Hip Pain

The hip is the second biggest joint in the body (the knee is the biggest). It is a very versatile and stable ball-and-socket architecture with an extensive range of movement. It bears the body’s weight via the connection between the pelvis and upper thigh and allows us to walk, run, and jump. The joint is comprised of two parts: the ball at the head of the femur (thighbone) and the socket (acetabulum). The acetabulum is the socket of bone lined with cartilage in the pelvis that accepts and surrounds the head of the femur and is designed for stability and bearing weight.

Hip osteoarthritis results from degenerative changes on the articulating surfaces of the hip joint. If you have a serious hip problem and your doctor told you that ultimately, surgery is the only answer, I would urge you to consider your options. Regenerative orthopedic procedures with stem cells and PRP have been shown to reduce pain and help the body use its own abilities to heal without surgery, resulting in shorter recovery times and fewer potential complications than invasive surgical procedures. The key as with all the other joints of the body is to restore stability by making the joint capsule and surrounding ligaments and tendons stronger and tighter.

Several ligaments and tendons surrounding the hip joint provide additional function and stability. Both ligaments and tendons can get torn or injured with wear and tear or trauma. In the case of hip tendons, the most common injuries are to the gluteal tendon attachments, the iliotibial (IT) band, the abductor tendons, and the hamstring tendons. Along with the actual ligamentous joint capsule of the hip, these structures are responsible for the stability and movement of the hip joint and, when damaged with tears and microtears, become the major pain generators of the hip. In fact, as we have seen with the knee and shoulder joint, these  connective tissues are much more highly innervated and are much bigger pain generators than the bony components. 

Unfortunately, x-ray picks up only bony changes and MRI, although it picks up connective tissue as well as bony changes, misses the microtears in the capsule and surrounding connective tissue that are so often the root cause of instability and are such big pain generators. As we have seen with the knee and shoulder, palpation interrogation testing is the gold standard of regenerative orthopedics and in experienced hands, is a much more accurate test than MRI or ultrasound to identify and prioritize the key pain generators.   

The Importance of Joint Stability

Most painful hip conditions, whether caused by chronic sprain or osteoarthritis (OA), share a common issue: underlying instability in the hip joint. As the hip joint becomes unstable, it begins to exhibit destructive movements outside the normal range of motion. This instability and abnormal movement pattern can exacerbate pain and lead to further damage. Therefore, the first priority in addressing these conditions is to stabilize and tighten the hip joint.

If we don’t stabilize the hip with regenerative injections, the pain will persist and may lead to additional complications such as labrum damage (tears) and bone spur formation. Conventional medical treatments often include cortisone injections. However, while cortisone injections may temporarily mask the pain, they do not address the underlying instability. More concerning, cortisone can weaken the joint over time, potentially leading to permanent damage.

Regenerative Strategies: 

For patients with mild hip sprain or OA, regenerative injections with dextrose or Platelet-Rich Plasma (PRP) may be sufficient. These treatments can help stabilize the joint and may allow patients to avoid more invasive procedures like joint replacement surgery. Dextrose and PRP injections work by promoting the body’s natural healing processes, thereby reducing inflammation and encouraging tissue repair.

In cases of more advanced degeneration and moderate to severe OA, stem cell therapy with PRP is recommended. Stem cells have the potential to regenerate damaged tissues, while PRP enhances this regenerative effect. Stem cells are the seed and PRP is the fertilizer. With this powerful combination we not only target the hip joint itself but also address the surrounding connective tissue structures that, if damaged or stretched, make such an important contribution to pain and instability. As with other areas of the body, for severe cases I sometimes recommend one or two Prolo primers prior to stem cell and a PRP booster six or eight weeks after stem cell therapy to optimize outcomes. The primers help set the stage for healing and start the tightening process. The PRP booster acts to reignite the stem cells to enhance regenerative healing. Stem cells survive about 4-5 months, so in case the regenerative healing is too slow and sluggish, it makes sense to reinvigorate the stem cells (if needed) at about the six or eight week mark.

Comprehensive Evaluation and Treatment Plan

A thorough evaluation of the whole low back, pelvis and hip complex is essential for effective treatment. In addition to directly assessing the hip joint, the doctor should examine the lower lumbar spine, the sacro-iliac ligaments, the gluteal attachments in the pelvis, the anterior hip capsule, the distal piriformis attachment, the hamstring attachments on the ischial tuberosity, and the iliotibial (IT) band. These areas can be significant pain generators and contribute to hip instability.

If these surrounding structures are found to be sources of pain on palpation interrogation testing and have the positive “jump sign”, a targeted approach using stem cells and PRP on the supportive connective tissue attachments as well as the joint itself can be really important and beneficial. For example, if the hip joint shows a positive jump sign (indicative of significant instability or pain) but other connective structures are also implicated, the stem cells and PRP should be injected directly into the hip joint, as well as to all the supporting tissues on a prioritized basis depending how strongly they light up (show up) on palpation interrogation.

Monitoring and Follow-Up

After initial stem cell and PRP treatment, it is crucial to monitor and assess the patient’s progress. If significant pain still persists at the six week mark post-treatment, a PRP booster can be administered both intra-articularly (within the joint) and on the relevant pain generators. For structures like the gluteal attachments, IT band, or hamstring attachments that remain tender on palpation, additional PRP and Prolo booster sessions may be warranted.

Prolotherapy involves injecting a dextrose solution into the affected areas to stimulate healing and strengthen connective tissues. However, caution is advised when administering dextrose injections. Since stem cells continue to exert their regenerative effects for at least three to four months post-injection, it is important not to disrupt their activity by introducing dextrose into the joint too soon. For this reason, for at least four months after stem cells, Prolo injections to the surrounding supporting tissues is fine, but I usually don’t inject Prolo solutions intra-articular (into a joint) where the stem cells and PRP are still working. Inside the joint capsule, I make a point of only using PRP boosters for at least four months. If required, they can reignite and stimulate the stem cells that are rebuilding tissues. 

For those suffering from hip pain due to sprain or OA (whether mild or severe), exploring regenerative options with an experienced regenerative specialist can be a crucial step towards achieving lasting relief and improved quality of life. Active rehab without too much load is recommended and an important adjunct to the regenerative injections. For ligaments and tendons to heal properly, we need natural movement and lots of it. Pain should be the guide although patients need to know that sometimes pain is delayed so I advise never to overdo it at the beginning and incrementally increase activity as tolerated. Walking with optimal orthotics is the best and easiest rehab. Also pool exercises and aqua therapy as well as cycling can be very useful to improve muscle strength and range of movement without too much weight bearing. Stretching should be very gentle for at least six weeks as we don’t want to overly pull on the new connective tissue that’s forming. Range of motion will naturally increase as the connective tissue stabilizing the joint strengthens, relieving the muscle spasm of the muscles surrounding the joint.

The Regenerative Advantage

Regenerative therapies offer a promising alternative to conventional treatments for hip OA and sprains. Unlike cortisone injections, which provide temporary relief but may weaken the joint, regenerative injections aim to address the root cause of pain and instability. Remember, stem cell regeneration is not a pain management treatment like steroid injections etc.. It works by promoting natural healing and tissue repair. The result is a structural rebuilding of damaged tissues and long-term improvements in joint function and pain reduction.

The regenerative approach to treating hip OA and hip sprains focuses on stabilizing the joint and addressing underlying pain generators. Through the use of dextrose, PRP, and stem cell therapies, patients can experience significant pain relief and improved joint function. A comprehensive evaluation and targeted treatment plan are essential for optimal outcomes. By avoiding the pitfalls of conventional treatments like cortisone injections, regenerative therapies offer a path to long-term healing and joint health. Incidentally, we generally suggest that all stem cell patients discontinue pharmaceutical anti-inflammatories like Alleve or Ibuprofen at least two weeks prior to stem cell. They tend to interfere with regenerative healing. Instead we suggest tylenol, tylenol with codeine and tramadol if painkillers are required to help alleviate the pain while their body is healing. 

A major goal of stem cell and PRP therapy is not only to delay, but to eliminate the need for more invasive procedures like joint replacement surgery. This is particularly advantageous for younger patients or those with mild to moderate hip degeneration who wish to maintain an active lifestyle. However, even if a patient is older and has advanced “bone-on-bone”  hip OA, stem cells have been shown to be effective. We may have to work harder and use Prolo primers and PRP boosters but it can still work. Many regenerative doctors have noticed the same thing, the severity of the condition does not have a huge impact on the outcome. It’s more related to the health, healing capability and commitment of the patient to regenerative healing and rehab and avoiding the risks of surgery.  

The future of hip and orthopedic treatment lies in harnessing the body’s natural healing abilities, paving the way for active, pain-free living. Stem cells and regenerative healing is the medicine of the future!

Hip Labrum Tears

The hip labrum is a raised lip of cartilage that surrounds the socket (acetabulum) in the pelvis and helps secure and stabilize the head of the femur in the hip joint. Hip labrum tears can readily be identified with an MRI and are due to the following factors.The most common factor is Instability of the hip joint. As the joint loosens, abnormal hip movement can lead to labral tears as well as degeneration of the joint surface (osteoarthritis). Advanced age and excess body weight can increase a person’s risk for developing both osteoarthritis and labral tears. As well as wear and tear degeneration, Injury and trauma can also cause labral tears. This is particularly common in people who play higher-impact contact sports such as ice hockey, football and soccer. It can also occur in sports with sudden torquing of the hip that can occur with an aggressive golf swing and planted feet. 

In many cases, labral tears are picked up on MRI but the patient has no signs or symptoms at all. If there is pain, in all likelihood it may be due to a separate issue like sacroiliac (SI) joint dysfunction, pinched nerves in the low back, or sprains / strains of the hip girdle muscles, ligaments, or tendons. Occasionally, patients with a hip labral tear might experience a clicking, locking or catching sensation in the hip joint, pain in the hip or groin region or stiffness and a limited range of motion. 

If you’ve been told by a surgeon that a labral tear is causing your hip pain and surgical repair is your only solution, we suggest you evaluate all of your options. At RegenOrtho, we’ve successfully treated many hip labrum tears without surgery. Whether a hip labral tear is due to an acute injury or a degenerative condition, regenerative injections with stem cells and PRP can reduce pain and may help your body use its own innate abilities to heal hip labrum tears without surgery, resulting in shorter recovery times and fewer potential complications than invasive hip surgeries. If we heal the underlying instability, the labrum, just like discs and knee cartilage, can heal itself! The corollary of course is even if you have surgery to treat the labral tear, you will have a much better long term outcome if you also use stem cells and PRP to heal the underlying instability. It always makes sense to try and heal the underlying root-cause wherever you can. Statistics show that hip labrum surgery alone without stem cell follow-up is often unsuccessful. In fact, in one 2014 study, 45% of patients who underwent arthroscopic hip surgery for labral tears had retears within five years after surgery. I generally recommend that patients consider having stem cells and PRP to treat their OA and labral tear, keeping surgery as a backup in case, God forbid, the stem cells fail to alleviate the pain and discomfort. 

Incidentally, orthopedic surgeons may not mention this, but surgical “cleaning up” of a labral tear means removing part of the labrum. This can ultimately result in degeneration and osteoarthritis in the joint. This is similar to what we are finding with removal of knee cartilage, it ultimately results in accelerating OA and increasing pain. We should always try and maintain the integrity of the natural anatomy as much as possible.

Pelvic Enthesopathy: What’s the Primary Pain Generator, Hip or Pelvis?

Identifying the Real Source of Pain

Over the years, I have encountered numerous patients who came in complaining of hip pain, only to discover that the actual issue was pelvic enthesopathy. Similar to cases involving low back pain, it’s often challenging for individuals to pinpoint the exact origin of their discomfort. The difficulty arises because of biotensegrity and the fact that everything in the body is interconnected. Consequently, pelvic enthesopathy frequently accompanies hip pain. When the hip joint becomes unstable and starts to loosen, the gluteal muscles, which are responsible for moving the hip, tighten and go into spasm in an attempt to splint and stabilize the joint. If this instability persists for an extended period, the attachments of the gluteal muscles can stretch. This stretching can transform them into a secondary but significant pain source when treating hip conditions.

For example, let’s say a patient presents complaining of hip pain, but palpation testing of the hip itself yields negative results. In such cases, my immediate next step is to examine the pelvis. It’s not unusual for pain originating from the pelvis to radiate to the hip area. Therefore, if you experience hip pain, ensure that your doctor thoroughly tests the pelvic gluteal attachments for signs of weakness looking for the “jump sign” (a sudden, sharp pain elicited by palpation). The principle of biotensegrity and the interconnectedness of the body explains why conditions like pelvic enthesopathy can manifest as hip pain. Understanding this concept is crucial for accurately diagnosing and treating musculoskeletal pain.

Once pelvic enthesopathy is diagnosed it is fairly straightforward to treat with stem cell/PRP, PRP alone or Prolo alone. Depending on what solutions you select you may need to inject the attachments multiple times to heal the region. Once they are healed, pain and spasm will disappear and proper function will be restored.  

Iliotibial Band (IT Band): A common component of Hip Pain

Iliotibial band (IT band) enthesopathy frequently accompanies hip pain syndromes. The IT band runs along the lateral border of the femur, and its involvement in hip pain can be identified through palpation testing. If palpation interrogation indicates IT band involvement, it should be treated with regenerative injections. Typically, two or three sessions of prolotherapy (Prolo) with dextrose are administered. However, if these sessions do not result in improvement, it may suggest that the tears within the IT band are too large to heal with dextrose alone. In cases where Prolotherapy is insufficient, the regenerative power can be increased by administering two or three sessions of Platelet-Rich Plasma (PRP) therapy or using stem cells and PRP.

IT band enthesopathy is a common component of hip pain syndromes and requires careful assessment and targeted treatment. Prolotherapy with dextrose is often the first line of therapy, but PRP or stem cells and PRP may be necessary for more significant tears. In addition to injection treatments, self-massage of the IT band can be highly beneficial. Using a massage spindle roller, such as “The Stick” (available at thestick.com), once or twice daily can help alleviate tension and pain in the IT band. An alternative is to use foam rollers with floor exercises, using the body weight to exert pressure on the IT bands. These rehab exercises can complement the effects of regenerative therapies, promoting better outcomes for patients with significant pain from IT band tears and microtears.