Common Problems Around The Hip
With Mr Gavin McHugh

I am going to be talking about common problems around the hip. I will firstly talk about the kind of patient that you see and to start you have the ‘In Denial’ patient and thee are the type of people that just get on with things and they are often the last person themselves to notice that there is a problem. Everyone else in the family has noticed that this person has been on a downhill spiral for the last 2 or 3 years. They are maybe slower at getting around the place, they are often grumpy because they are not sleeping at night due to pain and they are considerably immobile. It is a classic with the hip in many ways because it often presents in such a slow and insidious manner it just creeps up in patients and I often describe it as a farmer in the mid 60’s as the classic stereotype but not often by any means and a lot of people can surprise you. If they come to a consultation with their partner they will always look across and say their not too bad and their partner is rolling their eyes up towards the ceiling and this type of patient tends to present with a lot of stiffness they struggle with things like getting their socks and shoes on, they might have problems if they are a farmer with things like uneven ground and walking distance can be reduced as well but they just knuckle down and get on with it.

There are sometimes people who just don’t like taking painkillers or you might get people who live off pain killers and anti-inflammatories for the last couple of years just to get through the day as I said they might not have even been able to put on their shoes and socks for the last couple of years so I just described the classic in denial patient. In general, they are walking with a really obvious limp but they are masking things quite well. They’re x-rays will generally show that they have advanced arthritis and really when it comes to having something done it is a little bit of a no brainer in terms of progressing with a hip replacement but as I say talking them in to going ahead can be half the battle sometimes again usually with the help of family members.

The second patient I like to present is the supergran type of character and people say “my mum is 85 and last year she was getting around the shops no problem and suddenly she has just really slowed up in the last while”. The reason I present it is because often it’s put down to something like getting older and I really don’t like the phrase that someone is getting deconditioned because they are getting older and generally they just have a warn hip and that is normally just a mechanical issue that is really slowing them down.

Sometimes patients will turn around to me and say am I not too old to have my hip replaced and I think to myself no your too old to not have your hip replaced because when you get older and your strength starts to reduce anyway then the last thing you want is to have a warn and painful hip and quite often I’ll suggest to patients that do go ahead with it that it represents their best opportunity or chance of getting back to normality afterwards and its pretty strange that as opposed to the insidious decline in the last patient quite often this can deteriorate quite quickly and some of the patients say that 3 months ago they can do something an now they no longer can. They say things like they can hardly get up to put the kettle on in the kitchen and as I say in terms of your mobility you will often jump down a level of mobility very quickly with any deterioration in that someone who is completely independent will go down to 1 stick then they will go down to a crutch or even 2 crutches and then as you see there they move onto the walking frame.

In many ways the more we can intervene to correct a mechanical issue the more we can keep people independent for longer and certainly I am of the belief assuming from a medical point of view that it is possible that hip replacement is not what it was like years and years ago in terms of what it takes and involves for the recovery process. Yes, the risks are there but they are considerably lower than many years ago when blood loss was considerably more throughout the surgery.

The third patient then that I will present is the 40 year old weekend warrior and this is someone who used to play a lot of sports so they may have played a lot of GAA growing up or football and they play 5 a side 2 or 3 times a week and again it just tend to come on, they may have been aware of the hip or niggle in their groin for quite a while, sometimes they are getting treated for a groin strain type of issue for the last year or so and it slowly is starting to creep in with them and they are finding it more and more difficult to go ahead with their indoor football or 5 a side or whatever it is they enjoy doing again it could be multiple different sports. It can progress quite slowly and often times they will appear going with a problem but not in bits so they are not able to go ahead with their day to day activities but more so their sporting days are becoming that bit more difficult and this is something that represents a dilemma because often they have a significant amount of arthritis in their hip but ultimately the only option for them is going to be a hip replacement but it is a real one to web. As opposed to the first two cases this is really one where you have to sit down and have a chat with regards to the risks and benefits of going ahead and whether or not the hip replacement is going to live up to your expectations and what you want and quite often these patients can be happy enough knowing what the problem is, knowing how to handle it and if that means taking an anti-inflammatory twice a week before playing their indoor football they can do that and manage things pretty well but in due course it will deteriorate with time but as I say there is a time and a place for everything but just jumping into a hip replacement is often not ideal in this type of patient cohort.

It can occasionally be worth trying a guided injection into the hip joint itself and again I’ll talk about that later but what I will often do with patients like this is and it sounds kind of strange but I say to them “the option is a hip replacement you come back when you’re ready” and the question they ask then is how will I know and I just say to them “you will know when” and sure enough they come through the door maybe 2 years later and say yeah I’m ready and what has triggered that is maybe it waking them up from their sleep during the night and that’s often the trigger, they may have noticed more difficulty with their day-to-day activities that they haven’t had before so even like trying to get through the day in work is more of a struggle and even things like getting into a car can require a manoeuvre as can putting on socks and shoes and that’s all the type of triggers that allow the patients to realise that they need something done.

This patient I will talk about now is the topic at the moment with the new documentary on Netflix which is very mesmerising and this patient is what I call the cliff edge patient and this is the patient who suddenly deteriorates and I’m talking about someone who goes from being completely normal to almost having a broken leg level of discomfort and this can happen over night after a minor twist and when I quiz these patients they may have been aware of a little bit of stiffness or the occasional bit of stiffness after sitting but then all of a sudden deteriorating rapidly to the point where they might come in on 2 crutches.

Often from a mechanical point of view what can happen is part of the cartilage that was worn has just flaked off or sometimes the bone beneath has just collapsed a little bit and it just gathers a large amount of inflammation and sever pain. It’s unfortunate that these are the type of patient that can’t wait a huge length of time to be seen as it is cruel to see the degree of pain that they can come in with and often although it may seem as an aggressive bit of action they are just better off going ahead with a hip replacement is the way to treat these it is almost the same as a broken leg with the same level of discomfort that they will present with.

The next patient that we see is called the double nappies and this is the patient who has had previous issues with their hip either as a child for example having a click in their hip or their mum saying they had to put on double nappies for a few months when they are younger. Occasionally they actually have been under the paediatric service and had procedures done to try and help their hip or essentially, they were born with a shallow socket or the hip just completely out of the joint. The procedures would have been to try and put the hip back in the socket and keep it there with time. These hips often function really well for a number of years but as I often say if you think of a analogy with regards to cars when you weren’t given the Mercedes of hips and if the hip is a little bit shallower then it will wear out at a certain stage. Some of these patients may have had a little limp especially more after demanding activities the problem is they do deteriorate early and that’s when I say they weren’t given the Mercedes of hips and often times they can be in their late 20’s early 30’s and this patient asks why have I got arthritis in my hip and as I say like a lot of things in this business it is purely a mechanical issue and because that socket is shallower it will wear with time and it leads to the development of premature arthritis in many ways and no different from all the other patients in general the treatment whilst we try and prolong things for as long as are reasonably possible the ultimate treatment for these patients is going to be a hip replacement and once again the odd one of these can get some improvement with an image guided injection with a course of physiotherapy to strengthen their glutes and muscle area in general can help and improve things.

With regards to physiotherapy in terms of the hip specifically I have no problem with strengthening activities in general ill often say to avoid lots of stretching activities and I often find if anything lots of stretches around the hip tend to aggravate the hip and make it worse and I have seen it make things worse and often that is the reason that they need to just pull back a bit from their stretching and they can get longer out of their hip essentially before they progress into having a replacement.

The next patient is the typical 50ish year old female who either attends reformer pilates or a yoga class and has started to notice some pain in their groin area, they may notice that some of the exercises they are doing in the classes allow them to notice that one leg is a bit different than the other but often they don’t have an awful lot of symptoms at this stage other than when they are doing their classes. This is often the patient where they’re not always sore but they are getting some degree of pain from around the hip and it is quite often that they come in expecting a hip replacement as such and they are thinking to themselves that they are ready for one. When talking to this patient about the pros and cons about everything I am a firm believer in thinking that if your range of movement in your hip is almost the same then a hip replacement isn’t going to make it an awful lot better and the fact is the movement in the joint afterwards can actually provide a bit of discomfort afterwards it’s very easy to irritate a lot of the muscles that work around the hip joint and you can be lead to be somewhat underwhelmed with the result of a hip replacement in this cohort of patients, I would certainly recommend an image guided injection in and around the area and quite often patients will get improvements from this and buy quiet a bit of time before progressing onto a hip replacement.

The common theme of this talk is injection versus hip replacement and why is that? Well keyhole surgery in the hip offers a very limited set of indications and in general these are younger patients who have got liberal tears which are the cartilage tears around the hip and in general if someone comes in and sees me in their 40’s, 50’s, 60’s with hip pain then there is no option for something like keyhole surgery on the hip so we are left with doing nothing, trying an injection and anti-inflammatories versus some kind of a hip replacement and again these patients have to be very strong in deciding whether or not they are going to go ahead with it.

The next patient is the high-level endurance athlete and they might not be an ultra-marathon runner but they might just love running 10km’s regularly, they might’ve done a Dublin marathon or competitive running in the time frame of last year. These are the people who are left really disappointed to find out that they have arthritis in their hip and it is quite strange as it may have been developing for several years but because they are fit and active they are not really aware of it and as I said they are quite disappointed to discover they have well established arthritis in their hip and ultimately all I can offer is a hip replacement.

It’s interesting while some surgeons do allow their patients back running I tend to say that in general from a mechanical point of view it doesn’t make a lot of sense to me doing a lot of running after a hip replacement. I absolutely would look at a hip replacement as an opportunity to get back to the vast majority of things that you enjoy doing and if that is football, tennis, golf all of these activities are absolutely fine I even have no problems with skiing but if you are the type of person who runs 10km 5 times a week I think that from a mechanical point of view it is likely to catch up with that hip and cause premature failure of the hip and I think getting more focused on something like swimming or cycling will buy them a lot more time with their hip be it replaced or not. It is the type of patient who is really disappointed to learn that they have arthritis in their hip and in due course their only option is going to be a hip replacement. Over the last generations we are pushing boundaries more and more and their not even in their 40’s but they are in their 50’s, 60’s and I have seen 70’s I remember one gentleman who ran a marathon in his early 70’s and it is just incredibly demanding on your body and whether we like it or not as we get older in age our collagen is changing and as it changes it makes us more and more prone to developing injuries and sometimes they are in the form of tendon injuries and tears or sometimes they are just discomfort in tendons or they are joints starting to give way and be weight bearing joints whether it be the hip, knee or ankle and as I said it can be frustrating to know whilst their mind is fully focused they have a joint that is letting themselves down.

The next patient then I will mention is my common patient that is females around the age of 50 who enjoys walking and a lot of middle-aged females enjoy walking and it’s great because it coms with so many additional benefits but quite often these people are often either just perimenopausal or postmenopausal and it’s a particular I suppose in some ways something that I see quite frequently is that they come in presuming that their hip is worn and in actual fact their hip is absolutely fine and where they’re sore or painful is over the outside of the hip itself or just to the side of the buttocks, essentially they can’t lie on that side as it is incredibly sore so to even press the bony prominence over the side and as I say this is completely unrelated to the hip joint itself which usually presents with pain in the groin area and that the pain is on the outside but it can be extremely severe as well and really stop people in their tracks. This as I mentioned in terms of tendon is where your gluteal tendons insert into the tip of the ridge counter and unfortunately, they are put under a lot of demand when we’re walking, the insertion becomes either inflamed or just mildly degenerative and I often describe it as a frayed rope in terms of how it’s presenting and giving symptoms.

These are the patients who not needing a hip replacement need a course of physiotherapy and can potentially get relief with a steroid injection over the area and quite often it will take a second or third injection to settle this down and sometimes people’s own GP will be able to give this. Sports Medicine will often do a lot of these as well and I’ll do some myself. It’s not the actual hip that is the cause of the problem extremely common, I had one clinic last week and I must’ve seen 12 people in a row with a similar problem and it just seems to come in ways potentially around this time of year as well people are trying to do more walking over the summer and it’s only after a couple of months that it really starts to limit them in their tracks and on one hand whilst I think the exercise is really good and comes with multiple benefits not just from a musculoskeletal point of view but it is activity related and some times it does mean pulling back on the walking a bit. In general, stopping the activities isn’t going to work in with these degenerative types of conditions as if you stop the activity as soon as you start back a few weeks later it will come back with a vengeance so you have to try limit your activities and to strengthen the area up with some physiotherapy, steroid injection and I’ll often suggest a talk with their GP in terms of the assumption that they are perimenopausal that the formulations of HRT that are available now can make a considerable difference and I think there is no doubt that oestrogen plays a very important role, obviously it’s well beyond the remit of my expertise but as I say it’s just something that I see quite frequently.

Even though arthritis is quite common it can present in a multitude of different ways with pain and discomfort and at the end of the day it makes a lot of sense to get these issues addressed and treated to potentially prevent them getting worse with time.

I would say in general if you are not in a lot of pain you probably don’t need a hip replacement just yet, particularly if you are younger I would say it is a case of just getting a bit more out of it.

I spoke about the disability aspect of things as well and I am conscious sometimes in younger people that a lot of stiffness can really cause trouble and catch up. Again, that’s where the consultation comes in we’re seeing someone and seeing how much they act and behave and how it is interfering with things as that helps make the decision.

My general answer to everything is yes. The only thing I allude to is long distance running and that is something I recommend you stay away from but the kayaking specifically would cause quite a bit of flexion but there are precautions we put in place for the first few weeks until everything heals up. After that, I ideally want someone to have as close to a normal hip as they can so I’m happy with whatever.

Years ago, the risk of a hip dislocating or popping out of a socket was considerably higher when not to get too technical but we used a lot smaller of a head in comparison to what we would use now. In most females now, we would use a 32-millimetre head and in males it would be a 36-millimetre head and as you can imagine it has to jump the radius in order to get out whereas years ago the head was only 22-millimetres and it was much smaller. It should enable people to enjoy a lot more activities as such.

Absolutely, we actively give people the Nordic walking poles usually a couple of weeks post operation and that’s just to promote the style of walking, the Nordic style is actually really beneficial after a hip replacement in terms of getting you upright and getting the weight going through the hip and getting a normal gate pattern without limping so I would actively encourage it.

Probably not is the answer. Injections in a hip can be a little bit hit or miss and they do seem to work a lot better on the knee but I do think if you get it early in the hip there is a real role for it and some people can get lucky and get 8/9 months out of a single injection but it’s not going to do any harm but is it going to help anymore? Possibly not.

In general, I would say yes. I often describe that a hip’s own worst enemy is itself and the general consensus in among the public is that hips are fantastic and easy and have no problems.

Knee’s on the other hand are not as good and the outcomes are not as good so I think people come in with a lower expectation for knees and a lot of the happiest people you will see are people that have had their knees replaced and they say it was a complete game changer.

On a similar level with a hip, if someone comes in with a little bit of discomfort either over the side which I spoke about or the occasional pinch in their groin that they were almost quite disappointed with it because they were expecting it to be perfect.

At the end of the day it is a replaced joint it is generally a replaced joint that is far better than the one that was in 97/98% of the time and half of them would have forgotten that their hip was replaced. Some people do just have that conscious sensation that it just feels a little bit different whether that is psychological or not I don’t know.

The ball is in the socket so it should not move within the socket, bar a millimetre or two but just normal walking it is articulating in and against the socket.

Anything can happen to the socket as well, the socket can migrate in the bone that it is fixed in but it’s extremely unlikely and other things can happen but it is so rare now a days with hips thankfully because they rarely move once they’re in and we sometimes see hips that are 20/25 years and they start to cause problems such as actively loosening or wearing away the plastic liner that tends to be older hips that have been in place for years where the plastic wasn’t the same high quality as it would be now, we don’t really see it on modern implants.

Most people would start with their GP referral and I think occasionally that is important as well especially because people will be going through their insurers and more often than not you will see insurers asking their clients for the GP referral as it is just one little obstacle that they like putting in the way, I think you should attend the GP anyway but I think it can make things safer for them in the long run also.

The problem with a bilateral in the first two days means you are almost like a tortoise on its back because the single hardest thing is getting out of bed so you actually have to start with the hardest activity. Normally if you have one side done you can use the other leg to help yourself up a little bit but with both hips done its just that little bit more challenging.

Once you get over that first day or two it is almost like the two hips recover at the same pace and I have patients coming back 6 to 8 weeks post operation and there really is no difference in the bilateral in comparison to the one side done on a hip replacement.

It is the same with bilateral knees from my point of view there is no motive behind me to do the two but I have seen it work so often and I think it really is an opportunity for patients sometimes to get things fixed rather than push it out for another six months to a year.

If it’s on the same side in general the consensus would be that you would start with the hip above because the hip will occasionally refer the pain to the knee but a knee will not refer pain to the hip so we tend to address the hip first.

On the odd occasion I have actually done the hip and knee together at the same sitting it is a little bit more unusual than say both hips together and both knees but it really just depends on the patient.