When you have a painful hip and your MRI shows nothing. Now what?
Ross Hauser, MD, Caring Medical Florida
David N. Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C , Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
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.
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 “acute hip pain with the lack of radiographic evidence of joint destruction.”
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, starts an accelerated joint osteoarthritis, or in the case of this article, a super accelerated hip osteoarthritis. In our clinics, 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.
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. . . 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.”
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 is 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 degenerative hip disease is threatening our ability to walk, our pain mechanisms starts 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 (3), 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 because the hip is crying out for treatment
The hip does cry. The hip does panic. The hip cries and panics when it it is in pain. This is not some 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 SOS of a sinking hip. The conversion of the hip’s energy to sending pain messages reduces the hip’s ability to heal.
Let’s pretend that you are on that ship to the left. Let’s pretend that ship is your hip.
The ship has struck an iceberg. It is now damaged beyond its crew’s ability to repair it. The ship/hip needs help or it will sink.
Your hip is now sending SOS messages to the brain in an attempt to get the brain to send help to prevent the ship from sinking. What type of help? Inflammation to create swelling to keep the hip stable (or afloat). Immune cell crews that get rid of the damaged tissue to make way for repair and immune cell crews that bring new material to the site of damage and start repairing damaged tissue.
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 the 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, (3) suregons 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,(4) 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 article on degenerative hip disease and how we treat it. Some of our articles include:
- 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 hip replacement may work for you
- Greater trochanteric pain syndrome and bursitis treatment
In this video, Ross Hauser, MD demonstrates and describes the Prolotherapy treatment. A summary transcription is below the video.
Prolotherapy is an injection of a simple sugar, dextrose. Dozens of research studies have documented Prolotherapy’s effectiveness in treating chronic joint pain.
- This is a hip procedure on a runner who has hip instability and a lot of clicking and popping in the front of the hip.
- This patient has suspect labral tear and ligament injury.
- The injections are treating the anterior part of the hip which includes the hip labrum and the Greater Trochanter area, the interior portion, the gluteus minimus is treated.
- The Greater Trochanter area is where various attachments of the ligaments and muscle tendons converge, including the gluteus medius.
- From the front of the hip (1:05) we can treat the pubofemoral ligament and the the iliofemoral ligaments
- From the here posterior approach I’m going to inject some proliferant within the hip joint itself and then of course we’re going to do all the attachments in the posterior part of the hip and that will include the ischiofemoral ligament, the iliofemoral ligaments. We can also get the attachments of the smaller muscles you’re obviously going to get you know some of the smaller muscles too including the Obturator, the Piriformis attachments onto the Greater Trochanter
- Hip problems are ubiquitous, the hip ligament injury or hip instability is a cause of degenerative hip disease and it’s the reason why people have to get to get hip replacements.
- This athlete is training for a half marathon and did not want have their training regiment stopped because of this injury and believe it or not within 10 days of this treatment the athlete was back to running. At the time of this video they were scheduled to have another treatment. One treatment may not resolve a runner’s injury. Depending on the injury we get people sometimes back to their sport really quickly sometimes it takes a few treatments before they’re back to their exercise
If you have questions about your hip pain, you can get help and information from our Caring Medical Staff
1 Mavrogenis AF, Flevas DA, Panagopoulos GN, Megaloikonomos P, Igoumenou V, Vottis C, Sakellariou V, Kontogeorgakos V. Rapid destructive arthritis of the hip revisited. European Journal of Orthopaedic Surgery & Traumatology. 2015 Oct 1;25(7):1115-20. [Google Scholar]
2 Huerfano E, Bautista M, Bonilla G, Palau-Lazaro M, Llinás A, Monsalvo D. A case of rapidly destructive osteoarthritis of the hip with onset of less than six weeks. J Clin Orthop Trauma. 2017 Aug;8(Suppl 1):S72-S75. doi: 10.1016/j.jcot.2017.02.005. Epub 2017 Feb 24. [Google Scholar]
3 Buikstra JG, Fary C, Tran P. Arthroscopic findings of a diagnostic dilemma- hip pathology with normal imaging. BMC Musculoskelet Disord. 2017 Mar 21;18(1):120. doi: 10.1186/s12891-017-1485-5. PMID: 28327166; PMCID: PMC5361835. [Google Scholar]
4 Kapetanakis S, Dermon A, Gkantsinikoudis N, Kommata V, Soukakos P, Dermon CR. Acetabular labrum of hip joint in osteoarthritis: A qualitative original study and short review of the literature. Journal of Orthopaedic Surgery. 2017 Oct 10;25(3):2309499017734444. [Google Scholar]
5 Fukui K, Kaneuji A, Fukushima M, Matsumoto T. Inversion of the acetabular labrum triggers rapidly destructive osteoarthritis of the hip: representative case report and proposed etiology. The Journal of arthroplasty. 2014 Dec 1;29(12):2468-72. [Google Scholar]