Rapid destructive hip osteoarthritis: When MRI and X-Rays show nothing and suddenly you need a hip replacement

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

A patient will come into our office. They have reached out to us because they have a very painful hip. They had an x-ray, they had an MRI, and both times the images revealed nothing that should be causing this person’s terrible hip pain. So the hip doctor sends the patient to a spine specialist because, if the pain cannot be seen in the hip, it must be in the spine. The spine specialist refers the patient to a physical therapist before ordering more tests because the spine specialist does not see the hip pain as coming from the spine. We see this paradox often in new patients. You can find more information on the complexity of hip-spine in our article: Hip-spine syndrome can lead to failed hip replacement and lumbar spinal fusion complication.

This person, now in our office will tell us that the physical therapy to their spine seems to be making their hip pain worse. Now what? Well, they are in our office looking for another answer.

Article outline:

• Listen to your hip. It may be warning you about your “acute hip pain with the lack of radiographic evidence of joint destruction” as being an imminent problem of rapidly destructive osteoarthritis Your hip may be in a state of panic.
• Where is all your hip pain coming from? Your doctors are not seeing on the MRI or x-ray.
• Your hip is in a state of panic. This is why you have more pain than your MRI is showing.
• My doctor did not know what else to do, so I got a cortisone injection.
• “. . . almost complete disappearance of the femoral head within a few months.”
• Only a few weeks from nothing to femoral head collapse – cases like this may be more frequent than thought.
• Did years of anti-inflammatory medications cause this? Is past medication use the reason you went from hip pain to urgent surgery need in a matter of weeks? Does this only impact older patients?
• Is it anti-inflammatory use and cortisone injects that is causing this? This is what the doctors suggested: It is controversial.
• The paradox: Too much inflammation and too much anti-inflammatories can cause rapid hip destruction.
• Does hip replacement on the other side cause rapidly destructive hip disease to the “good hip?”

Listen to your hip. It may be warning you about your “acute hip pain with the lack of radiographic evidence of joint destruction” as being an imminent problem of rapidly destructive osteoarthritis Your hip may be in a state of panic.

We hope you find this to be an informative article that will show you that you have to believe your hip when it is talking to you (signaling more pain) and not an MRI. There is a phenomenon in medicine called rapidly destructive osteoarthritis. This is osteoarthritis breakdown that suddenly, without a seemingly good explanation, accelerates joint osteoarthritis, or in the case of this article, a super accelerated hip osteoarthritis. In our clinic, we see many patients with a lot of pain and seemingly no answers. This is especially true for the people we see who have more hip pain than his/her MRI is showing and more pain than his/her doctors will believe they are having.

This article will focus on understanding the rapid breakdown of the hip joint and what may be done to prevent the need for total hip replacement, however, as you will see in the x-rays below, the hip may reach a point of being too far gone and replacement surgery will be necessary.

Where is all your hip pain coming from? Your doctors are not seeing on the MRI or x-ray.

A patient walks into the surgeon’s office with acute hip pain. The doctor orders an MRI, the MRI reveals nothing. Obviously, if there are degenerative elements in the hip, loss of cartilage, bone on bone destruction, hip instability causing soft tissue structural damage, there will be pain. But in an accelerated degenerative hip disease environment, where the hip is eroding and degenerating every second of every day, this pain can be greatly magnified beyond anything an MRI is showing.

Why and how?

Because nature designed us to walk. When the degenerative hip disease is threatening our ability to walk, our pain mechanisms start to panic and begins sending out a warning signal that something needs to be done, the hip needs treatment before it is too late and you can no longer walk. This is a basic survival mechanism.

So let’s understand that:

1. Your hip knows it is in a degenerative state.
2. Your hip knows it needs some type of help.
3. Your hip labrum (see below), acting as a communication center, starts sending SOS urgent messages to the brain to mobilize the healing mechanism.
4. This is before MRI or x-ray can reveal what is going on.

Your hip is in a state of panic. This is why you have more pain than your MRI is showing.

Your hip is panicking because it wants to survive, it does not want to be replaced. It is gambling its resources away from trying to fix more damage than it can to its ability to send more SOS messages of pain. The gamble is, to send more SOS messages that pain is getting worse and extreme pain is coming, the hip has to take resources away from healing itself. So the hip is doing minimal repair because it knows if not enough help arrives – the minimal repair will not keep the hip afloat, the hip will sink and die.

• This is why you have more pain than your MRI is showing. Your hip knows it is sinking, an MRI picture of the hip may not show this. This is a situation where a lot of pictures only confuses the situation and prevents you and your doctor from understanding what is happening in your hip.

My doctor did not know what else to do, so I got a cortisone injection.

A patient will tell us a story about a sudden and debilitating pain that “came from nowhere.” Their story goes something like this:

I am an active person and I have been having some hip pain. Most of my pain is at night when I sleep on that side. I was doing my regular weekend work around the house, lawn chores, fix up, and cleaning when out of nowhere, I got this really sharp pain in my hip. I stopped for the day and rested. Over the next few days, the pain got worse. I tried ice, anti-inflammatory medications, creams, balms, and ointments. The pain still got worse. I went to the doctor. I had an x-ray and an MRI. There was nothing there. My pain worsened to the point that my doctor said it must be some type of inflammation and with nothing else to offer I had a cortisone injection and blood work to check for infection.

“. . . almost complete disappearance of the femoral head within a few months.”

In this image: X-ray of severely degenerated hip. No cartilage remains (arrow) in this left hip joint, thus the patient would be a candidate for hip replacement.

Let’s look at a recent study for the surgeon’s eye view of this problem. It comes from a team of Greek orthopaedic surgeons from Athens University Medical School and Attikon University Hospital. It was published in the European Journal of Orthopaedic Surgery & Traumatology. (1)

“Rapid destructive arthritis of the hip is a rare entity with unknown pathogenesis and outcome. . . it is characterized by a rapidly progressive hip disease resulting in rapid destruction of both the femoral (the ball) and acetabular (the socket) aspects of the hip joint, with almost complete disappearance of the femoral head within a few months. . . The initial presentation includes acute hip pain with the lack of radiographic evidence of joint destruction, rapidly progressing to complete vanishing of the proximal femur within a few months.”

Only a few weeks from nothing to femoral head collapse – cases like this may be more frequent than thought.

An August 2017 study in the Journal of Clinical Orthopaedics and Trauma (2) reported on a case of a 76-year-old female who presented with hip pain of sudden onset and normal X-rays. Six weeks later she presented with increased pain intensity, functional limitation, and evidence of a collapse of the femoral head in the X-rays.

Here the doctors documented a case of rapidly destructive osteoarthritis of the hip. They also noted that the situation of rapidly destructive osteoarthritis of the hip is “a complex entity that might be more frequent than previously described and which clinical course could vary between few weeks and several months.”

Facts surrounding the need for hip replacement in rapidly progressive osteoarthritis of the hip

A September 2022 paper in the European journal of orthopaedic surgery & traumatology (3) outlined some facts surrounding the need for hip replacement in rapidly progressive osteoarthritis of the hip.

• There is no universal definition of rapidly progressive osteoarthritis of the hip, however, a loss of joint space of 2 mm or more per year or 50% or more in one year with no other cause can be classed as rapidly progressive osteoarthritis of the hip.
• Due to the rapid loss of joint space and associated bone loss, total hip arthroplasty is seen as the only viable treatment option. (The hip is too far gone.)

In reviewing eight previously published studies on rapidly progressive osteoarthritis of the hip, the researchers offered these observations on 270 patients with an average age of 71 years.

• The majority of patients (88.1%) were female.
• The mean Body Mass Index of these patients was 27.6 (considered overweight).
• Six of the eight studies reported on the need for additional reconstructive devices (beyond ball and socket replacement) and procedures including the use of acetabular roof augmentation (strengthening the top of the socket where the weight of the body falls on the hip), acetabular reinforcement devices and revision acetabular components.
• There is also little by way of long-term data on outcomes in these patients.

In September 2020, doctors reported in the journal Arthroplasty Today (4) the following data concerning people diagnosed with rapidly progressive osteoarthritis.

• Patients with rapidly progressive osteoarthritis are older (average age 72.7 years compared with the average age of hip replacement patients who are an average of 68.8 years old.
• Patients with rapidly progressive osteoarthritis are thin. They have a significantly lower Body Mass Index than hip replacement patients.

Did years of anti-inflammatory medications cause this? Is past medication use the reason you went from hip pain to urgent surgery need in a matter of weeks? Does this only impact older patients?

A December 2021 paper in the journal Skeletal radiology (5) reported on the results a controlled clinical trial of 1471 patients following intra-articular corticosteroid injection and the possible development of rapidly progressive idiopathic arthritis of the hip. The researchers found one hundred six of the 1471 injected subjects (7.2%) met the criteria for rapidly progressive idiopathic arthritis.

• Compared to controls, patients with rapidly progressive idiopathic arthritis were older, had narrower hip joint spaces, and higher Croft scores (a one to five hip osteoarthritis score with 5 being worse) before injection (more severe osteoarthritis).

A November 2021 paper in The Journal of bone and joint surgery. American volume (6) documented an association between hip corticosteroid injection and rapidly destructive hip disease. According to the study authors, “While the risk of rapidly destructive hip disease following a single low-dose (less than 40 mg) triamcinolone injection is low, the risk is higher following high-dose (more than 80 mg) injection and multiple injections. . . . caution should be taken with intra-articular hip injections utilizing more than 80 mg of corticosteroid and multiple injections. ”

Is it anti-inflammatory use and cortisone injects that is causing this? This is what the doctors suggested: It is controversial.

• The development and origin of rapidly progressive osteoarthritis are unclear.
• It was noted that significantly higher use of NSAIDs existed among the rapidly progressive osteoarthritis group. Some studies have implicated these drugs in the formation of rapidly progressive osteoarthritis group, suggesting they impair bone turnover however, this has been challenged by other studies.
• Intra-articular steroid injections have also been linked to the rapidly progressive osteoarthritis group.
• There is no clear cut evidence.
  • In our Caring Medical article When NSAIDs make pain worse, we cite research published in the medical journal Pain. (7) Here doctors suggest that the reason a joint replacement is recommended and performed is that NSAIDs do not work and, in fact, cause the pain that leads to joint replacement recommendations. They write: “Difficulty in managing advanced osteoarthritis pain often results in joint replacement therapy. Improved understanding of mechanisms driving NSAID-resistant ongoing osteoarthritis pain might facilitate the development of alternatives to joint replacement therapy. (These findings) suggest that central sensitization (a heightened sense of pain) and neuropathic features contribute to NSAID-resistant ongoing osteoarthritis joint pain.”

The paradox: Too much inflammation and too much anti-inflammatories can cause rapid hip destruction.

A May 2022 paper in The American journal of pathology (8). These findings suggest that the activation of inflammasome signaling (the body’s call to increase inflammation) in the synovium (joint fluid) results in an increase in local inflammation and osteoclastogenesis (the death of bone cells), thus leading to the rapid bone destruction in rapid destruction coxopathy (rapid osteaorthritis.)

Doctors at the Hospital for Special Surgery in New York and Weill Cornell Medicine, published this observations in May 2022 in PM & R: the journal of injury, function, and rehabilitation. (9) The suggestion is following steroid injection the prevalence of rapidly progressive osteoarthritis of the hip following intra-articular steroid injections into the hip was lower than previously reported but still clinically relevant.

• “Numerous studies have indicated that intra-articular steroid injections to the hip are beneficial for short-term pain relief. However, recent studies have drawn concerns of rapidly progressive osteoarthritis of the hip  following intra-articular steroid injections.”

In this research, a total of 924 patients (average age 59 years old, mostly female, who received an intra-articular hip steroid/anesthetic injection to one hip were observed and followed. The most common steroids used were triamcinolone and methylprednisolone.

• Review of pre- and post-injection imaging revealed 26 cases of rapidly progressive osteoarthritis of the hip, for an overall prevalence of 2.8%.
• Compared to those without rapidly progressive osteoarthritis of the hip, patients with rapidly progressive osteoarthritis of the hip were significantly older (average age 64 vs. 59  and had a shorter duration of symptoms prior to their injections (average three months vs 12 months.
• Rapidly progressive osteoarthritis of the hip following intra-articular steroid injections was lower than previously reported.

Does hip replacement on the other side cause rapidly destructive hip disease to the “good hip?”

A June 2022 case report published in the journal Orthopaedic surgery (10) reported on a 64-year-old male patient with complete collapse and necrosis of the right femoral head complicated with severe bone destruction at 10 months after left total hip arthroplasty. From good hip to complete collapse, according to imaging results, was 7 months. The patient was in rapid destruction for two months before symptoms appeared. The doctors warned however that “the cause (of the good hip breakdown has not been determined based on medical history, symptoms, signs, imaging evaluation results, laboratory examination results, and pathological examination results, though it has been identified as severe idiopathic aseptic necrosis of the femoral head with rapid progression. . . however, “Hopefully, with this case report, more attention will be paid to the contralateral hip joint in patients undergoing unilateral total hip arthroplasty by clinicians and rehabilitation physicians, and a clinical reference will be provided for the research on rapid destruction hip disease.”

What are we seeing in this image?

This is a comparison x-ray of a normal hip and that of a person who had frequent cortisone injections into their hip. In our article: Alternatives to cortisone shots, we documented research that suggests cortisone may be responsible for accelerated joint destruction. Here is a summary of our article:

• From the International Journal of Clinical Rheumatology, (11) a paper entitled: Future directions for the management of pain in osteoarthritis.
  • Dangers of a cortisone injection include cartilage and joint destruction, especially in those with osteoarthritis of the joint. “Corticosteroid therapy, as well as NSAIDs, can lead to the destruction of cartilage, suggesting that a positive effect on joint pain may also be associated with accelerated joint destruction, which is an extremely important factor in a chronic, long-term condition such as osteoarthritis.”

Why is my hip labrum screaming at me? The hip labrum makes some patients have more arthritis pain than they should.

Another study from Medical University researchers in Greece sought to explain these phenomena of our bodies creating more pain sensation than what MRI revealed structural damage would indicate.

In this research, published in the Journal of Orthopaedic Surgery (12), the doctors focused on the acetabular labrum of the hip. They speculated that in Grade III and Grade IV hip osteoarthritis, the labrum sends more pain signals to the brain, and possibly the hip labrum itself is orchestrating an accelerated degenerative process by converting the hip’s energy into sending these messages to the brain. In our article Doctors question Hip Labrum Surgery, we write:

The hip labrum is an important ring of cartilage that holds the femoral head, or top of the thigh bone, securely within the hip anatomy. It also serves as a cushion and shock absorber to protect the hip and thigh bones. Damage or degeneration to the labrum causes pain and hip instability and bone overgrowth in an attempt to stabilize the area.

The hip labrum makes some patients have more arthritis pain than they should

The doctors of our second study looked at the normal acetabular labrum of the hip and the relationship between free nerve endings (pain detectors) and mechanoreceptors (sensors that detect pressure and other things that may cause pain). Then they looked at the free nerve endings and mechanoreceptors in the hip labrum of patients with hip osteoarthritis.

The purpose was to see why some patients had more pain than they should.

A remarkable finding: More pain messages are being sent to the brain because the hip is crying out for treatment

The hip does cry. The hip does panic. The hip cries and panics when it is in pain. This is not a colorful explanation. It does happen. Here is how:

A finding that the second study researchers found so remarkable was that the hip’s pain signaling mechanism changed during the progression of hip disease. The free nerve endings’ pain detectors localized themselves to the central part of the hip labrum and the mechanoreceptors localized themselves to the out edges of the hip labrum.

• In other words, the hip was rebuilding its pain reporting system to match the urgency of the situation. The hip is panicking because it sees its survival is threatened. To get more messages out, the mechanoreceptors convert themselves into free nerve endings so more pain messages can be sent to the brain. But there is a price to pay for this new communication system. The conversion of the hip’s energy to sending pain messages reduces the hip’s ability to heal.

The pain switch is in the hip labrum.

Here is a study from 2014 that will tie this all together and show you that the hip labrum is your hip’s early warning signal that rapidly destructive osteoarthritis is coming and doctors should believe the hip labrum before they believe an MRI.

In the Journal of Arthroplasty,(13) a medical journal dedicated to joint replacement, a team of doctors at Kanazawa Medical University in Japan wanted to know what turned the slow, degenerative, eroding processes of the hip into rapidly destructive osteoarthritis. Where was the switch that created accelerated destruction? The switch was in the hip labrum. Just like the Greek researchers above, the Japanese team was able to understand that the hip labrum was at the center of rapid hip destruction.

This is what this study revealed:

• The pathophysiology (the conditions that cause) rapidly destructive osteoarthritis of the hip is unknown but it may be coming from the hip labrum
• This study documented cases of inversion (collapsing on itself, turning inward) of the hip acetabular labrum. This is a typical condition if the labrum in initial-stage rapidly destructive hip osteoarthritis.
• Subchondral (cartilage and bone) insufficiency fractures of the femoral heads were seen just under the inverted labrum in 8 of the 9 patients of the study.
• Therefore, inversion of the acetabular labrum may be involved in rapid joint-space narrowing and subchondral insufficiency fracture in rapidly destructive hip osteoarthritis.

What does this mean? The labrum is recognizing before anything else, rapidly destructive hip osteoarthritis is coming. It sees it before the MRI, it sees it before many of your doctors. The Labrum sees it coming and is trying to tell you it is coming by making your hip more painful.

Degenerative Hip Disease Treatment

Our website is filled with articles on degenerative hip disease and how we treat it:

• Non-surgical Treatment of Acetabular or Hip Labral Tears
• Treating avascular necrosis of the femoral head without hip replacement
• Platelet Rich Plasma therapy for treating Hip Osteoarthritis
• The evidence that alternatives for a hip replacement may work for you
• Greater trochanteric pain syndrome and bursitis treatment

Non-Surgical treatment options

For some people, their hip may be too far gone. They have very limited or no range of motion in their hip or hips. Their femoral head may have already completely collapsed. These patients should consider hip replacement with their orthopedic surgeon.

We have a very extensive article Alternatives to hip replacement: The evidence for non-surgical treatments, on our website. It is summarized here:

In this section we will discuss three regenerative medicine techniques and hip replacement:

• Treatment option: Prolotherapy injections. This is the injections of dextrose, a simple sugar that provokes a healing response in damaged soft tissue. This would include the hip ligaments, the hip tendon’s attachments that connect muscle to bone (the enthesis), and the hip cartilage.
• Treatment option: Platelet Rich Plasma injections (PRP Therapy). This is an injection treatment that uses your blood platelets. This treatment also works on the soft tissue. We have an extensive article on Platelet Rich Plasma for treating Hip Osteoarthritis that goes deeper into this subject.
• Treatment option: Stem Cell Therapy. In our clinic:
  • We use bone marrow-derived stem cells.
  • We do not use this on every patient.
  • This treatment is typically reserved for patients who have significant damage to their hips, but where there is a realistic expectation that the treatment will help the patient avoid a hip replacement.
• Treatment option: Hip replacement. 

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

Some of the key aspects we look for:

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 for a hip replacement but was actually a better candidate for Prolotherapy.

Are you a Prolotherapy candidate?

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 so extensive, the patient will need a recommendation for total hip replacement.

Can our treatments work for you?

To demonstrate hip instability being caused by ligament damage, the hip joint should be adducted, externally rotated and flexed. The Hauser Hip Maneuver does just this to stress the hip capsule and ligaments and test for stability. Typically, excessive motion, soft end feel, subluxation and crepitation can be felt during this maneuver in unstable hips. In some cases, crepitation can even be heard.

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your hip problems and hip instability.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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References

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This article was updated March 17, 2023

• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.