If you suffer from the pain and stiffness of hip arthritis, a steroid shot may seem like a miracle. After all, anything that can give you complete relief from that pain (even if just for a short time) is amazing. However, a new study has found that these injections can cause a domino effect that results in even more serious hip problems. And that can happen very quickly.
Before turning to steroids that can damage bones, let’s give this a second thought. Especially since there are some proven safe and effective treatments for hip pain that won’t prove to be bone damaging!
Dr. Connie Chang, a radiologist at Massachusetts General Hospital, examined patients X-rays after hip steroid injection. She kept finding “rapidly” developing changes, namely bone “death and collapse” occurring several months after such injections.
Dr. Chang arranged a study of close to 250 patients with hip arthritis, some of whom received a steroid shot in their hip and some who didn’t. And as soon as three months later, she was finding “new” occurrences of bone death, eventually affecting up to a quarter of the volunteers who had been given a shot.
Along with that, around 17 percent of those who got a steroid shot suffered from bone collapse in the “head” of their femur bone.
Dr. Chang said that joint and bone changes in those with arthritis usually develop “slowly over time.” That’s been my clinical experience over the years. This is why I talk about your age and current pain levels before getting a cortisone shot. If you are young there is a lot of risk. If you are old but plan on living a long time, let’s talk about this.
The fact is that steroids can cause damage to your bones.
The Mayo Clinic warns that steroids are the most “common cause” of “avascular necrosis” (which is basically the death of bone tissue caused by a lack of blood supply, eventually leading to collapse of the bone) that isn’t caused by bone trauma.
The University of Michigan Medical School and the VA Center in Ann Arbor, Michigan, found that you don’t have to be taking steroids for a long time to suffer some serious side effects.
Even a low dose, such as 20 mg a day or less, can trigger sepsis… triple your risk of a blood clot… and double the chance of breaking a bone.
While steroids can be lifesavers, say, during a bad asthma attack, the truth is that, given the risks they come along with, they’re given out way too haphazardly.
Before you resort to a shot in the hip, why not first give these alternative treatments a try?
• Laser: This treatment uses light therapy and has been proven to reduce inflammation and decrease pain in numerous conditions, including arthritis.
• Shockwave therapy: This has been a remarkable therapy for my patients. It penetrates deep into the tissues to increase circulation and stimulate the breakup of scar tissue and other pain producing substances.
• Exercises: Having a skilled doctor that can guide you through stretches and exercises can help keep your hips moving smoother.
• Natural anti-inflammatories: Taking a daily supplement of omega fatty acids that contain DHA and EPA made by Metagenics (offered to our patients) is well known to reduce swelling, pain, and inflammation.
“Steroid injections for arthritic hips: More trouble than they’re worth?” Robert Preidt, November 29, 2017, U.S. News & World Report, usnews.com
What I do as a practitioner is provide the kind of care I want for myself and my family. My practice style is interactive, meaning we make decisions together, co-decide treatment options for pain relief, and I will help you achieve new range of motion. If you need weight loss I have very successful practical plans, and if you want to improve your fitness I can help guide you along. I’m formally trained in pain reduction strategies, flexibility and mobility training, weight loss, strength training, cardio and all its many forms, nutritional supplements, diets, and stress reduction. I have studied all of these concepts for 35 years. The things I continue to do and use are methods I know have worked for other people. I have stayed at the top of my game by staying in active practice, I’ve continued learning, I am an instructor to other Doctors around the world, I enjoy writing, sharing, and I continue to learn my craft.
I have been challenged by difficult patients with chronic pain, over-achievers with lots of stress, and patients with crazy character. I’ve learned and tried many different techniques, studied with masters and put together my own processes based on what works. For example if you ask me “What’s a good exercise?” I will say ‘One the patient does’ – I teach the ones I know patients do because I live it every day. As I have gotten older I have become more direct, a no nonsense style, and I have applied ‘healthy aging’ knowledge to myself and my patients. I am more serious about helping people regain lost range of motion in the neck, shoulders and back and then it is up to you to never lose it. That is my ‘healthy aging’ program for patients.
A session with me starts with getting to know you. Then we make a plan or program. Maybe you will need to schedule twice a week, once a week, once every two weeks. I don’t know that answer until we meet. I will teach you what you can do at home on your own. The truth is that what we do in the office is 10-20% of your change, the other 80-90% is what you do at home. Please call my West Los Angeles office 310-444-9393 for an appointment.
In this study patients with chronic low back pain who followed cognitive intervention and exercise programs (versus surgery) improved signi?cantly in muscle strength compared with patients who underwent lumbar fusion. In the lumbar fusion group, muscle density (meaning ‘weak muscles’) decreased signi?cantly at L3–L4 compared with the exercise group.1
In addition to exercise therapy for chronic low back pain, current treatments include laser therapy and shockwave therapy for spinal problems, especially when scar tissue has formed. If you have damaged spinal ligaments causing spinal instability or ‘Enthesopathy’ (areas of irritable ligament attachment to bone) a trial of exercise and laser is highly recommended.
Dr. Jeffrey Tucker has created new treatments combining laser therapy, shockwave therapy and exercise to stimulate stem cell activity. Most up-to-date doctors agree that treating back pain patients with conservative care is better than injections or surgery. Doctors that understand how to treat chronic low back pain such as degenerative disc disease, address the problems of spinal ligament instability and scar tissue formation by stimulating the body’s natural ability to regenerate the discs indirectly – decrease spinal stiffness, increase paraspinal muscle activation/strength, and increase hydration in the discs.2 This approach helps decrease pain in the low back.
Please feel free to call my office for a consultation 310-444-9393
- Keller A, Brox JI, Gunderson R, Holm I, Friis A, Reikerås O. Trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain randomized to lumbar fusion or cognitive intervention and exercises. Spine (Phila Pa 1976). 2004 Jan 1;29(1):3-8.
- Röllinghoff M, Schlüter-Brust K, Groos D, et al. Mid-range outcomes in 64 consecutive cases of multilevel fusion for degenerative diseases of the lumbar spine. Orthopedic Reviews. 2010;2(1):e3.
West Los Angeles Chiropractor
Patients who are thinking about spinal injections or surgery, or have had spinal surgery (fusion, disc procedure, etc.) should see a Chiropractor trained in proper exercise therapy and who uses laser therapy and other new technology such as acoustic wave therapy to improve spinal strength and stability. In addition, scar tissue and muscle atrophy needs to be evaluated and treated. This can help prevent costly and risky injections and surgery.
Why is failed back surgery syndrome so common? Researchers at the Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University in Japan:
Up to 25% of patients report unimproved or worse pain and up to 40% are not happy with the outcome of lumbar fusion.
The possible reasons for poor results include instrumentation failure, inadequate surgical technique, and poor patient selection.
In patients who had continued pain after back surgery, muscle biopsies revealed:
Atrophy of paraspinal muscles
Loss of muscular support leading to disability and increased biomechanical strain and possibly failed back syndrome.1
In another study researchers found that the muscles adjacent to the fusion (the paraspinal muscles of the lumbar spine) play an important role in recovery. The muscles become weak and unstable after a spinal fusion.2 If those muscles remain damaged or weakened, the spine is unstable and pain persists.2
I can’t say enough about this…Doctors at Oslo University Hospital examined patients who had continued pain 7 to 11 years after spinal fusion. They found reduced muscle strength and density of tissue one year after lumbar fusion: 27% reduction in muscle density.3 Again, patients need a skilled practitioner like myself to help them properly build strength and stability…but I recommend doing this before injections or surgery if at all possible.
1 Ohtori S, Orita S, Yamauchi K, et al. Classification of Chronic Back Muscle Degeneration after Spinal Surgery and Its Relationship with Low Back Pain. Asian Spine Journal. 2016;10(3):516-521.
2 Malakoutian M, Street J, Wilke HJ, Stavness I, Dvorak M, Fels S, Oxland T. Role of muscle damage on loading at the level adjacent to a lumbar spine fusion: a biomechanical analysis. Eur Spine J. 2016 Sep;25(9):2929-37.
3 Froholdt A, Holm I, Keller A, Gunderson RB, Reikeraas O, Brox JI. No difference in long-term trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain 7 to 11 years after lumbar fusion versus cognitive intervention and exercises. Spine J. 2011 Aug;11(8):718-25.
In a recent study in the journal PMR, (June 2017) a Washington University School of Medicine team found links between the hip and the spine affecting pain and function. The key finding was that hip disease, before it was even evident on an MRI as osteoarthritis, could cause problems in the lower back.1 The hip was the true disguised pain generator in back pain patients. This is no surprise to me and my patients. Every patient in my office has had a hip evaluation if they present with low back pain. This truly is a case where the science is catching up with what active practitioners have known for years.
What is this research telling us? If you had an MRI of your hip, and nothing presented itself as obvious, then the doctor may chase something in the spine that is not causing the pain.
The link that the researchers are still missing is that tight and immobile hips cause increased dysfunctional motion in the lower lumbar spine and this causes excess rubbing and irritation in the low back.
The same team of researchers, publishing earlier in February 2017 were also able to conclude that physical examination findings indicating hip osteoarthritis (loss of range of motion and acute pain) are common in patients who also have low back pain. A patient presenting with low back pain should be examined for hip osteoarthritis).2
1 Prather H, Cheng A, May KS, Maheshwari V, VanDillen L. Association of Hip Radiograph Findings with Pain and Function in Patients Presenting with Low Back Pain. PM&R. 2017 Jun 16.
2. Prather H, Cheng A, May KS, Maheshwari V, VanDillen L. Hip and Lumbar Spine Physical Examination Findings in People Presenting With Low Back Pain With or Without Lower Extremity Pain. J Orthop Sports Phys Ther. 2017 Feb 3:1-36. doi: 10.2519/jospt.2017.6567.
By Jeffrey Tucker, DC, DACRB
We all know if your feet hurt, you probably don’t function well, and we all know many patients complain of foot pain at one time or another. What are the exercise strategies we can use to help improve the function of our patients’ feet? I try to develop an exercise program for the intrinsic muscles, extrinsic muscles, neuromotor control and arthrokinematics. Here’s a four-phase program you can use in your practice.
Changing Foot Biomechanics: Start by Observing the Feet
Changing the foot biomechanics starts with the foot examination, which includes visual analysis, shoes and socks off. I note pronation, supination, calluses, bunions, hammer toes, a deviated great toe (hallux abducted valgus), and scars (especially surgical that the patient forgot to tell me about).
Visual analysis is followed by some functional tests (small knee bends, squats, etc.) and then palpation, feeling for point tenderness in the foot, ankle, calf, knee, etc. Palpation gives me an opportunity to trace the pain. As needed, I perform ortho and neuro tests, etc., and then maybe decide to offer the patient an orthotic. Read More
November 9-November 10, 2017 “Xiam, China – Deep Muscle Stimulator”
December 2-December 3, 2017 – St. Louis- Logan University “Performance Health #3” More Information
December 16-December 17, 2017 Minnesota- Northwestern University “Performance Health #1” More information
January 13-January 14, 2018 Minnesota- Northwestern University “Performance Health #2” More Information
January 27-January 28, 2018 Florida- Palmer College- “Be The Expert” More Information
February 17-February 18, 2018 Minnesota- Northwestern University -“Performance Health #3” More Information
April 6, 2017 – Las Vegas “CLX Training”
Both Shockwave and laser help damaged disc and bulges by:
- Stem cell activation: Stem cells are effective in inhibiting disc degeneration and disc herniation. It’s a pretty complex interplay between the stem cells and the immune system cells but the result can be disc tissue regeneration.
- Stem cell activation: This will promote regeneration of the outer tissue of the disc and help contain and lessen the bulge (scar tissue formation).
- Stem cell activation:The increased number of cells to the area brings more oxygen to the damaged disc and accelerates healing by reversing the low-oxygen (degenerative or dying) environment in the spine. Everything heals better and faster with increased oxygen.
- Stem cell activation reduces and prevents herniation by suppressing the non-healing inflammation.
Office phone 310-444-9393
References: Cunha C, Almeida CR, Almeida MI, Silva AM, Molinos M, Lamas S, Pereira CL, Teixeira GQ, Monteiro AT, Santos SG, Gonçalves RM, Barbosa MA. Systemic Delivery of Bone Marrow Mesenchymal Stem Cells for In Situ Intervertebral Disc Regeneration. Stem Cells Transl Med. 2016 Oct 11. pii: sctm.2016-0033.
One of the therapies I find useful for DDD is shock wave therapy. PiezoWave Pulse Therapy and EnPuls are two of the top brand names in this type of non-invasive treatment. Shock wave therapy changes the degenerative disease environment of the inner spine to a healing environment.
Shock wave therapy stimulates stem cells. When stem cells are stimulated towards the spine or a targeted joint they initially start a line of new communication with the immune system and begin exchanging messages. The stem cells tell the immune cells to call healing factors to the site of damage and to meet them at the points where repair is needed. This is when healing begins.
Using the current research to explain how this change of environment works: When introduced into a diseased joint or spine, stem cells display plasticity and multipotency. This is the ability to change/morph into other cell types and multiply. One of the specific cell types is called Mesenchymal stem cell (MSCs) or connective tissue stem cells. These suppress inflammatory T–cell proliferation and provide an anti-inflammatory effect. The shockwave treatment actually stimulates a ‘controlled irritation’ or ‘controlled injury’ that leads to the beginning of the bodies dampening effect on the chronic inflammation.1
Shockwave therapy also signals the native stem cells and other growth factors to regroup and begin repairing damaged joints.
Stem cells and the herniated disc
A bulging disc bulges because the soft jelly like nucleus (inner colloid substance of the disc) are able to push through the weakened, damaged outer wall of the disc.
New research suggests that stem cells, without direct injection to the site of disc lesions in the spine, can repair disc lesions by changing the healing environment of the spine.
1 Davatchi F, et al. Mesenchymal stem cell therapy for knee osteoarthritis: 5 years follow-up of three patients. Int J Rheum Dis. 2016 Mar;19(3):219-25
- Arthroscopy Journal 2015 – doctors concluded that PRP injections are a viable treatment for knee osteoarthritis and should be considered in patients with knee osteoarthritis.6 Studies like these add to the accumulating evidence that PRP can halt and reverse meniscus degeneration.7,8
- J Orthop Res. 2016 – doctors confirm that stem cell therapy stimulates the regeneration of meniscal tissue. Specifically with regard to post-meniscectomy meniscus growth (with stem cells).9 This means we can use the PIEZOWAVE and EnPuls to stimulate regeneration even after surgery.
- Doctors at the University of Iowa found that stem cells and cartilage cells could be influenced to migrate to the site of “white-zone” where the most difficult meniscus tears are. I use Laser therapy, PiezoWave Pulse Therapy and EnPuls shockwave to do just that!
- I do think stimulating the tissues with PiezoWave and EnPuls shockwave can promote regeneration and is a promising new strategy in meniscus repair.10
- Stimulating stem cell based strategies for meniscus tissue is a fundamental role in meniscal regeneration.
- Pihl K, Roos EM, Nissen N, JøRgensen U, Schjerning J, Thorlund JB. Over-optimistic patient expectations of recovery and leisure activities after arthroscopic meniscus surgery. Acta Orthop. 2016 Sep 13:1-7.
- Brelin AM, Rue JP. Return to Play Following Meniscus Surgery. Clin Sports Med. 2016 Oct;35(4):669-78. doi: 10.1016/j.csm.2016.05.010. Epub 2016 Jul 9. Review.
- Noyes FR, Barber-Westin SD. Long-term Survivorship and Function of Meniscus Transplantation. Am J Sports Med. 2016 Sep;44(9):2330-8.
- Niu W, Guo W, Han S, Zhu Y, Liu S, Guo Q. Cell-Based Strategies for Meniscus Tissue Engineering. Stem Cells International. 2016;2016:4717184. doi:10.1155/2016/4717184.
- Blanke F, Vavken P, Haenle M, von Wehren L, Pagenstert G, Majewski M. Percutaneous injections of Platelet rich plasma for treatment of intrasubstance meniscal lesions. Muscles Ligaments Tendons J. 2015 Oct 20;5(3):162-166.
- Campbell KA, Saltzman BM, Mascarenhas R, Khair MM, Verma NN, Bach BR Jr, Cole BJ. A Systematic Review of Overlapping Meta-analyses. Arthroscopy. 2015 Nov;31(11):2213-21. doi: 10.1016/j.arthro.2015.03.041. Epub 2015 May 29.
- Wu CC, Chen WH, Zao B, Lai PL, Lin TC, Lo HY, Shieh YH, Wu CH, Deng WP. Regenerative potentials of platelet-rich plasma enhanced by collagen in retrieving pro-inflammatory cytokine-inhibited chondrogenesis. Biomaterials. 2011 Sep;32(25):5847-54. Epub 2011 May 25.
- van Buul GM, et al. Platelet-Rich Plasma Releasate Inhibits Inflammatory Processes in Osteoarthritic Chondrocytes. Am J Sports Med. 2011 Nov;39(11):2362-70. Epub 2011 Aug 19.
- Seol D, Zhou C, Brouillette MJ, Song I, Yu Y, Choe HH, Lehman AD, Jang KW, Fredericks DC, Laughlin BJ, Martin JA. Characteristics of meniscus progenitor cells migrated from injured meniscus. J Orthop Res. 2016 Nov 3. doi: 10.1002/jor.23472.
- McCrum CL, Vangsness CT. Postmeniscectomy Meniscus Growth With Stem Cells: Where Are We Now? Sports Med Arthrosc. 2015 Sep;23(3):139-42. PUBMED Meniscus Growth With Stem Cells