My approach to hip pain

January 14, 2017

 

 

One of my readers has asked me to talk about how I treat hip pain.

 

Hip pain is a big deal. Pain in general is a big deal. It’s worth talking about this because acupuncture should be considered a mainstream treatment of choice in addressing pain. It’s not really alternative, although it’s often described that way (it hasn’t been for several thousand years) and it’s non-pharmacologic.

 

Why is non-pharmacologic important? Because it’s useful to avoid medication when possible and when cost-effective. In general, it’s cost-effective to take an aspirin or ibuprofen for an acute sore shoulder when compared to the cost of an acupuncture treatment. It’s not cost-effective to depend, long term, on aspirin, ibuprofen, naproxen (Aleve), and other non-steroidal anti-inflammatories (NSAID’s), acetominaphen (which while also an NSAID works mainly by elevating the body’s pain threshold, with only minimal anti-inflammatory action; see https://livertox.nlm.nih.gov/Acetaminophen.htm), or on opioid-based pain medication like hydrocodone (Norco and Vicodin) and oxycodone (Percocet and OxyContin).

 

Long-term use of NSAID’s can be harmful. For example, According to “Recognizing the Risks of Chronic Nonsteroidal Anti-Inflammatory Drug Use in Older Adults”, by Zachary A. Marcum and Joseph T. Hanlon,  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3158445/, chronic use of NSAID’s by older adults carry the risk of gastrointestinal, kidney, cerebrovascular and central nervous system complications.

 

It’s not necessary to provide citations about the current opioid epidemic. Whether from the news or from personal experience, almost everyone reading this blog knows horror stories of individuals and families in distress because of opiate addiction, much of which starts through the use of prescription medication. People become dependent on the meds, their children find the bottles in the medicine cabinet and start experimenting.

 

Opioids can prolong pain as well as deaden it. According to a paper by Tianna Hicklin, Ph.D. published by the National Institutes of Health in NIH Research Matters, “Opioid pain relievers may prolong pain”, https://www.nih.gov/news-events/nih-research-matters/opioid-pain-relievers-may-prolong-pain, rats with nerve injuries that are “treated with morphine were sensitive [to touch stimulus] for longer and to a higher degree [than control rats]. A pain pathway different from the one affected by opioid receptors is involved. Morphine is also known to activate cytokines, molecules that activate inflammation.

 

From my personal and clinical experience, I’m aware of several cases where intractable pain diminished, changed or disappeared when long-term opioid use was discontinued.

 

But, to return to the topic at hand: How do I treat hip pain?

 

 

 

Treating hip pain

 

Where is hip pain located? That’s not a trick question; rather, it reflects the subjectivity of pain.

 

As an acupuncturist, I work within a palpatory perspective. When I do a physical examination, I look for local areas requiring the attention of an acupuncture needle, which includes tenderness, tightness or even ticklishness. If someone visits my office complaining of hip pain, you would likely assume I’d find tight and tender muscles in the area of the hip, including the gluteus muscles (maximus, medius and minimus) and piriformis. If you did, you’d likely be right.

 

However, pain, including the location of pain, is a subjective phenomenon. When people complain of hip pain, the problem may actually be in the lower back (quadratus lumborum) or the abdomen (rectus abdominis); when there are problems here, the pain can refer to the hip. Everyone’s pain being different, every exam can turn up a different pattern of strain or injury.

 

Treating a local area of tenderness is an ancient practice in acupuncture. The name for such places are Ashi points. In modern terms, these are places where hypersensitive sensory nerves are firing more than they should; hence, they are painful to the touch. Suffice it to say, for today’s purposes, that, clinically, these are acupuncture points, which is why we place needles there. In another post, I’ll go into the specifics of what an acupuncture point is and why needling changes the terrain. Dr. Yun-tao Ma and his associates call these Symptomatic Points, or SA’s, and they distribute randomly in the body.

 

So, to treat hip pain, one must treat both muscles local to the hip and muscles that when injured or strained refer pain to the hip. I also treat what Dr. Yun-tao Ma calls Homeostatic Acupoints, or HA’s, which are areas that become tender when the body’s homeostatic balance is compromised, which occurs during periods of lessened health or because of injury. HA’s occur in a predictable (i.e., non-random) distribution. Dr. Ma and his associates examined 15,000 people; correlating statistically the areas of tenderness encountered in the subjects as a group, they determined where any given population of people will experience tenderness first. Some locations are obvious; some, less so. For example, HA 1 is in the forearm, HA 2 is on the anterior border of the SCM muscle, behind the earlobe, and HA 3 is in the upper traps, between the neck and the shoulder, where almost everyone enjoys a massage.

 

Following this model, when treating local, symptomatic points, I also treat homeostatic points in the same region. For example, when treating hip pain, I will also treat the HA’s in the iliotibial band, the gluteus muscles themselves and the lower back.

 

The third level of treatment involves treating the peripheral nerves that innervate, or travel to, the affected muscles. Broadly speaking, for hip pain this involves placing needles alongside the vertebral column in the lumbar spine. These are called Paravertebral Acupoints.

 

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

 

 

 

Recapping the four levels of treatment

 

As a recap: What is my approach to hip pain?

 

Level 1: Symptomatic points, which are randomly distributed in the muscles of the hip or which refer to the hip.

Level 2: Homeostatic points in the symptomatic region, which are distributed predictably in all human beings.

Level 3: Paravertebral points, where the peripheral nerves innervating the symptomatic region exit the spinal cord.

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

 

Incorporating all four levels of treatment leads to relief of pain, a restoration of the body’s sympathetic-parasympathetic balance, and a return to health in the affected muscles and other structures. Acupuncture is both pain-relieving and restorative of health.

 

These four levels of treatment result from seeing acupuncture as a whole-body approach and not isolating one problem without seeing the big picture. Given this comprehensive approach, comprehensive treatment may entail more than one visit. My own practice is to do as much as seems useful and practical at each encounter, to achieve as much as possible without creating a state of overwhelm. Too much treatment may feel overwhelming to someone who’s experiencing acupuncture for the first time.

 

The essence of good acupuncture, in my opinion, is simplicity. What seems simple on the surface reflects a careful logic nonetheless, and it may offer a comprehensive approach for issues beneath the surface that cause pain or disorder.

 

Illustration Acknowledgements:

  1. Figure 1. Gluteus maximus. (By BodyParts3D/Anatomography (BodyParts3D/Anatomography) [CC BY-SA 2.1 jp (http://creativecommons.org/licenses/by-sa/2.1/jp/deed.en)], via Wikimedia Commons).

  2. Figure 2. Gluteus medius.  Häggström, Mikael. "Medical gallery of
    Mikael Häggström 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.008. ISSN 20018762. Public Domain.

  3. Figure 3. Gluteus minimus. By Anatomography (en:Anatomography (setting page of this image)) [CC BY-SA 2.1 jp (http://creativecommons.org/licenses/by-sa/2.1/jp/deed.en)], via Wikimedia Commons.

 

© William Weinstein 2017

 

 

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