perspectives of nonoperative sports medicine physicians
(A) nonoperative interventions for the management of “hip” pain
EUGENE HONG, MD, CAQSM, FAAFP
SARAH C. HOFFMAN, DO, FAAP, CAQSM
Editor’s Note: I asked my close colleague Gene Hong to write on the core from the perspective of a nonoperative physician, yet someone who actively participates in sports medicine. Gene is the head of sports medicine at Drexel and team physician for a number of the college and high school teams in the Philadelphia area. Gene knows his stuff. He is an excellent diagnostician and carries an ultrasound probe in his hand much of the day. I was guessing he would talk about noninterventional topics. Instead, he chose to talk intervention, with needles and small knives. I should have predicted that. Indeed, a huge part of the perspective of “nonoperative” sports physicians nowadays is operative. Dr. Hong asked his sports medicine colleague Sarah Hoffman to join in the writing.
Determining the etiology of “hip” pain can be difficult, since pain from the same pathology can be referred to multiple anatomical regions. Therefore, it is a mistake to think in terms of a location being specific for one particular condition. For example, pain from the ball-and-socket hip joint may occur in the buttock, lateral thigh, inguinal crease, or adductor region.
Once one makes a definitive diagnosis, a variety of treatment options materialize. Our goal in this chapter is to describe a number of the “nonoperative” interventional options for “hip” pain, as well as to expound on their effectiveness when evidence permits. We will consider both intra- and extra-articular causes of pain. These include osteoarthritis or degenerative joint disease, femoral acetabular impingement, core muscle injuries, acute or chronic tendinopathy, and other conditions.
While physical and manual therapy options have been shown to be effective for some of these conditions, those treatment modalities will not be discussed. We also shall not discuss in this chapter the generally accepted initial steps in the treatment of many conditions (ie, oral nonsteroidal anti-inflammatory drugs [NSAIDs] or catabolic steroid, corticosteroid injections, ice, rest, or activity modification). Specific pathologies we shall not discuss include stress fractures; pediatric conditions such as slipped capital femoral epiphysis (SCFE) or Legg-Calvé-Perthes disease (LCPD), avulsion fractures, apophysitis, lumbar radiculopathy, and nonmusculoskeletal etiologies such as rheumatoid arthritis or infection.
PLATELET-RICH PLASMA
The autologous blood product derives from spinning whole blood and separating out a concentration of platelets.
Various preparations of platelet-rich plasma (PRP) have been used for a variety of pathologies, although definitive evidence of short- or long-term benefit remains skimpy. In vitro studies have shown increased synthesis of proteoglycans and collagen when PRP stimulates chondrocytes.1 Several animal studies have shown that PRP improves healing.2 Basic science studies suggest the treatment will be beneficial in patients, but clinical studies have not provided the evidence yet to prove that statistically due to a lack of power.3
Few studies focus on the intra-articular hip joint itself, making it necessary to postulate from the data for treatment of other pathologies, such as patellar tendinopathy or knee osteoarthritis.3–5 Several authors have found statistical improvement in patient outcome scores compared to hyaluronic acid injections for large joint arthritis. The benefit lasted just 6 to 12 months. The majority are case studies (ie, low level of evidence). In general, the small sample sizes and wide variability in treatment makes it difficult to draw conclusions.6,7 Only one of the above studies involved injection into the hip, and that study was inconclusive.6
The authors acknowledge the circular sent out to professional teams (see Chapter 10) concerning a potential danger of heterotopic ossification in the adductor region. Nevertheless, so far the published data support PRP to be safe in patients with tendinopathy. A 2011 case series by Finnoff et al5 demonstrated that the combination of tenotomy and PRP was safe in patients with chronic tendinopathy. PRP injections did not seem to carry the risk of tendon degeneration or other systemic effects that injections of corticosteroid injections seem to have, nor, of course, the risks of surgery.3
A systematic review in 2014 found that a variety of studies that looked at PRP for articular cartilage pathology. There was limited evidence of short-term benefit in symptomatic knee arthritis patients. On the other hand, definitive conclusions have been impossible due to bias and generally poor quality of those studies.7
PLATELET-RICH PLAMSA AND PERCUTANEOUS TENOTOMY
One interesting study compared PRP to extracorporeal shock wave therapy (ESWT).8 Forty-six athletes with jumper’s knee were randomized to receive either therapy. PRP treatment came out better than ESWT. However, there was no control group; plus, it was not clear if the benefit was due to the tenotomy performed at the same time as the PRP injection. Also, the authors did not comment on whether or not the patients had failed eccentric exercises, currently the gold standard for treatment of patellar tendinopathy.
Percutaneous tenotomy means functionally aggressive “needling.” This can be performed with a needle or a tiny scalpel blade. Variable amounts of cutting of fascia, epimysium, true tendon, or muscle fibers may occur. The procedure may be performed with or without PRP. Some examples of possible locations for tenotomy include but are not limited to proximal hamstrings or adductors, gluteus medius and minimus, distal rectus abdominis, and piriformis.
Percutaneous tenotomy is a step up in invasiveness and has been studied in the lateral elbow, patella tendon, and Achilles tendon. Results on those parts of the body have shown some promise. Data remain lacking for the role of tenotomy in “hip” tendinopathies and core muscle injuries.
HYDRODISSECTION
Hydrodissection is a method for separating nerves from adjacent tissue using injection of fluid, usually saline with anesthetic and/or steroid, and ultrasound guidance. It has been used for suspected peripheral nerve entrapment. Results are mixed. This has been used primarily in the abdominal wall, lateral thigh, and proximal adductor regions. One author describes an ultrasound-guided percutaneous neuroplasty of the lateral femoral cutaneous nerve for meralgia paresthetica. That resulted in immediate and long-term relief.9 A 2015 retrospective case series reported relief of medial knee pain after total knee arthroplasty after hydrodissection of the infrapatellar branch of the saphenous nerve with anesthetic and corticosteroid.10
ANESTHETIC INJECTION
Anesthetic alone has improved pain and function in the long term for “hip pointers.”11,12 Seventy-five percent of rugby players in the latter study felt the injection was very helpful, while the remaining 25% called it somewhat helpful. The roundness of the numbers and vagueness of the measurements suggest a low-powered study with bias. Probably, pure anesthetic has been tried in other core anatomic regions for long-term relief, but we could not find publications on this.
TOPICAL NITROGLYCERIN
Nitroglycerin also has had variable success in reducing pain with tendinopathy, but elsewhere in the body. The hip/groin region, so far, seems unstudied. In a randomized controlled trial for chronic lateral epicondylosis, topical nitroglycerin reduced pain.13 Similar results appeared in the literature for Achilles tendinopathy. The latter randomized controlled trial involved a glyceryl trinitrate patch plus physical therapy vs physical therapy alone. Another similar randomized controlled trial, which included placebo topical patches plus eccentric exercises, did not demonstrate significant changes.14
PROLOTHERAPY
Prolotherapy involves injection of irritant solutions, such as concentrated sugar, into the soft tissues. In theory, pain relief comes from either growth factors or ischemia triggered by the resultant inflammatory response.15 There is some evidence of improved outcomes for tendinopathy and osteoarthritis.16 In one study of elite male kicking-sport athletes with chronic groin pain, 20 of 24 patients had no pain and 22 of 24 remained “unrestricted” at 32 months after treatment. They had monthly injections of dextrose and lidocaine.17
ACUPUNCTURE
Limited studies exist about the effectiveness of acupuncture for hip and other joint pain. In 2007, Moe et al18 found no “moderate quality” evidence that acupuncture affected pain or function in patients with osteoarthritis. In one case report, the pain from a calcifying tendinitis of the gluteus medius completely resolved in a 68-year-old man after 3 months of treatment. He still had no pain and the calcifications had disappeared at 6 months.19 Crespin et al showed significant short-term pain relief with acupuncture after hip replacement. In that study, acupuncture was given at the same time as pharmacologic management.20
EXTRACORPOREAL SHOCK WAVE THERAPY
Theoretically, ESWT works for tendinopathy via some sort of mechano-biological mechanism. Reportedly, the ultrasonographic technique has analgesic and healing effects. Supposedly, ESWT promotes angiogenesis and bone remodeling. It does release substance P in rabbit femurs.21 In the knee, ESWT reduced “patients’ perceptions” of the clinical severity of their osteoarthritis compared to placebo.22 Moderate evidence suggests the technique may be effective for greater trochanteric pain syndrome when compared to home training and corticosteroid injection in short and long terms.23
OTHER MODALITIES
We could find no good studies in the sports medicine literature on the use of botulinum toxin, cryotherapy, or radio-frequency ablation in this region of the body. Logically, the use of each of those modalities makes sense for particular conditions, but, to our knowledge, we do not yet have good clinical scientific trials in the use of these interventions for core muscle injuries.
SUMMARY
The athlete’s core remains a largely unstudied area of the body with respect to the use of many of the therapeutic interventions described above. A number of these nonoperative interventions show potential promise in the lab as well as in the limited studies thus far. And while we have described a number of nonoperative therapies that are currently being used in clinical practice, there may be other interventions that are being employed and for which there are even less data. There is certainly a need for further research into the optimal nonoperative interventions to treat “hip” pain. At this point in time with our current understanding of the literature, the authors recommend that each clinical case, each athlete, be evaluated for the appropriate use of nonoperative therapies, and that treatment be tailored to the specific individual based on the diagnosis and contributing factors, including the expectations of the provider and the athlete.
SELECTED READINGS
Fortier LA, Hackett CH, Cole BJ. The effects of platelet rich plasma on cartilage: basic science and clinical application. Oper Tech Sports Med. 2011;19(3):154-159.
An interesting article on the basic science potential of PRP for cartilage injury.
Fitzpatrick J, Bulsara M, Zheng MH, et al. The effectiveness of patelet rich plasma in the treatment of tendonopathy: a meta-analysis of randomized controlled clinical trials. Am J Sports Med. 2016;44(6):1379-1381.
Current meta-analysis of the limited number of randomized controlled trials using PRP to treat tendonopathy—the good, the bad, and the better.
Van Leeuwen MT, Zwerver J, Van den Akker-Scheek. Extracorporeal shockwave therapy for patellar tendinopathy: a review of the literature. Br J Sports Med. 2009;43:163-168.
Good review article on the use of ESWT for patellar tendon injury.
Gambito ED, Gonzalez CB, Oquiñena TI, Agbayani RB. Evidence on the effectiveness of topical nitroglycerin in the treatment of tendinopathies: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2010;91(8):1291-1305.
If you are interested in a better understanding of topical nitroglycerin in the treatment of tendon injury, start with this article.
REFERENCES
1. Akeda K, An H, Okuma M, et al. Osteoarthritis and cartilage. Osteoarthritis and Cartilage. 2006;14(12):1272-1280.
2. Taylor D, Petrera M, Hendry M, et al. A systematic review of the use of platelet-rich plasma in sports medicine as a new treatment for tendon and ligament injuries. Clin J Sport Med. 2011;21(4):344-352.
3. Mautner K, Kneer L. Treatment of tendinopathies with platelet-rich plasma. Phys Med Rehabil Clin N Am. 2014;25:865-880.
4. Mishra AK, Skrepnik NV, Edwards SG, et al. Efficacy of platelet-rich plasma for chronic tennis elbow. Am J Sports Med. 2014;42(2):463-471.
5. Finnoff J, Fowler S, Lai J, et al. Treatment of chronic tendinopathy with ultrasound-guided needle tenotomy and platelet-rich plasma injection. PM&R. 2011;3:900-911.
6. Tietze D, Geissler K, Borchers J. The effects of platelet-rich plasma in the treatment of large-joint osteoarthritis: a systematic review. Phys Sportsmed. 2014;42(2):27-37.
7. Dold A, Zywiel M, Taylor D, et al. Platelet-rich plasma in the management of articular cartilage pathology: a systematic review. Clin J Sports Med. 2014;24(1):31-43.
8. Vetrano M, Castorina A, Vulpiani M, et al. Platelet-rich plasma versus focused shock waves in treatment of jumper’s knee in athletes. Am J Sports Med. 2013;41:795-803.
9. Mulvaney S. Ultrasound-guided percutaneous neuroplasty of the lateral femoral cutaneous nerve for the treatment of meralgia paresthetica: a case report and description of a new ultrasound-guided technique. Curr Sports Med Rep. 2011;2:99-104.
10. Clendenen S, Greengrass R, Whalen J, et al. Infrapatellar saphenous neuralgia after TKA can be improved with ultrasound-guided local treatments. Clin Orthop Relat Res. 2015;473:119-125.
11. Hall M, Anderson J. Hip pointers. Clin Sports Med. 2013;32:325-330.
12. Orchard J, Steet E, Massey A, et al. Long-term safety of using local anesthetic injections in professional rugby league. Am J Sports Med. 2010;38:2259-2266.
13. Ozden R, Uruc V, Dogramaci Y, et al. Management of tennis elbow with topical glyceryl trinitrate. Acta Orthop Traumatol Turc. 2014;48(2):175-180.
14. Steunebrink M, Zwerver J, Brandsema R, et al. Topical glyceryl trinitrate treatment of chronic patellar tendinopathy: a randomized, double-blind, placebo-controlled clinical trial. Br J Sports Med. 2013;47:34-39.
15. Alfredson H, Ohberg L. Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial. Knee Surg Sports Traumatol Arthrosc. 2005;13(4):338-344.
16. Distel L, Best T. Prolotherapy: a clinical review of its role in treating chronic musculoskeletal pain. PM&R. 2011;3(6S):78-81.
17. Topol G, Reeves D, Hassanein, K. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil. 2005;86:697-702.
18. Moe RH1, Haavardsholm EA, Christie A, Jamtvedt G, Dahm KT, Hagen KB. Effectiveness of nonpharmacological and nonsurgical interventions for hip osteoarthritis: an umbrella review of high-quality systematic reviews. Phys Ther. 2007;87(12):1716-1727.
19. Lin W, Liu C, Tang C, et al. Acupuncture and small needle scalpel therapy in the treatment of calcifying tendonitis of the gluteus medius: a case report. Acupuncture Medicine. 2012;30(2):142-143.
20. Crespin DJ, Griffin KH, Johnson JR, et al. Acupuncture provides short-term pain relief for patients in a total joint replacement program. Pain Med. 2015;16:1195-1203.
21. Gerdesmeyer L, Wagenpfeil S, Haake M, et al. Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff. JAMA. 2003;290(19):2573-2581.
22. Zhao Z, Jing R, Shi Z, et al. Efficacy of extracorporeal shockwave therapy for knee osteoarthritis: a randomized controlled trial. J Surg Res. 2013;185:661-666.
23. Mani-Babu S, Morrissey D, Waugh C, et al. The effectiveness of extracorporeal shock wave therapy in lower limb tendinopathy: a systematic review. Am J Sports Med. 2015;43:752-761.
DAVID STONE, MD
Editor’s Note: I also asked one of the great sports medicine physicians in the country to provide his viewpoint on the core—how he thinks about the whole concept, etc. The University of Pittsburgh’s David Stone provides some insightful comments.
“THE CORE”
In sports medicine, we generally view the core of the body as a muscular box that begins at the diaphragm and ends at the bottom of the pelvis. The abdominal muscles make up the front of the box, and the paraspinals and gluteal muscles, etc, the back of the box.1 Some authors include the anatomy as low as the thighs or as high as the deltoids.2 The core concept serves as a model for training athletes and enhancing performance.
The underlying assumption of the model is: Controlling the position of the trunk allows for optimal production, transfer, and control of force and motion.3 The same concept also applies to prevention of injuries to the knee, ankle, and upper extremities.
I’m all about that bass.
—This Meghan Trainor/Kevin Kadish song was the third best-selling single of 2014 and now a top seller of all time. The “bass” refers to the back and booty, etc. According to Trainor, the song and accompanying video promote “body confidence.” Some consider the lyrics controversial.
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