Non-Surgical Hip Treatments

Injuries to the hip can be caused by degenerative disease such as arthritis, traumatic injuries and sports injuries. These conditions may affect the bones & joints and impair the mobility as well as the quality of life of the patients. All these conditions require appropriate treatment, may be surgical or non-surgical to restore to normal activities. The non-operative orthopedic treatment options include nonpharmacological and pharmacological interventions. They are aimed at providing symptomatic relief and improving the quality of life of the patients. They can be used as a treatment option to treat certain conditions or to decrease pain as well as promoting functioning and quality of life after the surgical treatment.

Non- pharmacological Intervention

Non-pharmacological interventions may range from simple lifestyle modification or the physical exercises and rehabilitation programs. Some of the non-pharmacological interventions include:

• Weight reduction and physical exercise - The lifestyle changes resulting in weight loss in obese individuals and doing appropriate physical exercises plays an important role in prevention and management of the hip and knee conditions.
  
  The optimal weight (BMI) should be 18.5 to 25. BMI of 25-29 is considered over weight and BMI over 30 is considered as obese.
  
  Exercises are contraindicated in individuals suffering from cardiovascular diseases. Therefore rigorous exercises is not ideal for all patients and must be individualized for every patient and done under the supervision of a trained professional.
  
• Transcutaneous electrical nerve stimulation – The transcutaneous electrical nerve stimulation (TENS) method involves the use of low-voltage electric impulses to relieve the pain. It is believed to provide pain relief by inhibiting the conduction of pain impulses to reach the receptors in the brain and spinal cord. Patient is made to worn a device and this device generates the impulses that offer pain relief to the patients. Frequency of the impulses, duration of treatment and location of the electrical electrodes on the body are decided by your physician based on the severity of condition as well the response of the patient. Use for at least 4 weeks may provide better pain relief.
  It should not be used by patients having pacemaker or cochlear implants, or those suffering from epileptic conditions. It should also not be used during pregnancy.
  
• Thermotherapy – Thermotherapy involves application of hot or cold packs at the affected area. There is some evidence to support the use of cold therapy in providing symptomatic relief. It is contraindicated in individuals with thermoregulatory impairments. Individuals having peripheral vascular disease, diabetes, cardiovascular disease and hypertension, or who are pregnant should use it with caution.
  
• Acupuncture – This method involves insertion of sterile needles into specific acupuncture points or pressure points. It is believed that insertion of needles at specific points restore the flow of "qi", a form of energy and thereby relieves the pain. A modification in acupuncture is electro-acupuncture where the needles are stimulated by and electro-stimulator. Acupuncture performed by trained professionals is considered to be safe and offers pain relief however may have certain risks if treated by untrained professionals.
  
• Patellar tapping – Patellar tapping is used as a short term treatment particularly when performing normal activities deteriorates the knee condition. The principle behind the treatment is stabilization of knee joint by altering the distribution of stress and joint pressure. The response depends on the strapping technique used and the time for which it is strapped.
  
• Massage therapy – It is one of the oldest methods of treatment and reduces pain by increasing the circulation of blood and lymph as well by reduction of muscle tension or because of the therapeutic effect of the touch.

Pharmacological Interventions

Pharmacological interventions include management of pain using medicinal preparations such as pain relieving capsules or injections.

• Non-steroidal anti-inflammatory drugs – These are known as NSAIDs and are found to be effective in reducing pain and inflammation of the hip and the knee. Caution must be taken while using NSAIDs for overdosing as they are known to cause hepatotoxicity. Patients with liver diseases must have extreme care while using them. They cause a range of side effects, chances of which increase with the concomitant use of diuretics, angiotensin converting enzyme inhibitors, angiotensin 2 receptor blockers, anticoagulants or oral corticosteroids.
  
• Weak and strong opiods – Opioids are prescribed when use of analgesic medications or NSAIDs does not offer symptomatic pain relief, if other treatments have intolerable side effects or in whom the surgery is delayed or contraindicated. Though they offer better pain relief they are known to cause side effects such as dry mouth, nausea, vomiting, dizziness and constipation. Overdose may lead to respiratory depression.The dose is reduced slowly otherwise cause withdrawal effects. They are also known for addiction.
  
• Disease modifying anti-rheumatic drugs and biological agents – Disease modifying anti-rheumatic drugs (DMARDs) aim at halting the progression of disease and offer symptomatic relief. Biological agents are the antibodies against the disease causing agents manufactured using genetic engineering technology. These agents are recommended in individuals with severe disease condition.
  
• Other treatments – Your physician may recommend the use of braces and orthoses, prescribe chondroitin sulphate, electromagnetic therapy, vitamin supplements, herbal and other dietary therapies. Therapeutic ultrasound has very less scientific proof of being effective.

Though there is little scientific evidence for various non-surgical techniques, in offering symptomatic pain relief ,they were found to be effective in certain cases and are considered to possess minimal side effects. Discuss with your physician about these therapeutic options before initiating the treatment.

Injection Therapy

Intra-articular injections are recommended in treating various orthopaedic conditions including sports injuries and degenerative disease, arthritis. Steroid preparations are often used for intra-articular injections and they possess anti-inflammatory activity. Corticosteroid intra-articular injections are useful in treating knee arthritis associated with synovitis and effusion.

In intra-articular therapy the steroid is given directly into the affected joint. Thus it gives an opportunity to physicians give higher doses as required, localize the effect and also minimize the adverse effects on other organs. Sometimes infection at the injected site may occur. Thus extreme precautions are taken to maintain sterile procedures while giving the injection. Repeated intra-articular injection in a joint leads to cartilage damage. So injection in a particular joint are repeated only after few months of gap. Sometimes local anesthetics are also given with corticosteroids to improve pain management with a low dose of corticosteroid.

Image guidance tools such as ultrasound, fluoroscopy and radiopaque tracer are now being increasingly used to facilitate intra-articular injection in difficult to reach joints such as hip and shoulder joints. After intra-articular injection you should give rest to the joint for few days as reduced activity delays the absorption of the steroid from the joint and prevents its systemic effect.

Apart from cortisone injections the other non-traditional agents used for injection therapy include viscosupplements (joint lubricants) and orthobiologic injections (PRP and stem cells).

Viscosupplementation

Viscosupplementation refers to the injection of a hyaluronan preparation into the joint. Hyaluronan is a natural substance present in the joint fluid that assists in lubrication. It allows smooth movement of the cartilage covered articulating surfaces of the joint.

Synvisc is one of the most commonly used hyaluronan preparations. It is indicated in the management of shoulder, knee, hip or ankle osteoarthritis that has not responded to non-surgical treatment options such as pain medications, physical therapy and corticosteroid injections.

Synvisc provides symptomatic relief and delays the need for surgery. It is injected directly into the joint to replenish the diminished synovial fluid, thereby enhancing its lubricating properties. A single dose or a total of three separate doses of Synvisc, over several weeks, may be required for optimum benefit.

Some patients may experience mild pain, swelling, warmth and redness at the injection site for up to 48 hours following a Synvisc injection. Headache and joint stiffness may also occur in some cases. Ice packs and an analgesic may be used, if required, to ease the discomfort. Any strenuous activity such as jogging or tennis should be completely avoided for 48 hours to a week after the injection and should be resumed only after consultation with your doctor.

Synvisc injection not only supplements the hyaluronan in the joint but also stimulates the production of hyaluronan in the treated knee. This provides gradual symptomatic relief over the course of the injections. This effect may last for several months.

Platelet rich plasma (PRP) Therapy

Platelet rich plasma (PRP) is concentrated portion of blood plasma enriched with platelets or containing more amounts of platelets. Blood plasma contains vital growth factors that help in repairing the injured tissue and platelets contain Vitamin K that plays a major role in formation of blood clot. This therapy is used to treat foot and ankle pain, tendon injuries, sports injuries, and others form of injury.

The tendons and ligaments have very poor blood supply and will delay the time of healing. Injection of PRP results in accumulation of excessive amounts of platelets at injured site. Platelets degranulate releasing several growth factors and cytokines which stimulate one or more phases of tissue regeneration.

In this procedure the blood is drawn from your body and centrifuged to separate blood plasma (liquid separated on top) and blood products (settled at the bottom). The plasma is taken and kept aside in a sterile injection. This is later injected in a sterile environment into the site of injury to reduce pain. An ultrasound is done by the physician to find out the actual place of injury. This will form blood clot and help in degranulation of platelets which releases the growth factors to the site of injury. These growth factors associate with other blood cells (monocytes, neutrophils, fibroblasts) which help in the healing the injury.

PRP therapy uses our own blood. Hence the treatment is associated with minimal or no risk factors, or contraindications. However, it is also used in the formation of bone in cases of fractures which helps in the formation of new bone tissue. It helps in patients being active however is limited to activities like swimming and biking.