Labral Tears and Hip Preservation

Episode 28 - Labral Tears and Hip Preservation

[00:00:00] Cory Leman: Welcome to IBJI's OrthoINFORM, where we talk all things orthopedics to help you move better and live better. I'm your guest host, Corey Lehman. I oversee the personal training and wellness services for IBJI. Our goal with OrthoINFORM is to provide you with an in depth resource about common orthopedic procedures that we perform and see how they work.

Today, it's my pleasure to welcome Dr. Andrew Riff, a board certified, fellowship trained orthopedic surgeon who specializes in hip arthroscopy, hip preservation, and sports medicine. Upon receiving his medical degree from Georgetown University School of Medicine in 2011, Dr. Riff completed an orthopedic surgery residency and sports medicine fellowship at Rush University Medical Center.

During his fellowship, Dr. Riff was an assistant team physician for the Chicago White Sox, Chicago Bulls, Chicago Fire, as well as DePaul University. Dr. Riff joined Hinsdale Orthopedic in 2019 after practicing at Indiana University Health. So Dr. Riff, welcome. Great to be here with you. And today we're talking all things hip, which is obviously your specialty.

[00:01:16] Dr. Riff: Thanks very much, Corey. I appreciate you having me and putting this all together. Um, yeah, I could talk about the hip all day. I usually do, I suppose. Awesome. I

[00:01:24] Cory Leman: love it. So let's dive in real quick. What do you see the most of in terms of just hip injury, things that bother people, what's coming to you and what do we need to know?

[00:01:36] Dr. Riff: Yeah, so I am an orthopedic surgeon who specializes in sports medicine and generally that That means arthroscopic surgery of the knee, hip, and shoulder. But I have a particular interest in hip arthroscopy, and that constitutes probably about 50 percent of my surgical practice. And so what I see primarily are teenagers and young adults with hip pain.

They're young. There are a lot of hip surgeons out there who do nothing but hip replacement. That probably constitutes, you know, 90 percent of hip surgeons out there. , and so I am one of the few that, uh, has a particular interest in hip preservation surgery, where we are trying to keep, your hip, keep all your parts intact, , and hopefully not even proceed with surgery.

But, , in most cases what that means is pain that is localized Deep in the groin, , most patients are a little surprised to hear that. They, you know, and it can make the diagnosis a little bit challenging. Um, on the lateral or outside part of the hip or deep in the butt. That's where hip joint pain is generally felt.

And in most cases, this is pain that comes on without trauma. Um, you know, there are some traumatic injuries that I will treat, but more often than not, when I'm seeing hip pain, it is, uh, something that comes on slowly and gradually and, , is the result of an underlying anatomic abnormality within the hip.

Most of the problems that I treat stem from a structural deformity to the way that the hip is structured. And so many patients are shocked to hear it. They'll come into the office and they'll say, I don't need x rays. I don't think I've got a fracture. But what we're really looking for is to try to see What the morphology or architecture of the hip joint looks like and how that plays into the injury that they are now developed.

[00:03:24] Cory Leman: Okay, you said a couple of things there that actually really interest me because I feel like I have a lot of conversations with people where they'll say something like, I have this pain. In the front of my hip, like you just alluded to, that groin region. Or they point to that, that outside area of their hip.

Is it possible that, that pain presents itself differently for people like that could actually be the same injury or if is there usually something that's going on like if I feel that pain in the front of my hip is that typically indicative of a certain hip condition?

[00:04:03] Dr. Riff: Yeah, it's a really great question.

When patients experience hip joint pain, it is Almost a different experience for every patient. , and , hip joint pain, you know, 95 percent of cases of hip joint pain can be attributed to either hip osteoarthritis, hip impingement. Labrum tears and hip dysplasia. That really kind of runs the gamut.

[00:04:26] Cory Leman: So those, I, I'm pretty familiar with arthritis and I think most of our listeners probably are. What is that second one you mentioned, that impingement, what, what's, what is being impinged in the hip that's causing pain?

[00:04:38] Dr. Riff: Yeah. So we talked about how, you know, frequently there is a structural abnormality to the way that the hip is, is formed.

And in many cases, this is a combination of a, of genetic factors and. , exposure to certain activities. But there are sort of two varieties of impingement. There is what we call pincer impingement, which is an overly deep hip socket that leads to reduced clearance for the ball in moving within the socket.

Or, cam impingement, which is an A non spherical or kind of egg shaped femoral head, the upper part of the femur bone, uh, that leads to abnormal bumping of the edge of the ball on the margin of the socket. And majority of cases have some combination of both, um, but in essence, it's, you know, irregular bumping of the edge of the ball on the margin of the hip socket when patients lift their leg up in front of them.

[00:05:26] Cory Leman: And is that, is that causing pain because that bone is rubbing against Cartilage or how does that work? Exactly

[00:05:36] Dr. Riff: right. Yeah. So it, you know, it catches all of the structures that kind of live in between the two bones together. Um, and in most cases that is the combination of the labrum, which is sort of a soft tissue gasket seal that lives right on the margin of the socket.

, I tell patients it's kind of like a gummy worm that lives right on the edge of the socket. of the hip socket and kind of creates a seal around the ball. And then also the articular cartilage or cushioning within the joint, uh, sort of towards the rim of the socket that kind of gets pinched as well.

[00:06:05] Cory Leman: Now, you, you mentioned the morphology of, of the hip and some hips being like a, a deeper socket. Uh, how would I know, is that something that I have to have imaging on? And also, is there anything I can do that in my own power that changes? How that really, that, I guess, femur bone glides within the socket?

[00:06:29] Dr. Riff: I mean, obviously a question I receive almost every day, what can I do to change this?

And unfortunately by the time patients present with hip impingement, you know, they are who they are, you know, that, that is sort of the way that their bones developed. And like I said, there's a lot of genetic factors that may contribute. There's no supplement you can take that can alter the way that those bones are structured.

 You wouldn't know, I guess, unless you had an x ray of your hip, uh, which would clearly elucidate sort of the, um, anatomic abnormalities within the hip joint. Some clues are, are diminished hip range of motion. So frequently patients will come in to me and say, you know, Doc, I've had hip pain for three months, but I've always had, you know, quote unquote, tight hips.

You know, even looking back to my, you know, my days as a high school football player or cheerleader, volleyball player, you name it, you know, I've always had. You know, it's always been hard for me to get these hips to loosen up, and that can be often an indicator that there are some of those bony abnormalities that lead to premature bumping.

And what patients often attribute to soft tissue tightness has always been sort of an underlying, you know, bony restriction to the way that the joint can actually move.

[00:07:38] Cory Leman: Okay, so let's, let's just, let's play out a scenario here. Let's say I'm coming to you, doc, and I've got some, I've got some pinching going on in the front of the side of my hip, some pain.

Um, Where do we start? What does that look like? What are you looking for? And what would you advise me?

[00:07:56] Dr. Riff: You know, so generally I'll take a history initially and kind of get a bit of a story, but the clues that I'm looking for if I suspect a patient, you know, has had Uh, may have hip impingement or a labrum tear.

And again, the two kind of go hand in hand because it's that repetitive impingement that ultimately leads to the tearing of the labrum.

[00:08:14] Cory Leman: So what I'm, what I'm hearing you say is that impingement is almost like a prerequisite step that happens before. In most cases, you know, so you have what narrowing of that joint space or like you said that tracking and that's creating that impingement.

Exactly right. And then if that happens long enough, what you're saying is that can actually fray the cartilage or create a tear.

[00:08:36] Dr. Riff: That's exactly right. And, uh, you know, vast majority of cases are attributable either to impingement. or dysplasia. And dysplasia is an overly shallow hip socket. Again, sort of related to development.

The vast majority of those cases are attributable to positioning within, within the uterus during fetal development. So even before you're born, you're, you know, the dysplasia occurs. But, you know, it's that abnormality in the way that the hip or hip socket or ball is, is developed that ultimately contributes to these, these tears.

And so, you know, very frequently patients will ask me, You know, how the heck did I tear this labrum? I don't, I never did anything. I never, you know, fell off a ladder, was in a car accident, but I'm getting off track. The most common things that I'm looking for in the office on the history are, you know, chronicity of symptoms.

You know, frequently these patients will have had pain for a lengthy period of time. You know, by the time most of these patients reach my office, they have had pain for six to eight months at least, because in most cases, this is not a debilitating pain. People think they've, they've tweaked their hip.

They've strained a hip flexor and that will ultimately dissipate on their own and it's usually the fact that these symptoms are lingering that bring them to my office. And

[00:09:51] Cory Leman: what if they ignore those symptoms for longer than six to eight months? Let's say it's been three years, four years, five years. Is that obviously you want to, you want things to work well and you want to be pain free, but how problematic is that?

[00:10:08] Dr. Riff: You know, I will tell you, I mean, I don't know, doctors were the worst patients, but I will tell you, I've, I frequently take that approach myself when I have little, you know, orthopedic injuries, most things do get better. And I will tell you, you know, as it relates to hip labrum tears, you know, I don't feel there is an.

a major urgency in getting these treated. So I think it is appropriate in many ways to, you know, to ride, ride it out a little bit and see if it's going to turn the corner. Um, but yeah, once it's been present for six or eight months, I think. Certainly intervention is appropriate, and it's time to start thinking about what can I do to make this better.

Um, and so yeah, other complaints that we'll often hear are, you know, pain with prolonged sitting. That is probably the most classic symptom when we are seated. Our thigh bone kind of rotates up and kind of bumps against the margin of the ball or the margin of the socket and cramps. Pinches the labrum, um, and so the vast majority of patients with labrum tears will have discomfort when seated or with prolonged car rides.

Many patients will endorse pain when trying to cross their legs or lifting their leg up to put a pair of pants on. We'll also hear complaints of clicking or popping within the hip. That's a little more variable, but certainly a common complaint that we'll hear as well. And then difficulty with running or pivoting maneuvers.

It's a fairly common one.

[00:11:22] Cory Leman: So let's say I walk into your office. And I, you diagnosed me with hip impingement. I'm, from what you can tell, I don't necessarily have any labral tear yet, but I've got some discomfort there. What should I do?

[00:11:38] Dr. Riff: You know, so I tend to take a pretty graduated approach. You know, I, I feel that, you know, like we talked about, I don't, I don't think surgery is necessarily an urgency.

It's an, it should be a last resort for the bulk of our orthopedic conditions. A lot of this will depend on how severe your symptoms are, but in most cases, we'll start with a course of physical therapy. The goal of physical therapy is to strengthen the glute muscles, reduce soft tissue tension in and around the hip.

 So the main things that we're working on are, , Building the butt, we do that through bridge exercises, clam exercises, , mini squat exercises, you know, side lunges, , and then soft tissue mobilizations. I find that, you know, hands on treatment for hip impingement is really important.

Patients really respond well to massage. , dry needling, cupping, uh, those sort of modalities. And so I hear a lot of patients will say, you know, can I just do this on my own? I mean, absolutely. You can do the strengthening component on your own, but I do think if this has been lingering, it's, it is valuable to get in with your physical therapist to really get some of that hands on treatment.

Cause I feel like it can make a big difference in a lot of cases.

[00:12:44] Cory Leman: Talk to me a little bit about, like, it, it makes sense to me why the tissues Loosening in around the hip and the soft tissue work would bring relief. Why would strengthening something like a glute muscle, like what is that doing inside the joint that is providing relief?

[00:13:00] Dr. Riff: Yeah, it's a great question. , I think we, you know, it's a little overly simplistic in some ways, but I sort of think of the muscles as kind of the shock absorber for the joint. And the stronger those muscles are, the less pressure the joint will often feel. And the other thing is the, the labrum serves a role as a, as a, um, you know, like I said, a gasket seal or a, a seal that contributes to stability of the hip joint.

And I think that the stronger the muscles are in and around the hip, the more stable the joint becomes because it, that soft tissue enclosure is able to kind of prevent the, the ball from subtly moving, uh, within the socket in a way that we're, we're hoping to avoid.

[00:13:38] Cory Leman: Yeah, no, that makes, that makes a lot of sense.

Take me to that next phase though. Let's say I've moved beyond impingement and through. And, and I guess this is another question. On a labral tear, is that something you have to have imaging for, or can you usually tell without imaging? Okay, this is a tear.

[00:13:58] Dr. Riff: You know, in most cases, I have a strong suspicion after, after talking to a patient about their symptoms, examining them, seeing kind of what provocative maneuvers or rotational maneuvers of the hip cause discomfort on my exam.

And then looking at their x rays, you know, that for me is 95 percent of the equation. You know, usually before we start to do more invasive treatments, you know, injections and potentially considering surgery, we do often get an MRI to, you know, confirm our suspicions and also to rule out, you know, other potentially worrisome conditions.

You know, there, there can be a lot of crossover. We'll frequently see patients that have, may have a labrum tear, but they also have a stress fracture in and around the hip and we want to make sure that before we charge in there and, and scope the hip tube. Treat a labrum tear that they were not just missing a stress fracture and that's been a different problem all along.

[00:14:50] Cory Leman: Now that's, is that something that you would see commonly? Is there an age demographic you would see that stress fracture in? Because that's something I, I, I didn't know. I'm learning here as well with our listeners, but like, tell me in what cases you're noticing Oh, this might actually be a stress fracture.

You

[00:15:09] Dr. Riff: know, it's not terribly common, but it's often that kind of middle aged, , 30s and 40s, you know, weekend warrior who is trying to ramp up their running and is experiencing pain in the groin. And, that frequently can be the consequence of a labrum tear, or it could be, you know, a femoral neck stress fracture.

And, you know, it's a relatively rare diagnosis, but it's one you don't want to miss. So that's oftentimes a reason that we'll get the scan.

[00:15:33] Cory Leman: And then all the more reason to, to obviously pay attention to what your body's saying, right? Because, , it can compound. Okay. So if, If I come in and, and we determine that, all right, I have some type of tear, , What is that first step?

In your opinion, are we going to some type of injection? Are we surgery? Does it just depend? How do you make that decision?

[00:15:58] Dr. Riff: You know, so I'm a big believer in kind of shared decision making. There's no one size fits all approach within orthopedics. And patients come in with a strong sense of kind of the direction that they ultimately want to go.

And, you know, I'm just here to kind of facilitate the treatment that best fits the patient. And so, you know, in most cases, like I said, I think physical therapy is probably the least invasive strategy that is most likely to render a lot of improvement. But once we've gotten to a point where, you know, Where PT is not helping, or patients are just in too much pain to con consider, you know, to consider further physical therapy.

You know, my n my next line of defense is either, you know, an injection of some variety or consideration of surgery. And again, a lot of it comes down to the patient's goals. You know, we'll frequently see I treat a lot of high school athletes and college athletes and, you know, many of 'em will come to me, midseason and sort of say, you know, doc, I, I.

It's my senior year on the football team. I really love to get through the season. I've got another kid, he's a college football player, you know, came to me in October. His team was doing great. He was there starting running back. You know, he has aspirations of hopefully playing in the NFL. And, uh, you know, wanted to get through a season.

Like I mentioned before, I, you know, in most cases, I don't, I don't see surgery as a major urgency. So, frequently, For patients who are not performing at their level, but have, you know, near, near term hopes of performing at a high level, you know, an injection of cortisone can make a huge difference. And so that's often a strategy we'll take on, you know, and Majority of cases, it's not a definitive fix.

It can offer really lasting relief, but that can be a nice next step. Other patients, you know, maybe due to preconceived ideas about injections, you know, or poor experiences with injections in the past may come to me and just say, you know, doc, it's been going on long enough. I've tried the therapy. I'd rather you just consider surgery to repair it.

[00:17:52] Cory Leman: Yeah, and I'm glad you mentioned that because I often find myself asking this question and talk with a number of individuals in the health and fitness field. What are the drawbacks of something like a cortisone shot? Like if you went that route, is there any type of, you know, things that I could expect?

in terms of negative side effects?

[00:18:16] Dr. Riff: You know, yeah, so in medicine in general, you know, there's no free lunch anywhere. You know, there's, there's no intervention that doesn't have some element of a drawback, but I, I generally feel that the cortisone injections are quite safe. You know, I personally have had some hip pain for about a year and a half.

You know, it, it has, it's never been terribly severe, but has limited my ability to run. I labrum tear. Like I said, not horrible, but about six months ago decided to pursue an injection because, you know, I've seen what benefit some of my patients have experienced and it helped me a ton. It reduced my symptoms by about 95%.

Got me back to a point where I could play tennis four or five days a week and run and, you know, as long as my symptoms remain at this level, I'm never taking things any further. You know, I think ultimately, One or two injections are quite safe. When you talk about repetitively injecting a joint, you start to worry that that cortisone, um, can cause tissue atrophy.

And the tissue we're worried about in the joint is the cartilage. And I think there are certainly some good basic science studies that demonstrate if used excessively, you know, in animals, you know, we do see cartilage deterioration in that joint. And so, you know, I tell patients, you know, One or two injections prior to surgery, quite safe.

But if you're at a point where you're needing three or more injections, you probably should start to consider what can I do to definitively repair the problem.

[00:19:41] Cory Leman: Yeah, I actually really like to hear that because I feel like as a patient, then You know, okay, this, this shot is giving me relief for a period of time, but not only is it doing that, it's also telling, it's giving me more definitive answers, right?

It's giving me a clearer path to, okay, this is worn off, um, I still have this pain, okay, maybe surgery is, Or maybe one more shot and we'll see, but I like how it does sort of provide a roadmap and, you know, just buys you more time as

[00:20:14] Dr. Riff: well. Right. You know, exactly. I, I frequently use injections to kind of, you know, separate a serious problem for a transient.

If an injection affords good temporary relief, but the pain returns, it's a good clue that this problem is, you know, significant enough that we may need to consider doing something more invasive.

[00:20:34] Cory Leman: Let's say we go that route. Now we're like, all right, doc, I'm ready for, I'm ready for surgery and you've got to do a scope on my hip.

Talk me through what that looks like. What do we normally see? What does that entail? How much are you? Scoping out walk me through the dirty details here.

[00:20:52] Dr. Riff: You know, so the procedure is done arthroscopically like you mentioned kind of two small poke holes, each about half an inch or so in length. , one of those is for our camera.

One of those is for our instrumentation. The goals are sort of threefold. The first procedure is to repair the labrum and in most cases that is kind of reinforcing its attachment to the bone on the margin of the hip socket. And that is done utilizing little devices called suture anchors, they're plastic screws that get embedded in the margin of the socket.

They have stitches attached to them that we loop around the labrum to sew it back to the edge of the socket. Um, and then, we re contour the foot. Both sides of the joint to remove that overhanging bone on the margin of the socket, if that's the patient's problem, or in more case, more often, recontouring the periphery of the ball to eliminate that, , that cam impingement, or that, , aspherical portion of the ball that's been impinged.

That's putting pressure on the margin of the socket. And then we're closing the patient's joint capsule. That's sort of the soft tissue envelope that kind of maintains hip joint stability, another contributor to hip stability. So it's important to kind of close that capsule to reduce the likelihood of hip instability after the procedure.

And that's something that has, you know, really come up, come to, you know, become pretty clear in the last 10 years or so in our sports medicine literature. historically when this procedure was done, you know. Patients, or surgeons were repairing the labrum and recontouring the ball, uh, but not all surgeons were repairing the capsule and so patients were experiencing ongoing instability and so, you know, I think, at this point, I think the vast majority of surgeons are doing it, but it is an important question for patients to ask, you know.

of their surgeon, are you going to repair the capsule after you complete the procedure?

[00:22:38] Cory Leman: Yeah, I know. I think that's obviously really helpful. Hip pin stability doesn't sound good to me. I want to make sure, especially if I'm getting surgery, you know, we're getting this cleared up. And in light of that, what can I expect in terms of recovery?

How long are we getting back to pre treatment? Injury levels of activity pain free.

[00:23:03] Dr. Riff: Yeah, so the, you know, the procedure generally is a pretty straightforward recovery in most cases. You know, it, again, it's, it's nice that the, the incisions are small. The risks are low. I tell patients, you know, the risk of infection, blood clot, neurovascular injury, a lot of the things that patients worry about as it relates to surgery in general are, are at.

Quite minuscule with this procedure. , the biggest downside of this procedure is just, you know, like most things, the recovery and, , the, the first three weeks or so patients are on crutches. They can bear the weight of the leg on the ground, but avoid, , full body weight. They're working with their therapist between weeks three and four to kind of get off of crutches and start walking normally.

The biggest drawback is it's a longer recovery than most patients anticipate as it relates to getting back to full activities. So you know, it has a high success rate in vast majority of cases. It cures the pain definitively and allows patients to get back to all of the activities that they desire to return to.

But usually it's, you know, about four months before patients are ready to return to running and usually five or six months before they're returning to, you know, cutting, jumping and pivoting sports. So part of the reason we don't take the procedure lightly.

[00:24:15] Cory Leman: Have you ever gone in on a surgery and Thought to yourself, wow, this is something that should have been operated on a lot sooner.

Like is it, is a labrum tear something that you can make a lot worse and cause degeneration? Or is it like, Hey, if it's torn, it's torn. It kind of is what it is and we'll fix it when we fix it.

[00:24:37] Dr. Riff: Yeah. That's a great question. Cause you know, the, in most cases it is the, in patients who have A larger cam deformity or a bigger deformity to the ball side of the socket, uh, that I, that I tend to believe that.

We recognize that that bigger cam is a major risk factor for the development of labrum tears, but it's also a risk factor. udoor actually pertains to the mobility, sports performance, the We frequently will ask, particularly young men who are more likely from a demographic standpoint to develop, cam deformities, , if anybody in their family has, , had a history of hip trouble and those young men with a really big cam, vast majority or you know, it's, it's not an uncommon occurrence where they will say, you know, actually my dad just underwent a hip replacement in the last, you know, couple years and, and largely that's because that cam deformity.

That is now causing their labrum tear has led to the evolution of arthritis in their father. I frequently tell patients with those big CAMs, I would, I'd rather address it in your teens than your twenties. I'd rather address it in your twenties than your thirties. And by the time most guys with a big CAM.

Come to my office in their 40s, it's pretty typical that they will start to exhibit some signs of osteoarthritis and that's not something we can generally cure with the scope. Um, and so, you know, it's against that old adage, you know, an ounce of prevention is better than a pound of cure. You know, we like, that's where that term hip preservation comes in.

Our goal is to hopefully, you know, address these before they become so problematic that patients ultimately require a hip replacement.

[00:26:21] Cory Leman: Well, and that's, I'm glad you went there because that's my next question for you is like, when is that, uh, next phase? Like, okay, this is not a labrum repair anymore. Like, there's nothing that can be really be repaired at this point.

It's, we got to get to a replacement. Yeah. When do you see that?

[00:26:39] Dr. Riff: You know, it's often a harder decision than you would often, you'd often realize. My, my job is mostly kind of dealing, dealing in the shades of gray. You know, patients, Patients in their teens and 20s it's usually an easy call that, that arthroscopic surgery is kind of the way to go.

Uh, patients in their, you know, 60s and 70s, it's usually a pretty easy decision that replacement is the way to go, but oftentimes it's those patients in their, you know, 40s and 50s that come in and they have, they have hip impingement, they have a labrum tear, but they also exhibit some signs of early joint space narrowing or a little cartilage erosion, you know, to the articular cartilage on the interior of the hip joint that we have to kind of make a judgment call on which is the better route to go.

And there are a couple of factors that we look at, you know, if patients have. Normal joint width on an x ray is about four millimeters in the hip. Um, if they, if patients have less than two millimeters of joint space, uh, within the hip joint, the likelihood of success with a, with an arthroscopic procedure is pretty low.

So we're, we're likely going to, you know, push them more in the direction of further conservative treatment or, you know, consideration of a replacement at that point. If their x rays look pretty good and they've got a little bit of early cartilage wear on the MRI, you know, we may. We may kind of, you know, for lack of a better word, roll the dice and say, Hey, let's, let's try a scope here and see if it does the trick.

And, you know, it's possible that that early cartilage wear could catch up to you down the road and replacement may be in the cards, but patient symptoms may be severe enough to warrant a scope at that time.

[00:28:10] Cory Leman: And if I do go to that, uh, full blown replacement, what does that look like afterwards? Uh, In what ways will I be limited?

In what ways will I feel like I have a new lease on life? Yeah.

[00:28:25] Dr. Riff: You know, so in some ways I tell patients almost every day, I wish I did hip replacement because it is one of the best operations we have in orthopedics. It has a, an unbelievably high rate of patient satisfaction. And for most patients who undergo a hip replacement, you know, it's a common.

It's a great question. You know, the benefit is that it generally feels like a normal hip and patients walk out of the hospital in most cases, you know, without a brace, without crutches and they're pretty comfortable. There tend to be walking surprisingly well. Which is incredible. It's shocking. It's shocking.

My uncle had his hip replaced a couple of years ago and I walked out of the hospital with him and he said, you know, I can already tell it feels better and, you know, it's just, that's not the case in my world for, for the arthroscopic hip procedure. You know, it's generally a little bit of a recovery.

Patients don't feel better immediately in most cases. Um, but again, it does allow you to kind of keep all your parts and we don't worry about it. those parts necessarily wearing out in the way that we worry about the metal and plastic prosthesis of a, of a hip replacement wearing out. And so, you know, in most cases are, you know, I defer to my, my joint replacement colleagues in, in outlining the restrictions afterwards.

 We tell patients, you know, those parts are made of metal and plastic and they can wear out. And so, you know, repetitive pounding is something that is pretty common. is probably something you want to avoid. Running and jumping are not things that you should be doing in high volume after a hip replacement.

 Living here in Chicago, we all know kind of the saga of Bo Jackson, you know, got back to playing pro baseball after having his hip replaced. And there's a reason that he's on his, you know, fourth hip replacement at this point, because those, those parts are not perfect, you know, and so.

[00:30:09] Cory Leman: Okay. So then that, I think that's a good analogy and good to remember too.

Like, okay, just because this is metal and plastic doesn't mean that it's going to be durable forever. It's like anything, right? Exactly. Um, okay. So we've talked about hip labral tears, stress fractures, replacements. What else are you seeing with the hip? Like what would be something else common?

[00:30:32] Dr. Riff: Yeah. So we, I also treat a number of You know, tendon problems in and around the hip. So while the vast majority of hip problems that we see are, you know, pain localized kind of deep within the groin or deep in the buttock that is, you know, attributable to the hip itself, there are, there are a couple of hamstring or a couple of tendon problems, namely the hamstring and the gluteus medius and minimus tendons, uh, that can be sources of kind of chronic hip joint pain.

Um, you know, that hamstring pain. Most cases are the result of an acute trauma, you know, a patient in their 40s, 50s, or 60s who is playing a sport and Take, you know, slips or you know, lunges and feels a pop over the, in their buttock. Their leg turns black and blue and, you know, they've pulled the, the hamstring tendon off of the sit bone or the ischium bone in their pelvis.

Uh, the. That's usually, you know, a jarring enough event that most patients will know something's awry and they'll seek an opinion and an MRI is quickly around the corner. You know, the more insidious problem that we'll see are these gluteus medius and minimus tendon tears on the outside of the hip.

That's usually kind of, you know, Chronic lateral hip pain or pain more on the outside part of the hip, uh, and that is pain that again, similar to the labrum, kind of comes on slowly and without, uh, a specific trauma per se. What causes something

[00:31:59] Cory Leman: like that?

[00:32:00] Dr. Riff: You know, and it's, it is one of, you know, many, Tendons that are afflicted throughout the body by a process called tendinosis, which is a chronic degeneration of the tendon.

And I frequently tell patients that our tendons are like the rubber bands that connect the muscles to the bone. And in the same way that we've all, you know, stretched a rubber band a thousand times and ultimately seen it snap, your tendons can kind of go through that process as well. You know, everything that we do in our day to day life causes strain through our tendons.

And, you know, as we get into our 30s, 40s, and 50s, our repair mechanisms kind of slow down a little bit and our ability to heal little micro tears within the tendon diminishes and there is the potential that those little micro tears can aggregate and form initially partial thickness tears where part of the tendon will peel off the bone and then eventually full thickness tears where the tendon will fully peel off the bone and those full thickness tears can be very painful and they can lead to In the case of the gluteus medius and minimus, they lead to a limp, they lead to pain laying on the side, uh, they lead to difficulty climbing stairs, and they lead to a significant degree of, of gait imbalance or, or difficulty,

uh, walking on irregular

[00:33:15] Cory Leman: terrain. Would something like that impact the hip socket? Like, can these conditions play on each other?

[00:33:22] Dr. Riff: They definitely can. You know, and I, like we talked about earlier, when, when patients present to me with a hip joint problem, you know, Building those glute muscles can be very important, you know, and it can help to reduce that joint related pain.

Uh, and so frequently I think that in patients who have maybe a little early arthritis and a, a glute tendon abnormality, you know, partial or full thickness tear, you know, obviously it's going to be harder to build that muscle if the tendon is torn. Uh, and so it can, it can limit the efficacy of kind of physical therapy as a potential strategy.

[00:33:54] Cory Leman: No, that makes sense. Talk me through a little bit about, um, Lifestyle, habits and choices. Are there things that we are doing today, um, just generally speaking, that maybe aren't good for our hips? Or we need to be aware of, like, how, how are these things, obviously genetics play a role, obviously your activity, you have acute trauma, things that happen, but, you know, for some of the more chronic or ongoing things that develop over time.

Are there things we can do to prevent it?

[00:34:26] Dr. Riff: Yeah, it's a, it's a really, really good question. I rack my brain on this every, every single day. You know, what can I tell patients to, to do to just maintain their joints, you know, for the better. And I think, you know, as we get into our, So within our thirties and forties we all tend to see a fair bit of uh, deconditioning of our core.

I think we all, you know, tend to neglect our core a little bit and I think their, the core tends to be kind of essential to the health of the lower extremity in general. Um, you know has a major contributor to the potential for knee and ankle injuries as well. And so spending that little bit of extra time in the gym, you You know, working on your core and your glutes, I think, is really essential.

Um, yeah, I've noticed that, you know, you know, again, with my little hip issue that I've had over the last couple of years, you know, being conscientious about, you know, building those, those bridge exercises, clam exercises, you know, prone kickback exercises, all those things really help to, you know, optimize the core.

lower the risk of lower extremity injury and, you know, just generally help to, you know, prevent, I think, falls later in life as well. So, you know, as we get into our 60s and 70s, you know, the most catastrophic thing that can happen to really set you back is, you know, a fall and a fracture. And I think having good core and pelvic control helps to limit that risk as well.

[00:35:48] Cory Leman: No, absolutely. What about in terms of Sitting. I know there's a lot of discussion around just the postures we assume. Does any of that have an impact from a, from an expert, from a physician standpoint, you know, Is there things we should be doing? Should we be changing positions? Should I get a standup desk?

Should I not be sitting? What do you think?

[00:36:13] Dr. Riff: Yeah, it's tough. I mean, we're all sort of, , beholden to the man we've all got. We've all got jobs and we have to provide to our, provide for our families. , and there are certain jobs that you just can't avoid, you know, the amount of sitting that we're doing.

 At the outset of the pandemic, you know, I think we were all sitting a little bit more and I, I do think I saw a little bit of an uptick in the amount of impingement that. In the office as a result of, you know, that prolonged sitting, we talked about that earlier as a common complaint for patients with hip impingement.

 I do think that, a stagnant lifestyle is probably not at the, you know, at the benefit of our joint. So yeah, if you have the opportunity to have a sit stand workstation, I think that's probably best. You know, it , limits the, the, the work , risks of prolonged sitting as well as, you know, prolonged standing and time on your feet.

Um, but I do, you know, I recognize some of this is a little bit unavoidable.

[00:37:03] Cory Leman: So why do you, and this might just be anecdotal evidence, you know, from somebody who's spends a lot of time in the fitness and health space, but it seems like this whole Hip labrum, hip issue. It just seems like there's been, it's a lot more prevalent.

I don't know if it's because we're talking more about it because research has discovered or we know what to do, but is it just me or does it seem like

[00:37:27] Dr. Riff: Yeah, you know, so you're exactly right. , this diagnosis of hip impingement didn't Enter the medical lexicon until 2003. So it's really, you know, only about 20 years old.

Um, you know, this is a baby in terms of medicine entirely. And, you know, within the last, you know, 10 or 15 years, the number of hip arthroscopic procedures that are performed nationwide have increased. Probably about a hundred fold. , and so there's definitely a learning curve here. Um, we have, we're going through it as a group.

 There, it's been a major benefit. I, you know, I think there are a lot of patients who, and I see every day who regain immense quality of life through going through this procedure to some degree. At times, I do wonder, are we doing too many to some degree? But, uh, you know, that's why I think it's important to take sort of that graduated approach.

A lot of these do improve on their own just because you're diagnosed with a labrum tear doesn't mean you're destined to surgery. I think it's important to kind of go through the motions to some degree, but if your pain is severe and you're limited in your ability to do things. You know, I think you got to take, uh, take the next step and do what you need to do to reclaim your quality of life.

But you're exactly right. You know, hip impingement, , is a name that just, a term that wasn't thrown around years and years ago. Similarly, the glute medius tears didn't really enter the medical literature, , until 1998. The number of glute tendon repairs that we're performing has dramatically increased as well.

 With that, um, Evolution, um, comes a major benefit to patients, , but I think in the next, you know, 20 or 30 years, our, uh, decision making on kind of who really needs these procedures will improve dramatically as well. Yeah.

[00:39:08] Cory Leman: It's good to hear. What, you've mentioned a few of like the exercises, some of the lifestyle things you do.

Um, is there any other things that you would Pieces to your routine or just your day to day that you do to kind of encourage hip health? Personally,

[00:39:23] Dr. Riff: I'm not a huge believer in stretching, , for hip impingement because it's a, an excessive contact of the edge of the ball and the margin of the socket. .

Stretching actually can be more harmful than beneficial. And so I had a young girl recently who came to the office and we directed her to physical therapy. And the one intervention that her therapist sort of recommended was avoid the excessive stretching that she was performing. And it essentially resolved her problem.

And so,

[00:39:52] Cory Leman: right. Cause that's not what you would normally think, right? Or that's not what we've been told like, Oh, stretch and this will feel better.

[00:39:57] Dr. Riff: You know, and the, the problem in, with hip impingement is, you know, is a, you know, excessive contact, but when the labrum tears, it leads to increased micro motion of the ball within the socket.

And so by stretching, you're actually kind of loosening the joint capsule, which I think can further, you know, worsen the instability to some degree. So, patients are often shocked to hear it, but the strengthening thing is the main thing. Yeah,

[00:40:25] Cory Leman: I'm encouraged to hear that and I think one of the main takeaways too that I'm hearing from you is like, if you're having that reoccurring pain, if you're having some of that stuff going on, just get it checked, right, and um, obviously you're a proponent of, and you've said it here, like, I'm not trying to rush into surgery, like, let's work on this together.

Right. If patients are listening, they're experiencing some type of hip issue, where can they come see you?

[00:40:53] Dr. Riff: Yeah. So I'm, you know, I'm a part of the, the Hinsdale division of IBJI or, um, we are, I see patients, um, in Hinsdale, Westmont and Downers Grove, um, in the office Tuesday and Thursday and Friday, and usually pretty happy to get people in.

Pretty rapidly I think most patients will say that they can get in with me within a couple weeks. So it's usually not a horrible process.

[00:41:14] Cory Leman: What's something that you do in your everyday life to help you move better and live better?

[00:41:21] Dr. Riff: You know my thing is, you know, use it or lose it. And, uh, as you kind of get into your 30s, I've got a young family, you know, it's easy to kind of put yourself last to some degree.

Um, and I think it's just important to try to, you know, recognize that this is an investment in your longevity and, you know, you got to kind of commit yourself to, to moving two or three days a week. And, you know, that doesn't have to be a real long process, but, you know, carving out 10 or 15 minutes just to kind of, you know, Get a little aerobic exercise and work on core strengthening I think are, are pretty essential and you know, for me, I notice it most in my mental health, you know, and the, the mental and physical obviously play off of one another, but the, you know, the more I'm able to kind of, you know, um, work out the sort of the better my outlook on life generally is.

[00:42:12] Cory Leman: Yeah, I like it. I couldn't agree more. Super enlightening. Thank you for sharing all of your expertise around the hip. This has been great. Thanks, Corey. Appreciate you.