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Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

In this article, we will explore research on the various injection treatments offered to patients with hip pain. Included in this discussion are:

• Cortisone injections
• Hyaluronic acid injections
• PRP or platelet-rich plasma injections
• Combined PRP and hyaluronic acid injections
• Botox injections
• Stem cell injections from a patient’s bone marrow aspirate
• Prolotherapy injections of dextrose.

Summary topics of the injection treatments

• The typical first recommendation: Intra-articular corticosteroid injections. But the side-effects are concerning.
• The considerations and controversies –  the known side-effects of the cortisone injections.
• Concerns about cortisone are not new. Research is always developing an updated opinion on the impact of cortisone side effects.
• Efficacy and safety of multiple (corticosteroid injections).
• Cortisone and post-hip replacement infection: Surgeons are told to wait four months between cortisone injection and hip replacement.
• Hyaluronic acid or platelet-rich plasma in the treatment of hip osteoarthritis?
• Hyaluronic acid injections are better in grade 2 patients initially but then do not help.
• Will PRP work for your hip bone on bone?
• Can PRP can help you avoid a hip replacement?
• Research on when PRP may not work.
• “My doctor says he/she wants to give me both PRP and Hyaluronic Acid”
• Type A botulinum toxin.
• How about stem cell therapy?
• Stem cell therapy will likely not work if the doctor and the patient believe it is a “one magical shot treatment.”
• Understanding regenerative medicine injections requires an understanding of hip ligaments. The target of these injections and a target of bone on bone treatment.
• 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. Your bone on bone may NOT BE THE PROBLEM.
• When hip injections may and may not work.
• 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.
• The evidence for Prolotherapy injections for treating hip instability.
• The evidence for Platelet Rich Plasma injections for treating hip instability.

Injections for the bone on bone hip

We often see patients who are doing a lot of research on how to proceed forward with their problem of a bone on bone hip.

• One course of treatment they are researching is the conservative care treatment plan. If you are reading this article you are probably on this plan now or are looking for other options because this treatment plan is not, or has not helped you in your plan to avoid a hip replacement. This is the plan of painkillers, medications, physical therapy, hyaluronic acid, and cortisone injections until such time as a hip replacement procedure is strongly recommended. You may already be at the strongly recommended hip replacement stage.
• 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, we know you will spend hours in front of a computer searching for information, we 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.

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

Is it a bone-on-bone problem or is it a hip ligament problem?

In this article, we are going to make comparisons of some of the common hip injections designed to help bone on bone. For some people, some of these treatments will work great, for some people these injections will not work at all. We are also going to look at the problems some people have with their hips. Maybe your doctor keeps telling you, you have “bone on bone.” Maybe you do, but is that why you are having hip problems? Below we will demonstrate through independent research that people who had a hip replacement because of bone on bone had the same hip problems after the surgery. So clearly it was not the bone on bone, what else could it be? Hip ligaments. So the idea of injections for bone on bone, in some people, should be an idea of ligament weakness and ligament fraying.

The typical first recommendation: Intra-articular corticosteroid injections. But the side-effects are concerning

People will contact us with a medical history that included or will include cortisone injection into the hip as their main component of treatment, that is for now. For now meaning, until such time as a hip replacement can be confidently recommended. When is that? Usually when an MRI says “bone on bone.” Here is a story or two we may hear:

I am very concerned with cortisone injections.

I am not quite bone on bone yet. After a meeting with my surgical team and a second opinion with another orthopedist’s office, it was clear that I was being steered towards an eventual hip replacement. Because my hips were in different stages of degeneration they would be done separately at times in the future.

With good physical therapy and judicious use of cortisone injections, I should be able to put off the hip replacements for a couple of years. I am not comfortable with this. I am very active, I lead a sports-filled, physical activity lifestyle. I bike, I hike, I have a home gym. I eat healthily and take a lot of supplements. I am very concerned with cortisone injections. Unfortunately, I was told, there is no other way. There must be another way.

My MRI is bad – I am on the fast track to hip replacement

I have a new labral tear, I have a new cyst from the labral tear. I have rapidly developing hip osteoarthritis or as my doctor says, “I am on the fast-track to hip replacement.” I have had cortisone injections and I am wondering if this is causing my accelerated hip degeneration?

We have much more information on our website regarding accelerated hip osteoarthritis. Please see our article Rapid destructive hip osteoarthritis: All of a sudden you need a hip replacement.

The considerations and controversies –  the known side-effects of the cortisone injections

What are we seeing in this image?
We see the comparison of a normal hip versus a steroid-injected degenerative hip. The right side hip generation was accelerated by multiple cortisone injections.

Concerns about cortisone are not new. Research is always developing an updated opinion on the impact of cortisone side effects.

A December 2020 study in the medical journal Radiology (1) offered “Considerations and Controversies,” in the offering of cortisone injections for patients with knee and/or hip osteoarthritis. The considerations and controversies in part surrounded the known side-effects of cortisone injections. Here is what the researchers wrote:

“Current management of osteoarthritis is primarily focused on symptom control. Intra-articular corticosteroid injections are often used for pain management of hip and knee osteoarthritis in patients who have not responded to oral or topical analgesics.

Recent case series suggested that negative structural outcomes including accelerated osteoarthritis progression, subchondral insufficiency fracture, (stress fractures in the bone below the cartilage in the weight-bearing bones) complications of pre-existing osteonecrosis (in the hip avascular necrosis), and rapid joint destruction (including bone loss) may be observed in patients who received intra-articular corticosteroid injections.”

What these researchers were looking for was if there was a way that MRI or other imaging could predict which patients would be more prone to these side-effects so they could avoid getting the cortisone injection. What they found was:

“As of today, there is no established recommendation or consensus regarding imaging, clinical, or laboratory markers before an intra-articular corticosteroid injection to screen for osteoarthritis-related imaging abnormalities.

Repeating radiographs before each subsequent intra-articular corticosteroid injection remains controversial. The true cause and natural history of these complications are unclear and require further study.“

In other words, it is currently too difficult to determine with imaging, who would be more prone to these side effects.

An April 2021 study from doctors at the University of Nottingham published in the journal Rheumatology (2) retrospectively analyzed previously published research articles on the effectiveness and safety of multiple intra-articular corticosteroid injections for the treatment of osteoarthritis. The researchers compared the cortisone with a placebo.

A December 2022 paper in the journal Skeletal radiology (23)  lead by authors at Massachusetts General Hospital, Harvard Medical School reviewed previously published studies on the use of image-guided corticosteroid injections in the treatment of patients with knee and hip osteoarthritis. Among this papers reviews were that on 10 knee osteoarthritis outcome studies. The researchers observed cortisone “hip injections were found to be effective in treating short- and long-term pain and more effective than hyaluronic acid, Mepivacaine, NSAIDs, and normal saline in terms of improvement in pain and/or function. There was less impact on quality of life . . . (further) “hip injections may carry a risk of serious adverse outcomes.”

Efficacy and safety of multiple (corticosteroid injections) reflecting recommended best practice has yet to be assessed

Here is what they found:

• “Multiple (steroid) injections are no better than placebo for osteoarthritis pain according to current evidence. The preliminary finding of a detrimental effect on structural osteoarthritis progression warrants further investigation. Efficacy and safety of multiple (corticosteroid injections) reflecting recommended best practice has yet to be assessed.”

Cortisone and post-hip replacement infection: Surgeons are told to wait four months between cortisone injection and hip replacement

Doctors at the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL published a June 2021 study in The Journal of Arthroplasty. (3) Here are their concerns:

• Corticosteroid injections are commonly used for the treatment of osteoarthritis of the hip.
• There is a concern, however, that these injections may increase the risk of postoperative infection if a subsequent total hip arthroplasty is performed.

Therefore their study surrounded the investigation to determine the relationship between Corticosteroid injections and the risk of periprosthetic joint infection and surgical site infections following total hip arthroplasty (total hip replacement).

In their investigation, the researchers examined 29,058 patients who had a corticosteroid injection in their hip within 6 months prior to total hip replacement. What were their findings?

• Corticosteroid injections within four months of surgery were associated with a higher incidence of periprosthetic joint infection at six-month follow-up
• An injection within one month of surgery corresponded to a higher odds of periprosthetic joint infection than an injection four months prior to surgery.
• Furthermore, the number of Corticosteroid injections administered within the three months prior to total hip replacement demonstrated a dose-dependent relationship, with each subsequent injection increasing odds of periprosthetic joint infection. A similar relationship was observed for surgical site infections.

Conclusion: Surgeons should consider delaying elective total hip arthroplasty if a corticosteroid injection has been administered within the 4 months prior to the planned procedure.

Comparative research

In  November 2021, doctors in Italy published a comparative study in the journal BioMed Central Musculoskeletal Disorders (4). This article is filled with comparative studies, some even in contradiction with each other. The realistic expectation that any treatment will work better for you needs to be discussed with your doctor after a physical examination.

To this study, here the summary points of its comparative findings:

• The researchers selected eight previously published studies comparing hyaluronic acid with platelet-rich plasma, with corticosteroids, and with saline solution. Included were papers comparing corticosteroids to ketorolac or saline solution.

“Conclusions: The studies reviewed were heterogeneous (varied) regarding sample size, level of osteoarthritis, evaluated with Kellegren-Lawrence score, medications used, and follow up timings. However, we have observed that intra-articular injections of platelet-rich plasma seem to decrease pain in the short term and disability in long term, and in patients affected by hip osteoarthritis better than hyaluronic acid. The association of hyaluronic acid and corticosteroids could give better results compared to hyaluronic acid alone, while the use of intra-articular ketorolac and saline solution requires more studies.

Hyaluronic acid or platelet-rich plasma in the treatment of hip osteoarthritis?

We have an extensive article on this subject Hyaluronic acid or platelet-rich plasma in the treatment of hip osteoarthritis. It is summarized here:

In your quest to avoid a hip replacement surgery you may have been recommended hyaluronic acid injections. The thinking behind this, as we will see, is that by injecting a lubricant (hyaluronic acid) into the hip, bone-on-bone pressure can be relieved. Surprisingly there is not a lot of research on the effectiveness of this treatment. One could speculate that the reasoning for this is that the treatment will probably help in the short term, but it does not represent a treatment that can prevent the eventual need for a hip replacement. In essence, with hyaluronic acid injections for hip osteoarthritis, you are simply buying time and stalling the need for the surgery. Worse, the injections may offer no help and your hip condition will continue to worsen.

Buying time is appealing to those who work at physically demanding jobs, those who want to continue with sports, or those who are caregivers for others with worse medical problems than their own. Solving their hip pain problems without surgery is of course the ultimate goal. Unfortunately, hyaluronic acid injections for hip osteoarthritis has not been shown to be an effective treatment

In theory, the idea of replacing or supplementing the protective and lubricating fluids of the hip sound like a good idea.

In theory, the idea of replacing or supplementing the protective and lubricating fluids of the hip sound like a good idea. So why is it not the first line of treatment for hip osteoarthritis and why do leading research centers suggest that the treatments do not work as well as hoped? Because it really does not help.

In January 2019, research led by doctors at Northwestern University Feinberg School of Medicine in Chicago wrote these opinions in the medical journal Osteoarthritis and Cartilage. (5)

• “Hip osteoarthritis is difficult to treat. Steroid injections reduce pain with a short duration. With the widespread adoption of office-based, image-guided injections, hyaluronic acid is a potentially relevant therapy. In the largest clinical trial to date, we compared safety/efficacy of a single, 6-mL image-guided injection of Hylan G-F 20 (Synvisc) to saline (injections) in painful hip osteoarthritis.”
  • 357 patients.
  • All over the age of 35.
  • Patients suffered from mild to moderate hip osteoarthritis with “pain on walking.”

CONCLUSION: No better than the Placebo

• “A single 6-mL Hylan G-F 20 injection or saline for painful hip osteoarthritis resulted in similar, statistically significant/clinically relevant pain and function improvements up to 6 months following injection; no differences between Hylan G-F 20 and saline placebo were observed.”

These findings were also confirmed by researchers in August 2019 in the journal Medical Science Monitor. (6) They wrote: “Intravenous viscosupplementation does not reduce pain or improve function significantly better than placebo in a short-term follow-up. The benefits and safety of viscosupplementation should be further assessed by sufficiently-sized, methodologically sound studies with validated assessment of more clinically relevant end-points.”

A March 2020 study in the Journal of Orthopaedics (7) also found that:

• Hyaluronic acid injections can achieve satisfactory pain reduction and functional improvement. However, there was not enough evidence in the current literature regarding whether hyaluronic acid injections are superior to placebo or other types of intra-articular injections.

Hyaluronic acid injections are better in grade 2 patients initially but then do not help

A December 2020 study from the Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy published in the journal Acta Biomed (8) found that ultrasound-guided viscosupplementation with high weight hyaluronic acid could be a possibility in the treatment of hip osteoarthritis, especially in patients with grade 2 osteoarthritis. Subsequent injections are not characterized by similar positive effects. Outcomes of prosthetic surgery are not influenced by viscosupplementation.

Will PRP work for your hip bone on bone?

If you have come upon this page, it is likely that you have received a recommendation to Platelet Rich Plasma Injections for your hip pain and you are doing your research. We are going to try to offer help with that research, but first, we would like to take a moment to describe how we offer Platelet Rich Plasma Injections for your hip pain as opposed to how you may have been offered this treatment in other offices.

• 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.
  • This “one time,” treatment explanation 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 in 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.

We invite you to read our article The evidence for Platelet Rich Plasma therapy for treating Hip Osteoarthritis for a further discussion of PRP treatments

The highlighted portions of that article are presented below:

Can PRP can help you avoid a hip replacement?

• PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into areas of chronic joint and spine deterioration.
• Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma.
• The procedure and preparation of therapeutic doses of growth factors consist of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In our office, patients are generally seen every 4-6 weeks. Typically three to six visits are necessary per area.

Some people can avoid hip replacement with PRP injections. Some people will delay the need for hip replacement with PRP injections. Some people will not get any benefit from PRP injections and will need a hip replacement. The people in the latter group are typically people in a stage of advanced osteoarthritis and have lost all or significant amounts of a range of motion.

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

• Single PRP treatment is not how we utilize PRP treatments. We utilize PRP treatments in conjunction with Prolotherapy treatments (Prolotherapy is a simple injection technique that works to strengthen the hip ligaments and provide stability to the hip. This is explained below.)

In our experience, when somebody has the 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.

Research on when PRP may not work

We invite you again to see our article Platelet Rich Plasma Therapy Hip Osteoarthritis Treatments for a more detailed discussion of this research

• An August 2019 study published in the journal Pain Medicine (9) suggests in patients with mild/moderate hip osteoarthritis, PRP may provide pain relief and functional improvement for up to six months.
• A December 2018 paper published in the journal  Current Reviews in Musculoskeletal Medicine (10) wrote “PRP is a costly treatment not covered by insurance, and clinical trials have not demonstrated definitive efficacy, we recommend informing patients when providing PRP off-label.” What the doctors here suggest is that PRP will not help everyone.
• Also in the journal Current Reviews in Musculoskeletal Medicine (11) a June 2019 paper suggests: “Although PRP is safe to use and it can be easily applied in the clinics, case-specific considerations are needed to determine whether PRP could be beneficial or not. If the use of PRP is favored, then, the configuration/optimization of the preparation and administration/delivery strategy with or without a concomitant treatment may further enhance the clinical outcomes and patients’ experience.”
• And also in the journal Current Reviews in Musculoskeletal Medicine (12) a December 2018 paper suggested: “PRP is a promising treatment for some musculoskeletal diseases; however, evidence of its efficacy has been highly variable depending on the specific indication. Additional high-quality clinical trials with longer follow-up will be critical in shaping our perspective of this treatment option.”

“My doctor says he/she wants to give me both PRP and Hyaluronic Acid”

The idea is that while PRP rebuilds hip tissue, Hyaluronic Acid will act as a lubricant to help the PRP work better. As the research shows that did not happen.

The conclusion the doctors reached was that their results indicated that intra-articular PRP injections offer a significant clinical improvement in patients with hip osteoarthritis without relevant side effects.

The benefit was significantly more stable up to 12 months as compared with the other tested treatments. The addition of PRP + Hyaluronic Acid did not lead to a significant improvement in pain symptoms.

In another study in the medical journal Orthopedics, (13) doctors said both PRP and Hyaluronic acid worked well for patients with hip osteoarthritis, these researchers however offered a conflicting assessment.

Intra-articular injections of platelet-rich plasma and hyaluronic acid represent effective medical treatments for osteoarthritis. This study’s goals were to compare the clinical efficacy of the platelet-rich plasma and hyaluronic acid at 12-month follow-up in hip osteoarthritis patients

One hundred patients with chronic hip were consecutively enrolled and randomly assigned to 1 of 2 groups:

• group A received PRP and
• group B received hyaluronic acid
• both administered via intra-articular ultrasound-guided injections.
• Patients were evaluated at baseline and after 1, 3, 6, and 12 months
• Despite a slightly progressive worsening between 6- and 12-month follow-up, the final clinical scores remained higher compared with baseline with no significant differences between PRP and hyaluronic acid. Regarding clinical temporal evolution, multivariate analysis showed that HHS was not influenced by the type of infiltration, patient age, sex, body mass index, or degree of OA, whereas a significant association was detected between

The conclusion these researchers reached was: Intra-articular injections of PRP are effective in terms of functional improvement and pain reduction but are not superior to hyaluronic acid in patients with symptomatic hip osteoarthritis at 12-month follow-up.

While these studies show good results, we find more effective results can be achieved by treating the whole hip joint and surrounding ligaments and tendons to stabilize hip instability. Please read our article The evidence that alternatives for a hip replacement may work for you

Type A botulinum toxin

At our center, we do not offer Type A botulinum toxin as a pain relief treatment. We see botulinum toxin type A as a type of pain management and not as a reparative therapy. However, some people do get good initial benefits from these injections.

A November 2018 paper published in the journal Toxins (14) suggested that botulinum toxin type A treatment “is an innovative well-tolerated treatment in patients affected by hip osteoarthritis and that injections could be repeated without any significant adverse effects. Therefore, we confirm the relevance of this new therapy in the orthopaedic or rehabilitation field, in particular when a (total hip replacement) surgery is contraindicated or delayed. The novelty of this treatment is that a single treatment with BoNT-A injected in the adductor muscles improves both joint range of motion and pain.

A 2019 study (15) wrote: “The application of botulinum toxin type A (BoNT-A) produces in the applied muscle a temporary, delimitable and reversible flaccid paralysis, which applied in a strategic way achieves to reduce mechanical stress and pain.” The injections stop the muscles from spasming and help with hip pain. How effective is it? In this study the researchers looked at patients and assessed these injections “effect on pain perception, functionality, and rigidity, and changes in flexibility, internal and external rotation, before and 90 days after the application of botulinum toxin type A.”

• In this study: A total of 35 patients and 45 hips were treated (10 patients had both hips done). BoNT-A of 500 U was applied in the iliac, adductor brevis, and longus muscles, and then patients were assessed for a decrease in hip pain, stiffness, and improved perceived function.
• The researchers concluded:  The treatment with BoNT-A provides a conservative and safe option for the management of symptoms and physical restraint caused by hip osteoarthritis.

How about stem cell therapy?

In our clinical experience, we have seen bone marrow-derived stem cells and lipoaspirate-derived stem cells provide very satisfactory results for patient clients. These treatments do not help everyone and we also do not use these treatments as “first line,” treatments.

Is it possible, with just one shot of stem cells into the joint, to cure a person of pain? (Note: we are not discussing here the type of stem cell injected, such as those from the patient’s lipoaspirate, bone marrow, or those from amniotic fluid, etc. Though, it should be mentioned that the number of active stem cells found in amniotic fluid is negligible by the time the product reaches the medical office).

For the patient who has a lot of bone spurring and simply needs some lubrication in the joint, it is possible the single injection of PRP, bone marrow, lipoaspirate or any other ‘healing’ solution into the joint may work. This is why some of the joint osteoarthritis studies show that single shots of bone marrow, dextrose or even saline have amazing pain-reducing properties, sometimes lasting long-term.

However, for the patient who has significant hip instability that caused the hip cartilage cells to get destroyed, resulting in bone-one-bone hips, injecting stem cells into the joint without addressing the instability simply is not going to work. Unfortunately, many people waste a lot of money getting one very expensive shot of stem cells into their  hips with only short-term pain relief. In my opinion, it simply does not make sense that stem cell injections are going to work long-term if the cause of the cartilage cells dying, hip instability, is not addressed. If the hip instability is not addressed, the stem cells and future cells they form will end up getting ‘crushed to death’ as well in the presence of joint instability.

We have an extensive article Does stem cell therapy work? Will it work for you? This article is summarized here.

Stem cell therapy will likely not work if the doctor and the patient believe it is a “one magical shot treatment.”

• One out of 10 new patients that we see here at Caring Medical has already received stem cell treatment from another clinic.
• The reason that these patients are here is that they believe stem cell therapy will work for them if the treatment is more comprehensive.

A great myth of stem cell therapy is that it is a magical one-time injection into the joint. Thus, patients believe that if they get a single injection into the hip that somehow all of their pain is going to disappear. Or if they get “more stem cells,” that one injection will work even better.

The single-shot thinking debunked:

The damage that caused sufficient injury to your hip, enough so that you sought out stem cell therapy, possibly even as an alternative to joint replacement surgery, is accumulated damage from degenerative joint disease. It is damage from advanced hip instability that caused the hip cartilage cells to break down and gave you a bone-on-bone situation.

Hip instability comes from loose, weakened, unsupportive ligaments that, when healthy and strong, prevent the abnormal motion of the joint that causes joint destruction.

To treat this hip, you must go beyond the simple one-shot stem cell thinking. What is needed is a comprehensive treatment that treats all the stabilizing ligaments and structures of the joint to prevent the same destructive forces from continuing to break down the cartilage even after stem cell therapy was administered.

One injection “treatments” are not sustainable pain relief

People believe that one stem cell injection will make all their pains go away. For most this is not true. It is not true for the same reasons outlined above, a single injection will not be comprehensive enough to reverse the damage affecting the entire hip. This one-shot thinking leads to an unrealistic expectation of pain relief.

In the first treatment, indeed, many people will get pain relief. However, in our practice, we are looking for sustained more permanent pain relief. One injection treatments are not sustainable pain relief.

Ligament tissue and other soft connective tissue as well as bone heal over time. The ligaments over a four to six-week period. A second treatment is often needed to build on this healing. Sometimes a third and sometimes a fourth treatment is necessary depending on your level of joint degeneration. This comprehensive approach stops the destructive joint forces that prevent stem cell therapy from working.

In Caring Medical research we published in 2013 in the medical journal Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders, (16) we were able to show that Prolotherapy, Platelet-rich Plasma Therapy, and in this instance bone marrow aspirate (stem cells and healing factors)  supported chondrogenesis (Cartilage growth and repair) by enhancing the availability of pro-chondrogenic microenvironmental factors. In essence an environmental change from diseased to healing within the osteoarthritic joint by addressing supportive ligament and tendon damage.

This was achieved in our study by a combination of the above treatments.

While treatments based on either stem cells or the other mentioned treatments show effectiveness for osteoarthritis as a stand-alone or single therapy, treatments that combine these modalities may be especially promising.

Understanding regenerative medicine injections requires an understanding of hip ligaments. The target of these injections and a target of bone on bone treatment.

Avoidance of hip replacement despite a “bone on bone diagnosis,” may not have much to do with the bone on bone problem as much as it has to do with a degenerative condition being allowed to exist within your hip. That degenerative condition is hip instability caused by hip ligament laxity.

To be clear, for some people their bone on bone has reached a point that the ball of the hip socket has collapsed or the hip joint is surrounded by bone spur formation. When this occurs and the hip is now frozen in place without range of motion, a hip replacement is the only way. But what about the people above, our two stories of people who were told they had bone-on-bone but remained active? What about them?

Osteoarthritis is a progressive disorder involving joint instability and tissue destruction and it is not just bone

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.

Researchers look for the answer in hip ligaments, not a bone-on-bone diagnosis. Is bone on bone really the “end of the line?” Is it only a matter of time until the bone spurs take over?

In many people we talk to, bone on bone means “it is the end of the line,” joint replacement is the only way out. So they look for a “last chance,” way out of a hip replacement. So at what point does a bone on bone hip become a need for hip replacement? Here is another sample story we hear:

I am going to physical therapy now and I think I am doing okay, but the physical therapist says I am just delaying the inevitable, I will need a hip replacement. When I ask why? I mean I do have a decent range of motion in my hip, I am able to do the exercise, isn’t this a good sign? They tell me that I am developing bone spurs, it is only a matter of time until the bone spurs take over? So what can I do to prevent this?

In some people, not all, addressing the hip instability caused by damaged hip ligaments may alter the course of your degenerative hip progression to hip replacement.

Again to be clear, some people will need a hip replacement. Their hip or hips have reached a stage of degenerative disease that is unfortunately not reversible or even manageable. In other people, there may be an opening to treat their hip problems by addressing the damage and laxity of the hip base ligaments.

In some people, not all, addressing the hip instability caused by damaged hip ligaments may alter the course of your degenerative hip progression to hip replacement.

The strength of hip ligaments is your ability to hold your hip together

In the Journal of Biomechanics, (17) doctors in Germany reported on their findings of how the strength of ligaments could predict or prevent hip dislocation and hip instability. In other words, how the strength of the hip ligaments could hold your hip together or let your hip basically fall apart.

The doctors performed cadaver studies on hip ligaments in the 14 to 93-year-old age range. Here are the learning points from this research::

• “Hip joint stability is maintained by the surrounding ligaments, muscles, and the atmospheric pressure exerted via these structures. It is unclear whether the ligaments are capable of preventing dislocation solely due to their tensile properties, and to what extent they undergo age-related changes.”

The question is, can the hip ligaments alone prevent hip dislocation, or better understood as hip instability and the hip becoming hypermobile, and as the ligaments get older, do their strength and capabilities decrease?

The researchers then examined the iliofemoral, ischiofemoral, and pubofemoral ligament from cadavers.

They found that:

• “The ischiofemoral and pubofemoral ligament change age-dependently. (They get weaker with age).”
• Here is the conclusion: “Though the hip ligaments contribute to hip stability, the ischiofemoral and cranial iliofemoral may not prevent dislocation due to their elasticity.”

In other words, if these ligaments become too elastic, they cannot hold your hip together.

The hip ligaments may do even more to stabilize the hips

The idea that the whole hip may be held together by the complex ligaments structure of the pelvic region was the subject of another study that explored the role of hip ligaments in preventing degenerative hip disease. In a study (18), published in the medical journal Public Library of Science One (PLoS One) the researchers speculated that the hip ligaments may do more than previously thought in their function as a mechanical stabilizer. Because the hip is a ball and socket joint it operates with a far greater range of motion than a knee or ankle joint. Thus the hip requires stability through a far greater range of motion. 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.”

In other words, these ligaments may be doing far more than we think to keep your hip together.

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. Your bone on bone may NOT BE THE PROBLEM.

It tells patients being prepped 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, (19) 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.

This research and that of another recent study point out what has been obvious to many 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. (20)

• Hip ligaments prevent an 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.

When hip injections may and may not work

In this image, we see a patient with problems with 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 a good range of motion.

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.”(21)

This has led 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. (22)

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 led 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 an 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

• Regenerative Injection Therapy (Prolotherapy) for Hip Labrum Lesions: Rationale and Retrospective Study
  • This paper was published in The Open Rehabilitation Journal.
  • Hauser R, Orlofsky A. Regenerative injection therapy (prolotherapy) for hip labrum lesions: rationale and retrospective study. The Open Rehabilitation Journal. 2013 Oct 18;6(1). [Google Scholar]

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 in 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 it 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 with hip osteoarthritis.

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

• You can read about The evidence for alternatives to hip replacement
• Research on Platelet Rich Plasma Prolotherapy stimulating bone growth and repair

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your hip problems.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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References

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