Low Back and Hip Pain

From 33rd Annual Fingers to the Toes, sponsored by the University of California, Davis

Educational Objectives

The goal of this program is to improve management of low back pain (LBP) and the differential diagnosis of hip pain. After hearing and assimilating this program, the clinician will be better able to:

1.   Identify which types of LBP are most amenable to acupuncture.

2.   Recommend manipulation and mobilization techniques as complements to the medical management of LBP.

3.   Explain prolotherapy treatments intended to alleviate pain by stimulating the repair of connective tissues.

4.   Diagnose patients presenting with hip pain of unknown origin.

5.   Determine appropriate treatment for conditions causing hip pain.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Davis is on the Speakers’ Bureau for Genzyme Biosurgery. Dr. Meehan receives research support and honoraria from DePuy Ortho­paedics. The planning committee reported nothing to disclose.

Acknowledgments

Drs. Davis and Meehan were recorded at 33rd Annual Fingers to the Toes, held June 13-18, 2009, in South Lake Tahoe, CA, and sponsored by the University of California, Davis, Health System, the Office of Continuing Medical Education, and the Department of Orthopaedic Surgery. The Audio-Digest Foundation thanks the speakers and the sponsors for their coopera­tion in the production of this program.

Alternative Treatment Options for Low Back Pain

Brian A. Davis, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, University of California, Davis, School of Medicine, and Director, Physical Medicine and Rehabilitiation Sports Medicine Fellowship, Sacramento

Background: low back pain (LBP) costs $100 to $200 billion annually (2006); 90% of costs utilized by 10% of pa­tients; speaker asserts acute back pain does not typically resolve in 4 to 6 wk; 10% to 15% of patients presenting with acute LBP develop chronic pain; chronic pain highly resistant to treatment (patients develop physical, psycho­logic, and mechanical defense mechanisms)

Acupuncture: needles inserted along mechanical grids called meridians; manipulated either manually or electrically (manual treatment requires spinning and twirling of needles); traditional Eastern narrative  —  based on principles of “body energy balance” between universal forces known as yin and yang; imbalances said to disrupt flow of bodily energy (“Qi”), creating illness; discrepancies exist between 2000 documented treatment points and 30 to 40 well-accepted meridian charts (interferes with communication and control of research); empirical explanation  —  reasons for efficacy unclear; possibly linked to release or decrease of neurotransmitters (eg, enkephalins, endor­phins, endogenous opioids); gate theory of pain control states input from larger pain fibers blocks input from smaller fibers; slow pain information may be moderated by inhibitory pain gate neurons, typically larger or faster fibers; data indicate possible release of immuno- or vascular modulators; increases in adrenocorticotropic hormone documented after acupuncture (indicating possible sterol- or steroid-mediated effects); increases in substance P, bradykinin, serotonin, and tumor necrosis factor found near trigger points (similar to acupuncture points) after treatment; costs and benefits  —  no additional costs identified (compared to self-care or massage); rare complica­tions noted (typically local bleeding); often not covered by health insurance; provided by some worker’s compensa­tion programs; contraindications  —bleeding disorders (relative in patients with international normalized ratio of 2.5 to 3.0; acupuncture avoids deeper tissues; bleeding typically superficial and tolerable); platelet count below 50,000 to 75,000 per μL; adjacent skin infections; septicemia; relevant psychiatric illnesses; avoid electrical acu­puncture across brain, pacemakers, or other vital structures (eg, gonads); efficacy criteria  —  high expectations of treatment associated with poorer results; patients with lower expectations may do better; longer duration of symp­toms associated with decreased benefit (American College of Physicians and American Pain Society state that treatment still permissible after 4 wk of symptoms; meta-analysis  —  found acupuncture potentially as effective as active treatments (eg, mobilization, physical therapy, medication); randomized controlled trials (RCTs)  —  found superior to receiving no treatment; comparison to sham or placebo yielded conflicting data (may indicate better re­sults with only short-term follow-up); acupuncture found worse than massage therapy with long-term follow-up (hands-on aspect of massage may boost placebo effect); manipulation shows probable superiority in short and long-term; conclusion  —  greatest benefit when used in conjunction with other treatment options (ie, as adjunctive mea­sure)

Manipulation (mobilization): based on theory that minor skeletal misalignments can lead to pain and autonomic dysfunction; misalignment may cause negative feedback to nervous system, leading to afferent or sympathetic dys­function in periphery; high-velocity low-amplitude techniques  —  most common form of spinal manipulation ther­apy (SMT); joint goes slightly beyond passive range of motion; frequently accompanied by audible noise (possible cause, formation and dissolution of gas bubbles in joint due to pressure differences); efficacy  —method of action unknown; best evidence suggests treatment of primary afferent dysfunction within paraspinal tissues (may cause defects in motor control and pain processing); SMT may alter orientation or position of trapped autonomic struc­tures; afferent/efferent problem may cause autonomic dysfunction (as in reflex sympathetic dystrophy or complex regional pain syndrome); cost-effectiveness  —  cost of SMT similar to that of other outpatient therapies; SMT alone found better value than SMT plus exercise program; often covered by health insurance and worker’s compensation (typically limited to specific number of sessions); contraindications  —  infection; cancer; fracture; instability; sig­nificant neurologic deficit; leg weakness (not universal; high velocity techniques should be avoided where neuro­logic problems could be aggravated; speaker recommends massage and gentle stretching techniques for patients with conditions such as osteoporosis); risks  —  local pain; headache; fatigue; radiating pain (irritation of small nerves leading to other autonomic pain); cauda equina (risk 1 in 4,000,000 - 1 in 128,000,000); disk herniation (risk ³1 in 1,000,000); serious complications typically associated with unskilled practitioners; identifying reliable chiro­practors critical; speaker recommends constant communication to ensure only specified treatment given; worsening of radiculopathy reported; efficacy criteria  —  £2 wk of symptoms; pain proximal to knee; low scores on fear-avoid­ance belief questionnaire scores (indicating patient does not perceive work or activity as cause of pain); decreased mobility in ³1 levels of spine; 1 hip with internal rotation >35 degrees (indicated in RCT results); unknown how well SMT works in patients with chronic LBP; RCT results  —  4 out of 6 studies from 1997 to 2006 recommended SMT for chronic LBP; found equal to nonsteroidal anti-inflammatory drugs plus exercise; SMT found superior to “usual medical care” or placebo (speaker found study questionable); mobilization and distraction techniques found superior to exercise (short-term studies); high-dose SMT typically better than low-dose SMT; SMT found superior to acupuncture, chemonucleolysis, and other medication regimens; conclusion  —  review of studies finds SMT value equal to exercise programs in both short- and long-term treatment of chronic LBP; SMT may have potential for treating acute LBP

Prolotherapy (sclerotherapy): injections (typically targeted at ligaments or musculotendinous junctions) designed to promote repair of connective tissue; dates back ³60 yr; often combined with SMT; injections into any or all of posterior ligaments; rationale  —  attempts to create organized connective tissue to support loose or incompetent structures; common injection solutions  —  hypertonic dextrose (theoretically creates chemoattractant effect by dehy­drating and destroying cells); pumice flour (data indicates chemoattractant or chemotactic effect); RCT results  —  2 studies showed positive improvements in pain and disability; both evaluated 6 weekly injections of dextrose, glyc­erin, phenol, and lidocaine solution into lumbosacral ligaments vs anesthetics; all patients  did exercise, flexion-ex­tension stretching, and received steroid injection into gluteus medius; at 6 mo, prolotherapy group reported superior outcomes; 3 additional studies found no benefit of prolotherapy compared to placebo (after randomization); Co­chrane systematic reviews  —  found poor patient selection and significant treatment differences; could not summa­rize data, but results generally not positive when used in isolation; risks  —  accidental injection into spinal cord; nerve damage; headache and diarrhea (common); pneumothorax (rare); conclusions  —  no clear proven efficacy; may produce best results in combination with other treatments; overall risks low, but major complications possible

Differential Diagnosis of Hip Pain

John P. Meehan, MD, Associate Professor of Orthopaedic Surgery, and Chief of Adult Reconstruction Ser­vice, University of California, Davis, School of Medicine, Sacramento

Background: speaker reports successfully diagnosing hip pain based on history in 95% of cases; dividing pain into intra- or extra-articular classifications recommended; differential should proceed through 1) life- and limb-threat­ening conditions, 2) common conditions, 3) rare conditions; abdomen, lumbar spine, pelvis, and hip joint may refer pain to hip (in isolation or combination); speaker does not recommend dealing with proximal pain before hip pain (focus on pain reported as most problematic); abdominal causes  —  rectus muscle tears, hernia, and diverticulitis; lumbar spinal causes  —spondylolisthesis, disk disease, and stenosis; posterior gluteal pain typically correlates to lumbosacral (LS) spine; hip pain rarely descends below knee (pain below knee typically originates from LS spine); anterior pain  —  eg, groin pain, typically related to hip; gluteal pain and LBP  —   pain from back down left leg typi­cally indicates radicular pathology; side pain typically correlates to bursitis, iliotibial band syndrome, or trochan­teric bursitis; anterior groin pain  —  typically related to hip (originating from obturator nerve); pelvis  —  includes sacroiliac joints and synthesis pubis (in addition to hip joint); speaker recommends checking for insufficiency frac­tures of pubic rami and sacrum in elderly patients or osteopenia; hip joint  —  surrounded by extra-articular struc­tures (eg, tendons, muscles, ligaments, nerves) and intra-articular structures (bone, cartilage, labrum, synovium); many major nerve routes pass through hip; involvement of inguinal ligament may produce hernias; also includes neurovascular structures, cartilage (end of bone and fibrocartilage of labrum), and capsule

Life- and limb-threatening causes: identifying malignancies and metastases critical; “BLT and Kosher Pickle” (breast, lung, thyroid, kidney, and prostate)  —  mnemonic for recalling most common sources of metastases to bone; primary bone lesions typically sarcomas and myelomas (sarcoma predominant); infections  —  uncommon in nonreplaced hips (speaker reports 1 to 2 annually); should receive low priority on differential; infected hips almost universally unsalvageable because diagnosis typically does not occur before advanced stages; hip fractures and trauma  —  patients typically unable to walk; patients with stress fractures may walk with great difficulty (uncom­mon; speaker reports 1 to 2 stress fractures per year); femoral neck fractures  —  relatively common; majority of pa­tients unable to walk; not frequently caused by bone-destructive lesions

Examination: speaker recommends covertly observing patient’s walking (ie, without patient knowing); patients un­able to walk require additional attention; touching patient and correlating results with anatomy provides valuable information; Trendelenburg gait  —  stems from sagging of pelvis created by weak gluteus medius or gluteus mini­mus abductors; observed in children with cerebral palsy, severe hip arthritis, and nerve palsy; “toddler” gait” with center of gravity pushed to weaker side; antalgic gait  —  patient avoids bearing full force on painful leg; typically presents with quick transition between feet and minimized stance phase

Common causes: soft tissue disorders  —  predominantly bursitis (iliotibial or greater trochanter most common); healthy bursae typically empty of fluid, aside from small layer which moves without friction; inflammation causes bursae to swell with fluid (source of discomfort); trochanter injection  —  difficult to confirm placement in hip joint without radiography; push needle down to bone, pull back 1 to 2 mm, and inject (speaker recommends spinal nee­dle  and lidocaine); affects entire area; high patient satisfaction and 90% to 95% success with 1 to 2 injections; psoas tendinitis  —  less common; psoas tendon may break over iliopectineal prominence of pelvis; more often asso­ciated with groin pain; response to injection of cortisone into iliopsoas tendon sheath confirms diagnosis; adductors and hamstrings  —adductor injuries common in hockey and soccer players (hamstring in sprinters); adductor trauma typically produces groin pain (palpation should reveal pain source near origin of adductors on pubic rami); ham­string trauma originates closer to back (near hamstring origin at ischium); osteoarthritis  —  primary causes consid­ered once secondary causes excluded; identifiable secondary causes include avascular necrosis, developmental dysplasia, posttraumatic, rheumatoid arthritis, post-slipped capital femoral epiphysis, post Legg-Calvé-Perthes dis­ease, Paget’s disease (uncommon); radiographic signs of arthritis  —narrowing of joint space; osteophytes, sub­chondral sclerosis; periarticular cyst; invagination of synovial tissue into bone may produce subchondral cysts; primary osteoarthritis  —  typically unilateral in patients 60 to 70 yr of age; classified primary when opposite hip ap­pears healthy (secondary causes frequently involve both hips); presents with medial narrowing of joint space (supe­rior space normal); avascular necrosis  —  severe necrosis of femoral head; associated with trauma, corticosteroid treatment, and alcohol consumption; mean age of onset »35 yr; 10% of primary total hip replacements; societal costs outweigh procedural costs; unrecognized developmental dysplasia  —  insult to hip occurs at young age and infects growth plates; unhealed femoral neck fractures  —  patients typically present with failed pins; candidate for hip replace­ment; chronic bone remodeling  —uncommon now due to improvements in medical management of rheumatoid arthritis; labral trauma  —  more common in younger patients (often with history of trauma); x-rays typically normal (mag­netic resonance arthrography recommended); traction to expand hip joint recommended before inserting instru­ments (prevents trauma to articular cartilage); canes  —  reduce joint reactive forces; used in hand on contralateral side; touchdown weightbearing of leg preferable to no weightbearing (touchdown relaxes muscles across hip); im­pingement of hip  —  recent diagnosis (science still evolving); describes abnormal and painful contact between ace­tabular margin and femoral head in physiologic range of motion; cam-type femoroacetabular impingement  —  typically results from increased radius of femoral head in certain dimensions; eccentric osteophyte or improper de­velopmental formation of femoral head causes impingement (typically anterolateral) during flexing; may cause shearing injury of articular cartilage at margin of joint; treatment involves surgically reshaping femoral head into proper sphere; pincer-type femoroacetabular impingement  —less common; occurs between rim and femoral head-neck junction; small femoral head may cause impingement of labrum during flexing; greater prevalence in women (cam-type more common in men)

Surgical options: hip arthroscopy (more difficult procedure than knee arthroscopy); iliotibial band surgery (at­tempted when injections and stretching fail); prophylactic pinning (for femoral neck fractures); surface replace­ments (decreasing in popularity); hemi and total hip replacements; osteotomies; fusion; resection arthroplasty (avoided except in cases of unresponsive infection); osteotomy of femur  —  reorients femur to promote healing across fracture; fusion  —  uncommon due to success of joint replacements and other surgeries; hemiarthroplasty  —  common treatment for femoral neck fractures in elderly patients

Rare causes: osteopetrosis  —  bone becomes extremely tough and appears “marble white”; results from disorder of osteoclast function (impairs removal of old bone); synovial osteochondromatosis  —  metaplasia of synovium into rice bodies in cartilage

Suggested Reading

Braly B: Clinical Examination of the Athletic Hip. Clinics in Sports Medicine 25:199, 2006; Childs JD et al: Identifying pa­tients with low back pain who are likely to benefit from spinal manipulation. Annals of Internal Medicine 141:I39, 2004; Dage­nais S et al: Side effects and adverse events related to intraligamentous injection of sclerosing solutions (prolotherapy) for back and neck pain: a survey of practitioners. Archives of Physical Medicine and Rehabilitation 87:909, 2006; Harbach H et al: Minimal immunoreactive plasma b-endorphin and decrease of cortisol at standard analgesia or different acupuncture tech­niques. European Journal of Anesthesiology 24:370, 2007; Hawker G et al: Understanding the pain experience in hip and knee osteoarthritis – an OARSI/OMERACT initiative. Osteoarthritis and Cartilage 16:415, 2008; Hettinger DM et al: As­sessing the effect of sample size, methodological quality and statistical rigour on outcomes of randomised controlled trials on mobilisation, manipulation and massage for low back pain of at least 6 weeks duration. Physiotherapy 94:97, 2008; Pfirrmann CWA et al: Cam and pincer femoroacetabular impingement: characteristic MR arthrographic findings in 50 patients. Radiol­ogy 240:778, 2006; Tibor L, Sekiya J: Differential diagnosis of pain around the hip joint. Arthroscopy: The Journal of Ar­throscopic & Related Surgery 24:1407, 2008; Walker P et al: Lateral hip pain: does imaging predict response to localized injection? Clinical Orthopaedics and Related Research 457:144, 2007; Wang SM et al: Acupuncture analgesia: the scientific basis. Anesthesia and Analgesia 106:602, 2008; Woodley SJ et al: Lateral hip pain: findings from magnetic resonance imag­ing and clinical examination. The Journal of Orthopaedic and Sports Physical Therapy 38:313, 2008; Yelland MJ et al: Pro­lotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial. Spine 29:9, 2004.