Treating hip instability and hip arthritis with Prolotherapy and PRP injections

Ross Hauser, MD, Caring Medical Florida
Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Florida
David N. Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, IL

This article will explore the problems patients have in making a decision in their treatment of chronic hip pain causing by hip instability and degenerative hip disease or osteoarthritis

  • One course of treatment is the conservative care treatment, this is painkillers, medications, physical therapy, cortisone injections until such time as a hip replacement procedure is warranted.
  • Another course of treatment is the actual hip replacement procedure. There are many patients who have great success with this treatment. Ironically we see many of them in our office looking for alternatives to hip replacement for their other hip. Why? The typical response is, “I don’t want to go through all that again.”
  • The third course of action is regenerative medicine. We call this Comprehensive Prolotherapy in our office. The treatment may include stem cell therapy, Platelet Rich Plasma Therapy, dextrose Prolotherapy, or a combination of these treatments. This will be explained in the article below.

For someone in chronic pain, in this case from degenerative hip disease, I know you will spend hours in front of a computer searching information, I hope this article will offer you some insights and answers in helping to understand, manage and make decisions in regard to your chronic hip pain.

Are you a Prolotherapy candidate?

Treating hip instability with Prolotherapy and PRP injections: In this image we see a patient with problems of bone spurs. Is this person a good candidate for Prolotherapy? This person has some mild osteoarthritis in his right hip he also has a bone spur in this image it is depicted by the arrow. Even though the patient has good joint space, far from being bone on bone, the bone spur was limiting his range of motion. We can help this patient as a good candidate for Prolotherapy but he is not an excellent candidate for Prolotherapy because of the bone spur.

In this image we see a patient with problems of bone spurs. Is this person a good candidate for Prolotherapy? This person has some mild osteoarthritis in his right hip he also has a bone spur in this image it is depicted by the arrow. Even though the patient has good joint space, far from being bone on bone, the bone spur was limiting his range of motion. We can help this patient as a good candidate for Prolotherapy but he is not an excellent candidate for Prolotherapy because of the bone spur.

In this image we see an excellent candidate for Prolotherapy. Here the patient with chronic hip pain has good joint space and good range of motion.

In this image, we see an excellent candidate for Prolotherapy. Here the patient with chronic hip pain has good joint space and a good range of motion.

Is hip instability all about osteoarthritis and bone on bone? Understanding the role of hip ligaments in hip instability

Osteoarthritis is a progressive disorder involving joint instability and tissue destruction. Osteoarthritis feeds upon itself. It is the result of and the cause of excessive hip instability and the hip’s inability to stabilize itself. It begins with minor damage to the hip joint tissue, primarily the ligaments, and ends with destructive abnormal joint motion (hip instability) that leads to bone death as in avascular necrosis.

It is destructive abnormal joint motion (hip instability) that is the cause or the effect of itself in a myriad of conditions that led to chronic hip pain, including trochanteric tendonitis or bursitis, pelvic floor dysfunction, ischiofemoral impingement, iliopsoas bursitis, myofascial pain syndrome of the tensor fascia lata, gluteal muscle tears and strain, as well as ligament sprains of the hip.

You have these problems because your hip is wobbling and moving abnormally. What starts as minor ligament damage in most cases of early wear and tear, ends with hip joint destruction and the need for hip replacement.

The hip does try to stabilize itself. Typically through boney overgrowth and spurs that seek to lock or fuse the joint. Osteoarthritis is the cause and its own effect than in lack of hip range of motion.

In the Journal of Biomechanics, doctors in Germany reported on their findings of how the strength of ligaments could predict or prevent hip dislocation and hip instability.

The doctors performed cadaver studies on hip ligaments in the 14 to 93-year-old age range. What they found was the strength of the ligament varied widely and that the evidence to suggest the role of ligaments in preventing dislocations was too difficult to make. One thing they did note however was that the tested ligaments became weaker as they aged and lost their youthful elasticity.(1)

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

The role of the hip ligaments in coherence with the hip joint capsule are known to contribute to hip stability. Nevertheless, the contribution of the mechanical properties of the ligaments and gender- or side-specific differences are still not completely clear.

To date, comparisons of the hip capsule ligaments to other tissues stabilizing the pelvis and hip joint were not performed.

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.”(2)

What are these two 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 being prepped for hip surgery, whether it is a surgery for hip replacement or a torn hip labrumthat 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.(3)

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.(4)

  • Hip ligaments prevent excessive range of motion and contribute 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.

Chronic hip instability – Is it caused by hip arthroscopic surgery?

If you search the medical literature looking for research on hip instability, you will find dozens of new articles on hip instability after total hip replacement and hip arthroscopic surgery. You find very few on the role of ligament injury and damage before a hip surgery. Yet it is pain and lack of motion caused by hip instability that sends patients to these hip surgeries. Based on the literature, one could get the idea, that hip instability can only be cured with surgery. This article will not come to that conclusion.

Hip instability to you means grabbing for a chair, railing or anything you can hold unto. Medical research acknowledges these problems but seemingly in disproportionate awareness to patients before hip replacement and patient after hip replacement. The focus in research is on the patients after hip replacement.

Here is an example of the type of research that discusses hip instability, it is a recent study from the journal Knee surgery, sports traumatology, arthroscopy.

“The increasing use of hip arthroscopy has led to further development in our understanding of hip anatomy and potential post-operative complications. Iatrogenic (surgery causing) gross hip instability following hip arthroscopy is a concerning complication described in recent orthopaedic literature. Post-arthroscopy hip instability is thought to be multifactorial, related to a variety of patient, surgical and post-operative factors. . . This study reports a case of gross hip instability following hip arthroscopy, describing a (new surgical) technique of management through anterior hip capsuloligamentous reconstruction with Achilles tendon allograft.”(5)

Did you get all that? Follow the path:

  1. Patient has hip pain and instability
  2. Patient is recommended to arthroscopic labral or other clean up and repair surgeries
  3. Doctors are using hip arthroscopy in increasing numbers
  4. The surgery that promised repair, stability, and relief of pain, itself caused instability and more pain. (Mostly from dislocation and chronic subluxation (the hip keeps popping out of place)).
  5. Because of these hip problems happened infrequently or were reported infrequently, not much literature was given to solutions
  6. One solution was come up with a surgery to fix the surgery.
  • These surgeries were designed to save the hip from hip replacement, but, to do so, the surgeries needed to halt or significantly slow the progression of osteoarthritis. As research points out, surgery many times will not achieve this goal.

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 with the knee, spine, and pelvic pain. They will typically say to us, “My hip is the big problem, 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 amongst 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)

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

Doctors who see patients with hip pain significant enough for a hip replacement recommendation tend to focus mainly on the bone-on-bone situation.

Remarkable in their observations are recent studies that look at hip pain after replacement surgery. Since the bone-on-bone was alleviated by 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 and tendons. They write: “surgical management for hip disorders should preserve the soft tissue constraints (the hips and ligaments) in the hip when possible to maintain normal hip biomechanics.”(3)

This has lead to the popularity of tissue-preserving minimally invasive surgical approaches to the hip that may allow early short-term recovery, achieve hip joint stability, minimize muscle strength loss from surgery, spare the peri-articular soft tissues, and allow unrestricted motion in the long term, as described in research by surgeons at San Luca Hospital in Italy.(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.

Prolotherapy injections. Can they help you?

Prolotherapy is an injection of a simple dextrose-based solution that mimics our own body’s acute healing response at the damaged, torn, or degenerated ligament and tendon attachments. To the solution can be added minerals, fatty acids, or even a patient’s own healing cells from the platelets in their blood or stem cells from fat or bone marrow. Dozens of research studies have documented Prolotherapy’s effectiveness in treating chronic joint pain.

In this video, Ross Hauser, MD demonstrates and describes the Prolotherapy treatment. A summary transcription is below the video.

  • 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 been diagnosed with a suspect labral tear and hip ligament injury.
  • The injections are treating the anterior or front 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 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 target the attachments 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 to 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

Is Prolotherapy and appropriate treatment for you?

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. The best assessment would be an in-office physical examination.

  • 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.

Published research papers from our doctors at Caring Medical on Hip Disorders

In the Journal of Prolotherapy, we sought to show how Prolotherapy could provide high levels of patient outcome satisfaction while avoiding hip surgery. Here is what we reported:

  • We examined Sixty-one patients, representing 94 hips, who had been in pain an average of 63 months We treated these patients quarterly with Hackett-Hemwall dextrose Prolotherapy.
  • This included a subset of 20 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of eight patients who were told by their doctor(s) that surgery was their only option.

Patients in the study were contacted an average of 19 months following their last Prolotherapy session and asked questions regarding their levels of pain, physical and psychological symptoms, and activities of daily living, before and after their last Prolotherapy treatment.

Results: In these 94 hips,

  • pain levels decreased from 7.0 to 2.4 after Prolotherapy;
  • 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.

The results confirm that Prolotherapy is a treatment that should be highly considered for people suffering from chronic hip pain.

The evidence for Platelet Rich Plasma therapy for treating hip instability

Our offices have been offering regenerative medicine injections since 1993 as a service to people who wish to avoid hip replacement surgery. As part of our comprehensive program, we offer Platelet Rich Plasma Therapy, or as we describe it Platelet Rich Plasma Prolotherapy.

  • In Platelet Rich Plasma treatment, your blood is drawn from your arm, it is spun to concentrate the blood platelets which contain concentrated healing elements. The concentrated plasma “rich in healing platelets” solution is then injected into your hip.
  • In another office, Platelet Rich Plasma treatment may have been explained to you as a one-time injection treatment. You may have been told this one injection will help with your problems of hip pain and instability and address the concern of irreversible hip damage.
    • This “one time,” treatment you may have received in other offices is an explanation that may offer confusion in that many patients assume PRP injections are cortisone-like in that it is one injection offered at the time of treatment. The single injection PRP causes an inflammatory response, opposite of the cortisone injections effect of causing an anti-inflammatory effect. The effects of the two injections could not be more opposite. Patients are often confused when the inflammation gets worse after PRP and they tell everyone they know that PRP does not work.
    • This “one time,” treatment may also confuse patients who have or had been suggested to Hyaluronic acid. This is typically seen patients who ask about PRP injections “How long does this last?” Hyaluronic acid injections have a finite or limited beneficial effect and patients are typically told how long these types of injections will last. Please read this article comparing Hyaluronic acid vs platelet-rich plasma in the treatment of hip osteoarthritis

We have found PRP to be very effective as part of a comprehensive multi-dose treatment program

PRP treatments for hip pain will not help everyone. But because of the great variation in treatments researchers suggest that it is difficult to tell who the treatment can help and who the treatment will not help.

  • Single PRP treatment is not how we see PRP treatments. We see PRP treatments in conjunction with Prolotherapy treatments. In combination, we see these treatments as a means to not only delay the need for a hip replacement but to prevent the need for hip by repairing and regenerating tissue in the hip. We see this as the best chance for success.

In our experience, when somebody has degenerative hip disease and the cartilage is wearing away and being lost, you simply cannot repair the cartilage without addressing what is causing the cartilage damage. This is the joint erosion or irreversible joint damage you are hearing so much about. It manifests itself as instability in your hip, the feeling that your hip is giving way or is loose and wobbly.

  • It is important that anyone contemplating treatment with platelet-rich plasma therapy should address the instability issue by adding comprehensive Prolotherapy treatments to the PRP treatments. Please see our article The evidence that alternatives to hip replacement can work for you. This includes a more detailed discussion of the use of PRP in combination for hip osteoarthritis.

Our experience with PRP and hip instability and osteoarthritis

The video below is from 2010. We have been offering PRP treatments for even longer than that. Over the years we have found how to give these treatments in ways that will provide the patient the best chance for successful healing and the avoidance of hip replacement surgery. As pointed out above, PRP therapy does not work for everyone, sometimes a hip will be too far gone.

Dr. Hauser explains the treatment

We are starting the video at the treatment point at 4:15.

Video summary points

  • The initial injections anesthetize the back of the hip and around the hip. This makes the procedure a lot more comfortable for the patient
  • (At 4:35) The “red” injections is the Platelet Rich Plasma injection. You can see this is not a “one shot, treatment. The injections is moved around.
  • PRP is comprised of the portion of the blood that has the healing growth factors including platelet-derived growth factor, fibroblast growth factors, and healing factors that initiate the healing cascade.
  • We have found PRP injections to be effective for hip labral tears and for articular cartilage degeneration (the developing bone on bone situation)
  • (at 5:10) Prolotherapy injections follow up the PRP injections. Here I am injecting the greater trochanter area and then I also do around the hip and here we’re going to inject structures such as the iliofemoral ligament, the ischiofemoral ligament, as well as the muscle attachments into and around the hip.
  • The reason to do both PRP and Prolotherapy is that when someone has chronic hip pain, it is not only the joint itself that is damaged, the cartilage and the bone on bone, but it is also the supporting structures around the hip that can be damaged. If you don’t treat the structures around the hips, such as the muscle attachments, the tendon attachments, and the ligament attachments, the pain, for many people, will not resolve completely with only PRP.
  • As you can see from this video the procedure is very well tolerated it only takes a couple minutes and it works very well for labral tears and various tendinopathies as well.

There are more articles on our website surrounding the avoidance of hip replacement.

1 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]
2 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]
3 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]
4 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]
5 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]

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