Understanding and Treating Hip Pain

Episode 44 - Understanding and Treating Hip Pain

Dr. Chehab: [00:00:00] Welcome to IBJI's OrthoInform where we talk all things orthopedics to help you move better, live better. I'm your host, Dr. Eric Chehab. With OrthoInform, our goal is to provide you with an in-depth resource about common orthopedic conditions that we see every day. Today, it is my pleasure to welcome Dr.

Peter Thadani, who will be discussing the symptoms, causes, and treatments for hip pain. Peter, welcome to OrthoInform. Give our listeners a little bit of information about your background, your training 

Dr. Thadani: Well, thanks for having me today- yeah ... Dr. Chehab. Thank you for being here. And, uh, yeah appreciate the opportunity.

And so yeah, I'm an orthopedic surgeon with Illinois Bone and Joint, and I, uh, been with Illinois Bone and Joint for, uh, nearly 19 years. I, uh, did my undergraduate, uh, training uh, college at University of Illinois in Champaign. And then I went on to medical school at the University of Illinois in Chicago.

Uh, I did a, uh, a general surgical internship at, uh, Loyola University Medical Center, and then I did my orthopedic, uh, residency training at uh, University of Illinois in [00:01:00] Chicago. From there I went on and I did an a- adult hip and knee reconstruction fellowship at the Kerlan-Jobe Orthopedic Clinic in Los Angeles, California.

I practiced out there for a few years, and then I came back to the Midwest and practiced in a, um, uh, smaller group before joining IBJI in the end of 2007. And my practice focuses on, uh, treating uh, disorders, conditions of, uh, uh, the hip and knee, primarily in, uh, adolescents and adults. 

Dr. Chehab: Okay, awesome. And then there was some mention in your bio about an interest in engineering.

Um, tell us about that. 

Dr. Thadani: Sure. Well, uh, in high school I liked science, I liked math. I didn't know what I wanted to do when I went to college, but, um, my family is all engineers, so my dad said, "Hey, why don't you sign up for engineering?" So I, I started in, um, the engineering program, and then, uh, from that I became interested in biomedical instrumentation, biomedical engineering.

And, um, during college f- as part of that, I took a physiology class, which was a, a really exciting, interesting class. And from that I, kind of veered off into, uh, uh, interest in, , , [00:02:00] physiology of the human body and subsequently medicine. 

Dr. Chehab: Awesome. And obviously orthopedics is, we're kind of the carpenters of the body, the engineers of the body, so it's a natural fit there.

And particularly with arthroplasty, and you do an awful lot of hip and knee arthroplasty. That's right, yeah. Hip and knee arthroplasty, hip and knee r- replacement surgery, 

Dr. Thadani: that's, uh, the, the primary focus of my practice. And, uh, yeah, I do get to employ some, um, basic math, physics, engineering skills.

Dr. Chehab: Yeah. So we're gonna discuss today symptoms, causes, and treatments for hip pain. And, um, I thought we'd take a little bit of a anatomic approach to, to the discussion and maybe talk about extra-articular sources of hip pain, meaning the structures that surround the joint but are not in the joint itself, and then talk about the intra-articular sources of hip pain, which are the structures inside the joint.

Um, and so let's start with some of the common conditions that s- Some of the extra-articular, outside the hip joint conditions that we see. And I thought we'd start with hip bursitis. 

Dr. Thadani: Sure. Hip [00:03:00] bursitis, it's a, uh, a very common problem that we see and treat. So the bursa is a, uh, a fluid-filled sac.

We have numerous bursae throughout our, our body. But, uh, a, a bursa is a, uh, fluid-filled sac that's, uh, acts as like a, uh, cushion or a, uh, lubricating structure typically where, where tendons attach to bones. And in the, uh, hip there's, um, uh, several bursa, but the, there's a very prominent bursa called the greater trochanteric bursa which is, um, uh, directly on the side of the hip.

So if you were to, um, put your hand on the, uh, uh, side of your hip and press on your hi- what you would consider your hip bone, uh, the bursa is a little soft tissue cushion or, excuse me, a big soft tissue cushion that, uh, cushions over that hip bone. And, uh, bursitis is an inflammation or ir- or an irritation of that bursa.

Uh, so when that bursa becomes, uh, angry and inflamed, and that causes, uh, pain Uh, right on the point of the hip, on that hip bone on the side of the hip. Typically it occurs with classically with, uh, sleeping on that side. Persons find it [00:04:00] difficult or painful or impossible to sleep on that side.

And, um, also with activities such as st- stair climbing and sometimes with, um, uh, prolonged weight-bearing. But you, particularly with, again, lying on that affected side, a- as well as with stair climbing. Bursitis can, of the hip can affect persons of all ages, but we tend to see it in persons who are in a maybe a little older population.

And, um, it's typically a, um, a kind of a wear and tear or a degenerative type of condition. Oftentimes we see it associated with, uh, persons who have weak trunk and, and back musculature or somebodies who, who's had, um, uh, chronic back issues. Uh, and so the you know, the spine, the trunk, the hips, they all work in conjunction with one another to t- keep you, keep you upright and keep you propelled.

And if any of those links in that chain, so to speak are weak, it'll put stress on the other areas. So oftentimes our treatment of hip bursitis is focused on strengthening up the, uh, the core, the trunk, the back, uh, as well as [00:05:00] the hips to get all of those muscle group- groups, um, uh, strengthened and working together.

Dr. Chehab: So just to summarize that, the, there's a fluid-filled sac, the bursa, that allows the tendons to glide smoothly around the bones. If it becomes angry and inflamed, that's when patients have symptoms, usually on the outer zone of their leg, hurts with activities of daily living s- and particularly stair climbing, and hurts a lot with sleep you were mentioning.

And then, um, treatment is focused on reestablishing core strength with the back and the leg. And other treatments including stretching, is that involved with it? Um, is physical therapy the mainstay of treatment for hip bursitis? 

Dr. Thadani: I think it's one of the mainstays, yes. Yeah. Uh, so certainly, you know, we can treat, we can treat acute bursitis or, uh, chronic bursitis even in the office with a cortisone shot- Mm-hmm

which, um, uh, helps, um, give, provide some immediate relief. But the, uh, uh, really the the underpinnings of treatment for, uh, chronic resolution of the problem involves, you know, stretching, strengthening therapy, a- as well as, uh, you know, strengthening those other areas that we talked about.

[00:06:00] Yeah. Uh, anti-inflammatory medications can help as well, uh, acutely such as as can the cortisone shots. But the, uh, the thing that really helps to solve the problem or keep it away is the, the, the therapy modalities that you had mentioned. 

Dr. Chehab: Yeah. And it's a problem that can be solved. It's not a permanent condition for patients.

Dr. Thadani: You know, uh, for a lot of folks it, it is a, uh, chronic nagging coming and going problem, but it can definitely be solved, yes. 

Dr. Chehab: Yeah. Okay. And then are there surgical treatments for hip bursitis? 

Dr. Thadani: Well, in the past, um, bursectomy, uh, which is a, uh, surgical removal of the bursa had been tried in, in the past that had been tried via, uh, open methods, so a, a, a large surgical incision and excising the bursa.

Those, uh, treatments in the past have been met with, um, uh, varying degrees of success. More recently as arthroscopic techniques for the hip have become, um, more commonplace and, and, and more en vogue arthroscopic bursectomy can be helpful. The other thing that arthroscopic bursectomy or arthroscopic treatment affords you is that, uh, I think one of the reasons that, uh, in the past open bursectomy was ineffective was [00:07:00] that there were actually other things going on, other pathologies that were actually causing the pain.

So, uh, a surgeon would go in, remove the bursa but it was actually not, just simply bursitis that was going on. There were other, other things happening. And so with, uh, newer arthroscopic techniques, you can take a look around the entire inside of the hip, both, um, outside of the the joint and within the joint.

And so at the time of the surgery, you can take care of those other issues as well. 

Dr. Chehab: Yeah. So advantages obviously to the arthroscopic approach is being able to see more and treat more if needed. And but a hip bursectomy, whether arthroscopically or open, is not a common outcome for hip bursitis. 

Dr. Thadani: Not in isolation, correct.

Dr. Chehab: Yeah. Yeah. And then, um, in that same zip code, um, snapping hip. Can you discuss some of the reasons that snapping hip occur and how patients present with that? 

Dr. Thadani: Sure. So, uh, snapping hip tendonitis, uh, is a diagnosis of, um, a condition whereby, uh, the hip tendons or the soft tissues literally snap or, uh, catch, uh, as the tendons and muscles glide over the bone.

[00:08:00] Instead of gliding in a smooth fashion, the tendons actually catch and snap and cause a painful snap popping or snapping. There's pain, there's feeling of, um, uh, catching, uh, oftentimes there's feeling like the hip is gonna suddenly give way or collapse. Uh, there's two forms of, uh, snapping tendonitis.

Uh, we consider either external or internal snapping. External snapping is a snapping that occurs over that, uh, uh, that hip bone, so the bone on the side of the hip or what we call the lateral side of the hip. That can be a snapping or a binding of, um, uh, a tendon called the iliotibial band or the front part of the, the gluteus maximus.

So tendons and muscles that live on the side or the backside of the hip. And in contrast, internal snapping is a snapping of a tendon that lives in the front of the hip in the groin area called the iliopsoas tendon. And these various snapping conditions can occur with, uh, repetitive use deep flexion of the hip and, um, uh, rotational movements of the hip.

Dr. Chehab: And what are some of the treatments for external and internal [00:09:00] snapping hip? We'll start with the external snapping hip. 

Dr. Thadani: So external snapping, again, it's, uh, involving the, uh, the lateral or the the side of the hip. It's, uh, uh, stretching those, uh, those muscles and tendon units that are-- have become perhaps tightened or inflamed- Yeah

and, um, restoring, pliability and strength so that those tendons glide smoothly rather than, um, uh, being swollen and inflamed and snapping. Yeah. Uh, anti-inflammatories temporary rest, activity modification, those are things that can help to kinda simmer down the inflammation in the tendon while the therapeutic strengthening is taking effect.

Dr. Chehab: Is there an age group that you typically see external snapping hip in? Adolescents, adults?

Dr. Thadani: Yes. So, um, um, it's interested uh, lateral side of hip pain, so pain on the side of the hip. In, um, uh, adolescents or younger adults, it's typically a tendonitis, um, which can be with or without the snapping.

And then as, uh, in the older age gr- group, uh, it's more of the, uh, bursitis or even frankly, um, um, partial degenerative tears of the, of the tendons on the side of 

Dr. Chehab: the hip. Yeah. Yeah and then for the internal snapping hip, [00:10:00] um, what are some of the treatments for, for that? 

Dr. Thadani: Similarly to the treatment for the external snapping, so it's we see these, um, um, primarily again in adolescents and younger adults.

So a temporary period of rest, uh, refraining from athletic activity, although that's always tough to tell somebody to, to sit on the sideline and, uh, uh, take a break from doing what they love doing.

Dr. Chehab: Rest is a four-letter word, right? 

Dr. Thadani: That's right. Right. Yeah. But temporary rest, temporary rest- Yeah

uh, with the understanding that we wanna get people back to sport, back to their, uh, back to their life, back to their passion. But, uh, uh, temporary rest sometimes if it's really inflamed if there's a really significant pain component, then a temporary course of anti-inflammatory medicines, and the physical therapy treatment, stretching hands-on modalities, those sorts of things.

In rare cases cortisone injections into the tendon sheath can be useful. And in, um, extremely rare cases, a, uh, tendon surgery. 

Dr. Chehab: Yeah, yeah. And the tendon surgery involves? 

Dr. Thadani: Typically debriding and releasing the tendon, and, uh, that's often done arthroscopically. 

Dr. Chehab: Yeah. And then again, moving from, um- Around the hip, if we were to [00:11:00] look at abductor tears against, in the similar area in that greater trochanteric lateral aspect of the hip that people feel can you explain what happens with abductor tears what age group typically gets those, and, and what is the treatment for those type of conditions that cause pain around the hip?

Dr. Thadani: Sure. Yeah. And these are uh, very common, uh, injuries and... or excuse me, conditions. And we've, um, um, going back to our previous discussion of um, um, you know, arthroscopic bursectomy and why it may or may not have been effective oftentimes, uh, somebody who is being treated for having chronic, quote-unquote, bursitis, they actually have, uh, a tear of the abductor.

So the abductor group of muscles and tendons, it's the gluteus minimus, gluteus medius, uh, the two, uh, muscle tendon units that live on the side of the hip, and they attach into that, uh, hip bone on the side of the hip. And abductor tears occur typically from a degenerative wear-and-tear type of a process, so, um, over time with just use and life and wear and tear.

And, [00:12:00] um, y- we call, uh, we refer to abductor tears as the quote-unquote, "rotator cuff tears" of the hip, 'cause there's very very common parallels between the two. Most of these tears, again, occur from wear and tear. We do certainly see folks with, um, acute traumatic abductor tendon tears.

But by and large, they're, uh, mostly degenerative and wear and tear in nature. Uh, we commonly see these tears in a sort of a mature, more mature age population. 

Dr. Chehab: And how do they present? Are they hurting in, like saying, "Oh, I'm hurting at nighttime, I'm having difficulty sleeping," or are they having difficulty with their activities of daily living?

Both? What, what are the, what's the common presentation for an abductor tear, and how do you distinguish it from things like hip bursitis or just one of those things that diagnostic imaging or h- how are you able to make the diagnosis? 

Dr. Thadani: Yeah, so presentation, uh, as you mentioned, it's, it's all of the above.

It's, uh, it's pain on the side of the hip. It's, um, uh, pain with activities of daily living stair climbing significant difficulty sleeping on the affected side. It presents very, very similarly to, uh, [00:13:00] trochanteric hip bursitis- Yeah ... because those two structures, the bursa and the tendons, they live literally next door to each other.

Yeah. So the presentation, the, the, the patient's clinical symptoms are, are, are very similar. And so in the physical examination, we'll- tend to get more suspicious for an abductor tear if the person demonstrates weakness when we try and, uh, test those muscle groups. And, um, so if a person's presenting with that, uh, um, pain in that location as well as muscular weakness is- we go on and perform imaging.

Certainly with, uh, imaging, when a person comes to an orthopedic s- uh, surgeon's office, uh, we, we almost always start with plain, uh, r- X-rays just to- Yeah ... get an assessment of the structure. But if we're assessing for a soft tissue issue like a, an abductor tendon tear, we'll move on with advanced, uh, imaging um, such as an MRI scan or an ultrasound, but primarily MRI.

Dr. Chehab: And then, uh, with an MRI, with your clinical exam, when you make the diagnosis of an abductor tear, what's the treatment approach for that patient? Is it immediate surgery, or is it trials of physical therapy and then moving on to [00:14:00] surgery if that fails? 

Dr. Thadani: We always try nonsurgical treatment first. Yeah. For most patients, it, it will be effective, particularly if there's an 

Dr. Chehab: abductor tear- The nonsurgical treatments will be effective.

Dr. Thadani: Correct, yes. Yeah, yeah. Yes, I'm sorry. Nonsurgical treatment is uh, oftentimes effective, so we, we absolutely try and start with nonsurgical treatment first. And particularly in partial thickness tears, so tears that don't involve the entire 100% of the tendon, so the other remaining intact, healthy portion of the tendon, uh, muscle tendon unit rather can compensate for that uh, worn-out area.

And so physical therapy, uh, to strengthen, uh, the surrounding area. For temporary pain relief, we can prescribe NSAIDs, um, anti-inflammatory medications, or give periodic cortisone injections, although, uh, with a torn tendon, we tend not to, uh, recommend cortisone injections on a regular or repeated basis because over time, the cortisone could lead to some further tendon weakening.

Dr. Chehab: Of, of the remaining compensatory tendons, that's what- where the cortisone can have a detrimental effect? 

Dr. Thadani: Yes. 

Dr. Chehab: Yeah. And then how often do you think it, it works? Like, are you [00:15:00] taking a 50/50 approach with therapy, or is it 90% of the time that it works? What, what would be your guess on patients getting symptomatic relief of abductor tears with that treatment approach?

Dr. Thadani: Uh, I, I think it depends on a lot of factors. Uh, so the size of the tear, Yeah ... the, um, health of the surrounding musculature. But, um, um, i- if we take, uh, if we look at everybody that comes in with a, uh, a- an abductor tendon tear or partial thickness abductor tendon tear, I would say, uh, 50/50.

Dr. Chehab: Yeah.

Dr. Thadani: Yeah. 

Dr. Chehab: And then, um, with the surgical treatment of abductor tears, you can treat them both open or arthroscopic. Is there a preferred approach or both have equal outcomes? 

Dr. Thadani: I, I guess I'll back up. Just prior to surgery, the other non-surgical treatment we talked about um, medications, um, Yeah

cortisone injections and, uh, physical therapy. You know, in all of medicine, particularly in orthopedics, we're exploring, you know, biologic or regenerative type of treatments. I get asked about those types of treatments a lot by patients, as I'm sure you do as well. Um, and so, um, uh, there's a treatment modality, platelet-rich plasma, PRP.

Yeah. Um, that's [00:16:00] an injection of, um, y- the body's own cor- kind of growth factors into the area. That's a treatment that I'm sure you're familiar with, is, um, um, been employed for various different, uh, tendinopathies, so different tendon issues throughout the body. We've done that a little bit with, um, with uh, abductor tendon tears with varying degrees of success.

So- Yeah ... there's no harm in trying PRP. Um, it's a treatment modality that holds promise for the future when they've got the science more figured out, but it's something that we can certainly try for patients. 

Dr. Chehab: Yeah. 

Dr. Thadani: And then, um, I'm sorry, moving on to your, uh, answer to your question about, um, uh, surgical treatment.

So there is the option of, um, arthroscopic versus open surgery. I think the debate goes on between which is, uh, superior or not. Certainly for, uh, smaller or partial thickness tears, arthroscopic surgery has some advantage because oftentimes those partial thickness tears are involve the under surface of the tendon, so the tendon surface that you can't see if you go in from making an open incision, but, but y- what, which you can see on the underside from, uh, from an arthroscope.

Uh, [00:17:00] using the arthroscope arthroscopic approach for partial thickness tears can be, um, more advantageous in that regard. 

Dr. Chehab: Yeah. 

Dr. Thadani: For larger tears uh, perhaps using a more open approach, um, is more comprehensive. 

Dr. Chehab: Yeah. So that's abductor tears. Uh, let's talk about the SI joint as a source of hip pain.

Dr. Thadani: Sure. The, uh, SI joint uh, sacroiliac joint, it's a, uh, joint in the backside of the hip. Uh, it's the joint that joins together the lower spine with the pelvis. And as a hip specialist, we see a lot of persons who come in with, um, uh, what they describe as hip pain, but it's actually in the backside of the hip, and that's an area that where the pain can be, uh, generated either from, uh, something within the hip or something from the lower spine.

And so the SI joint, sacroiliac joint, is an area that, um, um, we see a lot of, persons with SI joint, uh, issues. So SI joint, um, arthritis or inflammation- Yeah ... those are two common pathologies. So it's pain, uh, i- in kind of the backside or the, uh, the, the mid to upper buttock [00:18:00] area. It can kind of radiate or wrap around into the side or the, uh, anteriorly or into the front or- of the hip or the groin area.

Dr. Chehab: Yeah. 

Dr. Thadani: Um, and that's pain with um, uh, it can present in different ways, with, wi- with sitting, with twisting, with turning, with movement, with bending. Typically does not, Excuse me. SI joint, um, troubles typically don't, um, uh, present with classic sciatica, so pain shooting in the leg or that sort of thing.

Dr. Chehab: And then imaging beyond X-rays, do you typically use that for SI joint diagnosis, or it's typically X-ray, maybe MRI? 

Dr. Thadani: Right. So SI joint, um, uh, uh, diagnosing SI joint pathology is typically done by history and physical examination. Yeah. Different physical exam maneuvers. Uh, we do plain X-rays, uh, although the, um, nature of X-ray imaging with the SI joint being kind of a complex three-dimensional joint with multiple contours.

If we're suspicious, then advanced imaging such as, uh, CT scanning or MRI, uh, imaging can be helpful. The MRI can, uh, show us again the, uh, three-dimensional nature of the joint, but, uh, it can also demonstrate if there's surrounding soft tissue [00:19:00] inflammation or, or fluid or w- inflammation within the joint itself.

Dr. Chehab: And then what are the treatment options for SI joint-generated pain? 

Dr. Thadani: Again, physical therapy strengthening and, um, stabilization of the area, of the lumbar spine and of the hip. And then oftentimes, um, uh, this is an area where we call on our, our pain management specialist colleagues to help us, and they can do image-guided injections into the joint- 

Dr. Chehab: Yeah

Dr. Thadani: Of cortisone primarily. And, uh, typically, you know, with those forms of treatment, um, uh, we're very effective at we're very successful at treating these problems. For a lesser percentage of patients who have, uh, ongoing severe pain that's not um, managed well with these treatments, then, um, there are, uh, newer procedures, uh, such as nerve ablations or, uh, SI joint, uh, fusions in rare cases.

Dr. Chehab: And then in terms of s- other invasive treatments, surgery, open surgery, very rarely for the SI joint? 

Dr. Thadani: I think that's really uncommon 

Dr. Chehab: I've never, I've never seen it on the schedule OrthoVolley 

Dr. Thadani: Right. No, I've n- uh, I, I, I'll be honest, I don't, uh, [00:20:00] do procedures on the SI joint. Yeah. That's when I call on my, uh, pain management and, uh, lumbar sp- spine colleagues.

Yeah. But they're nowadays, um, um, with, uh, new pain techniques, there's, um, uh, different, uh, neuro ablations and, uh, SI joint fusions, minimally invasive fusions 

Dr. Chehab: Now going from the back zone of the pelvis to the front of the pelvis with some of the avulsion injuries that can occur particularly in adolescents.

Can you discuss some of the injuries that occur in the front of the pelvis, AIIS, ASIS type of injuries that we see? 

Dr. Thadani: Certainly. So in our younger, uh, athletic patients, we see a lot of muscle and tendon strains. Thankfully, these are injuries that are, uh, self-limited in that they heal on their own with a period of, uh, rest, maybe even, uh, using crutches and some oral anti-inflammatory medications and physical therapy.

But, uh, in extreme cases, we do see, uh, what we call avulsion fractures, so whereby the the tendon and muscle unit has such a forceful contraction, particularly during athletic activity, that it actually pulls a, a, a, a small chip of bone away from the [00:21:00] pelvic bone. So anterior inferior iliac spine avulsion fractures, AIIS avulsion fractures, it's sort of the most extreme form of a, uh, hip flexor injury in that the hip flexor tendon literally pulls a, a small chunk of the bone away from the rest of the pelvic bone.

Thankfully, um, these injuries are, again, treated almost always non-surgically successfully. They're quite painful. Typically, uh, our patients need to be on crutches and, and rest for a period of time. But they do tend to, uh, heal up quite well over time. In our younger athletic population, those are persons that are generally very health- healthy, and they typically heal very nicely.

In very rare cases where the the bone has been really avulsed and, and pulled far away from, uh, where it, uh, it belongs, um, surgery would be required, but that's typically very, very rare. 

Dr. Chehab: Very rare. Yeah. So that initial pop, snap during athletic activity in the front of the hip I've had patients say they felt like they were shot.

They really present kinda dramatically, but they get better relatively quickly with rest, and it [00:22:00] heals most of the time, almost all the time like 99.9% of the time on its own. And, um, they tend to get back to athletics in what timeframe would you say? 

Dr. Thadani: Well, most of them, as you said, are, uh, yeah, it's, it's a very dramatic presentation.

Um, uh, initially quite painful, but then, you know, the pain really quiets down quite well uh, within a couple weeks. So most of them are chomping at the bit to get back to athletics within a few weeks, but I think it's best to hold them back for at least four to six weeks while the tendon truly heals.

Dr. Chehab: Yeah. I agree. And, um, so we'll shift gears now. Um, we were talking about extra-articular sources of hip pain. Let's go into the hip joint itself and some of the structures within the hip joint that can cause pain. Um, we hear a lot about labrum tears. So c- and then we also hear about impingement.

They're s- somewhat related. Um, so, let's discuss labrum tears first and, and what some of the presentation can be, and again, some of the treatment options that patients have. 

Dr. Thadani: Sure. Quick anatomy lesson. The hip, it's a ball and a socket joint, and the ball is typically spherical. [00:23:00] It's, uh, you could consider it like a, uh, you know, like a cue ball on a, a, a pool table.

Uh, it's, uh, very round spherical, smooth. And, um, uh, around the rim of the car- uh, excuse me, the rim of the socket is a, um, a ring of cartilage that's called the labrum. So the labrum, um, helps the socket bone hold the ball in place in the joint. And, um, some of the common intra-articular or within the joint hip conditions that we see and treat are, uh, hip labrum tears and sort of a corollary to that something called hip impingement or f- femoral acetabular impingement, FAI.

So a labrum tear is, um, what it sounds like. It's a tear of that labrum cartilage structure. And, uh, we see a couple of different presentations. One is a, in a, uh, typically younger athletic population with a traumatic labrum tear. Typically that's actually associated with a a mild, uh, subluxation or mild, um, uh, shifting of the ball partially out of the socket.

But more commonly, labrum [00:24:00] tears are seen in a, uh, more mature population where it's a degenerative or wear and tear type of a phenomenon. 

Dr. Chehab: And then in terms of diagnosing it discuss how we, we get to the diagnosis of, hey, you have a, a torn labrum of significance here. 

Dr. Thadani: Sure. The location of the pain is typically within, deep within the groin or within the joint.

The kind of classic story, sometimes people feel like they pulled their groin or that sort of thing. Oftentimes uh, with a, a acute traumatic injury it'll, the the onset will be pretty obvious. Yeah. They'll have pain with, uh, with movement, with, uh, flexion of the hip, with rotation of the hip.

Uh, with a labrum tear, oftentimes there'll be associated catching or snapping or popping or feeling that the hip is suddenly gonna collapse or give way. So those are what we call mechanical symptoms. 

Dr. Chehab: Sure. And then image-wise, what, what type of imaging you like to get, if any, but I assume we get imaging if you're suspicious of a labral tear.

Dr. Thadani: Sure. So again, uh, when a person comes to the office, we always start with plain X-rays to, to get a, a, a foundation of the structure of the joint. And then if we're suspicious for a labral tear, we'll [00:25:00] move on to order an MRI scan. In the MRI, if we're suspicious for, uh, if we wanna assess the labrum, uh, the MRI will do that with what's called an arthrogram, whereby the radiologist injects, um, a bit of liquid ink or liquid dye into the joint, and that helps to kind of outline the cartilage and make the cartilage stand out better on the MRI scan.

So that's a, a, a very helpful image, uh, helpful tr- diagnostic modality, the MRI arthrogram. 

Dr. Chehab: And so we, we both come across this quite a bit. The presence of a labral tear on MRI doesn't necessarily mean that the labrum is what's causing the pain. There's a big background noise of labral tears on, on MRI imaging.

Dr. Thadani: That's exactly right. That's- 

Dr. Chehab: How, how do you handle that? Like when, obviously you have to put it all together and the MRI's just a piece of it. 

Dr. Thadani: That's exactly right. So yes, uh, y- you know, certainly, and especially as uh, as, as persons get older you know, if you take a a certain number of patients who are 50 and above, uh, without any hip pain and throw them in an MRI scanner, there's gonna be a certain percentage of them that are gonna have labrum tears.

And as you said, some of that is, um, um, quote-unquote background noise, so it doesn't [00:26:00] mean that it's, uh, asymptomatic. So, putting it all together, so the history, um, patient's history with, um, having them describe the location and character of their pain and the type of the pain, w- combining that with the physical examination.

And then the other thing that's very useful is a, uh, a diagnostic injection. So injecting, uh, a bit of numbing medicine within the joint where the labrum lives, and if that, uh, injection temporarily takes away the pain and that's correlated with, you know, what we find in imaging and physical exam, then we can put that all together and be suspicious that it is the labrum.

Yeah. Uh, and if that, um, um, i- if that diagnostic injection doesn't yield a, a temporary positive result, then we go looking for other causes. 

Dr. Chehab: Okay. So that diagnostic injection would be quite helpful in the diagnosis of a labrum tear. 

Dr. Thadani: Typically quite helpful, yes.

Dr. Chehab: And then in terms of treatment what, what treatments are patients offered and what can they expect from those?

Dr. Thadani: Sure. So, again uh, you know, looking at the two different, um, uh, types of labrum tears, so the traumatic labrum tears in the young adult population typically we, we suggest surgery for that, and that's arthroscopic surgery to, uh, to, uh, [00:27:00] repair or debride the labrum repair if possible. In the, uh, older population where it's more of a degenerative type tear where the tear didn't occur from any specific injury but just over time it's come on we try nonsurgical treatment first.

Oftentimes I find an intra-articular or, or or a joint injection of a mixture of local anesthetic and cortisone can help. And then combining that with, uh, physical therapy to strengthen and stabilize the, uh, surrounding musculature, that helps to support the hip and take pressure away from that area.

Dr. Chehab: Okay. And then, and related to labrum tears in the hip, um, you mentioned hip impingement, femoroacetabular impingement, FAI. Tell us more about FAI. I c- it'll probably require another short anatomy lesson. Um, and, and, um, we'll get into that. 

Dr. Thadani: Yes. So FAI, fem- femoroacetabular impingement. So we had talked about the hip being a ball and a socket joint.

In a, um, a perfectly healthy hip, the, the ball is, is perfectly spherical and rounds and rotates very smoothly and freely within the joint. In FAI impingement there's a couple of conditions that can [00:28:00] happen. One, the ball can be out of round or more oval shaped. So if you think about a, um, a round ball rotating within or spinning around in a, uh, socket, that's-- that works out very well.

But if you put a, a, an egg or oval shaped ball within a socket, you know, it-- with certain movements that ball is gonna bind up, and that's, uh, that's what we call impingement. And that binding can grind away at the, uh, cartilage, both the surface cartilage on the socket side as well as against the labrum.

So oftentimes labrum tears are seen in conjunction with, um, uh, impingement anatomy or impingement morphology, as we call it. The other type of impingement that was classically described is what's called pincer impingement. So, uh, again, going back to the thinking about the hip as a ball in a socket the socket is a kind of a certain shape or certain contour.

Not too much, not too little. If the socket is, um, overly grown or overly- encasing of the ball that can bind the ball up at certain positions and movement. 

Dr. Chehab: And again, how does it present and what are some of the ways that you diagnose someone with symptomatic femoroacetabular [00:29:00] impingement?

Dr. Thadani: So a- again, with the, uh, intra-articular or joint problems within the hip, a lot of very similar and overlap of, of symptoms. Pain t- typically, classically within the groin, can radiate into the thigh can certainly be associated with mechanical symptoms or catching or locking or, uh, instability symptoms where the hip suddenly collapses.

X-rays are very helpful because they can oftentimes show particularly the, uh, femoro-sided or, or what we call cam type of impingement, where, as I mentioned before, the ball is not a spherical ball, but rather more of an oval. 

Dr. Chehab: Yeah. 

Dr. Thadani: And then, um, using advanced imaging such as CT scans or different, um, um, CT viewpoints that we can take and make different measurements to that have established criteria for, um, uh, what qualifies as impingement.

Dr. Chehab: Yeah. And then treatment options. 

Dr. Thadani: Yeah, treatment options. So a- again we typically try and start with non-surgical treatment. Physical therapy can be he- very helpful to, uh, help reestablish flexibility, and if you can reestablish a good pain-free arc of motion that can help the hip function more normally.

[00:30:00] Periodic cortisone injections or a, a trial of a cortisone injection to simmer the pain down from the acute, um, uh, e- episode while a person is able to try and rehab with therapy. You know, therapy is, uh, the combination of non-surgical cortisone injection and physical therapy has been shown to be effective probably about 50% of the time for hip impingement.

But, um, then if it's, um, uh, non-surgical treatment is not successful, um, then doing hip reconstruction surgery or hip preservation surgery, as we call it, and that's typically done arthroscopic these days, uh, whereby, Well, the surgeon goes into the joint and, um, uh, uh, reshapes or recontours, uh, the bone to, uh, restore a more normal f- A 

Dr. Chehab: spherical shape of the bone as opposed to the oval egg shape.

Dr. Thadani: That's right. Yeah. And then addressing the, um, um, there's oftentimes with, uh, impingement, oftentimes labral pathology, so addressing the labral pathology as well. 

Dr. Chehab: Okay. And then the last topic, intra-articularly arthritis. Obviously it's very, very common. Everybody knows somebody who has hip arthritis who's had a hip replacement.

I- we could talk forever about hip [00:31:00] arthritis and hip replacement. But let, let's just give a brief overview of, of how patients typically present, how we diagnose it, how we treat it. 

Dr. Thadani: Sure. Yeah. So again uh, remembering that the hip is a ball and a socket joint. The surface of the ball, the surface of the, uh, uh, socket are, are covered with a protective Teflon coating, if you will, of cartilage.

And arthritis is when that, that protective smooth coating starts to wear down or, or deteriorate. So hip arthritis usually presents as a, um, a slow onset, um, um, we call insidious onset, um, a progressively worsening problem. It's usually not a sudden onset, although for some people it can be.

And it's, um, um, as I mentioned before, uh, a lot of times people feel that they've had like a chronic, uh, quote unquote, "groin strain." So they'll feel pain primarily in the groin, although it doesn't have to be simply there. That's the most common location. It can radiate down into the thigh. It can radiate to the side of the hip.

It can even radiate into the back of the hip. And, uh, it'll be typically pain that's worse with with activity, so, uh, weightbearing activities, stair climbing, athletics, exercise, that sort of [00:32:00] thing. You know, as it, uh, progresses, sometimes people can really be, uh, hampered by it at nighttime.

It can disrupt their sleep. 

Dr. Chehab: Yeah. And once that happens, it seems like people really need treatment. Once your s- And a lot of these conditions really affect your sleep. 

Dr. Thadani: That's 

Dr. Chehab: right. That, that sleep disruption is- 

Dr. Thadani: Right ... 

Dr. Chehab: kind of the final straw in many cases. 

Dr. Thadani: Right. Yeah, any person who's, uh, had a significant, um, uh, shoulder or hip problem that, that gets them in their sleep, they, yeah they know what, uh, we're talking about.

Dr. Chehab: Yeah. And then th- there are non-operative treatment options for hip arthritis again, typically involving NSAIDs, physical therapy. But at some point, those tend to not be as effective, and people start seeking arthroplasty and hip replace- or hip replacement surgery. Um, so can you talk a little bit about some of the different techniques around hip replacement, what's your preferred method and what patients can expect after hip replacement surgery?

Dr. Thadani: Sure. If the arthritis reaches what's called the end stage, so a person has, um, pain or difficulties that are no longer livable or tolerable combined with the arthritis, um, demonstrating to us on X-rays that it's, it's really become quite severe, [00:33:00] then that's the point where we talk about hip arthroplasty or hip replacement surgery, which is invasive surgery, but it's an operation that's, uh, typically quite successful in terms of relieving pain and letting people get back to, um, uh, a more comfortable level of living.

And with hip replacements, people can really, really resume doing whatever activity they previously enjoyed doing. Uh, there are different ways of doing hip replacements, and I'm, uh, I- I'm always amazed our, our, our patient populcation, p- patient population is becoming more and more, um, uh, sophisticated and savvy, and people come in with very, uh, uh, very interesting and detailed, uh, questions.

"Doc, how do you do your hip replacement?" So what I'm alluding to there is, um, uh, there's different methods of doing the surgery. So, you can, um, um, do the surgery whereby you make an incision in the back of the hip, which is called the posterior approach. You can make an incision on the side of the hip, which is called the lateral or anterolateral approach, or you can make the incision on the front of the hip, which we call the anterior approach.

For each approach or each method of doing surgery, there's, there's pros and cons of it. I do my, uh, hip replacement surgeries via the anterior approach which is again, an [00:34:00] incision that's made on the, on the front side of the hip. Uh, the anterior approach, it's, uh, a technique that was, uh, really developed and popularized in Europe and, um, uh, then came to us and presented to us in the United States in the, uh, late '90s.

And it's really caught on in the last, uh, I'd say decade and a half. Um, the anterior approach is a method, um, uh, that's considered minimally invasive, so we don't cut any muscles. We don't cut any tendons. Uh, so it's a, um, um, a technique that lends itself to a recovery process that's um- sometimes quicker, easier, and less painful.

Dr. Chehab: Yeah. Okay. There are people who swear by the posterior approach, people who swear by the anterior approach, and each has its upsides and downsides. You've mentioned the upsides. Any downsides with an anterior hip approach that you might not have with a posterior approach? 

Dr. Thadani: So the potential downsides with anterior approach perhaps a little higher risk of an inadvertent, uh, fracture during or after the surgery.

And, uh, maybe a bit, uh, a small a higher risk of, uh, contracting a, uh, skin infection or a superficial infection- Yeah ... as you call it, after the surgery. Yeah. Some [00:35:00] say that there's a higher risk of nerve injury. I would submit that the risk of a, uh, a major catastrophic nerve injury is, is, is no different.

Certainly with the anterior- Which is 

Dr. Chehab: Very low. 

Dr. Thadani: Thankfully, uh, regardless of how a hip replacement is done, a catastrophic nerve injury the risk of that happening is extremely low. Extremely low. Correct. Yeah. Yes. 

Dr. Chehab: Yeah. Okay. So my guest today is Dr. Peter Thadani. Thank you for being here and talking about all the conditions around the hip that can cause pain.

Thanks so much for your time this morning. 

Dr. Thadani: Well, I appreciate it. This was, uh, a lot of fun, and, uh, I could talk about the hip all day long, but, I didn't wanna bore everybody with all that. But, uh, appreciate the opportunity. Wouldn't bore 

Dr. Chehab: me, 

Dr. Thadani: so. Great job. 

Dr. Chehab: All right, great. Thanks again for being here.

Dr. Thadani: You're very welcome. Thanks for the opportunity. Take care.