Rapid destructive hip osteoarthritis: All of a sudden you need a hip replacement
Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.
When painful hip MRI shows nothing, is it a sign of rapidly destructive hip osteoarthritis?
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 very often. 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.
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.
“almost complete disappearance of the femoral head within a few months”
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.”
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.
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?
In September 2020, doctors reported in the journal Arthroplasty Today (2) 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.
So 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. (3) 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. Our findings suggest that central sensitization (a heightened sense of pain) and neuropathic features contribute to NSAID-resistant ongoing osteoarthritis joint pain.”
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, (4) 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.”
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 (5) 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.”
Where is all this hip pain coming from that your doctors are not seeing on the MRI or x-ray?
The above study describes a problem. 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:
- Your hip knows it is in a degenerative state.
- Your hip knows it needs some type of help.
- Your hip labrum (see below), acting as a communication center, starts sending SOS urgent messages to the brain to mobilize the healing mechanism.
- This is before MRI or x-ray can reveal what is going on.
When there is a problem. Nature designed our body to talk and communicate. Sometimes doctors do not understand the message.
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 (6), 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.
Why is my hip labrum screaming at me?
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.
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.
But, the damage is there, the MRI is not seeing it
In a study published in the journal BioMed Central Musculoskeletal Disorders, (7) surgeons wrote: “In patients with a normal MRI without contrast and a positive response (relief of pain) to an intra-articular injection that failed conservative management, there is a 98% chance of intra-articular hip pathology being discovered on hip arthroscopy.”
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,(8) 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?
In the video below Ross Hauser, MD demonstrates a screening process to help patients determine if our treatments may be helpful.
Three patients are used to demonstrate:
- Who is a very good candidate for our Prolotherapy, PRP, or stem cell treatments.
- Who is a good candidate for our Prolotherapy, PRP, or stem cell treatments.
- Who is a poor candidate for our Prolotherapy, PRP, or stem cell treatments and these people should consider hip replacement surgery.
The first patient’s examination begins at 3:35
- This patient had been recommended for hip replacement. She was considered a very good candidate for treatment.
- Has good external rotation of the hip
- Has cartilage
- Minimal bone spurring
The second patient’s examination at 5:15
- This patient had been recommended for hip replacement. He was considered a good candidate for treatment.
- The patient has a lot of cartilage wear. The “ball,” of the hip joint still looks like a “ball” on an x-ray
- 6:10 patient’s range of motion limitations is discussed.
The third patient’s examination at 8:10
- This patient had been recommended for hip replacement. He was considered a POOR candidate for treatment.
- At 8:30 an x-ray of the hip shows advanced degeneration, the joint is basically destroyed. The hip is totally fused with no range of motion. This patient was advised to have a hip replacement.
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
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This article was updated January 15, 2021