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Hip Pain and Sciatica

Hip Pain and Sciatica

People will often visit the doctor looking for hip pain relief while other people will often attempt to take care of it themselves. Hip pain can frequently occur due to an injury or underlying condition as well as a variety of health issues. However, not many people who visit the doctor or attempt to take care of their hip pain expect it to originate as a result of sciatica. Many people’s misunderstanding concerning the origin of their pain is due to not understanding back and hip anatomy. �

 

Understanding Back Pain

 

Because of the complexity of the spinal cord and its nerve roots, back pain can often radiate or travel down buttocks, hips, and thighs, sometimes even extending as far down into the legs, knees, and feet.� Sciatica, or sciatic nerve pain, is a collection of symptoms, rather than a single injury or underlying condition, caused by the compression or impingement of the sciatic nerve. Sciatica is characterized by pain, tingling sensations, and numbness along the length of the sciatic nerve. �

 

The sciatic nerve is the largest and longest nerve in the human body. It extends from the lower back, down the buttocks, hips, and thighs, into the legs, knees, and feet. The irritation or inflammation of the sciatic nerve may also cause painful symptoms in the upper extremities. It’s essential to understand that an injury or underlying condition, as well as a variety of health issues, can cause back pain and sciatica. Sciatica is generally a symptom associated with numerous other medical problems. �

 

By way of instance, a herniated disc can cause back pain and sciatica. People may experience “hip pain”, however, the painful symptoms may not necessarily be indicative of a hip joint health issue. Degenerative disc disease can cause a narrowing of the spinal canal, referred to as spinal stenosis, which may cause hip pain. Spinal stenosis can cause hip pain with physical activity and fatigue. Spinal stenosis symptoms are relieved with sitting and will re-occur when physical activity is resumed. �

 

You will find differences in painful symptoms involving a herniated disc, spinal stenosis pain, and other health issues. Painful symptoms associated with a herniated disc often worsen when sitting and improve with physical activity. A herniated disc, much like spinal stenosis, can also cause sciatica and it may often be due to degenerative disc disease. Sciatica, or sciatic nerve pain, will generally radiate or travel down the buttocks, hips, and thighs into the legs, knees, and feet. �

 

Understanding Hip Pain

 

If the health issue originates in the hip joint itself, common painful symptoms may often include groin pain on the affected side, which can occasionally radiate down the inner region of the thigh into the front of the leg. The painful symptoms can also travel to the knee, making healthcare professionals and patients believe their pain is associated with a knee problem rather than a hip problem. Walking worsens the pain and with continued physical activity, the pain increases. �

 

Hip pain caused by health issues, such as arthritis, can cause painful symptoms to gradually worsen over time.� Minimal physical activity, even slight movements while in bed, can also ultimately worsen the painful symptoms. Other health issues, such as advanced congenital hip dysplasia or avascular necrosis of the hip, can also cause these painful symptoms. When the hip pain originates due to arthritis, the movements of the hip joint may often be limited or restricted. �

 

Occasionally, hip pain can be a result of another health issue referred to as bursitis. A weak abductor muscle, a leg length discrepancy, overuse, and a deteriorating hip joint can ultimately cause bursitis. Often times, the true source of a patient’s bursitis cannot be determined. Painful symptoms associated with bursitis include pain and discomfort on the side of the hip with prolonged walking, lying sideways in bed or when rising or standing from a chair as well as with similar movements. �

 

Sciatica Diagnosis

 

A comprehensive medical history and physical evaluation can help healthcare professionals determine the source of the patient’s symptoms. X-rays demonstrate specific bony/cartilage modifications, however, x-rays don’t always necessarily demonstrate health issues associated with soft tissues, such as tendons, ligaments, muscles, and even nerves. X-rays may also help diagnose degenerative disc disease when the patient is feeling well and not experiencing any painful symptoms. �

 

As previously mentioned above, because x-rays only demonstrate certain bony/cartilage changes, it’s essential for healthcare professionals to also request the patient to have an MRI, or magnetic resonance imaging, to confirm the presence of health issues associated with soft tissues, such as tendons, ligaments, muscles and nerve roots. That’s why it’s essential to undergo the background and physical evaluation which could confirm the diagnosis before beginning with the best treatment. �

 

Sciatica Treatment

 

The two types of health issues are frequently treated utilizing anti-inflammatory drugs and/or medications, especially in mild to moderate instances. Some types of analgesics can also be utilized intermittently. It is essential to understand that both health issues can be improved considerably through weight loss, stretches and exercises. Epidural blocks will help several types of spine health issues. Utilizing a cane when walking might help improve back pain, hip pain, and sciatica. �

 

Surgical interventions, whether if it’s a hip replacement for hip arthritis or spine surgery due to a herniated disc, spinal stenosis, or any other type of health issue, is generally considered to be the last resort for treating back pain, hip pain, and sciatica. Full physical evaluations are recommended and conservative treatment approaches are often tried first. Remember, there are many treatment options for hip pain and sciatica. Diagnosis is the first step to effective treatment. �

 

Sciatica, or sciatic nerve pain, is a collection of symptoms, rather than a single injury or condition, characterized by pain and discomfort, tingling sensations, and numbness anywhere along the length of the sciatic nerve. The sciatic nerve is the longest and largest nerve in the human body which extends from the lower back, down the buttocks, hips, and thighs, into the legs, knees, and feet. The compression or impingement of the sciatic nerve and irritation due to a herniated disc, among other health issues, can ultimately cause sciatica symptoms and low back pain. – Dr. Alex Jimenez D.C., C.C.S.T. Insight

 


 

Low Back Pain

 

VasyliMedical Low Back Pain

 


 

The purpose of the article was to discuss and demonstrate hip pain associated with sciatica. Sciatica is a collection of symptoms characterized by pain and discomfort, tingling sensation, and numbness. The scope of our information is limited to chiropractic, musculoskeletal and nervous health issues as well as functional medicine articles, topics, and discussions. To further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900 . �

 

Curated by Dr. Alex Jimenez �

 


 

Additional Topic Discussion: Foot Orthotics

 

Low back pain and sciatica are common health issues which affect many individuals worldwide. However, did you know that chronic pain may be due to foot problems? Health issues originating in the foot may ultimately cause imbalances in the spine, such as poor posture, which can cause the well-known symptoms of low back pain and sciatica. Custom foot orthotics, individually designed with 3-arch support can help promote overall health and wellness by supporting and promoting good posture and correcting foot problems. Custom foot orthotics can ultimately help improve low back pain and sciatica. �

 

 


 

Formulas for Methylation Support

 

Xymogen Formulas - El Paso, TX

 

XYMOGEN�s Exclusive Professional Formulas are available through select licensed health care professionals. The internet sale and discounting of XYMOGEN formulas are strictly prohibited.

 

Proudly,�Dr. Alexander Jimenez makes XYMOGEN formulas available only to patients under our care.

 

Please call our office in order for us to assign a doctor consultation for immediate access.

 

If you are a patient of Injury Medical & Chiropractic�Clinic, you may inquire about XYMOGEN by calling 915-850-0900.

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For your convenience and review of the XYMOGEN products please review the following link.*XYMOGEN-Catalog-Download

 

* All of the above XYMOGEN policies remain strictly in force.

 


 

Bisphosphonates: Mechanism of Action and Role in Clinical Practice

Bisphosphonates: Mechanism of Action and Role in Clinical Practice

Bisphosphonates are a type of drug/medication which blocks the loss of bone density to treat osteoporosis-related ailments. They are most frequently prescribed for the treatment of osteoporosis. Bisphosphonates have two phosphonate groups. Evidence demonstrates that they reduce the probability of fractures in post-menopausal women with osteoporosis.

Bone tissue undergoes continuous remodeling that is stored to provide equilibrium, or homeostasis, through osteoblasts generating bone and osteoclasts ruining bone. Bisphosphonates inhibit bone digestion by encouraging osteoclasts to undergo apoptosis or cell death.

The uses of bisphosphonates include the prevention and treatment of osteoporosis, Paget’s disease of bone, bone metastasis (with or without hypercalcaemia), multiple myeloma, primary hyperparathyroidism, osteogenesis imperfecta, fibrous dysplasia, and other conditions which exhibit bone fragility. The purpose of the following article is to discuss the mechanism of action and role in the clinical practice of bisphosphonates.

Abstract

Bisphosphonates are primary agents in the current pharmacological arsenal against osteoclast-mediated bone loss due to osteoporosis, Paget disease of bone, malignancies metastatic to bone, multiple myeloma, and hypercalcemia of malignancy. In addition to currently approved uses, bisphosphonates are commonly prescribed for prevention and treatment of a variety of other skeletal conditions, such as low bone density and osteogenesis imperfecta. However, the recent recognition that bisphosphonate use is associated with pathologic conditions including osteonecrosis of the jaw has sharpened the level of scrutiny of the current widespread use of bisphosphonate therapy. Using the key words bisphosphonate and clinical practice in a PubMed literature search from January 1, 1998, to May 1, 2008, we review current understanding of the mechanisms by which bisphosphonates exert their effects on osteoclasts, discuss the role of bisphosphonates in clinical practice, and highlight some areas of concern associated with bisphosphonate use.

Introduction

Since their introduction to clinical practice more than 3 decades ago, bisphosphonates have been increasingly used for an array of skeletal disorders. Bisphosphonates are now used to treat such varied conditions as heritable skeletal disorders in children, postmenopausal and glucocorticoid-induced osteoporosis (GIO), and bone metastases in patients with malignancies. Bisphosphonates can offer substantial clinical benefit in conditions in which an imbalance between osteoblast-mediated bone formation and osteoclast-mediated bone resorption underlies disease pathology; however, the more recently recognized association of bisphosphonate use with pathologic conditions, including low bone turnover states with resultant pathologic fractures, osteonecrosis of the jaw (ONJ), and an increased incidence of atrial fibrillation, has brought increased scrutiny to the current broad use of bisphosphonate therapy.

PubMed literature from January 1, 1998, to May 1, 2008, was reviewed using bisphosphonate and clinical practice as search terms. Additional articles not obtained in the primary search were identified by assessment of literature referenced in the reviewed articles. We present data on the development of bisphosphonates as therapeutic agents, the proposed mechanisms by which these agents exert their effects, and the current roles for bisphosphonate therapy in clinical practice. Additionally, we address some areas of concern for clinicians and draw attention to some currently unresolved issues associated with bisphosphonate use.

Chemical Structure as Basis for Clinical Activity

Structurally, bisphosphonates are chemically stable derivatives of inorganic pyrophosphate (PPi), a naturally occurring compound in which 2 phosphate groups are linked by esterification (Figure 1, A). Within humans, PPi is released as a by-product of many of the body�s synthetic reactions; thus, it can be readily detected in many tissues, including blood and urine.1 Pioneering studies from the 1960s demonstrated that PPi was capable of inhibiting calcification by binding to hydroxyapatite crystals, leading to the hypothesis that regulation of PPi levels could be the mechanism by which bone mineralization is regulated.2

 

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Like their natural analogue PPi, bisphosphonates have a very high affinity for bone mineral because they bind to hydroxyapatite crystals. Accordingly, bisphosphonate skeletal retention depends on availability of hydroxyapatite binding sites. Bisphosphonates are preferentially incorporated into sites of active bone remodeling, as commonly occurs in conditions characterized by accelerated skeletal turnover. Bisphosphonate not retained in the skeleton is rapidly cleared from the circulation by renal excretion. In addition to their ability to inhibit calcification, bisphosphonates inhibit hydroxyapatite breakdown, thereby effectively suppressing bone resorption.3 This fundamental property of bisphosphonates has led to their utility as clinical agents. More recently, it has been suggested that bisphosphonates also function to limit both osteoblast and osteocyte apoptosis.4,5 The relative importance of this function for bisphosphonate activity is currently unclear.

Modification of the chemical structure of bisphosphonates has widened the differences between the effective bisphosphonate concentrations needed for antiresorptive activity relative to those that inhibit bone matrix mineralization, making the circulating concentrations of all bisphosphonates currently used in clinical practice active essentially only for the inhibition of skeletal resorption.1 As shown in Figure 1, A, the core structure of bisphosphonates differs only slightly from PPi in that bisphosphonates contain a central nonhydrolyzable carbon; the phosphate groups flanking this central carbon are maintained. As detailed in Figure 1, B, and distinct from PPi, nearly all bisphosphonates in current clinical use also have a hydroxyl group attached to the central carbon (termed the R1 position). The flanking phosphate groups provide bisphosphonates with a strong affinity for hydroxyapatite crystals in bone (and are also seen in PPi), whereas the hydroxyl motif further increases a bisphosphonate�s ability to bind calcium. Collectively, the phosphate and hydroxyl groups create a tertiary rather than a binary interaction between the bisphosphonate and the bone matrix, giving bisphosphonates their remarkable specificity for bone.1

Although the phosphate and hydroxyl groups are essential for bisphosphonate affinity for bone matrix, the final structural moiety (in the R2 position) bound to the central carbon is the primary determinant of a bisphosphonate�s potency for inhibition of bone resorption. The presence of a nitrogen or amino group increases the bisphosphonate�s antiresorptive potency by 10 to 10,000 relative to early non�nitrogen-containing bisphosphonates, such as etidronate.1,6 Recent studies (described subsequently) delineate the molecular mechanism by which nitrogen-containing bisphosphonates inhibit osteoclast activity.

A critical pharmacological feature of all bisphosphonates is their extremely high affinity for, and consequent deposition into, bone relative to other tissues. This high affinity for bone mineral allows bisphosphonates to achieve a high local concentration throughout the entire skeleton. Accordingly, bisphosphonates have become the primary therapy for skeletal disorders characterized by excessive or imbalanced skeletal remodeling, in which osteoclast and osteoblast activities are not tightly coupled, leading to excessive osteoclast-mediated bone resorption.

Early non�nitrogen-containing bisphosphonates (etidronate, clodronate, and tiludronate) (Figure 1, B) are considered first-generation bisphosphonates. Because of their close structural similarity to PPi, non�nitrogen-containing bisphosphonates become incorporated into molecules of newly formed adenosine triphosphate (ATP) by the class II aminoacyl�transfer RNA synthetases after osteoclast-mediated uptake from the bone mineral surface.1 Intracellular accumulation of these nonhydrolyzable ATP analogues is believed to be cytotoxic to osteoclasts because they inhibit multiple ATP-dependent cellular processes, leading to osteoclast apoptosis.

Unlike early bisphosphonates, second- and third-generation bisphosphonates (alendronate, risedronate, ibandronate, pamidronate, and zoledronic acid) have nitrogen-containing R2 side chains (Figure 1, C). The mechanism by which nitrogen-containing bisphosphonates promote osteoclast apoptosis is distinct from that of the non�nitrogen-containing bisphosphonates. As elegantly illustrated in recent studies, nitrogen-containing bisphosphonates bind to and inhibit the activity of farnesyl pyrophosphate synthase, a key regulatory enzyme in the mevalonic acid pathway critical to the production of cholesterol, other sterols, and isoprenoid lipids6,7 (Figure 2, A). the analog is likely a direct function of the ability of bisphosphonates to selectively adhere to and be retained within bone before endocytosis within osteoclasts during osteoclast-mediated bone mineral dissolution and matrix digestion (Figure 2, B). Given the fact that nearly all patients now receive treatment with the more potent nitrogen-containing bisphosphonates rather than the earlier non�nitrogen-containing bisphosphonates, the remainder of this review focuses on this more recent class of bisphosphonates.

 

 

Additional Clinical Features

Although bisphosphonate-mediated induction of osteoclast apoptosis cannot be measured directly within the clinical setting, a temporal reduction in biochemical markers of bone resorption (namely amino- and carboxyl-terminal breakdown products of type 1 collagen in serum and urine) after bisphosphonate initiation is considered a reasonably reliable surrogate of bisphosphonate efficacy and potency. Maximum suppression of bone resorption occurs within approximately 3 months of initiation of oral bisphosphonate therapy given daily, weekly, or monthly and remains roughly constant with continuation of treatment.10�12 Resorption is suppressed more rapidly after intravenous (IV) bisphosphonate administration than after oral bisphosphonate therapy.

As might be anticipated, length of suppression is largely a function of bisphosphonate potency for mineral matrix binding, such that the most potent bisphosphonate, zoledronic acid, at a dose of either 4 mg13 or 5 mg (the dose approved by the Food and Drug Administration [FDA] for osteoporosis),14 effectively suppresses biochemical markers of bone resorption for up to 1 year in women with postmenopausal osteoporosis. Although the precise biologic half-lives of the currently used nitrogen-containing bisphosphonates remain the subject of debate largely because of technical challenges required to determine bisphosphonate levels in urine and serum, estimates for the potent bisphosphonate alendronate suggest a biologic half-life of more than 10 years after single-dose IV administration.15

A critical feature governing the clinical pharmacology of bisphosphonates is their bioavailability. As a class, bisphosphonates are very hydrophilic. Accordingly, they are poorly absorbed from the gastrointestinal tract after oral administration (generally with absorption of <1% for an oral dose), instead undergoing paracellular transport because they are not lipophilic.16 Further, only about 50% of the absorbed drug is selectively retained in the skeleton, whereas the remainder is eliminated in the urine without being metabolized. Skeletal uptake and retention are primarily dependent on host factors (renal function, prevalent rate of bone turnover, and binding site availability) and bisphosphonate potency for bone matrix.12 The amount of bisphosphonate retained after either oral or IV administration varies widely both between patients and across clinical conditions and is primarily believed to reflect variations in bone turnover.12

A previous impediment for many patients prescribed oral bisphosphonate therapy was the inconvenience associated with daily oral administration (requiring patients to remain upright for 30 minutes and refrain from eating any food both 2 hours before and at least 30 minutes after pill ingestion) and the relatively common association with gastrointestinal symptoms. The more recent development of pharmacologically equivalent preparations allowing for once-weekly (alendronate or risedronate) or even monthly (ibandronate or risedronate) oral administration has profoundly affected bisphosphonate delivery for most patients for whom convenience (and thus adherence to therapy) was an issue and has correspondingly lead to higher rates of adherence.17,18 Further, the availability of IV preparations (pamidronate, ibandronate, and zoledronic acid), which for most clinical conditions require even less frequent dosing, has eliminated the gastrointestinal adverse effects incurred by some patients managed with oral bisphosphonates, although the rate of acute phase reactions characterized by flulike symptoms (low-grade fever, myalgias and arthralgias, or headache) is increased in patients receiving IV rather than oral bisphosphonate treatment.14

Role in Clinical Practice

As aforementioned, bisphosphonates promote the apoptosis of osteoclasts actively engaged in the degradation of mineral on the bone surface. Accordingly, bisphosphonates have become the primary therapy for managing skeletal conditions characterized by increased osteoclast-mediated bone resorption. Such excessive resorption underlies several pathologic conditions for which bisphosphonates are now commonly used, including multiple forms of osteoporosis (juvenile, postmenopausal or involutional [senile], glucocorticoid-induced, transplant-induced, immobility-induced, and androgen-deprivation�related), Paget disease of bone, osteogenesis imperfecta (OI), hypercalcemia, and malignancy metastatic to bone.

Although each of the nitrogen-containing bisphosphonates is more potent than the non�nitrogen-containing bisphosphonates, their ability to suppress osteoclast activity (as measured by biochemical markers of bone turnover) varies. However, whether superior suppression of bone turnover is relevant for fracture prevention remains to be determined. Indeed, data suggest that adherence to long-term bisphosphonate therapy, rather than the specific bisphosphonate used, is the most important factor in determining the effectiveness of treatment for limiting fracture risk.19,20 Accordingly, studies examining bisphosphonate therapy adherence suggest that, by addressing patient concerns of medication safety and timing, clinicians can significantly improve adherence.21 Whether weekly or monthly oral bisphosphonate dosing leads to higher rates of adherence to therapy is currently unknown.

Osteoporosis

The most common clinical condition for which bisphosphonate therapy is used is osteoporosis, a skeletal condition characterized by compromised bone strength resulting in an increased risk of fracture. As previously noted, osteoporosis is a clinically heterogeneous disease with a range of origins, including hormone loss (postmenopausal and androgen-deprivation), iatrogenic (glucocorticoid-induced and transplant-related), physical (immobility), and genetic (eg, juvenile and OI-associated). Often these conditions overlap within individual patients.

Postmenopausal osteoporosis is characterized by an imbalance between osteoclast-mediated bone resorption and osteoblast-mediated bone formation such that bone resorption is increased. This relative imbalance leads to diminution of skeletal mass, deterioration of bone microarchitecture, and increased fracture risk. During the past 2 decades, bisphosphonate therapy has become the leading clinical intervention for postmenopausal osteoporosis because of the ability of bisphosphonates to selectively suppress osteoclast activity and thereby retard bone resorption. The fracture reduction and concomitant increases in bone density generally seen with bisphosphonate use are believed to result from a decline in the activation frequency of new remodeling units formed by osteoclasts, with relative preservation (at least initially) of osteoblast activity. As such, the initial stabilization and retention of trabecular connectivity allow the duration of secondary mineral deposition on the structural scaffold to be prolonged, thereby increasing the percentage of bone structural units that reach a maximum degree of mineralization.22 This increase in the mean degree of skeletal mineralization underlies both improvements in bone density and reductions in fracture risk after bisphosphonate therapy.

Importantly, this role for bisphosphonates was indirectly buttressed by the early termination of the estrogen and progesterone arm of the Women�s Health Initiative (WHI), because of concern about increased rates of coronary artery disease and breast cancer among women receiving hormonal therapy. For most practitioners and patients, the WHI results effectively limited the practice of treating postmenopausal osteoporosis with hormone replacement therapy, despite the strong evidence provided in the WHI and previous studies that estrogen is highly effective in preventing fractures.23

Among the oral bisphosphonates, both alendronate and risedronate have been conclusively demonstrated to reduce the number of vertebral24�26 and hip fractures,24,27 progression of vertebral deformities, and height loss in postmenopausal women with osteoporosis.28 Ibandronate, developed more recently and available in both oral and IV preparations, has been demonstrated to reduce only the risk of vertebral fracture,29,30 although the sample size estimates used did not allow sufficient power to detect an effect on nonvertebral or hip fractures. The relative fracture risk reduction in vertebral, hip, and nonvertebral sites in post-menopausal women with known osteoporosis after 3 years of bisphosphonate treatment is compared in the Table.

 

 

Reductions in fracture incidence occur before demonstrable changes (measured by dual-energy x-ray absorptiometry [DXA]) in bone mineral density (BMD), suggesting that stabilization of existing skeletal microarchitecture or decreased bone turnover is sufficient for fracture risk reduction.31 Daily alendronate use at doses of 10 mg for up to 10 years was well tolerated and was not associated with adverse skeletal outcomes.32 Whereas nearly all osteoporosis trials in which bisphosphonate therapy has been used involved postmenopausal women, general trials that have examined men with a diagnosis of either low bone mass or osteoporosis have demonstrated similar responses to bisphosphonate therapy.33�35

In the Fracture Intervention Trial Long-term Extension, postmenopausal women with low femoral neck BMD (but not necessarily with DXA-defined osteoporosis) were treated with daily alendronate for 5 years and then randomized to receive either alendronate or placebo for an additional 5 years. Women who discontinued alendronate therapy had statistically significant, although clinically relatively small, declines in BMD and associated increases in biochemical markers of bone turnover compared with women who continued therapy.36 Importantly, no significant differences were found for either nonvertebral fractures or all clinical fractures; however, there was a slightly higher (and statistically significant) risk of clinical vertebral fractures in the placebo group (absolute risk, 2.9%), but this was not a primary or secondary study end point. Formal studies of alendronate cessation with more statistical power for fracture assessment after discontinuation as a primary end point or of other bisphosphonates have not yet established that, for at least some patients with postmenopausal osteoporosis, a drug holiday could be reasonable after a period of bisphosphonate therapy.

Initial studies used daily bisphosphonate dosing; more recent studies have focused on weekly (alendronate and risedronate) or monthly (ibandronate, and more recently risedronate37) dosing, regimens believed to have pharmacodynamic equivalence to daily dosing of each drug. However, all studies to date using intermittent weekly or monthly oral bisphosphonate therapy have relied on surrogate markers, such as biochemical markers of bone resorption or changes in BMD measured by DXA, rather than primary fracture outcomes, for determination of efficacy. In contrast, the BONE trial, in which oral ibandronate was administered every other day for 12 doses every 3 months, did reduce vertebral fractures with intermittent dosing,30 although this dosing regimen is not approved by the FDA for treatment of postmenopausal osteoporosis. Nonetheless, intermittent weekly or monthly therapy is believed to be biologically equivalent for fracture prevention and has become the standard of care.

More recently, both ibandronate and zoledronic acid have been approved for IV administration to treat postmenopausal osteoporosis. Whereas ibandronate is approved for quarterly administration, zoledronic acid is approved for once-yearly administration. During the 3-year Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly (HORIZON) study period, annual IV administration of zoledronic acid led to significant decreases in vertebral (70% reduction), hip (41% reduction), and nonvertebral (25% reduction) fractures, with significant increases in BMD at the lumbar spine, hip, and femoral neck.14 In addition, administration of IV zoledronic acid within 90 days of surgical hip fracture repair and yearly thereafter was recently shown to reduce the incidence of any new clinical fracture by 35% and was associated with a 28% reduction in mortality.38 Further, in patients who have been treated with weekly alendronate for at least 1 year, switching to yearly zoledronic acid was not inferior to alendronate continuation, but yearly administration was preferred by patients.39 Whether IV preparations will become preferred bisphosphonate formulations for management of postmenopausal osteoporosis or after hip fracture is unknown. Nonetheless, it is clear that IV bisphosphonate delivery is particularly useful if adherence or gastrointestinal tolerance is a barrier to oral therapy or if patients prefer the relative convenience of IV bisphosphonate therapy.

Finally, several studies have focused on optimal timing of bisphosphonate therapy for management of osteoporosis in conjunction with other pharmacological agents with skeletal activity. Although combining a bisphosphonate with either estrogen or the selective estrogen-receptor modulator raloxifene leads to a slightly greater increase in BMD than treatment with a bisphosphonate alone, no good clinical trial data on fracture rates support routine use of these combinations.40,41 Other studies have evaluated patients receiving either recombinant full-length 1�84 human parathyroid hormone (PTH) or the PTH fragment 1�34 (teriparatide).42�44 In general, prior bisphosphonate treatment appears to blunt the PTH-induced anabolic skeletal response, as does concomitant treatment using bisphosphonate and either PTH or teriparatide.45,46 The most robust skeletal anabolic effects are seen in patients who receive initial PTH treatment and are subsequently maintained with bisphosphonate therapy.35,47,48

Glucocorticoid-Induced and Transplant-Associated Osteoporosis

Whereas bisphosphonates have become the primary therapeutic choice for treatment of postmenopausal osteoporosis, few recognize that glucocorticoid therapy leads to bone loss. A recent study found that most patients receiving long-term glucocorticoid therapy received neither regular BMD assessment nor a prescription for any medication for osteoporosis management.49 Numerous clinical trials have now determined that bisphosphonates are highly effective at limiting bone losses in patients receiving glucocorticoids or transplants. Recent work has shown that, in patients receiving a daily dose of at least 7.5 mg of prednisone, alendronate prevented bone loss more effectively than did the vitamin D3 analogue alfacalcidol.50 Further, in glucocorticoid-treated patients at high risk of fracture, including those with a history of fractures, those with rheumatoid arthritis, or those receiving high doses of glucocorticoid, bisphosphonate therapy is cost-effective.51

Accordingly, risedronate has been approved in the United States for both prevention and treatment of GIO and alendronate for the treatment of GIO. Both are more effective when calcium intake and vitamin D intake are adequate. As well, IV treatment with either pamidronate or ibandronate has been shown to limit skeletal loss from glucocorticoid therapy,52,53 although neither is yet approved for this indication. Notably, multiple studies have documented that both oral and IV bisphosphonate therapy are capable of limiting the bone loss that frequently occurs with either solid organ54�58 or bone marrow transplant.59�62

Finally, a recent study showed that patients with GIO treated with teriparatide had a greater increase in lumbar spine BMD and fewer new vertebral fractures than did patients who received daily alendronate during the course of 18 months.63 Whether teriparatide should supplant bisphosphonate therapy as the treatment of choice for patients with established osteoporosis who are receiving long-term glucocorticoid therapy remains unknown.

Immobility-Induced Osteoporosis and Other Causes of Acute Bone Loss

Immobilized patients, such as those with a recent spinal cord injury or cerebrovascular event, undergo rapid loss of bone, leading to a substantially increased risk of fracture, hypercalcemia, and frequently nephrolithiasis. Both oral (alendronate)64 and IV (pamidronate)65 bisphosphonate therapy have been shown to attenuate this bone loss and reduce biochemical markers of bone resorption. However, the number of clinical trials conducted using both these drugs remains small. Thus, fracture incidence, rates of nephrolithiasis, and long-term safety remain to be determined.

Unlike the generalized bone loss that occurs after immobilization, acute localized periprosthetic bone loss with associated implant loosening is a frequent complication in patients who undergo cementless total hip arthroplasty. Both alendronate66 and risedronate67 attenuate this acute periprosthetic bone loss of the proximal femur, although the long-term effect of bisphosphonate treatment on maintenance of implant integrity has not yet been reported.

Paget Disease of Bone

Whereas postmenopausal osteoporosis is characterized by generalized bone loss from increased osteoclast activity, Paget disease of bone involves 1 or more areas of disordered bone remodeling, in which accelerated osteoclast-mediated bone resorption is followed by imperfect osteoblast-mediated bone deposition.68 The resulting mix of poorly formed woven and lamellar bone frequently results in pain, fractures, and serious deformity, including bowing of weight-bearing long bones, skull enlargement, or numerous other skeletal deformities. As the cornerstone of therapy for Paget disease of bone, bisphosphonates profoundly suppress the increased bone resorption underlying the disease, generally leading to normalization of serum alkaline phosphatase levels used to monitor disease activity. Oral (alendronate69 and risedronate70) and IV (pamidronate71 and the recently approved zoledronic acid72) bisphosphonates are all FDA-approved for the treatment of Paget disease of bone and have largely replaced earlier FDA-approved therapies (non�nitrogen-containing bisphosphonates and calcitonin) because their ability to suppress osteoclast activity is superior.

Bisphosphonates in Malignancy

Many cancers are osteotropic and either metastasize to the skeleton (including but not limited to primary malignancies of the breast, prostate, lung, or kidney) or grow primarily within the bone marrow (multiple myeloma), where this growth frequently leads to hypercalcemia, severe bone pain, skeletal destruction, and pathologic fractures. Indeed, the skeleton is the most common site of metastatic disease, and 90% or more of patients with advanced cancer develop skeletal lesions.73

Breast Cancer

For patients with breast cancer metastatic to bone, treatment with IV preparations of pamidronate,74�76 zoledronic acid,77,78 and ibandronate79 has been shown to substantially relieve skeletal pain and reduce skeletal complications. Of the oral nitrogen-containing bisphosphonates, only ibandronate (given in a daily dosage of 50 mg) has been effective in reducing bone pain and limiting skeletal complications of breast cancer.80,81

Whether bisphosphonate use has an adjunct role in the treatment of women with breast cancer but no evidence of skeletal metastases is currently unknown but is suggested by the provocative finding that women with clinically limited operable breast cancer who received clodronate for 2 years had statistically significant reductions in development of bone metastases while receiving bisphosphonate therapy, as well as reductions in overall mortality when they were followed up for 6 years.82 Although bisphosphonate therapy for women receiving hormonal treatment of breast cancer has received less attention, the important role of limiting bone turnover to maintain skeletal integrity (particularly among premenopausal women in whom pharmacological estrogen deficiency has been introduced) has been more recently appreciated.83 Optimal bisphosphonate management strategies corresponding to numerous available pharmacological ovarian ablation regimens remain to be determined, although zoledronic acid (4 mg IV given every 6 months)84 has recently been demonstrated to prevent bone loss in premenopausal women receiving endocrine-based therapy for hormone-sensitive breast cancer. Likewise, in postmenopausal women with early hormone-dependent breast cancer, weekly oral risedronate was recently shown to prevent bone loss in those receiving aromatase inhibitor therapy.85

Prostate Cancer

Breast cancer is characterized by osteolytic lesions, but skeletal metastases from prostate cancer have been described as osteoblastic. The role of increased bone resorption in metastatic prostate cancer has recently been recognized.86 Among the bisphosphonates, only zoledronic acid has been demonstrated to reduce skeletal bone�related events in men with hormone-refractory prostate cancer,87,88 with an absolute risk reduction of 11% at 2 years compared with placebo.

As with women who undergo chemical hormonal ablation, men with hormone-responsive prostate cancer who receive androgen-deprivation therapy can benefit from judicious bisphosphonate use. Whereas IV pamidronate therapy prevented bone loss at both the hip and the spine in men with nonmetastatic prostate cancer who received gonadotropin-releasing hormone agonist therapy,89 a single annual dose of IV zoledronic acid was recently demonstrated to lead to increases in both spine and hip BMD (rather than the declines seen in patients who received placebo). These results demonstrate that annual IV bisphosphonate treatment can be a useful adjunct to maintain skeletal integrity in androgen-deprived men90 and are similar to results obtained with a more frequent dosing schedule.91 Oral risedronate at a daily dosage of 2.5 mg has also recently been shown to prevent BMD loss at the hip and been associated with a 4.9% increase at the lumbar spine.92

Multiple Myeloma

In multiple myeloma, clonal proliferation of malignant plasma cells within the bone marrow cavity results in osteolysis and skeletal destruction, accounting for much of the morbidity associated with the disease. Multiple studies have shown that both pamidronate and zoledronic acid have an important palliative role in reducing the incidence of hypercalcemia and skeletal bone�related events associated with myeloma,93�95 putting IV bisphosphonates at the center of current therapies to prevent and treat myeloma-associated bone disease. At present, no data support bisphosphonate therapy for patients with smoldering myeloma, myeloma without associated bone disease, or monoclonal gammopathy of undetermined significance, nor is oral bisphosphonate therapy recommended for management of myeloma-associated skeletal disease.

Given that patients with multiple myeloma have the highest incidence of ONJ among all oncology patients receiving bisphosphonate therapy, the choice of bisphosphonate, dosage, and duration of therapy have been the focus of considerable debate, cumulating in clinical practice guidelines from the American Society of Clinical Oncology96 and, more recently, a consensus statement from the Mayo Clinic Myeloma Group97 on the basis of a comprehensive review of the evolving literature. In the Mayo consensus statement, monthly infusion of pamidronate (because of a perceived higher risk of ONJ in patients receiving zoledronic acid) was favored, with discontinuation after 2 years if patients achieve remission and require no further myeloma treatment. If active treatment is still required, pamidronate can be continued at a reduced schedule of every 3 months. Although the International Myeloma Working Group generally agreed with the Mayo consensus statement, the group suggested that pamidronate therapy could be discontinued after a patient is in 1 year of clinical remission and that a reduced dosing schedule was not indicated.98 Thus, although bisphosphonates remain an important aspect of the pharmacological approach to myeloma bone disease, questions regarding their optimal use remain.

Other Malignancies

Use of bisphosphonates in other malignancies less frequently metastatic to bone, such as renal cell carcinoma, has been demonstrated to delay the onset and progression of skeletal disease,99 suggesting that patients with clinical conditions less commonly believed to affect the skeleton can also benefit from bisphosphonate therapy. At present, however, limited data support routine use of bisphosphonate therapy for other malignancies.

Bisphosphonate Therapy for Children

Although bisphosphonates have been used most extensively in adults, during the past decade they have become the mainstay of therapy for OI, a heritable skeletal disorder characterized by substantially diminished bone mass and severe fragility, usually resulting from mutations in the genes for type I collagen. A regimen developed by Glorieux100 of cyclic IV pamidronate (given in 3-day cycles every 2 to 4 months at an annual dose of 9 mg/kg) has been used most successfully, leading to an 88% increase in cortical thickness, a 46% increase in trabecular bone volume,101 and substantial improvement in functional status. More recently, several studies have demonstrated that oral alendronate can also lead to substantial increases in BMD and can limit fractures in OI affecting children.102�104 Although the precise mechanism by which bisphosphonates limit fractures in OI is unknown, histomorphometric analyses of bone biopsy specimens from patients with OI demonstrate increased rates of bone turnover resulting from increased osteoclast relative to osteoblast activity, leading to an overall loss of bone with each remodeling cycle.105 By specifically inhibiting osteoclast-mediated bone resorption, bisphosphonates presumptively allow bone-forming osteoblasts more time to promote bone formation, albeit in the setting of abnormal collagen matrix. Indeed, histomorphometric analyses of iliac crest biopsy specimens from patients with OI who had received pamidronate therapy demonstrated increased cortical thickness and number of trabeculae but no increase in trabecular thickness.101,106

Although bisphosphonate treatment is well established for OI in children, data are limited on efficacy and on risk of harm when bisphosphonates are used in children with osteoporosis secondary to chronic illness (such as cystic fibrosis, juvenile rheumatoid arthritis, or anorexia nervosa) or in those who have had serious burns. A recent systematic review of bisphosphonate therapy for children and adolescents with secondary osteoporosis concluded that too little evidence is available to support bisphosphonates as standard therapy, although treatment for periods of 3 years or less appears to be well tolerated.107 Well-constructed studies are required to develop clear guidelines to diagnose and treat all forms of osteoporosis in children.108

Finally, given the long skeletal half-life of bisphosphonates and evidence that pamidronate can be found in urine specimens up to 8 years after administration,109 care is warranted when considering bisphosphonate treatment for either adolescent or young girls who will reach reproductive maturity within a decade of treatment. At present, only limited, anecdotal data have assessed the safety of long-term pamidronate110 or other bisphosphonate treatment during fetal development.

Dr Jimenez White Coat

Bisphosphonates in clinical practice are utilized to treat osteoporosis, Paget’s disease of the bone, bone metastasis, multiple myeloma, and other health issues with fragile bones. Although bisphosphonates are recommended as one of the first-line treatments for post-menopausal osteoporosis, research studies have previously discussed the adverse effects of this class of drug/medication. It’s essential for patients to talk to their healthcare professional regarding the treatment options for their injuries and/or conditions.

Dr. Alex Jimenez D.C., C.C.S.T. Insight

Clinical Concerns Associated with Bisphosphonate Therapy

Osteonecrosis of the Jaw

Among potential adverse clinical events associated with the use of bisphosphonates, none has received greater attention than ONJ. As reviewed by Woo et al,111 nearly all ONJ cases (94%) have been described in patients receiving high doses of IV bisphosphonates (primarily zoledronic acid and pamidronate) for oncologic conditions. Prevalence in patients with myeloma ranged from 7% to 10%, whereas up to 4% of patients with breast cancer developed ONJ.111,112 More recently, however, a reduced dosing schedule in patients with myeloma, in which IV bisphosphonate was given monthly for 1 year and then every 3 months thereafter, was shown to decrease the incidence of ONJ compared with monthly bisphosphonate infusions.113

Whereas the incidence of ONJ is estimated to be 1 to 10 per 100 oncology patients, the risk of ONJ appears to be substantially lower among patients receiving oral bisphosphonate therapy for osteoporosis, with an estimated incidence of approximately 1 in 10,000 to 1 in 100,000 patient treatment years, although this estimate is based on incomplete data.114 Associated risk factors appear to be poor oral hygiene, a history of dental procedures or denture use, and prolonged exposure to high IV bisphosphonate doses.115,116 Whether concomitant chemotherapy or glucocorticoid use leads to an increased risk of ONJ is unknown.117 Once established, care for ONJ is largely supportive, with antiseptic oral rinses, antibiotics, and limited surgical debridement as necessary leading to healing in most cases.118 Although evidence-based guidelines at this time have not been established for any single malignancy or bisphosphonate, careful attention to dental hygiene including an oral cavity examination for active or anticipated dental issues, both before bisphosphonate initiation and throughout treatment, is likely to be paramount.

Although use of bisphosphonates and development of ONJ have been temporally associated, a causal relationship has not been identified. Thus, despite the burgeoning scientific literature that has developed since the association between bisphosphonate therapy and ONJ was first reported in 2003,119 many fundamental questions remain unanswered. As a first step in this process, a task force convened by the American Society for Bone and Mineral Research recently provided a standardized definition of ONJ as the presence of exposed bone in the maxillofacial region that does not heal within 8 weeks after identification by a health care professional.114 Given the current paucity of information on the true incidence, risk factors, and clinical approach to both prevention and treatment, preclinical basic and animal studies, as well as well-designed clinical trials, are necessary to both identify patients at increased risk of development of ONJ and more fully understand the association between bisphosphonate therapy and ONJ.

Atrial Fibrillation

In addition to the concern for ONJ, another concern with bisphosphonate therapy, which has recently come to light, is atrial fibrillation. In the HORIZON Pivotal Fracture Trial, in which patients were treated annually with IV zoledronic acid, a statistically significant increase in the incidence of serious atrial fibrillation (defined as events resulting in hospitalization or disability or judged to be life-threatening) was noted.14 The etiology of this electrophysiologic abnormality is unknown. Whether other bisphosphonate preparations are associated with increased rates of atrial fibrillation is currently unknown, but recent post hoc analysis of data from the pivotal Fracture Intervention Trials120 and from a large population-based case-control study121 suggest a correlation between alendronate administration and a slightly increased incidence of atrial fibrillation, although a larger population-based case-control study showed no evidence of an increased risk of atrial fibrillation or flutter with alendronate use.122 To date, concerns for atrial fibrillation do not appear to extend to patients receiving risedronate,123 nor was an increased rate of atrial fibrillation seen in the HORIZON Recurrent Fracture Trial, in which patients received IV zoledronic acid after a hip fracture.38 Clearly, more studies examining the potential relationship between bisphosphonate use and atrial fibrillation are warranted, as are focused discussions between clinicians and patients either currently managed with or considering initiation of bisphosphonate treatment.

Oversuppression of Bone Turnover

Because bisphosphonates inhibit osteoclast activity, there has been some concern that prolonged bisphosphonate treatment leads to �frozen bone,� characterized by over-suppression of bone remodeling, an impaired ability to repair skeletal microfractures, and increased skeletal fragility. Although increased rates of microfractures have been found in dogs treated with high doses of bisphosphonates,124 this finding does not appear to be common among postmenopausal women with osteoporosis treated with either oral or IV bisphosphonate therapy,22,125 although isolated cases of severely suppressed bone turnover and associated fractures have been reported.126,127 Nonetheless, the optimal duration of bisphosphonate therapy for postmenopausal osteoporosis, and nearly all other conditions for which bisphosphonates are used, remains unclear.

Hypocalcemia

Hypocalcemia after bisphosphonate administration most frequently follows IV infusion and can occur in patients with high rates of osteoclast-mediated bone resorption (such as in patients with either Paget disease of bone128 or a substantial skeletal tumor burden129), previously unrecognized hypoparathyroidism,130 impaired renal function, or hypovitaminosis D before treatment.131 Treatment is largely supportive, with calcium and vitamin D supplements as appropriate.

Acute Inflammatory Response

Approximately 10% to 30% of patients receiving their first nitrogen-containing bisphosphonate infusion will experience an acute phase reaction, most commonly characterized by transient pyrexia with associated myalgias, arthralgias, headaches, and influenza-like symptoms. This rate declines by more than half with each subsequent infusion, such that a rate of 2.8% was found after the third infusion in the HORIZON trial.14 The acute phase response is believed to be the result of proinflammatory cytokine production by peripheral blood ?? T cells.132 Pretreatment with histamine receptor antagonists or antipyretics can reduce the incidence and severity of symptoms among susceptible patients. Occasionally corticosteroids are of benefit.

A relatively rare adverse effect of bisphosphonate therapy of which physicians should be aware is ocular inflammation (conjunctivitis, uveitis, episcleritis, and scleritis). This complication has been found to occur with both oral and IV bisphosphonate therapy. In the largest retrospective study to date, an incidence of approximately 0.1% was found in patients treated with oral risedronate.133 Fortunately, ocular symptoms usually resolve within a few weeks after bisphosphonate discontinuation.

Severe Musculoskeletal Pain

Although all oral and IV bisphosphonate preparations list musculoskeletal pain as a potential adverse effect in their prescribing information, the US FDA recently issued an alert highlighting the possibility of severe, incapacitating musculoskeletal pain that can occur at any point after initiation of bisphosphonate therapy.134 This severe musculoskeletal pain was distinct from the acute phase response described previously. Fewer than 120 cases had been reported by late 2002 for alendronate and mid-2003 for risedronate in total.135 At this time, both risk factors for and incidence of this adverse effect are unknown.

Other Potential Complications of Bisphosphonate Therapy

Other complications associated with the use of oral and IV bisphosphonate therapies are well recognized. Esophageal irritation and erosion can occur with oral bisphosphonate therapy, particularly in patients with known gastroesophageal reflux disease or esophageal stricture. Strict maintenance of an upright posture for 30 to 60 minutes after ingestion with a full glass of water, depending on the oral bisphosphonate, and the use of weekly rather than daily preparations are both likely to limit the risk of adverse effects. For patients unable to tolerate oral bisphosphonates, IV preparations (as noted previously) are now FDA approved and not associated with gastroesophageal irritation.

Bisphosphonate doses and infusion rates should be adjusted for patients with moderate to severe renal insufficiency. If used in patients with creatine clearance values lower than 30 mL/min, bisphosphonates must be used cautiously. Particularly in patients who receive IV preparations, bisphosphonates can lead to rapid deterioration of renal function,136,137 likely because of their local accumulation in the kidney. For patients with renal insufficiency who receive IV bisphosphonate therapy, renal function both before and after drug administration should be determined. In patients with mild to moderate renal impairment, oral bisphosphonates rarely lead to further deterioration in renal function, likely because of their poor absorption across the gastrointestinal tract and thus limited short-term bioavailability.

Unresolved Questions

Bisphosphonates have been and continue to be used for other conditions without an FDA-approved indication for therapy. As noted, these include various pediatric populations with low bone mass, incident fractures, and prolonged immobility. Many healthy premenopausal women with either radiographic osteopenia or osteoporosis without fractures and postmenopausal women with osteopenia but without fractures now receive bisphosphonate therapy. Until further studies address these important clinical questions, it is important to tell such patients that we currently lack sufficient data from well-controlled clinical trials to determine either benefits or risks assumed with these pharmacological interventions.

Role of Calcium and Vitamin D

Despite the good intentions of many practitioners to limit fractures in their patients by instituting bisphosphonate therapy, the importance of assuring adequate vitamin D and calcium intake both before and after starting bisphosphate therapy is frequently overlooked. Hypovitaminosis D is common among many patient populations that are also prescribed bisphosphonate therapy and is particularly common among elderly patients who frequently have limited sun exposure, reduced dietary intake, or some renal impairment. This vitamin D insufficiency or deficiency limits dietary absorption of calcium, leading to secondary hyperparathyroidism and loss of skeletal calcium to maintain normocalcemia. Accordingly, among elderly women with osteoporosis, the persistence of secondary hyperparathyroidism blunted the increase in BMD in the lumbar spine in response to weekly alendronate.138 Although currently available data offer no consensus on optimal serum levels of 25-hydroxyvitamin D, a level of 30 ng/mL (75 nmol/L) or more is generally considered to be adequate; vitamin D intoxication occurs only when levels are higher than 150 ng/mL (374 nmol/L).139 For a more complete review of the role of vitamin D in maintenance of skeletal health and for recommendations for vitamin D replacement, please refer to the excellent recent review by Holick.139

Although guidelines for the maintenance of optimal vitamin D levels have changed substantially as we appreciate that vitamin D insufficiency and deficiency affect a far greater proportion of the population than previously recognized, recommendations for optimal calcium intake have been modified only slightly since being addressed by an expert panel convened by the National Institutes of Health in 1994.140 The panel concluded that optimal calcium intake is estimated to be 1000 mg/d for both premenopausal and postmenopausal women receiving estrogen replacement therapy and 1500 mg/d for postmenopausal women not receiving estrogen. Men younger than 65 years were estimated to require 1000 mg/d of calcium and men older than 65 years to require 1500 mg/d.140 More recent recommendations from the National Osteoporosis Foundation have suggested a calcium intake of 1000 mg/d for both men and women younger than 50 years, with an increase to 1200 mg/d from age 50 years onward.141 These recommendations are consistent with those of the Food and Nutrition Board of the Institute of Medicine.142 Further recommendations for calcium intake in children are detailed in both the National Institutes of Health�s and Institute of Medicine�s guidelines.140,142

Conclusion

Since their introduction to clinical practice, bisphosphonates have transformed the clinical care of an array of skeletal disorders characterized by excessive osteoclast-mediated bone resorption. Accordingly, the informed and judicious use of bisphosphonates confers a clear clinical benefit for carefully selected patients that outweighs the risks associated with bisphosphonate use. Maintenance of adequate calcium and vitamin D intake is crucial for all patients receiving bisphosphonate therapy.

Acknowledgments

We thank James M. Peterson for assistance with the figures.

Preparation of this article was supported by a Mayo Career Development Award to Dr Drake.

Dr Khosla has received research support from Procter & Gamble and has served on the advisory board for Novartis.

Glossary

  • ATP – adenosine triphosphate
  • BMD – bone mineral density
  • DXA – dual-energy x-ray absorptiometry
  • FDA – Food and Drug Administration
  • GIO – glucocorticoid-induced osteoporosis
  • HORIZON – Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly
  • IV – intravenous
  • OI – osteogenesis imperfecta
  • ONJ – osteonecrosis of the jaw
  • PPi – inorganic pyrophosphate
  • PTH – parathyroid hormone
  • WHI – Women�s Health Initiative

Footnotes

Individual reprints of this article are not available.

According to the article above, although the utilization of bisphosphonates in clinical practice provides healthcare professionals with new treatment options for skeletal disorders,�further research studies are still required. Information referenced from the National Center for Biotechnology Information (NCBI).�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

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Additional Topics: Acute Back Pain

Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain is the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA IMPORTANT TOPIC: Chiropractic Hip Pain Treatment

What is Metastatic Bone Disease?

What is Metastatic Bone Disease?

Cancer which develops in specific organs of the human body, including the lungs, breast, or prostate, among others, can sometimes spread into the bone, causing what is known as�metastatic bone disease, or MBD. Approximately more than 1.2 million new cancer cases are diagnosed every year, where about 50 percent can spread,�or metastasize, to the bones.

Through medical advancements, patients diagnosed with several different types of cancers, especially lung, breast, and prostate cancer, can live longer. However, primary cancers in more patients go through bone metastases, where they disperse�to the bone. Meanwhile, other types of cancers do not disperse so easily to the�bone. The most common cancers which develop in the organs and spread to the bones include:

  • Breast
  • Lung
  • Thyroid
  • Kidney
  • Prostate

Metastatic bone disease,�or MBD, can damage�and weaken the affected bone, causing pain along the site of spread.�Moreover, patients with MBD are at higher risk of suffering fractures or broken bones. The painful symptoms associated with MBD can make it challenging for the patient to engage in regular physical activities. The main concern of patients with metastatic bone disease is the loss in quality of life.

The extent of the effects of metastatic bone disease on a patient can change and is associated with how cancer has spread, which bones are affected, and how severe the bone harm is. Furthermore, there is a range of treatment choices available to treat MBD. Treatment help patients deal with pain to maintain activity levels and preserve their independence.

Metastatic Bone Disease Explained

The bones are the most common site of spread for cancers which begin in the organs, subsequent to the lung and the liver. Because many patients experience no painful symptoms of metastases to the liver and the lungs, these are often not discovered until the disease is in an advanced stage. In contrast, bone metastases are generally painful when they develop. Cancer most commonly spreads to these sites in the human skeleton:

  • Skull
  • Spine
  • Ribs
  • Upper arm
  • Pelvis
  • Long bones of the leg

Bone Damage

A tumor can completely destroy the bone at the site of spread, a process referred to as osteolytic bone destruction. Damage or weakened bones are most common in cancers which have spread from the lung, thyroid, kidney, and colon. New bone,�called osteoblastic, may also form due to the spread of cancer, more often seen in cancers from the stomach, bladder, and prostate.

Breast cancer often behaves in a combined osteolytic and osteoblastic method. Since the cancer cells secrete factors that interact with all the cells in the human skeleton, causing bone destruction, new bone formation, or both, osteolytic and osteoblastic metastatic bone disease happens. Also, breast cancer may commonly cause MBD in the hip and/or pelvis.

As a result of bone damage and weakness, patients with�metastatic bone disease are prone to fractures. Broken bones caused by MBD are termed “pathological fractures”.�Sometimes, the bone may be so weak that a fracture is imminent, termed “impending pathologic fractures”. Bedrest for lengthy intervals due to broken bones may result in chemical imbalances in the bloodstream, such as raised calcium levels, known as hypercalcemia. Patients with cancer that has spread to the spine can develop nerve damage which can result in paralysis or loss of using their arms and/or legs.

MBD Symptoms

A cancer patient who experiences any pain, especially in the back, arms, and legs should notify their doctor immediately. Pain which manifests without engaging in physical activities is especially concerning. The most common symptoms of�metastatic bone disease include:

  • Pain: MBD’s most prevalent symptom is pain. Patients may experience pain along their hip and/or pelvis, upper and lower extremities, and spine because the tumor may have damaged or weakened the bone.
  • Fractures: Broken bones, or fractures, can range from mild to severe and are generally a clear indication of the presence of MBD.
  • Anemia: The most common sites of spread, skull, spine, ribs, upper and lower extremities, and hip and/or pelvis, correspond to regions of bone marrow which produce high levels of red blood cells, responsible for carrying oxygen to cells. Anemia, or decreased red blood cell production, is a frequent blood abnormality with MBD.

 

 

MBD Diagnosis

Before following through with treatment for metastatic bone disease, it’s essential for the healthcare professional to understand the patient’s symptoms as well as their overall health and wellness. The doctor will ask for the patient’s medical history. After the medical history, the healthcare professional will perform a physical examination on the patient. The doctor may also utilize imaging diagnostics to help with the patient’s diagnosis.

Imaging Diagnostics

  • X-rays:�After the initial diagnosis, they may order x-rays. Because pain may often originate from other regions of the body, the healthcare professional will also order x-rays beyond the regions where the patient is experiencing discomfort. X-rays may tell an oncologist a great deal of information regarding how much bone is affected.
  • Other imaging tests: The doctor may also order a bone scan. This test can determine if other bones are involved with metastatic bone disease. In select situations, a computerized tomography, or�CT, scan and magnetic resonance imaging, or MRI, may be ordered, especially in scenarios where the spine or hip and/or pelvis are involved.
Dr Jimenez White Coat

A variety of cancers can commonly cause metastatic bone disease, or MBD, throughout different regions of the human skeleton. Bone metastases can cause painful symptoms, ultimately affecting an individual’s quality of life. Research studies have demonstrated that metastatic bone disease in the hip and/or pelvis is a prevalent health issue associated with breast cancer. Treatment may vary on the progression of the problem.

Dr. Alex Jimenez D.C., C.C.S.T. Insight

Metastatic Bone Disease Treatment

Advances in surgical techniques, as well as radiation and medical treatment approaches, have significantly improved the quality of life of patients suffering from cancer that has spread to the bone from the site of origin. Treatment options for MBD are based upon how far the cancer has spread, which bones are affected, and how the bone was damaged or weakened.

In many cases of metastatic bone disease, cancer has progressed to multiple bony sites. As a result, treatment is concentrated on managing the symptoms of pain and bone weakness as it is not intended to be curative. The most common treatment option for MBD includes drugs and/or medications, and radiation to control pain and prevent additional spread of metastatic bone disease, and surgery to stabilize weak and broken bones.

Patients with metastatic bone disease require a team approach. A medical oncologist works closely with a radiation oncologist, and an orthopaedic surgeon. Diagnosis is essential in order to follow through with the best treatment approach. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

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Additional Topics: Acute Back Pain

Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain is the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

 

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EXTRA IMPORTANT TOPIC: Chiropractic Hip Pain Treatment

Femoroacetabular Impingement

Femoroacetabular Impingement

Femoroacetabular impingement, or FAI, is a medical state where additional bone develops in a single or multiple of the bones which make up the hip joint, giving the bones an irregular form. As a result, the bones may rub against each other since they do not fit together properly. This friction can ultimately harm the joint, causing pain, discomfort and limiting movement.

Anatomy

The hip is commonly characterized as a ball-and-socket joint. The acetabulum, which is part of the large pelvis bone, forms the socket of the joint. The ball of the joint is the femoral head, that is the upper end of the thighbone or femur. A type of soft tissue, known as articular cartilage, covers the surface of the ball-and-socket hip joint.

Articular cartilage makes a smooth, low friction surface which aids the bones to slide easily across each other through movement. The acetabulum is also lined by strong fibrocartilage, known as the labrum. The labrum shapes a gasket across the socket, forming a tight seal to provide stability as well as to help properly support the hip joint.

With femoroacetabular�impingement, bone spurs or bone overgrowth, surround the femoral head, across the acetabulum. The extra bone causes the hip joints to come into close contact and prevents them from gliding smoothly and without friction during movements. With age, this can cause labrum tears and osteoarthritis, or the breakdown of articular cartilage.

Types of Femoroacetabular Impingement

According to doctors, there are three types of femoroacetabular impingement, or FAI: pincer, cam,�and combined impingement.

  • Pincer:�This variety of impingement develops when bone extends outwards from the standard rim of the acetabulum. As a result, the labrum is crushed beneath the rim of the acetabulum.
  • Cam: In cam,�impingement of the femoral head causes the joint to be unable to rotate smoothly. A bump forms on the border of the femoral head which grinds the cartilage inside the acetabulum.
  • Combined: Combined impingement suggests that both pincer and cam types of femoroacetabular�impingement are found.

Causes of FAI

Abnormal development of the hip bones and joints throughout childhood is the most common cause of femoroacetabular impingement. However, it is the deformity of a pincer bone spur�or a cam bone spur which leads to joint damage and hip pain. If the hip bones and joints do not form normally, there’s little which can be done to prevent femoroacetabular�impingement.

Many people may have FAI and never�experience symptoms from the condition. When symptoms develop, however, it generally indicates that there is damage to the cartilage or labrum and the health issue may progress. Moreover, athletes are more likely to experience symptoms of femoroacetabular impingement, although exercise does not cause FAI.

Symptoms of FAI

The most common symptoms of femoroacetabular impingement include: pain and discomfort; stiffness; and limping.�Pain associated with FAI frequently occurs in the region of the groin, although it may also occur toward the exterior of the hip. Twisting, turning, and squatting may cause a sharp, stabbing pain while the pain is generally described as a dull ache.

 

 

Diagnosis of FAI

For the first consultation, the healthcare professional will discuss the patient’s hip symptoms and talk about their general health and wellness. They will also examine the patient’s hip. As part of the physical evaluation, the doctor will conduct an FAI impingement test by bringing up the patient’s knee then rotating it towards their opposite shoulder. If this recreates hip pain, the test is positive for femoroacetabular impingement.

Imaging Diagnostics

The healthcare professional may also order imaging diagnostics to help determine whether the patient has femoroacetabular impingement, or FAI. The following imaging diagnostics below can be used.

  • X-rays: These will show whether the hip has shaped bones of FAI, and provide images of the bone. X-rays may also reveal signs of arthritis.
  • Computed tomography (CT) scans: More comprehensive than a plain x-ray, CT scans help the healthcare professional determine the specific contour of the patient’s hips.
  • Magnetic resonance imaging (MRI) scans: These tests create pictures of soft tissue. They will help the doctor find harm to the labrum and articular cartilage. Injecting dye into the joint may make the damage or injury show up more clearly.
  • Local anesthetic: The doctor can also inject a numbing medication into the hip joint as a test. It affirms that FAI is the problem if temporary pain relief is provided by the local anesthetic.
Dr Jimenez White Coat

Femoroacetabular impingement, or FAI, commonly affects the hip joint of many young and middle-aged adults. FAI occurs when the ball-and-socket joint of the hip causes abnormal friction and restricts range of movement. Furthermore, damage or injury to the articular cartilage or the labrum can affect the femoral head or the acetabular socket. Treatment options for FAI can range from alternative treatment options to surgery.

Dr. Alex Jimenez D.C., C.C.S.T. Insight

Treatment for Femoroacetabular Impingement

Non-Surgical Treatment

  • Lifestyle modifications:�The healthcare professional may recommend changes in physical activities that cause symptoms, simply altering the patient’s regular everyday routine.
  • Drugs and/or medications: The use of drugs and/or medications, such as ibuprofen, can be offered to help decrease painful symptoms and inflammation. The relief may only be temporary.
  • Alternative treatment options:�Treatment approaches like chiropractic care and physical therapy can help provide pain relief to patients with femoroacetabular impingement. Moreover, specific stretches and exercises can strengthen the muscles which support the joint and can boost range of movement. This can help relieve some stress and pressure on articular cartilage or the labrum.

Surgical Treatment

If imaging diagnostics and physical evaluations reveal additional hip joint damage and/or injury as well as the presence of other conditions and non-surgical treatment does not relieve the patient’s pain, the healthcare professional may recommend surgical interventions or surgery.

Arthroscopy

Femoroacetabular impingement can be treated with arthroscopic surgery. Arthroscopic surgical interventions are performed with thin instruments using little incisions. The surgeon then utilizes a small camera to look�inside the hip. The doctor can fix or clean out any damage to the labrum and articular cartilage by shaving the bulge on the femoral head and also trimming the bony rim of the acetabulum.

As the results of operation enhance, physicians will recommend surgery that is earlier for FAI. Surgical techniques continue to progress and at the future, computers may be utilized to guide the physician in reshaping and correcting the hip. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

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Additional Topics: Chiropractic for Athletes with Back Pain

Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain is the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA IMPORTANT TOPIC: Piriformis Syndrome Chiropractic Treatment

Impacted Femoral Neck Fractures

Impacted Femoral Neck Fractures

Hip fractures are characterized as any type of break in the upper region of the femur or thigh bone. The variety of broken bones generally depends on the circumstances and the force applied to the bone, where some can be more common than others. Impacted femoral neck fractures are common hip fractures which occur in many older adults in the United States.

Anatomy of Impacted Femoral Neck Fractures

The hip is a ball-and-socket joint which provides the femur the ability to bend and rotate at the pelvis. While any form of broken bones in the thigh bone or femur is considered a hip fracture, damage or injury to the socket, or acetabulum, itself is not considered a hip fracture. Below we will discuss hip fractures, particularly impacted femoral neck fractures, among others.

Causes, Symptoms and Diagnosis

Hip fractures frequently�occur due to a slip-and-fall accident or due�to a direct blow to the hip. Various health issues, including osteoporosis and stress injuries, as well as cancer, can sometimes weaken the bones and make the pelvis more vulnerable to fractures.�The neck of the femur is located under the ball of the hip joint. Impacted femoral neck fractures occur when a force presses against both ends of the femur at the femoral neck, pushing the broken ends of the bone together.

Patients with hip fractures experience symptoms of pain on the upper thigh or in the groin. They may also experience considerable discomfort with any attempt to flex or rotate the hip. In comparison to impacted femoral neck fractures, if the bone is completely broken, the leg may appear to be shorter than the non-injured leg. Also, the patient will hold the injured leg in a still position with the foot and knee turned outward in external rotation.

Diagnosis�for hip fractures commonly involves the use of x-rays of the hip, pelvis and/or femur. In several instances, if the patient experiences a slip-and-fall accident or a direct blow to the hip resulting in impacted femoral neck fractures, they may not be seen on a regular x-ray. Magnetic resonance imaging, or MRI, may be recommended to view some cases of hip fractures. The MRI scan will typically demonstrate any hidden hip fractures. Computed tomography, or CT, scans may also be utilized instead.

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Impacted femoral neck fractures are hip injuries which occur just below the femoral head, or the ball-and-socket hip joint, where the broken ends of the bone are jammed together by the force of the injury. This area of the thigh bone, or femur, is known as the femoral neck. Treatment for impacted femoral neck fractures may include rest and physical rehabilitation. Diagnosis for impacted femoral neck fractures is important for treatment.

Dr. Alex Jimenez D.C., C.C.S.T.

 

 

Treatment of Impacted Femoral Neck Fractures

Once a healthcare professional has diagnosed the patient’s hip fracture, their overall health and wellness will also be evaluated.�Treatment for femoral neck stress fractures depends on the patient’s age and on the extent of the broken bone. Treatment for femoral neck stress fractures�include bed rest for several days followed by a physical rehabilitation program.

Many femoral neck stress fractures are treated with surgery. It’s essential for the patient to talk to their doctor to discuss the best treatment option.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

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Additional Topics: Chiropractic for Athletes with Back Pain

Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain is the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA IMPORTANT TOPIC: Chiropractic Hip Pain Treatment

Femoral Neck Stress Fractures

Femoral Neck Stress Fractures

The hip is a ball-and-socket joint composed of the head of the thigh bone, or femur,�which acts as the ball and fits into the round socket of the hip bone, or acetabulum. The neck of the femur is located under the ball of the hip joint. Stress fractures to the femoral neck can entirely or partially detach the femoral head from the rest of the femur.

Femoral neck stress fractures can be either displaced, where the bone is transferred out of its normal position, or non-displaced, where the bone remains stable. These fractures may interrupt blood flow to the portion of the broken bone. In recovery, the blood supply prevents severely displaced femoral neck stress fractures from healing correctly.

Causes and Symptoms of Femoral Neck Stress Fractures

Femoral neck stress fractures can result due to: a small slip-and-fall accident or twisting of the hip in older adults, osteoporosis, a high-impact�injury, such as from an automobile accident, and�sudden strenuous physical activity or changes in physical activity in younger individuals unaccustomed to the events, including from sports injuries.�

The symptoms of femoral neck stress fractures generally include: pain and discomfort, radiating pain which extends to the knee, inability to bear weight on the affected lower extremity, shortening or sideways rotation of the leg, increased pain in the hip during the rotation of the leg, and inflammation on the side of the hip with the femoral neck stress fractures.

 

 

Diagnosis and Treatment of Femoral Neck Stress Fractures

A healthcare professional will diagnose femoral neck stress fractures based on the causes and symptoms of the health issue, followed by clinical evaluation. Many doctors order x-rays to diagnose femoral neck stress fractures. The doctor may also order�magnetic resonance imaging, or MRI, and computer tomography, or CT, scanning for a better diagnosis.

Treatment for femoral neck stress fractures depends on the patient’s age as well as on the extent of the broken bone. Treatment for femoral neck stress fractures may include�bed rest for several days followed by a physical rehabilitation program. A healthcare professional may prescribe drugs and/or medications to relieve pain, prevent blood clots and treat infection.

Many femoral neck stress fractures are treated through surgical interventions. Surgery for femoral neck stress fractures involves hip pinning if the bone is minimally displaced and the patient has�enough bone density. The surgeon performs this by making a small incision and then inserting several screws to stabilize the bones which are broken.

Hip hemiarthroplasty or partial hip replacement is utilized for displaced fractures where the surgeon will replace the�femoral head with a metal implant. The socket is not replaced in a partial hip replacement procedure. For total hip replacement, the surgeon will replace the socket of the hip joint, as well as the femoral head, with artificial metallic implants.

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Femoral neck stress fractures are hip injuries which occur just below the femoral head, or the ball-and-socket hip joint. This area of the thigh bone, or femur, is known as the femoral neck. Femoral neck stress fractures happen when the ball is disconnected from the rest of the femur, or thigh bone. Treatment for this health issue includes rest and physical rehabilitation.

Dr. Alex Jimenez D.C., C.C.S.T.

Conclusion

Femoral neck stress fractures occur�in the hip area below the ball-and-socket joint of the hip. A healthcare professional will suggest treatment based on the severity of the femoral neck stress fractures and the patient’s age.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

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Additional Topics: Chiropractic for Athletes with Back Pain

Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain is the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA IMPORTANT TOPIC: Chiropractic Hip Pain Treatment

Osteitis Pubis Treatment

Osteitis Pubis Treatment

Pain along the pelvis and groin region is known as osteitis pubis. Osteitis pubis develops through the inflammation of the pubic symphysis, or the joints of the major pelvic bones found at the front of the pelvis.

The pubic symphysis is a thin joint which generally provides very minimal motion. The joint retains the two sides of the pelvis together in the front, where they connect�at the sacrum in the rear side of the pelvis.

Osteitis Pubis Symptoms

Osteitis pubis is commonly characterized by pain in the front of the pelvis. Other causes of pelvic pain, such as a strain or a sprain, are frequently confused and diagnosed as osteitis pubis. While many patients report painful symptoms on one side, the�pain�typically occurs in the middle of the pelvis. Other symptoms of osteitis pubis include limping and weakness.

Osteitis Pubis Causes

For some patients, the pubic symphysis itself can become irritated and inflamed, causing the well-known symptoms of osteitis pubis. Other common causes of osteitis pubis comprise of: sports injuries, particularly from football, hockey, and soccer; pregnancy; gynecologic or abdominal surgical interventions; and trauma or injury from accidents.

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Osteitis pubis is known as the inflammation of the pubis symphysis which causes various degrees of lower abdominal, pelvic, and groin pain. Symptoms of osteitis pubis include pain and discomfort in the region of the pelvis when engaging in physical activities, and loss of flexibility. A variety of causes, including sports injuries, can cause osteitis pubis. Fortunately, rest alone can help treat this painful health issue.

Dr. Alex Jimenez D.C., C.C.S.T.

Osteitis Pubis Diagnosis

Diagnosis of osteitis pubis generally involves x-rays which demonstrate an irregular pubic symphysis with sclerotic, or thick, bone borders as a result of chronic inflammation. An MRI test is generally not required, however, it will help demonstrate the inflammation of the bone and the joint.

Additional tests may be performed to ensure there’s no infection in the bone which could also be causing symptoms similar to osteitis pubis. This complication is more of a concern for those patients who have had recent surgery or for those who are more prone to suffer from infections.

 

 

Osteitis Pubis Management

The most recommended treatment for osteitis pubis is rest. Since inflammation is the problem, the human body often only requires the joint to rest in order to heal correctly. Other treatment, however, consists of:

Rest

An essential treatment for osteitis pubis is rest as this will permit the intense inflammation in the pelvis and groin to subside. For many patients, rest alone is the only treatment necessary for their�osteitis pubis. If the pain is severe, crutches or a cane may provide additional assistance.

Ice and Heat

Ice packs and heating pads are among the most commonly used remedies for inflammation. Make sure to follow the instructions of your healthcare professional before utilizing ice and heat for your osteitis pubis symptoms.

Chiropractic Care

Chiropractic care is a well-known, alternative treatment option for osteitis pubis. A doctor of chiropractic, or chiropractor, will utilize a variety of treatment methods and techniques, to help restore strength, mobility, and flexibility while rest is needed to subside the painful symptoms. Chiropractic care can also help correct any spinal misalignments which may be causing additional pain and discomfort for the patient.

Drugs and/or Medications

Nonsteroidal anti-inflammatory drugs and/or medications, commonly referred to as NSAIDs, are frequent prescriptions provided for patients with hip pain brought on by problems like arthritis, bursitis, and tendonitis.

Treatment of osteitis pubis may take some time to completely relieve the painful symptoms. The use of drugs and/or medications is demonstrated to be better than the other treatment options listed above, although attempts to heal osteitis pubis with cortisone injections have been tested.

Surgical interventions are generally not necessary for patients with osteitis pubis.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

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Additional Topics: Acute Back Pain

Back pain�is the most prevalent cause of disability worldwide and the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA IMPORTANT TOPIC: Chiropractic Hip Pain Treatment

Understanding Trochanteric Bursitis

Understanding Trochanteric Bursitis

The hips are some of the most flexible structures in the human body, providing the necessary amount of strength and stability needed to support the human body when walking, running or jumping. However, the hip joint can also be vulnerable to damage or injury, resulting in debilitating hip pain. Trochanteric bursitis is hip pain brought on by the inflammation of the fluid-filled sac, or bursa, found on the outer border of the hip.

Trochanteric Bursitis Overview

There are about 160 bursae located around the entire body. Bursae act as a sort of “cushion” between soft tissues and bones, preventing bones from rubbing against tendons, ligaments, and muscles. Trochanteric bursitis can affect any of the bursae inside the human body. Trochanteric bursitis affects the outer part of the thighbone, or the femur, at the edge of the hip. This bony point is best known as the greater trochanter.

Another bursa, called the iliopsoas bursa, can be found on the inside of the hip. Inflammation of the iliopsoas bursa also triggers pain in the groin. Bursitis is considered to be one of the top causes of hip pain. Repetitive physical activities, such as climbing stairs, or even surgical interventions to the hip may cause inflammation in the bursa. Many doctors commonly refer to trochanteric�bursitis as greater trochanteric pain syndrome.

Signs and Symptoms of Trochanteric Bursitis

The main characteristic of trochanteric bursitis involves pain in the outer area of the hip or pain when laying on the affected side of the hip. The painful signs and symptoms will also generally become worse through certain physical activities, such as walking or climbing stairs. Pain may also�radiate down the�thigh and into the feet, or it may disperse. Pain can be sharp and fade into an ache, accompanied by swelling in the legs.

Causes of Trochanteric Bursitis

Common causes of trochanteric bursitis include�slip-and-fall accidents, strong blows to the hip, or lying on one side of the body for an extended period of time. Sports injuries involving�overuse from repetitive physical activities like running, bicycling, or climbing stairs, a ripped tendon or even standing may cause trochanteric�bursitis. Health issues, such as�bone spurs in the hip or thighbone, may consequently cause trochanteric bursitis.�

A variety of conditions and disorders may also lead to trochanteric bursitis, including spine problems, such as scoliosis or arthritis of the lumbar spine, even rheumatoid arthritis, and gout as well as thyroid disease. Moreover, legs of two different lengths,�hip surgery or prosthetic implants can create problems in the hips. Trochanteric bursitis is most common in middle-aged or elderly people and it is most prevalent in women than men.

 

Trochanteric Bursitis Treatment and Chiropractic Care

Avoiding the physical activities which caused trochanteric bursitis will allow time for the body to heal. After seeing a healthcare professional for diagnosis, the doctor may often recommend nonsteroidal anti-inflammatory drugs, or NSAIDs to help control pain and inflammation. The recommended amount should be used to avoid side effects. Some doctors may also use steroid injections to control pain and inflammation.

Many healthcare professionals may also recommend alternative treatment options,�such as chiropractic care and physical therapy to help improve trochanteric bursitis signs and symptoms. A chiropractor may utilize spinal adjustments�and manual manipulations to reduce pressure from the spine while a physical therapist may teach the patient exercises to maintain strength. A cane or crutches can also take the weight off a patient’s hip.

If pain relievers or alternative treatment options, such as chiropractic care or physical therapy, do not work for the patient, the healthcare professional might recommend surgery to remove the bursa. This procedure can be accomplished through very small incisions with a camera. Other treatment approaches should be considered before following through with surgery.� The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

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Additional Topics: Acute Back Pain

Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain is the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA IMPORTANT TOPIC: Chiropractic Hip Pain Treatment

Athletic Pubalgia Mechanism of Injury

Athletic Pubalgia Mechanism of Injury

Athletic pubalgia is a debilitating health issue which affects the groin. The injury commonly happens through sports that use sudden changes of direction or intense twisting motions. Also referred to as a sports hernia, athletic pubalgia is characterized as a tear or strain in any soft tissue (muscle, tendon, ligament) of the abdominal or lower abdomen region.

Physiology of Athletic Pubalgia

The soft tissues most often affected by athletic pubalgia are the oblique muscles found in the lower abdomen, especially in the tendons that attach the oblique muscles to the pubic bone. In many instances, the joints that connect the thigh muscles to the pubic bone,�known as the adductor muscles, are also stretched or torn as a result of athletic pubalgia.

Physical activities which involve planting the feet and twisting with maximum exertion can cause athletic pubalgia. A sports hernia is most prevalent in vigorous sports, such as hockey, soccer, wrestling, and football. Athletic pubalgia�causes pain and discomfort in the groin region which typically gets better with rest but comes back with physical activity.

A sports�hernia does not result in a visible bulge in the groin, such as the well-known inguinal hernia does. As time passes, athletic pubalgia can lead to an inguinal hernia, and abdominal organs can push against the diminished cells to form a visible bulge. Without treatment, this sports injury could lead to chronic, disabling pain and other symptoms.

Healthcare Professional Diagnosis

During the first consultation, a doctor will discuss the individual’s symptoms and how the injury happened. To�diagnose athletic pubalgia, the healthcare professional will look for tenderness in the groin or above the pubis. Although a sports hernia may be related to an inguinal hernia, the doctor may not find any hernias during a physical examination.

Furthermore, to help determine the presence of athletic pubalgia, the healthcare professional will probably ask the patient to perform a sit-up or to�bend the trunk against resistance. If you have a sports hernia, these tests will be painful. The doctor may also require�x-rays or magnetic resonance imaging (MRI) to help determine whether you have athletic pubalgia.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

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Additional Topics: Acute Back Pain

Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA IMPORTANT TOPIC: Chiropractic Hip Pain Treatment

Athletic Pubalgia and Adductor Strain

Athletic Pubalgia and Adductor Strain

Athletic pubalgia, also known as a hockey hernia,�hockey groin, Gilmore’s Groin,�sports hernia, or groin disruption, is a health issue of the pubic joint. It is a condition characterized by chronic groin pain in athletes and identified by a dilated ring of the inguinal canal. Soccer and ice hockey players are the athletes most commonly affected by athletic pubalgia, and both recreational and professional athletes can be impacted.

Athletic Pubalgia Symptoms

Symptoms of athletic pubalgia�generally manifest as pain following physical activity, most frequently through hip extension, and twisting and turning movements. The painful symptoms usually radiate into the adductor muscle region and the testicles, although it is often difficult for the individual to pinpoint the exact location of the�symptoms. Athletes with athletic pubalgia�experience soreness and stiffness after physical activity.

Any exertion which increases intra-abdominal pressure, such as sneezing or�coughing, as well as physical activity, can lead to pain. While pain in the stomach and pelvis can occur due to a variety of health issues, including injuries to the low back, or lumbar spine, the hip joint, the sacroiliac joint, and the abdomen, along with the genito-urinary system, diagnosis of athletic pubalgia demands skillful differentiation and evaluation.

 

Clinical Presentation of Athletic Pubalgia

The diagnosis of athletic pubalgia is based on the patient’s history, where healthcare professionals may also depend on the use�of magnetic resonance imaging,�or MRI. Symptoms can frequently be reproduced by certain movements, such as performing crunches or sit-ups. Pain associated with athletic pubalgia may also be elicited with the patient in a “frog posture,” in which the individual is supine with knees bent and heels together.

Many athletes experience concomitant fatigue or tearing of the�adductor muscles or labral tears of the hip. If there is stiffness in the adductor muscles post-injury, painful symptoms can manifest. Alternative treatment options should be to restore normal movement after the adductor has begun to heal, normally 6 to 8 weeks post-injury. Moreover, sleeping in a prone position with the hip on the affected side flexed and externally rotated can offer relief to some athletes with athletic pubalgia.

The precise prevalence of this health issue is unknown. Conservative therapies,�such as gentle stretching, may temporarily alleviate painful symptoms, however, definitive treatment options should be considered for long-term relief.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

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Additional Topics: Acute Back Pain

Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA IMPORTANT TOPIC: Chiropractic Hip Pain Treatment

Developmental Dysplasia of the Hip

Developmental Dysplasia of the Hip

The hip is commonly described as a “ball-and-socket” type joint. In a healthy hip, the ball at the top end of the thighbone, or femur, should fit firmly into the socket, which is part of the large pelvis bone. In babies and children with developmental dysplasia, or dislocation, of the hip, abbreviated as DDH, the hip joint may not have formed normally. As a result, the ball of the femur might easily dislocate and become loose from the socket.

Although DDH is often present from birth, it could also develop during a child’s first year of life. Recent research studies have demonstrated that infants whose thighs are swaddled closely with the hips and knees straight are at a higher risk for developing DDH. Because swaddling has become�increasingly popular, it is essential for parents to understand how to swaddle their babies safely, and they should realize that when done improperly, swaddling may cause health issues such as DDH.

Diagnosis for�Developmental Dysplasia of the Hip

In addition to visual cues, when�diagnosing for DDH, the healthcare professional will perform a careful evaluation, such as listening and feeling for “clunks” which indicates that the hip is placed in different positions. The doctor will also utilize other methods and techniques to determine if the hip is dislocated. Newborns recognized to be at higher risk for DDH are often tested using ultrasound. For babies and children, x-rays of the hip might be taken to provide further detailed images of the hip joint.

Treatment for�Developmental Dysplasia of the Hip

If DDH is discovered at birth, it can usually be treated with the use of a harness or brace. If the hip isn’t dislocated at birth, the condition might not be diagnosed until the child starts walking. At that point, treatment for DDH is much more complex, with less predictable results. If diagnosed and treated accordingly, children ought to have no restriction in function and develop the standard hip joint. DDH may result in atherosclerosis and other problems. It may produce a difference in agility or leg length.

In spite of proper treatment, hip deformity and osteoarthritis may develop later in life. This is particularly true when treatment starts after the age of 2 years. Therefore, diagnosis and treatment are essential in newborns and children with DDH. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

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Additional Topics: Acute Back Pain

Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA IMPORTANT TOPIC: Chiropractic Hip Pain Treatment

Evaluation of the Patient with Hip Pain

Evaluation of the Patient with Hip Pain

Hip pain is a well-known health issue which can be caused by a wide array of problems, however, the site of the patient’s hip pain can provide valuable information regarding the underlying cause of this common health issue. Pain on the inside of the hip or groin can be due to problems within the hip joint itself while pain on the outside of the hip, upper thigh and outer buttocks may be due to problems with the ligaments, tendons and muscles, among other soft tissues, surrounding the hip joint. Furthermore, hip pain can be due to other injuries and conditions, including back pain.

Abstract

Hip pain is a common and disabling condition that affects patients of all ages. The differential diagnosis of hip pain is broad, presenting a diagnostic challenge. Patients often express that their hip pain is localized to one of three anatomic regions: the anterior hip and groin, the posterior hip and buttock, or the lateral hip. Anterior hip and groin pain is commonly associated with intra-articular pathology, such as osteoarthritis and hip labral tears. Posterior hip pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, and less commonly ischiofemoral impingement and vascular claudication. Lateral hip pain occurs with greater trochanteric pain syndrome. Clinical examination tests, although helpful, are not highly sensitive or specific for most diagnoses; however, a rational approach to the hip examination can be used. Radiography should be performed if acute fracture, dislocations, or stress fractures are suspected. Initial plain radiography of the hip should include an anteroposterior view of the pelvis and frog-leg lateral view of the symptomatic hip. Magnetic resonance imaging should be performed if the history and plain radiograph results are not diagnostic. Magnetic resonance imaging is valuable for the detection of occult traumatic fractures, stress fractures, and osteonecrosis of the femoral head. Magnetic resonance arthrography is the diagnostic test of choice for labral tears.

Introduction

Hip pain is a common presentation in primary care and can affect patients of all ages. In one study, 14.3% of adults 60 years and older reported significant hip pain on most days over the previous six weeks.1 Hip pain often presents a diagnostic and therapeutic challenge. The differential diagnosis of hip pain (eTable A) is broad, including both intra-articular and extra-articular pathology, and varies by age. A history and physical examination are essential to accurately diagnose the cause of hip pain.

 

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Anatomy

The hip joint is a ball-and-socket synovial joint designed to allow multiaxial motion while transferring loads between the upper and lower body. The acetabular rim is lined by fibrocartilage (labrum), which adds depth and stability to the femoroacetabular joint. The articular surfaces are covered by hyaline cartilage that dissipates shear and compressive forces during load bearing and hip motion. The hip’s major innervating nerves originate in the lumbosacral region, which can make it difficult to distinguish between primary hip pain and radicular lumbar pain.

The hip joint’s wide range of motion is second only to that of the glenohumeral joint and is enabled by the large number of muscle groups that surround the hip. The flexor muscles include the iliopsoas, rectus femoris, pectineus, and sartorius muscles. The gluteus maximus and hamstring muscle groups allow for hip extension. Smaller muscles, such as gluteus medius and minimus, piriformis, obturator externus and internus, and quadratus femoris muscles, insert around the greater trochanter, allowing for abduction, adduction, and internal and external rotation.

In persons who are skeletally immature, there are several growth centers of the pelvis and femur where injuries can occur. Potential sites of apophyseal injury in the hip region include the ischium, anterior superior iliac spine, anterior inferior iliac spine, iliac crest, lesser trochanter, and greater trochanter. The apophysis of the superior iliac spine matures last and is susceptible to injury up to 25 years of age.2

Dr Jimenez White Coat

The hip joint is one of the larger joints found in the human body and it serves in locomotion as the thigh moves forward and backward. The hip joint also rotates when sitting and with changes of direction while walking. A variety of complex structures surround the hip joint. When an injury or condition affects these, it can ultimately lead to hip pain.

Dr. Alex Jimenez D.C., C.C.S.T.

Evaluation of Hip Pain

History

Age alone can narrow the differential diagnosis of hip pain. In prepubescent and adolescent patients, congenital malformations of the femoroacetabular joint, avulsion fractures, and apophyseal or epiphyseal injuries should be considered. In those who are skeletally mature, hip pain is often a result of musculotendinous strain, ligamentous sprain, contusion, or bursitis. In older adults, degenerative osteoarthritis and fractures should be considered first.

Patients with hip pain should be asked about antecedent trauma or inciting activity, factors that increase or decrease the pain, mechanism of injury, and time of onset. Questions related to hip function, such as the ease of getting in and out of a car, putting on shoes, running, walking, and going up and down stairs, can be helpful.3 Location of the pain is informative because hip pain often localizes to one of three basic anatomic regions: the anterior hip and groin, posterior hip and buttock, and lateral hip (eFigure A).

 

 

Physical Examination

The hip examination should evaluate the hip, back, abdomen, and vascular and neurologic systems. It should start with a gait analysis and stance assessment (Figure 1), followed by evaluation of the patient in seated, supine, lateral, and prone positions (Figures 2 through 6, and eFigure B). Physical examination tests for the evaluation of hip pain are summarized in Table 1.

 

 

Imaging

Radiography. Radiography of the hip should be performed if there is any suspicion of acute fracture, dislocation, or stress fracture. Initial plain radiography of the hip should include an anteroposterior view of the pelvis and a frog-leg lateral view of the symptomatic hip.4

Magnetic Resonance Imaging and Arthrography. Conventional magnetic resonance imaging (MRI) of the hip can detect many soft tissue abnormalities, and is the preferred imaging modality if plain radiography does not identify specific pathology in a patient with persistent pain.5 Conventional MRI has a sensitivity of 30% and an accuracy of 36% for diagnosing hip labral tears, whereas magnetic resonance arthrography provides added sensitivity of 90% and accuracy of 91% for the detection of labral tears.6,7

Ultrasonography. Ultrasonography is a useful technique for evaluating individual tendons, confirming suspected bursitis, and identifying joint effusions and functional causes of hip pain.8 Ultrasonography is especially useful for safely and accurately performing imaging-guided injections and aspirations around the hip.9 It is ideal for an experienced ultrasonographer to perform the diagnostic study; however, emerging evidence suggests that less experienced clinicians with appropriate training can make diagnoses with reliability similar to that of an experienced musculoskeletal ultrasonographer.10,11

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These are numerous causes for hip pain. Although some hip pain may only be temporary, other forms of hip pain can become chronic if left untreated for an extended period of time. Several common causes of hip pain include, arthritis, fracture, sprain, avascular necrosis, Gaucher’s disease, sciatica, muscle strain, iliotibial band syndrome or IT band syndrome and hematoma, among others described below.

Dr. Alex Jimenez D.C., C.C.S.T.

Differential Diagnosis of Anterior Hip Pain

Anterior hip or groin pain suggests involvement of the hip joint itself. Patients often localize pain by cupping the anterolateral hip with the thumb and forefinger in the shape of a �C.� This is known as the C sign (Figure 1A).

Osteoarthritis

Osteoarthritis is the most likely diagnosis in older adults with limited motion and gradual onset of symptoms. Patients have a constant, deep, aching pain and stiffness that are worse with prolonged standing and weight bearing. Examination reveals decreased range of motion, and extremes of hip motion often cause pain. Plain radiographs demonstrate the presence of asymmetrical joint-space narrowing, osteophytosis, and subchondral sclerosis and cyst formation.12

Femoroacetabular Impingement

Patients with femoroacetabular impingement are often young and physically active. They describe insidious onset of pain that is worse with sitting, rising from a seat, getting in or out of a car, or leaning forward.13 The pain is located primarily in the groin with occasional radiation to the lateral hip and anterior thigh.14 The FABER test (flexion, abduction, external rotation; Figure 3) has a sensitivity of 96% to 99%. The FADIR test (flexion, adduction, internal rotation; Figure 4), log roll test (Figure 5), and straight leg raise against resistance test (Figure 6) are also effective, with sensitivities of 88%, 56%, and 30%, respectively.14,15 In addition to the anteroposterior and lateral radiograph views, a Dunn view should be obtained to help detect subtle lesions.16

Hip Labral Tear

Hip labral tears cause dull or sharp groin pain, and one-half of patients with a labral tear have pain that radiates to the lateral hip, anterior thigh, and buttock. The pain usually has an insidious onset, but occasionally begins acutely after a traumatic event. About one-half of patients with this injury also have mechanical symptoms, such as catching or painful clicking with activity.17 The FADIR and FABER tests are effective for detecting intra-articular pathology (the sensitivity is 96% to 75% for the FADIR test and is 88% for the FABER test), although neither test has high specificity.14,15,18 Magnetic resonance arthrography is considered the diagnostic test of choice for labral tears.6,19 However, if a labral tear is not suspected, other less invasive imaging modalities, such as plain radiography and conventional MRI, should be used first to rule out other causes of hip and groin pain.

Iliopsoas Bursitis (Internal Snapping Hip)

Patients with this condition have anterior hip pain when extending the hip from a flexed position, often associated with intermittent catching, snapping, or popping of the hip.20 Dynamic real-time ultrasonography is particularly useful in evaluating the various forms of snapping hip.8

Occult or Stress Fracture

Occult or stress fracture of the hip should be considered if trauma or repetitive weight-bearing exercise is involved, even if plain radiograph results are negative.21 Clinically, these injuries cause anterior hip or groin pain that is worse with activity.21 Pain may be present with extremes of motion, active straight leg raise, the log roll test, or hopping.22 MRI is useful for the detection of occult traumatic fractures and stress fractures not seen on plain radiographs.23

Transient Synovitis and Septic Arthritis

Acute onset of atraumatic anterior hip pain that results in impaired weight bearing should raise suspicion for transient synovitis and septic arthritis. Risk factors for septic arthritis in adults include age older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint surgery, and hip or knee prostheses.24 Fever, complete blood count, erythrocyte sedimentation rate, and C-reactive protein level should be used to evaluate the risk of septic arthritis.25,26 MRI is useful for differentiating septic arthritis from transient synovitis.27,28 However, hip aspiration using guided imaging such as fluoroscopy, computed tomography, or ultrasonography is recommended if a septic joint is suspected.29

Osteonecrosis

Legg-Calv�-Perthes disease is an idiopathic osteonecrosis of the femoral head in children two to 12 years of age, with a male-to-female ratio of 4:1.4 In adults, risk factors for osteonecrosis include systemic lupus erythematosus, sickle cell disease, human immunodeficiency virus infection, smoking, alcoholism, and corticosteroid use.30,31 Pain is the presenting symptom and is usually insidious. Range of motion is initially preserved but can become limited and painful as the disease progresses.32 MRI is valuable in the diagnosis and prognostication of osteonecrosis of the femoral head.30,33

Differential Diagnosis of Posterior Hip and Buttock Pain

Piriformis Syndrome and Ischiofemoral Impingement

Piriformis syndrome causes buttock pain that is aggravated by sitting or walking, with or without ipsilateral radiation down the posterior thigh from sciatic nerve compression.34,35 Pain with the log roll test is the most sensitive test, but tenderness with palpation of the sciatic notch can help with the diagnosis.35

Ischiofemoral impingement is a less well-understood condition that can lead to nonspecific buttock pain with radiation to the posterior thigh.36,37 This condition is thought to be a result of impingement of the quadratus femoris muscle between the lesser trochanter and the ischium.

Unlike sciatica from disc herniation, piriformis syndrome and ischiofemoral impingement are exacerbated by active external hip rotation. MRI is useful for diagnosing these conditions.38

Other

Other causes of posterior hip pain include sacroiliac joint dysfunction,39 lumbar radiculopathy,40 and vascular claudication.41 The presence of a limp, groin pain, and limited internal rotation of the hip is more predictive of hip disorders than disorders originating from the low back.42

Differential Diagnosis of Lateral Hip Pain

Greater Trochanteric Pain Syndrome

Lateral hip pain affects 10% to 25% of the general population.43 Greater trochanteric pain syndrome refers to pain over the greater trochanter. Several disorders of the lateral hip can lead to this type of pain, including iliotibial band thickening, bursitis, and tears of the gluteus medius and minimus muscle attachment.43�45 Patients may have mild morning stiffness and may be unable to sleep on the affected side. Gluteus minimus and medius injuries present with pain in the posterior lateral aspect of the hip as a result of partial or full-thickness tearing at the gluteal insertion. Most patients have an atraumatic, insidious onset of symptoms from repetitive use.43,45,46

In conclusion, hip pain is a common complaint which may occur due to a wide variety of health issues. Moreover, the precise location of the patient’s hip pain can provide valuable information to healthcare professionals regarding the underlying cause of the problem. The purpose of the article above was to demonstrate and discuss the evaluation of the patient with hip pain. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

Curated by Dr. Alex Jimenez

Data Sources: We searched articles on hip pathology in American Family Physician, along with their references. We also searched the Agency for Healthcare Research and Quality Evidence Reports, Clinical Evidence, Institute for Clinical Systems Improvement, the U.S. Preventive Services Task Force guidelines, the National Guideline Clearinghouse, and UpToDate. We performed a PubMed search using the keywords greater trochanteric pain syndrome, hip pain physical examination, imaging femoral hip stress fractures, imaging hip labral tear, imaging osteomyelitis, ischiofemoral impingement syndrome, meralgia paresthetica review, MRI arthrogram hip labrum, septic arthritis systematic review, and ultrasound hip pain. Search dates: March and April 2011, and August 15, 2013.

Author Information:Aafp.org

 

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Additional Topics: Acute Back Pain

Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA IMPORTANT TOPIC: Hip Pain Chiropractic Treatment

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17.�Burnett RS, Della Rocca GJ, Prather H, et al. Clinical presentation of patients with tears of the acetabular labrum.�J Bone Joint Surg Am. 2006;88(7):1448�1457.

18.�Leunig M, Werlen S, Ungersb�ck A, et al. Evaluation of the acetabular labrum by MR arthrography [published correction appears in�J Bone Joint Surg Br. 1997;79(4):693].�J Bone Joint Surg Br. 1997;79(2):230�234.

19.�Groh MM, Herrera J. A comprehensive review of hip labral tears.�Curr Rev Musculoskelet Med. 2009;2(2):105�117.

20.�Blankenbaker DG, De Smet AA, Keene JS. Sonography of the iliopsoas tendon and injection of the iliopsoas bursa for diagnosis and management of the painful snapping hip.�Skeletal Radiol. 2006;35(8):565�571.

21.�Egol KA, Koval KJ, Kummer F, et al. Stress fractures of the femoral neck.�Clin Orthop Relat Res. 1998;(348):72�78.

22.�Fullerton LR Jr, Snowdy HA. Femoral neck stress fractures.�Am J Sports Med. 1988;16(4):365�377.

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24.�Margaretten ME, Kohlwes J, Moore D, et al. Does this adult patient have septic arthritis?�JAMA. 2007;297(13):1478�1488.

25.�Eich GF, Superti-Furga A, Umbricht FS, et al. The painful hip: evaluation of criteria for clinical decision-making.�Eur J Pediatr. 1999;158(11):923�928.

26.�Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children.�J Bone Joint Surg Am. 1999;81(12):1662�1670.

27.�Learch TJ, Farooki S. Magnetic resonance imaging of septic arthritis.�Clin Imaging. 2000;24(4):236�242.

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29.�Leopold SS, Battista V, Oliverio JA. Safety and efficacy of intraarticular hip injection using anatomic landmarks.�Clin Orthop Relat Res. 2001; (391):192�197.

30.�Mitchell DG, Rao VM, Dalinka MK, et al. Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings.�Radiology. 1987;162(3):709�715.

31.�Mont MA, Zywiel MG, Marker DR, et al. The natural history of untreated asymptomatic osteonecrosis of the femoral head.�J Bone Joint Surg Am. 2010;92(12):2165�2170.

32.�Assouline-Dayan Y, Chang C, Greenspan A, et al. Pathogenesis and natural history of osteonecrosis.�Semin Arthritis Rheum. 2002;32(2):94�124.

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36.�Torriani M, Souto SC, Thomas BJ, et al. Ischiofemoral impingement syndrome.�AJR Am J Roentgenol. 2009;193(1):186�190.

37.�Ali AM, Whitwell D, Ostlere SJ. Case report: imaging and surgical treatment of a snapping hip due to ischiofemoral impingement.�Skeletal Radiol. 2011;40(5):653�656.

38.�Lee EY, Margherita AJ, Gierada DS, et al. MRI of piriformis syndrome.�AJR Am J Roentgenol. 2004;183(1):63�64.

39.�Slipman CW, Jackson HB, Lipetz JS, et al. Sacroiliac joint pain referral zones.�Arch Phys Med Rehabil. 2000;81(3):334�338.

40.�Moore KL, Dalley AF, Agur AM.�Clinically Oriented Anatomy. 6th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2010.

41.�Adlakha S, Burket M, Cooper C. Percutaneous intervention for chronic total occlusion of the internal iliac artery for unrelenting buttock claudication.�Catheter Cardiovasc Interv. 2009;74(2):257�259.

42.�Brown MD, Gomez-Marin O, Brookfield KF, et al. Differential diagnosis of hip disease versus spine disease.�Clin Orthop Relat Res. 2004; (419):280�284.

43.�Segal NA, Felson DT, Torner JC, et al.; Multicenter Osteoarthritis Study Group. Greater trochanteric pain syndrome.�Arch Phys Med Rehabil. 2007;88(8):988�992.

44.�Strauss EJ, Nho SJ, Kelly BT. Greater trochanteric pain syndrome.�Sports Med Arthrosc. 2010;18(2):113�119.

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Close Accordion

Understanding Hip Pain and Knee Pain

Understanding Hip Pain and Knee Pain

I went through the physical therapy, and then I used chiropractic care, as well as crossfit, to kinda get me to that 100% mark. And I haven’t had a problem since, I continue to do crossfit and I use chiropractic care to make sure my body is aligned. It gives me that extra sense of feeling that I’m not gonna injure myself again, that my body is feeling good and 100%. I never have that feeling in the back of my mind, that, you know, I’m gonna injure myself. Sometimes I forget I even had a surgery and I think I can attribute that to a combination of chiropractic care and to the overall training aspect of crossfit. – Andrew Hutchison

 

There are a variety of causes for both hip pain and knee pain. While the hip joint can withstand a tremendous amount of wear-and-tear, it’s not indestructible. With age and usage, the hip cartilage can begin to degenerate, resulting in hip pain. Tendons and ligaments at the hip may also get excessive overused and can start to demonstrate signs of wear-and-tear over time. The anatomy of the knee, however, is more complex. The knee is collectively made up of bones, pads of cartilage and a joint capsule. Trauma or damage from an injury or degeneration associated with aging may cause knee pain.

 

Causes of Hip Pain

 

Hip pain is the general term used to define pain felt in or around the hip joint. Certain injuries and/or conditions may commonly cause hip pain. Arthritis, especially rheumatoid arthritis, are the primary culprits of hip pain in older individuals. Both may result in the breakdown of cartilage in the hip joint and can cause inflammation in the area. Combined with pain and discomfort, there’s generally also reduced range of motion in the hip as well as stiffness. Bursitis may also result in hip pain. The bursae are sacs of fluid which function by helping to reduce friction between the joints. If these become inflamed, however, they can lead to pain. Typically, it’s only repetitive movements that irritate the hip joint and result in pain.

 

Similar to bursitis, tendinitis can also lead to inflammation and is usually caused by repetitive stress from movements. Muscle or tendon strain can be a result of overuse. Repeated physical activities can additionally place unnecessary amounts of pressure on the ligaments, tendons and joints of the hip, especially in those which support the buttocks. If some of these are inflamed, the hip won’t be able to function normally and there will be painful symptoms as a result. Below, we will describe the various causes of hip pain as well as discuss their effects on the structure of the hip in detail.�Hip pain isn’t always felt in the hip itself as it may also be felt in the groin or thigh.

 

Tendonitis

 

The most frequent cause of severe hip pain is inflamed tendons, or tendonitis. This can generally be due to excessive exercise or physical activities. This health issue can be quite debilitating but it usually heals within a couple of days with proper care.

 

Arthritis

 

As mentioned above, one of the most common causes of chronic hip pain is arthritis. Arthritis can cause painful, stiff and tender joints, and it can cause walking problems. Various types of arthritis can cause hip pain, including:

 

  • Osteoarthritis might be the final result of age-related degeneration in the cartilage that surrounds the joints.
  • Trauma, damage or injury to a joint, like a fracture, may cause traumatic arthritis similar to atherosclerosis.
  • Infectious arthritis is a result of an infection in the joint caused by the degeneration of cartilage.
  • Rheumatoid arthritis is a result of the human body’s immune system attacking its own joints. This type of arthritis can ultimately destroy joint bones and cartilage.

 

Osteoarthritis is a a lot more commonly diagnosed than rheumatoid arthritis.It’s fundamental to understand the different types of arthritis as these can be powerful diagnostic tools to help effectively treat hip pain.

 

Trochanteric Bursitis

 

Another possible cause of hip pain involves a health issue medically referred to as trochanteric bursitis, as previously mentioned. This condition occurs when the bursa, which are liquid-filled sacs near the hip joint, become inflamed. Any number of variables can lead to trochanteric bursitis, such as hip injury, overuse of the joints, underlying health issues, or even the presence of other conditions like rheumatoid arthritis. This condition is reportedly much more common in females than in males.

 

Hip Fractures

 

Hip fractures are common causes of hip pain which most frequently occur in older adults and in people who have osteoporosis, which is a weakening of the bones associated with age and various other factors. Hip fractures cause very sudden and extreme hip pain, where they will require immediate medical attention. There are complications that can happen due a fractured hip, like a blood clot in the leg. A hip fracture usually requires surgical interventions to be corrected. Additionally, you may be required to seek further care from a qualified healthcare professional in order to engage in a rehabilitation program.

 

Less Common Causes of Hip Pain

 

There are additional, less common conditions that can result in hip pain. These include snapping hip syndrome and osteonecrosis, or avascular necrosis. Below, we will discuss these two health issues in detail.

 

Snapping Hip Syndrome

 

Snapping hip syndrome, which most commonly occurs in athletes, especially dancers, is characterized by a snapping noise or feeling from the hip. By way of instance, this snapping may happen when you’re walking or getting up from a chair. The problem is usually painless, but it can cause pain in several cases. Snapping hip with pain is generally an indication of a tear in the hip cartilage or other structure surrounding the hip joint.

 

Osteonecrosis

 

Osteonecrosis, also known as avascular necrosis, occurs when blood isn’t able to reach the bones, either permanently or temporarily. This can cause the reduction of bone. The cartilage of individuals with this condition is normal initially, however, it will eventually collapse as the disease evolves. Finally, bones may crack or crumble. It’s not always clear what triggers osteonecrosis. Joint harm, heavy usage of steroid drugs or alcohol, and cancer treatments could put you at greater risk of developing this condition, however, the cause is never determined in many osteonecrosis cases.

 

Causes of Knee Pain

 

Similar to hip pain, arthritis, especially rheumatoid arthritis and osteoarthritis, may commonly cause knee pain. With the breakdown of cartilage associated with osteoarthritis in the knee, the bones can begin to rub against one another, causing pain and discomfort which could eventually lead to other painful symptoms. Rheumatoid arthritis is a chronic inflammatory disorder of the joints and it can affect the soft tissue which lines the knee joints. The final result is inflammation, joint damage and joint pain at the knee. The knee joint is very prone to accidents. Typical knee injuries include: meniscal injuries, anterior cruciate ligament injuries and tendon injuries.

 

The meniscus might be damaged when the knee is bent and twisted in an unnatural way, where ligaments and tendons could also be overstretched and ultimately torn as a result. If it is not repaired, the probability of developing osteoarthritis increases. Any abrupt change in movement can additionally injure the anterior cruciate ligament. Nearly all causes of knee injury and knee pain are the result of a blow to the surface of the knee. Exercises or physical activities which could harm the complex structures of the knee include jogging and jumping. A dislocated kneecap is still another frequent source of knee pain. This occurs when the patella is moved from place and it can be very debilitating.

 

Temporary knee pain differs from chronic knee pain. Persistent knee pain is not always attributable to one incident. It the result of many causes or conditions.Persistent knee pain is characterized as long-term pain, swelling, or sensitivity in a single or both knees. The reason behind your knee pain can determine the symptoms you develop. Many conditions may cause or lead to chronic knee pain, and lots of treatments exist. Every person’s experience with chronic knee pain will most likely be different. Understanding the causes of knee pain can be a powerful diagnostic tool which can help healthcare professionals properly determine the proper treatment option for your specific health issue.�Common causes of knee pain include:

 

  • osteoarthritis: pain, inflammation and joint destruction brought on by degeneration of a joint.
  • tendinitis: pain in the knee which worsens when climbing, taking stairs, or walking up an incline.
  • bursitis: inflammation caused by repeated overuse or trauma of the knee.
  • chondromalacia patella: damaged cartilage under the kneecap.
  • gout: arthritis brought on by the buildup of uric acid.
  • Baker’s cyst: a buildup of synovial fluid, fluid which lubricates the joint, supporting the knee.
  • rheumatoid arthritis, or RA: a chronic autoimmune inflammatory disease that causes painful swelling, joint deformity and bone erosion.
  • dislocation: dislocation of the kneecap most commonly caused by trauma, damage or injury.
  • meniscus tear: a rupture in one or more of the soft tissues in the knee.
  • torn ligament: tear at one of the four ligaments in the knee, the most commonly injured ligament is the anterior cruciate ligament, or the ACL.
  • bone tumors: osteosarcoma, is the second most common bone cancer, which most commonly occurs in the knee.

 

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Dr. Alex Jimenez’s Insight

While the hip and knee joints are capable of sustaining various degrees of stress when performing physical activities, trauma, damage or injury as well as the degeneration of these complex structures, can ultimately lead to knee and hip pain. The balance of the human body as a whole is fundamental towards overall health and wellness. Therefore, if an individual experiences hip or knee pain, the entire structure and function of their body can be tremendously affected. It’s important for a person with knee or hip pain to seek immediate medical attention from a qualified and experienced healthcare professional, such as a chiropractor or physical therapist, in order to restore the balance of their entire body.

 

Treatment for Knee and Hip Pain

 

The treatment of hip pain is based upon the cause. For many instances of trauma, damage or injury, rest is generally enough to enable the hip to heal. By way of instance, exercise-associated hip pain is normally eliminated within a couple of days. When you have arthritis, a healthcare professional may sometimes prescribe drugs and/or medications to help relieve stiffness and pain. Furthermore, your physician will refer you to a doctor who can provide additional information regarding the cause of your hip pain along with recommending an alternative treatment option, such as chiropractic care and physical therapeutics, that will explain to you how you can perform rehabilitation exercises to help maintain joint strength, mobility and flexibility.

 

For injuries, therapy typically involves bed rest and the use of drugs and/or medications, such as naproxen, to alleviate pain, swelling and stiffness. Hip fractures, malformation of the hip and some injuries may require surgical intervention to repair or replace the hip. In hip replacement surgery, a surgeon will replace a broken hip joint with an artificial one. Although hip replacement surgery will need rehabilitation to become accustomed to the new joint, this type of treatment option is often considered.

 

Alternative Treatment Options

 

Some holistic remedies can offer relief from hip pain. Make certain you discuss treatment options with your doctor before considering any treatment option. Potential alternative treatment options include visiting a chiropractor for a spinal adjustment or manual manipulation. Chiropractic care is a well-known treatment approach which focuses on the diagnosis, treatment and prevention of a variety of injuries and/or conditions associated with the musculoskeletal and nervous system. Chiropractic care can help carefully re-align the spine as well as help reduce pain and discomfort, improve swelling and inflammation and even increase strength, flexibility and mobility on other structures of the human body. Physical therapeutics can also help treat both hip and knee pain.

 

There are many benefits of physical therapeutics, including increased range of motion, reduction of pain, less inflammation and swelling, as well as an overall improvement of quality of life. The first steps a chiropractor or physical therapist will perform if you have hip pain will consist of tests, such as a gait evaluation, range of motion measurement and intensity measurements. Afterwards, the healthcare professional will create a personalized treatment program. Treatment techniques may also include ultrasound and ice. There will also be specific exercises and stretches to help boost hip strength, mobility and flexibility to decrease pain. For knee pain, tests are also done along with active and passive treatments. Chiropractic care and physical therapeutics can help promote healing without the need for drugs and/or medications, and surgical interventions.

 

Bursitis, a frequent cause of knee pain, can be treated in the following ways:

 

  • Ice the knee for 15 minutes once an hour for three of four hours. Do not apply the ice directly to the knee, instead, cover your knee with a cotton towel. Put ice in a plastic zip-close bag, then place the bag on the towel.
  • Wear cushioned, flat shoes that support your toes and do not worsen your pain.
  • Avoid sleeping on your side. Use cushions positioned on both sides of your body to keep you from rolling on your side. When lying on the side, keep a pillow between your knees.
  • Stay seated when possible. Should you need to stand, prevent hard surfaces and maintain your weight evenly distributed on both legs.
  • Participate or engage in weight loss programs and strategies to lose weight if you are overweight or obese, to reduce the amount of stress that is placed on the knees.

 

If you are experiencing hip pain, knee pain or some other type of joint pain, make sure to contact a qualified healthcare professional, in order to receive a proper diagnosis to begin the best treatment approach for your specific health issue. Trained and skilled doctors will take you on the path to better healing. Make sure you prepare a one-on-one consultation to acquire a comprehensive examination and say good-bye to your pain. Healthcare professionals are devoted to providing you with a healthy and wholesome lifestyle.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Back Pain

 

Back pain is one of the most prevalent causes for disability and missed days at work worldwide. As a matter of fact, back pain has been attributed as the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience some type of back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

 

 

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EXTRA IMPORTANT TOPIC:�Chiropractic Care Hip Labral Tear Treatment

 

 

Minnesota Twins Pitchers Kyle Gibson/Trevor May & Chiropractic

Minnesota Twins Pitchers Kyle Gibson/Trevor May & Chiropractic

Sometime after Kyle Gibson starts for the Twins in their home opener Monday afternoon, the durable young right-hander will connect with perhaps the most important member of his support team this year: his Chiropractor.

Gibson is still just 28, smack in the prime of his career, but there were times during the second half last season when his lower back started to bark at him. In early August in Toronto, for instance, he was shelled for eight earned runs in just 4 2/3 innings.

�I had a problem in Toronto,� Gibson said.

�There were a couple starts where I didn�t sit down in between innings,� Gibson said, �because if I sat down, my hips just got tight.�

Meanwhile, fellow Twins pitcher Trevor May, 26, was dealing with lower back issues of his own. In May�s case, the additional pounding of making multiple relief appearances without much recovery time had caused issues with the hip and lower-back area of his left (landing) leg, as well.

May�s physical woes left him unavailable for days at a time while the Twins chased their first postseason berth since 2010. Massage and electronic stimulation could only do so much to keep May on the mound.

A few sporadic sessions with a chiropractor didn�t provide immediate results, so May discontinued them.

Upon returning to Seattle this offseason, the yoga devotee decided to up the ante and visit a chiropractor weekly for hour-long sessions. This time, he began to see the benefits.

�A couple weeks before spring training, I felt it coming on a little bit again,� May said. �I was like, what is going on? I got it adjusted and my chiropractor said, �Man, you are way, way out of whack.� He explained to me where my pain was and why the hip was pressing against where it was and if we get that moved back, just lengthened out, it�s going to be really sore for a few weeks, but then it�s just going to go back to normal.�

blog picture of pitcher looking at the ball he's just thrown

OVERCOMING FEARS

In 2014, his first full season in the majors, Gibson saw a chiropractor a few times at the recommendation of Twins closer Glen Perkins.

Gibson missed a start in late July after getting shelled at home for six earned runs against the Tampa Bay Rays.

�One of Perk�s guys came in and adjusted me,� recalled Gibson, who threw seven shutout innings at Kansas City his next time out.

That never led to a regular appointment, partly because of Gibson�s relative youth but also because of a long-held fear of what a chiropractor might do to a young athlete�s spine.

�My view of them was, �OK, I want you to lay on a table and I�m going to pop your back and you can come back in a week,� � Gibson said. �Once you start doing it, you�ve got to keep doing it the rest of your life. That was my view.�

A conversation with May early in spring training this year left him more open to chiropractic manipulation.

Hoping to build on the gains of a breakthrough 2015 but still bothered by soreness in his lower back, Gibson asked May for feedback on his chiropractor. May, who by then was going once at week to Darin Stokke at Lifestyles Chiropractic, had nothing but good things to say about the sessions.

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Dr. Stokke

�We found that baseball players get skeletally out of line,� May said. �They do one motion one way much harder (than most people), and my hips were really, really out of line. Seeing a chiropractor consistently has helped me make sure I�m getting readjusted and staying in line as much as possible.�

While initially there was some concern that the bullpen simply did not agree with May�s back, his chiropractic sessions convinced him (and the Twins) that he could manage the additional workload with proper preparation.

What derailed him in September 2015, as it turns out, was a problem with the set joint, where the left hip and lower back meet.

�It was all muscular,� May said. �It was just because one hip was closer to the spine than the other side. The other side was normal. (The left side) was just pressing so much and you get so much inflammation. It was just a perfect storm. It was just a little extra torque being in the �pen. That�s why it was bothering me. Now I�m on top of it.�

As May explained it to Gibson, realignment of the spine would allow the overtaxed areas of a pitcher�s core to meet the challenge of persistent pounding.

�Letting those muscles unflare and then heal and rebuild them back to where they�re supposed to be, that�s what we�re doing,� May said.

After doing some �normal treatment stuff� as a warmup, Stokke would check May�s alignment much the way a tire installer might need to check an automobile before sending it back out into traffic.

�He checks where you legs are,� May said. �If he sees you�re out of line, he puts you back in line, and the next day I try to do some exercises and heavy strength stuff, just to build those muscles back up. I�m seeing soreness go and I feel more in line and healthier.�

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BELIEF SYSTEM

Despite taking the loss in his season debut in Baltimore, Gibson reports much the same results from his twice-weekly chiropractic sessions this spring.

�Toward the beginning of spring training my back started getting sore again,� Gibson said. �Going twice a week helped get things moving in the right direction.�

Now that he feels his lower-back problems are under control, Gibson plans to scale back to a single visit per homestand. That way he won�t have to find somebody to visit on the road, while also limiting those realignment sessions to perhaps two per month.

�It has made a big difference in my hips and just everything,� said Gibson, who set career highs for starts (32) and innings (194 2/3) last season. �My skeletal system was basically allowing my muscular system to stay tight and not function properly. That caused some nerve irritation.�

blog picture of pitcher about to throw baseball

While May features the classic �drop and drive� delivery, Gibson is from the �tall and fall� school that should, in theory, produce less strain on a pitcher�s hips and back. That didn�t prove to be the case over Gibson�s first few seasons in the majors, so he finally realized adjustments were needed.

�Some of my problem was just that I had some tight hips pulling my pelvis out of line and causing some irritation in the nerve,� Gibson said. �There were certain things I realized I could pitch through. You find ways to get around certain sorenesses and aches and pains.�

If the Twins can get 200 innings out of Gibson and 65 to 75 relief appearances out of May, they won�t just have a better chance to end a postseason drought that has reached five years and counting. They could have additional members of their pitching staff lining up for realignment sessions.

�It�s good,� Gibson said, �to feel good again.�

Preventing Sports Injuries

Sourced through Scoop.it from: Dr. Alex Jimenez

By Dr. Alex Jimenez

Kyle Gibson, last season his lower back started to bark at him. The durable young right-hander connected with the most important member of his support team, his Chiropractor. While Trevor May, was dealing with lower back issues of his own. In May�s case, the additional pounding of making multiple relief appearances without much recovery time had caused issues with his�hip and lower-back area of his left (landing) leg, as well.

Iliotibial Band Syndrome

Iliotibial Band Syndrome

The iliotibial band, or IT band, is a ligament that begins at the pelvis, along the iliac crest, and travels down through the outside of the thigh from the hip to the shin. Most frequently caused by overuse from running sports and activities, knots can develop along the IT band and on the lower side of the leg, causing the ligament to become tight and inflamed, a condition known as iliotibial�

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