Hip Labral Disorders: Difference between revisions

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== Introduction ==
== Introduction ==


Disorders of the hip labrum is an umbrella term that includes any issues involving that labrum such as [[Femoroacetabular Impingement|femoroacetabular impingement]] (aka FAI) and acetabular labral tear (ALT). Amber and Mohan (2018) proposed that the term "fissure" is a better alternative to labral tears, at least in patients over the age of 40, in order to prevent overdiagnosis and unnecessary medical intervention.<ref>Amber I, Mohan S. Preventing Overdiagnosis of Acetabular Labral "Tears" in 40-Plus-year-old Patients: Shouldn't these be called Labral "Fissures" Instead? Acad Radiol. 2018;25(3):387-390.  
Disorders of the hip labrum is an umbrella term that includes any issues involving that labrum such as [[Femoroacetabular Impingement|femoroacetabular impingement]] (aka FAI) and acetabular labral tear (ALT). This mechanically induced pathology is thought to result from excessive forces at the hip joint. For example, a tear could decrease the acetabular contact area and increase stress, which would result in articular damage, and destabilize the hip joint.<ref name="Lewis">Lewis CL, Sahrmann SA. Acetabular Labral Tears. Phys Ther 2006;86:110-121.</ref> Amber and Mohan (2018) proposed that the term "fissure" is a better alternative to labral tears, at least in patients over the age of 40, in order to prevent overdiagnosis and unnecessary medical intervention.<ref>Amber I, Mohan S. Preventing Overdiagnosis of Acetabular Labral "Tears" in 40-Plus-year-old Patients: Shouldn't these be called Labral "Fissures" Instead? Acad Radiol. 2018;25(3):387-390.  
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Introduction[edit | edit source]

Disorders of the hip labrum is an umbrella term that includes any issues involving that labrum such as femoroacetabular impingement (aka FAI) and acetabular labral tear (ALT). This mechanically induced pathology is thought to result from excessive forces at the hip joint. For example, a tear could decrease the acetabular contact area and increase stress, which would result in articular damage, and destabilize the hip joint.[1] Amber and Mohan (2018) proposed that the term "fissure" is a better alternative to labral tears, at least in patients over the age of 40, in order to prevent overdiagnosis and unnecessary medical intervention.[2]

Clinically Relevant Anatomy[edit | edit source]

The hip labrum is a dense fibrocartilagenous structure, mostly composed of type 1 collagen that is typically between 2-3mm thick. It lines the acetabular socket and attaches to the bony rim of the acetabulum. The labrum has an irregular shape, being wider and thinner anteriorly and thicker posteriorly.[3][4]

Acetabular Labrum copyright and courtesy of Primal Pictures Ltd

It is thought that the majority of the labrum is avascular with only the outer third being supplied by the obturator, superior gluteal and inferior gluteal arteries. There is controversy as to whether there is a potential for healing with the limited blood supply and this is an important clinical consideration. The superior and inferior portions are believed to be innervated, containing both free nerve endings and nerve sensory end organs (giving the senses of pain, pressure and deep sensation).[3][4]

The labrum functions as a shock absorber, joint lubricator and pressure distributor. It resists lateral and vertical motion within the acetabulum along with aiding in stability by deepening the joint by 21%. The labrum also increases the surface area of the joint by 28%, allowing a wider area of force distribution and is accomplished by creating a sealing mechanism to keep the synovial fluid within the articular cartilage.[3]

Epidemiology/Etiology[edit | edit source]

The labrum of the hip is susceptible to traumatic injury from the shearing forces that occur with twisting, pivoting and falling. Direct trauma (e.g. motor vehicle collision) is a known cause of acetabular labral tearing.[4] Additional causes include acetabular impingement, joint degeneration and childhood disorders such as Legg-Calve-Perthes disease, congenital hip dysplasia and slipped capital femoral epiphysis.[5][6][7][8] While most tears occur in the anteriosuperior quadrant, a higher than normal incidence of posterosuperior tears appear in the Asian population due to a higher tendency toward hyperflexion or squatting motions.[5]The most common mechanism is an external rotation force in a hyperextended position. Microtrauma is believed to be responsible for labral lesions in cases where pain develops gradually.

According to a systematic review by Leiboid et al (2008),[9]

  • Hip labral tears commonly occur between 8 to 72 years of age and on average during the fourth decade of life
  • Women are more likely to suffer than men
  • 22-55% of patients that present with symptoms of hip or groin pain are found to have an acetabular labral tear[3]
  • Up to 74.1% of hip labral tears cannot be attributed to a specific event or cause[3]
  • Hyperabduction, twisting, falling or a direct blow from a car accident were common mechanisms of injury in patients who identified a specific mechanism of injury[9]
  • Women, runners, professional athletes, participants in sports that require frequent external rotation and/or hyperextension are at increased risk of a hip labral tear.
  • Those attending the gym three times a week have an increased risk of developing a hip labral tear[9]

Orbell and Smith (2011) note that the incidence of labral tears differ depending on the specific etiology.[10]

Mechanism of Injury[edit | edit source]

There are five common mechanisms of labral tears that are widely recognized:[10]

  1. Femoroacetabular impingement (FAI)
  2. Trauma: This can occur due to a shearing force associated with twisting or falling, mis-stepping on uneven ground or colliding with bicycles or vehicles. Repetitive hip hyperextension and external rotation (e.g. during terminal stance in running) can create stress at the chondrolabral junction (typically the 10-12 o'clock position) resulting in microtrauma and eventual labral injury.[11] It may also be associated with iliopsoas impingement resulting in labral injury at the 3 o'clock position.[11]
  3. Capsular Laxity: This is thought to occur in one of two ways; cartilage disorders (e.g. Ehlers-Danlos syndrome) or rotational laxity resulting from excessive external rotation. These forces are often seen in certain sports including ballet, hockey and gymnastics.
  4. Hip Dysplasia: Certain abnormalities of the femur. acetabulum or both (e.g. shallow acetabulum, femoral or acetabular anteversion, decreased head offset or perpendicular distance from the center of the femoral head to the axis of the femoral shaft) can lead to inadequate containment of the femoral head within the acetabulum, placing increased stress into the anterior portion of the hip joint resulting in impingement and possible tears over time.
  5. Degeneration

Classification[edit | edit source]

Labral tears can be classified in different ways.[3]

  1. Location: anterior, posterior or superior/lateral - it is generally accepted that most labral tears occur in the anterior, anterior-superior and superior regions of this acetabulum.
  2. Etiology
  3. Morphology:
Radial flap most common, disruption of free margin of the labrum
Radial fibrillated fraying of the free margin, associated with degenerative joint disease
Longitudinal peripheral least common
Unstable / Abnormally mobile can result from a detached labrum

Characteristics/Clinical Presentation[edit | edit source]

There is some variation in the presentation of hip labral tears. Patients frequently present with anterior hip and groin pain, although less common areas of pain include anterior thigh pain, lateral thigh pain, buttock pain and radiating knee pain.[9][3] The majority of patients (90%) diagnosed with acetabular labral tears have had complaints of pain in the anterior hip or groin. [3][4][12]This can be an indication for an anterior labral tear, whereas buttock pain is more consistent with posterior tears and less common.[12]

Mechanical symptoms associated with a tear are clicking, locking, popping, giving way, catching and stiffness. Patients often describe a dull ache which increases with activities such as running, brisk walking, twisting movements of the hip or climbing stairs.[4][3] Functional limitations may include prolonged sitting, walking, climbing stairs, running, and twisting/pivoting.[4][9][3]

The patient may report experiencing an audible pop or a sensation of subluxation at the time of the trauma, if there was a specific traumatic onset.[11]

Differential Diagnosis[edit | edit source]

Schmerl et al (2005) provide a thorough list for differential diagnosis of labral injury causing hip pain;[5][13]

Diagnostic Procedures[edit | edit source]

According to Heerey et al (2018), hip pain is poorly correlated with intra-articular hip joint pathology seen on diagnostic imaging.[14] In their systematic review, they found that the prevalence of cartilage pathology, bone marrow lesions, ligamentum teres tears was higher in symptomatic individuals than asymptomatic individuals, whereas the prevalence of labral pathology, paralabral cysts and herniation pits was similar in both groups.[14]

When diagnostic imaging is utililized, MR arthrogram has typically been preferred over MRI because it has shown greater accuracy in identifying defects in the labrum and cartilage.[15] However, more recent research suggests that 3T MRI is at least equivalent to 1.5T MRA for detecting these types of defects.[15]

Examination[edit | edit source]

***Diagnosed should be aided by physical examination of a patient. In some cases the first signs can be spotted while observing the patient; during a brief walk, the ipsilateral knee may be used to absorb the shocks created in ground reaction forces thus presenting with a flexed knee gait. Additionally related to gait, the step length of the affected leg may also be shortened, again to reduce the nociceptive input caused by walking. Aside from simple observation there are a number of provocative tests that can be performed. Because each test stresses a particular part of the acetabular labrum, they can also give an indication of where the tear is located.[12]

Labral tears can be difficult to differentiate from FAI and the two conditions can be present simultaneously.[11] Pain from an isolated labral tear may be associated with hip extension (compared to hip flexion for FAI) as well as signs of laxity.[11] Tightness in iliopsoas or pain with resistance testing of iliopsoas may indicate iliopsoas impingement with is associated with labral tearing but not FAI.[11] However,even if differentiating the two conditions remains difficult following physical examination, Heiderscheit and McClinton (2016) note that initial management of the two is the same.[11]

Provocative Tests[edit | edit source]

Strong evidence in support of provocative clinical tests for diagnosing hip labral disorders is lacking. Reiman et al (2015) conducted a systematic review to evaluate the clinical accuracy of several provocative tests. They found that most of the tests were predominantly sensitive but not specific and that none was capable of significantly shifting the post-test probability of a diagnosis of acetabular labral tear.[16] In addition, the studies that were investigated in the review were of low quality and were at risk of bias.[16] The authors noted the need for better quality studies in patients with and without hip pathology to evaluate the true clinical utility of these tests.[16] According to a 2008 study by Martin et al, symptoms of groin pain, catching, pinching pain with sitting, FABER test, flexion-internal rotation, adduction impingement test and trochanteric tenderness were found to have low sensitivities (.6-.78) and low specificities (.10-.56) in identifying patients with intra-articular pain.[17] Other tests found to have high specificities but lacking high-quality study designs and supportive literature include the Flexion-Adduction-Axial Compression test and palpation to the greater trochanter. Flexion-Internal Rotation-Axial Compression test, Thomas test, Maximum Flexion-External Rotation Test and Maximum Flexion-Internal Rotation Tests were found to have poor diagnostic measures.[9]

The following provocative tests have been indicated as useful in diagnosing hip labral disorders but because of low clinical accuracy (especially specificity), their results should be evaluated within the context of patient presentation and examination;

McCarthy test
  • McCarthy test, The affected hip needs to be brought into extension. If this movement reproduces a painful click, the patient is suffering from a labral tear.[18]
  • FABER Test, flexion-abduction-external rotation test elicits 88% of the patient with an articular pathology. However this test is non-specific and should be considered a general test for hip articular surfaces[13]
  • Anterior labral tear, the patient's leg has to be brought into full flexion, lateral rotation and full abduction. Then the leg has to be extended with medial rotation and adduction. Patients with an anterior labral tear will experience sharp catching pain and in some cases there might be a "clicking" of the hip[19].
  • Posterior Labral tear, is identified by bringing the patient's leg into extension, abduction and lateral rotation followed by an extension with medial rotation and adduction of the leg. Sharp catching pain with or without a "click" will be an indication for a posterior labral tear.
  • Impingement Test (Flexion-Adduction-Internal Rotation Test/FADIR), the patient is placed in supine and the examiner passively flexes the hip to 90 degrees while performing adduction and internal rotation. Similar to the FABER test, this should be considered a generalised test aditionally, test positions and definitions of a positive test vary in literature. The Impingement test (Flexion-Adduction-Internal Rotation Test) has a sensitivity of .75. [6]
  • Fitzgerald Test. The Fitzgerald test utilizes two different test positions to determine if the patient has an anterior or posterior labral tear. To test for a anterior labral tear, the patient lies supine while the physical therapist (PT) performs flexion, external rotation, and full abduction of the hip, followed by extending the hip, internal rotation, and adduction. To test for a posterior labral tear, the PT performs passive extension, abduction, external rotation, from the position of full hip flexion, internal rotation, and adduction while the patient is supine. Tests are considered to be positive with pain reproduction with or without an audible click[9][4]. The Fitzgerald test has a sensitivity of .98[9][6].
  • Resisted SLR
  • Anterior hip impingement test

Medical Management[edit | edit source]

The most common treatment and usually the first step on the treatment ladder is conservative treatment and medication (NSAIDs). When conservative treatment does not resolve symptoms, surgical intervention may be appropriate.

The most common procedure is an excision or debridement of the torn tissue by joint arthroscopy. However, studies have demonstrated mixed post-surgical results. Fargo et al found a significant correlation between outcomes and presence of arthritis on radiography. Only 21% of patients with detectable arthritis had good results from surgery, compared with 75% of patients without arthritis. Arthroscopic detection of chondromalacia was an even stronger indicator of poor long-term prognosis.[4]

For a simple tear, surgery involves a bioabsorbable suture anchor being placed over the tear to stabilize the fibrocartilaginous tissue back onto the rim of the acetabulum when the labrum has detached from the bone.

If the pathology is caused due to a malalignment (e.g. Perthes or hip dysplaysia), femoral or pelvic osteotomies are considered. A femoral osteotomy is a surgical treatment where the femur is cut and angled differently in an attempt to improve the mechanics of the leg.

Surgical treatment has been shown to have short-term improvement in patient reported outcomes and functional scores post-operatively, however the long-term outcomes remain unknown. [4][20]

Physical Therapy Management[edit | edit source]

The goal during physical therapy of an acetabular labral tear is to optimize the alignment of the hip joint and the precision of joint motion [4]. This can be done by:

  1. Reducing anteriorly directed forces on the hip by addressing the patterns of recruitment of muscles that control hip motion and by correcting movement patterns during exercises such as hip extension and during gait [4].
  2. Instructing patients to avoid pivoting motions, especially under load, since the acetabulum rotates on a loaded femur, thus increasing force across the labrum [3][4]

So far there has been no research on the efficacy of hip mobilization or manipulation in the treatment of labral disorders. Although it is suggested that the therapy should focus on optimizing the alignment of the hip joint and the precision of joint motion, avoiding pivoting motions and correcting gait patterns. [13]

As these patients have abnormal recruitment patterns of the hip muscles due to the biomenchanics of the pathology, treatment should optimize control of these muscles, specifically the hip adductors, deep external rotators, m. gluteus maximus, and m. iliopsoas muscles [4][21]. Additionally, if m. quadriceps femoris and hamstring muscles dominate, this should be corrected, as decreased force contribution from the m. iliopsoas during hip flexion and from the gluteal muscles during active hip extension results in greater anterior hip forces.[22]

Through gait and foot motion analysis, any abnormalities such as knee hyperextension causing hip hyperextension, walking with an externally rotated hip, or stiffness in the subtalar joint can be analysed and can be corrected through taping, orthotics or strengthening [4]. Gait analysis may also uncover decreased hip abduction during both the stance and swing phase, as well as decreased hip extension during swing phase -- characteristics that may be part of a hip joint stabilization strategy used by patients to compensate for deficient hip musculature functionality.[23]

Additionally, patients need to be educated regarding modification of functional activities to avoid any positions that cause pain, such as sitting with knees lower than hips or with legs crossed, getting up from a chair by rotating the pelvis on a loaded femur, hyperextending the hip while walking on a treadmill, etc.

After addressing abnormal movement patterns, focused muscle strengthening work and recovery of normal range of motion, patients eventually need to be progressed to advanced sensory-motor training and functional exercises, sport specific if applicable.[21]

If surgery is performed, usually the first six weeks post-surgery are NWB or TTWB. Active and active assisted exercises are appropriate in gravity-minimized positions to maintain motion of the hip. Stationary bike, not recumbent bicycle, is appropriate; end range hip flexion should be done passively rather than actively. Rehabilitation protocols are currently based on surgeon and PT experience and can follow either labral debridement or repair guidelines, depending on the procedure performed, and move through 4 basic phases. The four basic phases follow the general progression of initial exercises, intermediate exercises, advanced exercises and sports specific training. [7]

Phase I: Hip Resisted AROM ExercisesPhase 2: Hip Neuromuscular Re-education

Outcome Measures[edit | edit source]

international Hip Outcome Tool (iHOT)

Hip and Groin Outcome Score (HAGOS)

Hip Outcome Score (HOS)

Harris Hip Score (HHS)

Non-arthritic Hip Score

[[Lower Extremity Functional Scale (LEFS)|Lower Extremity Functional Scale]

Lequesne Hip Score

Key Research[edit | edit source]

  • Austin A, Meyer J, Powers C, Souza R. Identification of abnormal hip motion associated with acetabular labral pathology. J Orthop Sports Phys Ther. 2008;38(9):558-565.
  • Steadman Hawkins Research Foundation, Vail, Colorado, USA. New frontiers in hip arthroscopy: the role of arthroscopic hip labral repair and capsulorrhaphy in the treatment of hip disorders. Instr Course Lect. 2006;55:309-16.
  • Concurrent Criterion-Related Validity of Physical Therapy Examination Tests for Hip Labral Tears
  • A comprehensive review of hip labral tears
  • Groh M,Herrera J. A comprehensive review of hip labral tears.Curr Rev Musculoskelet Med 2009;2:105-117
  • Martin R,Enseki K,Draovitch P,Trapuzzano T,Philippon M. Acetabular labral tears of the hip:examination and diagnostic challenges.JOSPT 2006;36(7):503- 515
  • Enseki K,Martin R, Draovitch P,Kelly B,Philippon M, Schenker M. The hip joint: arthroscopic procedures and postoperative rehabilitation. JOSPT 2006;36(7):516-525
  • Lewis CL, Sahrmann SA. Acetabular labral tears. Physical Therapy. 2006;89:110-21.
  • Schmerl M, Pollard H, Hoskins W. Labral Injuries of the hip: a review of diagnosis and management. J Manipulative Physiol Ther. 2005;28(8):632.

References[edit | edit source]

  1. Lewis CL, Sahrmann SA. Acetabular Labral Tears. Phys Ther 2006;86:110-121.
  2. Amber I, Mohan S. Preventing Overdiagnosis of Acetabular Labral "Tears" in 40-Plus-year-old Patients: Shouldn't these be called Labral "Fissures" Instead? Acad Radiol. 2018;25(3):387-390.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskeletal Med. 2009; 2:105 - 117.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 Lewis C, Sahrmann S. Acetabular labral tears. Physical Therapy. 2006;86(1):110-121.
  5. 5.0 5.1 5.2 Schmerl M, Pollard H, Hoskins W. Labral Injuries of the hip: a review of diagnosis and management. J Manipulative Physiol Ther. 2005;28(8):632
  6. 6.0 6.1 6.2 Burgess RM, Rushton A, Wright C, Daborn C. The validity and accuracy of clinical diagnostic tests used to detect labral pathology of the hip: A systematic review. Manual Therapy 16 (2011) 318 – 326.
  7. 7.0 7.1 Garrison JC, Osler MT, Singleton SB. Rehabilitation after arthroscopy of an acetabular labral tear. N Amer J of Sports PT. 2007 Nov; 2(4): 241-249
  8. Burnett SJ, Della Rocca GJ, Prather H, et al. Clinical Presentation of Patients with tears of the Acetabular Labrum. The Journal of Bone Surgery: Volume 88-A · Number 7 · July 2006 pg 1448 - 1456
  9. 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 Leiboid M, Huijbregts P, Jensen R. Concurrent Criterion-Related Validity of Physical Examination Tests for Hip Labral Lesions: A Systematic Review. The Journal of Manual Manipulative Therapy. [online]. 2008;16(2):E24-41.
  10. 10.0 10.1 Orbell S, Smith TO. The physiotherapeutic treatment of acetabular labral tears. A systematic review. Adv Physiother. 2011; 13: 153-161.
  11. 11.0 11.1 11.2 11.3 11.4 11.5 11.6 Heiderscheit B, McClinton S. Evaluation and Management of Hip and Pelvis Injuries. Phys Med Rehabil Clin N Am. 2016;27(1):1-29.
  12. 12.0 12.1 12.2 Groh M,Herrera J. “A comprehensive review of hip labral tears.” Curr Rev Musculoskelet Med 2009;2:105-117
  13. 13.0 13.1 13.2 Schmerl M, Pollard H, Hoskins W. “Labral injuries of the hip: a review of diagnosis and management.” J Manipulative Physiol Ther. 2005;28(8):632.
  14. 14.0 14.1 Heerey JJ, Kemp JL, Mosler AB, Jones DM, Pizzari T, Souza RB et al Crossley KM. What is the prevalence of imaging-defined intra-articular hip pathologies in people with and without pain? A systematic review and meta-analysis. Br J Sports Med. 2018;52(9):581-593.
  15. 15.0 15.1 Chopra A, Grainger AJ, Dube B, Evans R, Hodgson R, Conroy J et al. Comparative reliability and diagnostic performance of conventional 3T magnetic resonance imaging and 1.5T magnetic resonance arthrography for the evaluation of internal derangement of the hip. Eur Radiol. 2018 Mar;28(3):963-971.
  16. 16.0 16.1 16.2 Reiman MP, Goode AP, Cook CE, Hölmich P, Thorborg K. Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis. Br J Sports Med. 2015;49(12):811.
  17. Martin RL, Irrgang J, Sekiya J. The Diagnostic Accuracy of a Clinical Examination in Determining Intra-articular Hip Pain for Potential Hip Arthroscopy Candidates. The Journal of Arthroscopic and Related Surgery. 2008;(52225):1-6
  18. McCarthy JC, Noble P, Schuck M, Alusio FV, Wright J, Lee J. “Acetabular and labral pathology.” In: McCarthy JC, editor. Early hip disorders. New York7 Springer Verlag; 2003. p. 113-33.
  19. Lewis CL, Sahrmann SA. “Acetabular labral tears.” Physical Therapy. 2006;86:110–21.
  20. Ayeni, O. R., Alradwan, H., de Sa, D., & Philippon, M. J. (2014). The hip labrum reconstruction: indications and outcomes—a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy22(4), 737-743.
  21. 21.0 21.1 Yazbek PM, Ovanessian V, Martin RL, Fukuda TY. Nonsurgical treatment of acetabular labrum tears: a case series. J of Ortho Sports PT. 2011 May; 41(5): 346-353
  22. Lewis CL, Sahrmann SA, Moran DW. Effect of hip angle on anterior hip force during gait. Gait Posture. 2010 Oct; 32(4): 603-607
  23. Kennedy MJ, Lamontagne M, Beaule PE. Femoroacetabular impingement alters hip and pelvic biomechanics during gait. Gait Posture. 30(2009) 41-44