Marc Darrow, MD,JD.
Over the years we have seen our fair share of people with a diagnosis of a bone-on-bone hips. The people we usually see have a lot of hip pain and instability which causes walking difficulties, balance difficulties and prevents these people from feeling stable on their feet. They also come into our office claiming that they have been told they only have one treatment option, hip replacement and that they should get on the list to get one. They are here in our office to ask, “Is hip replacement really my only option?”
Article summary
- Diagnosing Hip Pain and arthritis – MRI or physical examination.
- Abnormal findings = surgical procedure.
- More hip problems that may confuse the diagnosis.
- The hip replacement decision making process over the last ten years.
- The rush to hip replacement because of severe pain. But is the hip as bad as the pain?
- Hip pain relief – are all hip replacement options being explored?
Diagnosing Hip Pain and arthritis – MRI or physical examination
There are cases where the hip bone is very damaged and the femoral head or ball has collapsed completely. This creates a situation where the hip joint is now fused and the person cannot move or lift their leg. This person’s best option may be joint replacement. But most people I see with avascular necrosis of the hip or shoulder don’t need a surgery. Sometimes they only need a little education to help them understand what is happening in their hip and that they can avoid the hip replacement.
Abnormal findings = surgical procedure.
This simple equation is well documented in the medical literature. Medical journals are filled with studies suggesting that while MRI is frequently used to diagnose conditions affecting the hip, its effectiveness in determining hip pain is not as valuable as a physical examination for determining pain or arthritis problems. For the past ten years numerous papers have shown MRIs are inappropriately used and ultimately of no benefit to patients. Back in 2014 researchers wrote that (1) particularly in use among patients older than 50 years, who are unlikely to benefit from hip surgery other than hip replacement, MRI to justify hip arthroscopy was not beneficial to the patient. In the medical journal Pain Physician, doctors agreed, and they offered a commentary that warned physicians that the true causes of hip pain can be easily overlooked and misdiagnosed because of the MRI.(2) This is why an extensive physical examination should be part of the diagnostic process.
Did anything change in the past ten years? In November 2023 researchers wrote (3): “structural joint changes are frequent in asymptomatic population and neither radiographs (x-rays) nor MRI have shown a good correlation with pain and functional impairment.”
More hip problems that may confuse the diagnosis
PIRIFORMIS SYNDROME
Piriformis syndrome may cause pain in the buttocks, lower back, or down the leg. The piriformis muscle is in the buttocks, attaches to the pelvis and greater trochanter, and helps rotate the leg outward. The sciatic nerve is just beneath it. Occasionally the nerve is impinged beneath the piriformis muscle. When the muscle contracts, it pushes on the nerve, which causes the pain and its radiation down the leg. I rarely see true piriformis syndrome. Typically, the pain is at the enthesis of the piriformis or other buttocks muscles to the bone.
GREATER TROCHANTERIC BURSITIS AND ISCHIAL BURSITIS. Persistent hip pain from hip bursitis.
The areas around the hip are covered with and protected by several bursal fluid filled sacs. Each bursa produces lubricating fluid and functions to reduce pressure and friction around the muscles and ligaments over bone. These bursae can become irritated from injury, excessive pressure, and overuse. Inflammation of a bursa is called bursitis. More often this diagnosis is actually a tendinitis or tendinosis. Nevertheless, PRP is usually the correct treatment. Certainly not steroids, like cortisone, which deteriorate the tissue, and can make it worse later.
HIP EFFUSION
There is normally a small amount of synovial fluid contained in the hip joint that allows the cartilage on the bones to slide on each other. An excess of this fluid, often caused by overuse or arthritis, can cause pressure and pain in the joint. The fluid comes from synovial tissue surrounding the joint.
I use an ultrasound to visualize the joint, and if an effusion is present, I numb the area and aspirate the fluid. At the same time, platelet rich plasma or stem cells can be injected through the same needle.
Effusions are removed to reduce the joint pressure and to eliminate dilution of the regenerating cells from the patient’s body.
HIP TENDINITIS OR TEARS
Tendinitis occurs when a muscle is overused and pulls on the tendon that attaches it to the bone. In the hip, tendons perform an important role by keeping strong muscles attached to the femur (thighbone) as the 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 the hip bone, and the psoas muscle, which starts in your lower spine, are used when lifting the leg toward the chest. They come together in a tendon at the top of the femur, and that is the point where tendinitis occurs.
The hip replacement decision making process over the last ten years.
Recently a 2015 paper in the Journal of medical Internet research suggested (4) that the treatment of hip arthritis and hip injury, like those of other joint osteoarthritic problems, is redefining itself at a pace probably not seen since the advent of hip replacement surgery.
Some doctors are upset however that patients are not given the full story on hip replacement options and alternatives. Despite the availability of evidence-based guidelines for conservative treatment of arthritis, management of degenerated joints is often confined to the use of painkillers and the wait for eventual total joint replacement. This suggests a gap in knowledge for those with arthritis regarding the many different treatment options available to them.
How wide a gap? A 2016 study published in the journal Osteoarthritis Cartilage suggested that when given time and educational materials to deliberate whether or not to proceed with hip replacement, more patients decide not to have surgery.(5)
Updating the patient decision support interventions in 2023 and 2024.
In May 2023, as information became more available, certainly more available since 2015, researchers wrote in the International journal of surgery (6) “The increase in elective surgeries and varied postoperative patient outcomes has boosted the use of patient decision support interventions. However, evidence on the effectiveness of patient decision support interventions are not updated.” In updating patient decision guide data information, this study team “demonstrated that patient decision support interventions targeting individuals considering elective surgeries had benefited their decision-making by reducing decisional conflict and increasing disease and treatment knowledge, decision-making preparedness, and decision quality.”
In January 2024, (7) researchers found that patients,. already recommended to hip replacement, declined tools and information that would give them a better informed decision on alternatives to hip replacement if they had a more severe pain (average 7.2 on a scale of 10) and worse quality of life. Only 4% of these patients would explore non-surgical treatment.
The rush to hip replacement because of severe pain. But is the hip as bad as the pain?
A February 2022 study (8) suggests that people, or the brain, may perceive a much more painful hip than the MRI indicates. This is what the paper says: “Hip osteoarthritis is characterized by chronic pain, but there remains a mismatch between symptoms and radiological findings (the pain is worse than the MRI). Recently, brain connectivity (the brains understanding of body parts, like the hip for instance) has been implicated in the modulation of chronic peripheral pain, however its association with perceived pain in hip osteoarthritis is not understood.” To understand why some people felt more hip pain than the MRI revealed patients with hip osteoarthritis were asked to perform activities that the researchers suspected would cause them pain. What they found was “functional connections between brain regions associated with pain are altered in hip osteoarthritis patients, and several connections are modulated by performing painful activity.” In other words pain causes more pain. To remedy this, the hip needs to be made less painful.
Hip pain relief – are all hip replacement options being explored?
Someone who suffers constantly from pain and who does not want to learn to live with it may consider hip replacement as their only way to get back to a pain-free life and resumption of their normal activities. Others choose hip replacement because of concerns over losing their independence. This includes concerns over their ability to walk, drive, and perform daily and routine personal chores such as dressing, meal preparation, and hygiene. These same concerns are also brought up by people who do not want to have hip replacement. Hip replacement is a major surgery. The post-recovery rehab can put the person into these same situations that they were hoping to avoid, the inability to drive and be independent for weeks or months.
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References
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2 Tasoglu O, Sirzai H, Onat SS, Ozgirgin N. Is hip originated pain misdiagnosed? Pain Physician. 2015 Mar-Apr;18(2):E259-60.
3 Mourad C, Vande Berg B. Osteoarthritis of the hip: is radiography still needed?. Skeletal Radiology. 2023 Nov;52(11):2259-70.
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7 Bossen JK, Wesselink JA, Heyligers IC, Jansen J. Implementation of a Decision Aid for Hip and Knee Osteoarthritis in Orthopedics: A Mixed-Methods Process Evaluation. Medical Decision Making. 2024 Jan;44(1):112-22.
8 Railton P, Delaney AJ, Goodyear BG, Matyas J, Lama S, Sutherland GR, Powell JN. Altered activity of pain processing brain regions in association with hip osteoarthritis. Scientific Reports. 2022 Feb 18;12(1):1-9.