedic literature. Post-arthroscopy hip instability is thought to be multifactorial, related to a variety of patient, surgical and post-operative factors. . . This study reports a case of gross hip instability following hip arthroscopy, describing a (new surgical) technique of management through anterior hip capsuloligamentous reconstruction with Achilles tendon allograft.”(1)

Did you get all that? Follow the path:

  1. Patient has hip pain and instability
  2. Patient is recommended to arthroscopic labral or other clean up and repair surgeries
  3. Doctors are using hip arthroscopy in increasing numbers
  4. The surgery that promised repair, stability, and relief of pain, itself caused instability and more pain. (Mostly from dislocation and chronic subluxation (the hip keeps popping out of place)).
  5. Because of these hip problems happened infrequently or were reported infrequently, not much literature was given to solutions
  6. One solution was come up with a surgery to fix the surgery.
  • These surgeries were designed to save the hip from hip replacement, but, to do so, the surgeries needed to halt or significantly slow the progression of osteoarthritis. As research points out, surgery many times will not achieve this goal.

Hip instability and problems with balance and falls. How a weak hip creates degenerative disc disease, degenerative knee disease, and degenerative pelvic disease.

Many patients we see who have hip instability also have problems of the knee, spine, and pelvic pain. They will typically say to us, “My hip is the big problems, but I am falling apart all over.” These people are right, their hip is the big problem, but the hip problem is bigger than they think, the hip is causing problems all over the body.

Let’s look at a January 2018 study. This study is an illustration of the damaging effects of one joint being wobbly on the entire movement of the whole body. Obviously we will be looking at the hip as the culprit joint.

Women team handball players are amongst the most fit athletes. Their sport depends great stress on the player’s joints. The researchers from Auburn University, School of Kinesiology, Sports Medicine and Movement Laboratory examined how lumbopelvic-hip complex stability, via knee valgus, affects throwing kinematics (movement) during a team handball jump shot.

Read again how hip instability is being measured: the complex hip-spine-pelvic interaction and instability is being measured by knee angle. The greater the knee angle the greater the instability coming from the hip/spine.

Points to consider

  • The women with greater instability in the hip/spine/pelvic region through the ball with less force (they were weaker)
  • The women with greater instability in the hip/spine/pelvic region were at increased risk of injury in the upper (arm and shoulder) and lower extremities (Knee, ankle, feet) when landing from a jump shot because of the energy losses throughout the kinetic chain and lack of utilization of the entire chain.
    • What does all that mean? Their entire body was at risk of fall, loss of balance, impact injury.

You do not need to be a high level female team handball player to understand the problems in the hip cause and interact with instability in the lower spine and pelvis and these interactions put the knee, the ankle at risk for instability and loss of balance.(2)

Is hip instability all about osteoarthritis and bone on bone? Understanding the role of hip ligaments in hip instability

Osteoarthritis is a progressive disorder involving joint instability and tissue destruction. Osteoarthritis feeds upon itself. It is the result of and the cause of excessive hip instability and the hip’s inability to stabilize itself. It begins with minor damage to the hip joint tissue, primarily the ligaments, and ends with destructive abnormal joint motion (hip instability) that leads to bone death as in avascular necrosis.

It is destructive abnormal joint motion (hip instability) that is the cause or the effect of itself in a myriad of conditions that led to chronic hip pain, including trochanteric tendinitis or bursitis, pelvic floor dysfunction, ischiofemoral impingement, iliopsoas bursitis, myofascial pain syndrome of the tensor fascia lata, gluteal muscle tears and strain, as well as ligament sprains of the hip.

You have these problems because your hip is wobbling and moving abnormally.What starts as minor ligament damage in most cases from early wear and tear, ends with hip joint destruction and the need for hip replacement.

The hip does try to stabilize itself. Typically through boney overgrowth and spurs that seeks to lock the joint up. Osteoarthritis is the cause and its own effect then in lack of hip range of motion.

In the journal of Journal of biomechanics, doctors in Germany reported on their findings of how the strength of ligaments could predict or prevent hip dislocation and hip instability.

The doctors performed cadaver studies on hip ligaments in the 14 to 93-year-old age range. What they found was the strength of the ligament varied widely and that the evidence to suggest the role of ligaments in preventing dislocations was too difficult to make. One thing they did note however was that the tested ligaments became weaker as they aged and lost their youthful elasticity.(3)

Not knowing or understanding the hip ligaments and their role in hip stability and joint instability is being recognized as a major problem in the treatment of hip pain. Listen to what another team of German doctors have recently published:

The role of the hip ligaments in coherence with the hip joint capsule  are known to contribute to hip stability. Nevertheless, the contribution of the mechanical properties of the ligaments and gender- or side-specific differences are still not completely clear.

To date, comparisons of the hip capsule ligaments to other tissues stabilizing the pelvis and hip joint, were not performed.

Here is the concluding statement of the paper abstract: “Comparison of the mechanical data of the hip joint ligaments indicates that their role may likely exceed a function as a mechanical stabilizer.”(4)

What are these two studies telling patients about their hips? Doctors are unclear of the extent of the importance of the hip ligaments in stabilizing and repairing hip problems

It tells patients being prepped for hip surgery, whether it is a surgery for hip replacement or a torn hip labrum, that doctors are unclear of the extent of the importance of the hip ligaments in stabilizing and repairing hip problems and the non-surgical repair of the ligaments could be the crucial first step in hip surgery avoidance.

This was pointed out in research from 2007 in the medical journal Arthroscopy, which obviously specializes in surgical technique, here doctors wrote that doctors who understand the hip ligaments  could offer non-surgical options for hip pain. They highlighted that the ischiofemoral ligament, iliofemoral ligament, pubofemoral ligament, iliofemoral ligament, all  control internal rotation in flexion and extension. Understanding the independent functions of the hip ligaments therefore are essential in determining nonsurgical options.(5)

This research and that of another recent study  points out what has been obvious to many Prolotherapy doctors over the years. You can’t save the hip (prevent hip replacement) without saving and repairing the hip ligaments.

Here is a summary of that research that appeared in the Journal of Biomechanics.

  • Hip ligaments prevent excessive range of motion and contributes to synovial fluid replenishment (the natural lubrication process of joints) at the cartilage surfaces of the joint that prevents friction and wear and tear.
  • However, the repair of ligaments after joint preserving or arthroplasty surgery is not routine. (Which may lead to hip revision surgery)
  • In order to restore their biomechanical function after hip surgery you need to restore the hip ligaments to their normal tension.

Surgical ligament repair is technically demanding, particularly for arthroscopic procedures, but failing to restore their function may increase the risk of osteoarthritic degeneration.(6)

Remarkable in their observations are recent studies that look at hip pain after replacement surgery. Since the bone-on-bone was alleviated by replacement what could be causing the patient’s continued pain? Instability

Doctors who see patients with hip pain significant enough for a hip replacement recommendation tend to focus mainly on the bone-on-bone situation.

Remarkable in their observations are recent studies that look at hip pain after replacement surgery. Since the bone-on-bone was alleviated by replacement what could be causing the patient’s continued pain?

Doctors at Washington University in St. Louis School of Medicine suggest that it must be the hip ligaments and tendons. They write: “surgical management for hip disorders should preserve the soft tissue constraints (the hips and ligaments) in the hip when possible to maintain normal hip biomechanics.”(7)

This has lead to the popularity of tissue-preserving minimally invasive surgical approaches to the hip that may allow early short-term recovery, achieve hip joint stability, minimize muscle strength loss from surgery, spare the peri-articular soft tissues, and allow unrestricted motion in the long term, as described in research by surgeons at San Luca Hospital in Italy.(8)

Again, the realization that limited range of motion and/or pain with motion may not be solely caused by a bone-on-bone situation has lead doctors to further understand the relationship of the hip ligaments to pain and limited range of motion and in our research in the Journal of Prolotherapy we showed that treating weakened ligaments helped patients avoid a hip replacement surgery and increase hip function.

Treating hip instability with Comprehensive Prolotherapy

In our published research we looked at 61 patients, 33 of them had hip pain in both hips. Twenty of these patients were told that there were no treatment options available to them, with eight being recommended to surgery as their “only hope,” for hip pain alleviation.

Of the 94 hips treated in the 61 patients:

  • 89% experienced more than 50% of pain relief with Prolotherapy;
  • more than 84% showed improvements in walking and exercise ability, anxiety, depression and overall disability;
  • 54% were able to completely stop taking pain medications.(9)

Clearly the role in treating ligaments is very important to the patients wishing to avoid a hip replacement surgery or for those who had already undergone hip surgery and have pain after surgery.

Is Prolotherapy the right treatment for you hip pain and instability?

When we receive hip x-rays from prospective patients via email, they provide a good assessment of how many Prolotherapy treatments might be needed to achieve the patient’s goals. Best assessment would be a physical examination in office.

  • Rating a hip Prolotherapy Candidate: We will rate the potential hip pain patient on a sliding scale of being a very good Prolotherapy candidate to a very poor one. In a very good candidate’s x-ray, the ball of the femur will be round, fitting nicely into the socket in the pelvis, with good spacing between these two bones. This space is the cartilage that cushions and allows the femur to rotate freely within the socket.
  • Prolotherapy prognosis for hip patients: The prognosis ranking is lowered from very good to good, to questionable to guarded to poor, based on the following criterion:

1. Amount of joint space or cartilage that remains.

2. The presence or absence of bone spurs (osteophytes), and their locations

3. The shape of the femoral head itself. In very poor candidates, the hip does not even look like a hip anymore; the ball is flattened or egg-shaped and does not fit into the socket as well. Once the damage is this extensive, the patient will likely need a recommendation for total hip replacement.

This is best explained with a visual presentation. In the video below you will see a patient that was recommended to hip replacement but was actually a better candidate for Prolotherapy.

Questions about your hip pain? Ask our staff

1 Yeung M, Khan M, Williams D, Ayeni OR. Anterior hip capsuloligamentous reconstruction with Achilles allograft following gross hip instability post-arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy. 2017 Jan 1;25(1):3-8. [Google Scholar]
2 Gilmer GG, Gascon SS, Oliver GD. Classification of lumbopelvic-hip complex instability on kinematics amongst female team handball athletes. Journal of Science and Medicine in Sport. 2018 Jan 9. [Google Scholar]
Schleifenbaum S, Prietzel T, Hädrich C, Möbius R, Sichting F, Hammer N. Tensile properties of the hip joint ligaments are largely variable and age-dependent – An in-vitro analysis in an age range of 14-93 years J Biomech. 2016 Sep 17. PMID: 27667477 [Google Scholar]
4 Pieroh P, Schneider S, Lingslebe U, Sichting F, Wolfskämpf T, Josten C, Böhme J, Hammer N, Steinke H. The Stress-Strain Data of the Hip Capsule Ligaments Are Gender and Side Independent Suggesting a Smaller Contribution to Passive Stiffness. PLoS One. 2016 Sep 29;11(9):e0163306. PMID: 27685452. [Google Scholar]
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9 Hauser RA, Hauser MA. A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Hip Pain at an Outpatient Charity Clinic in Rural Illinois. Journal of Prolotherapy. 2009;2:76-88. [Google Scholar]

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