Hip Pain Overview

A common question that patients ask when considering a course of acupuncture treatments for hip pain is whether or not they should proceed with surgery or hold off for a period of time or not have surgery at all?

Questions of concern such as how acupuncture will actually help their hip pain, at what cost and will it really make any difference are usual concerns and I will usually respond by asking some questions on the nature of their pain, duration etc... and recommend four treatments to decide whether this modality is really going to help.

Four seems to be the magic number in my experience of structural acupuncture (Seitai Shinpo) as chronic conditions can be stubborn at first and results may last a few days initially. After four treatments the body seems to be getting the message and holding it’s new pattern, sort of like Maxwell waltz’s MD (plastic surgeon) observations in the 1950’s on noticing that it took 21 days for patients to accept to their new body adjustment be it a leg amputee or a new looking nose! He called it Psycho-cybernetics. In contrast, in a later study from the European Journal of Social Psychology 1. it was found that it takes anywhere from 18 to 254 days to break a habit. If we find that it is making a difference then patients will usually continue to have treatments for a few more weeks or months. Other issues usually resolve alongside their chief complaint because in Oriental medicine the overall body condition improves, not just one’s hip. Sleep, memory, mood, sexual function, digestion, other aches and pain s etc.. also improve with treatment.

Seitai Shinpo acupuncture is concerned with alignment of the pelvis and spine by releasing areas of contraction along the spine and relaxing the muscles which in turn allows for the structure to shift.In addition weight bearing exercises help restore alignment and one’s centre of gravity. I think that there is a time and a place for hip surgery particularly in cases of bone on bone which takes time to regenerate even with acupuncture but it’s not impossible. Once the pressure is taken off the affected side and blood flow is circulating again the shrunken cartilage can begin to regenerate particularly in younger patients in the 40 - 65yr old age group.

Many people decide to try acupuncture for a period of time and in most cases much relief has been experienced though in cases of bone on bone most do resort to surgery and are very thankful that they did as it gives many people new lease of life. Having acupuncture before and after surgery helps to expedite the healing process very quickly. There are pros and cons to surgery however and it is worth noting that one to two years afterward the body tends to weaken. Perhaps this is due to less intensive post op rehabilitation or lowered immunity, nevertheless it is common regardless of age.

There are many reasons for hip pain and for this article I would like to focus on some aspects of pain that were touched upon in a previous write up on osteoarthritis as well as some new information.

Osteoarthritis affects the joints of the hips and knees as well as the small joints of the hands, feet and carpal-metacarpal joints of the thumb, joints of the fingers and big toe more so than the shoulder and elbow are usually monoarticular (one sided) affecting Women more commonly. In the past it was believed to be more likely to occur in joints repeatedly subjected to trauma but recent studies agree that genetic factors are more likely to be major player in it’s development.

Monoarticular hip disease or Osteoarthritis of the hip joint usually occurs alone and is more common in men (Wood 1976) Pain in mono (one side) articular hip disease is usually persistent developing with slow intensity unlike osteoarthritic pain which tends to be episodic and as an acupuncturist it is important to assess the history of the patient when deciding a course of treatment, particularly if herbal medicine is going to play a role in healing.

So the belief that primary osteoarthritis is entirely mechanical in origin and due to wear and tear of the cartilage is no longer accepted in Western medicine. While it is a part of the picture other contributing biochemical factors are also contributors. So the primary change in osteoarthritis is the destruction of the articular cartilage, and with the narrowing the joint space that occurs as a result of these changes taking place in the bone itself. (Radio et al 1976) Osteophytes and the development of cysts contribute to pain but it is important to remember that the cartilage, synovium or menisci have no receptor nerve endings however the subchondral bone is well supplied with nerves and may cause pain initially. When the

nociceptive receptors become inflamed pain can occur in the joint capsule, adjacent muscles, collateral ligaments and the fat pads.

In terms of hip pain, it is proportional to the extent of joint damage over time. When one’s posture is compromised there is more tender areas that develop in the periarticular structures that are similar to trigger points which elicit pain when pressure is applied. Chemical substances such as prostaglandins, histamine, 5-hydroxytryptamine and polypeptide kinins are released from the inflamed synovial cells and are transported in the synovial fluid to the nearby articular fat pads and joint capsule where in turn they irritate the nociceptive receptors in these tissues. Fibrosis usually develops in the capsule and sometimes in the nearby muscles which causes the tissues to contract and when one moves one’s body it can lead to stimulation of the nerve receptors causing pain.

Case in point, Weigh bearing joints of the hip are further stressed in cases of obesity therefor dieting to loose weight and lessen the pressure on the attachments is of consideration.

Other reasons for hip pain include venous stasis and intraosseous hypertension which presents as pain that is worse toward the end of the day and is noticable at rest. Trigger point pain becomes activated in the periarticular tissues similar to that in the knee joints. TrPs usually show up around the greater trochanter and along the tensor fasciae latae (side of the upper leg) . so when we are trying to distinguish whether pain is due to osteoarthritis or muscular issues we can see that in the former there are oftentimes considerable range of motion limitations though not always. The upper part of the thigh and around the

greater trochanter as well as the glutes and their attachments. Its common that trigger points in these areas not only give rise to pain in the hip region but may also cause it to refer down the outer leg. Below the iliac crest is another hot spot and can refer pain down the back of the leg as well as in the hip region.

In severe cases patients usually come for acupuncture once a week initially and once every two weeks in addition to taking NSAIDs at a minimal dose or none at all which is always preferable considering that long term use can be harmful to the kidney, CNS and GI tract. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3158445/, More often than not there is no need for additional pain medication especially if homework exercises are being practiced regularly.

As an acupuncturist working with structural alignment, I palpate the body thoroughly and when I do a physical examination I look for local areas requiring the attention of a needle insertion, which includes the meridian itself or areas of tenderness or tightness. Areas including the gluteus muscles maximus, medius and minimus and piriformis are usually involved in hip pain.

Having said that, pain, including the location of pain, is subjective for each patient. When people complain of hip pain, the problem may actually be in the lower back (quadratus lumborum) or the abdomen (rectus abdominis) and when there are problems here, the pain can refer to the hip. In Seitai Shinpo each individual’s pattern will be different therefor every exam can turn up a different pattern of contraction, strain or injury. In each case though, the paraspinal muscles will be addressed as well as the low back area.

Treating a local area of tenderness is an ancient practice in acupuncture. The name for such places are Ashi points in TCM (Traditional Chinese Medicine) or trigger points in Western terms which are places where hypersensitive sensory nerves are firing more than usual which is why they are painful to the touch. Interestingly these areas are usually acupuncture points, which is why we place needles there. In another post, I’ll go into the specifics of what an acupuncture point is and why needling changes the terrain.

Finally, from a biomechanical perspective, people with hip pain may also experience shoulder or upper back problems, or knee pain, to name two examples. It’s important to examine these areas for tenderness and treat accordingly.

To recap in a systematic way below are the different approaches involved in a Seitai Shinpo

acupuncture treatment:

Area 1: Visual inspection of skeletal structure to diagnose each individual pattern and treatment plan.

Area 2: Palpating to locate tender points along the muscles of the hip, back, abdomen or those which

refer to the hip.

Area 3: Sitting up, laying face up and face down to access points along the spine, where the peripheral

nerves innervating the symptomatic region exit the spinal cord. Application of rice moxa cones to further

relax muscles and stimulate blood circulation, balance the autonomic nervous system and balance immune function.

Area 4: Other regions in the body experiencing pain or strain due to changes in biomechanics – how we move our bodies – as a result of the hip pain.

As we treat the whole body and root cause of disease, these four areas of treatment result from seeing acupuncture as a whole-body approach and not isolating one problem without seeing the big picture.

Therefor given this comprehensive approach, treatment may entail more than one visit depending on the duration of the problem and the age/lifestyle of the patient. My own practice is to do as much as seems useful and practical at each encounter thereby achieving as much as possible in as short time possible.

Too much treatment may exhaust the body in any one session therefor efficiency in the treatment room is key.

1. European Journal of Social Psychology 1.Lally.P, Jaarsveld C.M.V, Potts, H. Wardle. J. #40.

998-1009. 2010

2. Baldrey P E, Acupuncture, trigger points and musculoskeletal pain. 19: pp. 337-339.

3. Kellegen J H, Lawrence J S, Bier F 1963 Genetic factors in generalized osteoarthritis. Annals o

Rheumatic Diseases 22: 237-255

4. Travel J 1951 Pain mechanisms in connective tissues. transactions of the second conference. Josiah Macey Jnr Foundation, New York, pp. 86-125

Article by Adrienne Dooling, L.Ac

EMC of Pleasanton

Teresa Shen, L.A.c: CEO and Master Of Chinese Medicine, an acupuncturist of four generations of Chinese Medical practitioners. An expert in pain and stress management: stiff necks, back pain, shoulder, wrist and joint pains, migraines, addictions to drugs, infertility, and cosmetic acupuncture.

Adrienne Dooling L.Ac.,Acupuncturist Dooling specializes in structural alignment and chronic diseases including scoliosis, meniscus tears (incomplete tears), arthritis, rheumatoid arthritis, fibromyalgia, Crohn’s disease and other digestive issues. Dooling can help balance the autonomic nervous system through alignment of the pelvis and spine and is proficient in Seitai Shinpo, a specialized form of acupuncture, and Shiunko Moxibustion, also known as Japanese structural acupuncture.

Jax Chao, L.Ac, Eastern Medical Center of Pleasanton: Jax specializes in Acupuncture and Oriental Medicine with a focus on headaches, allergies, carpal tunnel, anxiety, and all kinds of muscular-skeletal pains.
Eric Wei Wang, DAOM L.Ac, Eastern Medical Center of Pleasanton: Eric specializes in Acupuncture and Oriental Medicine with a focus on orthopedics trauma and sport medicine.