Hip Pain and Hip Replacement
Ross Hauser, M.D.

The hip joint joins the leg to the pelvis. Unfortunately, for most people, both legs are not exactly the same. They may look the same, but from a bio-mechanical standpoint, they are not the same. One leg may be rotated either in or out, or one leg may be shorter than the other. The latter is especially common if one leg was broken during childhood. Because the hip joint connects the leg to the pelvis, the hip joint will sustain the brunt of any bio-mechanical abnormality that may occur. If one leg is shorter than the other, the hip joints will be stressed because the leg length discrepancy causes an abnormal gait (manner of walking).

With leg length discrepancy either hip joint can cause pain and usually both hip joints hurt to some degree. To propel the leg forward, the hip joint must be raised which strains the gluteus medius muscle and the posterior hip ligaments. Leg length problems are also associated with recurrent lower back problems because they cause the pelvis to be asymmetric. Prolotherapy to the sacroiliac and hip joints will correct the asymmetries in the majority of cases. The leg length discrepancy disappears from the leveling of the pelvis. If asymmetry remains after treatment, a shoe insert or heel lift will generally correct the problem.

A problem in the hip may commonly manifest itself as groin or inguinal pain. Pain from the hip joint may also be felt locally, directly above the hip joint in the back. When the hip joint becomes lax, the muscles over the joint compensate for the laxity by tensing. As is the case with any joint of the body, lax ligaments initiate muscle tension in an attempt to stabilize the joint. This compensatory mechanism to stabilize the hip joint eventually causes the area's muscles to tighten because of chronic contraction in an attempt to compensate for a loose hip joint. The contracted muscles can eventually irritate the trochanteric bursa causing a trochanteric bursitis. A bursa is a fluid-filled sac which helps muscles glide over bony prominences. Patients with chronic hip problems often have had cortisone injected into this bursa, which generally brings temporary relief. But this treatment does not provide permanent relief because the underlying laxity is not being corrected. Prolotherapy injections to strengthen the hip ligaments will provide definitive relief in such a case.

It is interesting to note that trochanteric bursitis, Pyriformi Syndrome (pain and weakness in the Pyriformi muscle of the hip), and weakness in the iliotibial band (muscles near the knee) also cause "sciatica". The sciatic nerve runs between the two heads of the pyriformi muscle. When the pyriformi muscle is spastic, the sciatic nerve may be pinched. Lumbosacral and hip joint weakness are two main causes of pyriforrni muscle spasm. Pyriformi muscle stretches and physical therapy directed at the pyriformi muscle to reduce spasm help temporarily, but do not alleviate the real problem. Prolotherapy of the hip and lower back strengthens those joints, thus eliminating the pyriformi muscle spasms.

HIP REPLACEMENT SURGERY
In 1994, the National Institute of Health gathered 27 experts in hip replacement and component parts to evaluate hip replacement. In their report, they noted that 120,000 artificial hip joints are implanted annually in the United States. They further stated, "Candidates for elective total hip replacement should have radiographic evidence of joint damage and moderate to severe persistent pain or disability or both that is not substantially relieved by an extended course of nonsurgical management." The National Institute of health is clearly recommending conservative treatment modalities prior to surgical intervention.

A concern with hip and knee replacements is that the replacement part becomes loose and requires replacement. A loose hip replacement can be treated successfully with Prolotherapy.

Snapping Hip Syndrome is a clinical entity that causes pain and snapping in the hip joint. There are several known causes, the most common being the iliotibial band snapping over the greater trochanter (at the top of your thigh bone). It can also be caused by snapping of the iliopsoas tendon over the iliopectineal line (in general the pubic area of the hip bone), the iliofemoral ligaments over the femoral head (where the thigh bone connects to the hip bone), as well as other places on the hip bone. The gluteal muscles can also make a snapping sound as they go over the greater trochanter. The psoas tendon can also cause snapping hip as it passes over the hip joint, producing pain with hip flexion. The question to ask is why is this happening? The psoas tendon is in the front of the hip joint, the gluteal muscles are over the hip joint, and the iliotibial band (tensor fascia lata) is on the side of the hip joint, yet all of these structures are considered part of the problem? We don't think so. Hip joint ligament weakness causes excessive movement of the hip joint and thus the greater trochanter, since they are connected. This excessive movement of the greater trochanter would then encroach on the iliotibial band or gluteal muscles, causing a snapping sound. If the hip joint laxity caused the hip to move forward it would encroach on the psoas muscle, causing hip snapping with movement of this muscle (hip flexion). It is easier to explain Snapping Hip Syndrome as one hip problem versus three separate muscle problems. This also explains the dramatic results seen with treating Snapping Hip Syndrome with Prolotherapy. Prolotherapy is the treatment of choice for Snapping Hip Syndrome because it gets at the root cause of the problem, which is hip ligament laxity. Prolotherapy to the posterior hip capsule and ischiofemoral ligaments generally resolves the problem if the condition involves snapping of the iliotibial band or gluteal muscles, because posterior hip laxity is involved in these conditions. In psoas-muscle-related Snapping Hip Syndrome, the hip joint is moving anteriorly, encroaching on the muscle. Prolotherapy to the anterior hip ligaments, namely the iliofemoral ligament, will tighten the joint and stop the anterior protrusion of the hip. Prolotherapy is extremely effective at permanently resolving Snapping Hip Syndrome because it repairs the underlying etiology of the problem, hip ligament laxity.

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