Hip Pain Treatment in Delhi By The Best Pain Specialist Dr. Amod Manocha

 

Hip Pain & Other Musculoskeletal Conditions

Globally, musculoskeletal pain is a common reason of disability and seeking medical advice. It may be localised to one area or present as a widespread/ multisite pain. Musculoskeletal symptoms may be a consequence of orthopaedic, neurologic or rheumatologic processes and hence a comprehensive history and examination is required. Based on the findings further tests and imaging are requested to confirm the diagnosis or rule out other serious conditions.

This section focuses on minimally invasive non surgical interventions available via pain clinic for joint pain and some other common musculoskeletal conditions. The interventions listed below are most often used as a part of multi-disciplinary management in combination with medications, physiotherapy, complementary therapy and psychology input  as required.

Hip Pain

Hip pain is a common condition and can be quite disabling because of the impact on walking. Pain may be localised to the front, side or back of the hip joint. Common cause for anterior hip pain is joint problems such as arthritis, that on the outer side of hip is greater trochanteric pain syndrome whereas posterior hip pain may arise from multiple sources such as sacroiliac joint, lumbar spine, piriformis muscle etc. It is important to evaluate lumbar spine as spine pathology commonly coexists and can be responsible for producing/ exacerbating hip pain.

When it comes to managing hip arthritis pain, there is a large lacuna in the treatment options as medications often offer limited relief or are limited by side effects and surgery is not always the answer as many are unwilling or unfit to have one. Some in their 40s and 50s are considered to be too young to undergo a joint replacement. Besides 5 to 15% of patients have persisting pain even after having a hip replacement. New treatment options including radiofrequency ablation, cooled radiofrequency and cryoablation offer a ray of hope for hip arthritis patients not keen on surgery. Although these options have been used most often for arthritis pain, they work equally well for other hip joint pain conditions such as avascular necrosis (AVN).

Common minimally invasive non-surgical interventions offered in pain clinic for hip pain include

Ultrasound guided Hip joint injection

Hip joint is one of the common joints to be affected by osteoarthritis (OA). As this joint has a significant role in mobilisation, pain and reduced range of hip movement can adversely affect daily activities, quality of life. Simple activities such as wearing shoes and socks can become a challenge.

Conservative treatment of hip osteoarthritis includes weight management, painkillers, activity modification and physical therapy. Injections can be used for diagnostic and therapeutic purposes. Diagnostic injections can help in differentiating hip pain from pain originating from other sources.

Steroid injections are the most commonly used injection option. As hip joint is a deep joint it is recommended that these injections are performed using ultrasound or x-ray guidance as a day case or outpatient procedure. Ultrasound guidance is preferred as it can be easily performed in the clinic and does not involve radiation exposure. Ultrasound helps to improve accuracy and reduce chances of complications. Most often a mixture of local anaesthetic and steroid is used for the injection. Local anaesthetics help to relax the muscle and steroids aid in reducing inflammation thus prolonging the effect of the injection.

Injection for Trochanteric bursitis, gluteal muscle tendinosis

Trochanteric bursitis presents as pain on the outer side of the hip. It has been renamed as Greater Trochanteric Pain Syndrome (GTPS) as it represents a number of conditions with similar presentation, including muscle tears, tendon problems, bursitis and trigger points. On the outer side of hip is present the greater trochanter (bony edge on the top of the thigh bone where the buttock muscles attach) and many bursae to prevent friction.

GTPS is more common in middle aged or elderly women and in athletes involved in prolonged running. Trauma, repetitive stress, leg length discrepancies and weak hip muscles are predisposing factors. It presents as pain on the outer side of hip which can radiate towards the knee. Lying on the affected side is uncomfortable.

Conservative management involves avoidance of aggravating activities, ice, weight management, painkillers and physiotherapy. I consider injections if the conservative management fails to produce desired results. Local anaesthetic and steroid injection can help break the pain cycle and facilitate physical therapy. The injection is performed under ultrasound guidance to ensure delivery of medication at the correct site.

Injection for Iliopsoas tendinitis, bursitis

The iliopsoas is made up of two separate muscles: the iliacus and the psoas. These span from the spine and pelvis to the upper part of the thigh bone and play an important role in maintaining upright posture, lifting the leg. Iliopsoas tendinitis or bursitis presents with hip or groin pain which can radiate towards the thigh. The pain tends to be worse with activities involving flexion of hip such as while walking, climbing stairs and wearing shoes. Injuries, overuse, previous hip replacement can predispose to development of this condition. In some cases, an audible clicking/ snapping sound originating can be heard.

Injections are considered if the conservative therapy fails to achieve the desired goals. The procedure involves injecting a mixture of local anaesthetics and steroid under ultrasound guidance.

Lateral cutaneous nerve of thigh block & radiofrequency treatment

Lateral cutaneous nerve of thigh supplies sensation to the front and side of the thigh. Injury, compression or entrapment of the nerve can lead to numbness, altered sensation and pain in the area innervated by the nerve. Recent weight gain or loss, tight belts and clothes are predisposing factors. Common site of compression of the nerve is as it enters the thigh travelling in close relation to one of the thigh ligaments. The nerve can be identified with the help of ultrasound and a guided injection can help to relieve the pain. Pulsed radiofrequency treatment is sometimes utilised to prolong the effects.]

NEWER TREATMETNS FOR HIP JOINT PAIN

New treatment options include radiofrequency ablation, cooled radiofrequency and cryoablation. The primary aim of these treatments is the interruption or reduction of the pain signals travelling from the hip joint to the brain. This is achieved by deactivating or stunning the nerves responsible for transmitting the pain signals from the hip joint. The method used for achieving deactivation is where these treatments differ.

These options can be considered for anyone with hip joint pain who has not responded well to non-surgical or surgical options. Typical indications include someone who

• Is not fit for hip replacement
• Doesn’t want to have surgery or is old and doesn’t want to go through extensive recovery and rehabilitation
• Is young and wants to delay the surgery as worries about wearing out of hip joint and need for repeat surgery are not unfounded
• Has persisting pain after hip replacement surgery
• Has chronic hip pain with inadequate response to other treatment options

All the above-mentioned treatment options share some common advantages such as

• Minimally invasive pain management options for those not keen on surgery
• Safe procedures without the increased risk of complications
• Can provide quick, lasting pain relief
•  Less pain can translate into improve functional ability  and reduced painkiller requirements, disability
• Day care procedure with no requirement for overnight hospital stay
• No cuts or incisions involved in the procedure
• No requirement for general anaesthesia
• Quick return to routine activities with no downtime and no requirement of prolonged rehabilitation

Diagnostic test injections are often performed prior to the radiofrequency procedure. This involves using small amount of local anaesthetic to numb the nerves in order to gauge the chances of success of the subsequent treatment. 50% or more reduction in pain after the test injection is considered a positive response and an indication to proceed with the treatment.

These new treatment options are discussed further in the section below

Radiofrequency Ablation (RFA)

This procedure uses heat generated by radio waves to target nerves carrying pain from the hip joint. Specialised needles are used for controlled, targeted application of heat to these nerves, impairing their ability to transmit pain signals resulting in pain relief.

The procedure involves placement of needles at specific locations targeting branches of two specific nerves (femoral and obturator nerve). These nerves are very small to be actually seen under ultrasound, but are located in a specific area which is targeted using x-ray and ultrasound guidance. Once the needles are correctly placed, they are connected to the radiofrequency machine and the treatment is performed, involving the application of heat generated by radio waves.

Post procedure, pain relief usually begins within one to two weeks and may last up to 24 months, individual responses however will vary with different levels of pain reduction. Those with a successful test injection have more chances of responding to the RFA treatment. RFA is safe to administer repeatedly in patients with consistent pain reduction.

Cooled radiofrequency ablation (c-RFA)

This procedure involves placement of needles at the same location as described previously in the radiofrequency procedure. Cooled Radiofrequency has water circulating through the device and the needle tip. cRFA is able to deliver more energy to the surrounding tissues, thereby creating a larger treatment area and increasing the chances of achieving effective pain relief.

Cryoablation

Cryoablation refers to the technique of inactivation or blocking the nerves for a long time by freezing them. The procedure is performed using a special probe called cryoprobe, which is a hollow needle through which the super-cooled gas such as nitrous oxide or carbon dioxide is delivered directly to the treatment area. The extremely low temperatures achieved in the area being treated can inactivate the nerves thereby reducing the pain.

The probe is guided close to the location of the nerves supplying the hip joint, using ultrasound and x-rays. Gas is delivered once the probe is in the correct place. An ice ball is created by a rapid decrease in the temperature at the tip of the probe. Once the procedure is finished, the cryoprobe is removed and the procedure site covered with a small bandage.

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