broad topic, and I potentially should have just limited to what I actually do, which is knee, but I did consult with some of my friends in the hip and foot and ankle world because I try to keep those out of my office, none of my conflicts are related to this talk. So I mean, there's a lot of, obviously, different types of lower extremity injuries, and some of these I never thought of, heard of, or talked about when I was a resident or a fellow. So hip abductor tendinosis and tear, never saw a hip abductor repair, at least in my training. Hamstring avulsion, absolutely not a super common injury, but certainly more common in the aging athlete. Quad and patellar tendon tear is very common, quad much more common in the aging athlete. Patellofemoral arthritis, which is my practice and my specific research interest. Patellofemoral replacement, again, I never saw one in my training, it's a pretty common operation for me. Bioplasty, I think that's starting to gain a little bit of traction as a treatment for early arthritis. Gastroc tears, never see that as part of orthopedic residency, that really doesn't come into the emergency room, but Achilles tears for sure, and again, I don't know a whole lot about plantar fasciitis, but I'll talk about it for a second. So hip abductor tendinosis and tears, I personally, at least at my institution, I send these to primary care, and by and large, the vast majority of these patients get better with physical therapy. And just like we worry about now, a tennis elbow patient, for these kind of patients, it's kind of the same thing, and you really want to avoid cortisone, and a lot of times I hear about it from patients who also have a knee problem, that they had a number of cortisone injections for their, quote unquote, trochanteric bursitis, and probably it was abductor tendinosis, and potentially should have been treated with something more biologic, such as PRP. My hip friends say PRP is about 50-50, as far as being helpful, but certainly doesn't cause any harm. And now the chronic abductor repairs are now managed operatively, and I'm told that's like fixing a rotator cuff, but again, I've never seen one, but certainly I have a low threshold for when patients are just asking me about this, sending them on to a surgeon just to see if that's a possibility. Back to sports, according to my hip friends, is about nine months, so this is the slowest return to sports of, I would say, the lower extremity injuries. Hamstring avulsions, acute slip and falls, water skiing, personally I refer these, but they need to be fixed as soon as possible. Their return to sports is the fastest for hip injuries, it's reliably about four to five months, and at least at our institution, by and large, these are done with a hand surgeon to dissect out the sciatic nerve. Hip scopes, labral repairs, FAI surgery, I think this becomes a little more controversial in the aging athlete, because early arthritis is common, and the efficacy of arthroscopy in these patient populations is variable. I think, by and large, these patients are treated with cortisone and physical therapy to start, and it is reasonable in patients without arthritis to consider a labral repair, even in the aging athlete. Return to sports for these patients is about six months. Cortisone, just like every other joint, one injection's okay if it's actually in the joint, not in the tendon, but the results in the aging athlete are worse. What do we really see a lot of, or at least, is quad and patellar tendon tears? Quad, really much more common in the aging athlete. We know the patellofemoral joint sees four to seven times the body weight with daily activities, just such as going up and down stairs, and we talk about aging and weight gain. I tell patients, you gain 10 pounds, it's 50 pounds to your knees, depending on what sport or what activity you're doing. As we all know, it's usually not a whole lot of trauma to tear the quad, it might be just a misstep or a bigger step down off a New York City bus, you can tear your quad, but it's also up to 10 times the force with just landing from a jump. In clinic, you may see a visible or palpable defect and have an extensor lag, but I would caution you to have a low index of suspicion. I've seen three out of four of the quad essentially torn, and they don't have an extensor lag, and I think having a low threshold for an MRI is a good way to practice. So any suspicion of a tear, but you do want to avoid any muscle atrophy, and there's different ways to do this procedure. I personally have gone to suture anchors, I at this point use two suture anchors in the patella, both for quads and patellar tendon tears, unless it's mid-substance. The way I was taught was drilling drill holes through the patella. I do this only in revision situations. I have seen some patella fractures after this, so I think at this point suture anchors work quite well. Chronic tears are, I think, one of the worst patient categories we take care of because they're really hard to treat. Here you can see a patient who had a patellar tendon repair. It healed in an elongated fashion, and so you can see significant patella alta. These are hard to treat. If it's the quad, you can do a V-Yplasty. If it's a patellar tendon, you really have to augment it with a hamstring or allograft tendon. So as far as the treatment post-op, I mean, I think we've all, or a lot of us have changed our practice now that we have blood flow restriction therapy. I think getting these patients moving a little bit right away is really helpful, allowing them to immediately weight bear with a brace locked in extension. As far as returning to a high-impact sport, it's at least six months. So there was a systematic review. I mean, there's been a number of them, but this one looked at 1,100 patients. And so with patellar tendon ruptures, this is really all men. This is not women. It's 88.6% men. The age was only 32. As far as quad tendons, it's 90% men with an average age of 52, so significantly older as we kind of see in our clinical practice. As far as return to sports, for patellar tendon, it was 80%, and for quad tendon, it's 70%. So I think Kat's talked before, if you just kind of quote patients that they're going to get back to sports at about 75%, I think you're pretty safe. What about patellofemoral arthritis? So I think this is like the neglected joint of the lower extremity. And I see patients all the time who are told, oh, you're way too young to have an arthroplasty. You just have to suffer. And luckily, we have the patellofemoral replacement, so I don't think you have to suffer. In a younger patient, meaning a 50-year-old, I still would consider doing an osteotomy if they have lateral wear, lateral tracking. But if you see this patient with complete, basically denudation of the cartilage on the trochlea, I think you have to start thinking about arthroplasty. So again, in a younger patient, I might consider an osteotomy with an osteochondral allograft. But in an older patient, and how old is old, it keeps getting older as I get older. But I would, in this case, usually go for a patellofemoral replacement. And it really depends on maltracking. So if you see a merchant view like this with significant maltracking, I think that's a good chance you can get away with an osteotomy. And here you can see significant patella alta. You have to worry a little bit about doing a patellofemoral replacement because it's hard to get the tracking right without the options you have with the total knee where you can change the rotation. Here you can see how much better you can make these patients, at least radiographically, with an osteotomy. So bipolar disease, if it's severe, I think an arthroplasty is reasonable. I do look at their age. My average age is 53. Eighty-five percent of these patients are women. And I think it's easy if they've had failed cartilage repair or an osteotomy in the past. But there are a small subset of patients that I sort of rush them into surgery. So if I see a patient like this where they've worn their lateral facet to 10 or 11 millimeters, I don't think these patients should be treated conservatively. I worry about the bone stock, and at a certain point, I'm not going to have enough bone stock for a patellar component, and I'm going to risk a patellar fracture. So a patient like this, I would strongly advise a patellofemoral arthroplasty. Why did this operation become more common, or why have I considered it so much more seriously in the past 12 or 13 years is that the implants got much better. So the trochlear component is longer. It better approximates normal anatomy. The patella component is the same as a total knee. And as I mentioned, the patient population is predominantly women. Generally, I make sure they've done a thorough course of physical therapy, except if you see a patient like this. Most of my patients have tried hyaluronic acid, cortisone, PRP. And again, I'm looking for some decent bone stock. If you have a failure of a patellofemoral replacement, it's usually that you chose the wrong operation. I MRI all these patients. I make sure their tibiofemoral joint is as good as it looks on X-ray. I do worry about progression of tibiofemoral arthritis. And if you have a patient who has patellofemoral arthritis partially because of patellofemoral instability, beware of those patients who still report instability because there's nobody more miserable than somebody who's had a PFJ and continues to dislocate. So in those patients, I do it with an MPFL. Joint loosening for patellofemoral arthroplasty is extremely rare, 0.2% to 0.7%. Again, not everyone with pathology needs surgery. So this woman ran the New York City Marathon a few months before I got this MRI. And so I think you need to understand that there's patients with severe arthritis who are really quite functional, and there's other patients with fairly mild to moderate arthritis who really are quite disabled. And how much of this has to do with this patient was premenopausal. So maybe when she hits menopause, she's going to fall off the cliff, but it is an interesting population. As far as what else, there was an interesting presentation at Anna this year talking about bioplasty, not subchondroplasty, but actually injecting BMAC and BMAC mixed with demineralized bone matrix. So this patient had some pretty mild lateral compartment arthritis, and you can see a significant amount of edema. She had no trauma, and the MRI image on the right was after a bioplasty. And so these patients anecdotally can do quite well clinically, and I don't typically MRI all of them. She got an MRI for another reason, and I was pretty happy with the improvement. And so this is something that I'm sort of slowly adding to my practice if I see a patient with early arthritis who's not a candidate for arthroplasty or an osteotomy. I think there is a role for bioplasty. Gastroc tears, these are fairly atraumatic. I tore my gastroc stepping, not misstepping, just stepping off a stepstool. Usually you don't need any imaging. We put them in a cam boot and have them weight-bearers tolerated immediately. I would be aware of the risk of DVT. I've seen two, well, one friend and one patient who got a PE after being weight-bearing as tolerated in a boot with a gastroc tear. So just kind of having that on your radar, you can immediately start range of motion, and usually they're back to sports in six to eight weeks. So it's a pretty quick recovery, and I think you can kind of tell these patients to push through the pain. It's better to move more quickly. But Achilles, again, I don't take care of Achilles tears anymore, but usually they're not particularly traumatic. I mean, some people walk into clinics saying they're just walking funny, and they're not sure what happened. My foot and ankle partner says 25% of his Achilles tears are due to pickleball. So pickleball is the theme of the week. It's a theme in the news, and it's certainly an interesting and fun trend and good for business. But obviously, they have a palpable defect, a positive Thomas test. When I was training, nobody did percutaneous. The problem with the percutaneous, it's the higher nerve injury rate, but open more skin issues. As far as back to sports, so again, I had to consult my foot and ankle partner for this. But as far as if a patient's treated with a cast, I think the trends have gone back and forth. But casting them in Aquinas, they do not get back the same strength. So he at least quotes his patients 80% to 85% of their strength, and they're back to sports at six to nine months. If they're treated operatively, at least he tells me they get 95% to 100% of the strength. So that's what he's telling his patients, but back to sports a few weeks earlier. So not a whole lot of difference, but depending on what type of athlete it is, you may caution them that the strength deficit will be more significant. Post COVID, he did say that there was an epidemic of Achilles tears, and part of that they thought was relative inactivity and then a more rapid ramp up of activity. And he somehow thinks that drinking more water is going to make this less common. We don't understand that, but I'm going to recommend it anyway. Drink more water. Achilles tendinosis, this again, I think can be one of those, it's like the tennis elbow. It's really frustrating. It usually isn't related to any particular activity. We typically just treat them with a heel lift, eccentric strengthening. Shockwave therapy is at least turning out to be fairly effective for these patients. But the nice thing is these almost never rupture. So you can tell somebody the good side of having Achilles tendinitis is they probably won't be able to be active enough to play the sports that are going to rupture their Achilles. And it can be a quite variable return to sports. Tendinitis, tendinitis tends to be in a younger athlete with inflammation and it's overuse. And we tend to see these right before the marathon where they've recently increased their mileage, more sprints or hill running. And this is just rest and potentially changing their running shoes. A lot of times we'll caution patients to avoid running temporarily and try to save up for the race and do more cross training, sometimes orthotics. And generally patients should be doing more weight training. And I think that's something that I tell patients who are 16 and I tell patients who are 65 that you need to do more weight training. Almost no athlete does enough weight training. And I think the more we focus on that, the more successful our patients will be. Plantar fasciitis, I don't know if you've had it, but it hurts a lot. And it's this tearing sharp sensation in the plantar aspect of the foot. It's usually first thing in the morning or after lunch. Women are at much higher risk for this. And this tends to be the overweight or non-athletic population. If you have a job where you stand on your feet a lot. Some patients who walk and run for exercise. And this is just, again, it's all about stretching. And most of us aren't very good about doing that regularly. So 90% of these patients are better in two months. Soft heel cups, stretching, cross training. Night splits. I personally couldn't sleep in a night split, but I do think these work well. And I don't think these should ever have a cortisone injection. Thank you very much. Thank you.

lower extremity injuries

hip abductor tendinosis

hamstring avulsions

quad and patellar tendon tears

Achilles tears