Our previous blog (click HERE) explained some of the background around the use of cartilage and bone marrow cells and the current evidence. We felt it would be useful to provide an update on our experience. The Manchester Hip Clinic is a national centre for hip arthroscopy and we have carried out nearly 1400 in total. Of these, we have carried out over 110 complex surgeries using cartilage and bone marrow cells since we started in 2017.
The aim of the primative cells (which we harvest from the patients’ thigh bone and centrifuge to form Bone Marrow Aspirate Concentrate (BMAC)) is to regenerate damaged joint surface cartilage. When we first started, we simply combined it with Tisseal (a biological glue) and dripped it onto the damaged area (see previous blog). However, that does not give it structural stability, our technique then progressed so that we either combined it with a biological scaffold (Hyalofast) or used the patients own cartilage. While it is a more challenging procedure to do, recent research has suggested that the use of these scaffolds leads to improved and longer lasting patient benefit.
Preparing the graft site
The ideal candidate seems to be someone with localised areas of damage and with good quality surrounding joint surface (see image). If the damage is too extensive, then the graft is not supported and is more likely to fail. Older patients (>55) and those with damage on the ball of the hip seem to do badly so we tend to recommend robotic assisted hip replacements (click HERE) to them.
The recovery period after a “normal” hip arthroscopy is usually up to six months. For patients who have cartilage treatment, that recovery can take up to 12 months with more extensive physiotherapy needed. This increased recovery period is probably due to the level of damage present and the muscle wasting/inflammation that patients develop before surgery. A useful way to think about it is that the surgery is to correct the damage, the physiotherapy is to strengthen the muscles afterwards and then we often recommend Pilates/Yoga to maintain that improved core/hip girdle strength and flexibility. The surgery/stem cell treatments seem to improve patients by 85-90% on average so it is more about improving a damaged hip rather than an absolute cure. After recovery, we normally recommend patients switch to non-impact cardio-vascular exercise afterwards such as cycling, swimming, cross-training or spin. The small number of patients that have remained symptomatic after treatment, tend to carry out impact exercise such as road running, squash, impact gym work etc. If we see these patients and they really wish to continue these activities, we often recommend Mako robotic hip replacement (click HERE) rather than hip preserving surgery.
What are bone marrow cells? Primative bone marrow cells are perhaps Nature’s best-kept secret. These cells, which are found in multicellular organisms, such as humans, not only have the ability to divide (mitosis) but also to form various structures such as cartilage, bone and many more. The process is called ‘differentiation’.
What types of bone marrow cells are there? There are two basic forms of primitive cell – the embryonic cell and adult cell. Adult cells, which are also known as mesenchymal stem cells or MSCs are of great interest to researchers, scientists and surgeons alike. MSCs are free of the controversy that surrounds the embryonic cells and yet have the potential to form new tissues. At The Manchester Hip Clinic we use the MSCs. This gives us the ability to repair and regenerate tissues such as cartilage and bone more effectively.
MSCs can be found at various locations in the body, including bone marrow, adipose tissue (fat) and peripheral blood. We favour the use of marrow-based or peripheral blood stem cells.
Where do the cells come from that are used in stem cell therapy? At The Manchester Hip Clinic, the cells are harvested autologously – directly from the patients. Consequently, there is no risk of disease transmission, rejection or ethical controversy that can exist using cells from an unrelated donor. All of us have a supply of MSCs in various tissues and these can be harvested using specialised techniques.
Where can bone marrow cells be used? By their very nature, these cells can be used in a variety of different situations to help in the repair and regeneration of damaged tissues and structures. In joint preservation, one role of these primitive cells is in the possible treatment of arthritis of the hip and knee joints. This can potentially be accomplished by regeneration of cartilage (gristle). In simple terms, the gristle on the joint surface is the barrier to arthritis. Once this layer is damaged, the joint is likely to progress to frank arthritis, which presents as pain, stiffness and loss of function. Primitive cell therapy or minced cartilage may be used in an attempt to encourage regeneration of this gristle layer. The procedure is designed to help preserve the natural hip and knee joints and perhaps to delay or prevent the need for more major operations such as replacement of the hip or knee joint.
Another area of particular interest for cell therapy in the hip and knee is to help with the regeneration of dead bone. In a condition called avascular necrosis, or AVN, there is death of a segment of the bone near the joint. This can sometimes progress onwards to become severe arthritis. Early reports of the use of stem cells to regenerate bone in AVN are encouraging.
There are many other reasons why primitive cells might be used. These techniques may be relevant to different patients and are employed as required.
What does the procedure involve? The procedure is in the form of arthroscopy (keyhole surgery) of the hip. Patients often ask whether cell therapy involves surgery on two separate occasions. For the techniques that we use, only a single operation is normally required. Most hip arthroscopy patients will have one night’s stay in hospital. Once the patient is under anaesthestic, a sample of their blood and/or marrow is taken with a special needle. In order to harvest the primitive cells, the aspirate is then processed in the operating theatre, while the patient is still asleep,. At the same time the keyhole operation (arthroscopy) is commenced to access the hip. The surgeon uses specialist arthroscopy techniques to prepare the tissue bed so that it is ready to receive the cells. The harvested cells, alongside a suitable scaffold, are then injected through the same keyholes that are routinely used for the arthroscopy. If the patient still has some usable cartilage left, this damaged cartilage can also be harvested, minced and then re-implanted with the prepared bone marrow cells direct to the damaged area.
What are the side effects? Any surgical intervention carries a degree of risk however the surgical procedures used for stem cell therapy are the same as those for routine hip arthroscopy operations. There is a theoretical risk of infection, but this is low and surgery is in any event covered by antibiotic treatment. As for the primitive cells, these are derived from the patient’s own blood or marrow, so there is no risk of rejection or disease transmission.
What is the evidence for stem cell therapy? Cartilage cell therapy is a relatively new procedure. However, it has created so much interest worldwide that extensive research has been taking place in this field. Animal and human studies have been published that have suggested a safe and favourable response to stem cell therapy in hips, knees and even ankles. Our practice routinely collects data on all patients who undergo surgical treatment under our care; assessment questionnaires are periodically sent to those who have undergone surgery. This is an invaluable source of information that helps us to inform our patients, publish in the literature, and to train others who are interested in the techniques we undertake.
As we move beyond the Third Corona-virus Omnicron peak, it is time for a coronavirus update. With the help of Spire Manchester, we have now begun treating patients once more. We are very conscious that while all the focus has been on treating the virus, a lot of people with significant joint problems have been struggling with significant pain and reduced mobility.
We continue to carry out face-to-face appointments for some patients but will always continue to use virtual technology (Zoom, Microsoft Teams, FaceTime and WhatsApp video) for patient convenience and to reduce unnecessary hospital visits. We have been operating continuously since July 2020 but we will not be able to get through as many operations per day as before due to the safety precautions needed. We have cleared our backlog of patients who were cancelled by the lockdown, as well as new patients that we have listed since. However, we will still be able to carry out between 6-8 robotic replacements or hip scopes per week, so we will manage to get through everyone before too long. We will be giving patients more information about the pros and cons of surgery in the presence of Coronavirus, as well as the precautions they need to take beforehand (Covid testing 48-72 hours before surgery) and what the hospitals will be doing to minimise their risks (testing staff regularly, separating surgery patients from other patients, minimising visitors etc).
The emergence of Coronavirus has led to additional risks that must be considered. At this stage, quality published research is rare but there is the possibility that there may be an increased risk in operating on patients who are asymptomatic carriers of Covid 19. This risk is greater in patients over 70 who have other medical conditions such as diabetes, obesity, cardio-vascular disease and BAME ethnicity and this may make them more likely of developing complications requiring ICU and leading to death after surgery. There are a number of precautions that we are taking to reduce that risk such as pre-surgery isolation in rare cases, Covid testing and using spinal anaesthetic rather than general. Further information will be provided by the hospital and is regularly being updated by both Public Health England and the British Orthopaedic Association. While there will always be risks involved in surgery, it is important to balance that against the risks of not operating.
Needless to say, we are really happy to get back to what we do best and will never complain about being too busy again!!!
Total hip replacement is one of the most successful operations that you can have. A successful one can literally be transformational. It can take a patient who is living with constant pain, dependent on strong pain killers, with very limited mobility and overnight, cure their pain and allow them to lead a fulfilling life. Because of the National Joint Registry, here in the UK, we can track patients after their surgery and see how long the implants last. We know that on average, if you have a well-designed implant (such as an Exeter), over 96% will still be in place and functioning well at 14 years. It is reasonable to predict that those implants will last 20 to 30 years. However, we know that if the components are not put in correctly or if the leg length or soft-tissue balance is not right, it can have a significant impact on the complication rate or how well the implant functions. This has led to the development of robotic hips.
Mako robot
Recently, some work has been done on what people are doing with their hip replacements after surgery. One paper published in 2019 showed that while all their patients returned to activity, there was a general move from high to low impact exercise. Another showed that after 10 years, 89% remained active but again there was a significant decrease in high impact sport. What is not clear is was that because patients were told to reduce their activity by their doctor/surgeon or was it because they themselves did not want to wear the new joint out? Perhaps by improving the accuracy of surgery and the muscle balance, we can have the confidence to enable people to maintain their desired level of activity?
The market leader by far in robotic assisted hip surgery is Stryker and the MAKO robot. They have well in excess of 500 machines around the world and over 40 in the UK. At the Manchester Hip Clinic and Spire Manchester, we started doing MAKO procedures in 2018 and are now the highest volume centre in the UK. Essentially, what MAKO does, is use CT scans to accurately map the shape of the patients own hip so that the new artificial one mirrors it exactly and then the robotic element ensures that the surgeon puts it in perfectly. Recent publications have shown that when using this technology, there is increased accuracy, improved patient function and quicker recovery.
Mako surgical planning
The use of MAKO has transformed how we do hip replacements. We see a lot of younger patients who have abnormally shaped hips that would previously have been very challenging to replace. With MAKO, we now have the confidence to know that we are choosing the correct implant and putting it in in the best possible position. That confidence allows us to encourage patients to return to sport and a range of different activities. If I was having a hip or knee replacement, I would definitely have it done using MAKO!
Clinical Pilates is a Physiotherapy led functional and dynamic exercise programme focused on retraining normal patterns of movement from a central stable core. This rehabilitation method is particularly effective in correcting the biomechanical imbalances around the hip, lumbar spine and pelvis through exercises that isolate the proximal hip and core muscles. Strengthening these deep stability muscles can help to correct muscle imbalance and improve hip joint function. It is widely popular all around the world, and you can Click here to find out about other clinics, but with a quick Google search, you will be able to find one close to you.
Pilates is different to other physiotherapy rehabilitation exercises because it concentrates specifically on “centering” which refers to activating the deep abdominal muscles, back muscles and pelvic floor in unison, while keeping the lower back in a neutral spine position. This restores the natural curves of the spine and improves body awareness by training the centre to remain active throughout the duration of the Pilates movements. If travelling to Manchester is awkward, why not visit CK Physio – London instead!
The Clinical Pilates concept of strength training is that there are different components which make up a functional core:-
Centering activates the supportive core. The controlled movements activate the strength core and the movements incorporate actions of the extremities which facilitates an effective method of core strengthening.
Alongside functional core strengthening, Pilates exercises also follow the APPI (Australian Physiotherapy & Pilates Institute) principles which include:-
Concentration
Breathing
Centering
Control
Precision
Flowing movement
Integrated movement patterns
Routine
These are all aspects which make Clinical Pilates a valuable method of strengthening.
Why Clinical Pilates for hip rehabilitation?
Every exercise in the Clinical Pilates repertoire has a particular movement focus. For example, some exercises focus on controlled strength, rotary stability, abdominal strengthening, gluteal strengthening or limb dissociation. These concentrated movements are the foundation of early stage rehabilitation from hip injury or surgery, allowing Physiotherapists to prescribe patient-centred, individualised Pilates exercises. Those who have suffered from a hip injury from a fall in Texas may find the services of a hip injury lawyer San Antonio useful in helping with a personal injury case.
Basic level Clinical Pilates exercises are often included in a thorough Physiotherapy assessment. These movements allow Physiotherapists to identify biomechanical imbalances and movement dysfunction. This facilitates the prescription of specific exercises to correct movement dysfunction and reduce hip symptoms to aid recovery.
Clinical Pilates can also help to prevent hip injury. . .
Commonly Clinical Pilates is used as a rehabilitation method in Physiotherapy for hip pain, hip dysfunction or following hip surgery. However, it is also a popular and effective method of injury prevention or prehabilitation.
Regular participation in classes will maintain and continually improve strength around the proximal hip and core muscles. This means the development of muscle imbalance, movement dysfunction or overloading leading to hip pain are less likely.
This is particularly relevant for the sporting or athletic population. A recent research study proved that a 6 week course of Clinical Pilates classes can improve functional movement and reduce the risk of injury in recreational runners (Laws et al, 2017).
Additional benefits of Clinical Pilates
Alongside improvements in core stability, flexibility and strength, Clinical Pilates has other health benefits including stress management, breathing control and relaxation. These exercises can be performed in 1:1 sessions or small group classes led by an experienced and fully qualified Physiotherapist to aid recovery from hip surgery or injury.
Who does this affect? Hip impingement is a relatively common condition in which there is a structural abnormality in either the femoral head (ball of the hip) or the pelvic cup. Normally, as the hip bends up, the bony cup and flexible cartilaginous rim (Labrum) sit into the concave femoral neck.
However, some patients have either a bump on their femoral head (cam impingement) or an over-hanging cup (pincer impingement) and this causes damage to the labrum and eventually the joint surface.
Symptoms Patients with hip impingement present with deep seated groin pain, usually worse on bending and may be present on both sides. There may be an associated deep click, which can be either due to a torn rim cartilage, or more commonly, an inflamed tendon running over the front of the hip (Psoas Tendon). If the condition has been present for some time, there may also be inflammation of the tissues surrounding the hip such as the outer hip (trochanteric bursitis), the groin muscles (adductor tendonitis) or inflammation of tendons in front of the hip (sartorius tendonitis). Eventually, as the damage continues, the patient may begin to develop more arthritic symptoms such as a dull ache in the groin and increasing stiffness. Hip-related pain is not always felt directly over the groin, it may also be felt on the outer aspect of the thigh, the buttock or traveling down the leg. Occasionally, the pain you do feel in the hip may actually be the result a problem in your back, a hernia or other diagnoses.
Causes Hip impingement is caused by bony abnormalities on the acetabular or pelvic rim, the femoral head (ball of the hip) or a combination of the two. Using a combination of plain x-rays and CT scans with 3-D reconstructions, it is possible to very accurately identify where the abnormality is and what needs to be removed at the time of surgery. The routine use of 3D CT has made a real difference to the success of the surgery and the eventual outcome for the patient.
Pure CAM deformity In a CAM deformity, there is an abnormal bump at the junction between the head/ball of the femur and the neck. This is evident on the image above. This area can be accessed from within the joint and shaving carried out using a small burr until the appropriate shape has been created.
Pure PINCER deformity In a PINCER deformity, there is an overhanging cup. This can be seen on both the plain x-rays and the CT reconstructions. Depending on the severity, the bony rim can be trimmed back leaving the soft cartilaginous rim in place (peri-labral rim recession), if it is a mild deformity or in more severe cases, by removing it, shaving back the bony rim and then reattaching the labrum using special bony anchors.
Mixed CAM/PINCER deformity In the majority of patients, there is a combination of CAM and PINCER impingement. In these cases both sides may need to be addressed if the patient is to get the best result. This can often be achieved by doing a peri-labral rim recession and a femoral head reshaping, thereby leaving the labrum in place and allowing for early mobilisation.
Investigations All patients undergo specialized x-rays of the hip as well as more complex scans such as CT and Magnetic Resonance Arthrography (MRA). These scans are used to confirm the soft-tissue damage and to accurately map out the bony deformity. This is very important when planning the surgery.
Non-surgical Treatment Professor Fehily has designed a specialized hip rehabilitation program. This was done in conjunction with his specialist hip physiotherapists. This was initially developed for patients following key-hole hip surgery but it is now being used for general hip rehabilitation. Other therapies such as painkillers, anti-inflammatory drugs, for example, liquid thc, as a more natural approach, and modification of activity can also be tried.
Surgical Treatment If the hip impingement is due to an underlying bony abnormality and physiotherapy has not cured the pain then surgery is recommended. The aim is to correct the bony deformity before there is irreversible joint damage. This is usually done by hip arthroscopy (keyhole surgery) where the deformity is shaved back via 2 or 3 small incisions. Occasionally some patients with pincer impingement do not simply have an overhanging front rim, instead, the entire cup is rotated backward (acetabular retroversion). If this is the case, then a simple rim trimming will not solve the problem and by decreasing the amount of head coverage, may actually speed up the onset of arthritis. These cases may need more significant pelvic surgery to alter the position of the cup (peri-acetabular osteotomy).
Hip arthroscopy is highly specialised and technically difficult surgery but can achieve excellent results if carried out correctly and on the right patient. Based on Professor Fehilys’ own experience and that of the wider orthopaedic community, certain patients do not do well from hip arthroscopy e.g. patients with significant hip arthritis, patients with severe childhood hip disease (hip dysplasia) or patients with inflammatory hip disease (e.g. rheumatoid arthritis). Occasionally, the bony deformity may be so large that an adequate bony reshaping is not possible using key-hole surgical techniques. In those cases the operation is done using an open technique. In some cases, the damage caused to the joint by the impingement may be so severe that the only reliable option is a joint replacement. However, if at all possible, we will try to preserve the joint using a combination of techniques such as micro-fracture and stem cell treatment (see Stem Cell Therapy). All patients are different and the advantages and disadvantages of the various treatment options can be discussed at the time of your consultation.
Hip arthroscopy is an innovative procedure that allows access to the hip joint using minimally invasive surgical techniques. It has been carried out episodically for some years, but in its current form has only been practiced over the last 5 to 10 years. It was pioneered by surgeons in the UK, Australia and the US and since then the indications have rapidly expanded. Initially it was used to remove loose bodies, take tissue samples and to investigate joint pain. However, since the concept of impingement has become clearer, it has been used to reshape both the pelvic cup (acetabular) rim and the femoral head/neck.
Investigations
Prior to surgery, all patients undergo specific x-rays of the hip as well as more complex scans such as CT and Magnetic Resonance Arthrography (MRA). These scans are used to confirm the soft-tissue damage and to accurately map out the bony deformity. This is very important when planning the surgery.
Each patient undergoes a general anaesthetic and the procedure takes approximately 1.5 to 2 hours to carry out. The patient is on their side and traction is placed on the leg. This distracts the hip and allows access to the joint. Using a combination of hollow needles and tubes, a camera is inserted into the joint.
Once there both the cartilaginous labrum and the joint surface cartilage are assessed. If the labrum is torn, it is repaired if possible as there is good evidence in the orthopaedic literature that this has a significant effect on long-term outcome. Occasionally the quality of the torn labrum is too poor for repair so it is debrided. If there is a defect in the joint surface cartilage then it is either debrided back or treated with specialised techniques such as micro-fracture or stem cell therapies.
Once the rest of the joint is inspected, the traction is released and access is made to the outer part of the hip joint. Once there, the abnormal bump is identified and removed using an arthroscopic shaver until it no longer catches.
Following the surgery, the patient undergoes a specialist hip rehabilitation program. This works on restoring range of movement and core stability. The patient initially remains partial weight bearing for between one and four weeks, depending on the surgery carried out, patients either go home on the day of surgery or the following day and are followed up by a dedicated therapist. They are reviewed in out-patients at six weeks and six months where their progress is carefully monitored.
Patient recovery can vary significantly following the operation. Most will return to normal day to day activities by six weeks, however, functional activity will continue to improve between six and nine months following the surgery. Occasionally, a small group of patients will remain uncomfortable following surgery and in these patients, a steroid injection into the hip joint can be very useful.
Compared to open surgery, the risks of hip arthroscopy are far less.There is a small risk of infection, blood clots, temporary nerve injury and groin bruising. Patients are routinely given antibiotics and a blood thinning drug to minimise some of these risks.
The outcome of hip arthroscopy is good, so long as the appropriate procedure is carried out. Professor Fehily has pioneered the use of 3D CT scans to accurately map out each patients bony deformity which then allows bespoke surgery, tailored to each individual patient. All patients undergo functional scoring both pre and post surgery and are then followed up long-term. A prospective database is kept of all patients and this has allowed us to identify who does and does not benefit from this surgery. On the whole, the majority of patients are significantly better following this procedure and this benefit is maintained into the long-term.
Professor Fehily carries out over 160 of these procedures per year and over 1300 in total. He is one of the highest volume surgeons for this procedure in the UK. He is an Honorary Professor at Salford University on soft-tissue hip problems, teaches physicians and physiotherapists about hip arthroscopy and is a regular member of faculty on both national and international courses teaching these advanced techniques to orthopaedic surgeons.
A painful hip can be through a one off injury but more commonly in clinic at Altius Healthcare we see pain that has come on gradually over a period of months and got worse. Patients describe a deep pain in either their groin or buttock or both and don’t recount a particular event. Their pain tends to vary in severity and is aggravated by certain movements that compress the joint surfaces including prolonged sitting. Combining physical therapy with other avenues can help people deal with the pain in a better manner. Medical marijuana has been known to aid in pain relief and depending on how you consume it, you can go and look at pipes and bongs online to find the best one for you. Alternatively, you can speak to your doctor if you are interested in using medical marijuana for pain management. Some doctors can write a prescription for you, which allows you to buy cannabis online to help give you pain relief.
Often these patients are scanned and the results of the imaging don’t match their pain presentation. Some have a large amount of damage in their hip but are relatively pain free and others are very painful with little to report on the scan. The majority of patients (regardless of their scan results) have muscular inhibition, as a result of the pain they are in and which we can address with home exercises which almost always helps them with their pain.
Patients with painful hips tend to keep going on them until they have picked up a poor movement pattern (limp) which sets off a cascade of events that if you don’t address with treatment and rehabilitation they continue to gradually get worse.
Once you are feeling pain the important thing to do initially is to identify the things that aggravate your pain and avoid them. This may sound like common sense but you would be surprised how many people try to push through the pain only to make it worse. For instance, if prolonged sitting is a problem, record how long it takes in sitting for you to get to 4/10 severity and then use this a s a guide to make sure that you don’t exceed this pain threshold in any one day.
Do take medication as well. People will not take medication because they think it will numb them so they do not know when they are making things worse. Once you know that without medication you can only sit for 40 mins then once you are taking medication stick to this rule of not sitting for longer than 40 mins for 3 days and then reassess your progress.
A person who has had hip pain for a month or longer will normally always have inhibition in their gluteal muscles (buttocks) and adductors (groins). In clinic, we would normally always prescribe exercises to help wake these muscles up. I often suggest a single leg bridge and a ball squeeze as a good place to start. Patients with hip pain also tend to have poor trunk strength, often worse on their painful side so we would also teach a modified plank exercise in three positions to strengthen the natural corset which is so important in stabilising the spine on the pelvis and off-loading the hips.
At the same time as addressing muscular inhibition, we also encourage patients to work on their spasm. We often find in clinic if the gluteals and adductors aren’t working properly, their default is to go into spasm to stop you moving which causes you more pain. We find teaching you deep pressure techniques with a foam roller can reduce spasm and pain and be a great thing to do before you do your strengthening rehab.
Regarding how much and how often. Obviously most patients are busy people and struggle to get anything done regularly just as some patients can over do it and aggravate things further. Therefore finding a balance is important and listening to your hip and how it is feeling, is of up most importance. I always suggest doing rehab Monday, Wednesday and Friday is a good place to start. The body needs to rest and recover from the strengthening you are doing and normally I say if you are sore (less than 4/10) during the exercises and and/or afterwards, that needs to be monitored and if you haven’t recovered by the next day and you are still 4/10 pain then you are doing too much of the wrong thing for you at that stage. During each rehab session I ask people to repeat each exercise three times until fatigue with a minutes rest between sets.
Catching hip pain early and treating it aggressively before you pick up a poor movement pattern is essential for a speedy recovery. Do not leave things for a month before you do something about it. Early intervention is key in managing any injury. So in summary, the devil is in the detail. We see many patients who make fantastic recoveries from severe hip pain with a huge amount of damage on a scan. The patients who do best are those who catch the pain early and make time to do the rehab properly and listen to their symptoms and don’t train with too much pain.
If in doubt and before you start doing the wrong thing it is important to get an accurate diagnosis. You should always get in to see an experienced physio or specialist sports medicine doctor with a special interest in the hip and groin as it is a specialist area and requires often a multi-centred approach.
If you would like further information or would like to send us a question please feel free to get in touch and we will help you as much as we can.
Who does this effect? Hip arthritis in young patients occurs when there is degeneration in the hip causing damage to the joint surface (figures 1 and 2). There are numerous different causes but the most common is osteoarthritis. However, it can occur earlier due to abnormalities within the hip. This may be due to a previous injury, childhood hip disease, femero-acetabular impingement (A misshapen hip that catches and causes damage to the hip joint), or problems with the blood supply to the hip.
How does it present? Commonly, this causes groin pain, often going down the thigh to the knee. The hip is stiff, and the patient walks with a limp. As arthritis becomes more widespread and severe, the pain becomes more constant, it may occur at night and be associated with increased stiffness, decreased mobility, and ability to exercise.
What investigations do you need? X-rays of the hip to confirm the diagnosis are taken as standard. More complex scans such as CT or Magnetic Resonance may be needed to pin down the diagnosis and help surgical planning.
Non-surgical Treatment To begin with, simple measures are tried such as painkillers, weight loss, and activity modification. Alternatively, some people have suggested the use of cbd isolate cream. Moreover, Oral supplements such as glucosamine and chondroitin may benefit some patients, especially with early arthritis. Injections such as steroid, hyaluronic acid or PRP may be used to either confirm the source of the pain (e.g. if the patient also has back pain) or in those patients who are not ready for a joint replacement.
When a patient has severe arthritis and painkillers no longer control the pain, hip joint replacement is advised. This has the benefit of relieving the pain and allowing the patient to return to a near-normal level of activity. If there is a waiting list for the surgery, patients will need help in curbing that pain for day-to-day living, this is where alternative medicines may be recommended. People who have suffered from pain have said that taking, herbal tablets, natural oils, CBD, medical marijuana, etc. have found relief from them. The latter has been lauded as one of the most brilliant ways of calming down pain and can be found on sites such as https://statesidelansing.com/contact. Before doing this, you must first speak to your doctor/consultant on how to go about this and if it is right for you to do.
In simple terms, the ball of the hip is removed and the thigh bone is prepared before the metal stem is inserted. The pelvic cup is then prepared and the artificial cup is inserted and held using either bone cement or an artificial coating that bonds directly to the surrounding bone surface (figures 3,4 and 5).
There are different forms of hip replacement and each one has a role to play depending on the patient’s age and activity level. Younger (<70) and more active patients, will have implants where the cup liner is made of a wear-resistant plastic and the ball of the hip will be made of ceramic, which is very smooth, hardwearing and produces less wear debris than traditional implants. Since 2018, we have pioneered the use of Robotics in hip replacement surgery. This allows for greater accuracy in positioning the implants and a faster recovery afterward. For more information about Mako robotic hips go to Robotic assisted hip replacement
As a sports physiotherapist I work in a number of diverse settings which gives me access to a wide range of clients from the elite professional footballer to the office worker who is a keen triathlete at the weekends. For each client the need is the same “how can I get the most out of my sporting hip and groin following injury in order to improve my performance.” Pain at the hip and groin region particularly can be very debilitating for the athlete, quite often it is very poorly understood area and as a consequence the problem can become chronic and result in an extended period on the sideline’s.
Diagnostics & Collaborative working Diagnostics play an important role as the hip and groin is a very complex area and problems can be difficult to diagnose. Orthopaedic consultant opinion together with radiographic imaging and specialist reporting is important in pinning down the correct diagnosis. A collaborative approach in assessment from leading specialists in Sports Medicine and the Sports Physiotherapist is the most effective route in treating the athlete in terms of getting them back to action as soon as is safely possible and providing a solution to ensure their long term fitness.
Focused & Progressive Rehabilitation First of all it is important to educate the athlete about their injury, the mechanism of injury often involving video analysis and the rehabilitation plan that will allow them to return to sport and avoid any injury reoccurrence. It requires a ‘buy in’ from both the therapist and the athlete to commit to a rehabilitation programme which will allow them to return to full fitness. Hip and groin injury can be multifactorial in nature but it is important to focus targeted rehabilitation at the region initially and then progress to more dynamic loading as symptoms improve. I have found the following progressive stages of rehabilitation to be most effective within the sporting population:
Intersegmental control and strength (such as a deadlift or double leg squat)
Linear mechanics and running load (such as barbell/overhead running and leg change drills)
Multidirectional mechanics and sprinting (such as a lateral shuffle or Zig Zag cutting)
Within these 3 phases the therapist encourages correct execution in technique and correct lumbo-pelvic form. Furthermore, a gradual increase in load progression, speed intensity and multi-directional movement patterns is also encouraged. Other treatment methods may also be incorporated if deemed necessary, such as improving the mobility of the lower extremities and spine with manual therapy and sports yoga, application of strength and conditioning principles, Shockwave therapy and clinical Pilates.
It is also important to keep the athlete focused and interested within rehabilitation. In order to achieve this outcome the therapist must make rehab specific to their sport; jointly develop drills with the athlete to mirror scenarios encountered within a game situation and make rehab proprioceptively demanding in order to retrain reaction timing and load response.
Profiling & injury prevention There is now a growing trend towards profiling of the athlete to highlight any injury risk factors and movement dysfunction that may predispose the athlete to injury. A specific screening tool devised by the therapist specific to the demands of the sport and/or the athletes overall physical capabilities is generally used twice a year in both a squad environment or on an individual basis to measure athletic performance. The screen may broadly include the following battery of tests:
Range of motion eg. Shoulder mobility
Strength testing eg. Adductor Squeeze test
Balance testing eg. Single leg landing
Work Capacity testing eg. Push up to failure
Movement Patten analysis eg. Squat form
Outcome measure eg. Triple hop for distance
Data produced from the screen allows us to flag up any potential weaknesses that could be a contributing factor to injury and have an adverse effect on overall physical performance. In order to nullify these weaknesses the athlete who presents as a high injury risk is given outlined bespoke action points to work on and then they are assessed more regularly, every few months throughout the year on key tests relevant to their profiling findings. This detailed monitoring allows us to prevent potential injury occurrence in key area’s such as the hip and groin and ensures the athlete remains fit, strong and pain free in order to achieve optimal performance.
Mike Kennedy MSc BSc (Hons) MHCPC MCSP MACPSEM
Manchester United Football Club Academy Physiotherapist Lead Physiotherapist, Mike Kennedy Chartered Physiotherapy & Pilates Highly Specialist Musculoskeletal & Sports Physiotherapist, Spire Perform Manchester Consultant Physiotherapist to the Professional Footballers’ Association (PFA) Associate Research Physiotherapist to the FASHIoN trial – Studying Hip Impingement
The Manchester Hip Clinic is committed to helping all kinds of people with hip problems to be free from pain and often to resume near-normal levels of physical activity – even those who may have thought that such relief would never be possible.
