You can listen to this episode by clicking here.
Speaker 1 (00:00:02):
Perfect.
Speaker 1 (00:00:06):
All right, welcome everyone. Today is another Tuesday on hernia Talk. I’m joined with you all live with the question answer session as many of we have this session every week, and it’s being live broadcasted on Facebook on my homepage. And for those of you that are registering via Zoom as also afterwards, I will make sure it’s all posted on YouTube as well, so you can watch it and share it with your friends. Today’s guest panelist is a very lovely friend of mine, someone who has helped so many of my patients. His name is Dr. Jason Snibbe. You can follow him on Instagram at Snibbe Ortho. He’s an orthopedic surgeon, but more than that, he’s a hip specialist. He is a bit more specialized than your typical orthopedic surgeon, which comes really handy in patients of mine that needs someone to look over their hip. So welcome Dr. Snibbe.
Speaker 2 (00:01:09):
Thank you very much. Thanks for having me.
Speaker 1 (00:01:12):
So we were talking a bit earlier Dr. Snibbe, you and I share a lot of patients. I’m very blessed to have you nearby in Los Angeles. We work at the same hospital at Cedar Sinai, and I see a lot of patients that come to me, not just for hernias, but for growing pain. And I’ve learned through you and others that growing pain isn’t necessarily always from hernia. And I’m really impressed how many patients have an orthopedic cause for their groin pain. I actually did know that. I certainly was not taught that in residency or medical school. Maybe you were, but I was not. And I feel that a lot of people that are struggling with their groin pain and can’t figure out why this surgery and that surgery and so on didn’t work is because they have an undiagnosed hip disorder. And with time, you’ve taught me all the different questions to ask. So I’m hoping that the patients that are on today can kind of learn from you in the next hour, what’s a hip, what hip disorders can mimic growing pain, how do we figure out if that’s the problem, what’s the test, what’s the treatment, and so on. So that’s the plan for today. Does that sound good?
Speaker 2 (00:02:31):
Yeah. And I think that us as hip surgeons, we have realized that the hip is not just all about the hip. The hip is part of your, the core of your body, and that the disorders of the hip really stress a lot of the areas that you specialize in, the rectus abdominance, the Inguinal areas. And so really patients that suffer from hip disease and suffer from hip injuries present with a lot of hernia hernias present with a lot of rectus abdominus stuff, abdominal stuff, and a lot of pelvic things. And I think that that’s really something that we have learned as a specialty that you can’t ignore the hernia aspect because we see it so much.
Speaker 1 (00:03:23):
And I feel that in my specialty, so many general surgeons don’t know the hip can cause some of the abdominal and pelvic pain that we see. And I, I’ve noticed that a lot of orthopedic surgeons don’t know that hip disorders can present with more general surgery type pains or GYN type pains or even urologic type pains. And so when they see that, they automatically assume it’s not from the hit. But there’s so much overlap in the pelvis. It’s a very complicated structure.
Speaker 2 (00:03:53):
Yeah, I agree. I agree. Absolutely.
Speaker 1 (00:03:57):
All right. Well, we already have some questions that were submitted ahead of time. We’ll just jump into it if you’re okay with that. Sure. Until more questions come in, let’s just go right at it. Why does hip pain causes growing pain and how can a hip disorder, like a labral tear present like an inguinal hernia?
Speaker 2 (00:04:16):
So the labrum, for those of you don’t know what the labrum is, a labrum is a ring of tissue that surrounds the socket of the hip. The hip is a ball and socket. And the labrum, the typical labral tear is typically anterior. Anterior means in the front of the hip. And so most patients that describe labral pathology or tears of the labrum will, they’ll describe pain in their groin. It won’t be in the middle of their groin, typically. It’ll kind of be up by where your hip flexor attached, kind of like where you feel your quad muscle kind of go up into your hip. It’s kind of in that area. So a lot of times hernias will be a little more to the inside, more in the central portion of your pelvis, where labral tears would be more what they call lateral more outside in the groin. And that’s a classic symptom. People will describe pain in their groin. They’ll describe clicking, they’ll describe aching. Those are very classic symptoms that we see patients describe. And I think the majority of labral tear are anterior, very, very rarely does the posterior labrum tear. So it’s always in the front. And that’s where when we stress, when we examine hips in the office and we stress them, that’s where they describe the pain
Speaker 1 (00:05:36):
And why. So the labrum is that the cartilage like a cartilaginous?
Speaker 2 (00:05:42):
So there’s good question. So there’s two types of cartilage. There’s articular cartilage, that’s the cartilage that covers the ball and covers the socket. That’s like a smooth coating that covers the bones. The labrum is cartilage, but it’s not articular cartilage. It’s called fibrocartilage. It’s kind of like what your mensicus is made out of in your knee. And so it surrounds the socket of your hip, and it provides a seal, provides a seal of your hip. And there’s some research that says that the hip has kind of a negative pressure. So in order for you to pop your hip out of the socket, it’s almost like those little suction devices that you put on a piece of glass. Yeah, that’s negative pressure that holds it there. So it’s the same thing that the labrum does. And we feel that when you tear your labrum or damage it, that negative pressure gets kind of disturbed. And when that gets disturbed, it’s bad for the cartilage. It’s bad for the environment of the hip.
Speaker 1 (00:06:42):
Okay. That’s the best that’s ever been explained to me. I just assumed the whole thing was covered with labrum. And then why do you tear it? Why does one get a labral tear?
Speaker 2 (00:06:52):
So there’s a couple ways you can tear your labrum. The most common ways that a thing called impingement. So there’s this really long medical term that’s confusing for patients called F A I. It stands for femoral, which is the ball acetabular, which is the socket impingement. So it has to do with the way the two bones interact. So sometimes the ball of a perfect ball, right, is like a baseball or basketball that rolls inside of a joint. But people that have impingement, the ball is more like an egg, so it’s more oblong. And so that bone drives inside the hip and tears the labrum. The other type of impingement is coming off the socket where there’s a little extra bone on the socket that causes the two bones to hit each other. That’s called pincer impingement. So there’s the ball impingement is called cam impingement. The socket is called pincer. And when those two hit each other, that tears the labrum. And that’s most common
Speaker 1 (00:07:49):
Bone, that’s an overgrowth of bone
Speaker 2 (00:07:53):
That that’s the way the bones overgrow when children are maturing in their life. So it’s when their growth plates are open, they can get these deformities in their hip. And some of it we believe is related to their activity, how active people are, for example, hockey players. So most hockey players are from Canada. And when they are literally like 3, 4, 5 years old, they go on the ice and they start skating. And that stress that puts on their hips creates some of this impingement. So like 90%, maybe more of all hockey players have impingement in their hip and professional hockey players. And then some of it though is genetics. So it’s like your mom, your dad, your cousin, your brother had this and you get it genetically. So it’s a little bit of both.
Speaker 1 (00:08:44):
I thought it was due to trauma.
Speaker 2 (00:08:47):
No, not really. Not really. I mean, it’s repetitive trauma. Sometimes you can have a traumatic where you fall or you get hit on the field or you have some incident and you can have a traumatic event. But when you look at the numbers, probably 80% of labral tear are due to chronic injury, repetitive injury, 20% are probably traumatic.
Speaker 1 (00:09:12):
So is there a way to prevent getting impingement?
Speaker 2 (00:09:17):
Not really. Okay. But there’s ways. So I’ve been really involved in ways to prevent labral tears from happening because if you have impingement and you do deep squatting, deep lunging certain types of exercises in the gym or the weight room that can cause injuries. So what I’ve been doing a lot is educating trainers in the collegiate level and the professional level to kind of analyze the athletes to say, let’s look at all the athletes that are at this university and let’s see who the people that have stiff hips are. And then those people will stay away from the deep squats and the deep lunges so they don’t have as many injuries.
Speaker 1 (00:10:02):
So this term stiff hip, is that based on the hip not wanting to do full range of motion because it gets caught?
Speaker 2 (00:10:12):
Exactly. So it used to be like when you and I were kids and you would go on play a sport, they’d say, oh, let’s say my hip, my Jason’s hips are stiff. That’s because you don’t stretch enough. But we’ve learned that it’s really not that it’s related to the way that the architecture of the hip is designed. And so when you examine a patient and they lack what we call internal rotation, when you try to rotate the hip in the lack of internal rotation and the lack of abduction is very common in patients with F A I and those patients. When we see those patients, and it’s typically about 20% of athletes have it, we put those people aside, we sometimes image them and diagnose them with F A I and then keep ’em away from certain exercises.
Speaker 1 (00:11:05):
So you have to have the impingement first and then you get the labral tear. That’s a side effect of it. Yes.
Speaker 2 (00:11:12):
But there are two other ways you can get labral tear. One way is from dysplasia. So what dysplasia is when instead of the ball covering the socket, only half of the ball is covered or percentage is less covered. So those people with dysplasia can get their hi, they have a higher incidence of arthritis and they have a higher incidence of labral tears. And then also we see a lot of women that have hyper mobility, and I have treated a lot of those women where their hips move around, all move all around, and those flexible hyperflexible. So instead of having the bone, they just have so much that the hip is able to rotate all the way up and hit and damage the labrum. Oh. So that’s another reason for labeled fairs.
Speaker 1 (00:12:03):
That brings up a good point about women, the hyperflexible. So I seem fair number of women that undergoes some type of gynecologic operation, and when they’re put in position, it’s called lithotomy. So they’re on their back and the legs are in stirs basically for hours. And there’s a technique to make sure that the hip is in line when they put the stir ups up. But you’re under anesthesia and it’s possible that the hip can be misaligned. And I’ve seen that then they get groin pain, but it’s really due to a hip injury. But what happens there from the lithotomy position?
Speaker 2 (00:12:48):
So there’s a couple things. So the incidents, which is important for everyone listening is the incidence of labral tear is 20% and 20 to 30% in the general population. Okay. So hold on one on one second. I think there’s a little noise outside, but can I just Oh,
Speaker 1 (00:13:08):
No problem. I don’t hear anything.
Speaker 2 (00:13:09):
One sec. Hold on. I got to turn this guy off. Hold on.
Speaker 1 (00:13:17):
This hip dysplasia is a good one because I just sent doctors to be a patient, I think last week or maybe the week before. And it was basically she had hip dysplasia, no one diagnosed it. They treat her like a regular labral tear. Sorry
Speaker 2 (00:13:36):
About that. Sorry about that. No
Speaker 1 (00:13:38):
Problem.
Speaker 2 (00:13:39):
So you were talking about incidents of labral tear. So about 20% to 30% of the general population have labral tears in their hip. And when you take, so majority of these women that get put in a lithotomy position when their hip is flexed up, you’re putting pressure on sometimes a very small labral tear. And what can happen is that pressure can cause swelling, inflammation, and irritation of the labrum and can kind of activate some symptoms so that that’s
Speaker 1 (00:14:14):
Like endometriosis surgery. Or they’ll do a hysterectomy often for pain to begin with. And oh, I’ve had growing pain ever since my GYN surgery and we work up other pelvic pain disorders, including hernias. It’s not that, but it’s pretty remarkable that it’s their hip and it’s potentially preventable. Is that preventable the way?
Speaker 2 (00:14:41):
Yeah, I mean, I think that for the gynecological surgeons, yeah, the more you take the hip out, the more you abduct the hip is better. If you bring the hip too far in and straight up, that’s going to cause impingement and cause irritation labrum. But when your hip is more abducted, more spread out, okay. It’s a safer, so
Speaker 1 (00:15:04):
You want it more like this and not more interesting. Okay. Good to know. Exactly.
Speaker 2 (00:15:09):
Exactly.
Speaker 1 (00:15:09):
And then can you tell me about the hip click? So when I ask questions, I ask questions for about groin pain that’s related to hernia. So it’s usually activity related and it can radiate into the inner thigh, anterior thigh around the lower back into the vagina, down the testicle. And when they lay flat, it gets better. So that’s classic symptoms associated with a hernia. Then I switch over and I start asking questions related to the hip. One of the questions I ask is, do we have a hip click? Why? What is a hip click? And why is that associated with a labral tear or impingement?
Speaker 2 (00:15:47):
So the labral tears and the injuries to the labrum can really create a lot of stress in the pelvis. And basically, I guess the simple way to put it is that when we talk about impingement, we talk about limitations and rage of motion. There’s a lot of stress on the abdomen and on the central portions of the pelvis. And those stresses can cause lots of different types of pain, lots of pain in the hernia area where your abdominal muscles attached to your pelvis and also down into your vagina or your testicular area. And so I think the way we talk about kind of pelvic issues is that if your hips don’t move, normally you don’t have normal range of motion in your hips. What happens is that you have to use all these accessory muscles, you have to use your abdominal muscles, your pelvic muscles in different areas to try and get your body to move. And when that stuff happens, it really creates a lot of stress in those areas.
Speaker 1 (00:17:06):
And then you get the click.
Speaker 2 (00:17:08):
Yeah. So when you talk about the click, the click is basically can happen from two reasons. It can happen from a labral tear. Your hip can click because the labrum is, as you move your hip around, the labrum can kind of click between the ball and the socket. You can also get a snap in your hip where sometimes you’re so as tendon, you’re so as tendon as a tendon, it lies deep in your hip and that glides across the front of your hip. And when that glides across the front of your hip, that creates sometimes a snap or a pop.
Speaker 1 (00:17:42):
Okay. So the questions I ask is about the hip click. I ask them if the pain goes away when they lie flat, and usually the answer is no. Whereas with the hernia, the pain, the groin pain goes away when the patient’s lying flat. And then I ask them if they have pain in their upper buttock area almost straight back. So the hip patients tend to have pain in the upper buttock, whereas the hernia patients, it’s just in the front, it’s not in the back as well. Is that just also in line with the hip joint?
Speaker 2 (00:18:13):
Well, usually the majority of hip patients will have anterior pain, will have pain in the front, but a certain percentage will have pain. Smaller percentages will have pain laterally on the outside or posterior. Yes. What we think about is posterior pain. If you have buttock pain or gluteal pain, we think we typically think more of the spine of more of the, because that’s where the cynic nerve comes out of the pelvis. So that’s typically more spine related.
Speaker 1 (00:18:45):
So we have some more questions about differentiating hip pain from other things. Can hip pain cause testicular pain?
Speaker 2 (00:18:54):
Not typically, but we typically see patients that have hip pain, like I was saying earlier, will stress the abdomen and some of the nerves in the abdomen. And that will cause what we describe as a sports hernia or I don’t know what you guys describe it. We call it in our world a sports hernia or athletic pubalgia. Right. Yeah, because I was saying earlier, when you have a stiff hip, you start stressing your abdominal muscles, and then around those abdominal muscles are the nerves that go down into the testicles. So a lot of patients that come to me that have chronic hip pain, that have labral tears and impingement will say, you know what? I get a lot of pain in my abdomen and I get a lot of pain in my abductors, and I get a lot of, sometimes I get referred pain into a testicle. And typically what I’ll do do with those patients is I’ll say, I usually tell them 70 to 75% of those patients will get better if I fix their hip. If I get rid of the impingement and I repair their labrum, they will get better. But a certain percentage we do those surgeries and they don’t get better, then I send ’em to you and you have to look at them for the hernia stuff.
Speaker 1 (00:20:07):
Got, okay. Another question is hold on. Can hip disorder cause pelvic floor spasm from the inflammation?
Speaker 2 (00:20:21):
Yes. So a lot of the same stresses. So there’s a lot of pelvic floor problems and pelvic floor dysfunction that happens from hip injuries. And the thing that’s important to know is that we always, for some reason, a lot of people, a lot of orthopedic surgeons that aren’t familiar with this stuff think, oh, pelvic floor, it’s got to be women. But actually there’s a lot of men that get pelvic floor disorders too. So it’s not just a female diagnosis, it’s actually, there’s men that get that. Yeah. And basically, right. And it’s the same, but some of the orthopedic surgeons say, well, pelvic floor, that’s a female problem. But it’s both genders and basically the stress that’s on the pelvis, again, from the lack of range of motion, and also probably from some compensation, because when your hip hurts, you start to change the way you run, the way you move, the way you perform or the way you walk. And so that causes a lot of pelvic floor dysfunction in patients. And again, most of the time when you fix the hip, a lot of that goes away,
Speaker 1 (00:21:27):
So Correct. So does the inflammation from the hip also cause pelvic floor pain or not?
Speaker 2 (00:21:38):
No. Well, I mean, it’s indirect mean if your hip is inflamed, it’s irritated, you’re compensating in weird ways, and then that causes the pelvic floor pain.
Speaker 1 (00:21:48):
So for a groin, hernias, I also ask pelvic floor questions because mm-hmm. <affirmative> hernias can also cause pelvic floor spasm so they can get a feeling of urgency to urinate or they urinate a lot, very frequent urination. You fix a hernia that goes away. They also have, if they go to a pelvic floor physical therapist, they get examined and they’re told their pelvic floor is very stiff or tense. That I think is the scene with hip disorders, men and women spasm, spasm of their pelvic floor.
Speaker 2 (00:22:26):
Yeah, I mean that’s, I think of pelvic, I mean maybe I’m wrong, but I think pelvic floor dysfunction is the spasm. Yeah. It’s the height muscles, it’s the kind of irritability of that area. And I think that all plays with hip disorders. And I think that the sad part about some of these diagnoses is that you and I are very familiar with these things, but I think for the people out there listening, it’s really important to understand that not a lot of orthopedic surgeons and not a lot of general surgeons are familiar with these kind of syndromes. Correct. And the sad part is that there’s many patients that you and I treat, that I’ve treated for years is that they go see four or five orthopedic surgeons. They’re like, I don’t know what’s wrong with you. I think you have a hernia here. I think you have, it’s your spine. They don’t really examine the hip. But a lot of times the physical therapists will examine the patient and they’ll say, what? People keep telling you all these weird things, I think it hits your hip, or I think it’s a hernia. A lot of the physical therapists or chiropractors, the people that are working with these people on a daily basis discover these diagnoses. And I think that, you know, and I have been lucky because we’ve educated each other, you’ve educated me about the hernia process and I’ve educated you about the hip process and together we’ve come a long way. Right. But I do think that it’s really important for people to understand that wherever you live, wherever you’re residing, you need to seek out specialists in these areas because a lot of times things get missed.
Speaker 1 (00:24:11):
I totally agree with that. And I feel that the, you’re right, the physical therapist and the pelvic floor PT are so in tune. One thing they do is they tell the patient you have so as impingement, and then they do these deep. So as releases, what does that do? Is that for real?
Speaker 2 (00:24:33):
I mean it, it’s sort of for most of the people that have diagnosis of, so as impingement, typically it’s not So as impingement, typically it’s a labral tear. Yes. An impingement, that’s typically what it’s people with hip replacements can get. So as impingement, whether the So as tendon will rub against the implant and they’ll get so as impingement, but really when hip arthroscopy and the treatment of hip, the non arthritic hip disorders mm-hmm. Developed, there was a whole thing about the psoas and there was a bunch of surgeons around the country that were cutting. So as tendons and people,
Speaker 1 (00:25:14):
Yeah. What’s this lengthening procedure I’ve heard about?
Speaker 2 (00:25:17):
Yeah. So what they do with the lengthening is they cut the psoas. So you lengthen it. But the problem with that is that it creates an enormous amount of weakness. It creates a weakness, it lengthens the muscle tendon complex, and it creates an enormous amount of weakness. Probably not a big deal in an elderly patient, but you would never do that on a young patient. But when hip arthroscopy was first coming out, there was a lot of surgeons that were cutting the, so I tendon in everybody, 22 year old girl, 16 year old boy, and there was enormous amount of weakness happening. So really as is not touched, we try not to touch it at all because you can leave people with permanent weakness. But I do think that there’s inflammation around it. There’s some people that have extra bone around the so as area. So during surgery we’ll shave that bone away and that will help their so as symptoms. But I think that a lot of that, so as impingement is labral pathology.
Speaker 1 (00:26:19):
Yeah, I I’ve noticed that trend as well. So here’s another question. You talked about the hip disorders and how medial or how in word the pain goes, it’s usually, you kind of answered this question, how far medial can hip pain extend? Can it get all the way to the pubic tubercle or to the midline, especially if you have bilateral or left and right hip problems? Does that ever happen or is that Yeah,
Speaker 2 (00:26:46):
I think that most of this stuff, most of pubic tubercle, midline, inguinal hernia is typically secondary. I think that people can have, that’s not coming from the hip. It’s coming because people are compensating in all these different ways to try and move their body and be athletic. But I think the hip doesn’t typically refer into those areas.
Speaker 1 (00:27:11):
Got it. Yeah, no,
Speaker 2 (00:27:12):
I agree. It’s collateral.
Speaker 1 (00:27:14):
It would be very odd to do it that far remedial. So the other questions I ask the patients because of the pelvic floor spasm, a lot of ’em have pain with intercourse, and that’s something notable. Do you see that with hips as well?
Speaker 2 (00:27:29):
Very common. Very common. The pain. The pain with intercourse is very, very common because obviously just like you’re talking about the lithotomy position, your hip is in a flex position and that that’s very uncomfortable. Mostly it’s obviously with women because in typical sex, women have their hips flexed. And so a lot of women come to me and say, listen, I can’t have intercourse with my partner because it kills my hip. It just, it’s so painful. Yeah, very
Speaker 1 (00:28:07):
Common. We had a couple patients I sent you, it was very interesting. So what they tell me is that, yes, when they lay flat, they light flat on bed, the pain doesn’t go away, which is atypical for hernia. So then I start thinking hip, and then they have to either frog leg their legs or they have to put a pillow under their leg to kind of prop that leg. And then they’re more comfortable. One guy would come to my office, you fixed him. One guy came to my office and he would bring either a tennis ball or a really thick paperback book, but a small one, and he would sit on it just on one side and that would help relieve his pain. How do you explain that?
Speaker 2 (00:28:52):
There’s a couple things there. So a lot of times the hip is a very deep joint in your leg. The knee is not. So as you know, when you get disorders of the knee, you sometimes get water in your knee, you get swell swelling. So the hip is the same, the hip is not immune to that. So the hip can get extra fluid when there’s inflammation, when your hip is straight, when you’re lying flat in a bed, your hip is flat. So the capsule lining of your hip is extremely tight, and that creates extra pressure around your hip. But when your hip is flexed, when you put a pillow under your knee and you bend your hip, you kind of flex your hip a little bit. Yeah, it relaxes the capsule. So now the capsules relax and there’s more room for the fluid to be there.
Speaker 2 (00:29:41):
So a lot of patient patients that have fluid in their hip or inflammation in their hip, they feel better when there’s a pillow under their knee. It relaxes their capsule. But one of the biggest syndromes that happens with hips is that is gluteal. Basically gluteal deactivation patients that have impingement, labral tears, their gluteal muscles don’t fire normally, and they get a lot of spasm and inflammation. And also there’s a muscle in the back of your hip called the piriformis. Yes. Which is a little tiny muscle. And so when your gluteal muscles don’t fire, normally the piriformis fires too much, and you get this kind of deep, we call it deep gluteal syndrome. Your piriformis gets irritated. Sometimes your sciatic nerve gets irritated, and in order to release that or to let that go, the patient sits on that area and they sit on it to make their symptoms go away.
Speaker 1 (00:30:44):
Got it. Okay. That makes a lot of sense. Because he’s the one that I really had to convince to see him because his own orthopedic doctor, we kept saying, it’s not your hip. And I don’t know why, but it’s just an atypical thing. So we discussed a lot about diagnosis. Can we move on to treatment options?
Speaker 2 (00:31:04):
Sure.
Speaker 1 (00:31:05):
So when you
Speaker 2 (00:31:06):
See a
Speaker 1 (00:31:06):
Typical patient Yeah, go ahead. Yeah. What are the options? What do you explain to them?
Speaker 2 (00:31:11):
So one of the things that I spent a lot of time looking at is length of time, how long it’s been bothering them. I think that if it’s beyond six months I’m thinking more that this patient might need a surgery to fix it, because it’s really extending into extended period of time. The critical thing for me is understanding what the architecture of the hip is. If you have impingement, if you have abnormal bone, there’s nothing that you can do really conservatively to get rid of that bone. Right. It’s
Speaker 1 (00:31:46):
A mechanical problem. You
Speaker 2 (00:31:47):
Can do pt, you can stretch. It’s a mechanical problem. So people that have classic impingement, majority of the time I tell them, you need a surgery to correct that. The only reason we don’t do surgery on people like that is if they’ve already developed arthritis in their hip. And then we’re thinking more joint replacement or arthritic change. So impingement, that abnormal bone is a precursor to arthritis. So when you look at people that have had impingement in their hips for many years, they will develop arthritis sometimes when they’re in their mid forties and their early fifties. So if they have arthritis, I’m treating them more with injections, conservative treatment and saying, listen, you got to going to prepare you to get a hip replacement. Got it. But with non arthritic hip, we talk about removing that bone. If it’s a person that’s hyper mobile that has dysplasia that really doesn’t have a lot of boney impingement, I’m typically trying to work with them on the conservative side trying to do, one of the things I do a lot of is biologic injections. So we do two types of injections, one where we draw their blood and we spin the blood down and remove the white blood cells and the red blood cells and get the plasma. It’s called platelet-rich plasma. And we inject that into the hip. And what it does is it can stabilize the cartilage, and on a microscopic level, it can scar down the labrum. It doesn’t heal the labrum, but it can make the labrum less symptomatic.
Speaker 1 (00:33:19):
And
Speaker 2 (00:33:20):
The other thing that we do when the patients don’t respond to PRP is a thing called BMAC. It’s called bone marrow aspirate concentrate. We actually take their bone marrow and we spin that down and get concentrated growth factors, and we inject that into their hip. And so there’s a lot of different things that we do. And then also we do lots of physical therapy. We do stretching, we do a lot of gluteal activation, a lot of core Pilates type exercises to really work on their body because sometimes we get people strong and they get better. They get better because they’ve been so deconditioned.
Speaker 1 (00:33:58):
So is that because the hip girdle kind of supports the joint better and it’s not banging itself so much?
Speaker 2 (00:34:04):
Yes, and a lot of these patients get, so when your gluteal muscles are weak, your hip tends to adduct. So adduct means your knee comes closer to your other knee. And when you do that, guess what? Your irritating your labrum more. Got it. So if your leg is more aligned with your body, you tend to have less labral irritation, less problems within your hip. And so as you get your glued stronger, a lot of patients get better.
Speaker 1 (00:34:32):
We have a couple questions, and that is that, what if you have two problems? What if you have a hernia and you have a hip problem? What’s the algorithm? Which one gets treated first? I kind of have my own answer. I don’t know if it’s the same as your answer.
Speaker 2 (00:34:49):
Yeah, I, I, yeah,
Speaker 1 (00:34:51):
I feel, yeah. So I feel that obviously we got to confirm the diagnosis, assuming there’s both problems in the same patient, which can happen. We’ve had some, I feel that you are probably going to require either physical therapy before surgery or surgery, and then physical therapy. And it’s hard to be really good at PT if you have a hernia to deal with. So I usually fix the hernia first, and then I let them go forward with the orthopedic problem because the PT part is important, and you don’t want the PT to be hindered because you have a hernia. That’s the way I think of it. I don’t know. Does that sound right?
Speaker 2 (00:35:30):
Well, I think you bring up a good topic, a great topic. I think that for us, a lot of times it can be confusing. And what I do a lot of is, and sometimes you do that, I’m sure too, is diagnostic injections. So sometimes if we’re unsure, we’re like, how much pain is the hernia? How much pain is the hip? Sometimes what I’ll do is I’ll inject, not cortisone, but just numbing medication into the hip. And I do that in the office under ultrasound guidance. And if we do that and the patient says, wow, my pain went away a miracle, I might say, fix your hip. Right? But if the hip, they say, you know what? It sort of got rid of my pain, but all my pain is in my inguinal area where my hernias, then I say, you got to go back to Dr. Towfigh and have your surgery. So that’s helpful. But I agree with you. I think the recovery from hernia surgery, for those of you out there, is much easier, right? Yeah. Where hernia surgery patients recover very quickly. I mean, would you agree? Six weeks? They’re pretty good, right?
Speaker 1 (00:36:31):
Oh, they should be. Yeah, for sure. A couple weeks.
Speaker 2 (00:36:33):
Yeah. But hip surgery, it takes them six to eight months to fully recover. It takes a lot of time for these patients to get their strength back, get their power back. So it’s a much long, longer process of recovery. So I think, yes, I think many times we like them to get their hernia fixed to see how it is. But if they have true bony impingement in their hip, true FAI, I think they need both. They’re going to need their hernia and their hip fixed. But there is some data out there in our literature that 70, 75% of the hernia symptoms get better with the hip repairing the hip. But if they have true, have really true impingement. But I think if they have a true hernia, true England or hernia, they need that fixed as soon as possible.
Speaker 1 (00:37:24):
I think it’s all about the history. We can do anything and show all these problems, but it has to fit the story. And I feel that some of the other questions I ask the patients are stairs and hills slanted flooring, or does that bother you? That tends to be more of a hip problem than a hernia issue. And then also soft shoes versus a hard surface. I feel that people with hip problems are much more sensitive to be on a hard surface, whereas for hernias, it doesn’t matter if you’re wearing, you’re on a
Speaker 2 (00:38:02):
Floor shoe
Speaker 1 (00:38:03):
Wear. Yeah. Yeah. That part doesn’t matter. The history is so important.
Speaker 2 (00:38:09):
It is. And I think that it’s funny how as long as I’ve been in practice, listening to the patient is one of the most important. The thing you learned in medical school the first year, listening to the patient discuss their problem, 99.9% leads you to the source. And I still think that that’s such an important tool in our bag of tricks. I think that the patients will lead you to where their pain is and where their problem is. But I do, and I do think that one of the most important principles that I educate my patients about is that labral tears are really common. They’re very common. When we get an MRI on somebody, a lot of times we’re not even the major. So many people have labral tears. We’re not even looking for the labrum. Sometimes on the MRI, we’re looking for other things that could be wrong.
Speaker 2 (00:39:02):
God forbid they have a tumor or a muscle injury or a stress fracture in the bone or something abnormal. We’re really trying to make sure we’re not missing anything because the labral tear is so common, but just because you have a labral tear does not mean you need surgery. There’s a lot of people, there’s millions of people walking around the world with labral tear. So we don’t operate on the MRI, we operate on the patient. We operate on what the patient feels and their symptoms. And I have hundreds of patients every year that come in with labral tears that we don’t operate on.
Speaker 1 (00:39:34):
So that’s a good leading into What imaging do you actually do? Do you go straight for MRI or is there a rule
Speaker 2 (00:39:40):
X-ray? You always, yeah. In the office, we always get x-rays of the patient. We get an AP of the pelvis looking at the whole pelvis and then a lateral of the hip to look at the side view of the hip. And then we typically get MRIs on everybody. It was for many years, the gold standard to get an arthrogram to put die inside the hip as the standard. But in the last five, six years, it’s become less and less of a standard because it’s so irritable to get that done. They basically take a needle and fill, your hip would die. And a lot of patients get a lot of pain from it. They got a little lot of dysfunction from it. So I have gone away from that. A lot of patients that a lot of patients that come see me have already had an arthrogram because their doctors or whoever they’re from have ordered it already.
Speaker 2 (00:40:33):
But if a patient sees me for the first time, I typically do not order it with die. The issue we get in that is a whole insurance thing because some of the insurances want to have an MRI with die to pay for the surgery. So sometimes we’re forced to get it, but I don’t do that. So I just get, but it’s not an MRI of the pelvis. It’s an MRI of the hip. And so that’s a very important distinction because an MRI of the pelvis looks at the whole pelvis kind of from far away. MRI of the hip is a zoomed in view, which shows more finer detail.
Speaker 1 (00:41:12):
Okay. I was going to ask you that because I get MRIs of the pelvis and the radiologists I work with are actually musculoskeletal radiologists. They’re really good at looking at the hip for me. And they’ll say, they’ll make comments even though it’s non arthrogram, it’s just a non-contrast, MRI pelvis. They will say things like, suspected hip labral tear recommend MRI of the hip. So I didn’t understand, I assume that meant an arthrogram, but you’re saying, so I don’t need to order arthrograms. Maybe I’m, am I?
Speaker 2 (00:41:44):
No, no. I mean, I think you need to order MRIs of the hip, but just don’t get the arthrogram. You don’t need to have them have an injection in their hip anymore. I think that we used to do that a lot, and it was, but a lot of, most of the surgeons around the country, like myself, who do a lot of hip surgery, we typically don’t order the arthrogram anymore. It’s also very helpful to not get the arthrogram because you can see little subtle areas of inflammation within the hip. You can see areas where there’s some fluid that you would not see. And I always say when you put dye inside of the hip, it looks like the sun. It’s like a bright area. So sometimes when you’re trying to look at something and you’re staring at the sun, it’s difficult to see the details. But when that dye is not in there, you can see some subtle details inside the hip you couldn’t see
Speaker 1 (00:42:33):
Prior. That’s good to know. And there’s no maneuver, right? They just lay flat on the MRI. There’s, there’s
Speaker 2 (00:42:40):
No, yeah, they just lay flat. But they use, with MRIs now, they use coils. They use these special coils that go around the joint. They use that for shoulders, hips, and knees to get better. Fine, like finer detail.
Speaker 1 (00:42:52):
Got it. And what about ultrasound? I’ve seen some, some radiologists use ultrasound for the hip. How does that help?
Speaker 2 (00:43:00):
So I mean, I use ultrasound for injections. I don’t really use ultrasound as a diagnostic tool. Sometimes when people come into the office and their hip is really hurting and they’re limping and they’re having trouble walking, yeah, I’ll put an ultrasound on the hip to look for an infusion to look for water, and then I’ll go in and pull the fluid out of their hip. And actually, that makes them feel amazing. I mean, they’ll come in crippled and you pull the fluid out of their hip and they walk out feeling amazing. Right. So I’ll give you that sometimes. But I use it mainly for injections. I don’t really use it as a diagnostic tool.
Speaker 1 (00:43:39):
Got it. We have a question that’s related to surgery. And when we do surgery in the groin area, we’ve been taught not to put any sutures in the periosteum because it’s been associated with having chronic pain. Now, I don’t know if it’s because that’s like a, you’re suturing Mesh and that’s the problem, but Oh yeah. We’re taught not to put it in. It can cause osteitis and osteitis pubis and all that. But as orthopedic surgeons, that what you do all the time? Or is it, what’s a thought behind
Speaker 2 (00:44:18):
I mean, the periosteum is, the way you think about it is it’s a covering around the bone. It’s like a covering. And when children’s periosteum can be very thick as we get older, the periosteum is very thin. It’s aligning around the bone, and there’s a lot of growth factors that are in the periosteum that help bones heal when they break and stuff like that. And cause you can get inflammation from that. We don’t typically, as orthopedic surgeons, we don’t put sutures into the periosteum, but obviously we put screws and anchors and lots of other stuff into the bone.
Speaker 1 (00:44:56):
We do. A lot of the bones are deeper than the periosteum.
Speaker 2 (00:44:58):
Deeper than the periosteum, exactly. So we don’t really put sutures into, but we put sutures. So when we do surgery, we hip surgery, we put sutures around the labrum and then bury those sutures into the bone using anchors that kind of secure the labrum to bone and provide stability of the labrum so it heals. So the tear heals, but we don’t really put sutures into the superficial area. But I think for you, in the pubic tubercle, there’s a lot of things happening there. There’s a lot of different structures attaching there and stuff like that. And that can cause probably some irritation from those sutures. I, I’m sure that that’s a issue, but we don’t really do that
Speaker 1 (00:45:47):
As part of, we discussed some of our colleagues that do surgery for athletic pubalgia, and part of it is to kind of sew the rectus or the adductor up to the pubic tubercle. But then don’t they put the suture into the periosteum? Or is it that they’re getting into the bone? You mean mean
Speaker 2 (00:46:06):
For the adductor?
Speaker 1 (00:46:07):
Yeah.
Speaker 2 (00:46:08):
Yeah, they put that into the bone. So those are, what they do with those anchors is they drill a hole into the bone and they put a screw, dissolvable screw into the bone, and then sutures come out of that. So it’s more deeper. Yeah,
Speaker 1 (00:46:22):
Deeper. Okay. So the issue is deeper, I guess you’re just so you’re not pulling on a flap of periosteum that maybe that’s what No, yeah. So we’re taught, well, not, we’re taught, we teach <laugh> not to put suture into the periosteum, but rather onto the rectus fascia on top of the periosteum, which is fine but when I do, some of the people who have nerve damage in their abdominal wall, we have to secure the Mesh to bone. So it’s really to the pelvic bone and the Rives, and they don’t have pain from that. But I think it’s because we just go deeper.
Speaker 2 (00:46:59):
Okay. Yeah. Yeah, that makes sense.
Speaker 1 (00:47:03):
Another question in the same line, it says, but if you’re putting screws in bone, aren’t you there by going through the periosteum? And could that then cause pain?
Speaker 2 (00:47:14):
Typically, it is a great question. In the past when the material that was being used for these screws, when I was a resident a long time ago, I won’t give you a number. I think
Speaker 1 (00:47:29):
Around the same time I was a resident,
Speaker 2 (00:47:31):
Probably same time you were a resident, we were spring chicken still, of course. But when screws go into the bone, this material that used to be made of was a type of plastic. And that plastic used to cause big reactions, big cysts and crazy amount of inflammation in the bone, like big holes in the bone. But now the technology has really advanced, and so now those screws are made of calcium and much, much less plastic. And so we don’t get those reactions anymore. I think the technology is really, or some of the anchors are made of AER substance called peak, which is kind of like a, it’s as almost as hard as bone, but it’s really strong. Doesn’t dissolve, but it’s really strong and you don’t get a allergic reaction to it. So we’ve come a long way. And I guess the answer to that is yes, if you put strange plastic substances probably in your business, some weird Mesh substances can cause reactions. And in our business, the same thing. When you put weird plastic in people, it can cause reactions. And so that’s why. But thank God we’ve advanced and technology’s advanced that we don’t have those issues anymore.
Speaker 1 (00:48:46):
Any other hip disorders we haven’t talked about? I feel like it’s almost always a f r femoral impingement with labral tears.
Speaker 2 (00:48:54):
Yeah. So a couple things. So on the side of your hip, when you lay on your side, there’s an area called the bursa. And so patients can get chronic bursitis. So on the side of your hip, there’s a bone, it’s called your greater trochanter. That’s the piece of bone you feel when you push on the side of your hip. Yes. Attached to that bone is a tendon called the gluteus medias, and that’s the most important muscle of your hip. There’s three muscles. There’s the minimus, the medias, and the maximus. The maximus is kind of your rear end. The minimus is the tiny little muscle inside your hip. And the medias the one in between is a critical muscle of your hip. If you cut that or damage that or injured it, you would have a limp for the rest of your life if it wasn’t repaired.
Speaker 2 (00:49:40):
But superficial to that, so there’s the trochanter, the buds medias attaches there, and just superficial to that is a bursa. And then superficial to that is your iliotibial band. Iliotibial band is a band of fascia. It’s a thick tissue that goes from your hip down to your knee. And some people get chronic bursitis where that bone rubs and causes irritation, where very majority of bursitis are treated with a combination of ice and heat and stretching out your IT band, doing foam rolling and different kind of yoga type stretching to stretch it out. But some people get chronic bursitis. And if it’s resistant to injections and physical therapy, I sometimes go into the bursa arthroscopically and remove the bursa and to relieve their symptoms. And then also people get tears of the gluteus medias in their hip, where I go in there and I repair those tears. It’s almost like a rotator cuff tear of the shoulder in elderly patients. Patients that are like, let’s say 75, 80 years old, many of them have gluteus medias tears, but we don’t fix ’em because they don’t heal. But people in their fifties and sixties that have gluteus medias injuries, we fix a lot of them and they get better.
Speaker 1 (00:50:58):
We have a question about a hip alignment issues. What about if you’re deconditioned or have a longstanding hernia you or problems with the repair, then you have hip alignment issues. What is that and how is that treated?
Speaker 2 (00:51:12):
Well, I think that the important thing about the body is that your body’s not just a hip. And it’s not just a pelvis, it’s the whole thing. So when you walk, your foot strikes the ground, it sends energy through your calf and your knee up your thigh into your hip and into your spine, into the rest of your body. We call that the kinetic chain. There’s a kinetic chain of forces that go through your body. So part of what we do, and part of why we, you and I, and many surgeons and doctors around the country work with a lot of body people, physical therapists, chiropractors, movement disorder people, they look at that. They look at their foot. So if you have pronated feet, if you have a high arch, we try to support that with orthotics or special types of shoes. If you have weakness in your quad or your hip musculature, strengthening those muscles can get your alignment better.
Speaker 2 (00:52:07):
And then also working on your flexibility. If you have one hip that’s tight and one hip says loose, there’s a lot of compensation. If you have an ankle that’s too stiff or a knee that doesn’t get straight, there’s certain things that can happen to your body that can affect things. In my business, we see a lot of patients that injure their foot, break their ankle, have a knee surgery, and then after they recover from that surgery, their other hip starts becoming painful because they’ve been compensating for so long, they tear their labrum on the other side because they’ve been compensating for this poor alignment. So I think getting evaluated is important by your doctor, your orthopedic surgeon, and then seeing a connecting with a good body person, a good physical therapist in town that really can incorporate your entire body in the whole thing. And I think that kinetic chain concept is critical for people to get better because if you just pay attention to the hip alone, you’re never going to get better.
Speaker 1 (00:53:05):
I agree. And I think something that I’m blessed to eventually do. It wasn’t like that when I first started practice which is that I have all my different specialists and we kind of coordinate. I learned from them, they learn from me, and it becomes a really, really great way of treating patients. And I feel like our medical system is so vertical, and a lot of my patients go to a neurologist. It’s not your nurse, they go to a spine doctor. It’s not your spine. And they’re, but they’re not really given any direction or not led. I kind of enjoy the puzzle solving and working with a different specialist. We don’t get to operate much together, which I think that’s probably a good thing. Shouldn’t I don’t see that any reason to do a hernia repair and a hip at the same time. I think it’s probably not a good idea. So the operation should not be done together. But I do drop in your, or every so often if I can’t <laugh> to see what you’re doing. Cause I did what a month as a resident. That’s about the most ortho
Speaker 2 (00:54:15):
Orthopedic you saw. Yeah,
Speaker 2 (00:54:17):
No, I think if it’s a minor thing, I think if it’s super minor, like a little nerve release or this or that, it can be done in combination. I think there’s some surgeons that are doing some of these kind of athletic pubalgia injuries where they’re releasing the abductor. And I have been doing some of that, if not hernia. But when someone has a very, let’s say they’ve had multiple hip arthroscopies and their abductor tendon is very painful, which is the tendon that’s on the inside of your thigh sometimes what I’ll do is I’ll do a hip arthroscopy and after this, the hip arthroscopy on the same sitting, I’ll make an incision over the abductor and release some of the fascia around it to release some of the tend in it. And that can make people a lot better, can relieve a lot of their symptoms and make them improve significantly. So I definitely think that there’s certain things that can be done, but I do agree it should be separate and addressed separately.
Speaker 1 (00:55:19):
But
Speaker 2 (00:55:19):
I’d love to operate on with you if you wanted to. <laugh>. Thank you. We have fun. I
Speaker 1 (00:55:24):
Do. We have a lot of fun. I wish I wish our specialties were such that we could be in the OR more than just like in the office together. But I do want to thank you for your time on this. As those of who are on hernia talk I bring in the best and the brightest. And anyone who I respect and recommend I bring here, I learned, I’ve learned so much as this hour. I had a totally different idea of what a labrum was. <laugh> patient. But it’s good. So thank you for teaching me that whole suction cup thing. That’s a great analogy. Yeah. And appreciate that. I want to give you a little plug. Some people may not know. Dr. Snibbe has invented these new shoes. Yeah, they’re called SNIBBs, SNIBBS. You can buy them online. I bought a pair for my mom, and I’ve told this to him before, multiple times. She loves the shoes. It makes her more. I love it. She has less hip and knee pain. She wears ’em in the house as well as outside the house. They’re cute. They don’t look like typical Nikes or anything but they look good. And I think, thank you. Do you wear them in the or?
Speaker 2 (00:56:43):
Yeah. I mean, basically I, myself and my partner, Daniel who, who’s a chef, we designed it for both of our specialties. It’s basically a shoe for anyone that stands for a long time for nurses, doctors, physical therapists, anyone that works in a hospital or a surgery center or doctor’s office. But also for all the service people that work as chefs, waitresses, waiters anyone that works on movie sets, anyone that stands for a long period of time. They’re waterproof, they’re slip proof. And we designed them for people to stand. And I personally designed the whole shoe to make it supportive and comfortable for people. And we, it’s really been a labor of love for me and I’ve really proud of what we’ve accomplished. We’re going to keep moving with the company and designing different things, and I think that it’s really exciting. But yeah, please visit the website. It’s www.snibbs.co. And it’s great shoes. They come in gray, white, and black, and try a pair. We’re getting amazing responses from it. Lots of people are wearing it, and I wear ’em in the or. I actually wear ’em my clinic as well. All my staff wears it. My PAs, my assistants, all the people in our hospital wear it. So they’re very popular now.
Speaker 1 (00:58:03):
I think clogs, the original clogs, the wooden clogs were invented for chefs and then surgeons and so on started wearing it. And the reason why it’s so good is because as surgeons, we need to stand a lot. So stability and standing is very important. Same with chefs are just standing. Walking is not a big part of what we do. It’s that standing. But what I learned though is ever since my back issues clocks are too stiff.
Speaker 2 (00:58:34):
Too stiff.
Speaker 1 (00:58:35):
And I think your tennis shoes offer the sponginess that you need. So you get less pressure on the back. And I think if you’re a normal person, you wouldn’t notice it. But once I start getting back problems, I notice that the sponginess and the support that you see, your shoes, I don’t get in clogs. So it’s not as good for your lower
Speaker 2 (00:58:59):
Back. And the problem with clogs is that it’s okay if you’re standing still, but the minute you want to walk, you want to go from the OR to go see your next patient. You’re kind of fumbling around. So we wanted to create a shoe that is comfortable standing still. It protects your foot. So, because the problem with tennis shoes is that blood oil, water goes right through the shoe onto your foot. So we want to protect your foot from all the elements, but then also have a shoe that’s comfortable standing still, but also comfortable when you’re going to walk and go see your patient, or you’re going to walk to your car to go home or you want to walk around. So we created a really versatile shoe and we’re proud of it. And thank you. Thank you for
Speaker 1 (00:59:44):
Well, congratulations on it, I tell you. Thank you. It’s a staple in my house.
Speaker 2 (00:59:48):
Thank you. Thank you. I’m glad you like it.
Speaker 1 (00:59:51):
Yeah, I do appreciate it. So we
Speaker 2 (00:59:54):
Appreciate you. Thank you for having me. Appreciate
Speaker 1 (00:59:56):
It. Thank you very much. I understand that you and other friends of mine and colleagues who I respect, you all have really long days at work and then for you to donate an hour of your time on a midweek when you can be with your family I really do appreciate. So on that note, I’m going to say goodbye. Thank you very much for your time. Thank you. And thank you for everyone else who’s joined us. It’s been great questions and lots of great interactive dialogue. I learned a lot. I hope you guys learned at least as much as I did. I will make sure this is posted on YouTube so you can watch it and share it with your friends or kind of catch up on areas where you are to learn more. You can of course follow me on social media, on Twitter and Instagram at Hernia doc and on Facebook at Dr. Towfigh where this is also being Livecast and will stay on for you. So thank you very much. Goodbye and I’ll see you next week on another Hernia Talk Live. Thank you.
