Tom Brady and Achilles Tendinitis

Tom Brady sat out of practice Nov 29, 2017 with achilles pain and missed a single practice the week prior (Nov 22) for the same injury. Achilles tendinitis is a problem that is more frequently seen in older athletes given the underlying nature of the problem. As we age, particularly in patients who have used their Achilles more (such as the athlete or overweight patient), the Achilles tendon degenerates. The Achilles is similar to a rope and its function is to connect the heel bone to the calf muscles, such that when the calf muscles fire, the ankle plantar flexes, or points down, thereby propelling the body forward and lifting the heel off the ground. Similar to a rope that you would see at a marina docking a boat, the "rope-like" achilles develops features of wear and tear over time such as fraying and damage to the substance itself. As the tendon degenerates, it typically swells and loses its normal tendon fiber orientation. This results in pain and limited function. We typically do not see tendinitis of the Achilles in younger patients because there is no underlying wear and tear contributing to the problem. In my practice, Achilles pain is seen in a teenager maybe once per year. In patients in their 20s, I see approximately 5 patients per year, in patients in their 30s approximately 20 patients per year, and in patients in their 40s or greater, 300 patients per year. In the setting of disc degeneration, the likelihood of having a tear, either partial or complete, is also higher. Pain prior to an Achilles rupture is known as a "prodromal" symptom. See Richard Sherman. He was dealing with tendinitis in Achilles all season before rupturing it in early November of this year. Achilles tendinitis without rupture or acute tearing is treated in the following ways: 1. NSAIDs (e.g. naproxen or ibuprofen or Celebrex): Dr. Carreira recommends short courses of these non-steroidal anti-inflammatories. This medication should be checked with your primary care physician to make sure that it is safe for you. 2. Activity modification: If it is painful to do a certain activity, try to limit this activity until the pain has improved and then resume gradually. 3. Heel lift: A silicone heel gel inserted into the shoe will lift the heel slightly and offload the tendon. Wearing a shoe with a slight heel will also have the same effect (e.g. a clog). I don’t think we’ll see Brady doing this one! For the insertional type of Achilles injury, a shoe without a heel counter (open back shoe) will decrease pressure on this painful area. 4. Physical Therapy: Minimal stretching is recommendable and a program of heavy load eccentric strengthening may be initiated. 5. Immobilization in a CAM walker: If these initial treatments have failed, immobilization in this boot is recommendable. 6. Surgery: If all else fails, surgery may be performed endoscopically (through small portal incisions) or open. The type of surgery depends on the location within the tendon, the extent of tendon injury, and any associated abnormalities. Shock wave therapy is not covered by insurance in the US but has some evidence of success. Platelet rich plasma is also not covered by insurance and has limited and mixed evidence for and against its efficacy.

Isaiah Thomas, Labral Tearing, and Femoroacetabular Impingement

The Celtics issued the following statement related to the hip injury during the 2016 playoffs: “Isaiah Thomas will miss the remainder of this year's postseason following re-aggravation of a right femoral-acetabular impingement with labral tear during Game 2 of the Eastern Conference Finals against Cleveland. Thomas initially injured the hip during the third quarter of the Celtics' March 15 game against Minnesota, forcing him to miss the next two regular season contests. The injury was further aggravated during Game 6 of the Eastern Conference Semifinals at Washington on May 12." In this case, the diagnosis appears clear in terms of the injury. Femoral acetabular impingement (FAI) is an abnormal alignment of bone either on the acetabular (cup side of the joint) and/or on the femoral side (ball side of the joint) that causes abnormal mechanics of the joint, particularly in positions of extremes of motion (most often flexion). FAI is correlated with hip injury, although there is not a direct cause and effect association. In other words, patients with femoral acetabular impingement (FAI) do not necessarily develop tears or need treatment for the impingement.Femoral acetabular impingement alone is not a reason for surgical treatment, although in the setting of hip injuries and labral tears, surgical treatment may be appropriate. In those cases in which surgical treatment of the labral tear is performed, the femoral acetabular impingement is treated at the same time, with the goal of removing any abnormal shear forces on the repaired joint and thereby prevent further future injury. Labral tears can be present in patients who have no symptoms. This has been shown in several studies, including studies performed in the NHL, in which players who had no symptoms were noted to have labral tears on MRI. Especially in patients who have a very recent onset of symptoms (< 3 months), a trial of nonoperative treatment in the setting of labral tears is a reasonable option. However, labral tears generally are not thought to repair themselves and subsequent imaging will oftentimes continue to show tears. For these reasons, in patients who have persistent symptoms with labral tears and femoral acetabular impingement, it is reasonable to consider surgical treatment. When considering surgery, factors that should be evaluated are the extent of symptoms, the condition of the joint in terms of potential articular cartilage injury, and whether improvement is ongoing. As the duration of symptoms becomes longer, the likelihood of pain resolving and function improving becomes even lower. The decision for surgical treatment is complex and many patient specific factors should be taken into account. Hip arthroscopy is a treatment for hip preservation, and the condition of the joint is very important in terms of predicting success. I like to use the analogy of a “broken car”. When taking a car to the mechanic, the likelihood of getting a 1990 car to run well and function well into the future is lower than fixing a 2016 car with minor damage. Similarly, the extent of injury to the labrum and articular cartilage is an important factor in predicting success. MRI scanning, x-rays, physical examination, and previous surgeries are all important factors to determine the extent of the problem and all may help to predict success.

A Focus on Injury in Sport

The reason for creating this blog is because of the interest that I’ve noted from patients, friends and family who ask me about injured players. Most frequently, the interest is related to how it compares to their problem, or because they are big fans of a particular team , or they want to know more about the status of a fantasy football player. I’ve been practicing for over 10 years, specifically in the areas of hip preservation and foot and ankle surgery and sports related injuries of the hip, foot and ankle. This blog will only cover injuries related to my areas of expertise. My experience comes from the treatment of players at all levels from high school to collegiate to professional in a variety of different sports. An important disclosure related to this blog is that the information that is made public, that is found in newspapers and on the Internet, may not be correct or may be incomplete. I have no firsthand knowledge of these players and their injuries and my discussion is based on public information. When I treat professional players myself, their privacy is essential and required. My personal care of any athlete would never be made public in a blog such as this.

Posterior Impingement of the Ankle

Patients with posterior impingement of the ankle oftentimes complain of pain in the posterior, or back of, the ankle. There may be an associated snap or catching sensation along with it, which may be caused by the tendon which lies next to this area, called the FHL (Flexor Hallucis Longus). Along with physical examination and plain x-rays, an MRI may be useful in making the diagnosis. The nonoperative treatment typically consists of NSAIDS, injections, and rest. If these fail, an endoscopic surgical technique may be used to remove the excess bone (Os trigonum or trigonal process) with release of the FHL (Flexor Hallucis Longus) tendon. This endoscopic technique is a minimally invasive technique that has the potential advantages of less bleeding, faster recovery, less scarring, and less pain.

Internal Snap of the Psoas (Iliopsoas) Tendon

The treatment for internal snapping of the hip may consist of a psoas tendon release in those patients who have failed nonoperative treatments and who have persistent pain. Nonoperative treatment for an internal snap typically consists of injections and avoidance of repetitive snapping if possible. Patients typically complain of a snap or click in the hip and on physical examination the snap can often be reproduced. Oftentimes there are other associated abnormalities in the hip that may be causing pain and that may need to be addressed. If there is no pain associated with the snap, typically no additional treatments are necessary. I have recently added a video to my website through youtube that demonstrates the arthroscopic surgical technique. Once the joint has been accessed arthroscopically, the procedure typically takes about 5 minutes to complete.

Types of treatment of hip labral (labrum) tears

There are 4 main treatment options for the treatment of labral tears. The best way to treat specific patterns of damage has not been fully clarified in publications on hip arthroscopy, but here I present some guidelines:
1. Debridement: This has been historically the main treatment for labral injury. This treatment is performed via hip arthroscopy and essentially consists of removing the damaged tissue with a shaver and/or with an electrocautery device. I perform this technique rarely, as preservation of this tissue when possible is beneficial.
2. Repair: This treatment also is performed via hip arthroscopy and consists of placing suture anchors in the bone and reattaching the labral tissue after it has been prepared. There is increasing evidence that this technique of repair is superior to debridement when possible.
3. Reconstruction: Also performed via hip arthroscopy, this technique may be performed when the labral tissue is too damaged or too small to be repaired. The technique consists of replacing the labrum with new tissue, and may be performed with autograft or allograft tissue.
4. Joint replacement: When the labral damage is associated with significant hip arthritis, the best treatment option is a hip replacement.

All arthroscopic allograft reconstruction of hip labral tear and deficiency

A young active patient who had previously undergone hip arthroscopy and labral debridement was reconstructed with allograft tissue. This was featured in a Channel 10 news story

Instrumentation for hip arthroscopy and hip labral (labrum) tears

How is it possible to reconstruct the hip if it is a deep, ball and socket joint? The answer in part lies in the instrumentation, which includes a number of curved, flexible, and long instruments to do the work. Progress in the area of hip arthroscopy has paralleled progress in instrumentation, which allows for improved access, manipulation, preparation, and refixation of the tissues.

Ankle fracture

Which ankle fractures are treated surgically? When do you treat them? The simple answer is that unstable ankle fractures are treated surgically. If both the medial and lateral sides of the ankle are fractured (called a bimalleolar ankle fracture) or if three sides are fractured (including the posterior malleolus, that is a trimalleolar ankle fracture), then surgical open reduction and internal fixation is recommendable. Fractures of the lateral malleolus alone, when displaced and in combination with a severe injury to the medial, or deltoid ligament, may also be unstable and benefit from surgical fixation. The timing for surgery is dependent on the skin and soft tissues, and is typically done around a week after the injury, to allow the swelling to minimize and thereby decrease risk for wound problems. The ankle fracture may also be treated within a few hours of the injury, before much swelling has developed.

Arthroscopy for ankle fractures?

When is ankle arthroscopy recommendable for ankle fractures? There are two randomized studies published on the use of arthroscopy in ankle fractures. One study demonstrated better results in patients who underwent arthroscopy at the time of open reduction internal fixation and the second study demonstrated equivalent results. Based on this data, I do not perform an ankle arthroscopy on all patients who have had an ankle fracture. With patient specific factors also considered, I tend to perform the arthroscopy on higher energy injuries, such as ankle subluxations or dislocations or syndesmosis injuries. At the time of arthroscopy, Ferkel reported a high rate of damage to the articular surfaces following ankle fractures, and my experience supports this fact. At the time of arthroscopy, loose bodies of cartilage alone or a combination of cartilage and bone can be treated, and the joint is looked at thoroughly to identify and treat any other associated injuries. This damage to the inside of the joint can be a cause of chronic pain if left untreated.

David Beckham torn achilles tendon

A few of my patients today wanted to get my impression of David Beckham's injury. Although I know of no specific details regarding his injury, based on the description in the media he suffered a complete tear. A completely ruptured or torn Achilles tendon is typically repaired surgically, particularly in a competitive athlete who wants to regain near normal strength and function. A complete tear of the Achilles treated non-operatively typically results in a more significant loss of strength with push-off as compared to patients who have a repair. Other tears, such as the peroneals or posterior tibial, typically are incomplete tears and are more chronic and slow in their progression. The main advantage of surgical intervention for a completely torn Achilles is restoration of strength and a decrease in rerupture rate, and the main disadvantage is wound breakdowns. Typically, recovery is at least as quick with surgery as compared to casting. Here in South Florida, the majority of these injuries that I have seen have been from tennis, followed by racquetball and basketball. I treated a patient last week from Miami who jumped off of a palm tree backwards.

Instructions added for recovery after surgery

After undergoing surgery and due to the effects of the medications for the anesthesia and pain control, patients may not remember well all that is discussed in the first hours after surgery. For this reason, I have added the postoperative instructions for foot and ankle onto my website www.hipfootankle.com.

The instructions regarding hip arthroscopy for the treatment of labral (labrum) tears, FAI (femoroacetabular impingement), and other causes of hip pain are provided prior to surgery as part of the hip arthroscopy information packet.

Ankle arthroscopy

What problems can be treated with ankle arthroscopy?

There are a number of different problems which are effectively treated with ankle arthroscopy. These reasons, or indications, are meant to serve as a guideline of the most common indications for ankle arthroscopy. Osteochondral defects or lesions, which are focal areas of articular cartilage damage on either side of the ankle joint (the tibia or more commonly the talus) may be treated with ankle arthroscopy. Anterior impingement, resulting from either excess bone or soft tissue along the front of the ankle joint, is most commonly seen in athletes. Loose bodies, which are loose pieces of bone or cartilage, may be removed. Septic arthritis, or infection of the ankle joint, also may be treated effectively, along with antibiotics afterwards.

New Website

Through the help of Liam Dempsey and lbdesign, we have launched a new website, www.hipfootankle.com.

Through the new website, you will find extensive information about hip, ankle, and foot injuries, as well as possible treatments. It is our hope that this site will serve as a valuable resource to all who are interested in learning more about these injuries.

Slipped Capital Femoral Epiphysis

This diagnosis occurs most commonly in boys between the ages of 10 and 17 who are commonly obese. Although typically of unknown cause, it has been associated with hormone abnormalities. 10 – 25% of cases are bilateral and trauma is associated with approximately 25% of cases. To make the diagnosis, X-rays typically are performed.

Signs and Symptoms
Groin pain may develop slowly or come on suddenly. The hip pain may extend to the knee or anterior thigh. Limited motion of the hip usually is present, with the leg being more comfortable in external rotation. Early in the process, plain films may reveal widening of the growth plate. More advanced changes result in slippage of the bone.

Differential Diagnosis
Other common causes of hip pain in this young patient population include muscle strain, avulsion fracture, or growth plate injuries in other areas around the hip.

Management
Surgical treatment consists of fixation when it presents initially. If symptoms occur later in life in patient who have been treated for this condition, the symptoms may be due to femoroacetabular impingement.

Femoroacetabular Impingement

Ganz and colleagues recently described the concept of femoroacetabular impingement (FAI) as a source of labrum (labral) tears and articular cartilage injury. Two bony abnormalities, CAM and pincer, frequently occur together. CAM impingement results from abnormal contact between an abnormally shaped femoral head and neck with a morphologically normal acetabulum. This type of impingement may be of unknown cause or may be associated with femoral neck fractures that have healed incorrectly, slipped femoral capital epiphysis, or Legg-Calve-Perthes disease. Pincer impingement results from abnormal contact between a normal femoral head with an abnormal acetabulum. This type of impingement is the result of focal (acetabular retroversion) or global (deep socket) over-coverage.

Because of its association with articular cartilage injuries and labral tears, there is considerable overlap in terms of presenting symptoms. Asymmetrical range of motion, especially into flexion-internal rotation or flexion–abduction–external rotation, may be noted. Radiographs and MRIs are the current standard to assess for FAI.

Open or arthroscopic surgical interventions include osteoplasty to reshape the head – neck junction of the femur or rim trimming to remove excessive bone from the acetabular rim.

Impingement is due to a bony abnormality and therefore no true preventative measure can be taken. Proper maintenance of core strength and muscle balance in and around the hip may help protect the soft tissues in the joint.

Degenerative arthritis

Degenerative arthritis refers to diffuse loss of normal articular cartilage in the joint and must be considered as the primary cause of hip pain, regardless of age. Osteoarthritis, traumatic arthritis, and rheumatoid arthritis are common causes of degenerative arthritis. Typically the presence and extent of arthritis tends to increase with age. Degenerative arthritis is the most common cause of hip pain in patients over fifty years of age.

Signs and Symptoms
Patients report progressively worsening pain, typically with a gradual onset. As activity increases, pain also tends to increase. A limp may develop, occasional sharp pains may be noted, and stiffness may be progressive. Radiographs reveal joint space narrowing, and possible cysts, spurs (also called osteophytes), and sclerosis (thickening of the bone adjacent to the joint). A decrease in range of motion may also be noted,

Differential Diagnosis
Differential diagnosis includes loose bodies, labral tears, ligamentum teres tears, and arthritis in the lumbar spine with radiating pains to the hip area.

Management
For patients with mild arthritis, nonoperative treatment may suffice. NSAIDS (non-steroidal anti0inflammatory medications), glucosamine and chondroitin sulfate, steroid injections, and hyaluronic acid injections may be effective. Activity modification is an option to minimize symptoms. Tylenol and the use of NSAIDS may be effective and should be discussed along with your primary care physician. There are concerns with the use of NSAIDS, particularly in the long term.

For patients who have failed nonoperative management, three surgical options exist:

1) For diffuse areas of articular cartilage injury, typically noted as joint space narrowing on plain x-rays, a total joint replacement is the best surgical treatment option.

2) For patients who have little to no joint space narrowing and who have localized or focal areas of articular cartilage injury:

2a) An open hip dislocation with treatment of the intra-articular abnormalities as well as any contributing abnormal bone alignment may be considered.

2b) An arthroscopic approach, through small incisions, may also be effective.

My approach to deciding which surgery is best is decided on an individual basis, with a number of factors taken into consideration, including but not limited to age and activity level.

Focal articular cartilage injuries

Causes include traumatic injury, e.g. from a direct blow to the greater trochanter or from femoroacetabular impingement. Xrays are very useful in determining the extent of articular damage and are routinely obrtained. In determining the presence of focal areas of chondral injury, MRIs have improved considerably in recent years and depend in part on the quality of the images and the experience of the reader. The presence of chondral lesions of the femoral head or the acetabulum has been shown to result in a poorer prognosis following arthroscopic treatment of a labral tear.

Signs and Symptoms
A deep ache in the joint may be reported by the patient, and the pain may be noted anteriorly, laterally, or posteriorly. A click or mechanical sensation in the joint will probably not be noted in the early stage of injury.

Differential Diagnosis
Differential diagnosis includes fractures, stress fractures, intra-articular derangement such as a labral tear, and degenerative joint disease.

Treatment
If nonoperative treatment consisting of activity modification, physical therapy, NSAIDS, and glucosamine chondroitin fail, treatment may consist of arthroscopic microfracture versus total joint replacement, depending on patient specific factors and the extent of articular cartilage injury.

Groin Strain

The most common acute injuries about the hip and pelvis from athletic competition are muscle strains. The musculature of the groin most often affected includes the adductor group (gracilis, pectineus, adductor brevis, adductor longus, and adductor magnus). The rectus abdominus, rectus femoris, and iliopsoas are also common muscles that can be affected. The mechanism of injury can be overuse causing microtears or a sudden forceful movement. A position of external rotation and eccentric forces often cause flexor / adductor strains, and the injury most typically occurs at the myotendonous junction or the tendonous insertion.

Signs and Symptoms
A strain can be felt as a sudden sensation of tearing or twinge while playing or may not be noticed until after the activity. Symptoms include pain and swelling. Focal areas of tenderness and swelling are often detected. With more severe injuries, a defect may be palpable. The history of injury, localized tenderness, and pain with resistance are the most notable measures for diagnosis.

Differential Diagnosis
Avulsions should be ruled out with an AP pelvis radiograph. Differential diagnosis also includes hernia, internal derangement of the hip (e.g. labral tears and chondral injuries), nerve entrapments, osteitis pubis, fractures and stress fractures.

Treatments
Strains should be treated with RICE and analgesics as needed for a minimum of 2 to 3 days. Range of motion exercises should be initiated early. As pain resolves, gentle isometric exercise progressing to more dynamic resisted exercise can be performed using pain as a guide. The athlete can gradually return to play when pain-free. A protective spica bandage may assist in the early phase of return to sport for flexor / adductor strains. The most common complication is recurring symptoms and in chronic cases, surgery may be indicated but is rare.

Prevention
Training programs should be specific for the level of athlete, timing during the season, and goals of the athlete. It is important to focus on general conditioning, specifically strength, endurance, and flexibility. Programs should include warm-ups and cool downs for training and matches.

Hip labral (labrum) tears

Patients with hip pain may end up getting an MRI which shows a labral (labrum) tear. Inevitably I get asked "What is that? I've never heard of it before."

Most labral tears are not associated with a traumatic onset. Running, sprinting, and frequent rotation of the hip while playing sports is thought to result in tears of the labrum. Bony structural risk factors include hip dysplasia and femoroacetabular impingement (FAI). Clinical assessment including history, physical, and radiographic analysis is 98% accurate in determining the presence of an abnormality within the hip joint. MRI with contrast injected into the hip joint(arthrography) is 65-90% sensitive for detecting labral tears. Relief of pain (lidocaine pain test) from an intraarticular anesthetic injection at the time of arthrography is very suggestive of intraarticular abnormalities and is useful in predicting improvement with arthroscopic intervention, particularly in patients with normal imaging exams.


Signs and Symptoms
In greater than 90% of patients with labral tears, pain is reported in the anterior hip or groin region. Less often pain occurs in the lateral or posterior hip region. Patients may also report clicking, catching, locking, or giving away. Range of motion restrictions in flexion, internal rotation, and/or figure four position may be noted. Provocative tests include the anterior impingement test of flexion, internal rotation, and adduction. A positive test causes pain in the groin and restricted motion. Pain in the joint with a resisted straight leg raise may be indicative of a labral tear.

Treatment
Unfortunately the labrum does not heal on its own if it is torn. The goak of non-operative treatment is to reduce the symptoms. If non-operative methods fail, surgical intervention of labral tears may be performed open or arthroscopically. The labrum can be debrided (cleaned-up) and/or repaired with suture anchors. Histologic studies have shown potential for labral healing. Conservative treatment may include limited weight bearing, NSAIDS, and avoidance of pivoting motions on the hip. Physical therapy can improve muscle recruitment to control hip motion.