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Hip Pain in Adults - Causes & Management

Jan 25 | 3:30 PM

Our modern sedentary lifestyle has given rise to a new crop of disorders that lead to hip pain due to inactivity, incorrect posture, and a host of other lifestyle factors. The central role of the hip in the body makes it conduct pain to linked pathologies. Thus, physicians often find it challenging to diagnose the underlying causes of hip pain. Join us live with Dr. Vaibhav Jain as he discusses the various reasons for hip discomfort, therapeutic approaches for each, and how to manage it.

[Music] so hello everyone uh very good evening um i'm dr samad i'm a dentist and i welcome you all on behalf of team netflix uh today we have with us uh dr webb of chain who is an expert in the field of orthopedics and joint replacement uh dr jane has more than 5000 joint replacement using navigation and robotics to his credit he specializes in oxford partial knee replacement and minimal invasive hip replacement with bone conservation he is a reviewer for international journal of knee surgery and also has contributed chapters and published papers in a number of national and international journals very warm welcome sir yeah thank you thank you so much thank you so much over to you sir yeah thank you and good evening all the audience and very happy republic day to all of you uh being in the eve of the republic day so let's start the topic my topic is uh hip pain in adults and the causes and management is a very wide topic but i just want to give a little bit of insight into this for our audience so they can get some idea and i will start my presentation with the case discussion so let's uh see this uh patient so by observing this patient only we have some idea that uh there is something is wrong either from the spine or from the hip point of view you can see there is a drop of the pelvis on the left side so if we walk if we saw the video of this patient someone can just play the video you just replay it excellent yes he is walking with a gate okay thank you so if i discuss about this case how he presented to my clinic it's a 25 year old male pain in the left hip and limping during the walking but he doesn't have any rest pain no radiating pain there when i examine this patient there is a shortening of the left leg of the five centimeter no rotational movement at the left half joint there is a fixed flexion deformity of the left around 15 degree and on the examination of the spine it was okay so in every case which present with the limb with the pelvic tilt you must examine the spine when i take the history there is a history of trauma 12 year back but no specific treatment was taken and no other comorbidities were there in this patient no history of any steroid intake and non-smoker non-alcoholic look at the x-ray of this patient either we suspect it's a problem with the spine or from the hip but on the examination of the hip we almost certain the problem is there in the spine you can see on the left side of the x-ray there is a complete loss of joint space and there is a asteroid protruded so that explain the clinical finding in this patient and almost completely destroyed it which is a joint replacement is the only answer if we talk about the treatment so total hip replacement is the answer in this patient let's come to the next case this is a 31 year old male patient who has a bmi around 38. is a non-diabetic no other comorbidities represented with a knee pain difficulty in walking and instability of the knee that is the presentation of this patient in to my clinic when to casting there is no history of trauma no history of any other constitutional symptom which is suggestive of any uh synovitis or inflammatory arthritis but on a history he was a smoker he is an alcoholic but no steroid intake so when i examine this patient there was a mediocre laxity of was there so why laxity was there because of uh any ligament injury or because of uh so an examine the ligaments they are all normal but he has a typical wasting of the muscles he has a five degree of vagus deformity which is usually common on spine examination no radiating pain no digital neurological deficit no scoliosis on an examination of hip he has antarctic gait restricted range of motion tender test was positive faber test was positive and no shortening was there so if i ask for investigation what investigation would you like to go so in orthopedics the simplest investigation is the x-ray of the joint but you have to whenever you are getting the axis of the hip you always get this x-ray of the spine so when i get the x-ray of the knee and the spine almost normal this is the x-ray of the pelvis do you find any abnormality if you look at carefully on the left hip there is a high sclerosis sclerotic area in a femur head with the cystic lesion surfacing there so that explains the pathology that explains the clinical presentation in this patient with a vascular necrosis uh obese smoker alcoholic patient with which explain the knee pain also retrospectively because there is a referred pain in the knee and laxity in the knee was there because of wasting of the muscles so this uh this is a patient this is how patients present if we talk about the treatment of this patient in this patient early when you present in grade 2 grade 3 of a b and the co decompression with the bone grafting is the treatment of choice and later on if the hip degenerates more then the total hip replacement is the answer if we talk about the vascular necrosis there is a dull acting or throbbing pain in a groin little hip or buttock referred pain up to the knee wrong use of a steroid smoking alcohol prior history of any fracture slipped capital hemorrhagic prices for these disease when you examine these patients there is a pain on ambulation restricted abduction internal rotation external rotation at the hip joint if we get the amazing x-ray if the we are getting the changes in the xa that means it's been the process has been going on for very long it's been six to nine months already must have passed and mri there are early changes it takes around one to three months after you know insult so we talk about the treatment of these and patients so depending upon the severity of the grade but we must protect them protected weight bearing we prescribe ecospring and bisphosphonate to these patients they have they have some role but some some patients improve with this medication some doesn't improve the core decompression on bone grafting you should always take a chance to do all these bone preservation surgeries you almost 70 percent of chances of recovery is there but if it doesn't anything doesn't have we must go for the total replacement in this patient let's talk about other conditions around the hip joint which is usually present in the clinic with a painful hip joint that's a femoral neck stress fracture it's a history the persistent growing discomfort increase with activity and history of endurance sport is always i mean most of the time it is present in examination the painful range of motion is there pain on palpation of greater torque and whenever you thump on the greater torque there is always transmission of the force to the neck of the femur and you always feel pain when we get the investigation cortical defect in femoral ex neck found in x-ray sometimes it found sometimes it doesn't found but if you get the mri acidis can a bone scan their confirmatory diagnosis in these if you talk about the treatment there's a two surface of the neck of the femur one is tensile surface one is compressor compressing surface the superior surface is a tensile surface in which uh in if the surfa if the problem is inferior surface we should known weird bearing for the four week will work very well but if it is there in a superior surface which is tensile surface we need to fix it by the implant and if you talk about the prognosis it can progress to unstable fracture even if you're not treated properly other common condition which is present very common in our opinions uh trochanteric bursitis the history pain over the greater talking trouble pain aggravates during transition from standing to line now lying down so there is a transitional pain from standing to lying down an examination pain on the palpation over the greater talking tab amazing no you don't find anything on the amazing the treatment part the physio is the ice packs protection from direct trauma if it is very severe a local steroid injection is works very well in this kind of patient next very common problem which is called iliotible tibial band syndrome that are histories a little hip or thigh or knee pain snapping as you table and process over the greater talking track slips over to get your token and then you feel strapping of the irritable band on examination there is over test which is typically described as whenever you flex the knee in a later position because of tight band it is stain 190 degree of the position if we talk about the treatment the physio eyes massage and set and they respond very well to these but we need to diagnosis diagnosis is important and other uh problem is peripheral syndrome it's a very common problem common problem the history's dull posterior pain may radiate down to the leg we mix the radicular pain from the spine history of track competition or prolonged sitting nowadays because of lockdown it's a very common problem we are facing a lot of uh we are getting a lot of problem of uh a lot of patients with the pyramid syndrome when examined that the pain aggravates on the active femoral active external rotation passive internal rotation and palpation of the sia technologies aggravation of the pain investigation and diagnosis of examination and exclusion if we examine we clinically diagnose this these condition we can get the mri we found because it mimics with the radiating pain from the spine we draw create there's a physio and say rest activity modification and sometimes the local steroid injection also works very well another very common problem with algebra aesthetica long tall patients pain and paresthesia of the antirelated drawing and thigh examination when applied pressure medial and resuperclass like spinary reproduction of the pain burning numbness of is the common presentation if we don't diagnose a mostly clinical diagnosis treatment the most important avoid compression over the nerve then you should be a lose clause avoid using belt and local steroid injection works very well in this patient so this is just a description of the anatomy so this is the a i say asis and they say uh [Music] the arrow is showing where you put the pressure where it passes the nerve and because of entrapment there is a pain another condition which is illegal helios bursitis in this history the pain or snapping on the medial groin or thigh area when i when you examine these patient pain on active and passive flexion extension of the hip diagnosis no image no finding in the imaging unless until you find any history of old fracture sometimes when there is a fracture around the gate greater torcanter or around the lesser trochanter you can correlate the findings of your source bursitis and the treatment is physio local steroid injection works very well this is the most important thing because there is a lot of pain in the hip joint which are referred pain so you have to identify the problem when no obvious muscular skeleton or bony origin to pain and treatment doesn't provide expectant result you have to think about the common referred pain that is most importantly from a spine from male and female sexual organ from intestinal tract from urinary tract from vascular structure you have to focus and you have to keep in mind to diagnose these pains let's discuss some x-rays that is our vascular necrosis the typical presentation of the etherscular necrosis in the advanced stage in which the hip hip joint space is completely destroyed the hair looks sclerotic shortening and so the subcontracts represent at this stage the treatment in these patients are the total replacement another x-ray is a you can see there's a how much destruction of the hip joint is there on a right side you can see the establishment becomes so wide and the femur head is completely absorbed and the only neck is there so this appearance is called the motor and pistol appearance there is a complete destruction of the hip joint you have to assess these patients for the infective marker esr crp and you have to look for other another foci for the tuberculosis because about in thirty percent of the patient there is a secondary focus of the tuberculosis present you have to get the chest x-ray spine excellent this patient to start put on att once you start the att and patient becomes asymptomatic after that you can look uh for the total replacement in this patient this is a typical exercise of the inflammatory arthritis in which on the left side the joint space is completely reduced there is a sclerosis of the both side joints there is a pelvic tilt because of the fixed deformity in this patient though could be most probably this ankylosing is spondylitis but could be rheumatoid arthritis you have to get that actually be 27 as positive if these patients are very painful to plan for the total replacement is the only answer in this patient this is the post-septic arthritis in which destruction of the femoral head is there and must be the insult in the initial period of the patient's life and uh if the if it's very symptomatic very painful you have to go for a total replacement this uh another condition which is hip dysplasia hip dysplasia usually it's very difficult to diagnose on the first look of the x-ray but you have to keep in mind there's a honor when you compare with the right right side from the left side the right side of the hip is little bit of power if cea angle center edge angle which is marked in the x-ray is less than 25 degree you have to label it the dysplasia there is a disturbs biome disturb biomechanics of the hip is there the hip is prone for degeneration and if you diagnose this condition on a time you can avoid the hip replacement in this patient you can go for periosteum or osteotomy increase the coverage of the hip like in this patient you can see in the lower uh down x-ray there's a hip is out and you can see the above x-ray in which period osteotomy was done we try to cover the hip and these patients works very well if you operate them on time there's certain conditions which are more common in the western population and in the uh in the sports person so laboratory in laboratory tests for impeachment that extreme flexion and flexion abduction action rotation these are the tests which are positive or painful initially we put on them on conservative management if surgery is needed if not relieved by the conservative treatment we did the surgery of arthroscopy either we will excise the laboratory or repair it another condition which is called femorostalar impingement which is a precursor of the primary osteoarthritis in western most of the western population that the test for the impeachments are positive hip is prone for degeneration conservative treatment is the mainstay of the treatment but if hip uh it doesn't work then hype arthroscopy you try to remove the deformity of the femoral neck which is there but these conditions are more i mean less common in the indian population because of our habits for the cross like sitting and squatting which is rarely present in the western population we discuss about one case invasive we present it to my clinic so this is the pre upgrade which is very i mean uh is typically limping with a short team gate depressed bullied by many colleagues in a college young gentleman he's a 13 year old male 2 will fall at the time of uh injury the hip pain unable to bear weight on a left leg fractured neck of human was there cystic like in the neck of the femur was there blood investigations were normal so all the infective parameters for rule out and uh he got investigation somewhere the cities can other there is no lesion in the other part of the femur he got operated with a fixation and bone grafting and curettage of the lesion and the unreasonable bone cyst was diagnosed at that time there's a six month of the post surgery head and neck got collapsed screw getting loose no sign of infection was there although not a failed surgery both surgical non-union cut out screws head and neck it's collapsed there's a one year post stop we try to preserve the he was he tried to preserve the hip with the one year post primary surgery valgus osteotomy was there with the mayor's procedure in which tried to revascularize the head of the femur patient remains in hip spiker for three months started walking after that but unfortunately six months i was walking full weight bearing or start me was united but implant was removed after one year of post surgery remaining extra imbibed in the bone and this was the condition of three year after so that's when this patient presented to me his age was 18 year three year after implant removal relatively pain free fixed abduction deformity was there shortening about four centimeter no sign of the infection serum marker or normal this is how this presented to me and it's very difficult in this situation to decide what to do but being in a young patient 18 year old bully by many such a great lib and we decided to operate uh with the total replacement because nowadays the implant for the total placement are there they're quite long lasting 30 35 year with the longevity longevity of 30 35 year represent you're able to operate this patient there's a lot of interoperative problem difficult to bring down the hype this class over gtp prophylactic and circular voice there's a lot of it's not easy case to do ultimately uh he is it works very well his limb land discrepancy is now around one centimeter which he can compress and is a pain-free improved data psychological improvement was there so this is the video of the post surgery so this is how this patient is walking the great is tremendously improved and we can whatever limping was there we can back to the presentation please so whatever limping was there we can compensate this limping with the shoe race and so if we talk about the now we discuss lot of cases lot of x-rays we broadly classify the hip condition in a hip pain in at least congenital dramatic vascular metabolic inflammatory infection imprisonment neoplastic neurological medications these are all these all hip conditions which i could elaborate and i could this is a one slide which is there you have to think all the condition in them and then you have to think about the diagnosis and if you talk about the location then when the intra articular extracticular and pathologic condition outside the hip joint so intra-articular the liberal tr the corner defect fvi capsular laxity ligamentum disease inflammatory uh osteoarthritis luther synovitis all the other condition is there extra articular if we talk about there is a talkantic bursitis as we discussed femur is tubular impingement and your irritable brain iliopsoas besides snapping hay pillow femority or the periphery on the periphery of the hip and other pathological kind as we discussed there is genital urinary inter-abdominal referred pain sports hernias and most importantly that is from the spine so you have to always always always must must examine the spine whenever you are dealing with the hip patient so these are the common conditions which present tuberculosis trauma is called necrosmitten disorder effort pain from the spine the common condition which we encounter in our cleaning one thing i want to emphasize on the importance of the history so once you take the proper history you may be able to reach honestly of the diagnosis the age even the youngest there's a trauma developmental disorder if your middle east elderly the arthritis and femoral neck fracture and there's a pain the onset of the pain is acute the trauma infection chronic pain arthritis inflammatory condition location there's a little hip or thigh so maybe bursitis entrapment snapping it buttock posterior the chronic is consistent spinae triology growing on medial side hip joint or stability theology of empathic spine occurrence the ambulation motion the hip joint uterus is not value spine at night there is a tumor infection the night crisis the typical of the infection in the tumor in a trauma there is a flaw fall motor vehicle accident the fracture dislocation procedure activity repeated uses the femoral stress fracture as we discussed on endurance sport neurologically the pain numbness tingling lcfn spine etiology sciatica history of arthritis multiple joints and systemic inflammatory disease so these are the importance of the history how taking the history you can able to diagnose the causative pain around the hip joint whenever you examine these patients approach should be approached systematically don't ignore the normal hip you should always take the reference of the good hip of the patient and expose both hips and perform inspection palpation range of motion passive and active in all planes muscle strength spatial tests as indicated so inspection gate is the most important you have to and i saw you in a patient how a patient is walking he said you can make the diagnosis by walking the patient can affect it uh lag beer weight observe for intelligate the painful gate large tenderness wide gate decreases step size observe patient transfer online to sitting standing estimate high symmetry of the lycra and the pelvic tilt so this is a tender mic which you can easily do in your office the positive for hip abductor weakness so on a palpation you have to palpate all the bony structure around the hip they like rest the anterior surface like spine greater talking still to brush the side joint spine and muscle according to complain of the patient spatial bony attachment of the muscle you have to focus on range of motion active and passive range of motion both need to be examined active restricted passive normal you should think of the muscle weakness active and passive both restricted inter-articular extraterror pathology your hypothetical there so range of motion abduction adduction reflection extension internal action rotation so you need to examine whole group all group of the muscles the special test i told you over test is for the illutable brand and pd4 mrs in which on a adduction and internal rotation there is a painful in the piriformis forcer there is a log role in which in the simple test you lie down the patient and you try to do the internal external rotation if intra-articular pathology in acute stage it's a painful petri test is better test is flexion abduction acting noise a test for impeachment so in whenever you suspect impingement you try you you do this test and remove almost confirmative so whenever you get in with the most important and simple simple investigation in the orthopedics the x-ray you get the x-ray so it's a very supportive of your diagnosis and then mri in cities cannot the other thing so and if you are not getting some time the interarticular injection or local injection is useful in diagnosing the condition from inter articular to extracticular you give the injection you see the response in the patient if it is the if the pain disappears you are almost certain about the pathology where is that exactly the pathology whether inter-articular or extra articular or in any other surrounding or any rapper if we talk about the treatment of the hip condition so depending on the diagnosis what is the diagnosis and how you're doing but broadly the conservative treatment in which physical therapy physiotherapy local injections exercises supporting therapy in the form of anti-inflammatory medication are the main state we go for surgery then if you if you decide the sazine and either you try to preserve the hip which is given to us by the god that is heat preservation in hyperthroscopy osteotomy co-decompression and if we can't get the uh we can't get any relief from these uh patients presented to of us in various advanced stages these hip preservations are not possible and total hip replacement is the answer if we go about the conclusion of this presentation then hip pain in the adult can be a challenging problem to diagnose but if we do the systemic examination and careful institution we can almost get our diagnosis systemic approach is required to diagnosis referred pain should be ruled out from the spine from the genitalia from the abdomen should be ruled out extra articular interateropathy should be well differentiated yeah i have explained you about the test about the local injections how you can diagnose conservative treatment in the early phase for the most of the time early technologies physical therapy and supportive measure the um mainstay and if you go about the surgery you talk about the surgery if it doesn't respond to then surgery observation in the core decompression osteotomy hip arthroscopy is the answer we if we are not able to preserve the hip and total hip replacement is the answer that it improves the quality of life dramatically to the patient and the long lasting implant 30 30 to 5 years longevity there so this is possible even in the young patients with a good bearing with the bone preservation bearings bone preservation implants are there but of course you need to certain precautions to be followed in life long if you are going for total replacement that has to be clearly communicated to the patient so the hip replacement is the most successful surgical procedure so called surgery of the millennium in our landsat channel so that's so here i i end my presentation thank you thank you all for if you have any query here is my email with my full name at the right hotmail it's my phone number and you can always i'm always welcome to ask any question and over to you oh thank you so much so uh we have quite a few questions yeah yeah so dr narayana is asking osteoarthritis as a cause of hip pain like can you elaborate a little yeah yeah osteoarthritis is a condition in which there is a destruction of the joint space and uh there is a in advance stage there is no movement is there on a hip so primary osteoarthritis is rare condition in our indian population we usually get secondary osteoarthritis in the pre disposing factor like in rheumatoid disorder and colluding spondylitis secondary to a vascular necrosis or post traumatic these are the condition after which the osteoarthritis called as secondary osteoarthritis primary authority usually the predisposing factor for primary osteoarthritis are labral tears or impingement femoral acetabular impingement which is very rare in our country this is common in a western population where a habit of cross-like sitting and squirting is very less so and if we talk about the treatment of primary osteoarthritis if it is advanced stage in early stage we try to put them on conservative management an exercise program uh painkillers for the short duration uh for the calcium multivitamin vitamin d to improve improve the bone strength and if the patient doesn't relieve then total lip replacement is the answer it's a very successful surgery very i mean satisfying surgery for the patient yeah all right so oh we have a question from dr priyanka uh can you please explain tests for impingement your test for impeachment as i told you there is a impingement there is a pain in extreme flexion or any extreme abduction extreme addiction so whenever you suspect the impeachment always go for patrick test which is called flexion abduction external rotation test and flexion addiction internal notation that is also a test for imprisonment so these two tests uh are the tests for imprisonment clinically you can go for for the initial evaluation of the patient does hip yeah cause any issues during pregnancy like is there any criteria which we follow uh [Applause] hip replacement during pregnancy [Music] is there any issue yes so if patients have a hip replacement before the pregnancy so there are certain uh position we always ask the patient to maintain he has to maintain the cross like sitting or adduction of the to avoid the adduction and internal rotation of the hip so whenever when a patient have a hip replacement he has to keep in mind these these precautions and to communicate to the doctor so whenever he is either getting uh i mean for planning for normal delivery or suggerience action so he issue doctor should always consider to keep the precaution in mind and secondly during after pregnancy or during the pregnancy we used to use metal on metal implants previously later on we find that metal on metal implants are teratogenic for the baby which is there in the bomb so later on the metal on the implant were stopped using especially in a female all over the world so because whenever there is a metal amino there is certain heavy metal ions found in a body those heavy metals could be teratogenic for the baby so nowadays implant wise it's a completely safe on the pregnancy we have to keep the precaution if patient is a patient has hip replacement before the surgery we try to avoid the hip replacement during the surgery during the pregnancy because patient has to go for anesthesia and all these things which could be i mean could be harmful for the baby which is there now and post pregnancy whenever the baby is uh is quite is not having breastfeeding till the time the baby breastfeed after that they can plan for the total replacement so so we have question from dr santosh like um the management of avian hemp a vascular necrosis of the hip is a very common condition uh which we encounter especially in young patients common causes are i was which is there in a steroid use alkaline so the management start to the the moment you saw the patient uh the causative factor is there either steroid use or smoking or alcoholism we have to uh stop that thereafter we have to evaluate uh how much is the patient's symptoms how much is disabled whether in acute phase we have to give the supporting management exercise and then come to the grade of the evm if it is great to grade three grade of the abn in which the hip the head of the femur is although destroyed but the joint is preserved we should always and the patient is young relatively young maybe 30 35 year up to a 40 year of age relatively young we should give a try or co decompression and bone grafting in this patient because the chances of recovery in this patient is almost 50 50. we can get the pain if we can operate a young patient in which we can get a chance of 50 of recovery with his natural hip is there in the place i think we should take a chance we always go for even up to i personally up to the grade three i go for the co-decompression and bone grafting and if the hip is completely destroyed and it's a painful then of course the total replacement is the answer in which there's a lot of good uh ceramic bearing implants are there which have a considerable long life for 30 35 years so so this is how we decide in av and patient is what grade is there and what uh how we presented up and access and we encourage him to always do the exercises to keep the muscle strengthen in the whole course of the treatment yes uh so we have question from dr vashno uh is asking can you please elaborate more on obertest in orbit is very difficult to tell me actually without demonstrating it but the patient is in a little position we uh ask the patient to you know flex the knee in affected position so it will be like a patient is like that if you say straight position and if you ask the patient to uh bend the knee so if the illutable band is tight over here is the thigh suppose it's a thigh table bend is right over here it will sustain in like this position without giving any much support here but if if your idiotable brand is normal the knee will drop like that so this is the over test which which is we perform for the tightness of the name so there's a you can find in the literature also if i then i'll send it to you and link of the over test and then you can send to dr vishnu or they can dr vishnu if you read my email you can email me i'll send you the detail of the test [Music] so uh so we have a question from dr huffy's is there any specific role of calcium and vitamin d after thr and for how many months there is no specific role of for calcium and vitamin d for the total hip replacement as such but the total hip replacement of course the implant is in the bone so for the general health of the bone you have to keep the bone strengthened so for that the calcium should be sufficient in the bone calcium and there's a no there should not be a very severe osteoporosis for that because if the severe osteoporosis is there even with the trivial fall we get a chances of fracture or the loosening of the implant or failure of the implant so we we try we ask the patient to keep maintain their bone health so vitamin d and calcium are both are important to maintain their bone health as so they are not directly no direct relationship with the total hip replacement okay so so we have question from dr santosh like treatment plan for sciatica the treatment plan for sciatica in which we look for the irritation of the nerves so initially we put them on the physiotherapy program so and the conservative management anti-inflammatory medications for the short course and the spinal exercises and all these program i think 90-95 patient works very well in this kind of patients unless until if there is a spinal pathology there but most of the patients respond to the treatment very well so we have question from dr priyanka um for the so what is the medical treatment of peripherals syndrome yeah peripheral pyriformis is the muscle which is present uh around the hip joint is action rotator of the hip so there is a it comes after the greater ciatic noise you see inflammation of there and uh it mimics with the radiating pain so in the medical treatment or we can say the conservative management which we always the same the physical therapy high specs and anti-inflammatory medication sometimes short course of steroid oral steroids but local steroid injections in expert and works very well in such kind of patients and they respond very well to all these patients so we have a question to dr sayak [Music] glucosamine and chondroitin sulfate and primary osteoarthritis [Music] glucosamine and connecting surface both are known as chondroprotective agents so we mostly prescribe these medications in grade one or grade two uh osteoarthritis of the knee not in here so because there is a main or primary osteoarthritis is very common in the india of knee is very common in india so these are cartilage protective agent it they works are around in 50 of the cases they have a very mild anti-inflammatory properties and in some patient is work some patient in grade 1 or grade 2 arthritis they take these medication and even we can prescribe this medication for the longer period of time so no these are very the side effects of these medications are almost none you can take it for a longer time that's the mechanism of action is not very clear that's why this works in fifty percent of cases so if there is patient i have a grade one grade 2 or osteoarthritis they can start this medication take it for a longer time see if they are responding to this medication for the three months they take they can take this medication for the three months continuously and they are responding very well and continue it for the two year three year five year down the line whenever till the time they are comfortable so yeah of course exercise the supplement they also need to do the exercise along with this medication right sir i think we've almost answered most of the questions and thank you so much everyone for coming thank you so much so have a very good evening you're looking forward for your next session thank you so much

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dr. Vaibhav Jain

Dr. Vaibhav Jain

Senior Consultant Joint Replacement and Adult Reconstruction, VIMHANS Nayati Hospital, New Delhi | Fellow National University Hospital Singapore | Fellow Asia Pacific Orthopaedic Association, Chiang M...

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dr. Vaibhav Jain

Dr. Vaibhav Jain

Senior Consultant Joint Replacement and Adult...

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