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Okay, well, I'm out here for you.

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It is not a pride-swallowing siege,

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and I want to share with you a diagram

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perhaps you've seen across the globe:

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the staging diagram for hip labral pathology.

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Not unlike, but different than the

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grading system used for menisci of the

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knee, for the labrum of the meniscus of the knee have

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some common traits.

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One of those common traits

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is intra-meniscal signal.

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The intra-meniscal signal in the knee, I'll draw

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a knee meniscus, frequently looks like this.

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Looks like two little bunny ears coming down.

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Just kind of fades away and stops

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in the center of the meniscus.

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That doesn't occur with

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any frequency in the hip.

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It's more of an amorphous signal intensity

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in the center of the meniscus that I've

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colored in in this type A meniscus,

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which is more triangular, and I've colored it

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in in the type B meniscus, which is more

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round or meniscoid, the less common shape.

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Now, what can you attribute this signal to?

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Well, it is an accumulation of water that occurs

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in the meniscus through diffusion along collagen

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bundles, and it is present in almost every adult

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and is an asymptomatic finding, unless it is

1:20

bright on T2 associated with meniscal expansion.

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So I frequently will either ignore it,

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or comment on it and then

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dismiss it as an incidental finding.

1:31

Let's go to stage two.

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We have two variations of the meniscus:

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one triangular, one round.

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Remember, you can also have a flat meniscus,

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which in my experience is uncommon.

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And an absent meniscus, which is very rare.

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In my experience, less than 1%.

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Literature says 3%.

1:49

So here we've got a partial tear, and it looks

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like you've come in with your scissors and made

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a cut and then your hand got a little trembly

1:56

and you made another cut right next to it.

1:58

It is not a smooth, round area of shallow

2:05

signal alteration, but rather somewhat serrated.

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Now, what do you do with this?

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Is it a tear?

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Yes, it's a tear.

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Especially if it's in the superior

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or anterior superior quadrant.

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But a lot of elderly people have these,

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whether it's in the type A or type B meniscus.

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So what I do with it is,

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I use my common sense.

2:28

I use my neocortex to figure out

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what else is going on.

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Is there an effusion?

2:33

Where are the symptoms?

2:34

Are there hip and groin symptoms?

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Do I have a cyst?

2:38

Do I have chondromalacia?

2:40

Do I have swelling in the region?

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Is the meniscus displaced?

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I use a lot of secondary signs.

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And what type of patient is it?

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If it's a 78-year-old man, I am certainly

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not going to go out and preach that

2:55

this patient has a traumatic tear.

2:58

I'm going to preach that the patient

2:59

has a chronic progressive labral tear

3:02

associated with some of the other

3:04

degenerative changes that I might see.

3:07

If it's a 30-year-old that's playing

3:09

tennis, that has a bump cyst complex,

3:13

an asphericity of the hip, and other signs of

3:16

CAMP-type impingement. I'm going to be more

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aggressive with this partial thickness tear,

3:22

looking again for the other indirect signs

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that the tear is indeed contributing,

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perhaps with an erosion or abrasion of the

3:30

hyaline cartilage, to the patient's symptoms.

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So not only am I going to use the secondary

3:36

signs, I'm going to put it in the context

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of the patient's age and what they do.

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I'm going to synthesize.

3:45

On the other hand, if it's a 15-year-old and

3:49

they are running cross-country, this is highly

3:52

likely to be symptomatic even though they may

3:55

have only mild changes of dysplasia or mild

3:58

changes of CAMP-type impingement with asphericity.

4:01

So very active individuals, people

4:04

that are jumping, running, hurdling,

4:06

are more likely to be symptomatic

4:08

with this kind of lesion.

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So I am much less aggressive with

4:11

the 50-year-old, 60-year-old,

4:13

and 70-year-old in describing the tear.

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That's not to say I don't call it a tear.

4:19

That's to say that I'm not going to draw

4:21

as much attention to it so that the tear

4:24

becomes repaired or surgerized in that

4:27

55 or 60-year-old with DJD, unless there are

4:30

other findings that specifically point to

4:32

this labrum as the cause of the symptoms.

4:34

When we get to the bottom, it's easy.

4:37

You've got a through-and-through tear,

4:39

the labrum is displaced, you'll often have secondary

4:42

signs like the capsule being stripped away off

4:46

the periosteum, it'll be separated this way.

4:49

You'll have areas of hyaline ulceration,

4:53

hyaline penetration, there'll be a large

4:56

effusion, there'll frequently be a history

4:58

of trauma, the patient will have groin

5:00

pain, and many other supportive signs

5:04

that tell you that this is the one that is

5:07

causing the patient's clinical syndrome.

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Let's move on, shall we?