Natural Hip Pain Relief

The hip joint is the largest weight-bearing joint in the human body. The hip joint consists of the thighbone or femur, which joins the pelvis at a deep socket called the acetabulum. The hip joint is a ball and socket joint meaning it allows multidirectional movement and is supported by multiple muscles, ligaments and tendons. Because the hip joint is the largest weight-bearing joint and does allow for multidirectional movement it is vulnerable to injury especially “wear and tear” or degenerative disease that adversely affect the joint’s range of motion and the ability to bear weight.

Your Hip is Connected to Your Whole Body, and so is Your Pain and Inflammation

As a result, the cause of hip pain and inflammation comes from many factors, requiring a whole-body approach to relieving pain.

Dr. Squires’ approach brings together a holistic treatment of all the factors contributing to your chronic inflammation and pain. Personalizing treatment to the factors most impacting your source of pain.

And combines it with a Regenerative Medicine approach that stimulates your own body’s healing response naturally.

Regenerative medicine is a cell-based therapy using advanced scientific techniques in the treatment of degenerative disease, orthopedic injuries, and joint conditions.

Discover how Dr. Squires can help by scheduling an initial consult »

Hamstring Tendinopathy

The common hamstring tendon attaches the sits bone (ischium of the pelvis) to the lower leg bone (tibia). Hamstring tendinosis is usually due to chronic repetitive microtrauma during sports such as long-distance running, sprinting or jumping as well as sports with burst of speed from forceful takeoff or requiring forward swing of the leg. Tendinopathy is a result of an inflammatory response to overuse that often results in pain, swelling, weakness, and decreased function. The continual inflammatory response can lead to degenerative changes, decrease blood supply, disorganization of tendon fibers, and a failed healing response.

Individuals will experience pain while sitting, pain and tightness with forward kicking or hamstring stretching or feeling a constant pulling at the insertion of the tendon located at the sits bone.

Treatments usually are conservative with rest, physical therapy, non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen/Advil or steroid injections. NSAID use is controversial due to increasing evidence that NSAID usage may interfere with the healing process and be detrimental in tendinopathy. Many papers show corticosteroids lead to soft tissue damage, cell death, and tendon atrophy.

It is important to find the root cause of hamstring or buttock pain. The root cause could be an isolated injury of the hamstring as discussed above. It could also be associated with low back pain from the lumbar spine, a sacroiliac injury, a hip joint injury such as a labral tear or even a knee injury because the hamstring crosses both the hip joint and the knee joint. All of these areas need to be evaluated for a comprehensive treatment that resolves the root cause of pain.

Regenerative Medicine and Hamstring Tendinosis

• Prolotherapy uses a dextrose based solution to create an inflammatory response recruiting fibroblast, growth factors, and even stem cells to an area of injury. In turn, this helps stimulate repair of tissues reinforcing connective tissue resulting in ligament/tendon strengthening and stability.
• Platelet Rich Plasma (PRP) involves taking your own blood and processing it to get endogenous growth factors, immune cells, and fibroblasts (precursor to connective tissue) and injecting them into the site of injury. PRP uses your own cells to facilitate healing.
• Tendon healing utilizes the cells provided by platelet-rich plasma to instigate an inflammatory response, cellular proliferation, and tissue remodeling.
• Platelet Rich Plasma (PRP) seems to enhance angiogenesis (improved blood supply) which may accelerate the healing process.
• Platelet Rich Plasma (PRP) treatment can enhance tendon healing because it promotes activation and differentiation of tendon stem cells.
• Studies have demonstrated that PRP can increase both the number of cells and the cellular component by enhancing fibroblast proliferation and collagen production, and thus strengthen healed tendons and ligament. These studies showed that PRP improved not only collagen production in tendons but also their tensile strength and decreased scar tissue formation.
• Extracorporeal Shockwave Therapy (ESWT) has been shown in studies to treat tendonitis or partial thickness tears in tendons. A study comparing the effectiveness of shockwave therapy to other non-operative treatments for chronic proximal hamstring tendinopathy found 85% improvement in pain with the individuals treated with shockwave. Study cited below.
• It should be noted that regenerative medicine efficacy remains controversial and research should continue. There are many factors that contribute to increased efficacy including processing/preparation of PRP, how much is injected, activation of PRP, injection technique, timing, number of application and timing of injections as well as comorbidities or concomitant therapies.

Gluteus Medias Tendinopathy and Trochanteric Bursitis

Gluteus Medias tendon is the most common tendon injured in the outer hip. Tendinopathies of gluteus medias can result from an injury, but most often from instability and overuse. Overuse and instability result in inflammation, degeneration, and weakness that can predispose the tendon to tear. Symptoms include pain and weakness on the side of the hip that can alter your gait leading to further exacerbation of symptoms.

It is often associated with trochanteric bursitis because the gluteus medias tendon attaches on the greater trochanter of the femur (thigh bone) on the outside of the hip. At the attachment, there is a bursa, which is a fluid-filled sac that cushions the tendon attachment to reduce friction and facilitate movement. The bursa can become inflamed and painful with increased instability resulting in increased rubbing at the tendon attachments. Treatment should focus on strengthening and stabilizing the tendons and muscles surrounding the hip joint as well as assessing compensation in the low back, knee and ankle.

Common treatments are physical therapy, corticosteroid injection, oral anti-inflammatories, and rest. NSAID use is controversial due to increasing evidence that NSAID usage may interfere with the healing process and be detrimental in tendinopathy. Many papers show corticosteroids lead to soft tissue damage, cell death, and tendon atrophy, and inhibit collagen synthesis.

Studies have shown greater clinical improvement and reduction in symptoms with Platelet Rich Plasma compared to Corticosteroid injections.

Hip joint and low back instability needs to be addressed to treat the root cause of gluteus medius tendinopathy and trochanteric bursitis. Ligaments and tendons can lose their tensile strength with chronic wear and tear leading to decreased stability and increased movement. Muscles will contract to try to stabilize an unstable joint, which can pull on the tendons putting more strain on them and increasing pain and inflammation leading to further damage. More muscles and connective tissue will get recruited to try and stabilize. Pain and tightness can move to the iliotibial band, piriformis, muscles in the low back, and muscles surrounding the knee.

Treatment approaches are the same for other tendons and ligament injuries. Proper alignment is crucial for stabilization and healing. I recommend physical therapy, chiropractic, and osteopathic manipulation to ensure proper movement and function with any injection therapy for gluteus medias injuries and trochanteric bursitis.

Regenerative Medicine Therapies for Gluteal Tendon and Trochanteric Bursitis

• Prolotherapy uses a dextrose based solution to create an inflammatory response recruiting fibroblast, growth factors, and even stem cells to an area of injury. In turn, this helps stimulate repair of tissues reinforcing connective tissue resulting in ligament/tendon strengthening and stability.
• Platelet Rich Plasma (PRP) involves taking your own blood and processing it to get endogenous growth factors, immune cells, and fibroblasts (precursor to connective tissue) and injecting them into the site of injury. PRP uses your own cells to facilitate healing.
• Tendon healing utilizes the cells provided by platelet-rich plasma to instigate an inflammatory response, cellular proliferation, and tissue remodeling.
• Platelet Rich Plasma (PRP) seems to enhance angiogenesis (improved blood supply) which may accelerate the healing process.
• Platelet Rich Plasma (PRP) treatment can enhance tendon healing because it promotes activation and differentiation of tendon stem cells.
• Studies have demonstrated that PRP can increase both the number of cells and the cellular component by enhancing fibroblast proliferation and collagen production, and thus strengthen healed tendons and ligament. These showed that PRP improved not only collagen production in tendons but also their tensile strength and decreased scar tissue formation.
• Extracorporeal Shockwave Therapy (ESWT) has been shown in studies to treat tendinitis or partial-thickness tears in tendons.

Piriformis Syndrome

Piriformis syndrome is inflammation of the sciatic nerve secondary to irritation or compression by the piriformis muscle. Trauma to the gluteal region is the most common cause though it can be caused by overuse such as in athletes or on the other end prolonged sitting. There can be anatomical variants of piriformis muscles where the nerve goes through the muscle increasing chances of compression. Piriformis syndrome can also be a compensation for foot instability resulting in contraction of hip muscles trying to stabilize instability. It has also been associated with sacroiliitis or hypermobility of the sacroiliac joint which is also compensation of increased contraction of hip muscles trying to stabilize an instability putting more strain on the muscle resulting in compression of the sciatic nerve.

Most common symptoms are chronic gluteal pain which radiates into lower extremity similar to L5-S1 radiculopathy. Pain is also increased by bringing the leg inwards or rotating the leg inwards.

Treatments include physical therapy, steroid injections, botox injections and anti-inflammatories.

Regenerative Medicine Treatments for Piriformis Syndrome and Sciatic Pain

• Perineural Injection Therapies – Perineural injection therapy specifically targets neuropathic pain and neurogenic inflammation meaning the nerve fiber itself is damaged, injured, or chronically inflamed. The therapy involves superficial injections of dextrose along cutaneous nerve pathways. Injections of dextrose correct glycopenia (low levels of glucose) restoring energy balance and raising pH creating a more neutral environment and restoring tissue physiology. The dextrose also opens ion-gated channels to decrease nerve signaling, which calms down the inflammation around the nerve allowing time for the nerve to heal.
• These therapies can be combined with prolotherapy to treat ligaments associated with joint instability in the low back, sacrum, and foot.

Osteoarthritis of the Hip Joint

Osteoarthritis of the hip joint is degeneration of cartilage and joint space narrowing. Osteoarthritis is caused by chronic low-grade inflammatory responses from chronic overuse. Chronic inflammatory processes produce degrading enzymes trying to clean up the inflammatory debris that overtime weaken collagen networks and breakdown cartilage. Even metabolic processes such as diabetes and cardiovascular disease contribute to inflammatory responses leading to cartilage damage inside the joint. As cartilage breaks down there is abnormal bone formation (osteophytes) trying to stabilize a weakened joint, tearing of surrounding connective tissue, and loss of synovial fluid which provides nutrients and acts a shock absorber.

Common symptoms are joint pain, limited ability to sit, stand or walk, decreased range of motion, symptoms are worse in the morning and exacerbated by increased activity.

Conservative treatments are non-steroidal anti-inflammatory (NSAIDs) like ibuprofen or Advil, physical therapy, steroid injections, hyaluronic acid injection. If osteoarthritis is severe enough surgical intervention is a total hip replacement. Chronic NSAID use has been shown to lead to increased risk of stomach ulcers, acute renal failure, and stroke/myocardial infarction. Corticosteroid injections pain relief is temporary and can cause further soft tissue damage, cell death, reduced bone mineral density, and inhibit collagen synthesis.

Regenerative Medicine Treatments for Osteoarthritis of the Hip

Regenerative medicine injections stimulate the body’s natural immune response encouraging growth factors, fibroblast, immune cells, stem cells and collagen building precursors to the injured area to promote healing and repair.

• Platelet-rich plasma (PRP) therapy involves using your own blood plasma and platelets as an enriched source of growth factors, immune cells, and collagen-building precursors to stimulate healing of bone and soft tissue. PRP has been shown to modulate the repair and regeneration of damaged articular cartilage in the joints and delay further degeneration of cartilage. Studies have replicated reduction in pain, decreased inflammation in the joint space and improvement in the quality of life scores.
• Studies have found that intra-articular platelet-rich plasma injections of the hip to treat hip osteoarthritis, are well tolerated and potentially efficacious in delivering long-term and clinically significant pain reduction and functional improvement.
• Autologous stem cell (from your own body) therapies using both mesenchymal stromal cells (MSCs) and hematopoietic stem cells have shown therapeutic potential for advanced osteoarthritis. In orthopedic injuries and degeneration, stem cells have the potential to signal for the repair of damaged tissue with possible regeneration of tissue. It is important to note that research is mixed with regard to whether regenerative medicine truly regenerates tissue. What does seem to be more reproducible is a decrease in further degenerative changes, pain, and improved function.
• Platelet-rich plasma (PRP) therapy with Surgery
  • “Recent studies support the use of PRP intra-articular injections, not only as a conservative treatment, but also after surgical procedures as many researchers attempted to enhance cartilage repair by combining surgical procedures such as microfractures with growth factors (GFs). PRP has been shown to improve the reparative response of focal defects of articular cartilage after surgery compared to surgery alone and also to increase the durability of repair tissue over time”
    • doi:10.11138/ccmbm/2013.10.1.026

Regenerative Medicine does not work for everyone and there are many variables to be considered when choosing what treatment is right for you. Differences in PRP concentrations, PRP preparation methods, source of stem cells, injection techniques, accurate diagnosis, determination of pain generators, conjunction with other therapies from everything to different injection therapies to physical therapy.

It should not be underestimated the importance of treating whole-body inflammation and optimizing immune function in order to get the best results from treatments. All of these should be considered and I believe comprehensive treatments lead to optimal healing.

Rheumatoid Arthritis

Rheumatoid Arthritis is an autoimmune disorder that affects synovial membranes and articular surfaces in the joint space. Rheumatoid arthritis can occur in any joint in the body. It often is noticed in smaller joints first such as fingers and toes though it may affect multiple joints at once. Individuals will experience morning stiffness, pain and stiffness is usually on both sides, fatigue, weakness, and joint swelling are common.

The common etiology of all autoimmune disorders is chronic inflammation. This results in an overwhelmed immune system, which leads to immune dysfunction and the inability of the body’s defense system to recognize self from non-self.

This means your body starts seeing its own tissues as foreign and attacks the tissues like they are the common cold virus. This results in even more inflammation, and your body becomes stuck in a vicious dysfunctional cycle.

Current conventional treatments focus on symptom suppression using nonsteroidal anti-inflammatory drugs, steroids, or immune-modulating drugs. The problem with these pharmaceutical treatments is they severely depress an already depressed immune system. This results in unpleasant and often debilitating side effects including, but not limited to, infections, blood sugar dysregulation, weight gain, nausea, vomiting, dizziness, gastrointestinal dysfunction, muscle pain, and fatigue. Despite this long list of side effects, people may experience only moderate relief from their symptoms or may often experience no relief at all.

There are many multifactorial causes of inflammation in the body including:

• Environmental triggers
• Dietary influences
• Intestinal permeability
• Social/psychological stressors
• Infections
• Hormonal imbalances
• Genetic susceptibility

By understanding the impact, they each have on our body we can successfully integrative a treatment approach which restores your body’s natural balance and its innate ability to heal itself.

Femoroacetabular Impingement

Femoroacetabular Impingement is caused by repetitive microtrauma from an impingement of the head of the thigh bone (femoral head) against the hip socket of the pelvis (acetabulum). Femoroacetabular Impingement leads to degeneration of the labrum (a ring of fibrous cartilage that lines the hip socket) and the cartilage of the hip joint which will further lead to osteoarthritis and abnormal bone growth further exacerbating symptoms.

The progression of femoroacetabular impingement to further degenerative changes of the joint is often ligamentous instability from the repetitive microtrauma of impingement creating a harsh inflammatory environment. As instability continues the inflammatory response continues leading to a degeneration of cartilage and joint space narrowing. The body will try to stabilize the joint with bone by increasing calcium deposits leading to bone spurs, the bones rub together creating friction and further inflammatory responses and degeneration.

Common symptoms include hip and groin pain, increased pain with weight-bearing, pain with walking uphill, jumping, squatting, and sitting.

Treatment depending on severity starts conservatively with anti-inflammatories, muscle strengthening to relieve hip joint stress, non-loading activities such as cycling or elliptical.

Surgical treatment may be very helpful for cleaning out debris in the joint as well as reshaping the bone so it does not continue to impinge. A full hip replacement may be indicated depending on severity and age.

Treatment Considerations

• Surgery can significantly improve pain and mobility and should be considered in the treatment of femoroacetabular impingement. Though surgery may be the best option especially if bone growth is inhibiting range of motion. In a study to determine the incidence of osteoarthritis after arthroscopic hip surgery for Femoroacetabular Impingement Syndrome. A clinical diagnosis of hip osteoarthritis was found in approximately 22% of young patients undergoing hip arthroscopy in as little as 2 years. (1)
• Hip femoroacetabular impingement (FAI) has been found to be the primary cause of revision surgery after hip arthroscopy. Meaning that after a hip surgery using a small camera with small incisions (arthroscopy) individuals needed another surgery because they now had FAI. (4)
• Physical therapy has been shown to be efficacious in the treatment of femoroacetabular impingement and may even prevent the need for surgery. (2)
• Imaging may not tell the whole story. It is important that you are treated as an individual based on clinical history and physical exam and not just on imaging results. Radiographic signs of Femoroacetabular impingement were not associated with the degree of hip pain or a positive anterior impingement sign, which suggests that radiographic findings may not be important in the clinical diagnosis of FAI. (3)
• Stem cells are undergoing more research and have shown promising results. A study was conducted looking at the combination of hip arthroscopy and adjuvant intra-articular injections of expanded BM-MSCs (bone marrow – mesenchymal stem cells) seems to be safe and produce interesting results at middle-term follow-up in patients with large chondral defects or mild osteoarthrosis of the hip which are still not candidates or refuse a total hip replacement. (5)
• Prolotherapy and Platelet Rich Plasma (PRP) can be used for joint stability and degenerative changes in the joint space.
• Prolotherapy injections is a great therapy to help strengthen tendons and ligaments to improve joint stability. This therapy can be combined with physical therapy for further strengthening of surrounding muscles and appropriate ergonomics.
• Platelet Rich Plasma therapy involves using your own blood plasma and platelets as an enriched source of growth factors, immune cells to stimulate healing of bone and soft tissue. PRP has been shown to modulate the repair and regeneration of damaged connective tissue and delay further degeneration of connective tissue. PRP is a great therapy for partial tears and moderate arthritis.

Labral Tear

The labrum is a strong fibrous cartilage rim that deepens the hip socket and allows support for the hip joint.

Tears to the labrum can be from:

• Trauma due to extreme hip rotation such as in sports like hockey, soccer, gymnastics, and dance
• Common in individuals with hypermobile joints.
• Often associated with degenerative changes in the hip.

Degenerative changes are a result of chronic low-grade inflammatory responses from overuse. Chronic inflammatory responses produce degrading enzymes trying to clean up the inflammatory debris that overtime weaken collagen networks and breakdown cartilage predisposing the weakened cartilage to tear. Labral tears in the hip associated with degenerative changes are extremely common as we age and can be asymptomatic.

Common symptoms are hip pain in the front of the hip or groin. Pain may be associated with clicking, snapping, or locking.

Treatments include activity modification, anti-inflammatory medication (NSAIDs), and steroid injections. Therapies should be carefully considered due to chronic NSAID use being shown to lead to increased risk of stomach ulcers, acute renal failure, and stroke/myocardial infarction. Corticosteroid injections pain relief is temporary and can cause further soft tissue damage, cell death, reduced bone mineral density, and inhibit collagen synthesis.

Surgical repair may be indicated depending on the severity of the tear, associated degenerative changes, and age of the individual. Surgical repair can have positive clinical outcomes; however, it should be considered there is a strong potential progression of degenerative changes following labral repair or surgery to clean up the joint (arthroscopy). The degenerative changes from these surgeries can lead to needing a joint replacement or may lead to the need for revision surgery.

• A study examining 552 arthroscopic hip procedures for symptomatic labral tears found that 20 years post arthroscopic labral debridement (removal of torn or weakened portions of the labrum) 40% needed a total hip replacement. Common factors that increased conversation to a total hip replacement were those older than 40 years old and had the presence of combined femoral head and acetabular chondral damage. the probability of conversion to total hip replacement by 20 years post labral tear repair and arthroscopy from 12% for a patient younger than 40 years with a Grade 0-II femoral and acetabular Outerbridge grade to 92% (for a patient older than 40 years with a Grade III-IV femoral and acetabular Outerbridge grade. (2)
• In research done at Physical Medicine & Rehabilitation, Mount Sinai Hospital, New York they determined the importance of the evidence supporting the acetabular labrum’s role in preventing premature arthritis and enhancing stability of the hip joint. They found that when conservative measures fail, surgery is necessary and the philosophy behind this has shifted, now that there is evidence supporting the acetabular labrum’s role in preventing premature arthritis. Success rates of arthroscopic labral debridement (removal of torn or weakened portions of the labrum) are lower with worsening degrees of labral tear and secondary degenerative (osteoarthritis) changes. With these findings, they concluded that surgeons’ arthroscopic debridement of labral tears should be done to preserve as much healthy labral tissue as possible to stabilize the joint and prevent early-onset osteoarthritis (3)

Based on these findings regenerative medicine is an extremely important treatment for labral tears especially when there are degenerative changes in the hip joint.

• Platelet Rich Plasma therapy involves using your own blood plasma and platelets as an enriched source of growth factors, immune cells to stimulate healing of bone and soft tissue. PRP has been shown to modulate the repair and regeneration of damaged connective tissue and delay further degeneration of connective tissue. PRP is a great therapy for partial tears and moderate arthritis.
• PRP has shown promise as a minimally invasive treatment for hip labral tears. Studies have shown decreased pain and improved function with treatments.
• PRP injections can help not only in cases of osteoarthritis but also with high-level athletes who present with acute hip inflammation due to intra-articular pathology such as femoroacetabular impingement-induced labral tear. In these cases, PRP improves inflammatory symptoms and enables a quick return to play without the possible negative effects of steroids. (1)
• Autologous stem cell (from your own body) therapies using both mesenchymal stromal cells (MSCs) and hematopoietic stem cells have shown therapeutic potential for advanced osteoarthritis. In orthopedic injuries and degeneration, stem cells have the potential to signal for the repair of damaged tissue with possible regeneration of tissue. It is important to note that research is mixed with regard to whether regenerative medicine truly regenerates tissue. What does seem to be more reproducible is a decrease in further degenerative changes, pain, and improved function.

Avascular Necrosis (AVN)

Avascular Necrosis or Osteonecrosis is a result of decreased blood supply to the head of the thigh bone (femur), which sits in the socket of the pelvis. Without a blood supply, the bone is unable to get nourishment and dies (necrosis). Causes of disruption of blood supply can be from trauma such as fracture or dislocation, corticosteroid use, alcohol abuse, or blood disorders.

Common symptoms are hip, groin, or gluteal pain that may refer to the thigh or knee. Decreased range of motion with a catching or popping sensation.\

Treatment Options

• Avascular Necrosis grade I and II may respond to platelet-rich plasma and autologous stem cell treatments with stem cell sources from both adipose and bone marrow. Using both adipose and bone marrow allows for mesenchymal stem cells, which signal the body’s regenerative and healing mechanisms and hematopoietic stem cells, which signal for increased blood supply to the area. This is important because avascular necrosis is due to a lack of blood supply resulting in bone death.
  • Surgical intervention at this stage would be core decompression involving drilling into the area of dead bone to reduce pressure and increase blood flow.
  • A study cited below found a complete resolution of AVN in a 43-year old man after four weekly injections with a mixture of PRP and autologous adipose-derived stem cells (ASCs) into the femoral head under US guidance
• Avascular Necrosis grade III and IV which means there has been a collapse of the bone (femur head) usually requires an arthroplasty or full hip replacement.