Last updated 14 hours ago
Many times, patients come to my office, and tell me they have a labral tear in their hip on MRI. Then, they ask me to fix it arthroscopically. This blog talks about why the labrum is important in the hip and how different treatment options can vary in results.
What is a labral tear?
The labrum is a rim of cartilage that surrounds the hip joint. A labral tear occurs when the labrum peels away from the socket (acetabulum), and becomes detached. This is the type of tear that is most likely to cause hip functional issues.
Figure 1. Chronic, inflamed labral tear.
The labrum is important!
Initially, when hip arthroscopy as a field was in its infancy, it was actually debated whether or not hip labral tears actually caused pain for a patient. As more experience was gained, the typical symptoms of a labral tear of the hip were known: sit to stand pain, feelings of catching in the hip, pain with prolonged sitting, pain getting in and out of cars, and pain with twisting activities. Early results showed improvement with debridement (trimming out) the torn labrum (success rate around 70%). However, while taking out a torn labrum can “smooth out” the joint and eliminate catching, it does not restore normal labral function.
The hip labrum has multiple functions. It increases the depth of the socket (acetabulum) of the hip, giving it increased stability. It also protects the articular cartilage (gliding cartilage) of the hip; the degeneration of this gliding cartilage it what leads to arthritis of the hip. An optimal hip arthroscopy will restore normal hip labrum mechanics.
Repairing a labral tear:
As sports medicine surgeons, we are always striving for improvement in our patient’s function and pain levels. Therefore, we transitioned from trimming out a torn hip labrum to hip labral repair. Fortunately, we have been performing shoulder labral repairs for quite a while, and the techniques and implants for shoulder labral tear repair were transferred to the hip. Soon, we were able to reproducibly repair a hip labrum, anchoring the labrum back down to the bone.
Figure 2. Labral repair arthroscopic picture. The suture (surgical thread) is attached to the acetabular bone, and the labrum is tied down to the bone.
Repairing the tear is not the end of the story:
We now know that MOST labral tears of the hip, especially in younger patients, are caused by a bony mismatch of the hip. The hip is supposed to be a round on round joint, and extra bone (that develops in a patient’s early teenage years) can cause increased pressure on the hip labrum, eventually causing a labral tear. This condition is called FemoroAcetabular Impingement syndrome (FAI). When labral repair was COMBINED with arthroscopically treating FAI, the results improved dramatically.
What if the labral tear is not repairable?
In my practice, the vast majority of labral tears can be repair, with suture to bone fixation. In cases where the labrum is not repairable, then labral debridement is reasonable. Depending on how I assess the stability of the hip joint at time of surgery, sometimes I do a labral reconstruction, where I used a tendon graft to reconstruct the labrum.
Figure 3. Arthroscopic picture of a labral reconstruction using a donated graft. The type of fixation used is exactly the same as with labral repair. Note the similarities with how this looks compared to Figure 2.
Derek Ochiai, MD, is a board certified orthopaedic surgeon, specializing in arthroscopic Hip Preservation surgery at Nirschl Orthopaedic Center.
Follow Dr. Ochiai on Twitter @DrDerekOchiai.
Nirschl Orthopaedic Center is a leader in sports medicine and general orthopedic services. Schedule an appointment with an orthopaedic doctor today by calling our Arlington, VA location at (703) 525-2200. You can also visit our website to learn more about hip injuries and other orthopedic issues, as well as our services.
Last updated 7 days ago
What does elbow pain, shoulder pain, knee pain, lateral hip pain, ankle pain, and heel pain all have in common? Answer: These are common areas for tendon overuse injuries (tendinosis / tendonitis). Pain in these areas can be functionally debilitating, affecting athletes and non-athletes alike. This article reviews what tendinosis is and the possible treatments of this injury are.
What is tendinosis?
Tendinosis is an overuse, “wear and tear” of a tendon. While the term “tendonitis” is still used interchangeably with tendinosis, in most cases, the term tendinosis is correct, since laboratory studies done at our institution by Dr. Robert Nirschl on tendon overuse show that there is little inflammation at the site of injury. Tendons connect muscles to bones, and near the attachment site to the bones, some tendons have a poor blood supply. This means that as a tendon is subjected to increasing stress (especially a quick increase in activity level), that tendon may get some fraying and partial tearing, and the blood supply is not robust enough to naturally heal the tendon. This can create a cycle of chronic pain, where activities cause pain, and when the patient rests, the pain improves. Then, because the underlying tendinosis has not healed, when the patient stresses the tendon again, the pain returns.
What are the symptoms of tendinosis?
Typically, patients will describe a sharp pain with activities. For instance, for lateral tennis elbow (tendinosis of a tendon that extends the wrist), patients may feel a sharp pain with lifting a gallon of milk or shaking someone’s hand. For rotator cuff tendinosis, a patient may feel pain reaching to put on a seat belt, or trying to get the sugar out of the top shelf in the kitchen. In more severe cases, there may also be a dull, baseline pain, even at rest. Sometimes, this can affect sleep as well. Uniformly, the activity that incited the tendinosis is affected, be it sports or dance or gardening or working on the computer.
How is tendinosis treated?
First, if the symptoms are mild and have been only present for a few days, doing a short period of relative rest, staying away from activities that inflame the area of pain, is reasonable. If a patient can take over-the-counter anti-inflammatories such as ibuprofen or naproxen, then these medications can give some comfort with daily activities. The tendinosis area can have a poor blood supply, but there is some blood supply, and sometimes mild wear and tear can heal on its own. If the pain dissipates, then slowly ramp up activities to the desired level.
If the pain is persistent, a patient should probably be examined by a sports medicine physician. A physical examination and sometimes X-rays can usually confirm the diagnosis of tendinosis. Some minimally invasive treatment options at that point could include the following:
Physical therapy - The primary goal of physical therapy is to “build up a new blood supply” to the area of tendinosis through exercise. The body is adaptive and dynamic, and by carefully introducing exercise designed to stress the area of tendinosis in a controlled fashion, this can lead to a cure. There are also physical modalities that can be used, to improve ultrasound, electrical stimulation, and iontophoresis (see article with co-authors Dr. Nirschl and myself).
1. Bracing. “Counterforce” bracing is a concept where the stress at the area of tendinosis is dissipated and spread out over a broad surface area, decreasing the pain and improving function. By itself, it is not a cure for tendinosis, but can make a patient/athlete more comfortable and active during treatment.
2. Medications. NO MEDICATION CURES TENDINOSIS. However, anti-inflammatories and Tylenol can decrease pain, and this can be useful for function and to improve the patient’s ability to do the physical therapy exercises, which can lead to a cure.
3. Cortisone injections. Cortisone injections also do not cure tendinosis. However, if someone is having an acute flare of pain, sometimes cortisone injections are necessary to calm down the pain enough to respond to physical therapy.
What if the tendinosis pain persists?
Many times, the above treatments are very effective for treatment, but sometimes tendinosis can be resistant to these treatments. Typically, this is because the tendinosis tissue damage is more advanced, and the body cannot regenerate a strong enough blood supply to heal this tissue. In these cases, WHEN MORE CONSERVATIVE TREATMENT OPTIONS FAIL, the following are further treatment options.
1. Platelet Rich Plasma (PRP) injections. The patient has their own blood taken, and it is spun down with a centrifuge, to concentrate the body’s natural growth factors. This growth factor laden fluid is then injected at the site of the tendinosis. This can recruit healing cells to the area of tendinosis, to spur healing.
2. Tenex FAST procedure. The FAST procedure uses both ultrasound to identify the precise areas of tendinosis and a needle probe delivering a specific frequency of high energy ultrasound to remove the tendinosis tissue. In cases where the tendinosis is recalcitrant to healing, this has the benefit of removing that tissue. The procedure is outpatient based, and usually recovery is within 4-6 weeks. Here is a short video of a Tenex procedure done for Achilles’ tendinosis.
3. Surgical resection and repair. This is still the “Gold Standard” for treatment of tendinosis, that fails other more conservative treatments. In this procedure, the area of tendinosis is directly visualized and removed. The normal tendon that remains is stitched together. Dr. Nirschl pioneered the procedure for Tennis Elbow (elbow tendinosis). A paper co-authored by Dr. Nirschl and myself showed excellent results of surgical resection and repair of tennis elbow, even when it is on both the inside and outside of the elbow.
Treatment of tendinosis can be challenging, and a “one size or treatment fits all” approach is not adequate for all patients. However, with proper treatment, the overall success rate for treating tendinosis and getting patients back to their normal activities is very high.
Last updated 1 month ago
Dr. Derek Ochiai
Hamstring injuries in sprinting athletes are common injuries, as demonstrated by Jozy Altidore’s hamstring injury in the United States’ first World Cup match of 2014. Fans of American football cringe when they see the speedy wide receiver be wide open down the field, all of the sudden to pull up and fall to the ground. Unfortunately, these injuries can affect athletes of all levels, not just at the elite professional level. This blog explains hamstring injuries and treatments.
What are the hamstring?
The hamstring are large muscles at the back of the thigh. Their main function is to power the knee into flexion, as well as extend the hip. They attach at the ischium (which is commonly called the “Sit Bone”) and attach just below the knee.
Why are they important?
The hamstrings are very important in sprinters, or any athlete who quickly accelerates. Picture quick acceleration as the feet “grabbing the ground and pulling the ground backwards” similar to a climber doing this with their arms, and you can get a sense of how having powerful knee flexors can help with sprinting. Recreation athletes and non-athletes also use their hamstrings, but the stress on their hamstrings is usually less, unless an accident is involved.
How do hamstrings get injured?
Hamstring injuries occurs from two major mechanisms. The first is with rapid forward acceleration, where the hamstring muscles and tendons get quickly overloaded, and strains either the muscle bellies of the hamstring (in the middle of the back of the thigh) or at the starting point (origin) at the sit bone. The second mechanism is usually by a fall, where the affected leg is forced forwards, and the athlete “does the splits” and over-stretches the hamstring.
Is this a bad injury?
First of all, most hamstring injuries heal adequately without surgical intervention. However, the TIME it takes to heal can be quite prolonged. This is an injury that can keep a professional football player out of multiple games, waiting for adequate healing. In general, injuries at the “meat” of the hamstrings (or in the middle of the thigh) are muscular strains, and have the quickest healing potential. Injuries where the pain is near the bone of the pelvis (ischium) have the longest healing potential, as this is a tendon injury, and tendon healing is prolonged, partly because of the decreased blood supply of a tendon relative to a muscle. Tendon injuries are graded Grade 1-3, with one being least severe (a stretch) and three being the tendon has pulled completely away from the bone.
What can be done to prevent hamstring injuries?
In general, before undertaking athletic activities, an adequate strength and conditioning program should be undertaken, to ensure that the muscle strength is adequate. Pre-activity stretching of the hamstrings and warming up are also helpful. Two common hamstring stretches are shown below.
How do I know if I injured my hamstring?
Depending on the location of the hamstring injury, the pain can be in the back of the thigh or at the Sit Bone. Many times, a patient with a hamstring injury will describe a sharp pain, and suddenly be limited in walking or unable to walk. Back of the thigh bruising and swelling is common.
How are hamstring injuries treated?
First of all, this is not an injury to try to “gut through” and ignore. Prompt medical attention is important. A sports medicine trained physician can correctly diagnose the TYPE of hamstring injury, which can guide treatment. Typically, I start physical therapy relatively quickly, to decrease stiffness and control the formation of scar tissue. Anti-inflammatories can be helpful. Until pain controlled such that the patient can walk without a noticeable limp, many times crutches are required. In some cases, platelet rich plasma injections can be utilized to speed the healing process. In Grade III hamstring tendon injuries, where the tendon has pulled completely away from the bone, many times the best option is surgical repair of the tendon, sewing the tendon back to the bone.
If you have an orthopaedic injury contact Nirschl Orthopaedic Center at 703-525-2200 or visit our web site.
Last updated 1 month ago
By Dr. Derek Ochiai
Our society is becoming more global and travel friendly. Many times, patients with a specific medical issue may decide to travel out of town to have definitive medical treatment, including surgery. While there may be very good reasons to want or need to do this, the patient may have additional issues and needs that must be considered prior to making this commitment. As a surgeon who often sees patients who travel from out of town for a specialized procedure that I do, I am well aware of these issues. This article will talk about what to ask and look out for when traveling for surgery.
Patients have reasons that they wish to travel to have surgery. The doctor or center that they are choosing may have a specific expertise for a medical condition. The patient may also travel to be closer to their family to make for an easier recovery.
There are four specific issues that a patient should consider prior to having surgery out of town. First, how long can the patient stay away from home? While a surgery may normally take a set amount of time for initial recuperation, the surgery may not be without complications. If the surgeon wants you to stay an extra week after the procedure and you were not prepared to do so, is that personally and financially feasible? Second, what happens if there is a late complication after the patient returns home? The surgeon may request that you return for follow-up care and this can be an additional expense and time away from home and work. If you cannot get back to that surgeon, are their other physicians local to you who would be willing and able to treat you? Third, how communicative is the surgeon? Many orthopaedic procedures rely on physical therapy and post-surgery protocols after surgery. If the patient or other health care providers have questions regarding this, how does this get communicated to the surgeon? Does he/she answer email? Is the surgeon comfortable with treating a patient “over the phone”? Finally, how comfortable is the surgeon treating a patient whom he/she will not be following long term? Do they have a system in place to handle issues of communication and follow-up?
The most important step a patient can do is to research doctors and facilities ahead of time. Many times, doctors who are accustomed to seeing patients from out of town have a system in place to accommodate this. The patient can gather their medical records, radiographic images and MRI’s, that can be mailed ahead of time for the surgeon’s review. If a patient is thinking about having their surgery performed out of town, a call to the surgeon, asking if this system is in place, can save some unnecessary expense. It is far better for patients to know ahead of time if they are an appropriate candidate for a procedure, rather than travel to the facility only to find otherwise. A patient should also ask to speak to the billing department, as the center and surgeon either may not participate with their insurance or the specialized procedure may not be covered by their insurance. By talking to the staff, the patient can definitely get a sense of how experienced the office is in dealing with patients from out of town, which can help with the patient’s comfort level.
All patients should set up a pre-operative appointment well before an intended surgery. This will relieve pre-surgery anxiety for the patient who now knows their doctor prior to having the surgery. Sometimes, no matter how great a doctor looks on the internet or how convenient it would be to have the surgery there, a patient may meet the surgeon and decide to look elsewhere. If the pressure of already scheduling the surgery is looming, this may unduly influence an important decision. Keep in mind that many centers may also have a surgical cancelation fee.
Medical tourism has its benefits and drawbacks. If a patient actively researches and prepares before surgery, the benefits can be maximized, and the drawbacks diminished.
Dr. Derek Ochiai is a board certified orthopaedic surgeon, specializing in Hip Arthroscopy and Sports Medicine, at Nirschl Orthopaedic Center for Sports Medicine and Joint Reconstruction. Follow him on Twitter @DrDerekOchiai. For more information go to the web site at www.nirschl.com or call or office at 703-525-2200.
Last updated 3 months ago
By Dr. Robert Nirschl, MD, MS
Sports injuries are classified as either an overuse or an acute injury. Most sports injuries are a result of overuse and they occur when the body has been pushed too hard, too fast or too long. Pain and swelling are the first indications of overuse injury, and, as is the case for acute injury, “PRICEM” is the rule of thumb for general treatment.
Protect the injury or it may easily become an acute injury. Don’t play through the pain. Stop the activity causing discomfort and rest. Put ice on the injured area as soon as possible, but be cautious about direct application that might cause “ice burn”. Compression reduces the swelling. Use an elastic bandage around the injury. Spandex clothing, a neoprene sleeve, or an elastic stocking may serve the same purpose and might also offer some limited measure of support and protection. Elevate the injury above the level of your heart and continue to do so even during sleep.
It is important to let an overuse injury completely heal before subjecting the injured area to additional stress or abuse. Playing hurt has the same effect as ripping a wound open repeatedly before it can heal. It not only won’t heal, but it may result in a very serious or even irreversible problem. It is also important to reduce the irritative chemical inflammation to aid in the healing process. Compression, ice and elevation are all associated with that component, but medication may be needed as well. Frequently, aspirin or ibuprofen (Motrin, Aleve, Advil, etc.) in therapeutic dosages are effective, but cortisone or some other prescription drug may be necessary. Aspirin at that dosage may cause an upset stomach so buffered aspirin is recommended. Aspirin is not recommended for children because of the risk of Reye’s syndrome. It can also retard blood clotting (helpful to prevent strokes and heart attacks) but should not be taken 10 days in advance of surgery.
Ice is effective in reducing the pain and swelling in an injured area when inflammation is present. Subsequent treatment with heat will facilitate healing by increasing blood flow to the region for removal of excess liquid and toxins that are a by-product of the injury, as well as enhancing nutrition and oxygenation. It is even possible to create a pumping effect with alternate heat (30 minutes) and cold (5-10 minutes) applications. Massage can also be used to aid circulation to the injured area. But care should be taken not to irritate or abuse the injury, and extreme caution should be used with a mechanical massager.
The best way to prevent sports injuries is to follow a good warm-up and conditioning program. A regular exercise program with weights and resistance equipment will help structural development that can better withstand the physical stress that will be encountered during sports. Stretching before and after sports activity will better prepare those muscles and tendons for future use. Some of the more common soft tissue injuries that result from overuse are:
Sprains: A sprain is an injury to a ligament, a firm band of tissue that supports the joints. Three types of sprains can occur: Grade 1- the ligament is stretched; Grade 2- some of the fibers are torn; Grade 3 – the ligament is totally torn. Sprains are usually the result of twisting trauma, and most commonly occur in the ankle and/or knee joint.
Strains: A strain is an injury to a muscle-tendon unit. Like sprains, strains can be classified according to severity – stretched, a partial tear, or a complete tear. Strains may occur when muscles lack strength and flexibility. Deficient warm-up or exposure to extreme cold or unusually stressful activity are additional important factors. Strains in the hamstrings and groin adductors (rear and inner muscles of the upper leg) are common, but strains in muscles of the shoulder girdle are becoming recognized as an important contributing factor to shoulder tendinitis as well as primary injury. Strains are always accompanied by weakness.
Tendinitis/Tendinosis: Tendinosis is a degeneration or injury of a tendon and is generally caused by repetitive trauma. Tendinosis is common in tennis and other sports and repetitive use occupations. Tendinosis, rather than tendinitis, is the correct term as we now know that inflammatory cells are not present in the injured tendons. The most commonly affected tendons are the Achilles, tendon, tendons at the knee (runner’s knee), tendons of the posterior tibial muscles-tendon attachment (shin splints), and tendons of the elbow (tennis elbow) and shoulder (rotator cuff tendinosis). Treatment may include medication for pain control, physical therapy to heal, and control of overuse with counter-force bracing. As a last resort, surgery may be an option. Practicing proper sports techniques will also go a long way in preventing tendinosis.
Bursitis: Bursitis is an overuse injury that results in the inflammation of bursa and is most common in areas near the elbow, shoulder, knee, heel and hip. Bursa are fluid-filled sacs found in regions where friction occurs. Their main function is to minimize friction between bones and tendons, tendons and ligaments or even bone and bone. The condition is frequently found in association with tendinosis and the bursal inflammation. Players with injury to the knee bursa have excessive swelling due to accumulation of fluids in the bursa over and just below the knee cap. Other common bursitis areas include the shoulder, tip of the elbow, outer hip and under the Achilles tendon. The bursa sometimes must be drained or even removed before proper healing can take place. Cortisone is very effective in reducing the bursal inflammation, but other anti-inflammatory drugs maybe sufficient.
Contusions: A contusion, or bruise, is an injury to soft tissue or bone in which the skin is not broken. A hard direct blow is the most common cause and a collection of blood (a hematoma) may form beneath the skin in the injured muscles, tendons or bone. Icing or some other form of cold application that will contract the blood capillaries will minimize the damage by preventing accumulation and swelling.
It takes a long time for most players to admit to themselves that they are not indestructible, and they usually learn the hard way. Loss of flexibility and dehydration of tendons and ligaments with age make aggressive senior players more subject to injury but even the young are vulnerable. Much of this can be avoided by maintaining good strength and flexibility programs, practicing good pre- and post- work out preparation, becoming well informed about injury potential, and by simply using good judgment and control of abuse by using functional counter-force bracing. Following those principles, young people and should be able to continue active sports through their senior years. The enjoyment of that endeavor should result in maintained good health and physical conditioning that will enhance and extend your quality of life.
If you have pain or any orthopaedic injury, contact the experts at Nirschl Orthopaedic Center or Virginia Sportsmedicine Institute in Arlington, Virginia. Schedule an appointment with our orthopaedists today by calling 703-525-2200 or visit our web site.