IT BAND SYNDROME

What is it?
The iliotibial band (“IT band”) is a thick band of fascia (a kind of hard flesh) that extends down the outside of the upper thigh. It begins on the pelvis, crosses the hip and knee, and attaches just below the knee. Pain is a result of friction or rubbing of the iliotibial band against the bone on the outside of the knee, which results in irritation of the band. It is one of the most common knee injuries (second only to patellofemoral pain syndrome) and has been reported in as many as 12 percent of runners. Athletes involved in cycling, weightlifting, football, soccer and tennis may also experience pain from the IT band. 

Symptoms

• Pain on the outer part of the knee with sporting activities
• Popping or rubbing sensation on the outer knee
• Pain after sitting for long periods of time with the knee bent
• Pain typically worsening with activities

Sports Medicine Evaluation and Treatment
A sports medicine physician will ask an athlete questions about potential risk factors for ITBS, including running mileage, change in mileage, uphill and downhill running routines, and track workouts. Running the same direction around a track for a long time may worsen ITBS symptoms. A sports medicine physician will perform a thorough physical exam of the athlete’s knee and leg. The provider may look at muscle imbalances, flexibility, leg length, hip and knee alignment, running gait, foot arches and footwear.

For ITBS, imaging is not usually necessary, unless the physician suspects that other causes within the knee may be causing the pain. Treatment of ITBS includes rest, ice and anti-inflammatory medications. Athletes may also have to alter training routines during the recovery period to avoid activities that cause pain. Stretching is an important component to the treatment of ITBS, as well as identifying and correcting strength imbalances. Other treatment options include steroid injections, foot orthotics and very rarely, surgical referral.

Injury Prevention
Athletes should maintain appropriate flexibility and strength, and ensure a proper warm-up prior to activity. 

Return to Play
Athletes may expect to return to activity once the symptoms have improved. Cross training is often a useful tool to use to aid in recovery. Once symptoms are improved, the athlete can gradually return to activity, generally over a period of about four to six weeks.

Authors: AMSSM Members Raul Raudales, MD, and David Berkoff, MD

ARE YOUR HIPS SNAPPING MORE THAN YOUR FINGERS?

What is Snapping Hip Syndrome?

Snapping hip occurs when a muscle, tendon, or ligament rolls over a bony prominence in the hip. Snapping hip can occur in different areas of the hip:

• Front. Snapping at the front of the hip can involve the hip flexor muscle rolling over the front of the hip bone, or the hip ligaments rolling over the thigh bone or tissues of the hip joint.
• Side. This condition involves the ITB (iliotibial band) rolling over the outer thigh bone or the big muscle on the back of the hip (gluteus maximus) sliding over the outer thigh bone.
• Back. This condition involves one of the hamstring muscles rolling over the bottom of the hip bone.

Snapping hip can occur when the hip muscles are excessively used and become fatigued, tight, and/or swollen.

Athletic activities like track and field, soccer, horseback riding, cycling, gymnastics, and dance can trigger the condition. It can also occur during everyday activities that require repeated forceful movement of the legs.

How Does it Feel?

Snapping hip causes a snapping sensation and sound that can be felt in the front, the side, or the back of the hip. Often, the snapping can be pain-free. If it causes pain, the pain usually ceases when the leg movement causing the snapping is stopped. In athletes and dancers, the snapping can be accompanied by weakness and may diminish performance.

The snapping is most commonly felt when kicking the leg forward or to the side, when bringing the leg behind the body, when rising from a chair, or when rotating the body or the leg.

Often, walking and running in a straight line are snap-free and pain-free, although in some people these activities are limited by the pain of the structure that is snapping.

Signs and Symptoms

With snapping hip, you may have:

• Snapping or popping in the front, side, or back of hip when lifting, lowering, or swinging the leg
• Weakness in the leg when trying to lift it forward or sideways
• Tightness in the front or back of the hip
• Swelling in the front or side of the hip
• Difficulty performing daily activities such as rising from a chair and walking

How Is It Diagnosed?

If you see your physical therapist first, the therapist will conduct a thorough evaluation that includes taking your health history. Your therapist will ask you:

• How you injured your hip and if you heard a pop when you suffered the injury
• If you feel snapping, popping, or pain
• Where you feel the snapping or pain
• If you experienced a direct hit to the leg
• If you saw swelling in the first 2 to 3 hours following the injury
• If you experience pain when lifting your leg forward or backward, walking, changing directions while walking or running, or when lifting the knee
• If you participate in any repetitive, forceful, or plyometric (quick explosive jumping) sport activities.

Your physical therapist also will perform special tests to help determine whether you have a snapping hip, such as:

• Asking you to lift your leg quickly
• Asking you to push against the physical therapist’s hand when he or she tries to push your leg outward, backward, and forward (muscle strength test)
• Gently feeling the muscle to determine the specific location of the injury (palpation)

Your therapist may use additional tests to assess possible damage to other parts of your body, such as your hip joint or lower back.

To provide a definitive diagnosis, your therapist may collaborate with a physician or other health care provider. The physician may order further tests—such as an x-ray or magnetic resonance imaging (MRI)—to confirm the diagnosis and also to rule out other potential damage. However, these tests are not commonly needed for snapping hip syndrome.

How Can a Physical Therapist Help?

Your physical therapist will design a specific treatment program to speed your recovery, including exercises and treatments you should perform at home. This program will help you return to your normal life and activities and reach your recovery goals.

The First 24-48 Hours

Your physical therapist may advise you to:

• Rest the injured hip by avoiding walking or any activity that causes pain. In rare cases, crutches may be recommended to reduce further strain on the muscles when walking.
• Apply ice packs to the affected area for 15 to 20 minutes every 2 hours.
• Consult with another health care provider for further services such as medication or diagnostic tests.

Reduce Pain

Your physical therapist can use different types of treatments and technologies to control and reduce your pain, including ice, heat, ultrasound, electricity, taping, exercises, and special hands-on techniques that move muscles and joints (manual therapy).

Improve Motion

Your physical therapist will choose specific activities and treatments to help restore normal movement in the leg and hip. These might start with movements of the leg and hip joint that the therapist gently performs, and progress to active exercises and stretches. Treatment for snapping hip often involves manual therapy techniques called trigger point release and soft tissue mobilization, as well as specific stretches to muscles that might be abnormally tight.

Improve Strength

Certain exercises will benefit your injury at each stage of recovery, and your physical therapist will choose and teach you the appropriate exercises that will restore your strength, power, and agility. These may be performed using free weights, stretchy bands, weight-lifting equipment, and cardio exercise machines such as treadmills and stationary bicycles. For snapping hip syndrome, muscles of the hip and core are often targeted by the strength exercises.

Speed Recovery Time

Your physical therapist is trained and experienced in choosing the treatments and exercises to help you heal, get back to your normal life, and reach your goals faster than you might be able to on your own.

Return to Activities

Your physical therapist will collaborate with you to decide on your recovery goals, including return to work and sport, as well as design your plan of care to help you reach those goals in the safest, fastest, and most effective way possible. Your physical therapist will use hands-on therapy and teach you exercises and work retraining activities. Athletes will be taught sport-specific techniques and drills to help achieve sport-specific goals.

Prevent Future Re-injury

Your physical therapist can recommend a home exercise program to strengthen and stretch the muscles around your hip, upper leg, and core (abdomen) to help prevent future injury. These may include strength and flexibility exercises for the hip, thigh, and core muscles.

If Surgery Is Necessary

Surgery is rarely necessary in the case of snapping hip syndrome. If it is required, your physical therapist will help you minimize pain, restore motion and strength, and return to normal activities in the speediest manner possible after surgery.

Can this Injury or Condition be Prevented?

Snapping hip syndrome can be prevented by:

• Warming up before starting a sport or heavy physical activity. Your warm-up should include stretches taught to you by your physical therapist, including those for the muscles on the front, side, and back of the hip.
• Gradually increasing the intensity of an activity or sport. Avoid pushing too hard, too fast, too soon.
• Following a consistent strength and flexibility exercise program to maintain good physical conditioning, even in a sport’s off-season.
• Wearing shoes that are in good condition and fit well.

DIAGNOSED WITH OSTEOARTHRITIS

Our last post, ARE YOU AT RISK FOR OSTEOARTHRITIS? focused on the "before" aspect of a diagnosis, and what risk factors increase your chances for a diagnosis. DIAGNOSED WITH OSTEOARTHRITIS is going to focus on the "after" aspect - what to do after you've been diagnosed. 

1. First and foremost: do not self diagnose.

See your primary care physician, or an orthopaedic specialist. A series of tests and health history questions will allow most medical practitioners to be positive about an osteoarthritis diagnosis, but for physical proof, you'll need either an X-ray or an MRI. 

Why an X-ray? More advanced cases of osteoarthritis will be visible in an X-ray.  Severe cartilage degeneration will be visible (or more realistically, will be nonexistent) by recognizing what's out of place in comparison to where they're anatomically in place.  Joints that are suffering from osteoarthritis will look noticeably different in an X-ray compared to that of a healthy joint. 

2. Talk to your doctor about your options.

Depending on the severity of your case, your doctor may present you with a multitude of paths to assess, or potentially just a fair few.

Non-surgical opportunities include but are not limited to: steroid injections to lessen inflammation and reduce pain, physical therapy to strengthen muscles and therefore lighten the load on the joint, or pain medications to allow you to continue functioning with minimal pain.

Surgical opportunities, or joint replacements, are extremely common. Depending on age or the severity of your case, you may be a prime candidate for a partial or total joint replacement. This will require physical therapy to aide your body in returning to full range of motion and strength, but most cases are completely successful and will allow you to return to the lifestyle you enjoy with less pain than in you have had in probably 5 or more years. 

3. In the meantime: less is not more.

While it may feel as though movement is going to aggravate and inflame that joint, lack of movement is consequentially worse. The lack of movement weakens the muscles, and therefore, adding more pressure on the joint when it's loaded. Lack of movement will essentially make it significantly more painful to move - and therefore, making the condition feel much worse. Movement, as well as strengthening, is key to maintaining a quality of life until the correct treatment option for you can be identified and agreed upon. 

4. Ice, and Anti-inflammatories

Icing the joints can lead to some stiffness, but it can also decrease the activity of inflammatory responses that lead to increased swelling from bone-on-bone activity and therefore, decreases the residual pain. Not only does it limit the inflammatory response by constricting the blood flow into that joint, but also allows you to feel relief temporarily until the numbness from the cold entirely wears off. An anti-inflammatory can help aide in minimizing your inflammatory (immune) response, but be sure to talk with your doctor about which anti-inflammatory works best for you and your specific medication protocol. 

LABRAL TEARS OF THE HIP

Introduction

Acetabular labrum tears (labral tears) are amongst some of the most difficult recoveries, and the most difficult to diagnose.  Generally, there are fewer orthopedic surgeons who perform minimally invasive hip labral repairs than any other surgical hip procedure involved with the hip. The reason is simply because these injuries can be worsened so quickly from small, seemingly-harmless movements - so a good reconstruction is vital. Labral tears can cause pain, stiffness, and other disabling symptoms of the hip joint. The pain can occur if the labrum is torn, frayed, or damaged. Active adults between the ages of 20 and 40 are affected most often, requiring some type of treatment in order to stay active and functional. New information from ongoing studies is changing the way this condition is treated from a surgical approach to a more conservative (nonoperative) path.

This guide will help you understand

• what parts of the hip are involved
• how the condition develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the hip are involved?

The acetabular labrum is a fibrous rim of cartilage around the hip socket that is important in normal function of the hip. It helps keep the head of the femur (thigh bone) inside the acetabulum (hip socket). It provides stability to the joint.

Our understanding of the acetabular labrum has expanded just in the last 10 years. The availability of high-power photography and improved lab techniques have made it possible to take a closer look at the structure of this area of the hip.

The labrum is a piece of connective tissue around the rim of the hip socket (acetabulum). It has two sides: one side is in contact with the head of the femur, the other side touches and interconnects with the joint capsule. The capsule is made up of strong ligaments that surround the hip and help hold it in place while still allowing it to move in many directions,

Finding out that there are two separate zones of the labrum was an important discovery. The extra-articularside (next to the joint capsule) has a good blood supply but the intra-articular zone (next to the joint) is mostlyavascular (without blood). That means any damage to the extra-articular side is more likely to heal while the intra-articular side (with a very poor blood supply) does not heal well after injury or surgical repair.

The labrum helps seal the hip joint, thus maintaining fluid pressure inside the joint and providing the overall joint cartilage withnutrition. Without an intact seal, the risk of early Degenerative arthritis increases. A damaged labrum can also result in a shift of the hip center of rotation. A change of this type increases the impact and load on the joint. Without the protection of the seal or with a hip that’s off-center, repetitive motion can create multiple small injuries to the labrum and to the hip joint. Over time, these small injuries can add to wear and tear in the hip joint.

Causes

How does this condition develop?

It was once believed that a single injury was the main reason labral tears occurred (running, twisting, slipping). But with improved radiographic imaging and anatomy studies, it’s clear now that abnormal shape and structure of the acetabulum, labrum, and/or femoral head can also lead to the problem.

Injury is still a major cause for labral tears. Anatomical changes that contribute to labral tears combined with repetitive small injuries lead to a gradual onset of the problem. Athletic activities that require repetitive pivoting motions or repeated hip flexion cause these type of small injuries.

What are these “anatomical changes”? The most common one called femoral acetabular impingement (FAI) is a major cause of hip labral tears. With FAI, there is decreased joint clearance between the junction of the femoral head and neck with the acetabular rim.

Related Document: Femoroacetabular Impingement of the Hip

When the leg bends, internally rotates, and moves toward the body, the bone of the femoral neck butts up against the acetabular rim pinching the labrum between the femoral neck and the acetabular rim. Over time, this pinching, or impingement, of the labrum causes fraying and tearing of the edges. A complete rupture is referred to as an avulsion where the labrum is separated from the edge of the acetabulum where it normally attaches.

Changes in normal hip movement combined with muscle weakness around the hip can lead to acetabular labrum tears. Other causes include capsular laxity (loose ligaments), hip dysplasia (shallow hip socket), traction injuries, and degenerative (arthritic) changes associated with aging. Anyone who has had a childhood hip disease (such as Legg-Calvé-Perthes Disease, hip dysplasia, Slipped capital femoral epiphysis) is also at increased risk for labral tears.

Symptoms

What does this condition feel like?

Pain in the front of the hip (most often in the groin area) accompanied by clicking, locking, or catching of the hip are the main symptoms reported with hip acetabular labral tears. Joint stiffness and a feeling of instability where the hip and leg seem to give away are also common. The pain may radiate (travel) to the buttocks, along the side of the hip, or even down to the knee.

Symptoms get worse with long periods of standing, sitting, or walking. Pivoting on the involved leg is avoided for the same reason (causes pain). Some patients walk with a limp or have a positive Trendelenburg sign (hip drops down on the right side when standing on the left leg and vice versa).

The pain can be constant and severe enough to limit all recreational activities and sports participation.

Diagnosis

How will my doctor diagnose this condition?

The history and physical examination are the first tools the physician uses to diagnose hip labral tears. There may or may not be a history of known trauma linked with the hip pain. When there are anatomic and structural causes or muscle imbalances contributing to the development of labral tears, symptoms may develop gradually over time.

Your doctor will perform several tests. One common test is the impingement sign. This test is done by bending the hip to 90 degrees (flexion), turning the hip inward internal rotation) and bringing the thigh towards the other hip (adduction).

Making the diagnosis isn’t always easy. In fact, this problem is frequently misdiagnosed at first. That’s because there are many possible causes of hip pain. The pain associated with labral tears can be hard to pinpoint. Your doctor must rely on additional tests to locate the exact cause of the pain. For example, injecting a local anesthetic agent (lidocaine) into the joint itself can help determine if the pain is coming from inside (versus outside) the joint.

X-rays provide a visual picture of any changes out of the ordinary of the entire structure and location of the hip position. Magnetic resonance imaging (MRI) gives a clearer picture of the soft tissues (e.g., labrum, cartilage, tendons, muscles).

One other test called a magnetic resonance arthrography (MRA) is now considered the gold standard for diagnosis. Studies show that MRA is highly sensitive and specific for labral tears. This test may replace arthroscopic examination as the main diagnostic tool. Arthroscopic examination is still 100% accurate but requires a surgical procedure.

With MRAs, contrast dye (gadolinium) is injected into the hip joint. Any irregularity in the joint surface will show up when the dye seeps into areas where damage has occurred. MRAs give the surgeon an excellent view of the location and extent of the tear as well as any bony abnormalities that will have to be addressed during surgery.

Treatment

What treatment options are available?

In the past, when arthroscopic surgery was the only way to confirm the presence of a labral tear, the surgeon would just go ahead and remove the torn edges or pieces during the arthroscopic examination procedure. However, studies over the years have called this approach into question. With removal of the labrum, changes in the way the hip functioned, increased friction of the joint, and increased load on the joint led to degenerative changes and Osteoarthritis.

Surgeons stopped cutting out the torn labrum and started repairing it instead. Physical therapists started doing studies that showed strengthening muscles and resolving issues of muscle imbalances could reduce the need for surgery with the traditional risks (e.g., bleeding, infection, poor wound healing, negative reactions to anesthesia).

More efforts are being made now to manage labral tears with conservative (nonoperative) care. This is a possibility most often when there are no symptoms of labral pathology. Patients with confirmed labral tears but who have normal Hip Anatomy or only mild changes in the shape and structure of the hip may also benefit from conservative care.

Nonsurgical Treatment

Physical therapy will probably be suggested. Your physical therapist will carry out an examination of joint motion; hip, trunk, and knee muscle strength; posture; alignment; and gait/movement analysis (looking at walking/movement patterns). A plan of care is designed for each patient based on his or her individual factors and characteristics.

Nonoperative care starts with activity modification. You should avoid pivoting on the involved leg and avoid prolonged periods of weight-bearing activities. You physical therapist will work with you to on strengthen your hip muscles, restore normal neuromuscular control, and improve your posture. All of these things can improve your hip function and reduce your pain.

Tight muscles around the hip can contribute to pinching between the femoral head and acetabulum in certain positions. A program of flexibility and stretching exercises won’t change the bony abnormalities present but can help lengthen the muscles and reduce contact and subsequent impingement.

A special strap called the SERF strap (SERF means Stability through External Rotation of the Femur) made of thin elastic may be applied around the thigh, knee, and lower leg to pull the hip into external rotation. The idea is to use the strap to improve hip control and leg movement during dynamic activities. It is important to strengthen the muscles at the same time to perform the same task and avoid depending on external support on a long-term basis.

Some patients may also benefit from intra-articular injection with cortisone. Cortisone is a very potent antiinflammatory medication. Injection into the hip joint may reduce the symptoms of pain for several weeks to months.

Surgery

Arthroscopy is commonly used to repair the torn labrum. The arthroscope is a small fiber-optic tube that is used to see and operate inside the joint. A TV camera is attached to the lens on the outer end of the arthroscope. The TV camera projects the image from inside the hip joint on a TV screen next to the surgeon. The surgeon actually watches the TV screen (not the hip) while moving the arthroscope to different places inside the hip joint and bursa.

During this procedure, your surgeon will trim the torn and frayed tissue around the acetabular rim and reattach the torn labrum to the bone of the acetabular rim. This procedure is called labral refixation. Each layer of tissue is sewn back together and reattached as closely as possible to its original position along the acetabular rim.

When repair is not possible, then debridement of the torn labral tissue may be necessary. Debridement simply means that the torn or weakened portions of the labrum are simply removed. This prevents the torn fragments from getting caught in the hip joint and causing pain and further damage to the hip joint.

In some cases, open treatment of Femoroacetabular Impingement and/or correction of bone abnormalities are required. These procedures are much more involved and usually will require a stay of several days in the hospital.

Related Document: A Patient's Guide to Femoroacetabular Impingement

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

The goal of conservative management is to relieve pain and improve function by correcting muscle strength imbalances. When both legs have nearly equal strength, it is possible to resume a full and normal level of all activities as long as there is no pain during any of those movements or activities.

For the young or active adult, this includes activities of daily living as well as recreational and sports participation. Older adults experiencing labral tears from degenerative Arthritis may expect to be able to resume normal daily functions, but may still find it necessary to limit prolonged sitting or standing positions.

After Surgery

Correction of the problem causing labral tears can result in improved function and pain relief. The hope is that early treatment can prevent arthritic changes but long-term studies have not been done to proven this idea.

Recovery after surgery needed to address hip labral tears usually takes four to six months. In other words, patients can expect to resume normal activities six months after surgery. Many athletes or highly active adults find this time frame much too long for their goals and preferences.

Patients who follow the recommended rehab plan of care respond well to progression of the exercises and seem to recover faster. Discharge from rehab takes place when the patient can perform all exercises with good form and without pain or other symptoms. Any repeat episodes of groin and/or hip pain must be reported to the orthopedic surgeon for evaluation right away.

AVASCULAR NECROSIS OF THE HIP

You may have heard this term before, or had a friend or family member who struggled with the same, but what exactly is it?

Avascular necrosis is the death of bone tissue due to a lack of blood supply. Also called osteonecrosis, avascular necrosis can lead to tiny breaks in the bone and the bone's eventual collapse.

The blood flow to a section of bone can be interrupted if the bone is fractured or the joint becomes dislocated. Avascular necrosis is also associated with long-term use of high-dose steroid medications and excessive alcohol intake.

Anyone can be affected by avascular necrosis. However, it's most common in people between the ages of 30 and 60. Because of this relatively young age range, avascular necrosis can have significant long-term consequences. Although it can happen in any bone at any joint, osteonecrosis is most likely to occur at the epiphysis (end) of a bone, and more commonly in the ball-and-socket joint, such as the shoulder or hip. 

Symptoms

Many people have no symptoms in the early stages of avascular necrosis. As the condition worsens, your affected joint may hurt only when you put weight on it. Eventually, the joint may hurt even when you're lying down.

Pain can be mild or severe and usually develops gradually. Pain associated with avascular necrosis of the hip may be focused in the groin, thigh or buttock. In addition to the hip, the areas likely to be affected are the shoulder, knee, hand and foot.

Some people develop avascular necrosis bilaterally — for example, in both hips or in both knees.

When to see a doctor?

See your doctor if you have persistent pain in any joint. Seek immediate medical attention if you believe you have a broken bone or a dislocated joint.

Causes

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced. Reduced blood supply can be caused by:

• Joint or bone trauma. An injury, such as a dislocated joint, might damage nearby blood vessels. Cancer treatments involving radiation also can weaken bone and harm blood vessels.
• Fatty deposits in blood vessels. The fat (lipids) can block small blood vessels, reducing the blood flow that feeds bones.
• Certain diseases. Medical conditions, such as sickle cell anemia and Gaucher's disease, also can cause diminished blood flow to bone.

For about 25 percent of people with avascular necrosis, the cause of interrupted blood flow is unknown.

Risk Factors

• Trauma. Injuries, such as hip dislocation or fracture, can damage nearby blood vessels and reduce blood flow to bones.
• Steroid use. High-dose use of corticosteroids, such as prednisone, is the most common cause of avascular necrosis that isn't related to trauma. The exact reason is unknown, but one hypothesis is that corticosteroids can increase lipid levels in your blood, reducing blood flow and leading to avascular necrosis.
• Excessive alcohol use. Consuming several alcoholic drinks a day for several years also can cause fatty deposits to form in your blood vessels.
• Bisphosphonate use. Long-term use of medications to increase bone density may be a risk factor for developing osteonecrosis of the jaw. This complication has occurred in some people treated with these medications for cancers, such as multiple myeloma and metastatic breast cancer. The risk appears to be lower for women treated with bisphosphonates for osteoporosis.
• Certain medical treatments. Radiation therapy for cancer can weaken bone. Organ transplantation, especially kidney transplant, also is associated with avascular necrosis.

Medical conditions associated with avascular necrosis include:

• Pancreatitis
• Diabetes
• Gaucher's disease
• HIV/AIDS
• Systemic lupus erythematosus
• Sickle cell anemia

Possible Complications

Untreated, avascular necrosis worsens with time.  Eventually the bone may become so weakened that it collapses.  Avascular necrosis also causes bone to lose its smooth shape, potentially leading to severe arthritis and residual pain.

Questions to Ask Your Doctor

• What's the most likely cause of my symptoms?
• What kinds of tests do I need?
• What treatments are available?
• I have other health conditions. How can I best manage them together?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions.

Testing and Diagnosis

During a physical exam your doctor will likely press around your joints, checking for tenderness. Your doctor may also move the joints through a variety of positions to see if your range of motion has been reduced.

Imaging tests

Many disorders can cause joint pain. Imaging tests can help pinpoint the source of pain. The options include:

• X-rays. They can reveal bone changes that occur in the later stages of avascular necrosis. In the condition's early stages, X-rays usually appear normal.
• MRI and CT scan. These tests produce detailed images that can show early changes in bone that may indicate avascular necrosis.
• Bone scan. A small amount of radioactive material is injected into your vein. This tracer travels to the parts of your bones that are injured or healing and shows up as bright spots on the imaging plate.

Treatment Options

The goal is to prevent further bone loss. Specific treatment usually depends on the amount of bone damage you already have.

Medications and Therapy

In the early stages of avascular necrosis, symptoms can be reduced with medication and therapy. Your doctor might recommend:

• Nonsteroidal anti-inflammatory drugs. Medications, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve, others) may help relieve the pain and inflammation associated with avascular necrosis.
• Osteoporosis drugs. Medications, such as alendronate (Fosamax, Binosto), may slow the progression of avascular necrosis, but the evidence is mixed.
• Cholesterol-lowering drugs. Reducing the amount of cholesterol and fat in your blood may help prevent the vessel blockages that can cause avascular necrosis.
• Blood thinners. If you have a clotting disorder, blood thinners, such as warfarin (Coumadin, Jantoven), may be recommended to prevent clots in the vessels feeding your bones.
• Rest. Reducing the weight and stress on your affected bone can slow the damage. You might need to restrict your physical activity or use crutches to keep weight off your joint for several months.
• Exercises. You may be referred to a physical therapist to learn exercises to help maintain or improve the range of motion in your joint.
• Electrical stimulation. Electrical currents might encourage your body to grow new bone to replace the area damaged by avascular necrosis. Electrical stimulation can be used during surgery and applied directly to the damaged area. Or it can be administered through electrodes attached to your skin.

Surgical and Other Procedures

Because most people don't start having symptoms until avascular necrosis is fairly advanced, your doctor may recommend surgery. The options include:

• Core decompression. The surgeon removes part of the inner layer of your bone. In addition to reducing your pain, the extra space within your bone stimulates the production of healthy bone tissue and new blood vessels.
• Bone transplant (graft). This procedure can help strengthen the area of bone affected by avascular necrosis. The graft is a section of healthy bone taken from another part of your body.
• Bone reshaping (osteotomy). In this procedure, a wedge of bone is removed above or below a weight-bearing joint, to help shift your weight off the damaged bone. Bone reshaping might allow you to postpone joint replacement.
• Joint replacement. If your diseased bone has already collapsed or other treatment options aren't helping, you might need surgery to replace the damaged parts of your joint with plastic or metal parts. An estimated 10 percent of hip replacements in the United States are performed to treat avascular necrosis of the hip.
• Regenerative medicine treatment. Bone marrow aspirate and concentration is a novel procedure that in the future might be appropriate for early stage avascular necrosis of the hip. Stem cells are harvested from your bone marrow. During surgery a core of dead hip bone is removed and stem cells inserted in its place, potentially allowing for growth of new bone.

Source: Mayo Clinic Diseases and Conditions Education