Solving Hip Pain

By Benjamin J. Schwartz, MD

When Courtney Gilman limped into my clinic, it was hard to believe he was walking let alone working as a tennis professional. Courtney had all the classic signs: stiffness, groin pain, difficulty sleeping at night, abnormal gait, and significant limitation in his quality of life and activities of daily living. A physical exam revealed decreased rotation of his hip and reproduction of thigh and groin pain with resisted flexion of his leg. X-rays performed in the office confirmed what I already knew, Courtney was a classic case of advanced arthritis of the hip.

The CDC estimates that 54 million Americans have been diagnosed with arthritis by a doctor with 31 million suffering from osteoarthritis (often called “wear and tear” arthritis). While arthritis has often been thought of as a disease of the elderly, almost two-thirds of those diagnosed with the disease are under the age of 64. The number of arthritis sufferers is expected to climb close to 70 million by 2030 as the “Baby Boomer” population (those born between 1940 and 1960) ages. The burden of arthritis treatment on the healthcare system is expected to grow significantly with some concern that demand for services will outstrip the supply of arthritis doctors.

The most classic symptom of hip arthritis is groin pain (often described as a pulled muscle that never goes away) that is typically dull and aching in nature. Patients often experience loss of range of motion of the hip which can lead to difficulty putting on shoes and socks and a limp. It may become difficult to get up from a sitting position, lift the leg to get in and out of a car, negotiate stairs, or turn over in bed at night. In some cases, the pain may radiate into the front of the thigh and even as far down as the knee. Back pain may develop or worsen as a patient’s gait becomes altered to accommodate the stiff, painful hip.

Treatment for hip arthritis includes activity modification, physical therapy, non-steroidal anti-inflammatory medications (Motrin, Aleve, Advil), cortisone injections, ambulatory aids, and avoidance of offending activities. Because there is no known cure for arthritis, definitive treatment involves hip replacement surgery reserved for those who have failed other treatment and can no longer tolerate the pain and limitations caused by their hip.

Hip replacement surgery, also referred to as total hip arthroplasty or THA, involves removing damaged bone and cartilage and replacing it with a metal, ceramic, and plastic implants. The high success rate of hip replacement and ability of patients to return to pain-free activity after surgery have led some to label THA the “operation of the century.” Advances in anesthetic techniques, pain management protocols, rapid mobilization, surgical approaches, and implant technology has drastically changed the recovery from hip arthroplasty with many patients spending 23 hours in the hospital and healthy, motivated patients having their surgery on an outpatient basis.

Courtney was admitted to the hospital on the day of surgery and underwent spinal anesthesia with sedation which may allow for faster recovery and less risk to surgery. Using the muscle-sparing direct superior approach, his implants were placed while minimizing the damage to surrounding soft tissues. At the time of surgery, local anesthetic was injected into the surrounding tissues to aid in pain control and reduce the need for postoperative narcotic medications. Due to these measures, Courtney was able to ambulate with physical therapy the afternoon following his surgery and was discharged home the following day.

Several studies have shown that most patients do not require formal physical therapy after hip replacement surgery. Courtney was able to gradually increase his activities and was walking with minimal assistance within 2 weeks and without the need for regular narcotic medication. By 6 weeks, his gait and muscle strength had improved to the point that he was able to return to the tennis court and begin getting his game back.