The different kinds of injections for bone on bone hip

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

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.

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.

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 the 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 healthy and take a lot of supplements. I am very concerned with the 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

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 the 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.

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 to 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 lead by doctors at Northwestern University Feinberg School of Medicine in Chicago wrote these opinions in the medical journal Osteoarthritis and Cartilage.(2)

CONCLUSION: No better than the Placebo

These findings were also confirmed by researchers in August 2019 in the journal Medical Science Monitor.(3) 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 (4) also found that:

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.

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

“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, (5) doctors said both PRP and Hyaluronic acid both 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 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:

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 hip replacement may work for you

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. 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.”

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 the 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 damaged 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 breakdown 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, (6) we were able to show that ProlotherapyPlatelet 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 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 therapists 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 othere 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(7) 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::

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, does their strength and capabilities decrease?

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

They found that:

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 (8), 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 joints. 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 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, (9) 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.(10)

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

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.

 

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.

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.

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:

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,

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.

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.

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.

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

References

1 Guermazi A, Neogi T, Katz JN, Kwoh CK, Conaghan PG, Felson DT, Roemer FW. Intra-articular Corticosteroid Injections for the Treatment of Hip and Knee Osteoarthritis-related Pain: Considerations and Controversies with a Focus on Imaging—Radiology Scientific Expert Panel. Radiology. 2020 Dec;297(3):503-12. [Google Scholar]
2 Brander V, Skrepnik N, Petrella RJ, Jiang GL, Accomando B, Vardanyan A. Evaluating the use of intra-articular injections as a treatment for painful hip osteoarthritis: a randomized, double-blind, multicenter, parallel-group study comparing a single 6-mL injection of hylan GF 20 with saline. Osteoarthritis and cartilage. 2019 Jan 1;27(1):59-70.  [Google Scholar]
3 Liao YY, Lin T, Zhu HX, Shi MM, Yan SG. Intra-Articular Viscosupplementation for Patients with Hip Osteoarthritis: A Meta-Analysis and Systematic Review. Medical science monitor: international medical journal of experimental and clinical research. 2019;25:6436. [Google Scholar]
4 Acuña AJ, Samuel LT, Jeong SH, Emara AK, Kamath AF. Viscosupplementation for hip osteoarthritis: Does systematic review of patient-reported outcome measures support use?. J Orthop. 2020;21:137‐149. Published 2020 Mar 25. doi:10.1016/j.jor.2020.03.016 [Google Scholar]
5 Battaglia M, Guaraldi F, Vannini F, Rossi G, Timoncini A, Buda R, Giannini S. Efficacy of ultrasound-guided intra-articular injections of platelet-rich plasma versus hyaluronic acid for hip osteoarthritis. Orthopedics. 2013 Dec;36(12):e1501-8. [Google Scholar]
6. Hauser RA, Orlofsky A. Regenerative injection therapy with whole bone marrow aspirate for degenerative joint disease: a case series. Clin Med Insights Arthritis Musculoskelet Disord. 2013 Sep 4;6:65-72. Google Scholar
7 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]
8 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]
9 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]
10 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]

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