Psoas Lengthening

Partial Psoas Lengthening

Psoas Lengthening
The iliopsoas (Psoas) is a muscle that originates within the pelvis and passes over the front of the hip joint before inserting on the femur (thighbone) at the lesser trochanter. As it travels from inside the pelvis to the femur it starts as a muscle and transitions to a tendon. The primary function of the iliopsoas is to flex the hip joint (serve to bring the knee to the chest). In some instances this tendon/muscle can become irritated and/or tight. Athletes and individuals who engage in sports or activities (such as running and sprinting) that involve rapid and repetitive hip flexion are at a greater risk for injury of this muscle/tendon. If the iliopsoas is tight for a long period, it may rub across the front of the hip joint and cause a snapping sensation and/or damage to structures of the hip, a scenario known as psoas impingement. Psoas impingment can be accompanied by significant pain and disability and when accompanied by a snapping sensation and/or sound is referred to as “internal snapping hip syndrome.” Dr. Anz will evaluate a patients symptoms and physical examination. The first step for treating psoas impingement is a trial of stretching, anti-inflammatories, physical therapy, and rest. In many cases, the inflammation will resolve and the symptoms decrease. A trial of physical therapy is necessary with a goal of guided stretching and hip strengthening. If pain and snapping sensations do not improve, Dr. Anz may recommend surgery to lengthen the muscle/tendon unit. The iliopsoas is an important stabilizer of the hip joint, so for some patients this may not be the best option. Dr. Anz will determine if this approach will offer the best outcome based on a patient-by-patient basis. When a psoas lengthening is deemed appropriate, he will use an arthroscopic approach. During surgery, keyhole incisions are used at the hip where he can insert a small camera and surgical tools to view the inside of the hip joint and perform the lengthening. To relieve tightness and eliminate the symptoms of the tendon rubbing over the front of the pelvis, Dr. Anz will release the tendon portion of the iliopsoas at the hip leaving the muscle portion of the iliopsoas intact. This lengthening leaves the hip flexor attached to the femur, but releases the tension creating the problem. Following arthroscopic hip surgery for psoas hip impingement, Dr. Anz will prescribe a through rehabilitation program. This will consist of a progressive plan that will involve week-by-week rehabilitation exercises and a set of recommended protocols. Depending on the length of prior symptoms and associated injury, most patients are able to return to their previous activities within 4-6 months following surgery. For additional information on the treatment for psoas impingement, or to learn more about arthroscopic hip surgery and partial psoas lengthening, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute. 
Hip Pain

Hip Labral Repair

Hip Pain

Injury Overview

The acetabular labrum is a type of cartilage that covers the rim of the hip socket (known as the acetabulum).  It may be injured as a result of a sports accident or an acute injury such as a hip dislocation or subluxation. It also can be injured gradually with time in settings of femeroacetabular impingment.  The labrum exists to provide stability to the hip joint mainly by creating a negative pressure seal at the hip, this aids smooth hip motion and flexibility.  Damage to the labrum may be a major source of hip pain and weakness for athletes. However, not all labral tears are associated with hip pain.  Some studies have shown that they may exist in patients without pain/dysfunction at the hip.

If a acetabular labral tear is identified, it is important to determine that it is associated with pain from the hip joint.  When a labral tear is identified, strengthening the muscles around the hip joint will improve function and decrease pain in most instances.  If initial strengthening measures do not improve a patient’s symptoms, Dr. Anz may recommend a hip labral repair using hip arthroscopy.  During this procedure, Dr. Anz will use a small camera and tiny instruments to enter the hip and view the acetabular labrum and surrounding structures. Treatment for the actual tear will involve shaving and smoothing out the torn portion of the labrum (debridement) and/or reattaching healthy segments with sutures (repair).  Repair involves sutures (strong string-like material) and absorbable anchors (strong screw-like implants) which have been developed specifically for the hip.  The sutures and anchors are used to secure the labral tissue to the base of the acetabulum.

In some situations the labral tissue may be damaged beyond repair.  This can occur in scenarios where femeroacetabular impingment has been present for many years.  In these instances, Dr. Anz may perform reconstruction of the labral tissue using a graft. The graft will come from the patient or from a cadaver in order to reconstruct the damaged labrum. The goal of labral repair or reconstruction surgery is to restore the negative pressure seal which the labrum creates, thus restoring near-normal biomechanics of the hip.

Following hip labral repair surgery, Dr. Anz will prescribe a week-by-week rehabilitation protocol to follow.  This will be a progressive process where the patient works with a therapist to regain full range of motion and strength back to the hip joint. Depending on the exact nature of the surgery and complexity of the injury, recovery is estimated at 4-6 months.

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For additional information on labral tear repair surgery, or to learn more about arthroscopic hip surgery, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute. 

Gluteus Medius Injury

Gluteus Medius/Minimus Repair

Gluteus Medius Injury

The gluteus medius and gluteus minimus are muscles which are important for motion and stability of the hip joint.

 They are key to activities of daily living as well as sporting activities. The muscles originate on the pelvis and insert on the femur, at the greater trochanter. The greater trochanter is an area near the top portion of the femur (thighbone). In some instances the tendinous attachment of these muscles can undergo degeneration and/or detachment at their insertion site on the greater trochanter. This injury to the tendon can result in hip weakness, pain, and/or disability. Surgeons have recently begun utilizing arthroscopic surgery techniques for repair of these tendons where they insert on the greater trochanter.

In patients with hip pain and weakness, Dr. Anz will first evaluate for signs of tendon injury. If the gluteus muscles are found to be injured, some can improve with rest and therapy to strengthen muscles around the hip. Anti-inflammatory medication and stretching can also help decrease symptoms for some patients. If pain and functional limitations persist, surgery to repair the tendon at the attachment site may be helpful. The arthroscopic repair of the gluteus medius and/or minimus tendons is usually accompanied with removal of surrounding tissue that has become irritated, including inflammed greater trochanter bursal tissue. Additionally, a tight band of tissue overlying the area, the iliotibial band, may also be released. In some instances, can help decrease pain associated with inflammed bursal tissue, also know as bursitis.

During surgery, the torn gluteus medius or minimus tendon will be reattached to the native attachment site near the top of the femur on the greater trochanter. Suture anchors are embedded in the bone and strands of suture are then passed through the pulled-off portion of the tendon using specialized passing instruments. By tying these sutures, the torn tendon is once again attached to the bone.

Gluteus Maximus, Gluteus Medius, Gluteus Minimus

Following arthroscopic hip surgery for a gluteus medius repair or gluteus minimus repair, patients will need to avoid certain hip motions and exercises for 6 weeks. A brace helps to decrease stress at the repair site during this time as well.

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For more information on arthroscopic hip surgery or for additional resources on the repair of a gluteus medius or minimus tear, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute.

Hip Runner Orthopedics

Chondroplasty

Hip Runner Orthopedics

Articular cartilage is a soft, fibrous tissue that covers the ends of bones within a joint, allowing for smooth, low-friction motion. Articular cartilage can become damaged through trauma associated with sporting accidents, femeroacetabular impingment, or as a result of the normal aging process. 

While certain structures within the hip joint may be capable of healing, articular cartilage has an extremely low healing potential. Chondroplasty is a procedure intended to remove mechanical symptoms related to cartilage injury and help prevent further injury to the cartilage. The goal is to delay the onset or progression of arthritis of the hip, which is often the result of cartilage damage.

When articular cartilage becomes damaged, loose flaps of cartilage may cause mechanical symptoms and/or can break off and become lodged in the hip joint. Eventually, cartilage damage may leave exposed bone resulting in bone-to-bone grinding sensations and a loss of joint motion. This is often associated with hip pain and hip stiffness, thus limiting movement and function. Arthroscopic hip chondroplasty is a procedure that Dr. Anz performs to remove mechanical symptoms and improve function. The approach has been shown to be most successful in patients with small, partial thickness injuries where the damage has not yet reached the bone itself and when the deforming force causing the cartilage injury can also be removed, such as in the setting of CAM femeroacetabular impingment. During this procedure, which is performed arthroscopically using tiny keyhole incisions, the loose flaps of cartilage are removed. Using a camera (arthroscope), Dr. Anz will be able to visualize where the loose pieces of fragmented cartilage are located, and will remove them. He will also address other abnormalities in the same surgery. In patients who are found to have exposed bone from loss of cartilage with good intact surrounding cartilage a microfracture procedure may also be performed to regenerative tissue. Although microfracture cannot restore normal cartilage, it does produce functional tissue.

Following arthroscopic hip chondroplasty, Dr. Anz will prescribe a thorough physical therapy and rehabilitation program. This will be a progressive process and will work on restoring motion, strength and full function of the hip joint. Patients who undergo a microfracture procedure can expect to be on crutches for 8 weeks.

Hip MRI

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For more information on arthroscopic hip surgery, including chondroplasty of the hip for articular cartilage treatment, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute. 

A volleyball player jumps to spike the ball.

Hip Arthroscopy

A volleyball player jumps to spike the ball.

Dr. Adam Anz is trained in hip arthroscopy and uses this approach to treat a number of hip conditions.

Hip arthroscopy uses tiny, keyhole incisions to insert a small video camera (known as an arthroscope) and surgical tools inside the hip joint. The camera projects onto a high-definition video screen giving Dr. Anz and his surgical team a clear picture of structures in and around the hip.  This allows first-hand analysis of injury and can be done in order to repair and correct problems.

Historically, hip surgery has involved an open approach to the joint.  This involves making an incision on the skin and approaching the joint with a surgical dissection. Arthroscopic hip surgery has advanced in recent years making it possible to treat some problems with smaller incisions and without a surgical dissection.  While not all hip problems can be treated with hip arthroscopy, this technique opens the door for treatment of some hip injuries with a less invasive manner.

Dr. Anz uses an arthroscopic approach to address the following acute and degenerative conditions of the hip:

  • Femeroacetabular Impingment (also known as FAI Impingment)
  • Acetabular Labral Tears
  • Synovitis/PVNS
  • Psoas Tendon Pathology and Internal Snapping Hip Syndrome
  • Removal of Loose Bodies
  • Iliotibial Band Snapping and Trochanteric Bursitis
  • Articular Cartilage and Chondral Damage
  • Gluteus Medius and Minimus Tears
  • Hip Instability
Dr. Adam Anz performs surgery.

Following hip arthroscopy, it is important to follow the rehabilitation regimen that is set forth by Dr. Anz and by your physical therapist. Recovery following surgery is a partnership between the doctor, physical therapist, and patient. The results of the surgery are most effective when a post-operative rehabilitation program involving physical therapy and exercises are implemented daily. Dr. Anz can make recommendations for physical therapists in your area to help facilitate this process.

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To learn more about hip arthroscopy, or to schedule a consultation please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute. 

Acetabuloplasty

Acetabuloplasty (Pincer Impingement)

Acetabuloplasty

Femeroacetabular Impingment, often referred to as FAI for short, refers to a condition where there is a abnormality of the shape of the bones of the hip joint. 

FAI can include an abnormality of the femur, bone in the thigh, where it is shaped like a ball (Femoral Head), or FAI can include an abnormality of the pelvic bone where it is shaped like a socket (Acetabulum). In some scenarios, there may be abnormalties of both the femoral head and acetabulum. A pincer lesion is an anatomic abnormality of the acetabulum where there is too much bone covering the femoral head. The pincer lesion may cause impingement at the hip with certain hip motions. With time and repetition, impingement at the hip can lead to degeneration of the acetabular labrum and cartilage within the hip joint. A surgical treatment for pincer impingement is acetabuloplasty, where the bone causing the impingment is shaved with a burr.

Before Dr. Anz will recommend surgery for hip impingement, he will first try non-operative measures consisting of rest, activity modification, and physical therapy to strengthen the core musculature and muscles around the hip. Injections into the hip may also be used for diagnostic and therapeutic purposes. If a patient continues to have ongoing hip pain, acetabuloplasty surgery for hip impingement may be recommended. The goal of an acetabuloplasty is to correct the bony conflict by removing excess bone . Often this procedure will be coupled with measures to address any labral or cartilage damage that may also exist.

Dr. Adam Anz performs surgery at the Andrew's Institute.

During this procedure, Dr. Anz will use an arthroscopic surgical approach using two to three keyhole incisions. A camera (known as an arthroscope) is inserted into the hip to visualize the excess bone while the other incision is used to insert instruments to remove the excess bone. Often an arthroscopic burr is used to accomplish this. Hip acetabuloplasty entails taking away the area of over coverage on the acetabular side to relieve the bony impingement and create space allowing normal motion.

Following acetabuloplasty surgery for hip impingement, a thorough physical therapy program will be prescribed. This will include a progressive week-by-week plan that will work to restore motion of the hip while protecting repairs. Patients are typically on crutches for four weeks and placed in a brace to protect their hip during healing.

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For more information on FAI impingement of the hip, pincer impingement of the hip, or for additional resources on treatments acetabuloplasty and arthroscopic hip surgery, please contact the office of Dr. Adam Anz, orthopedic hip surgeon in Gulf Breeze, FL.

A hockey player slides to defend a goal.

Fasciotomy (Iliotibial Band Release)

A hockey player slides to defend a goal.

The IT band (iliotibial band) is a thick band of fibers that runs the length of the outside of the hip and thigh—from the pelvis all the way down to the tibia (shinbone) just below the knee. 

Sometimes irritation and snapping can occur where this structure passes over a boney prominence known as the greater trochanter. This irritation is called bursitis and often occurs naturally as we get older. In athletes long episodes of training without rest or a proper stretching regimen can also cause bursitis and a tight IT band resulting in iliotibial band syndrome.

When patients present with IT band syndrome and/or greater trochanter bursitis, Dr. Anz will first recommend a trial of non-operative measures. This includes a period of rest, eliminating any activity that may flare the symptoms (e.g. running long distances), and methods aimed to decrease inflammation at the location. Physical therapy is often helpful to guide patients on methods to decrease the tension on the IT band as well as to help strengthen the adjacent musculature and core.

Surgery is treat IT band tension and bursitis is rarely necessary, and in some instances it may not be helpful. The rare instance where surgery is necessary is in cases of external snapping hip syndrome which does not respond to non-operative measures. Dr. Anz ultilizes an endoscopic technique to approach surgical cases of external snapping hip syndrome. First, he will perform an iliotibial band release (known as a fasciotomy). Using an arthroscope in an endoscopic fashion, Dr. Anz will get a visual of the IT band and will perform a small release in the fascia. 

Dr. Adam Anz performs a surgery at the Andrew's Institute.

He makes this release at the area of maximum tightness by cutting a diamond shape release at the area of the greater trochanter. The goal is to prevent further snapping sensations. This limited release also slightly lengthens the entire IT band. A second step is a trochanteric bursectomy. This involves the removal of inflamed bursal sac and irritated tissue.

Following surgery to treat IT band tightness, patients can be weight bearing as tolerated as long as an additional tendon repair has not been performed. Dr. Anz will prescribe a rehabilitation program that will focus on strengthening of core musculature and hip stabilizers in addition to continued IT band stretching.

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For more information on IT band tightness, or to schedule a consultation to learn more about arthroscopic hip surgery, fasciotomy, or iliotibial band release, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute.

A soccer player rejoices with her team.

FCL Reconstruction

A soccer player rejoices with her team.

There are four major ligaments, or “restraints” to the knee joint.  They include the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and posterior lateral complex (PLC).  

The PLC is on the outer side of the knee and has three major components: the fibular collateral ligament (FCL, sometimes referred to as the LCL), the popliteus muscle and tendon, and the popliteofibular ligament.  The FCL can become damaged or torn with certain twisting injuries.  Commonly, this injury is sustained in high movement athletics such as football or soccer.  In some instances, the FCL may heal on its own after an injury; however, in certain instances, the ligament is torn to the extent that an FCL reconstruction is necessary.

By examining the knee and obtaining X-rays where the ligament is stressed, it is possible to determine which injuries will heal without surgery and which will require surgery.  If surgery is needed, Dr. Anz will perform an open FCL reconstruction, which will involve either harvesting one of a patient’s  hamstring tendons or the use of a donor tendon, which is also called an allograft.

After surgery, physical therapy is extremely important in order to obtain an optimal result.  Physical therapy begins immediately; however, knee range of motion is limited for 2 weeks.  Patients also cannot place weight on their leg for 6 weeks, as this is the amount of time which is necessary for tendon to heal to bone.  Strengthening begins at 8 weeks, and patients typically return to jogging at about 6 months depending on the extent of the injury.

Human Knee Diagram

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For additional information on FCL knee injuries, or to learn more about FCL reconstruction surgery, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute. 

PCL Reconstruction

PCL Reconstruction

PCL Reconstruction

The PCL (posterior cruciate ligament) is a ligament that is located inside the knee joint near the back of the knee.

This particular ligament is responsible for keeping the bone in the leg from moving backward (or posterior) in relation to the bone in the thigh.  A PCL can become damaged or injured through sports or other traumatic accident such a motor vehicle collision. Some of these injuries may present themselves as mild tears, while others represent full tears.  PCL knee injuries are not as common as ACL knee injuries, however, many times it is because a PCL knee injury may simply go undiagnosed.

Mild PCL knee injuries can oftentimes heal on their own. In certain instances the ligament is torn to the extent that a PCL reconstruction may be necessary.

Dr. Anz performs PCL knee reconstructions following a thorough assessment of the knee using an MRI so that the extent of the injury, location, and pattern of injury can be determined.

Surgical reconstruction of the PCL is usually only recommended for grade III PCL tears. During a PCL reconstruction, Dr. Anz will reconstruct the ligament using a graft. This graft usually consists of donated tissue (i.e. the quadriceps) from another person (known as an allograft). Sutures will be used to complete this process and to tightly secure the ligament to as close to its native footprint as possible.

PCL Reconstructive Surgery

Following PCL reconstruction surgery, a brace is required for six months to prevent gravity from stretching out the reconstructed ligament.  Physical therapy is a very important part of the recovery process and is recommended in order for the patient to make a full recovery and receive optimal results.  It is recommended, that after surgery, rehabilitation begin so that patients can begin striving towards range of motion, strengthening of the knee, and full mobility. Initially, patients cannot place weight on their leg for 6 weeks.  Strengthening begins at seven weeks, and running and cutting sports are delayed for up to 24 months.

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For additional information on ligament injuries of the knee, or to learn more about PCL reconstruction surgery of the knee, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute. 

ACL Reconstruction

ACL Reconstruction

ACL Reconstruction

Injury Overview

ACL knee injuries are among the most common injuries for athletes.  The ACL (anterior cruciate ligament) is one of four ligaments that make up the knee joint and is responsible for keeping the shinbone (tibia) from sliding forward on the thigh bone (femur) and providing stability for movements requiring rotation of the knee. Cutting and pivoting athletes, including soccer players, football players, basketball players, and skiers, are at a higher risk for developing an ACL knee injury because of the sudden pivots, twists, and turns associated with these sports. The ACL can also be torn in cases that do not involve sports, such as tripping, missing a step, or any other traumatic hit to the knee.  Typically, the knee sustains a “pivot shift” event where the bones of the knee shift in an abnormal way.

Symptoms

Patients who have an ACL injury are typically present after a twisting injury event. If during a practice or competition, athletes typically report that they could not continue to perform/compete during that day and that the knee swelled immediately after the injury.  Swelling inside the knee from the injury routinely causes it to swell to the size of a softball.  Sometimes, athletes report the sound of one or more pops.  After a few days, the swelling improves and the function returns.   After an ACL injury,  recurrent feelings of “giving away” or instability of the knee are common. These episodes can be problematic because continued pivot shifting events can be associated with further injury to the knee, including injuries to the medial meniscus.   The knee can shift with certain movements such as pivoting to open a door or cutting with an attempt to return to sport.

Diagnosis

Listening carefully to the athlete’s history of injury is always the most important first step to knowing the problem.  Examining the patient thoroughly is the second step, and the Lachman test, anterior drawer test, and pivot shift test are ways to test the ACL for injury. These tests are not painful; however, it is understandable to be apprehensive of tests of knee stability.  X-rays are important to see the bone anatomy of an injured athlete, as overall alignment affects the forces on ligaments and knees, and to rule out fractures.   MRI is an additional necessary test when an ACL is expected in order to confirm the diagnosis and look for associated injuries, as in many instances the lateral meniscus is injured at the time of an ACL injury.

Treatment 

Nonoperative Treatment

Depending on the patient’s lifestyle and goals, the ultimate objective is to return the patient to their pre-injury activities.   This involves an individualized treatment plan to regain stability and full mobility of the knee. 

Human Knee Diagram

In some cases of isolated ACL injury, surgery may not be necessary, depending on a patient’s goals. Conservative treatment consists of rest, ice, elevation, anti-inflammatory medications, and physical therapy to strengthen the muscles around the knee and to improve neuromuscular control around the knee.  An ACL brace can also help protect the joint during the rehabilitation process.

Surgical Treatment

In athletes who are returning to cutting and pivoting activities, ACL reconstruction surgery is most often recommended.  In some instances, an ACL repair can be considered. During ACL reconstruction surgery a tendon graft of a similar size is used to replace the injured tissue. Reconstruction surgery is performed arthroscopically and involves removing the injured tissue and creating a new ligament with a graft. The graft used during the reconstructive process is most often taken from the patient.   The central third of the patellar tendon, the central third of the quadriceps tendon, or two of the four hamstring tendons are the most commonly used grafts.   Although donated tissue using a graft bank from a donor can also be used, it has been associated with a higher reinjury rate in some studies.   Graft choice is individually decided with the patient.

Post-Operative 

After a reconstruction surgery, a thorough physical therapy program is extremely important for rehabilitation.  Rehabilitation will be a progressive process that may initially limit movement.  The first phases focus on swelling and the return of normal knee motion.  Further phases focus on regaining strength, balance, and functional movement patterns.

Recovery Time

After an ACL reconstruction, cutting and pivoting activities are limited until around the 7-month time point as graft maturation takes time.  Two studies on reinjury rates suggest that risk decreases significantly with every month until the 9-month time point.1,2  For this reason, in most instances a return to cutting/pivoting sports is cautioned before the 9-month milestone.  However, every athlete is unique and situations are unique.  Some instances dictate a sooner return to the sport than 9-months upon understanding the risk.  Post-operative rehabilitation and return to sport is a joint effort/decision between the patient, Dr. Anz, the physical therapist, and the athletic trainer and is necessary to achieve the most optimal outcome.

Athletes with ACL injuries should not feel bad if it takes time to return to their sport.  In many instances, it takes athletes one to two years to make a full return.  A study in high-school and college football players found a return to sport rate of 32% at one year and 64% at two years.  53% of high school players and 50% of collegiate players identified fear as a major or contributing factor to not returning to play sooner.3 Dr. Anz and his team serve as advocates to help athletes return safely and expeditiously to their sport, considering and helping with all hurdles along the way.

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Dr. Adam Anz is an orthopedic knee surgeon in Gulf Breeze, FL.  For additional information on ACL knee injuries or to schedule a consultation to discuss ACL reconstruction surgery, please call our office today.

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