Femoroacetabular Impingement (FAI)
Femoroacetabular impingement also called as FAI occurs due to the structural abnormalities in the bones that form the hip joint. The ends of the two bones that form the hip joint have abnormal shape due to which the bones tend to move against each other creating unnecessary friction and damage to the joint and thereby pain in that area.
What does a hip joint look like normally?
A hip joint is basically a ball-and-socket joint. The femur or the thigh bone has a portion named femoral head that forms the ball and the socket is acetabulum, a portion of the pelvic bone. The two surfaces of ball and socket are covered with articular cartilage that allows the movement of the bones with very little friction. The bony ends smoothly glide during movements. Labrum is a type of fibrous cartilage that surrounds the joint for better stability of the hip joint.
What happens in a person with FAI?
When a person is suffering from FAI, his femoral head or sites on the acetabulum grow projections. Due to the abnormal growth the bone ends tend to strike against each other while hip movements. Normally the bone ends move smoothly against each other but bony outgrowths make movements difficult and painful. There comes a time when repeated rough movements lead to the labrum tears and damage to the articular cartilage.
What are the types of FAI?
FAI can be of three types generally-
Pincer FAI- This is when the acetabulum is defective because of an extra growth of acetabular bone beyond the normal edge. Such a growth can prove to be extremely injurious to the labrum and can lead to a crushing injury.
 Cam FAI- The CAM type of FAI is due to the defect in the shape of the femoral head. Instead of being round, the shape of the femoral head becomes distorted due to bony growth. This restricts the normal rotation of the femoral head within the acetabulum and hence the hip movements become tough and painful. In due course of time, the cartilage starts wearing away due to chronic rubbing.
Combined FAI- This type of FAI has the combination of both Pincer and CAM type. It simply means that both the femoral head and the acetabular rim have bony overgrowths. The degree of movement difficulty increases with increased complexity.
It is tough to realize whether one has this problem until the symptoms appear. The best part is that some people live their lives undisturbed and actively along with FAI and never counter any trouble like limited movements. Those who develop symptoms have already undergone harm to their labrum or articular cartilage. In such cases, people come up with the complaints of hip joint pain, inability to walk straight and experiencing a rigidity that restricts their free hip movements. The symptoms of FAI show a variation from one individual to another. Some have reported to have a mild ache all throughout. Others have severe pain in the groin region mostly specially while squatting.
If you suffer from hip pain or low back pain that has not improved despite various measures, contact our renowned and talented sports medicine specialists at Orthopedic Surgery San Diego to undergo an evaluation.

Hip Impingement, or Femoroacetabular impingement (FAI), is a condition normally caused by mal-development of hip bones during the growing years. As a result, hip bones are not aligned and people with FAI suffer a sharp stabbing pain in the groin upon performing movements involving hip bones such as twisting and squatting. Sometimes, the pain is a dull ache in quality. When the hip bones rub against each other, the joint is damaged and tearing can happen. Also, the breakdown of these structures may predispose the person to developing osteoarthritis (OA).
Since pain in the groin area can mean a lot of things, it is essential for health care providers to conduct first an assessment that would support diagnosis of hip impingement or FAI. For an instance, if the pain occurred for the first time, a review of recent activities that might have caused the pain is done. Also, a rest may be taken to see if the comfort is restored. Over-the-counter (OTC) anti-pain drugs may be used too.  However, if none of these can address the symptom, persons with potential hip impingement or FAI are advised to seek professional medical help.
Diagnosis is a combination of imaging studies and physical assessment. One test included in the physical assessment is the impingement test. To do this, the doctor brings the knees upward and towards the chest and then rotates it inward going to the opposite shoulder. If patient feels pain, he is positive for impingement. Current imaging studies utilized in diagnosing hip impingement or FAI includes the following: x-ray, magnetic resonance imaging (MRI), and CT Scans.
X-ray is ordered to produce internal structures’ images on film. The film is then given to the doctor for final reading. The doctor will try to look for structural irregularities, particularly in the space where two bones meet in the hip region that may suggest hip impingement or FAI. Aside from irregularities, a greater bone size may also be noted around the socket.
If the doctor can’t sufficiently tell by x-ray or if collected assessment data are still not enough to diagnose hip impingement or FAI, MRI is ordered. This is a more accurate imaging study which uses magnetic field and radiowaves to produce more detailed images of tissues. Also, it can produce a three-dimensional image that can be viewed in different angles. With MRI, tissue structures are viewed. Through this technique, tears in the cartilage are now possible to be detected, especially the cartilage (labrum) that runs along the rim of the socket.
Lastly, computerized tomography (CT) scan is ordered as one of the options. The technology of CT scan uses computers and x-ray equipment to produce various images of the internal environment of the body. Both CT and MRI scans will play a great role when doctors decide if the person will need surgery.
While hip impingement or FAI may be triggered by some movements especially by athletes, it may be relatively unpreventable if it’s brought by growing years. Therefore, it is important to act on the first sign of pain in the groin area. The rule of the thumb is, the longer it is not diagnosed the severe its consequences are to the hip bones and movement of a person.
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        Since misalignment of the hip bones can affect the activities of daily living of an individual that has hip impingement or femoroacetabular impingement (FAI), initial treatment is geared towards managing the pain, which is the usual chief complaint. While treatment can be both surgical and non-surgical, nonsurgical ones are being instituted first. Therefore, if pain management do not relieve the pain, surgical management is the next step to be taken.
Non-surgical treatments involve resting the affected part, modifying activities that may precipitate worsening of the condition, rehabilitation through physical therapy to strengthen the muscles, and anti-inflammatory drugs as well as pain medications. People with hip impingement or FAI are initially advised to follow certain changes in their activities’ frequency, duration, and intensity. These changes in activities are done to safeguard the integrity of the joint as well as to avoid moving it in a way that would be painful. In addition to this, structured exercises with physical therapists are also done to strengthen the muscles in the hip region which serve as the anchors and weight-bearers. These structured exercises promote hip’s range of motion as well as relieve stress on the injured cartilage. Lastly, pain medications are prescribed and administered to help manage the pain and inflammation. An example of this drug is ibuprofen.

In some cases where non-invasive treatments are not effective, the doctor may opt to do surgery. While surgery does not promise 100 percent recovery from hip impingement or FAI, it is the best way to treat FAI as of now. It is the only way to relieve pain and improve function of the affected part. The surgery of choice is based on the extent of the affectation and severity of damage in the cartilage.
For cases with less severe cartilage damage, surgery to be conducted involves surgical instrument to manipulate the anatomical flaw. This means reshaping the ends of the bones to be able to fit the two perfectly. The most common site of this surgery is at the outside edge of the socket. Another surgery is called microfracture. In this technique, the damaged cartilage is cut. Another approach is to drill holes into the damaged part. Both of these approaches are geared towards stimulating cartilage growth. However, microfracture is not frequently used. There is also a new approach which utilizes blood parts to stimulate growth of cartilage.
            The typical hip impingement or FAI surgery is done through arthroscopy. In this surgery, a lighted scope called arthroscope with a camera on its head is inserted into a button-size incision to view the internal environment of the affected hip. This surgery is done on an outpatient basis. Therefore, patients can go home after once stable after few hours of monitoring. During arthroscopy, any frayed cartilages are repaired, bony rims are trimmed, and bumps are shaved. On the other hand, for some severe cases, a larger incision is required and an open surgery is done.
The rule of thumb in hip impingement surgical treatment is the earlier a person subjects himself to surgery, the higher the chances of his complete recovery.
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A Quest in Determining If There is a Need to Change the Strategy in Managing Fasciotomy Incisions in the Lower Leg
According to National Center for Health Statistics in the United States, there are 492,000 tibial fractures per year accounting to 70,000 hospitalizations, 800,000 private clinic check-ups, and 500,000 hospitalization days. The common causes of tibial fractures include motor vehicular accidents, sports injuries, and falls.
Fractures are usually managed with either casts or splints. While these methods promote healing and realignment, the pressure that accrues inside the muscles of the leg can result in a complication called compartment syndrome. Signs and symptoms of compartment syndrome include pallor, pulselessness, paraesthesia, pain, and in some cases, paralysis. The doctor will try to cut a small portion of the cast to release the pressure. This procedure is called windowing. If it is not effective, the next step is called bivalving, where the cast is divided into two. However, in severe cases of compartment syndrome, a surgery called fasciotomy is needed to be performed.

Now, after fasciotomy, the wounds are currently managed through bringing patients back to operating room for a series of debridements. This is to facilitate delayed primary closure (DPC) of fasciotomy wounds. However, a team of researchers led by Dr. Michael J. Weaver questioned the effectivity and efficiency of this strategy. Consequently, a study entitled “Delayed Primary Closure of Fasciotomy Incisions in the Lower Leg: Do We Need to Change our Strategy?” was conducted. It was published in Journal of Orthopedic Trauma last December 22, 2014.
The main objective of the study was to determine whether the current strategy of ‘bringing back patients to the operating room for successive debridements allow primary closure of fasciotomy wounds’. The main outcome measure of the study would be based on the ‘number of fasciotomy wounds closed by DPC after the initial fasciotomy procedure.’
The research design utilized was a retrospective cohort study of 104 adult patients from two urban level 1 trauma centers. These patients had acute compartment syndrome at the time they had either open or closed tibia fracture. Data needed for the study were derived from these patients’ medical records and radiograph results. Participants included in the study had their fasciotomy wounds managed either through DPC or split thickness skin grafting (STSG), depending on individual conditions.

Nineteen (19) out of 104 patients (18%) were treated with DPC while 42 patients (40%) underwent STSG. On the second debridement, three out of 43 remaining patients underwent DPC. Through examining these previous cases, researchers found out that no open fractures were documented to be closed by DPC. In terms of the number of hospitalization days, it was found out those patients who underwent STSG on their first debridement has significantly stayed shorter in the hospital compared to those who underwent additional procedures to manage their fasciotomy wounds. The result was a 12.2 days versus 17.4 days at 0.005 level of significance.
In conclusion, the study recommends considering the option of providing skin grafting to these wounds especially on open fractures as it can significantly decrease the number of hospitalization days. On the other hand, DPC technique can rarely close fasciotomy wounds which weren’t possible to be close during the first post-fasciotomy surgical procedure. Lastly, the study recommends exploration of other techniques to utilize to avoid repeated debridement.
If you have sustained an injury and wish to undergo an evaluation or obtain a second opinion, contact our specialists at Orthopedic Surgery San Diego.

RECONSTRUCTION SURGERY COULD BE REQUIRED AFTER AN INJURY TO THE ANTERIOR CRUCIATE LIGAMENT.

The anterior cruciate ligament (ACL) is one of four main ligaments of the knee. A rupture or tear to the ACL is a common injury suffered by active persons. Surgical reconstruction is often required to regain full knee function and stability. ACL reconstruction surgery should always be done by highly-trained orthopedic surgeons, also known as orthopedists.
How does this injury usually occur?
Most ACL injuries happen during sports and athletic events which are non-contact, and therefore have no external contact with the knee joint. This suggests that the injuries are as a result of abnormal movements such as pivoting, sudden changes of direction and bursts of speed.
Soccer, basketball and volleyball are some of the sporting activities which have the highest risks and incidences of anterior cruciate ligament injury.

Do all ACL tears or ruptures require surgery?
Your orthopedist will, after a comprehensive examination, present you with the results that will help you to decide whether or not to opt for surgery. Bear in mind that the goal of surgery is to restore as close as possible the level of stability and function to the knee which you had before you had the injury.
You may opt for surgery if :
Your knee is very unstable due a completely torn, or a severely partial tear of the ACL.
After undergoing a rehab program your knee is still unstable.
You are very active in sports or have a job where full knee strength and stability is needed.
You have a chronically unstable knee which is affecting your quality of life.
You have injuries to other parts of the knee such as the cartilage or meniscus.
You may choose not to have surgery if:
You have an ACL tear that may respond to rest and rehabilitation.
Neither sporting activities nor your job require a perfectly stable knee.
You feel able to complete a rehab program to stabilize your knee and strengthen your leg muscles to reduce chances of another knee injury.

Does ACL reconstruction surgery work well?
ACL surgery, when performed by a competent orthopedic surgeon, has a high success rate with very few problems relating to the surgery itself.
Many surgeons use arthroscopic surgery in preference to open surgery. Arthroscopy makes it easier for the surgeon to see and work on knee structures. Arthroscopy also uses smaller incisions than those required in open surgery, and the operation can be simultaneously done when identification of any other knee damage or injuries. Is needed.
Arthroscopic surgery can be performed under spinal or general anesthesia, depending on the choice of the patient.
Post operative care and physical rehabilitation is a most important part which contributes to the success of the procedure. For satisfying results, religiously follow the instructions of your doctor to re-establish a fully functional, stable knee.
If you have been told you sustained an ACL tear or wish to obtain a second opinion, contact our sports medicine specialists to provide you options that best suite your needs.

Hip arthroscopy, which at one time was once not performed as often as shoulder or knee arthroscopy, is quickly becoming a common procedure. In the past few years, there has been a rise in professional baseball players receiving the surgery.
Alex Rodriguez, third basemen for the New York Yankees, underwent the procedure in 2013 to repair a torn labrum after years of gradual limited mobility and a few injuries to the hip. Former Colorado Rockies player, Todd Helton, suffered from a degenerative back condition and eventually had hip arthroscopy to repair a labral tear in 2012. His former teammate and current Colorado Rockies short stop, Troy Tulowitzki, who suffered from a degenerative back condition, complained of persistent groin pain. Upon examination by the Rockies head trainer, Keith Dugger, it was revealed that Troy, too, had a labral tear. After undergoing hip arthroscopy he was forced to miss the remainder of the 2014 MLB season in order to recover.
Tulowitzki is expected to need four to six months to heal completely. After extensive physical therapy, Tulowitzki is expected to make a full recovery, and will be able to play without any physical limitations moving forward.

Hip surgery is recommended after nonsurgical treatments such as rest, physical therapy, medications, or injections that reduce inflammation, are ineffective in relieving groin pain. Before undergoing arthroscopy, a physical examination, full medical history, and tests, such as an MRI, will need to be performed to further assess if there are any problems that could interfere with the surgery. If there are more health risks involved, than a more extensive evaluation may be required before surgery can be executed.
This surgery requires the leg on the side of the injured hip to be put in traction. The leg will be pulled away from the socket for enough space to allow the surgeon to insert instruments that enable full view of the entire hip joint. Once traction is set, the surgeon proceeds to make buttonhole size punctures in the hip in order to insert arthroscopic tools, which allows the surgeon to see the inside of the hip and find the damage. The surgeon will insert other instruments through each incision made if need in order to smooth torn cartilage or repair it. The orthopedist can also trim bone spurs that are caused by Femoroacetabular impingement (FAI), and remove the inflamed synovial tissue.
Following the surgery, the doctor formulates a rehabilitation plan, which involves surgical recovery, then a plan for physical therapy once the limping is gone and the wound has healed. Physical therapy is needed to help achieve the best possible recovery from the surgery. This will include exercises that will help restore the strength and mobility in the hip, along with teaching the patient stretches and minor repetitive movements to do at home to continue building strength.

In most cases, a full recovery is made and the patient can resume activities… However, in some situations it may require a few lifestyle changes to ensure protection of the joint and also to prevent any further injury or reoccurrence. In a few cases, the damage can be too severe to be completely fix or reversed.
If you are suffering from groin or low back pain that has not improved despite many measures, it is possible you have unrecognized FAI. Contact the sports medicine specialists at Orthopedic Surgery San Diego today for an evaluation or second opinion to understand the treatment measures that can best alleviate your pain.