Preventing arthroscopic hip surgery or replacement
Tips for chiropractic patients and care providers on avoiding arthroscopic hip surgery or hip replacement
In the United States, 3-7% of older adults will deal with some form of hip osteoarthritis during their lifetime. “Osteoarthritis” or “OA” is the proper term for overuse or age-related degenerative joint conditions. While there are other types of hip problems such as fractures or soft-tissue injuries, the majority of people will be diagnosed with and seek care for the degenerative type, attempting to in the end avoid arthroscopic hip surgery.
Hip replacements and alternative methods
These degenerative hip problems result in almost 200,000 hip replacements each year in our country. Not only are these surgeries expensive, but they involve intense and time-consuming rehabilitation, as well as the potential for a variety of postsurgical problems.
While some individuals may truly need arthroscopic hip surgery, many others are either borderline surgical candidates or not prepared to go under the knife without first exhausting other treatment options. In these cases, a combination of appropriate exercise and chiropractic care may significantly delay the need for surgery or even help avoid it altogether.
Exercise for supporting muscles
Exercise and physical activity are widely known to have a positive effect on the health and condition of our joints. When looking at the hip, we find a large “ball and socket” joint between the femur and pelvis that bears much of our weight when doing any “vertical” activity such as walking, running or standing.
Surrounding that joint and providing dynamic support is a complex arrangement of muscles including the glutes, hip flexors, quads, hamstrings and adductors, just to name a few. Weakness in these muscle groups can put unwanted, additional load on the hips and result in excess wear and tear. By engaging in regular exercise, especially resistance exercise, we can ensure that the supporting muscles around the hip are strong and have the ability to support the hip throughout our daily activities.
Another added benefit of physical activity is that exercise can stimulate chondrocyte activity in joints. Chondrocytes are the small, cellular structures that maintain and produce the cushion-like connective tissue surrounding and lining most of the joints in our body. If we can stimulate chondrocyte activity, we can aid in the physical process of repairing damaged tissue and building new, healthy tissue.
The good news is that if you aren’t comfortable in a gym environment or your degeneration is too advanced to participate in “traditional” weightlifting, even the simplest body weight exercises can be extremely effective. Movements like air squats, lunges, hip thrusts/bridges, etc., are safe and efficient methods of improving muscular strength and endurance. If patients have the strength and ability to engage in even more demanding types of exercise, encourage them to do so.
Strength exercises vs. cardio
If resistance exercise is good, what about cardio? Like walking or running? The answer is somewhat complex.
Many studies show that in the context of hip health, it may be possible to overdo certain types of cardiovascular activity. A study from 2015, which measured how much load our hips experience when moving, showed that when walking, an average adult will experience hip contact forces of approximately 4 to 5.5 times their body weight. That load may increase up to 10 times our body weight when running 12 km/h (approximately the pace of an 8-minute mile).
For example, a 180-pound individual will experience hip contact forces of nearly 1,000 pounds when walking, and upwards of 1,800 pounds when running. Does this mean cardiovascular exercise is necessarily bad for the hip? No, but we must understand that those hip contact forces do create a cumulative effect over time. Multiple studies show a positive relationship between a runner’s age, running pace, total mileage and degenerative hip disease, likely due to the increased hip contact forces that occur during running.
What does this mean for patients? While we can’t make specific recommendations for cardiovascular exercise, we do know that extremely high mileage combined with a fast running pace could put you at a higher risk for degenerative hip problems, and the more degeneration there is, the more likely you are to encounter problems. In the context of hip health, this means a regular walking routine may benefit patients greatly, while running must be carefully managed.
If you want to engage in more vigorous cardio, try something like swimming or an elliptical that takes some of the load off your joints.
In adding exercise to a “surgery-prevention routine,” the chiropractor or physical therapist should determine what types of movements and loads are appropriate while making sure patients follow proper and safe form. When utilized properly, exercise can play a valuable role in delaying the need for arthroscopic hip surgery or other surgical intervention.
Research and the chiropractor’s role
Numerous studies have been aimed at the relationship between chiropractic/manual therapy and degenerative hip disease, but one highlights the benefits extremely well.
A 2004 study compared “manual therapy” to “exercise therapy” in 109 individuals who were previously diagnosed with hip osteoarthritis. The exercise group focused on active exercises to improve muscle function and joint motion. The manual treatments (aka chiropractic care) included: identifying and stretching the short/tight muscles within the hip complex, traction of the hip joint, and manipulation of the joint in “each appropriate limited position.”
The participants were split into two groups and treated over a five-week period, and the results were very impressive:
Primary outcome success rates were 81% for manual therapy compared to just 50% for exercise therapy;
The manual therapy group had significantly better outcomes for improved range of motion, hip function, stiffness and pain;
The positive outcomes experienced by the manual therapy group endured after 29 weeks.
In addition to manipulating the hip joint, another consideration should be leg length difference (LLD), a sign of biomechanical issues with the pelvis, SI joints and/or lumbar spine. Interestingly, research shows a potentially strong relationship between LLD and the occurrence of degenerative hip disorders, likely because altered weight-bearing on a joint could be a contributing factor for osteoarthritis. While there are other methods of analyzing pelvic/low back function and alignment, the research focuses on LLD because it’s easily quantifiable and reliable.
LLD and stressors
Researchers propose that pelvic tilt or torsion, visible through measured leg length difference, places unequal stress/load on the hips and potentially reduces the contact area of the cartilage within the joint.
The combination of these stresses may increase pressure on the cartilage and bone within the joint, leading to degenerative hip conditions. We see evidence for this in a survey of 100 patients who were diagnosed with hip osteoarthritis. The researchers measured each person’s LLD just prior to hip surgery and found that their hip osteoarthritis was on the side of the longer limb 84% of the time. Other studies have shown very similar findings with regard to knee osteoarthritis as well.
For chiropractors treating patients with degenerative hip issues, the focus is on restoring normal joint motion to the hips, as well as eliminating or reducing the amount of measured leg length difference. Regardless of what methods or techniques are used to accomplish this, addressing these areas may significantly reduce the need for surgical intervention and have a positive impact on patients’ overall function and pain levels.
Arthroscopic hip surgery and variable options
While some patients truly need arthroscopic hip surgery or replacement to protect their quality of life, many others have options when it comes to degenerative hip issues.
Appropriate exercise programming, combined with specific chiropractic care, may drastically improve an individual’s function and mobility, significantly reduce their pain levels, and either delay or avoid the need for surgical intervention.
By Daniel Keadle, Read more: Chiropractic Economics