General Discussion Triathlon Talk » Hip Labral Tear - Cortisone injection required before surgery? Rss Feed  
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2010-04-08 12:25 PM

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Subject: Hip Labral Tear - Cortisone injection required before surgery?
I'm in the middle of finding out whether I have a hip labral tear or not - the MRI is tomorrow. Based on my symptoms and lack of response to PT so far, my bet is on them finding a tear. I think the MRI injection will also include a lidocaine injection to the labrum itself - the pain will temporarily be gone if the labrum is the issue.

According to my orthopedist, if a tear is found, the next step is to have a cortisone injection to the hip to take the pain away. If/When the pain comes back once the injection wears off, then we talk surgery. However, he also said that he doesn't have much luck with the cortisone injection being successful in young, active people (not super-young anymore, but definitely active!).

My question is: has anyone gone straight from the MRI/lidocaine to surgery? Good idea? Bad idea? Is the cortisone really a required step, or is he  practicing 'defensive medicine', to make sure he covers all bases before surgery?

It's not that I don't trust the doctor (he came highly recommended from two separate sources and performs plenty of hip arthrograms), although I will certainly practice due diligence and get a second opinion, but if I'm going to end up in surgery, I'd rather get it over with!

Thanks for the help!


2010-04-08 12:36 PM
in reply to: #2777435

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Queen BTich
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Subject: RE: Hip Labral Tear - Cortisone injection required before surgery?
I would suggest you post this in the "Injuries & Sickness" forum. One of the moderators is an orthopaedic surgeon.

I'm in a similar situation, getting an MRI this week to rule out some fractures or Labral tear.

Good luck.
2010-04-08 12:38 PM
in reply to: #2777435

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Subject: RE: Hip Labral Tear - Cortisone injection required before surgery?
Thanks, will do. Somehow I missed that forum when looking down the list!
2010-04-08 2:29 PM
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Subject: RE: Hip Labral Tear - Cortisone injection required before surgery?
I've been through this process last year. It is far too complicated to diagnose a hip labral tear over the internet, but here are a few thoughts:
1. The test to diagnose this is as you described. It's called an MRI arthrogram.
2. Yes if its an intra articular process, then you will have pain relief with the injection.
3. Labral tears and FAI are generally complex to treat. Only a few surgeons in the country have the experience to deal with these arthoscopically.

Pm me if you have questions. BTW the MRI hurts a bit so be forewarned.

And good luck
2010-04-08 2:43 PM
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Subject: RE: Hip Labral Tear - Cortisone injection required before surgery?
I was just diagnosed with a hip labral tear this week and will be consulting with a surgeon soon, but my ortho and PT both essentially said that the injury is something that I can manage through strengthening the muscles around it and generally staying in shape.

Once it's torn, it's torn -- it's not going to get better and running isn't going to make it worse (depending on the scale of the tear, I assume). So, I figure I'll be conservative with how I use it and get a sense for how far I can push until the pain gets too intense. At that point, I'll think about the surgery which, as the previous poster noted, is something that only a handful of docs can do well.
2010-04-08 6:19 PM
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Subject: RE: Hip Labral Tear - Cortisone injection required before surgery?
It is true that when the cartilage is torn it will not heal without surgery.

However, there is a concern for osteoarthritis with the tear. What happens is that bone rubs on bone. There is not definitive data on this but most of the elite orthos doing the arthroscopic surgery favor early intervention to avoid arthritis.

So basically the suggestion is to alter lifestyle (not running or doing activities that do not worsen the problem) and strengthen the hip muscles.

If you have a labral tear I respectfully submit that you are taking on a risk of arthritis if you continue to train without the corrective surgery.


2010-04-08 6:37 PM
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Subject: RE: Hip Labral Tear - Cortisone injection required before surgery?
I have labral tears in both hips. My PT, regular orthopedist, as well as a hip surgeon all have recommended that I use PT and conservative measures for as long as possible and avoid surgery if I can.

I have no issues with surgical correction, but the hip is a tricky area.
2010-04-09 6:03 AM
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Subject: RE: Hip Labral Tear - Cortisone injection required before surgery?
I was told the MRA was going to hurt really bad, I had two. The first was a breeze no pain at all just pressure and the second was at a different hospital and was a little uncomfortable but not to bad, again just pressure from the fluid they inject. The cortisone shot only gave me relief for a couple of days.

I had 3 laberal tears and a broken femur head, and a torn femoral artery from a fall at work. There's only a few doctors in the country that can do the surgery to repair everything and I wasn't sure I would be running very well again after this accident.

Surgery was a year ago January and I'm finally back to running and training for a sprint in June. Get the right doctor and get it fixed. Do the PT and don't get in a hurry and you will be good as new.

Tracy

Tracy
2010-04-09 7:20 PM
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Subject: RE: Hip Labral Tear - Cortisone injection required before surgery?
Actually the arthroscopic procedure has been out for a while, but isn't that commonplace.  If all they're doing is trimming the cartilage back, it's as simple as a knee scope ... kinda.  When I was an orthopaedic rep, I only did 3 in two years.  PM me if you want the company name I rep'd for.
2010-04-09 7:27 PM
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Subject: RE: Hip Labral Tear - Cortisone injection required before surgery?
wkrives - 2010-04-09 8:20 PM

Actually the arthroscopic procedure has been out for a while, but isn't that commonplace.  If all they're doing is trimming the cartilage back, it's as simple as a knee scope ... kinda.  When I was an orthopaedic rep, I only did 3 in two years.  PM me if you want the company name I rep'd for.


Unfortunately there are still only a handfull of experts who have really good results with cartilage tear or FAI injuries.

Mark phillipon is the king. He is in Colorado.

I expect in the next decade it will become more readily available, but definitely don't have the surgery unless you are seeing someone who has good numbers and results.

I also second the notion that PT is a key part of recovery.

I haven't gone through this, but researched it extensively last year.
2010-04-09 9:10 PM
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Subject: RE: Hip Labral Tear - Cortisone injection required before surgery?
Personal preference, but...I'd let most orthos do a simple knee scope. The number of folks I'd let scope my hip is way, way smaller.

When it comes to joint replacement, hips lead knees in advances and how athletic you can be...when it comes to scopes, it's def, reversed.


2010-04-09 10:31 PM
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Subject: RE: Hip Labral Tear - Cortisone injection required before surgery?
PennState - 2010-04-08 4:19 PM  . If you have a labral tear I respectfully submit that you are taking on a risk of arthritis if you continue to train without the corrective surgery.


this is actually a pretty common misconception ... a labral tear in your hip is not very likely to increase your risk of arthritis.  (and even if it did, we're talking on the order of tens and tens of years before any significant degenerative joint disease is seen.)  the labrum doesn't act in a manner similar to a meniscus and doesn't really 'protect' the articular cartilage or provide shock absorption/force distribution as a meniscus does.  the most common form of degenerative joint disease is osteoarthritis, which results in inside-out wear, meaning that the very center point of contact (in the hip, for example) or your femoral head and the apex of the dome of your acetabulum are the first to wear.  this pattern works its way outward, usually somewhat symmetrically in cases of hips, within the joint, as time goes on.  (rheumatoid arthritis is a whole different ball game and the cartilage and jointspace destruction there starts on the outside/periphery for very different reasons than those seen in osteoarthritis.)  since the labrum is basically a near-circumferential bit of tissue essentially there to deepen the "socket," so to speak, it is only typically in contact with the periphery of articular cartilage on the femoral head -- and not really influencing the acetabular articular cartilage at all.  

also -- very very much in agreement with mmrocker.  a hip scope is a very highly technical procedure.  pretty much any orthopaedic surgeon (and most residents beyond their 2nd or 3rd year in training) can stick a scope in a knee and not do much damage, trim out some meniscus, etc.  many can also get into a shoulder and do similar things -- repair a SLAP tear, address a Bankart, etc.  fewer can get into a shoulder and do it well than can get into a knee.  now take the orthopaedic surgeon population and apply it to hip arthroscopy.  VASTLY fewer surgeons can do this and do it competently.  knees and shoulders are cake compared to hips.  most require some sort of fluoroscopic guidance (xray) to even get into the hip and in the correct position.  moreover, in order to scope a hip you (the patient) need to be in traction, which brings with it an entirely different set of associated surgical risks.  

if you're even going to head down the path of considering operative measures to address your acetabular labral tear, do your research on who does them and who does them well.  at the very least, make sure it's someone who is subspecialty trained in sports, for starters, and who *regularly* does hip scopes.  and lots of hip scopes.  many surgeons can do much more damage and make you feel worse, rather than better.  and if they try to address any femoral-acetabular impingement (FAI) on top of things (with bony resection procedures, if impingement is the issue,) when done incorrectly, these procedures can completely destabilize the hip/soft tissue balance and run things completely out of whack.  

my recommendation is always - always - try physical therapy and exhaust all conservative measures first before even considering going to arthroscopic repair or debridement of a hip labral tear.  if your issue is femoral-acetabular impingement, however, this may be an entirely different ball of wax; be sure to address this with a sports orthopod who does a ton of hips.  

good luck!  



Edited by novas 2010-04-09 10:37 PM
2010-04-10 7:22 AM
in reply to: #2777435

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Subject: RE: Hip Labral Tear - Cortisone injection required before surgery?
Thanks everyone for the input. I just had the MR-arthrogram yesterday and I did get pain relief with the numbing injection. I'll know more when I have a follow-up meeting with the ortho on Tuesday. The numbing and dye injections were uncomfortable, but not that bad; my hip was definitely sore the rest of the day and a little bit sore still this morning.

I'm assuming the doctor will recommend a cortisone injection next. I'll try it out and hope that it works for at least a short period of time. I'll be interested to see what he thinks about continuing to exercise with the injury as it currently stands. I've backed off from biking and running because of it, but if the pain is manageable and I'm not doing further damage, maybe I can put this off a bit. Somehow it feels a bit strange to be going for surgery for pain that isn't that strong (even though it has significantly impacted my lifestyle with the no running, biking or skiing!).

As for researching doctors, most of the info I've found so far is mentions by posters to various message boards. Maybe this is a dumb question, but how do I find out about different doctor options? I'm in the Boston area, so I'm lucky enough to have quite a large pool. The ortho I'm currently seeing is Scott Martin at the Brigham. He was recommended to me by two separate people (my PT and a doctor friend who is not an ortho but deals with related issues) as the right doc. Obviously I'll be asking him how many and how often he performs hip arthroscopies and with what sort of results. Any other suggestions for good docs in the Boston/New England area?

Again, thank you all for the help!
2010-04-15 8:14 AM
in reply to: #2777435

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Subject: RE: Hip Labral Tear - Cortisone injection required before surgery?
Just a quick update - I met with the doctor on Tuesday and he confirmed the tear. But since the pain level is so low at this point, he said to just go ahead and work back up on the cycling and running and see what happens. His words were: "if you need the surgery, you'll be back".

So I'm diving back in! I had already started cycling again, and I ran my first mile in three months today, which felt great!!

I think the true test will be next ski season. The tri sports are all linear, which he didn't think would pose any problems. Skiing involves more lateral movements, which could be an issue. My hope is that if I'm strong at the end of tri season I'll be able to move that into skiing as I have in past years and try to avoid any problems.

Again, thanks for the advice and input - much appreciated!
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