Table of Contents
A hip joint is a large joint where the leg joins the pelvis. If this joint experiences damage for whatever reason, it may result in the condition termed osteoarthritis. This medical condition is common and is not fully understood by many. In the United States alone, there are an estimated 10 million people who are affected by osteoarthritis. Osteoarthritis is known as the “wear and tear arthritis.” This term is used to describe the deterioration of the cushioning surfaces on the end of bones over time. When these surfaces continue to break down, the bones may rub together during movement causing pain. In the body, the weight-bearing joints are the most commonly affected by osteoarthritis for they have been under more stress throughout the years. This is why the hip is one of the most commonly affected joints with osteoarthritis.
Causes of Front Hip Pain and Herniated Disc Hip Pain
The front of the hip joint is a common place to experience pain. It can be caused by many different conditions and it’s of primary importance to isolate the cause of your symptoms. The most common causes of pain in the front of the hip joint are arthritis, hip impingement, and a labral tear. Pain can also be referred from the lower back, pelvis, or from the sacroiliac joint at the back of the pelvis. Iliopsoas tendinitis is a painful ‘snap’ or ‘pop’ in the groin often experienced by athletes or people who have recently taken up sport/exercise. This is caused by inflammation of the hip flexor tendons as they travel from the pelvis into the femur. The spinal discs are made up of a tough outer layer and a gel inside. The outer layer can tear or split, which allows the gel in the center to bulge out. This is known as a herniated or prolapsed disc. If this occurs in the lumbar spine at L4/L5 or L5/S1, it can cause sciatica, with pain, tingling, numbness, and/or weakness that travels into the leg. If the disc prolapse is large enough, it can pinch the nerve against the bony roof of the spinal canal (the nerve root). This can cause severe leg pain and is known as ‘nerve root compression’.
Importance of Early Treatment
Patients with a herniated disc and hip pain that have received no relief from a course of conservative front hip pain treatment, or those with significant functional impairment (such as weakness or a limp), may be candidates for surgery if the diagnosis has been confirmed. The surgery for treatment of the underlying spine condition can lead to resolution of the pain in the hip. Outcome studies have shown that total hip replacement in patients with arthritis changes in the hip secondary to underlying spine problems has a poorer outcome and higher revision rate compared to those with primary hip arthritis. This is another reason why it is important to differentiate between spine and hip problems in patients with pain referred to the hip.
Early treatment is essential to prevent complications of the hip caused by underlying spine conditions such as a herniated disc. The hip is a weight-bearing joint, and any change in the mechanics of movement of the spine or lower limb can cause increased loading of the hip joint. Pain from the hip joint is often felt in the buttock, groin, and sometimes the front of the thigh. Pain from the low back and spine can also be referred to the hip and cause pain that is felt to be arising from the hip but is not coming from the hip joint itself. This can be very difficult to differentiate, and it is not uncommon for a patient to have both hip and spine problems. Delay in diagnosing and treating the primary cause of hip pain (whether it is from the hip joint itself or from the spine) will often lead to secondary changes in the hip joint due to limping or altered walking patterns, the pain being more difficult to control, and an increased likelihood of the problem becoming chronic and more difficult to treat.
Non-Surgical Treatment Options
Physical Therapy and Rehabilitation
Patients with hip impingement and labral tears often demonstrate weak and underactive muscles, most commonly the hip abductors and external rotators. Studies by Casartelli et al., Barrios, and Crossley have identified a trend of higher levels of pain in the presence of weaker hip abductor muscles in patients with FAI. The association between weak hip abductors and a higher level of symptoms suggests abnormal mechanics caused by muscle weakness may be a contributing factor to pain in symptomatic hips. Randomized control trials by Casartelli and Ito have shown that therapeutic exercise can lead to improvement in pain and increased muscle function for patients with FAI. While the literature suggests the possibility that muscle strength can be improved with exercise, there is a lack of high-quality studies investigating the specific effects of therapeutic exercise in patients with FAI and hip impingement, and in particular, the differences between various surgical and non-surgical groups. Physiotherapists may play a large role in rehabilitation following surgery, and as an adjunct to current non-surgical management, physiotherapists can use their clinical reasoning skills to apply principles of exercise and manual therapy to potentially address functional muscle weaknesses and movement impairments of the hip. This may include activity modification, gait retraining, muscle balance around the hip joint, and the restoration of normal joint mechanics. Step one is to understand the basic principles of the exercises… and this is to know which muscles are affected and to apply/load the muscles in a way that is specific to improving function. The physiotherapists can then progress these exercises into more functionally based activities and aim to ultimately address the underlying functional limitations with hopes of improving the long-term outcomes for these patients.
Medication and Pain Management
Medication is almost always a part of a herniated disc hip pain treatment without surgery. The type of medication varies according to the individual’s needs and medical history. And while some medications are viewed as relatively benign, all medication has potential side effects, some quite serious. The purpose of taking medication is to reduce pain and inflammation. Patient response to medication varies so the effectiveness and the side effects of the medication are closely monitored by the physician. If a patient has a relatively mild episode of hip pain, he or she will usually start with over-the-counter medications such as acetaminophen or an anti-inflammatory drug – ibuprofen. If after 4-6 weeks there is no improvement, the doctor may switch the patient to stronger anti-inflammatory medications or a muscle relaxant. It is at this point that the patient’s liver, kidney, stomach, and heart functions are taken into consideration, as the use of Non-Steroidal Anti-Inflammatory Drugs can affect these organs. People with a history of peptic ulcer disease or gastrointestinal bleeding are not candidates for this type of medication. In fact, age is a very important factor in considering the use of NSAIDs. A recent study has confirmed excess mortality related to NSAID use in people over age 60. Because of potential side effects, corticosteroids are used to treat acute and severe episodes of hip pain while hoping to avoid surgical intervention is also carefully considered. An anabolic steroid is sometimes also recommended. Unfortunately, many patients requiring treatment for a herniated disc may have to discontinue using medications due to side effects. Finally, narcotics are considered for those with severe disabling hip or leg pain which does not respond to other medication. A steroid or long-acting anesthetic is injected into the joint under x-ray guidance to find out if the hip joint is the cause of the pain. If the medication works well, and it should since the needle position is confirmed, a hip joint injection may be recommended. The effects of this can last for several months.
Alternative Therapies
Alternative therapies include a vast array of treatments, some more successful than others with a limited evidence base. In general, most of Dr. G’s patients find the alternative therapy that works best for them through trial and error. More often than not, this can involve finding something that aggravates the pain and then avoiding it. However, this should not be the primary goal of using alternative therapy. Injections are also an alternative therapy, covered on a different page. One of the most successful therapies for many orthopaedic conditions, including hip pain, is weight loss. This is likely to be most effective for pain coming from arthritis in the hip. It is well known that the body’s joints have a finite lifespan and this can be drastically reduced with weight on the joint. Weight loss can be a difficult and frustrating issue for many patients, and Dr. G will endeavor to support his patients through this and any of the other treatments regarding weight loss with evidence of the effect on their hip pain.
Surgical Treatment Options
Joint osteoarthritis is the most common cause of a hip replacement in the elderly. Arthroscopy and joint preservation provide a way to treat mechanical hip problems and degenerative conditions not only in young adults but also those in their 40s and 50s so as to maintain good quality of life and function in the long term.
Arthroscopy of the hip may also prevent or delay the onset of osteoarthritis and the need for a hip replacement later in life. Osteoarthritis is a wear and tear/degenerative joint condition. Any loss of articular cartilage is irreparable as this tissue has no blood supply and cannot form new cells. Therefore, the ability to perform joint-preserving procedures such as repair of labral tears, removal of loose bodies, and correction of bony impingement with arthroscopy is vital in order to avoid the early onset of osteoarthritis.
The hip is a deep-seated ball and socket joint with the femoral head forming the ball and the acetabulum forming the socket. Because of this, arthroscopy of the hip requires a very specialized technique and is a relatively new procedure. It has recently shown great advancement and become more effective. At present, the best results are obtained in the treatment of early arthritis, impingement, cartilage damage, and labral tears in the young adult. 90% of mechanical hip symptoms in this group can be resolved through arthroscopy.
Arthroscopy and Hip Joint Preservation Surgery Arthroscopy is a minimally invasive surgical procedure that is used to see, diagnose and treat problems inside a joint. The word arthroscopy comes from two Greek words, “arthro” (joint) and “skopein” (to look). The advantage of arthroscopy over traditional open surgery is that the joint does not have to be opened up fully. Arthroscopy uses much smaller incisions and can be faster and less traumatic for the patient.
When non-surgical treatment such as medication and physical therapy does not work, surgical treatment options would then need to be considered. There are three surgical treatment options for hip pain and herniated discs. Each has differing indications and methods, and it is important to discuss with your doctor to determine which is most appropriate.
Arthroscopy and Hip Joint Preservation Surgery
Arthroscopy or keyhole surgery is a procedure where a small camera is inserted inside the hip joint. The images captured by the camera are then projected onto a TV screen, and this allows the surgeon to look inside the hip joint without making a large incision. With these magnified images, the surgeon is able to use small instruments to carry out the surgery through 1-3 small incisions. Arthroscopy of the hip is a technically demanding procedure and it requires an experienced surgeon to carry this out. Indications for hip arthroscopy vary, and it can be both diagnostic and therapeutic. Hip arthroscopy is commonly used to treat Femoroacetabular impingement (FAI) and labral tears. In the hands of an experienced hip arthroscopy surgeon, these conditions can be effectively treated, thus preventing progression to hip osteoarthritis. Other conditions which can be treated effectively with arthroscopy include Synovitis, loose bodies, and certain types of hip joint infection. Overall, hip arthroscopy is a relatively low-risk procedure which is effective for certain hip conditions. However, it is important to note that the results of arthroscopy are very much operator dependent. A good outcome from arthroscopy is very much reliant on an accurate diagnosis and the correct identification of the primary pathology. In addition to this, the surgeon must have the necessary experience to treat the diagnosed condition. For more complex conditions, it may be necessary to refer to a more experienced hip arthroscopy surgeon straight away.
Hip Replacement Surgery
Hip replacement surgery is considered when arthritis has destroyed the hip joint and the pain and functional limitation it causes is no longer satisfactorily controlled by anti-inflammatory medications or walking supports. It is a surgical procedure in which the damaged joint is removed and replaced with an artificial joint. People who benefit from hip replacement surgery usually have: – Hip pain that limits everyday activities such as walking or bending. – Hip pain that continues despite the use of anti-inflammatory medications. – Stiffness in a hip that limits the ability to move or lift the leg. – Pain that limits the ability to walk more than a few blocks without severe pain. – Failure to substantially improve with other treatments such as anti-inflammatory medications, glucosamine, physical therapy, or exercise. Candidates for hip replacement surgery should meet with a surgeon to determine the best approach for the surgery. It’s best to be in the best possible health before undergoing the procedure to obtain the best outcomes. During the surgery, the damaged bone and cartilage are removed from the hip joint and replaced with artificial parts. After the surgery, there are a few different ways to fix a damaged hip, and different materials of the artificial joint. Consulting with the surgeon is the best way to make an informed decision on what is best for the patient.
Minimally Invasive Spine Surgery for Herniated Discs
There are a number of minimally invasive procedures to achieve a discectomy for disc herniation. A microdiscectomy is performed through a small incision and the use of an operating microscope. This allows the surgeon to make a smaller hole and retract less muscle to remove the disc. An endoscopic discectomy uses a small video camera and a tiny incision to direct the surgery inside the disc. This is performed under magnified view allowing clear visualization for the removal of disc fragments. Both procedures have shown to be equally effective compared to standard open discectomy. The aim of these procedures is to relieve leg pain and allow the body to heal a disc herniation by itself. Although in some severe cases where there is a significant collapse of disc space and loss of disc height, a fusion procedure may be necessary to stabilize the disc segment. However, there has been continuous debate over the use of minimally invasive techniques for fusion surgery.
Minimally invasive spine surgery has become a favorable treatment option for disc herniation. It is also called “keyhole” surgery. The advantages of such an approach are reducing the injury at the operation site, less tissue damage and muscle interruption, and quicker recovery. In treating a lumbar herniated disc, a discectomy is the most common surgical procedure. It involves removing the herniated piece of the disc which is pressing on the nerve. In the past, this could only be achieved by a wide opening through an incision in the back with some retraction of the back muscles from the spine. This approach could increase postoperative pain and is associated with a longer recovery time.
Specialized Hip Pain Treatment Centers in Singapore
Top Hospitals and Clinics Patients with acute and severe hip pain can seek consult at the Emergency Department at the Singapore General Hospital or the A&E at Tan Tock Seng Hospital. Both are large public hospitals with good orthopaedic departments. For less urgent cases there are outpatient consultations at the various polyclinics and orthopaedic specialist outpatient clinics. Nothing but the best will do for some patients. There are now many private medical institutions in Singapore that cater to the needs of the wealthier class who may prefer private healthcare or who have insurance coverage that allows them to bypass the public hospitals. Private medical care is more costly but there is usually minimal waiting time for consultations and procedures. A few of the top private hospitals in Singapore with good orthopaedic departments would include Gleneagles, Mount Elizabeth and Novena. They have a few of the best orthopaedic surgeons practicing there and offer a comprehensive range of services including specialist clinics, physiotherapy and occupational therapy services, and facilities for hip surgery ranging from arthroscopic to total hip replacement. These facilities are more than adequate for managing all types of hip pain.
Singapore is renowned for its high quality healthcare facilities and up-to-date medical technology. This is also reflected in the specific healthcare services provided for patients with hip pain and herniated disc in the hip. Apart from the generally good facilities in our public hospitals, there are also private medical institutions that offer comprehensive and specialized services for hip pain.
Top Hospitals and Clinics
Patients with hip pain and/or injury from a herniated disc can access specialists and surgeons at specific hospitals and clinics in Singapore. The Singapore General Hospital offers the Singapore Musculoskeletal Clinic with visits to orthopaedic surgeons who have experience with patients suffering from herniated discs which cause back, leg, and even neck pain. Mount Elizabeth Hospital provides a Back and Neck Centre which is equipped with various healthcare professionals experienced in treating patients with musculoskeletal conditions. Patients can even request for a specific doctor to be assigned to them. The Changi Sports Medicine Centre, which is located in the Changi General Hospital, offers a one-stop centre for athletes and active individuals with musculoskeletal injuries. The centre also offers rehabilitation facilities to aid patients’ return to their sporting activities and active lifestyle. With dedicated care to patients with musculoskeletal injuries, these specialised centres provide a comprehensive approach to treating patients with hip pain and/or injury from a herniated disc. This resource has a list of many healthcare professionals and the specific clinics that they practise at which are located in different hospitals around Singapore. Patients can easily find a healthcare professional located near them. Whether it is a neurosurgeon for a severe herniated disc injury, an orthopaedic surgeon for the treatment of hip pain, or a physiotherapist for the rehabilitation of a hip injury, there are many experienced professionals available to suit the needs of different patients.
State-of-the-Art Facilities and Technologies
Hip pain sufferers in Singapore are fortunate with a number of specialized non-surgical and surgical treatment options. Sufferers of hip pain secondary to a variety of conditions will often seek treatment with a Rheumatologist, who specializes in medical management of musculoskeletal conditions. Rheumatologists are relatively few and far between in Singapore and often extremely busy and hard to get an appointment with. This is because there is a vast array of musculoskeletal and systemic conditions, which may cause hip pain and for many of these conditions, the non-operative management is the optimal one. A common example is a young individual with hip pain from an inflammatory condition. High dose anti-inflammatory medication or in some cases disease modifying medication is the best option and an experienced Rheumatologist can guide the patient on this. Physical and Occupational medicine specialists can at times offer similar non-operative treatment methods to Rheumatologists, but less frequently and with less specific expertise on the medical management of musculoskeletal conditions.
Treatment centers where hip pain is the primary focus are relatively rare, but they tend to attract those who wish to avoid an often-default recommendation for chronic hip pain, that is a total hip replacement. When the chronic pain sufferers seek alternative treatments to a hip replacement, they are reluctant to consult surgeons who have a bias towards operating. Instead, the chronic pain sufferer will seek assessment and care in a setting where the specialists are skilled and experienced in hip replacements, but are also very familiar with non-surgical treatments and the natural history of the condition. Physiotherapists often have close links with such surgeons and will seek their advice on the best ways to manage and rehabilitate a patient with a specific hip condition.
