Hip-spine syndrome before and after failed hip replacement and lumbar spinal fusion complication
Ross A. Hauser, MD; Danielle R. Steilen-Matias, MMS, PA-C
This article will present various scenarios in regard to someone’s combined problem of the lumbar spine and hip degenerative disease. In this article, you will see research that suggests a lumbar fusion can cause hip replacement dislocations if the hip replacement followed the fusion. You will see research that suggests that hip replacement may alleviate low back pain without the need for a lumbar fusion. You will see research on positive outcomes and the development of low back and hip pain after surgery. You will also see research that suggests you may have had the wrong surgery. It is challenging enough to think about getting a major surgery such as a spinal fusion or a hip replacement. It is even more challenging to think that after you had a spinal fusion you really needed a hip replacement, or that you already had a hip replacement and now you are now being told that you need a spinal fusion. This is the situation many people face.
- Misdiagnosis: “To focus on the incorrect anatomic site would be a disservice to the patient.”
- “There is no consensus on which pathological (hip or spine) condition should be addressed first.”
- The complexity of the hip, pelvic, and low back instability.
- Hip-Spine Syndrome is born after doctors notice patients still have pain after hip replacement and spinal fusion.
- The confusion of Hip-Spine Syndrome is significant and can lead to poor surgical choices.
- Pelvic pain in a spinal fusion patient.
- Patients with Hip-Spine Syndrome are made worse by Hip Replacement and Spinal Fusion.
- The limited research available suggests spinal pathology predicts and warns of less pain relief and worse outcomes after total hip replacement.
- The complex interplay between the lumbar spine and hip warrants attention and further investigation.
- Understanding reduced range of hip motion causes more lower back pain.
- Pelvic tilt was the most common factor measured in patients who had a total hip replacement, but the back pain was helped.
- Hip replacement after spinal fusion.
- Does spinal fusion increase the risk of hip replacement?
- Does having a hip replacement first prevent the need for lumbar fusion?
- Ischiofemoral impingement causing lumbar pathology.
- Is it really Gluteus medius syndrome?
- How could my Hip MRI be so wrong?
- A Review of Research on the Value of Hip Scans.
- It is hard to figure out what is causing the patient’s hip pain. It can be any one of a number of things, the MRI seems to be the tool most doctors like to use, but is it any good?
- So how could my hip MRI be so wrong? Here is a March 2019 study.
- Injections may help identify the pain source in hip-spine syndrome.
- Injections may present a successful non-surgical treatment option for hip-spine syndrome.
- Prolotherapy: Treating the ligaments in sacroiliac joint dysfunction.
X-ray of lower back, pelvis, and hips showing areas of sclerosis noted by the arrows. Hardening of the bones or joints (sclerosis) is typically the earliest x-rays sign of joint instability and osteoarthritis. The bone is hardening because of greater pressure on it due to ligament injury causing joint hypermobility or instability. This particular patient was recommended a multi-level fusion but she was a good candidate for Prolotherapy injections which are described below. She was able to have recovery without surgery. These are not typical results of everyone. These injections may not help every patient and the treatment may not be able to prevent surgery in every case.
I had lower back pain, I was diagnosed with lumbar spinal stenosis. I had fusion surgery. After the surgery, I had the same pain
These are the types of emails we receive.
It was my hip all along
I had lower back pain, I was diagnosed with lumbar spinal stenosis. I had fusion surgery. After the surgery, I had the same pain. Now my doctors think it was my hip all along.
It was my back all along
I had a hip replacement because my MRI showed osteoarthritis and I was in a lot of pain. After the surgery, I still had the same pain. Now my doctors think it was my back all along. Now I should get a spinal fusion.
How can this be?
Some of you may be thinking that this is far-fetched, how can this be? If you are among those thinking this, you are then not among the people who had a hip replacement because of back pain and a spinal fusion because of hip pain. You are not among the people who neither they nor their doctors realized they were getting surgery for the wrong thing. Below we will present the research and clinical findings.
Some people do very well with getting both these surgeries. These are not the people who are reaching out to us. We see the people with the problems we described above, those we will describe below, and those who would rather not go through these major surgeries. But again, more people have successful surgeries than failed surgeries.
Two studies below will serve as an introduction to the controversies of hip replacement following spinal fusion. More research is presented below.
Misdiagnosis: “To focus on the incorrect anatomic site would be a disservice to the patient.”
Published by the American Academy of Orthopaedic Surgeons 2022 Instructional Course Lectures (14) is a discussion that suggests: “Disorders of the hip and spine commonly coexist and are difficult to disentangle. When they do occur together, the pathology is often referred to as hip-spine syndrome. When a hip-spine syndrome is suspected, it is critically important to properly identify the relative contributions that the hip and spine each provide to a patient’s overall clinical presentation. To focus on the incorrect anatomic site would be a disservice to the patient.
“There is no consensus on which pathological (hip or spine) condition should be addressed first”
An October 2021 paper from the Department of Orthopedics, the University of Colorado published in The Journal of
Bone and Joint Surgery. American Volume, (15) offered these learning points to doctors:
- The proper diagnosis and treatment of patients with concurrent hip and spine pathological processes can be challenging because of the substantial overlap in symptomatology.
- There is no consensus on which pathological condition should be addressed first.
- A prior spinal fusion can increase the risk of hip replacement dislocation.
- A proper understanding of sagittal (front- to back proper alignment of the spine from head to pelvis) balance and restoration of this balance is integral to improving patient outcomes following spinal surgery.
First, Danielle R. Steilen-Matias, MMS, PA-C explains the common problems we see in our patients.
Learning points summary:
- Hip-spine syndrome is a pain syndrome characterized by injuries in both the hip and the low back that impact each other.
- At 0:27 of the video, the interactions of the hip and the spine are demonstrated with a model of the pelvis.
- Hip-spine syndrome commonly involves your hip and your sacroiliac joint or even the low back part of your spine. When you develop injuries or degenerative wear and tear in both the hips and the low back, these injuries impact each other. The back pain can make the hip pain worse, the hip pain can make the back pain worse as the degenerative disease is accelerating in both areas.
- Many times we will see a patient in the office. They will have a very specific diagnosis that their problems all come from the hip, or they will have a very specific diagnosis that their problems are all coming from the lower back. After we do a physical examination and talk to the patient about their medical history, it is clear that this patient has issues in both the hip and spine.
- Often we find that patients have completed a conservative care treatment course for their lower back or they have completed a conservative care treatment course for their hip, yet they still have pain. In this situation, conservative care may have been directed at the wrong pain triggers.
- In patients like this, we treat the hip, spine, sacroiliac joint, and sacrum areas with Prolotherapy to bring stability into the area by restoring normal function to damaged or weakened spinal and hip ligaments. (The treatment is explained below in greater detail).
- At Caring Medical we have a very high success rate in treating patients effectively and alleviating their chronic pain with Prolotherapy.
In this next section, we will explore research leading up to clinical observations in helping patients with hip and low back pain problems.
What are we seeing in this image? The complexity of the hip, pelvic, and low back instability.
To some surgeons, the back is the back and the hip is the hip. If the MRI shows disc degeneration, then there is justification for spinal surgery. If the MRI shows hip degeneration, then there is justification for hip replacement. This x-ray below belongs to Ross Hauser, MD. It is not one of his patients, it is actually HIS x-ray. Dr, Hauser’s years of ironman competitions and other “hardcore” competitions certainly took a toll. Look at what is going on here and the extent of pelvic, hip, and spine problems.
Dr. Hauser had this x-ray when he had acute pain in his left lower back and sciatic-like symptoms.
- A decrease in distance from the ischial tuberosity to the top of the iliac crest. The Ischial tuberosity, the bony prominences at the base of the pelvis, or commonly, the “sit bones” or the “seat bones,” are just that. The bones you sit on. This is a suspected pain origin when a patient complains of “pain in the butt.” That Dr. Hauser’s ischial tuberosity has moved closer to the top of his iliac crest signifies that he has pelvic tilt.
- The lower back pain and sciatic-like symptoms were in part coming from pelvic distortions.
Hip-Spine Syndrome is born after doctors notice patients still have pain after hip replacement and spinal fusion
Above we described people with hip pain after spinal fusion and back pain after hip replacement because surgery addressed the wrong issue. Let’s let the surgeons take over from here.
Research from the Vanderbilt Orthopaedic Institute published in The Journal of the American Academy of Orthopaedic Surgeons (1) warns doctors about wrong surgeries.
“The incidence of symptomatic osteoarthritis of the hip and degenerative lumbar spinal stenosis is increasing in our aging population. Because the subjective complaints can be similar, it is often difficult to differentiate between intra- and extra-articular hip pathology (intra meaning the pain is in the hip joint at the ball and socket location, extra means the supporting ligaments and tendons that lead to hip instability) from degenerative lumbar spinal stenosis.
These conditions can present concurrently, which makes it challenging to determine the predominant underlying pain generator. . . Determining the potential benefit from surgical intervention and the order in which to address these conditions are of utmost importance for patient satisfaction and adequate relief of symptoms.”
The above study was published in 2012, certainly, things have changed. Let’s start moving towards 2021.
The confusion about Hip-Spine Syndrome is significant and can lead to poor surgical choices
Doctors at the University Hospitals Cleveland Medical Center wrote in the September 2017 edition of Orthopaedics and Traumatology, Surgery and Research:(2)
- Researchers have recently proposed the concept of “hip-spine syndrome”, however, there exists limited evidence available to differentiate whether these accompanying or associated hip and spine pain and inflammation are due to anatomic/structural causes, or systemic/metabolic effects.
- Comment: In other words, the confusion of the hip spine is significant and can lead to poor surgical choices. Not only is hip-spine syndrome a diagnosis for suggesting that the patient’s pain needs to be thought of as possibly coming from the hip, from the spine, and from both, but in addition, a problem of factors that may include systemic/metabolic factors, such as inflammation from obesity or autoimmune problems and disease. PLEASE NOTE: Again we are being issued warnings of the possibility of continued pain after a complicated surgery was possibly performed on the wrong area.
Here are more factors the doctors discussed:
- Age was the strongest predictor of arthritis at each site (back and hip).
- Anatomic/structural influences on the lumbosacral-pelvic junction contribute toward the development of arthritis (Concurrent structural damage) that is separate from any systemic/metabolic effects.
- Surgeons performing total hip replacement should remain aware of the relationship between low back pain and hip arthritis, although future research is necessary regarding the optimal surgical treatment of these patients. Of course, we believe that future research is necessary regarding optimal NON-surgical treatment of these patients.
Total hip replacement concurrent with extensive spinal corrective fusion with pelvic fixation for adult spinal deformity has an extremely high rate of posterior hip dislocation
A February 2021 paper in the European Journal of Orthopaedic Surgery & Traumatology (19) cited this research in exploring the high dislocation rates following total hip replacement before or after spinal surgery in extensive spinal corrective fusion with pelvic fixation for adult spinal deformity.
This study followed 23 adults (27 hips) who underwent both extensive spinal corrective fusion with pelvic fixation and total hip replacement between 2010 and 2018. The rate of total hip replacement dislocations was extremely high-22% (6 of 27 hips) of patients. All dislocations occurred posteriorly in patients with prior total hip replacements that were performed using the posterior approach. The pelvic tilt was significantly greater in patients with total hip replacement dislocations than in those without. Conclusion: “Total hip arthroplasty concurrent with extensive spinal corrective fusion with pelvic fixation for adult spinal deformity has an extremely high rate of posterior hip dislocation. The posterior surgical approach and prior total hip replacement were high-risk factors for dislocation. Hip and spine surgeons need focused pre-surgical planning to account for this risk.”
What are we seeing in this image? Pelvic pain in a spinal fusion patient
In this x-ray image of a pelvis, we see a previous surgical fusion in a patient. This patient developed severe bilateral sacroiliac pain following the surgery. We can see the close proximity between the fusion instrumentation and the sacroiliac joints.
A July 2020 study in The American Journal of Sports Medicine (3) noted: “Medical research suggests that lumbar spine disease is an independent risk factor for poorer outcomes following total hip replacement; however, the effect of lumbar spine disease on hip replacement outcomes has not been fully investigated. At present, (July 2020) there is little in the research investigating the effect of coexisting hip and lumbar spine disease on outcomes after hip replacement.”
Note: Above we started this article with a study from 2012 suggesting that hip-spine pain is an under-investigated phenomenon. This is still so in July 2020. In this study, it was found that Patients with known lumbar spine disease who underwent hip replacement had a significantly greater percentage improvement at 24-month follow-up compared with those without a history of lumbar spine disease, and outcomes were ultimately not significantly different. No increased risk of reoperation was noted in patients with concomitant lumbar spine disease. Hip replacement helped these people’s back pain without the ultimate need for spinal surgery as well.
Patients with Hip-Spine Syndrome made worse by Hip Replacement and Spinal Fusion
We just presented an outcome where patients had a hip replacement and it helped their back pain. Here is a study with non-similar results.
University and hospital researchers in Sweden made the connection between poor hip replacement outcomes and previous lumbar fusion surgery.
Writing in the Joint and Bone Journal, (4) they examined patients who first had the lumbar surgery, then proceeded later to a total hip replacement. Their research conclusions are presented here:
- “Lumbar spinal surgery prior to total hip replacement is associated with:
- less reduction of pain,
- worse health-related quality of life,
- and less satisfaction one year after total hip replacement
- This is useful information to share in the decision-making process and may help establish realistic expectations of the outcomes of total hip replacement in patients who also have previously undergone lumbar spinal surgery.
The limited research available suggests spinal pathology predicts and warns of less pain relief and worse outcomes after total hip replacement
These same unfortunate results had been previously reported earlier in 2017 by doctors at the Department of Orthopaedic Surgery, the University of California, San Francisco in The Journal of Arthroplasty:(5)
- The coexistence of degenerative hip disease and spinal pathology is not uncommon for the number of surgical treatments performed for each condition increasing annually.
- The limited research available suggests spinal pathology predicts and warns of less pain relief and worse outcomes after total hip replacement.
The UCSF researchers concluded their study with:
- Patients with preexisting lumbar spinal fusion experience worse early outcomes after primary total hip replacement including higher rates of complications and reoperation.
- The complex interplay between the lumbar spine and hip warrants attention and further investigation.
What are we seeing in this image?
This image is being used to demonstrate the interrelationships between the thoracic spine, lumbar spine, and the hips and normal or abnormal movement. In this example, the skeleton is trying to touch its toes. There are three different lumbopelvic rhythms or movements used to bend the trunk forward and toward the floor with knees held straight, a normal kinematic strategy used to bend the trunk from a standing position. A limited flexion in the hips (caused for example by tight hamstrings or other impediments) that great affection is required of the lumbar and lower thoracic spine. C. With limited lumbar mobility, greater flexion is required of the hip joints. In B and C, the dash line circles and arrows indicate regions of restricted mobility.
The most common compensatory scenario seen in chronic hip pain cases is lumbar hyperextension, anterior pelvic tilt, gluteus muscle weakness, femur internal rotation, knee valgus stress and lateral patellar displacement, tibial internal rotation, medial ankle collapse (and instability) and foot hyper pronation.
There are lots of theories as to why this occurs. I believe it either begins with knee medial ligament laxity or anterior hip laxity. Since joint instability is a progressive disorder, it is safe to assume that if medial knee instability developed first and it is not addressed appropriately, it will progress to medial ankle instability and anterior hip instability. The body compensates for this with tibial and femur internal rotation and lumbar hyperextension to allow the body to stay upright and walk. Those with these issues can undergo chiropractic manipulation for the lumbar and pelvic distortions or start an exercise program of gluteus medius strengthening, balance work and core strengthening. This will all help, but it is not going to stop the collapse of the medial knee and ankle and anterior hip. It will slow the progression, but unfortunately it will still progress. In patients we see in this degenerative condition we stabilize the joints with Prolotherapy and then start an active guided and targeted exercise program. Then, the muscles strengthening will work more efficiently because the underlying joints are stable. Trying to rehab unstable joints by exercise simply just doesn’t work. Please see my article Hip pain and hip instability | What happens if hip muscles are weak?
Pelvic tilt was the most common factor measured in patients who had a total hip replacement, but the back pain was helped
A March 2022 scoping review study of 5185 patients who had a total hip replacement published in the journal BioMed Central Musculoskeletal Disorders (17) found pelvic tilt was the most common factor measured in patients. Decreased sacral slope and lower pelvic incidence were associated with an increased risk of dislocation in patients with total hip replacement. Lumbar spine scoliosis did not change significantly after total hip replacement in patients with bilateral hip osteoarthritis. Finally, one study indicated that low back pain improvement was not correlated with postoperative changes in spinopelvic alignment parameters. Conclusion: “Changes in spinopelvic alignment may occur after total hip replacement and may improve with time. Patients with a total hip replacement dislocation usually show abnormal spinopelvic alignment compared to patients without a total hip replacement dislocation. Low back pain usually improves markedly over time following total hip replacement.”
Understanding reduced range of hip motion causing more lower back pain
Doctors from Washington University School of Medicine in St. Louis and Northwestern University Feinberg School of Medicine wrote in The Journal of Orthopaedic and Sports Physical Therapy (6) of patients with hip-spine syndrome with known hip arthritis and reduced range of hip motion.
- They found on examination, 101 patients with hip arthritis (68 women, 33 men) with an average age of 47.6 years:
- 81 (80%) had reduced hip flexion;
- 76 (75%) had reduced hip internal rotation
The researchers concluded: Physical examination findings indicated hip dysfunction is common in patients presenting with low back pain. Patients with low back pain and positive hip examination findings have more pain and worse function compared to patients with low back pain but without positive hip examination findings.
A January 2022 study published in The Journal of Arthroplasty (18) comes from Japanese researchers looking to be able to predict which patients would have more successful surgeries by way of pre-surgery spinal examination. The researchers noted that spinal disorders and low back pain have been associated with worse clinical outcomes of total hip replacement. In this study, 151 patients had a total hip replacement and before the surgery, they had a low back pain visual analog pain scale score of greater than 2 on a scale of 0-10.
- Ninety-five patients (62.9%) were classified into the low back pain improved group. Sagittal spinal imbalance (front to back tilt) and high Cobb angle (more spinal tilt towards scoliosis) were the key spinal factors associated with persistent low back pain. These findings suggest that hip surgeons should evaluate spinal alignment before total hip replacement in patients with low back pain.
Hip replacement after spinal fusion
An October 2020 study in the European Spine Journal (7) examined the risk factors for patients in need of a second or revision surgery of their hip replacement. The risk factor they examined was if the patient had also had spinal fusion surgery.
Here are the learning points of this study:
- “There is a known correlation between the procedures of lumbar spinal fusion, total hip arthroplasty (replacement), and the complication of hip dislocation and revision occurring in patients. However, there is no consensus as to whether the risk of this complication is higher if total hip replacement is performed before or after lumbar spinal fusion.”
So what these researchers tried to determine was if the risk of the need for a replacement or revision of the first hip replacement was greater in patients who had the lumbar fusion first or following the hip replacement.
What did they discover? “Lumbar spinal fusion remains a risk factor for dislocation and revision of total hip arthroplasties (replacements) regardless of whether it is performed prior to or after total hip arthroplasty. Further preoperative assessment and altered surgical technique may be required in patients having total hip arthroplasty who have previously undergone or are likely to undergo lumbar spinal fusion in the future.:
If you have hip pain requiring replacement, and you have back pain requiring fusion surgery, there is a good chance that you will need a hip replacement, spinal fusion, or then another hip replacement revision procedure.
Does spinal fusion increase the risk of hip replacement?
An August 2021 paper in the Journal of Neurosurgery. Spine (16) comes to us from the Pritzker School of Medicine, Feinberg School of Medicine, Northwestern University, and the Department of Orthopaedic Surgery and Rehabilitative Medicine, University of Chicago.
In this paper the researchers say “strong evidence links symptoms of hip and spine pathology to postsurgical outcomes.” in other words, the level of spine or hip degeneration and the history of spinal fusion or hip replacement can greatly impact surgical outcomes. To continue with this study: “Recent studies have reported increased rates of hip dislocation in patients previously treated with total hip arthroplasty who had undergone lumbar fusion procedures. However, the effect of this link on native hip-joint degeneration remains an area of ongoing research.” The question being asked is, while it is known that spinal fusion can increase the risk of hip replacement dislocation, what is spinal fusion’s impact on a hip that has yet to be replaced, does it accelerate the hip damage?
The answer according to this paper: “Although lumbar fusion was initially hypothesized to have a significant effect on the rate of total hip arthroplasty, lumbar fusion was not associated with an increased need for future total hip arthroplasty in patients with preexisting hip osteoarthritis. Additionally, there was no relationship between fusion construct length (the amount of fused lumbar segments) and the rate of total hip arthroplasty. Although lumbar fusion reportedly increases the risk of hip dislocation in patients with prior total hip arthroplasty, these data suggest that lumbar fusion may not clinically accelerate native hip degeneration.”
Does having a hip replacement first prevent the need for lumbar fusion?
An August 2021 paper in the journal Orthopaedic Surgery (17) suggests that hip replacement can alleviate low back pain. In this paper, researchers investigated the relief of low back pain after hip arthroplasty in patients with hip joint and spinal degenerative diseases and discussed the effects of unilateral and bilateral hip surgery on the relief of low back pain.
- In this retrospective study, 153 patients (69 males and 84 females, aged: 43-88 years) who had undergone total hip arthroplasty and also suffered from lumbar degenerative diseases were followed.
- The 153 patients had:
- been diagnosed with severe hip degenerative disease and also been diagnosed with lumbar degenerative disease;
- undergone total hip replacement surgery
- The improvement of hip joint function after one or both side hip replacement and the relief of low back pain were studied
Of the 153 patients, only nine patients still had persistent or aggravated low back pain after hip replacement. Among them, six patients underwent subsequent lumbar surgery (five patients had pain relieved after reoperation and one patient had not) and the other three patients chose conservative treatment for pain.
Conclusion: Total hip replacement can relieve low back pain while relieving hip pain and restoring hip function in patients with both hip and lumbar degenerative disease, thus possibly avoiding further spinal surgery.
Ischiofemoral impingement causing lumbar pathology
In a January 2017 paper entitled: The Hip-Spine Effect: A Biomechanical Study of Ischiofemoral Impingement Effect on Lumbar Facet Joints, Doctors at Baylor University and the University of Texas (8) found a relation between ischiofemoral impingement and lumbar facet joint load during hip extension.
They suggested that limited terminal hip extension due to simulated ischiofemoral impingement significantly increases L3-4 and L4-5 lumbar facet joint load when compared with non-ischiofemoral impingement hips.
This study directly links ischiofemoral impingement to increased lumbar facet loads and supports the clinical findings of ischiofemoral impingement causes lumbar pathology. Assessing and treating hip disorders that limit extension could have benefits in patients with concomitant lower back symptoms.
Is it really Gluteus medius syndrome?
When this patient comes into our clinic, we talk with them about the difficulties in isolating one part of the pelvic-hip-spine complex as the main culprit of their problem. This we find especially true in treating a patient with problems of Gluteus Medius tendinopathy. We are not the only ones to understand this challenge.
A February 2020 study in the Journal of Physical Therapy Science (9) offered this:
“Gluteus medius syndrome is one of the major causes of back pain or leg pain and is similar to greater trochanteric pain syndrome, which also presents with back pain or leg pain. Greater trochanteric pain syndrome is associated with lumbar degenerative disease and hip osteoarthritis. Gluteus medius syndrome is also related to lumbar degenerative disease, hip osteoarthritis, knee osteoarthritis, and failed back surgery syndrome. Accurate diagnosis of gluteus medius syndrome and appropriate treatment could possibly improve lumbar degenerative disease and osteoarthritis of the hip and knee, as well as a hip-spine syndrome and failed back surgery syndrome.”
How could my Hip MRI be so wrong?
So again, you went and had an MRI of your hip. Your MRI came back and showed a lot of degenerative problems. You may have been told you have “bone on bone,” but nothing can be done for this short of hip replacement. You went in for hip surgery. After months of rehabilitation, you still have the same hip pain. Upon further review and another MRI, it is determined that your pain is actually coming from your SI joint and/or your lower back. You may be finding yourself on this page because you are now researching alternatives to SI joint and low back surgery.
Something we hear, perhaps more often than one would think is, “how was my hip MRI so wrong?”
A Review of Research on the Value of Hip Scans
A person with long-term hip pain management will typically tell us about all the tests, images, scans, CDs, and other digital images they have of their problem hip. They then will ask how can they get these films to us. These patients are very anxious to avoid either a hip arthroscopic surgery or a hip replacement surgery. They sometimes think that the quicker we can review their images, the quicker they can avoid the surgery.
We tell many of these people, “come in for an examination. Let us look at how you walk and what type of range of motion you have in your hip. Then if we need to confirm or dismiss something in your hip, we will take a look at your films.” In our thinking, the quicker we can do a physical examination, the quicker we can assess whether or not we can help them avoid hip surgery.
For some people, telling them that we do not want to see all these imaging studies first, is hard to understand.
For these people, their entire problematic hip medical history has been guided by imaging. Some people are so confused by this that they mistake what we are telling them into asking, “Do I need to get a new MRI?” The answer is almost always NO. In our experience, people who have already had a hip replacement on one side, even a successful one, and do not want to “go through all that again,” understand the limitations of film best.
Pictures of the hip, are they worth it?
Ross Hauser, MD discusses some very common MRI findings in asymptomatic patients and why MRI can lead to surgery even when that may not be the true pain-producing structure.
What are the types of imaging a person can be ordered when they have chronic pain? Are these tests accurate in helping him or her in treatment? Are these tests accurate?
A look at the imaging studies
Usually, a person with chronic hip pain will come into our office and they will have one, two, three, or all four of the following performed over a period of time.
- Hip X-ray
- Hip CT (computed tomography)
- Hip MRI (Magnetic resonance imaging), and
- Hip Ultrasound
What’s the difference between these imaging techniques?
Perhaps the question is not what is the difference in the techniques, but rather what is the difference in how helpful these images can be.
The x-ray shows:
For the most part, the initial imaging examination will be an X-ray. An X-ray will be most effective in showing degenerative bony abnormalities and loss of joint space, signifying cartilage loss. In degenerative hip disease, it is usually the X-ray that convinces someone with hip pain that they have advancing hip osteoarthritis, bone death or avascular necrosis, bone spurs, and loss of cartilage.
The CT scan shows:
CT or CAT scans are looking for soft tissue damage that the x-rays do not see. This would be muscle, ligaments, and tendons. Because of the complexity of the hip, this imaging test is usually not favored for hip pain patients as images are poorly defined.
The MRI shows:
For some people, the end-all of all end-alls is the MRI image. It is extraordinarily difficult for people to believe that their MRI is not telling the correct story of their hip pain. The research questioning MRI accuracy will be shown below.
An MRI is looking for things the X-ray and the CT scan cannot show. This would be soft tissue damage, fluid buildup, or hidden swelling. The MRI may also reveal bone deformities that the X-ray did not show.
- When you are offered a hip MRI, you may hear terms such as Direct or Indirect Hip MRI Arthrography. The terms signify a difference in the use of contrast material to make the image clear. Indirect is where contrast material is injected into the bloodstream and circulates through the body, or Direct, where contrast material is injected directly into the hip.
Ultrasound allows visualization of pathology during motion. In our clinic, we use this tool on selected patients to see directly and immediately into the joint. We can then treat the visualized musculoskeletal condition with Prolotherapy. We also will use this tool in patients seeking treatment for pain following joint replacement.
It is hard to figure out what is causing the patient’s hip pain. It can be any one of a number of things, the MRI seems to be the tool most doctors like to use, but is it any good?
July 2017: Doctors at Queen Elizabeth Hospital in the United Kingdom and the University Medical Centre, Rotterdam, The Netherlands wrote in the European Journal of Orthopaedic Surgery and Traumatology: (10)
“The assessment of a patient with chronic hip pain can be challenging. The differential diagnosis of intra-articular pathology causing hip pain can be diverse. These include conditions such as osteoarthritis, fracture, and avascular necrosis, synovitis, loose bodies, labral tears, articular pathology and, femoroacetabular impingement. Magnetic resonance imaging (MRI) arthrography of the hip has been widely used now for diagnosis of articular pathology of the hip.”
In simpler terms, it is hard to figure out what is causing the patient’s hip pain. It can be any one of a number of things, the MRI seems to be the tool most doctors like to use, but is it any good?
Here are the research findings:
- A retrospective analysis (looking back on) of 113 patients who had MRI arthrogram and who underwent hip arthroscopy was included in the study.
- The MRI arthrogram findings were compared to those found on arthroscopy.
What is happening here is that these patients got an MRI. They went to arthroscopic surgery. Arthroscopic surgery is considered the gold standard for determining what is going on in your hip because there is a camera inside your hip taking pictures. When the MRI is doubted this is the “look-and-see hip surgery,” you may be told to get. In this study, what was seen from the “outside” the MRI was compared to what was seen on the inside “the arthroscopic surgery.”
We are going to talk about two terms sensitivity and specificity in MRI readings. You may have heard your doctor discuss them and may not have been sure what he/she was really talking about. So let’s explain what these terms mean. It may give you a much deeper understanding of the accuracy of what your hip MRI report says:
Hip Labral Tears
- In this research, the doctors found Labral tear sensitivity at 84% and specificity of 64% against the arthroscopic findings.
Let’s say you went and had an MRI for a hip labral tear. The radiologist tells you, based on this research, that the test has a sensitivity of 84% and specificity of 64%. What does this mean?
- The MRI will identify something (sensitivity) as a labral tear 84% of the time. But it is really only a labral tear (specificity) 64% of the time, the overall accuracy of 80%.
You may have hip delamination. This is where the cartilage separates from the bone.
- Researchers found delamination on MRI 7% of the time but were pretty positive it was delamination (specificity 98%) when they did find it. The overall accuracy of MRI for delamination accuracy is 39%.
AN MRI to determine articular cartilage defects
The articular cartilage is the cartilage that wraps the bones of the ball and the socket of the hip. Chondral changes is a term to describe damage to this cartilage. The study results on the accuracy of this MRI test are going to be somewhat surprising.
- Chondral changes-sensitivity 25%, specificity 83%, accuracy 58%.
This is one of the determinates of “bone on bone,” the probable single diagnosis that sends more people to hip replacement than any other. Accuracy 58%. Let that sink in.
AN MRI to Femoro-acetabular impingement (CAM deformity)
Femoroacetabular Impingement (FAI) or sometimes diagnosed simply as Hip Impingement is a condition where abnormal contact and rubbing of the ball and socket portion of the hip bones create joint-damaging friction. This “bone-on-bone” situation subsequently develops into degenerative osteoarthritis in addition to causing injuries to the labral area. Please see my article for more on this subject Femoroacetabular Impingement and Prolotherapy
- The MRI diagnosed Femoro-acetabular impingement (CAM deformity)-sensitivity 34% of the time. When it was diagnosed, it was diagnosed correctly 83% of the time. Overall accuracy is 66%.
An international team of researchers conducted computer model tests to assess the roles of the hip / spine ligaments in pelvic unalignment. Publishing in August 2022 in the Journal of anatomy (20), the researchers found ligaments to be important.
“The alteration in mechanical properties of posterior (back) pelvis ligaments may cause a biased pelvis (twisted or tilted) deformation which, in turn, may contribute to hip and spine instability and malfunction. . . The deformation of the lumbopelvic complex relative to a given load was predominant in the medial plane (A medial or body split in the middle vertical deformity can be the left side higher than the right side pelvic deformity). The effect of unilateral resection (releasing or cutting the ligaments on one side to “even things up” on deformation appeared to be counterintuitive (not good common sense), suggesting that ligaments have the ability to redistribute load and that they play an important role in the mechanics of the lumbopelvic complex.”
It is interesting to note bone on bone diagnosis accuracy of 58% – 66%
We see many patients, who after our examination are told that our treatments can help them say to us, “But I have bone on bone, my only option is a hip replacement.” Remember what we said above. For some people, the end-all of end-alls is the MRI image. It is extraordinarily difficult for people to believe that their MRI is not telling the correct story of their hip pain.
The conclusion of this study from the research team is?
“Our study conclusions are MRI arthrogram is a useful investigation tool in detecting labral tears, it is also helpful in the diagnosis of femoroacetabular impingement. However, when it comes to the diagnosis of chondral changes, defects, and cartilage delamination, the sensitivity and accuracy are low.”
Not the only study
This was not the only study to document the problems of hip MRI. In May 2018, doctors in Australia published these findings in the Journal of Orthopaedic Surgery and Research. (11)
“Conventional non-arthrographic (no contrast dye) MRI offers an accurate non-invasive (non-surgical) method to screen patients with symptoms referable to the hip by revealing the presence of labral tears, chondral defects, and ligamentum teres tears/synovitis. This study demonstrates that tears and synovitis of the ligamentum teres as potential sources of hip pain can be accurately identified on conventional non-arthrographic MRI. However, MRI has poor specificity and negative predictive value, and thus, a negative MRI result may warrant further investigation.”
What does this mean?
It means that when the MRI looks at your hip it is pretty confident when the labral tears, chondral defects, and ligamentum teres tears/synovitis (the big ligament of the hip) are obvious. BUT, when this damage is not so obvious and the person has hip pain, we should listen to the patient and not rely on the MRI to contradict them. “A negative MRI result may warrant further investigation.” In our office, this further investigation is a physical examination.
So how could my hip MRI be so wrong? Here is a March 2019 study
In March 2019, in the surgeon’s journal Clinics in Orthopedic Surgery, (12) surgeons and radiologists at the Chung-Ang University College of Medicine in Seoul, Korea shared these findings with the international medical community.
We are going to go back to talking about sensitivity (the test’s ability to identify something that may be causing your pain) and specificity (the MRIs ability to determine that what it thinks is causing your pain is in fact actually causing your pain).
In this research, the doctors and radiologists investigated the sensitivity, specificity, and accuracy of magnetic resonance imaging (MRI) and computed tomography arthrography (CTA), on the basis of arthroscopic findings, to diagnose acetabular labral tears and chondral lesions.
- They reviewed the results of MRI and subsequent CTA in 36 hips that underwent arthroscopic surgery (33 patients; 17 males [17 hips] and 16 females [19 hips]; average age, 35 years)
- All patients had positive impingement test results and groin pain.
The sensitivity, specificity, and accuracy of computed tomography arthrography for detection of acetabular labral tears by two observers were 60%, 80%, and 64%, respectively, and 65%, 70%, and 69%, respectively.
- In other words, 64% of the time or 69% of the time, the computed tomography arthrography and its interpretation correctly identified acetabular labral tears. How was this verified? By observation during arthroscopic surgery.
- So it is possible that 31-36% of people had arthroscopic surgery to DISPROVE what the computed tomography arthrography suggested.
If you think that is bad. Here is the comparison to MRIs
- The MRI offered little help to the radiologists in determining the accuracy of reading in acetabular labral tears. The MRI could only think it found the problem according to one observer, 36% of the time, and 46% of the time to the other observer.
What could the researchers conclude other than:
- “This study demonstrated that the accuracy of MRI to detect an acetabular labral tear and a chondral lesion of the hip joint was not sufficient. CTA was reliable in the diagnosis of acetabular labral tears. However, both CTA and MRI were also of limited value to detect chondral lesions.”
Injections may help identify the pain source in hip-spine syndrome
In a March 2020 study published in the surgical journal Orthopedics (13), doctors looked at the overlapping symptoms between hip and lumbar spine pathologies and the complication of diagnoses and treatments this problem causes. They suggest that diagnostic injections may help and write: “in hip-spine syndrome when a pain source cannot be elucidated, an ultrasound- or fluoroscopic-guided intra-articular hip injection may be a powerful and reliable diagnostic tool.”
Injections may present a successful non-surgical treatment option for the hip-spine syndrome
We are going to demonstrate Prolotherapy treatments for various disorders around the hip-spine and pelvic complexes. The most important point is that we can treat all these areas in the same visit, we can address the hip and spine together.
Prolotherapy: Treating the ligaments in sacroiliac joint dysfunction
The Spinal ligament repair injection treatment option Prolotherapy
Summary and Learning Points of Prolotherapy to the low back
- Prolotherapy is multiple injections of simple dextrose into the damaged spinal area.
- Each injection goes down to the bone, where the ligaments meet the bone at the fibro-osseous junction. It is at this junction we want to stimulate the repair of the ligament attachment to the bone.
- We treat the whole low back area including the sacroiliac or SI joint. In the photo above, the patient’s sacroiliac area is being treated to make sure that we get the ligament insertions and attachments of the SI joint in the low back.
- Why the black crayon lines? This patient has a curvature of her spine, scoliosis, so it is important to understand where the midpoint (center) of her spine is. In this patient, we are going to go up to the horizontal line into the thoracic area which is usually not typical of all treatments.
- After treatment we want the patient to take it easy for about 4 days.
- Depending on the severity of the low back pain condition, we may need to offer 3 to 10 treatments every 4 to 6 weeks.
For more information on the combined use of PRP and Prolotherapy please see Prolotherapy treatments for lumbar instability and low back 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.
In this video Prolotherapy treatments are demonstrated by Ross Hauser, MD:
- 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 a suspected 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, and 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 iliofemoral ligaments.
- From the 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 treat the attachments of the smaller muscles too including the Obturator, the Piriformis attachments onto the Greater Trochanter
- Hip problems are ubiquitous, 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.
For a more specific diagnosis of your hip – spine problems please refer to these papers on our site:
- Platelet Rich Plasma therapy for treating Hip Osteoarthritis
- Greater trochanteric pain syndrome and bursitis treatment
- Comparing Gluteus Medius Tendinopathy Injections and Surgery
- Does hip preserving arthroscopic surgery lead to hip replacement anyway? The evidence.
- When a painful hip MRI shows nothing
- Why physical therapy and exercise does not help your hip pain and what can help
- Sciatica and lumbar radiculopathy Prolotherapy treatments
- Treatment options for Lumbar Spondylolisthesis
- Non-surgical treatment options for lumbar spinal stenosis
- Pelvic Floor Disorders, Pelvic Girdle Pain, and Symphysis Pubis Dysfunction following childbirth
- Failed Back Surgery Syndrome treatment options – the new research
- Why physical therapy and yoga did not help your low back pain
Questions about our treatments?
If you have questions about your back and pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.
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This article was updated September 3, 2022