NON-SURGICAL TREATMENT

It is really important to know that not all hip problems will need an operation. If you are experiencing hip pain for the first time, although it is important we determine why the hip is painful, the chances are that once we know the cause, we can treat the hip in ways that do not involve an operation to improve things for you. If these do not work or your symptoms have been present for a while, we may need to consider surgery but part of my aim will be to explain all of the options to you so you can make an informed decision as to which kind of treatment is best for you.

 

Non-surgical treatments: doing nothing!

The most basic form of non-operative treatment is carrying on as you are! Much as this may sound a bit strange to start with, there are a variety of hip problems that are described as self-limiting. This means that they are problems that you might need to protect for a short while whilst a problem such as a muscle strain improves on its own.

 

Non-surgical treatments: pain relief medication

During a period of protecting the hip, after a hip injury or in the early phases when a hip begins to become affected by a condition such as arthritis, you may need to take pain relief. Pain relief comes in many forms. The most common type we think of is taking tablets such as paracetamol or anti-inflammatories. Caution should be taken with anti-inflammatories if you suffer from stomach irritation, have a history of bleeding from the stomach or the rest of the bowel, have asthma or problems with your kidneys. If these are not controlling your pain then oral codeine can be added. If this is still not controlling your pain, it is important that other treatments are considered as national treatment guidelines recommend that we do not wait until strong morphine type pain relief is required before considering treatment such as hip replacement.

 

Anti-inflammatories can also be applied topically, or rubbed into the painful area. These have been shown to be just as effective as taking the tablet varieties but with a lower risk of side effects. This may be in part due to the benefit that comes from massaging the area.

 

Non-surgical treatments: TENS

Pain is transmitted from painful joints to the brain by nerves. The nerves that carry pain signals have a maximum frequency at which they can transmit signals to the brain. TENS (transcutaneous electrical nerve stimulation) works by applying continuous or pulsed stimulation to the nerves via the skin which reduces the number of pain signals that the nerves transmit. This can be an effective form of treatment and TENS devices are now small, battery powered and can be bought from most pharmacies. They are typically suitable to apply whilst you are at rest but it is difficult to get them to stick or stay in place when you are moving.

 

Non-surgical treatments: walking aids

You may find that you hip pain is helped by using a walking stick, crutch or other walking aid. If you do use one, then you need to use it in the opposite hand to the side you get pain on, the stick should be used so that it contacts the ground at the same time as the foot of your painful side and the weight shared between the stick and the leg. This leads to less force going through the hip and muscles around the hip, easing the pain experienced. It can also help prevent limping which leads to less load being put through other joints and may help symptoms there too. Even if you would prefer to avoid using a stick, it is worth doing so before going forward for surgery as you will need to use them in the early phases of your recovery so this will be easier if you are already used to them.

 

Non-surgical treatments: hot and cold packs

You may already have tried applying hot or cold packs to the area and these can often provide some relief. Heat can be particularly effective for the stiffness that develops when the joint remains in the same place for a period of time or is aching. Just be careful to not apply packs or hot water bottles to the area directly to the skin if they are too hot and limit the time the packs are applied for to prevent skin damage. Cold or ice packs can be particularly effective if the joint feels inflamed or sore after activity, Again care should be taken not apply ice directly to the skin, you can wrap it in a towel or similar to prevent this and exposure should be limited to no more than 20 minutes at a time.

 

Non-surgical treatments: physiotherapy

Physiotherapy is an important part of the treatment of nearly all joint and musculoskeletal problems. The critical factor is the exercises and activity that you perform rather than who supervises the activity.  It is perfectly reasonable to perform self-directed exercises in the first instance. Even if you are very active or even usually participate in sports to a high level, physiotherapy can still be of benefit as particular muscle groups may be weak, soft tissues overly tight or joints affected by contractures.

 

Physiotherapy can help by strengthening muscles that help support and offload joints. It can also help to improve the strength of muscles, such as the abductors of the hip, that help you walk normally and hence decrease the strain on other joints such as the back, other hip and knee. You may find as the muscle strength improves around the joint, that you experience less pain. Although some elements of the stiffness that you may experience can’t be improved with physiotherapy, such as that arising from the bone spurs that form when you have arthritis, tightness of the joint capsule and the muscles around the joint can be improved with exercises and therapy. 

 

Exercises should be commenced even if you think that you will definitely need surgery. The stronger we can make the muscles around the joint, the less likely it is you would need surgery but even if you do end up needing an operation such as hip replacement, it will make your recovery progress more smoothly and rapidly. If you do have an operation, physiotherapy exercises, either self-guided or under the supervision of a physiotherapist, will be a critical part of your treatment and recovery.

 

Non-surgical treatments: intra-articular injections

We will consider together whether it may be appropriate to consider injections into the affected hip. There are a few different situations where this may be appropriate. If you have problems arising from your back and your hip, they can be a useful way to separate out which is the main cause of your pain or how effective treatment such as joint replacement may be in improving your symptoms given your other problems. There are times when you may have pain due to arthritis in a joint but it may not be the right time for you to consider an operation such as hip replacement to treat this. There may be other important things happening in your life at the same time so that you would prefer to delay definitive treatment or perhaps you are planning on retiring in the next year and are looking for something to tide you over until you do given the recovery period following joint replacement. 

 

Sometimes you may suffer from marked pain, even if there is only early arthritis in the joint. This is because when cartilage breaks down, it causes irritation to the lining of the joint which then becomes inflamed and sore, producing more fluid and leading to a swollen joint. If the arthritis is quite early, it may not be appropriate to have a joint replacement as the symptoms may settle down or the benefits that surgery can offer may not be great enough to make the risks worthwhile. If this is the case for you, an injection can provide relief for a period of time, typically up to 3 months to see if your symptoms will settle. Lastly, you may decide that a hip replacement is too risky for you after we have discussed the benefits and risks of surgery. This may be due to other health problems that you have, making surgery more risky than it would normally be. In such cases, we may be able to improve your pain to a level where the symptoms are acceptable for you with one or more injections.

 

When injections into the hip are performed, we use local anaesthetic and steroid. This helps reduce the pain and inflammation in the joint. They are considered to be relatively low risk. One of the biggest risks is that they don’t lead to any benefit for you which is the case in about one in three patients. After the injection is performed, the hip may initially feel a bit more sore as additional fluid has been put into the joint and the steroid can be irritant to the joint before its anti-inflammatory effect kicks in. This is one of the reasons that we use local anaesthetic at the same time, to reduce this initial irritation. Any time a joint is penetrated, even when deliberately with an injection such as this, there is a risk of bacteria entering the joint and causing infection. For this reason, we take great care to ensure the injections are done under sterile conditions with the use of ultrasound or x-rays to guide us if needed. The risk of this is very rare and occurs less than one in five thousand cases. There is also a risk of bleeding but we know where the major blood vessels are and avoid these. The risk of bleeding is increased if you take blood thinners and if this is the case, we may need to check your clotting levels before going ahead. If steroid from the injection escapes into the soft tissues just underneath the skin, it can cause a loss of pigment in the skin or dimpling due to atrophy of the fat cells. 

 

It is possible to inject other substances into the joint such as hyaluronic acid, platelet rich plasma or stem cells. All of these are expensive in comparison to local anaesthetic and steroid and have no good evidence of an increased benefit. Indeed, in the case of hyaluronic acid, the risk of adverse effects is higher meaning they should not be considered as a first line injection.