The evidence for Prolotherapy as a hip-preserving alternative to arthroscopy and hip replacement

alternative to arthroscopy and hip replacementRoss Hauser, MD

For someone in chronic pain, in this case, from degenerative hip disease, I know you will spend hours in front of a computer searching for information that will help you. The times you are searching the most are most likely when you are in a more acute painful situation.

If you are like others we have helped, you have reached a point of “hip preservation.” This means that your hip has not degenerated enough for hip replacement and that there is a chance that you can save your hip from replacement surgery.

I hope this article will offer you some insights and answers in helping you understand, manage and make decisions in regard to your chronic hip pain. Later in this article, we will talk about something you may have not discussed with your healthcare providers, ligament repair with regenerative injection therapy.

If you have been given a recommendation to get a hip replacement please see my article The Evidence for Alternatives to Hip Replacement

The hip preserving non-surgical treatments you are prescribed and we do not recommend

You may have just returned from a follow-up visit to your orthopedic surgeon. Over time he/she may have been exploring conservative care options for you but now you have more pain and more hip instability following these treatments. Your hip may be making a lot of noise such as grinding, clicking and popping as a signal to you that something is not right. It may give way on a staircase, getting out of your car may now be a challenge. Let’s explore how you got here.

  • One course of treatment is the conservative care treatment. This is usually a combination of painkillers, anti-inflammatory medications, physical therapy, hyaluronic acid injections, and cortisone injections. You may continue getting these treatments until such time as a hip replacement procedure is warranted.
    • We have written extensively on these treatment options: Please see our articles:
      • Exercise and physical therapy fail to restore muscle strength in hip osteoarthritis patients
        • In this articl,e we will discuss why exercise and physical therapy fail to restore muscle strength in hip osteoarthritis patients.
      • Hyaluronic acid vs platelet-rich plasma in the treatment of hip osteoarthritis
        • We do not recommend viscosupplementation for hip osteoarthritis, this article provides supported research and clinical observation. It also shows success with PRP or platelet rich plasma injections, a type of regenerative medicine treatment we utilize.
      • Anti-inflammatory medications. (This is not something we recommend. Please see my article When NSAIDs make pain worse. I explain why chronic non-steroidal anti-inflammatory drug (NSAIDs) usage can make pain worse in the long-term and accelerate the need for joint replacement.)
      • Stronger Pain medications.  This particular recommendation has very little long term appeal as it can make your situation worse. Please see our article, when Painkillers make pain worse.
      • Corticosteroids / cortisone or steroid injection. (This is also a treatment we do not recommend. Please see my article Alternative to cortisone shots, in which I examine new research that is providing more warnings that cortisone does not heal and, in fact, accelerates deterioration of already damaged joints.

The hip preserving non-surgical treatments we do recommend – Hip ligament regeneration / cartilage regeneration

Doctors who see patients with hip pain significant enough for a hip replacement recommendation soon or sometime in the future, tend to focus mainly on the bone-on-bone situation. It is very unlikely that you have seen an orthopedist who discussed anything but arthritis, joint space, cartilage and bone on bone. Now think to yourself, when did anyone talk to you about your hip ligaments?

What do hip ligaments have to do with bone on bone / no cartilage in my hip? Everything!


Weak ligaments rub your hip the wrong way

In the research below we are seeing that doctors are now accepting the fact that people do not wake up one morning with advancing bone on bone hip osteoarthritis. Bone on bone hip osteoarthritis is the end result of continued, prolonged, unrelenting hip joint erosion. What is causing this erosion? For man,y it is weak, damaged, loose, hip ligaments.

The white bands are ligaments. Notice that you cannot see the ball of the hip because they are surrounded by ligaments.

How important are your hip ligaments when we talk about degenerative hip disease?

How important are your hip ligaments to pain free and stable motion?

Look at the simple illustration to the left. Look at the hip joint where the ball and socket meet. Where is the ball of hip? You can’t see it because it is wrapped in supportive ligaments. The hip works because those ligaments help hold the ball to the socket.

  • The three main ligaments of the hip, the iliofemoral, pubofemoral and ischiofemoral ligaments are very strong. They keep your hip stable.
  • When these ligaments are not strong your hip becomes unstable.
  • When your hip is unstable. The ball starts to rub the socket the wrong way.
  • The next time your hip is causing you pain, think to yourself, my hip is being rubbed the wrong way.

The ligaments need to be saved to save your hip

Remarkable in their observations are recent studies that look at people who still had hip pain after hip replacement surgery. Since the bone-on-bone was alleviated by the hip replacement what could be causing the patient’s continued pain?

Doctors at Washington University in St. Louis School of Medicine suggest that it must be the hip ligaments. They write: “surgical management for hip disorders should preserve the soft tissue constraints (ligaments) in the hip when possible to maintain normal hip biomechanics.”(7)

Your painful wobbly hip needs help

To recap, osteoarthritis is a progressive disorder involving joint instability and joint destruction. Instability causes your hip to be rubbed the wrong way and when that happens, this rubbing or destructive abnormal joint motion leads to chronic hip pain and a possible diagnosis of:

  • trochanteric tendinitis or bursitis,
    • Please see my article Greater trochanteric pain syndrome. Greater trochanteric pain syndrome begins with minor damage to the hip joint tissue, primarily the ligaments, and ends with destructive abnormal joint motion (hip instability) that leads to inflammation and eventual problems of degenerative hip disease.
    • Pelvic floor dysfunction. Please see that article for information on the problems of bowel movement dysfunction, urinary incontinence, unexplained back and pelvic pain and other symptoms attributed to Pelvic Floor Dysfunction.
  • Ischiofemoral impingement, please see our article if you have severe buttock pain along with tenderness on the ischial tuberosity (the sit bones).
  • iliopsoas bursitis, an inflammation of the bursa that sits under the iliopsoas muscle of the hip
  • myofascial pain syndrome of the tensor fascia lata. This is a pain on the outside of the hip that originates with the tiny muscle on the outside of the pain that causes  lot of pain.
  • gluteal muscle tears and strain, The gluteal muscle is a buttock muscle.
  • as well as ligament sprains of the hip.

Research: We know the hip ligaments are important, they may be more important than we think.

As I mentioned above, when you first go to a doctor with hip pain, it is rare for the doctor to acknowledge that your problem may be from the ligaments. The reason? Ligaments are not cartilage and they are not bone. It is easier to describe to someone that they have “bone on bone” than joint instability causing a premature arthritis condition.

Doctors not knowing or understanding the hip ligaments and their role in hip stability is slowly being recognized as a major problem in the treatment of hip pain. Listen to what a team of German doctors have recently published:

  • We know that the hip ligaments contribute to hip stability.
  • We do not know how ligament damage affect men and women differently or how ligaments affect inside, outside, front or back hip pain.
  • We do not know clearly know how ligaments interact with other tissues stabilizing the pelvis and hip joint, as research is scant.

Here is the concluding statement of the paper abstract:

  • “Comparison of the mechanical data of the hip joint ligaments indicates that their role may likely exceed a function as a mechanical stabilizer.”(4)

Again, the realization that limited range of motion and/or pain with motion may not be solely caused by a bone-on-bone situation has lead doctors to further understand the relationship of the hip ligaments to pain and limited range of motion and in our research in the Journal of Prolotherapy we showed that treating weakened ligaments helped patients avoid a hip replacement surgery and increase hip function.

What happens when you let ligament damage progress? You back, your knees and your ankles are subjected to surgery on their own.

What are studies telling patients about their hips? Doctors are unclear of the extent of the importance of the hip ligaments in stabilizing and repairing hip problems

It tells patients on course for hip surgery, whether it is a surgery for hip replacement or a torn hip labrum, that doctors are unclear of the extent of the importance of the hip ligaments in stabilizing and repairing hip problems and the non-surgical repair of the ligaments could be the crucial first step in hip surgery avoidance.

This was pointed out in research from 2007 in the medical journal Arthroscopy, which obviously specializes in surgical technique, here doctors wrote that doctors who understand the hip ligaments  could offer non-surgical options for hip pain. They highlighted that the ischiofemoral ligament, iliofemoral ligament, pubofemoral ligament, iliofemoral ligament, all  control internal rotation in flexion and extension. Understanding the independent functions of the hip ligaments therefore are essential in determining nonsurgical options.(5)

This research and that of another recent study  points out what has been obvious to many Prolotherapy doctors over the years. You can’t save the hip (prevent hip replacement) without saving and repairing the hip ligaments.

Here is a summary of that research that appeared in the Journal of Biomechanics.

  • Hip ligaments prevent excessive range of motion and contributes to synovial fluid replenishment (the natural lubrication process of joints) at the cartilage surfaces of the joint that prevents friction and wear and tear.
  • However, the repair of ligaments after joint preserving or arthroplasty surgery is not routine. (Which may lead to hip revision surgery)
  • In order to restore their biomechanical function after hip surgery, you need to restore the hip ligaments to their normal tension.

Surgical ligament repair is technically demanding, particularly for arthroscopic procedures, but failing to restore their function may increase the risk of osteoarthritic degeneration.(6)

From ligament injury to Hip instability and problems with balance and falls. How a weak hip creates degenerative disc disease, degenerative knee disease, and degenerative pelvic disease.

Many patients we see who have hip instability also have problems of the knee, spine, and pelvic pain. They will typically say to us, “My hip is the big problems, but I am falling apart all over.” These people are right, their hip is the big problem, but the hip problem is bigger than they think, the hip is causing problems all over the body.

Let’s look at a January 2018 study. This study is an illustration of the damaging effects of one joint being wobbly on the entire movement of the whole body. Obviously, we will be looking at the hip as the culprit joint.

Women team handball players are among the most fit athletes. Their sport depends great stress on the player’s joints. The researchers from Auburn University, School of Kinesiology, Sports Medicine and Movement Laboratory examined how lumbopelvic-hip complex stability, via knee valgus, affects throwing kinematics (movement) during a team handball jump shot.

Read again how hip instability is being measured: the complex hip-spine-pelvic interaction and instability is being measured by knee angle. The greater the knee angle the greater the instability coming from the hip/spine.

Points to consider

  • The women with greater instability in the hip/spine/pelvic region through the ball with less force (they were weaker)
  • The women with greater instability in the hip/spine/pelvic region were at increased risk of injury in the upper (arm and shoulder) and lower extremities (Knee, ankle, feet) when landing from a jump shot because of the energy losses throughout the kinetic chain and lack of utilization of the entire chain.
    • What does all that mean? Their entire body was at risk of fall, loss of balance, impact injury.

You do not need to be a high level female team handball player to understand the problems in the hip cause and interact with instability in the lower spine and pelvis and these interactions put the knee, the ankle at risk for instability and loss of balance.(2)

Strengthening and repairing ligaments with Comprehensive Prolotherapy injection

So know we have reached a point where we will discuss the alternative to treatments you have been trying for years without effectiveness. We will now turn to Prolotherapy injections.

Caring Medical published its research in 2009 where we looked at 61 patients, 33 of them had hip pain in both hips. Twenty of these patients were told that there were no treatment options available to them, with eight being recommended to surgery as their “only hope,” for hip pain alleviation.

Of the 94 hips treated in the 61 patients:

  • 89% experienced more than 50% of pain relief with Prolotherapy;
  • more than 84% showed improvements in walking and exercise ability, anxiety, depression and overall disability;
  • 54% were able to completely stop taking pain medications.(9)

Patients who had Pain, Crunching Sensation, Stiffness.

In our study, we asked patients to rate their pain, crunching sensation and stiffness on a scale of 1 to 10.

  • Score of 1 being no pain/crunching/stiffness and 10 being severe crippling pain/crunching/stiffness.
  • The 61, representing 94 hips had an average:
    • Score of 7.0/10 for pain,
    • Score of 2.0 for crunching sensation
    • Score of 4.4 for stiffness

After treatment:

  • Before: Score of 7.0/10 for pain. After: Score of 2.4/10 for pain
  • Before: Score of 2.0 for crunching sensation. After: Score of 2.4/10 for crunching sensation
  • Before: Score of 4.4 for stiffness. After: Score of 2.0/10 for crunching sensation.
  • It should be pointed out that 54% of these people had a starting pain level of eight or greater, while only 5% had a starting pain level of three or less,
    whereas after Prolotherapy only 2% had a pain level of eight or greater while 77% had a pain level of three or less.

Patients who had issues with Range of Motion

In our study, we asked patients to rate their pain, crunching sensation and stiffness on a scale of 1 to 7.

  • Score of 1 being no motion,
  • 2 through 5 were fractions of normal motion,
  • 6 was normal motion, and 7 was excessive motion.

After treatment:

  • Before: The average starting range of motion was 4.3 and ending range of motion was 5.1.
  • Before Prolotherapy, 30% had very limited motion (49% or less of normal motion), this decreased to only five percent after Prolotherapy.
  • Prior to Prolotherapy, only 36% had 75% or greater of the normal range of motion but this improved to 75% after Prolotherapy.

Pain Medication Utilization.

  • Sixty percent of the patients discontinued pain medications altogether after Prolotherapy.
  • In all, 75% of patients on medications at the start of Prolotherapy were able to decrease them by 75% or more after Prolotherapy.
  • None of the patients had to increase pain medication usage after stopping Prolotherapy.
  • Before Prolotherapy, the average patient was taking 1.1 pain medications but this decreased to 0.3 medications after Prolotherapy.
  • Before Prolotherapy, 23% of patients were on two or more pain medications, but this decreased to 2% after Prolotherapy.
  • Sixty-nine percent of patients using additional pain management therapies before Prolotherapy were able to decrease them by 75% or more after treatment

Walking Ability.

  • Before Prolotherapy, 59% of patients experienced compromised walking ability, but this decreased to 39% after Prolotherapy.
  • Specifically, 38% could walk three blocks or less before Prolotherapy, but this decreased to 10% after Prolotherapy.
  • While 27% of patients could walk less than one block before Prolotherapy, all could walk greater than that distance after Prolotherapy.

Exercise and Athletic Ability.

  • In regard to exercise or athletic ability prior to Prolotherapy
    • 30% reported totally compromised ability (couldn’t do any athletics),
    • seven percent ranked it as severely compromised (less than 10 minutes),
    • 23% ranked it as very compromised (less than 30 minutes) and
    • a total of 84% ranked it as at least somewhat compromised.
  • After treatments: 80% of patients were able to do 30 or more minutes of exercise with 40% not being compromised at all.

Disability.

  • 40% reported an overall disability of at least 50% (could only do about half of the tasks they wanted to).
    • This decreased to 11% after Prolotherapy.
  • Sixty-seven percent noted they had at least a 25% overall disability prior to treatments and this decreased to 24% after.
  • Before receiving Prolotherapy, five of the patients were dependent on someone for activities of daily living (dressing self and additional general self care).
    • All five regained complete independence after Prolotherapy.
  • Before Prolotherapy, 11% considered themselves completely disabled in regards to their work situation, but this decreased to seven percent after Prolotherapy.

We concluded this research study with these observations:

The results of this retrospective, uncontrolled, observational study, show that Prolotherapy helps decrease pain and improve the quality of life of patients with chronic hip pain.

  • Decreases in pain and stiffness and improvements in range of motion reached statistical significance even in patients whose medical doctors said there were no other treatment options for their hip pain or that surgery was their only option.
  • Ninety-five percent of patients stated their pain was better after Prolotherapy.
  • Over 70% said the improvements in their pain, crunching and stiffness since their last Prolotherapy session have very much continued (75% or greater).
  • Eighty-nine percent of patients stated Prolotherapy relieved them of at least 50% of their pain.
  • Fifty-nine percent received greater than 75% pain relief. Only two patients had less than 25% of their pain relieved with Prolotherapy.

Is Prolotherapy the right treatment for you hip pain and instability?

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

  • Rating a hip Prolotherapy Candidate: We will rate the potential hip pain patient on a sliding scale of being a very good Prolotherapy candidate to a very poor one. In a very good candidate’s x-ray, the ball of the femur will be round, fitting nicely into the socket in the pelvis, with good spacing between these two bones. This space is the cartilage that cushions and allows the femur to rotate freely within the socket.
  • Prolotherapy prognosis for hip patients: The prognosis ranking is lowered from very good to good, to questionable to guarded to poor, based on the following criterion:

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

If you have questions about hip pain, Get help and information from our Caring Medical Staff

Prolotherapy Specialists alternative to arthroscopy and hip replacement

1 Yeung M, Khan M, Williams D, Ayeni OR. Anterior hip capsuloligamentous reconstruction with Achilles allograft following gross hip instability post-arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy. 2017 Jan 1;25(1):3-8. [Google Scholar]
2 Gilmer GG, Gascon SS, Oliver GD. Classification of lumbopelvic-hip complex instability on kinematics amongst female team handball athletes. Journal of Science and Medicine in Sport. 2018 Jan 9. [Google Scholar]
Schleifenbaum S, Prietzel T, Hädrich C, Möbius R, Sichting F, Hammer N. Tensile properties of the hip joint ligaments are largely variable and age-dependent – An in-vitro analysis in an age range of 14-93 years J Biomech. 2016 Sep 17. PMID: 27667477 [Google Scholar]
4 Pieroh P, Schneider S, Lingslebe U, Sichting F, Wolfskämpf T, Josten C, Böhme J, Hammer N, Steinke H. The Stress-Strain Data of the Hip Capsule Ligaments Are Gender and Side Independent Suggesting a Smaller Contribution to Passive Stiffness. PLoS One. 2016 Sep 29;11(9):e0163306. PMID: 27685452. [Google Scholar]
5 Martin HD, Savage A, Braly BA, Palmer IJ, Beall DP, Kelly B. The function of the hip capsular ligaments: a quantitative report. Arthroscopy. 2008 Feb 1;24(2):188-95. [Google Scholar]
6 Van Arkel RJ, Amis AA, Jeffers JRT. The envelope of passive motion allowed by the capsular ligaments of the hip. Journal of Biomechanics. 2015;48(14):3803-3809. [Google Scholar]
7 Smith MV, Costic RS, Allaire R, Schilling PL, Sekiya JK. A biomechanical analysis of the soft tissue and osseous constraints of the hip joint. Knee Surgery, Sports Traumatology, Arthroscopy. 2014 Apr 1;22(4):946-52. [Google Scholar]
9 Hauser RA, Hauser MA. A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Hip Pain at an Outpatient Charity Clinic in Rural Illinois. Journal of Prolotherapy. 2009;2:76-88. [Google Scholar]

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