Marc Darrow MD,JD

Many golfers play as long as they can with a painful hip. Then one day the hip pain becomes severe enough that it is just not worth playing any more. As avid and recreational golfers, many people do not embark on surgery to get themselves back on the course. They get the surgeries because of other quality of life factors or they need to return to work. But as golf is an important aspect of their lives, if they can get back to playing, that would be an added bonus to the surgery.

The question many people wrestle with is, surgery or no surgery?

Many golfers know other golfers who had very good success with surgery so it is easy to think surgery would be the answer. For many people surgery may indeed by the answer. But what if you cannot get a surgery in a timely manner or you do have a job that you cannot take the time off of work? Maybe you are simply not interested in the months of extensive physical therapy or the rehab required to recover or maybe you are simply not interested in getting a surgery? Are there options?

The realities of hip replacement and the return to sport

A December 2019 paper published in the journal International orthopaedics (1) examined the return to golf after hip replacement.

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Marc Darrow MD,JD

Over the years we have seen many patients with hip pain. Many of them having a “hip bursitis.” If you have a diagnosis of bursitis, you know what it is, as most you have been diagnosed with a trochanteric bursitis or an iliopsoas bursitis. Sometimes both. The iliopsoas bursitis is felt in the groin area on the inside of the hip. The trochanteric bursitis is felt on the outer part of the hip.

However, most of the patients we see may or may not have a bursitis even though they have a diagnosis of one and they are on anti-inflammatory medications. Bursitis is an inflammation of the protective, fluid filled sacs that prevent excessive friction between the functional soft tissue of the hip, i.e., the ligaments and tendons, and the bones they attach to and rub against. These bursae can become irritated from injury, excessive pressure, and overuse. More often this diagnosis is actually a problem of tendonitis or tendinosis. However, for the purpose of this article, I will focus on the problem of bursitis.

Once a diagnosis of bursitis is made, the patient will typically be given a “healing,” regiment that will include:

• Activity modification and rest
• Nonsteroidal anti-inflammatory drugs (NSAIDs).
• Physical therapy.
• Injection of a corticosteroid

These treatments may be effective for some, non-effective for others. Once the cortisone injection or injections fail to provide any relief, the patient will usually start seeking other options. One option is Platelet Rich Plasma therapy or PRP. PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. Why PRP?
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Marc Darrow MD,JD

Many times a prospective patient will come into our office for a consultation and ask if we can do both Platelet Rich Plasma injections and Stem Cell injections at the same time. The idea comes from visits to other clinics where it is discussed with patients that Platelet Rich Plasma injections either prior to or at the same visit will make stem cell therapy more effective. The answer we give is no, the use of bone marrow concentrate more commonly bone marrow stem cell therapy contains a rich source of blood platelets. Simply, it is getting both treatments at once.

Give me a chance to back this up with some research.

Let’s start with a 2012 study. (1) Here the research team wanted to determine whether platelet-rich plasma (PRP) could be made into a bioactive scaffold capable of endogenous (using the body’s own healing and response system), growth factor release for cartilage repair. In essence these researchers made a patch of platelets.

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Marc Darrow MD,JD

Tendinitis occurs when a muscle is overused and pulls on the tendon that attaches it to the bone. In the hip, tendons perform an important role by keeping strong muscles attached to the femur (thighbone) as the legs move.

Hip abductor tendon tears

Hip abductor tendons are crucial for good gait and stability in the hip joint. When I see someone with hip pain and they have a good range of motion and no sign of degenerative arthritis, that is the clue that we are looking at something in the soft tissue, be it the labrum, the ligaments complex or the hip tendon complex. In many people, it is a combination of all three.

As mentioned, I see the person who may have degenerative or traumatic injury tears to their hip tendons. They do have outside hip pain and a degree of muscle weakness. This person is typically the athlete or person who does physically demanding work and a lot of them are trying to continue with activity or job with the pain.

Sometimes I see the patient who has continued pain after hip replacement. Sometimes the tendons and muscles are injured during the surgery.

Treatment options

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Marc Darrow MD,JD

Many times a patient will come into our office with a stack of MRIs, a post-surgical report, and a promise that they were told that they could resume their running after a hip resurfacing procedure. Unfortunately for them, the surgery did not meet their expectations. Recently published research in the American Journal of Sports Medicine, says “Running is possible after hip resurfacing, and runners can even return to some level of competition, but this short follow-up series of hip resurfacing in athletes should be interpreted with caution regarding implant survival.”(1)

A study from 2019 (2) presented a more optimistic outlook. Here the researchers suggested: “Patients undergoing hip resurfacing improved their preoperative gait pattern of a significant limp to a symmetrical gait at high speeds and on inclines, almost indistinguishable from normal controls. Hip resurfacing with an approved device offers substantial functional gains, almost indistinguishable from healthy controls.”

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Marc Darrow MD,JD

Knee pain is one of the most common problems we see at our institute. When it comes to a more active individual, there can be many knee pain causes. One possible cause is Iliotibial band syndrome or more often referred to as IT band syndrome. It is also commonly referred to by patients as “pain on the outside of my knee.” The people I see with this problem are usually long distance runners and those who are starting up a very aggressive exercise routine and they overdo it.

The pain of IT band syndrome is very familiar to those who have it and those who treat it. It is usually located not only on the outside of the knee but on the length of the the outer thigh from hip to knee. What causes this pain? As just mentioned, overuse injury especially in distance running and over doing it when you start a new exercise program. As you bend your knee, the IT band at its attachment at the shin bone can impinge or trap soft tissue beneath it causing pain. The friction of rubbing against this soft tissue can also thin out and wear away at the Iliotibial band itself.

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Marc Darrow MD,JD

Many people email us about their hip and back pain. Some have been recommended to a hip replacement, some have been recommended to a spinal surgery. Some have been recommended to both surgeries and they are in the process of choosing between one or the other and exploring options to help them avoid one or the other surgery, even both. Some at this point are not even deciding which to get first, they may simply take the first one that is available.

The question that comes in to us is about stem cell therapy as an option and “which would you treat first? My hip or my back?” The benefit of stem cell therapy is that in the same visit, if you are a good candidate for treatment, we can treat both of your pain challenges at the same time. In this scenario, both areas can begin a simultaneous healing process. You do not have to wait for you hip to heal to start spinal treatments, you do not have to wait for your back to heal to start hip treatments. Below I will discuss the science behind these treatments.

Research: The question of which to have surgery on first, the hip or the spine, is much more complex and risky than thought

The option to have lumbar spinal surgery and hip replacement at the same time is clearly one that is not recommended for obvious reasons. So a decision has to be made. Spinal surgery or hip replacement surgery? One has to come first and one has to wait.

At Washington University School of Medicine, Departments of Orthopaedic Surgery and Neurology and Physical Therapy, surgeons and therapists wanted to examine patients who had hip osteoarthritis and back pain. The hip-spine complex can be a tricky and complex area to diagnose. Finding the true source or sources generating a patient’s pain can be equally complex. This makes the first surgery decision even more difficult.
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Marc Darrow MD,JD

We are getting many emails from people who are waiting for a hip arthroscopic surgery or trying to find other solutions. Now a leading surgical center, the Hospital for Special Surgery says this: “The percentage of patients with hip arthritis who had a hip replacement within two years of hip arthroscopy was unacceptably high at 68%, according to a new study of more than 2,600 patients by investigators at Hospital for Special Surgery (HSS). Prior hip arthroscopy was also associated with significantly worse outcomes after hip replacement.”

This was from a May 18, 2020 Press statement

“Arthroscopic hip surgery should not be performed in patients with a diagnosis of osteoarthritis”

This conclusion warning that people with hip osteoarthritis should not have arthroscopic surgery comes from Hospital of Special Surgery research published in the journal Hip International.(1) Here is the concluding remarks of that research:
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In many patients that come into our office, there is a complexity of symptoms and pain in multiple joints. In one patient, for instance, it could be back pain, hip pain, and knee pain. In the patient history, we ask that patient if they have been recommended to any surgeries? Sometimes they will respond, “yes, I have been recommended to back surgery,” or sometimes they will say, “my spinal surgeon is suggesting back surgery, my orthopedist is recommending hip surgery. The two of them agree that I should have the hip surgery first then the spinal surgery.” Sometimes a patient will say that their doctors are recommending a spinal surgery, hip surgery, and bi-lateral knee replacement, which surgeries first are dependant on which is thought to be the worst of their problems.

In this article I will discuss research that suggests that in some of these situations, where a patient has hip, back and knee pain, the rush to surgery may be sending many patients to an inappropriate or unnecessary surgery knee replacement.

Knee pain complaints in women over 50. Is it really knee osteoarthritis or is it hip pain? Back pain? Weight?

Here is an interesting 2018 study (2) centered on women over the age of 50.

The researchers of this study investigated the factors associated with the level of knee pain in community-dwelling women aged 50 years or older. The radiographic grade of knee osteoarthritis, presence of low back pain, level of hip pain, Body Mass Index and presence of depressive symptoms were significant factors associated with the level of knee pain in the study group. For women without knee osteoarthritis, knee pain was found to increase according to increasing age, BMI, level of hip pain, and presence of low back pain. For women with knee osteoarthritis, knee pain was significantly associated with radiographic grade of knee osteoarthritis, BMI, level of hip pain, presence of low back pain, and presence of depressive symptoms.

Previous studies have indicated that patients with hip disease can go to the doctor with with knee pain. The sensory nerves of both the hip and knee joints originate from the femoral, sciatic, and obturator nerves (nerves at the L2-L4 lumbar region that impacts the mid-thigh). Hip joint pathology is known to be an important cause of pain referred to the knee joint. In addition, spinal problems can cause anterior knee pain through radiating pain or through the weakness of the quadriceps muscle. A previous study showed a high percentage of spinal symptoms in patients with knee pain, compared with controls. Although hip or back pain does not necessarily represent hip pathology or radiculopathy, our study results suggest that associated hip and spine disorders need to be evaluated in women with knee pain.

The question is. Women with knee pain without MRI evidence of osteoarthritis and women with knee pain with clear evidence of osteoarthritis. In this study the doctors warned to check the back, the hip, depressive episodes, and weight to determine the true cause of pain. This could prevent a recommendation to surgery that was not needed, worse, the wrong joint gets operated on.

Having the wrong joint replaced is not a new problem, it happens quite often, especially when the hip is involved.

In a study published in the medical journal Modern Rheumatology,(3) surgeons discussed the complexity of hip disease and how it impacts other joints and areas of the body.

Here the surgeons found that:

• Hip disease was the cause of knee pain in 29% of patients.
• Hip disease was the cause of low back pain in 17% of patients.

Their warning to their fellow surgeons?

• “be aware of hip disease masquerading as knee pain or low back pain” That is how wrong surgeries may be performed.

“Patients may still be undergoing knee arthroplasty for degenerative lumbar spine and hip osteoarthritis.”

Here is study from surgeons in the United Kingdom. Published in the medical journal International Orthopaedics, (4) the surgical team of this study wanted to answer the question as to why up to 20% of total knee replacement patients complain of persisting pain after the knee replacement. Here was there answer:

• The investigators examined 45 consecutive patients with pain after total knee replacement. Of the 45 patients, one-third, 15 patients had degenerative hip and lumbar spine disease. Nine patients had unexplained pain.
• The study concluded: “Patients may still be undergoing knee arthroplasty for degenerative lumbar spine and hip osteoarthritis. We suggest heightened awareness at pre- and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.”

The patients still had knee pain after knee replacement because it was not their knee generating the knee pain, it was the hip and spine.

A 2017 study published in the journal Clinical Orthopedic Surgery, (4) doctors found that in the patients they examined with pain after knee replacement

• 25.6% of the patients in the study were found to have nerve entrapment in the spine,
• 15.4% were found to have hip osteoarthritis or femoral head avascular necrosis.

Knee pain persisted after knee replacement because the problem was not the knee but the hip and spine.

Physical examination can help rule out “wrong joint surgery”

I have written extensively on this website about the problems of MRIs sending people to surgery that they do not need. W\hat an MRI cannot do is gently press on the hip joint. If we can press on the hip joint and you get a shooting pain in your knee, we can have a realistic expectation that knee replacement may not be the answer. If we can gently press on your spine, and this creates a knee pain, we may come to the same conclusion. Knee replacement may not be the answer.

Do you have questions? Ask Dr. Darrow

A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025

PHONE: (800) 300-9300 or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician.

Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.

REFERENCES:
1. Dibra FF, Prieto HA, Gray CF, Parvataneni HK. Don’t forget the hip! Hip arthritis masquerading as knee pain. Arthroplasty today. 2018 Mar 1;4(1):118-24.
2 Lee KM, Kang SB, Chung CY, Park MS, Kang DW, Chang CB. Factors associated with knee pain in 5148 women aged 50 years and older: A population-based study. PLoS One. 2018 Mar 8;13(3):e0192478. doi: 10.1371/journal.pone.0192478. PMID: 29518078; PMCID: PMC5843201.
3 Nakamura J, Oinuma K, Ohtori S, Watanabe A, Shigemura T, Sasho T, Saito M, Suzuki M, Takahashi K, Kishida S. Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip. Modern rheumatology. 2013 Jan 1;23(1):119-24.
4. Al-Hadithy N, Rozati H, Sewell MD, Dodds AL, Brooks P, Chatoo M. Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies? Int Orthop. 2012 Jan 11.
5. Lim, H.-A., Song, E.-K., Seon, J.-K., Park, K.-S., Shin, Y.-J., & Yang, H.-Y. (2017). Causes of Aseptic Persistent Pain after Total Knee Arthroplasty. Clinics in Orthopedic Surgery, 9(1), 50–56. http://doi.org/10.4055/cios.2017.9.1.50 — 1494