Regenerative Relief for Hip Impingement with PRP Therapy

Regenerative Relief for Hip Impingement and Instability

Abstract

Hip pain, particularly in active individuals like dancers, can be a complex issue stemming from conditions like femoral acetabular impingement (FAI) and underlying hypermobility. This post explores the diagnostic and therapeutic journey for a patient presenting with these challenges. We will delve into the use of advanced imaging, specifically ultrasound, to visualize the intricate structures of the hip joint, including the femoral head, acetabulum, and labrum. I will walk you through a state-of-the-art regenerative medicine procedure: an intra-articular hip injection combining Platelet-Rich Plasma (PRP) with a unique plasma protein concentrate. This discussion will cover the physiological rationale behind this approach, the technical details of performing an ultrasound-guided injection, and how this innovative therapy integrates with a holistic, evidence-based chiropractic and functional medicine framework to promote healing, restore function, and manage instability. We will explore the latest findings from leading researchers, underscoring the shift towards biological solutions that harness the body’s own healing potential.

Understanding the Patient’s Presentation: A Case of Hip Instability

Today, I want to share a case that beautifully illustrates the intersection of biomechanics, diagnostics, and regenerative medicine. My patient is a young, talented dancer who came to me with persistent hip pain. Her symptoms included a sensation of clicking and pain at the end range of motion, classic signs that point toward potential intra-articular (inside the joint) pathology.

Her history revealed a significant degree of hypermobility, meaning her joints naturally have a greater range of motion than average. While this can be an asset for a dancer, it can also predispose an individual to joint instability. When a joint is unstable, the structures that are meant to provide stability—like ligaments and the labrum—are placed under excessive stress. This can lead to microtrauma, inflammation, and pain. In her case, we diagnosed a hip impingement, also known as FAI, coupled with this underlying instability. FAI is a condition where the bones of the hip are abnormally shaped, causing them to rub against each other during movement, which can damage the joint.

In our initial workup, we used diagnostic ultrasound to obtain a real-time, dynamic view of her hip. This is a powerful tool in my clinic that allows us to see the anatomy with incredible clarity without radiation.

• On the ultrasound screen, we can clearly identify the key structures:
  • The femoral head: The “ball” part of the hip’s ball-and-socket joint. It appears as a smooth, rounded structure.
  • The acetabulum: The “socket” of the hip joint, located on the pelvis.
  • The labrum: A crucial cartilaginous ring that lines the rim of the acetabulum. It acts like a gasket, deepening the socket, providing a suction seal for stability, and protecting the joint cartilage. On ultrasound, it appears as a triangular structure nestled right over the femoral head.

Our detailed scan confirmed that there wasn’t a large, frank tear in her labrum. Instead, the findings were more consistent with chronic irritation, inflammation, and instability—what we often term “labral fraying” or “labral irritation.” This is a common scenario in hypermobile athletes where the constant micro-movements strain the labrum over time. The clicking she experiences is likely the femoral head subluxating or shifting slightly within the overly mobile joint, causing the labrum or other tissues to snap.

The Regenerative Strategy: PRP and Plasma Protein Concentrate

Given that the primary issue is instability and tissue irritation rather than a major structural tear, our goal is to stimulate the body’s healing mechanisms to repair and strengthen the affected tissues. This is where regenerative medicine comes into play. For this patient, I decided on a treatment combining Platelet-Rich Plasma (PRP) and a highly advanced plasma protein concentrate.

Why PRP?

PRP is a concentrate derived from the patient’s own blood. Blood is composed of red cells, white cells, plasma, and platelets. Platelets are the main contributors here. They are our body’s first responders to injury. When an injury occurs, platelets rush to the site and release a host of powerful growth factors. These are signaling proteins that orchestrate the entire healing cascade. They call in stem cells, promote the formation of new blood vessels (angiogenesis), and stimulate the production of new collagen and other matrix components to rebuild tissue.

By concentrating these platelets and injecting them directly into the irritated hip joint, we are essentially creating a super-physiological healing environment. We are delivering a high dose of these natural healing signals precisely where they are needed most, encouraging the labrum, joint capsule, and surrounding ligaments to repair and strengthen.

The Role of the Plasma Protein Concentrate

To augment the effects of PRP, we are also using a plasma protein concentrate. This is a more viscous, potent biologic derived from the same blood draw. While PRP is rich in platelet-derived growth factors, this concentrate is exceptionally high in proteins such as fibrinogen. When injected, fibrinogen converts to fibrin, forming a biological scaffold.

Think of it like this: the PRP growth factors are the “construction workers” and the signaling “foremen,” while the fibrin scaffold from the protein concentrate is the “framework” upon which they build. This scaffold provides a structure for new cells to attach to and helps hold the healing components in the joint space for a longer period, allowing for a more robust and sustained healing response. The viscous nature of the concentrate also provides some immediate cushioning and lubrication to the joint.

The Precision of Ultrasound-Guided Injection

Delivering these biologics to the right spot is absolutely critical. The hip joint is a deep, tightly enclosed space, and a “blind” injection (one done without imaging) has a very high miss rate. To ensure 100% accuracy, I exclusively use ultrasound guidance for intra-articular hip injections. Fluoroscopy (live X-ray) is another excellent option, but ultrasound offers the distinct advantage of visualizing soft tissues—such as muscles, tendons, the labrum, and, crucially, blood vessels and nerves—in real time, without radiation exposure.

The Procedure Step-by-Step

1. Preparation and Mixing: We prepared a total of six cubic centimeters (cc’s) of the biologic injectate. This consisted of 4 cc’s of high-concentration PRP and 2 cc’s of the plasma protein concentrate. It’s important to note that the hips cannot tolerate the high volumes that larger joints, like the knee, can tolerate. Therefore, we use a smaller volume while increasing the concentrations of platelets and proteins to maximize the therapeutic effect. I use a 23-gauge needle for this mixture. The protein concentrate is quite viscous on its own (requiring a larger 21-gauge needle), but diluting it with PRP makes it flow more smoothly. Before injection, I meticulously purge all air from the syringe to prevent artifacts on the ultrasound image and avoid injecting air into the joint.
2. Patient Positioning and Landmarks: The patient is positioned comfortably. Using the ultrasound probe, I re-identify our key landmarks. The red dot on the screen corresponds to our planned skin entry point. I first scan medially (toward the body’s midline) to locate the femoral artery. Its pulsation is clearly visible, and this is our primary “no-fly zone”—we must avoid it at all costs. I then scan laterally (away from the midline) to get a perfect, crisp view of the target: the space between the femoral head and the acetabulum. Optimizing the image by ensuring the ultrasound beam is perpendicular to the bone gives us the sharpest possible view of our target pathway.
3. The Injection: After sterilizing and anesthetizing the skin entry site, the procedure begins. I give the patient a “one, two, three, poke” countdown. As the needle enters the skin, I can track its entire journey on the ultrasound screen in real-time. It appears as a bright, hyperechoic line. I carefully advance the needle, steepening the angle as needed, navigating through the soft tissues. My focus is unwavering on the needle tip. The goal is to guide it precisely into the intra-articular space, the potential space between the labrum and the femoral head.
4. Confirmation and Delivery: Once the needle tip is confirmed within the joint space, I begin the injection. As I gently depress the syringe plunger, I can see the fluid—our PRP and protein concentrate mixture—flowing and expanding the joint capsule. This visual confirmation is paramount. It tells me we are precisely where we need to be. The patient reported some soreness, which is expected. If a patient experiences sharp pain or I feel significant resistance, it might indicate that the needle tip is in dense soft tissue, such as the capsule itself, rather than in the joint’s free space. In this case, the fluid flowed beautifully, bathing the joint in the regenerative solution. The ultrasound image showed a beautiful expansion of the intra-articular space with the fluid, which is precisely the result we want.

The Role of Integrative Chiropractic Care

This injection is a powerful catalyst for healing, but it is not a standalone solution. True, long-lasting recovery requires a comprehensive, integrative approach. This is where chiropractic care and functional rehabilitation are essential co-pilots on this journey.

Following the injection, the body begins the repair process. Our job is to guide this process and address the root biomechanical faults that led to the injury.

• Manual Therapy and Mobilization: As a Doctor of Chiropractic, I use gentle, specific manual therapies. We are not performing high-velocity adjustments on an unstable, recently injected hip. Instead, we use soft-tissue techniques such as myofascial release to address muscular imbalances and trigger points in the surrounding gluteal muscles, hip flexors, and the piriformis. We also employ specific joint mobilizations for the sacroiliac (SI) joints and lumbar spine, as dysfunction in these areas can directly alter hip mechanics and contribute to impingement and instability.
• Neuromuscular Re-education and Stabilization: The most critical component of post-injection care for a hypermobile patient is neuromuscular re-education. The brain and muscles have developed faulty movement patterns. We must retrain them. This involves a progressive stabilization program that focuses on:
  • Activating the Deep Stabilizers: We start with foundational exercises to engage the deep core muscles (like the transverse abdominis) and the deep hip rotators. These muscles are crucial for providing dynamic stability to the joint.
  • Proprioceptive Training: We work on improving the joint’s sense of position in space (proprioception) through exercises on unstable surfaces and single-leg balance work. This helps the nervous system better control the joint and prevent micro-instabilities.
  • Correcting Movement Patterns: We analyze and correct fundamental movements like squatting, lunging, and hinging. For this dancer, we will eventually break down her specific dance movements to ensure she performs them with optimal biomechanics, reducing stress on the healing hip.

By combining the biological “kick-start” of the PRP injection with the structural and functional corrections of integrative chiropractic care, we are addressing the injury from every possible angle. We are not just patching the problem; we are rebuilding the joint and retraining the body to move in ways that protect it in the future. This evidence-based, multi-faceted approach is the future of musculoskeletal and sports medicine.

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References

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Krych, A. J., Thompson, M., Link, J. M., & LaPrade, R. F. (2020). The role of biologics in the treatment of femoroacetabular impingement. Journal of the American Academy of Orthopaedic Surgeons, 28(Supplement 1), S22-S27. https://journals.lww.com/jaaos/fulltext/2020/03011/the_role_of_biologics_in_the_treatment_of.4.aspx

Laver, L., Marom, N., Dnyanesh, L., Mei-Dan, O., Espregueira-Mendes, J., & Gobbi, A. (2017). PRP for cartilage repair: the knowns and the unknowns. Journal of Orthopaedic Surgery and Research, 12(1), 1-8. https://josr-online.biomedcentral.com/articles/10.1186/s13018-017-0629-5

Reurink, G., Jansen, J. P. C., Bisselink, R., Vincken, P. J., Gouttebarge, V., Frings-Dresen, M. H. W., … & Weir, A. (2016). Diagnosis of femoroacetabular impingement: a systematic review of the accuracy of clinical tests. British Journal of Sports Medicine, 50(14), 864-870. https://bjsm.bmj.com/content/50/14/864