Percutaneous interventional pain management is a good alternative treatment
The hip joint is the more stable joint of the human body and is composed of femoral head and acetabulum. It is made of cartilage, ligaments and fluid. Muscles and tendons help the hip joint move. It can withstand repeated motion and a fair amount of wear and tear. For that reason, one of the main diseases of the hip is osteoarthritis and, as in the knee, the ultimate treatment is prosthetic surgery. Despite that, percutaneous interventional pain management (Steroid, Platelet Rich Plasma or Hialuronic Acid Injection) are a good alternative treatment for some patients who are not eligible for an operation or experience persistent or intense pain after surgery or while waiting for surgery.
Most Common Syndromes
Hip osteoarthritis is one of the most common causes of hip pain in the older population.
Meralgia paresthetica is a compression neuropathy of the lateral femoral cutaneous nerve that causes pain, numbness and/or tingling sensation at the anterolateral aspect of the thigh. Symptoms can be aggravated by prolonged hip extension and relieved by hip flection such as sitting. Treatment must address any aggravating factors such as obesity or tight-fitting clothes, adding to medication, icing and a nerve block injection. In chronic refractory cases, surgery may be considered.
Athletic pubalgia is a complex syndrome which can have many different etiologies and be perceived as pain in slightly different locations, mainly at the abdominal wall, the inguinal area, the adductors insertion and the pubic symphysis. Treatment depends on the underlying cause.
Femoral neck fracture/stress fracture
Femoral neck fractures are a typical fracture in the old population with osteoporosis, usually associated with low energy trauma. Because of regional blood supply, these fractures are almost always treated operatively.
Femoroacetabular impingement describes a syndrome where abnormal contact between the femur and the acetabulum is established, causing hip pain and progressively labral or chondral injury, leading to premature hip osteoarthrosis in the long run. Usually, symptoms happen more in active people and athletes because of more intense use of the joint. Definitive treatment is always surgery, although medication and physiotherapy along with activity modification may be sufficient in mild cases.
Hip labral tear
Hip labral tear describes a rupture of the labrum, which is the structures the covers and amplifies the acetabulum. It can happen as a consequence of femoroacetabular impingement, trauma, dysplasia, capsular laxity, and degeneration. The main symptom is anterior hip/groin pain, sometimes accompanied with clicking or locking and/or a sensation of instability. If there’s a minor tear, treatment can be conservative, but when this fails or when dealing with major tears surgery may be indicated.
Iliopsoas bursitis (internal snapping hip)
Iliopsoas bursitis is a common cause of groin pain in athletes and may be associated with other related entities, namely iliopsoas tendonitis or impingement and/or snapping hip. The main symptom is hip pain which can be associated with snapping sensation during hip movement. Treatment includes activity modification, medication, physiotherapy focusing on strengthening and stretching not only iliopsoas muscles but all the abdominal and hip region muscles. Occasionally steroid injections may help and ultimately, surgery may be considered.
Legg-Calvé-Perthes disease describes a pathologic situation that happens in children where blood supply to the head of the femur is temporarily interrupted, leading to necrosis of the bone cells and gradually the femoral head starts to collapse. With return of blood supply, bone will suffer a remodeling and grow again, specially in younger children. The main goal of treatment other than addressing symptoms, is trying to help the femoral head grow into a more rounded shape to fit the socket of the hip joint, either with physiotherapy or with surgery.
Osteoarthritis/Osteonecrosis of the hip
Hip osteoarthritis is one of the most common causes of hip pain in the older population. It is a degenerative disease of the hip joint that causes progressive loss of articular cartilage of the femoral head and acetabulum, leading to pain with movement, stiffness, and progressive difficulty in walking. Conservative treatment includes use of medication, physiotherapy, weight loss (if it’s the case), low-impact physical activity, and image-guided injections. In severe cases or when conservative treatment fails, surgery may be indicated.
Transient synovitis of the hip is a common cause of hip pain in children and is characterized by inflammation of the synovium. This is a benign condition, but it is important to distinguish it from a process of septic arthritis. Usually in small children the only symptom is a limp or refusal to bear weight or even just limb protection and disuse. Fever can be present in some cases. Treatment is conservative and involves supportive care, rest and NSAIDs if needed. In a normal situation, symptoms should improve in 24-48 hours.
External snapping hip
External snapping hip is most commonly due to a rub and snap of the iliotibial band moving over the great trochanter. There can be pain associated with the snapping sensation or it can be asymptomatic in which case there is no need to treat. Otherwise, when pain is present, treatment includes stretching the muscles of the thigh, taking oral medication, doing physiotherapy, and receiving a steroid injection if needed. In few cases where conservative treatment is not successful surgery may be considered.
Greater trochanteric pain syndrome
Greater trochanteric pain syndrome is a common cause of pain on the lateral aspect of the hip. It is usually a combination of pathologic conditions such as minimus or medius gluteus tendinopathy and trochanteric bursitis, associated to biomechanical imbalances and weakness of these muscles. Pain is typically most intense at the great trochanter but can radiate upward or downward to the knee. It is aggravated by weightbearing activities and side lying at night. Treatment starts with medication, relative rest, physiotherapy, occasionally an infiltration or shockwave therapy and in recalcitrant cases surgery.
Muscle tear or avulsion
A muscle tear refers to a disruption of fibers within a muscle. This is more frequent to happen during sports practice and may be caused by acute trauma or overuse of a muscle that is usually not well prepared. Symptoms include local pain, which is exacerbated by movements that use that muscle, swelling, decreased strength. Treatment starts with relative rest, icing, medication, and physiotherapy. Sometimes, depending on the severity of the injury surgery may be the treatment of choice.
Sacroiliac joint dysfunction
Sacroiliac joint dysfunction is a disorder presenting with low back and groin pain that can be confused with other causes. Usually, the pain aggravates with position changes such as standing from a seated position or sitting on a hard surface and alleviates with lying down or walking. Treatment includes oral and topical medication, relative rest, physiotherapy, manual manipulation, image-guided injections, nerve ablation or ultimately surgery in case nothing works.
Short-lasting unilateral neuralgiform headache attacks (SUNHA) is characterized by sudden brief attacks of severe unilateral head pain in orbital, periorbital, or temporal regions, accompanied by ipsilateral cranial autonomic symptoms. There are two subtypes: short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA). In SUNCT, the ipsilateral autonomic symptoms must consist of both conjunctival injection and lacrimation.
Corticosteroids medications are used to reduce pain and inflammation and can be taken oral or through an injection.
Peripheric Nerve Block
This minimally invasive procedure, as radiofrequency ablation and cryoablation, should be guided for ultrasound or fluoroscopy.
Cryoablation uses cold temperatures and is a minimally invasive procedure guided for ultrasound or fluoroscopy.
Radiofrequency ablation is a minimally invasive procedure guided for ultrasound or fluoroscopy.
PRP (platelet rich plasma) contains 2-5 times the usual number of platelets and have a regenerative effect on the tissues.
Pharmacological management pain is commonly part of the treatment and a wide range of drugs can be used to manage pain.
”Before I start with my trip through the Pain Center I would like to say thank you to Dr. Costa and his wonderful team. I feel much better than before.Karola KoenigGermany
”After the treatment I am only happy to say how I really feel. With some stretch exercises and physiotherapy, I feel great and get on with my life. Thanking you.Carole LeeThe Netherlands