What are the common causes of hip pain in individuals under 50?

For individuals under 50, common causes of hip pain include stress fractures (especially femoral neck stress fractures in endurance athletes) and femoral acetabular impingement (FAI). Other sources can include issues with bone, cartilage, ligaments, joint capsule, or muscle and tendons. Referred pain from the back can also manifest as hip pain.

How are femoral neck stress fractures diagnosed and treated?

Femoral neck stress fractures are diagnosed using MRI, which is considered the gold standard as X-rays are often negative in early stages. Treatment depends on the fracture location: compression-sided fractures typically require 6-8 weeks of rest and crutches, while tension-sided fractures are higher risk and often require surgical pinning for quicker recovery and to prevent complications like avascular necrosis (AVN) of the femoral head.

What is the utility of stem cell therapy and PRP in orthopedics, and are they the same?

The term 'stem cell therapy' is often misused in orthopedics; true stem cell therapies are largely unregulated and illegal in the US for orthopedic conditions. Platelet-rich plasma (PRP) uses a patient's own concentrated platelets and has shown promise as a symptom-modifying treatment for conditions like tennis elbow, some gluteus medius tears, and knee arthritis. It does not introduce new 'pluripotent' stem cells to regrow tissue, but rather leverages growth factors to reduce symptoms, sometimes better than cortisone or hyaluronic acid.

How do running and other activities impact knee cartilage, and is running 'bad for the knees'?

Inactivity is detrimental to cartilage, while appropriate activity promotes cartilage health by stimulating chondrocytes to produce more matrix proteins. The impact of activities like running depends heavily on individual biomechanics and alignment. Forces up to 7-8 times body weight can be experienced at the kneecap during activities like squatting or running. Good mechanical alignment, where a plum line from hip to ankle passes through the center of the knee, generally predicts better outcomes and lower risk of degeneration. Overtraining, however, can lead to cartilage breakdown.

What are the different graft options for ACL reconstruction, and which is considered best?

Common autograft (patient's own tissue) options for ACL reconstruction include the patellar tendon (central third with bone plugs), hamstring tendons (semitendinosus and/or gracilis), and increasingly, the quadriceps tendon. Allografts (cadaver tissue) are also an option, but carry a higher risk of rerupture in younger patients (under 34). The patellar tendon is often considered the 'gold standard' due to predictable bone-to-bone healing and strength, though it can lead to more early recovery pain and kneeling pain. Hamstring grafts result in weaker hamstrings. The choice often depends on patient activity level and preferences regarding post-operative pain and recovery time.

What is the prognosis for arthritis development after an ACL tear, even with reconstruction?

Approximately 50% of individuals who experience an ACL tear will develop signs of arthritis within 15 to 20 years, regardless of whether the ACL is reconstructed or not. While reconstruction is important for stabilizing the knee to prevent further meniscus tears and allow participation in sports, it doesn't fully restore normal joint mechanics or eliminate the long-term risk of arthritis. The initial traumatic injury itself can initiate changes in joint loading that persist, predisposing to arthritis.

When is surgery recommended for a meniscus tear, and when is conservative treatment preferred?

Meniscus repair is strongly considered for younger patients with peripheral tears (good blood flow) or bucket-handle tears that lock the knee, as preserving the meniscus helps prevent arthritis. For older patients with advanced arthritis and degenerative meniscal tears, surgery (trimming) is often no better than conservative treatment, as the pain may stem more from the underlying arthritis. The decision to operate depends on tear type, patient age, presence of arthritis, and correlation of pain with the tear.

What are the indications and recovery expectations for total knee replacement surgery?

Total knee replacement is indicated for patients with advanced arthritis in multiple compartments of the knee who have failed conservative treatments and whose quality of life is severely impacted. The surgery involves resurfacing the distal femur and proximal tibia with implants, often with a plastic button for the patella. Recovery can take up to a year, with significant non-linear improvement in the first 6 months. While hip replacements have very high satisfaction, knee replacements generally have an 85% satisfaction rate, and patients may not experience it as a 'normal' knee.

What are common foot and ankle injuries and their general treatment approaches?

Common foot and ankle injuries include Achilles tendinitis and ruptures (often due to overtraining or certain antibiotics), and ankle sprains (most common). Plantar fasciitis, stress fractures of the calcaneus, second, third, and fifth metatarsals (especially problematic for the fifth due to poor blood supply), arch collapse (posterior tibialis tendon dysfunction), and bunions are also seen. Most ankle sprains are treated conservatively. More severe issues like chronic arch collapse or certain fractures may require surgical interventions like fusion or bone cuts, with ankle replacements also becoming an option for advanced arthritis.

What is the 'female athlete triad' and why is it problematic for athletes?

The female athlete triad is a condition often seen in female runners who are undernourished, characterized by a risk of osteoporosis, stress fractures, and menstrual abnormalities. It indicates a relative energy deficiency where the body isn't getting enough fuel to support both athletic activity and basic physiological functions, making them susceptible to bone and hormone health issues.

How can one choose a good orthopedic surgeon?

When selecting an orthopedic surgeon, look for clear communication, active listening, and a willingness to discuss alternatives and potential complications. A good surgeon should explain the rationale for treatment, what to expect post-operatively, and a plan for troubleshooting if recovery is not as expected. They should be able to provide probabilities for complications in their own practice, not just quote literature. Avoid those who seem rushed or defensive when asked questions about alternatives.

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264 ‒ Hip, knee, ankle, and foot: common injuries, prevention, and treatment options

Peter Attia MD

Science & Technology5 min read139 min video

Jul 31, 2023|137,544 views|1,986|133

Peter Attia MD Dr. Peter Attia Early Medical The Drive Podcast The Drive Longevity Zone 2

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TL;DR

Orthopedic surgeon Adam Cohen discusses common hip, knee, ankle, and foot injuries, their causes, prevention, and treatment.

Key Insights

Developmental dysplasia of the hip, if undetected early, inevitably leads to arthritis due to uneven force distribution.

Femoral neck stress fractures, particularly on the tension side, pose a high risk due to potential blood supply disruption and may require surgery.

Weakness in the hip abductor muscles (gluteus medius/minimus) is a common cause of hip pain and precursor to various lower extremity injuries.

ACL tears increase the long-term risk of arthritis, and while reconstruction protects the meniscus, it doesn't fully eliminate this risk.

Isolated meniscus tears in young, non-arthritic individuals should be strongly considered for repair to prevent future arthritis.

Achilles tendon injuries, including tendinopathy and ruptures, are common in middle-aged individuals and can be insidious, sometimes linked to fluoroquinolone antibiotics.

Ankle sprains, while usually treated conservatively, can lead to cartilage damage and future arthritis if not managed properly or if associated with osteochondral defects.

Effective orthopedic consultation involves active listening, clear explanations of procedures, alternatives, risks, and a plan for troubleshooting if issues arise post-treatment.

HIP ANATOMY AND EARLY DETECTION

The hip is a ball-and-socket joint, inherently stable due to its deep socket (acetabulum) and the femoral head. Problems can begin in utero with developmental dysplasia of the hip, where a shallow acetabulum leads to uneven pressure and eventual arthritis. Early detection via physical exams and ultrasound is crucial to ensure proper socket formation, preventing long-term mechanical issues and pain.

COMMON HIP PAIN SOURCES AND STRESS FRACTURES

In individuals under 50, hip pain differential diagnoses include bone/cartilage issues, connective tissue problems, or muscle/tendon issues. Endurance athletes are particularly at risk for femoral neck stress fractures, which present as groin pain and are best diagnosed with an MRI. These fractures, especially on the tension side, can disrupt blood supply to the femoral head, potentially requiring surgical intervention with pins.

FEMOROACETABULAR IMPINGEMENT AND HIP STABILITY

Femoral acetabular impingement (FAI) involves a bony bump on the femoral neck (cam lesion) that pinches the acetabular rim and labrum during movement, causing tears and potential cartilage damage. This condition is thought to arise from repetitive stress during high-impact sports affecting growth plate closure. The labrum also contributes to hip stability by creating a seal, though ligamentous laxity or dysplasia can compromise this stability.

GLUTEAL MUSCLE DEGENERATION AND CORE STRENGTH

The gluteus medius and minimus, acting as the hip's 'rotator cuff,' are crucial for stability. These tendons, similar to the shoulder's rotator cuff, can degenerate with age or repetitive stress, leading to significant pain and weakness. Maintaining strength in these abductor muscles, as well as hip flexors and adductors, through targeted exercise, including eccentric training, is vital for preventing lower extremity injuries and improving overall joint health.

HIP AND KNEE REPLACEMENT PROCEDURES

Total hip replacement involves replacing the femoral head with a stem and a cup in the acetabulum, while hip resurfacing preserves the femoral head. Advances in surgical approaches, particularly the anterior minimally invasive technique, have significantly reduced morbidity. Knee replacement involves implanting components on the femur, tibia, and sometimes the patella to restore joint function, though satisfaction rates are generally lower than with hip replacements.

KNEE ANATOMY AND BIOMECHANICAL STRESS

The knee is a less stable joint than the hip, comprised of the femur, tibia, patella, and crucial ligaments (ACL, PCL, collaterals) and menisci. The menisci distribute force, and ligaments provide stability. High forces, up to seven times body weight on the patella during activities like squatting, highlight the importance of cartilage health. Inactivity is detrimental, but excessive, poorly aligned activity can also damage cartilage.

ACL TEARS AND ARTHRITIS RISK

ACL tears, predominantly non-contact, significantly increase the long-term risk of developing arthritis, regardless of reconstruction. While an ACL reconstruction aims to protect the meniscus and allow desired activities, it doesn't fully restore normal joint mechanics or prevent arthritic changes. The mechanism often involves a valgus knee position, internal tibial rotation, or hyperextension, exacerbated by poor neuromuscular control.

MENISCUS TEARS AND TREATMENT CONTROVERSIES

Meniscus tears, particularly in younger individuals without arthritis, are best repaired to preserve the joint's shock-absorbing function. Tears in the periphery with good blood supply are repairable, while degenerative tears in older individuals may require trimming (meniscectomy). Controversies exist regarding surgical outcomes compared to sham procedures, mainly concerning degenerative tears in arthritic knees, where non-operative management might suffice.

PATELLOFEMORAL PAIN AND NON-SURGICAL MANAGEMENT

Patellofemoral pain syndrome, often resulting from overloading the kneecap due to increased activity or poor mechanics, can be treated conservatively. While quadriceps strengthening is key, focusing on hip abductor strength is crucial to correct leg alignment and reduce stress on the kneecap. Blood flow restriction (BFR) training offers a way to stimulate muscle growth with lower loads, potentially beneficial in early recovery phases.

TOTAL KNEE REPLACEMENT CONSIDERATIONS

Total knee replacement is indicated for advanced arthritis unresponsive to conservative treatments like physical therapy, injections, or bracing. Excess body weight significantly exacerbates knee joint forces, making weight loss a critical factor in delaying or avoiding surgery. Recovery is a long, non-linear process, potentially taking up to a year, and while most patients achieve good function, limitations on high-impact activities remain.

ANKLE AND FOOT ANATOMY AND COMMON INJURIES

The ankle joint, formed by the tibia, fibula, and talus, is covered in cartilage. Common injuries include Achilles tendinopathy, often painful and difficult to treat non-surgically, and ruptures, sometimes associated with fluoroquinolone antibiotics. Ankle sprains, typically involving the ATFL, usually heal conservatively but can damage cartilage, increasing arthritis risk. High ankle sprains involving the syndesmosis ligaments may require surgery.

FOOT ARCH COLLAPSE AND SESAMOID FRACTURES

The posterior tibial tendon is vital for maintaining the foot's arch. Its dysfunction can lead to arch collapse and pain, sometimes requiring fusion of foot bones (arthrodesis). Stress fractures, particularly in the navicular and fifth metatarsal's watershed zone, are serious and often linked to nutritional deficiencies or relative energy deficiency in athletes. Bunions, a deviation at the first metatarsophalangeal joint, may require osteotomies and can be exacerbated by tight footwear.

HEEL PAIN AND TARSAL TUNNEL SYNDROME

Heel pain can stem from various sources, including plantar fasciitis, Achilles tendinitis insertion, or stress fractures of the calcaneus. Nerve compression, similar to carpal tunnel, can cause tarsal tunnel syndrome. Additionally, pain originating from the S1 nerve root can present solely as heel pain, emphasizing the need for a thorough diagnostic approach to pinpoint the exact cause of discomfort.

CHOOSING AN ORTHOPEDIC SURGEON AND PATIENT EXPECTATIONS

Selecting a competent orthopedic surgeon involves assessing their listening skills, clarity in explaining procedures, alternatives, and potential complications. A surgeon should provide a realistic outlook on recovery, outline risks, and offer a plan for managing post-operative issues. Open communication about personal risk profiles and outcomes from the surgeon's own practice is crucial for building trust and ensuring appropriate care.

Mentioned in This Episode

●Products

●Tools

●Organizations

●Concepts

●People Referenced

Common Questions

Developmental dysplasia of the hip (DDH) occurs when the hip socket (acetabulum) doesn't form properly, often because the femoral head (ball) is not concentrically reduced in the socket during fetal development or early childhood. A shallow socket leads to uneven pressure distribution and 'edge loading,' which mechanically overloads the cartilage and can cause arthritis over time. Early diagnosis, often with ultrasound, and interventions like the Pavlik harness are crucial for proper hip formation and preventing future arthritis.

Topics

Health & Longevity Human Performance Science & Mathematics Physical Therapy Tendon Health Sports Injuries ACL Reconstruction Hip Pain Orthopedic Injuries Knee Pain Ankle Sprains Joint Replacement Fracture Management

Mentioned in this video

personBo Jackson

A famous athlete with a well-known hip dislocation injury, mentioned as an example of rare hip dislocations.

supplementPlatelet-Rich Plasma (PRP)

A biologic therapy using a patient's own concentrated platelets to promote healing. It is effective for some conditions like tennis elbow and gluteus medius tears, and knee arthritis.

organizationFederal Trade Commission (FTC)

A US government agency working to crack down on deceptive advertising related to stem cell therapies.

conceptfemoral neck

A part of the proximal femur, prone to stress fractures, particularly in specific locations.

toolultrasound

A diagnostic imaging technique increasingly used by orthopedic pediatric specialists to quantify hip positioning and ensure the ball is properly seated in the socket in infants.

conceptDynamic Neuromuscular Stabilization (DNS)

A training philosophy that includes exercises like the DNS star position, which eccentrically and concentrically loads hip adductors.

organizationNYU

New York University, where a colleague conducted a study on misleading stem cell therapy websites.

conceptCMS

Centers for Medicare & Medicaid Services, also involved in regulating misleading claims about stem cell therapies.

studyMRI

The gold standard for detecting stress fractures in the femoral neck, showing bone marrow edema or lesions and sometimes a crack.

supplementHyaluronic Acid

An injection used for arthritis in the knee, showing better long-term results than cortisone, and potentially offering a disease-modifying effect when combined with PRP. Can be used off-label in the hip.

conceptpolyethylene

Material used for the plastic liner in total hip replacements and as a component in knee replacements. Its wear is a limiting factor in joint replacement longevity.

conceptPosterior Tibialis Tendon

An incredibly important tendon for maintaining the arch of the foot, prone to attrition and a cause of painful arch collapse.

organizationFDA

The Food and Drug Administration (US regulatory body) that has a strong warning against unapproved stem cell therapies, regulating the use of human cells and tissues.

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