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Note: This article was written on Friday, before the diagnosis that Percy Harvin needed surgery. Regardless, it outlines the specifics of the injury and the possible post-op recovery time.
The purpose of this article is to provide a general look at the structural components of the acetabular labrum, the damage that can affect it, and the treatments possible. The reason I am writing it is because I have seen a lot of reporters with fuzzy journalism degrees, and people who are very accomplished at Twitter, spreading falsities and fallacies. There is nothing more annoying than a fearmonger who operates from a base of ignorance. This is my attempt to supply professional information to you directly, and let you decide if you want to leap off a building or not.
I am going to try and keep this write-up as layman as possible. There have been multiple volumes written about a topic I am going to spend one sentence on. I apologize now if you are incredibly interested in capsular laxity, or ligamentum teres tears.
In order to look at this scenario, we need to decide to accept a few assumptions as hypothetical facts. If they prove to be incorrect, that is fine, and probably for the best. But at least we will have this as a guide for future use.
Assumption One: Percy Harvin is not skiving off, and is legitimately suffering from a hip problem as has been reported. It is altogether possible that Harvin is playing this up, and will be fine in a few weeks. That does not help us now, however.
Assumption Two: That hip problem is related to a "slight labrum tear".
An introduction to me: in addition to being a spy, fireman, and fighter jet pilot, I am also an RN on a TRACU. A TRACU (Trauma Recovery & Acute Care Unit) is a specialized facet of an ICU that deals with the rehabilitation and pre/post-surgical needs of patients before we can send them to general surgical floors. I have been a member of surgical teams operating on labrum tears, I have managed the care for post-surgical patients, and I have been a member of their rehab teams. These patients include some amateur/professional athletes.
Before becoming an RN, I was interviewing for Medical schools (my MCAT score is 32, if anybody wants to compare me to Greg Faulker). By being an RN, pre-Med for undergrad, graduating with a BS in Microbiology/Bioengineering, and volunteering in hospitals for hundreds of hours, the vast majority of my closest friends are physicians. Using my own experience and discussing the issue with these physicians, I have attempted to put together a basic look at hip anatomy, labrum tear causation, treatment options, and the recovery timeline.
A Brief Look at Hip Anatomy
One's hip is a vacuum sealed ball-and-socket joint. The femoral head (the ball of the femur), fits inside the acetabulum (socket of the pelvis), which ideally provides frictionless rotation. The acetabular labrum is a ring of cartilage that surrounds this socket. Its primary purpose is to increase surface area of contact to the femoral head, and thereby deepen the socket. This prevents subluxation of the joint (complete or partial dislocation), and acts as a "gasket". Other purposes include pressure distribution, shock absorption, and joint lubrication. As can be seen, it is a critically important joint for a profession that relies on speed, change-of-direction, and agility.
Labrum Tear Types and Causation
There are a variety of factors contributing to tears, but the vast amount of the etiology is related to being an elderly lady who lacks calcium and the will to live. I am going to ignore the unrelated causes, and briefly discuss what may have contributed to Percival's injury. THIS IS CONJECTURE, but educated conjecture, and the cause will most often lead one to the solution.
Labral tears are identified by location, morphology, and etiology.
Location: anterior, posterior, and superior/lateral.
Morphology: radial flap, radial fibrillated, longitudinal peripheral, and unstable.
Type 1 tear: detachment of labrum from the surface.
Type 2 tear: cleavage planes (rips) within the labrum itself.
I am going to skip all of this, and go super general (These are listed in ascending order of severity). Tears come from three things: 1.) Trauma that causes isolated damage 2.) FAI (Femoroacetabular Impingement), AKA "wear-and-tear" 3.) Chronic conditions (dysplagia/degeneration). Let's look closer at these.
Cause 1: An Isolated Traumatic Event
This is most often seen in contact sports and automobile accidents (the two have a great deal in common), and is the result of SIGNIFICANT trauma to the hip joint that results in either subluxation, or full dislocation. The action of the femoral head pulling out of the socket tears the cartilage ring of the labrum, or even the inner portion. This can change the landscape of the acetabulum, which results in impaired hip motion. This can lead to pain, and inflammation.
Cause 2: Femoroacetabular Impingement (Think "A-Rod")
Professional Athletes are extremely susceptible to this (especially baseball players), due to repetitive motions performed under heavy physical stress. Think about how many times per day a baseball player swings a bat, and all the force that is on their hips. All of that force applies a great deal of friction to the joint, which can break down the bone itself, or the cartilage surrounding it. This is a problem systemic to the joint, can be interconnected with other comorbidities, and often has vague borders. Moreover, it will almost certainly lead to hip osteoarthritis.
FAI is a huge field, and vastly inapplicable to this discussion. In the interest of keeping this general, I will not discuss the many forms of FAI, but will instead show the four forms: Cam (cog), Pincer (pinched), mixed.
Cause 3: Chronic/Degenerative Conditions
This is the part where you shit your pants. Think Greg Oden, Marcus Tubbs, or Brandon Roy.
This is a condition where the morphology of the joint is no longer conducive to friction-free movement. It can be caused by trauma that was uncorrected, FAI that has reached a critical point and was undetected, or (and this is scary) a genetic malformation of the joint that is only now manifesting, due to the increased physical strain. Unfortunately, all three are plausible, and all three end careers.
Treatments and Scenarios
The most basic form of treatment for a "slight" labrum tear is to take some NSAIDs (Non-Steroidal Anti-Inflammatory Drug [ibuprofen]), and rest your hip until it feels better. Do you know how many times I have seen that done? Five, you are correct. Do you know how many times that has ended in the patient eventually having the surgery anyway? Five, you are so smart!
Percy Harvin is having surgery, just accept that now. Whether it is before the season, during, or after, he's going under the knife. He has historically been quite involved with his personal health, and is not the type of player who will (or even can) "gut through" with limited range of motion in his lower limbs. Jene Bramel MD, of Mercy Memorial Hospital in Ohio, believes that it is a 60+% chance that Percy has surgery, and describes Harvin as "...very involved, knowledgeable about his medical care. Multiple opinions for migraines, not shy about giving specifics on ankle." I believe that matches up with what we have seen.
(If Dr. Bryan Kelly tells Percy Harvin that he does not need surgery, that will be two physicians that have told him "no". That is great, but I believe that Harvin WANTS surgery. Do you blame him? Continuing to utilize a joint that is experiencing an increase in friction WILL eventually lead to osteoarthritis. That would effectively end his career).
So let's skip all that naturopathic bullshit that will not work for Percy or us, and get right into some good ol' American, allopathic slaughterhouse surgery!
There are multiple forms of surgery for correcting a labral tear, but we are only going to discus the two most applicable: hip arthroscopy and shaving for a Type 2 tear, or labral repair/refixation for a Type 1 tear.
Hip Arthroscopy and Shaving
We will assume that Harvin has already had fluoroscopy and an MRA to determine location and form of the injury/loose bodies. Arthroscopy is the gold standard for diagnosing joint tears.
Percy will be placed supine on the table. He will be given a spinal anesthetic that will serve to achieve maximum muscle relaxation, so as to decrease the amount of traction needed. Multiple ports will be incised into his hip. This allows for different angles of entry, while simultaneously avoiding the nerve bundles that litter that area (hitting the Sciatic nerve will ruin someone's life). It should be noted here that this joint possesses a strong vacuum seal, and is buried deep under muscle. Though the incisions are small and minimally invasive, they do cause trauma.
Surgeons will use the arthroscope (a small camera) to "put eyes" on the joint itself, as well as any foreign bodies that have come from the damaged area. If there is worry that the joint itself is damaged, distraction of the femoral head may be necessary. The labrum and labrocapsular junction will be examined for structural integrity, and to rule out detachment from the acetabulum. The head and neck of the femur will also be examined for structural integrity.
Assuming that it is a small labral tear, small tools will then be used to remove the foreign bodies. The physician will use a motorized shaver or radiofrequency probe to debride the torn labral tissue, and leave as much healthy labrum as possible.
"The patient is then sewn up" says Steven K. Dailey MD of Tulane University, "Whatever is left of the labrum is what the patient lives with." This would be a problem for a player like Harvin, who needs the labrum to provide what was listed above.
Is this the form of surgery Percy undergoes? I do not think so, as it is less a complete fix, and more of stopgap. Dr. Bramel agrees, "my reading suggests that most tears are repaired rather than debrided. Probably surgeon dependent." This matches up closely with I have experienced within the past year. I asked Dr. Dailey about what he has seen: "Yeah, I think so. We have been seeing here that debridement is just putting off a larger problem, when the patient is an athlete. What works for grandma doesn't work for Harvin."
This brings us to the most likely treatment.
Labral Repair and Refixation
The beginning this process is the exact same as above. The difference is that instead of using debridement to shave off the torn labrum, the cartilage is repaired using absorbable sutures and anchors. The focus of this surgery is to retain healthy tissue, and limit the loss of function.
I could explain this process to you, but I think you will trust it more from both this picture, and by hearing it straight from the surgeon's mouth (assuming the surgeon doesn't just use a Da Vinci).
Doctor Dailey: "I'm going to start by debrideing as little as possible. Really, I only want to smooth it if I can't refix the fray, or if it is going to interfere with the joint motion. This maintains as much of the labrum as possible. Next, I'm going to use sutures to attach the split ends of the labrum together. Finally, I'm going to attach those sutures into the pelvis itself using anchors. This will only take me a few hours."
It should be noted that 63% of hips scoped for labral tears also possess cartilage abnormalities, and in 80% of those patients labral and articular lesions were found in the same area. This would increase surgery time, and possibly recovery time. While preserving the labrum is the highest goal, anything that impinges friction-free movement (as would be the case in FAI) needs to be shaved off.
Diagnosis & Timelines
This is what we really care about; how long will Harvin be out? You need to ask yourself, do you want Percy Harvin at 60-80% all season, or 100% for nine games? That is assuming he won't need to shut it down halfway through the season because of pain and limited range-of-motion, and that his recovery timeline is average for an athlete. Harvin strikes me as more Derrick Rose than Ronnie Lott, but he still comes to play on Sundays.
So what if the treatment is no surgery? Just NSAIDs and rest?
"Well, you're probably not going to see him practice a whole lot." says Dr. Dailey, "why put your body through that kind of pain when it doesn't matter? I would think that he would sit out most days except walkthroughs, play hard on Sunday, get a cort shot, and do it again." The "cort shot" he is referring to is cortisone, a corticosteroid used to decrease inflammation. The danger of this treatment is obviously that he is ignoring and exacerbating the problem. Sacrificing the long-term, as it were.
In order to see why Harvin will need surgery, let's look at a potential diagnosis. We discussed three earlier: trauma, FAI, and chronic. My guess? I think Harvin has FAI, caused by sudden trauma. I do not think it is a degenerative condition, because I believe we would have seen symptoms earlier. I believe that Harvin took a hit some time ago (maybe in 2010, when he was listed with hip pain that caused " a catch"? That is a classic symptom), that changed the landscape of his joint. Over time, this change in morphology has caused increased friction, and has led to a larger tear. Dr. Jene Bramel agrees, so I posed the question to Dr. Dailey...
"Oh yeah, I don't doubt it. The way he plays? This could have been an issue since then, and it is only showing symptoms...That means that it could be a small tear, sure. But it also could indicate osteoarthritis."
I then asked Dailey about a scenario in which the tear was exacerbated by the hit Richard Sherman put on Harvin last year.
"You're sick."
My initial gut reaction was that this is a simple fray requiring three weeks of rest, a few weeks of rehab, and then he is ready to go. But after looking at it more closely, I believe we have the right diagnosis above. Operating under this hypothetical diagnosis, and acknowledging that the treatment would be repair of the labrum, what kind of timeline should we anticipate? My own experience, and the opinions of both physicians, matches completely.
"He'll be out the same day, walking around after a a few weeks. Hmm, I want to say 6-8 weeks" said Steven Dailey, "because of his youth, and profession. I have to be conservative though, and say he is probably looking at 9-12 weeks. 16 weeks or more would be worst case scenario."
Dr. Bramel agreed: "3-4 months is the probably sweet spot...protocols I've seen online suggests sports specific rehab begins 9-12 weeks."
After that surgery and recovery though? It will take him a while to get to full speed, but assuming that it was FAI, and surgery is a success, there is a 91% chance he regains optimal hip movement and health.
Conclusions
If the assumptions that we agreed upon initially are correct, you want to see Percy Harvin undergo surgery. If this is a real problem, he needs to correct it now, and be at his peak during our final playoff push. That is when he is the most important to our team.
If he chooses not to undergo surgery, and this is FAI due to a change in landscape it will get worse, it will cause comorbidities, and it WILL end his career prematurely.
Our offense could be Top 3 without Percy Harvin, based on how it was functioning in the 2nd half of last season. So why risk permanent injury just to have him for six extra games? Bring him back in Week 7, and prepare to light the League on fire.