What is Arthritis?
Arthritis is caused by wear of the cartilage that covers the bones around joints. Cartilage provides a smooth surface to allow mobility. When this cartilage wears out, the bone eventually becomes exposed. The condition can affect any joint in the body. The hip is one of the most common joints to be affected.
The condition can range from mild to very severe depending on how much damage or degeneration is present in the cartilage. Treatments vary depending on the severity of the degeneration and symptoms.
There are many causes of arthritis. Trauma to a joint, such as a fracture, can damage cartilage and eventually lead to arthritis. A prior infection in the joint can eventually lead to cartilage damage that causes arthritis. There are many inflammatory conditions that cause arthritis. Some of these conditions include: rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and lupus.
There is certainly a hereditary component to arthritis. Many people who develop hip arthritis have a someone in the family who had arthritis in the past.
Excessive weight (obesity) is a risk factor for the development of hip arthritis.
Femoroacetabular impingement (link to the section) is also a cause of hip arthritis.
In many cases, there is no obvious cause to explain the arthritis. This is called “idiopathic arthritis”.
The diagnosis of arthritis can be made after a clinical examination by a physician and plain X-rays. A simple series of weight bearing X-rays is usually all that is needed to make the diagnosis of arthritis and plan the non-operative or operative treatment. An MRI is not necessary to diagnose osteoarthritis and rarely will change any management decisions.
Non-Operative Options for Hip Arthritis
As with most arthritic conditions the early treatment is nonsurgical. There are a variety of non-surgical options available:
1) Weight Loss
Weight loss is crucial in the non-operative management of hip pain, whether from impingement, bursitis or arthritis. Due to the mechanics of the hip joint, for every pound increase in body weight your hip feels approximately 3 pounds of force with each step. So losing 20 or 30 pounds can decrease the force across your hip by 60-90 pounds!
A physiotherapist or personal trainer can guide patients through a low impact exercise regime to help attain their weight loss goals. Diet is crucial for weight loss especially in order to obtain and maintain the weight loss goal. Your family physician should be able to help you out with weight loss resources in the community.
Physiotherapy is crucial for management of hip pain. It works. Very often pain around the hip is a result of imbalance of the muscles that support the core (abdomen & back), hips and knees. Physiotherapists are experts at assessing and treating these imbalances. Once a program is learned often it can be continued at home as part of your regular fitness regime 3-5 times per week.
3) Pain Medications
Over the counter pain medications can help a great deal with hip pain. Traditionally, Tylenol (acetominophen) has been used as a first line treatment for arthritis pain, for example. However, recently there has been some question as to the value of Tylenol for arthritis pain and back pain. Some well-designed placebo controlled studies have shown minimal benefit of Tylenol when compared to placebo for arthritis pain.
Anti-inflammatory medications (NSAIDs) such as Advil (ibuprofen) are very useful to control both inflammation and pain. There are a number of products on the market, over the counter and prescription that can be suggested by your surgeon or family physician. They differ in their strength as well as their side effect profile. One over the counter medications that is stronger than Advil and you may find useful is Aleve (naproxen). There are also prescription strength anti-inflammatory medications that you may want to discuss with your surgeon or family physician such as toradol, Vimovo or Celebrex, for example.
There are some side effects to any medication but in particular with anti-inflammatories you should speak with your family physician if you have a history of ulcer, heart disease, high blood pressure or kidney problems, to name a few. Depending on your condition you may only need pain medications or anti-inflammatories for a short course. For example, an acutely inflamed hip without major internal injury may respond to a short course of anti-inflammatories and physiotherapy which limits the potential side effects of long term anti-inflammatory use.
Eventually, if the pain becomes more severe, it cannot be managed with over-the-counter medications or anti-inflammatories. Sometimes, stronger pain medications such as narcotics are required. These medications should be used as a last resort. There are many more side effects, and these medications can be quite addictive. A consultation with a surgeon is recommended if the pain is severe enough to require narcotic medications.
These supplements can be purchased in many supermarkets and health food stores. There is no good evidence in well controlled scientific studies of significant pain relief or improvement in function with use of these supplements. At this time there are no high quality scientific studies to demonstrate a significant effect of other natural medications on arthritic pain or function.
5) Activity Modification
Changing some of the activities that you take part in on a daily basis can reduce the forces on your hip and improve your symptoms. The extent of activity modification will depend on the extent of your symptoms and your diagnosis. For example, a patient with an inflamed hip from impingement may only need to change their daily routine minimally to gain excellent symptom relief, compared to a patient with significant arthritis that may have to limit more activities. Try to minimize activities that aggravate your hip, such as climbing stairs, low chairs, or impact activities. Avoiding high impact activities (running/jogging) and taking part in low impact activities such as cycling or swimming will reduce the impact on your hip.
6) Walking Aids
Using walking aids such as walking poles or a cane can reduce the forces on your hip and also decrease the pain that typically would occur with activities.
There are different types of injections that can be provided to help manage your pain. Depending on the type and severity of your condition, injections can have variable effectiveness. Ask your physician whether you may benefit from different types of injections.
These “steroid” injections can be very useful to help treat joint pain. The benefits from a steroid injection are generally short lived. Patients usually notice pain relief for approximately 3-8 weeks. These injections can be useful if you have an important event coming up or a holiday where you may need quicker, but short term pain relief. In an non-arthritic hip, repeated injections should be avoided and injections should not be provided at greater than 3 or 4 month intervals.
b) Viscosupplementation (Hyaluronic Acid)
These injections are like a lubricant that is put directly into the joint. They contain hyaluronic acid which is a natural substance found in a healthy knee. Examples of viscosupplementation medications on the market you may have heard of are Synvisc, Durolane, Monovisc and Cingal. There are many studies showing the benefits of viscosupplementation in a degenerative joint. The majority of patients notice some benefit. Repeat injections can be done when the pain starts to return. Patients usually notice 5-6 months of pain relief, but some patients notice improvement for longer periods of time.
The cost of these injections are not covered under the medical services plan. Depending on the brand of injection material used, the cost can range from $350-$550. Most extended health care plans will cover the majority of the cost.
c) Platelet Rich Plasma (PRP)
There are many studies documenting the effectiveness of PRP when treating joint pain as a result of degenerative change. The doctor injects a high concentration of your own platelets into the joint. Platelets are a normal component of blood, and they assist with blood clotting. However, they also contain many growth factors that can help with pain relief in degenerative or painful joints. Many studies show the pain relief with PRP can be similar to the results achieved with injection of hyaluronic acid.
The procedure involves the drawing of a blood sample from the patient. The blood is then spun in a device called a centrifuge. This separates the components of the blood. The doctor will then take the platelets from this sample and inject it into the joint. Patients should not take anti-inflammatories or aspirin for at least a week prior to receiving PRP because the medication has a negative effect on the platelet action.
PRP is also not covered under the medical services plan. The costs can range from around $500 to over $1000 depending on several factors. Very few extended health care plans will cover the cost of this treatment.
d) Stem Cell Treatment
The use of stem cells to treat joint disease is a relatively new treatment available to patients. At this time, Health Canada does not allow this treatment. Some patients travel to the US to pursue stem cell treatment. There are no long term studies documenting the benefits of this treatment and more research is needed. Stem cell treatment is very expensive (e.g. $4000-8000 USD) and with limited data caution should be used prior to investing in this treatment.
Whenever a doctor uses a needle to inject a substance into a joint, there are potential risks. There is a risk of infection, but luckily the risks are very small. After any injection, some patients notice an increase in pain and swelling for a very short period of time. This is usually normal. However, if the pain and swelling are significant, there are difficulties with bending or standing on the leg, there is redness, or a fever develops then you need to be assessed urgently in the emergency department.
Some patients develop local reactions to the substance that was injected into the joint. Some patients can experience allergic reactions to various hyaluronic acid injections. These reactions are very rare.
What is Hip Replacement?
The surgical treatment for hip arthritis is to replace the hip joint. A hip replacement involves surgically removing the damaged acetabulum and femoral head, and replacing them with new metal, plastic or ceramic joint surfaces to restore the function of the hip joint. For appropriate patients, the results of hip replacements are excellent and among the most successful operations in orthopaedics. The life span of a standard hip replacement is 20-25 years in most patients. There are different options for hip replacement materials that your hip replacement surgeon will be able to discuss with you. If you require a hip replacement you will be directed towards a surgeon in your local area with expertise in hip replacement.