Labral Tear

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Definition/Description

An acetabular labral tear can cause pain if the labrum is torn, frayed, or damaged. Labral tears cause groin pain or pain in the anterior side of the hip, and less commonly buttock pain. 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.

Labral tears could be further classified as:

• Anterior labral tears - the pain will generally be more consistent and is situated on the anterior hip (anterosuperior quadrant) or at the groin. They frequently occur in individuals in European countries and the United States.
• Posterior labral tears - are situated in the lateral region or deep in the posterior buttocks. They occur less frequently in individuals in European countries and the United States, but are more common in individuals from Japan.

Clinically Relevant Anatomy

The acetabular labrum is a fibro-cartilaginous rim, which encompasses the circumference of the acetabulum. It helps to keep the head of the femur inside the acetabulum, and varies greatly in form and thickness.

The labrum has three surfaces:1

1. Internal articular surface - adjacent to the joint (avascular)
2. External articular surface - contacting the joint capsule (vascular)
3. Basal surface - attached to the acetabular bone and ligaments.
   

The transverse ligaments surround the hip and help hold it in place while moving.

On the anterior aspect, the labrum is triangular in the radial section. On the posterior aspect, the labrum is dimensionally square but with a rounded distal surface.

The functions of the acetabular labrum are:

• Joint stability
• Sensitive shock absorber
• Joint lubricator
• Pressure distributor
• Decreasing contact stress between the acetabular and the femoral cartilage
  

Epidemiology/Etiology

In studies of patients with a labral tear, researchers have attributed the injury to a variety of causes:

• Direct trauma - e.g. motor accidents, falling with or without a hip dislocation, slipping
• Sporting activities that require frequent external rotations or hyperextension - e.g. ballet, soccer, and hockey, running and sprinting
• Specific movements including torsional or twisting movements, hyper abduction, hyper extension, and hyper extension with lateral rotation

The condition is not age related. The reported age of people with hip pain and a labral tear spans from 8 to 75 years old.

Structural risk factors for the condition include:

• Acetabular dysplasia
• Degeneration
• Capsular laxity and hip hypermobility
• Femeroacetabular impingement (FAI) (Byrd and Jones 2003, Wenger et al. 2004)

Characteristics/Clinical Presentation

• Sex - Occurs in both sexes with the same frequency
• Symptoms - A constant dull pain with periods of sharp pain that worsens during activity. Walking, pivoting, prolonged sitting and impact activities aggravate symptoms. Some patients describe night time pain. The symptoms can have a long duration, with an average of greater than two years.The injury is usually caused by the hip joint being stressed in rotation. The pain is mainly in the groin, but could be in the trochanteric and buttock region.
• Mechanical Symptoms - A variety of mechanical symptoms have been reported, including clicking (most frequently),locking or catching, or giving away. The significance of these signs is questionable.
• Range of motion: It usually isn't restricted however at extremes, invoke pain.
  • These specific manoeuvres may cause pain in the groin:
    • Flexion, adduction, and internal rotation (FADDIR TEST)of the hip joint are related to anterior superior tears
    • Passive hyperextension, abduction, and external rotation are related to posterior tears
      

Differential Diagnosis

The differential diagnosis of labral tears may include the following diagnoses:

• Athletic pubalgia
• Snapping_Hip
• Septic (Infectious) Arthritis
• Piriformis syndrome
• Contusion
• Strain
• Osteitis pubis
• Trochanteric Bursitis
• Avascular necrosis of the femoral head
• Fracture
• Dislocation
• Inguinal or femoral hernia
• Legg-Calve Perthes disease
• Slipped Capital Femoral Epiphysis
• Referred Pain from the lumbosacral and sacroiliac areas
• Tumor

Investigations

Plain radiographs and computed tomography may show hip dysplasia, arthritis, and acetabular cysts in patients with acetabular labrum tears, they are useful for excluding other types of hip pathology. MRI helps in diagnosing acetabular labral tears.

• MRA (magnetic resonance arthography) - Produces the best result, as the intra-articular or systemic infusion of gadolinium is required to obtain the detail necessary to study the labrum. The principle of the procedure relies upon capsular distension. The outline the labrum with contrast and filling any tears that may be present. MRA has limitations regarding the sensivity for diagnose acetabular labral and articular cartilage abnormalities, it has also been proven that MRA may be less effective in identifying posterior and lateral tears.
• Diagnostic-image-guided intra-articular hip injections - Can also be helpful in the diagnosis of labral tears.
• Hip arthroscopy - Used as a diagnostic gold standard for ALT and is used as therapeutic medium.

Conservative Management

Includes relative rest, anti-inflammatory medications, and pain medications if necessary. Combined with a 10-12 week intensive physiotherapy program. The patient's pain may lessen during this period but it is possible that the pain will return once the patient returns to his normal activities. When conservative management is unable to control the patient’s symptoms, surgical intervention may be considered.

Outcome Measures

• Lower Extremity Functional Scale (LEFS)
• International Hip Outcome Tool (iHOT)

See Outcome Measures Database for more

Examination

Physical Examination

The test is considered positive if one or more of these symptoms are reproduced during the test: click, clunk, or pain in the groin region.

• Impingement test - The hip joint is passively flexed to 90°, internally rotated, and adducted (see video below).
• FABER Test - The lower extremity is passively placed in a figure-of–four position, and slight pressure is applied to the medial side of the knee. (Positive in 7 of 18 cases)
• Resisted straight leg raise test - The patient's hip is flexed 30° with the knee in extension and a downward pressure applied.(Positive in 1 of 18 cases)
• McCarthy sign/Thomas Test (hip flexion to extension manoeuvre) - With the patient in a supine position, the subject fully flexes both hips. The examiner slowly/passively extends the subject’s lower extremities and moves the hips into external rotation. The test is repeated, but with the hip in internal rotation.
• Internal rotation load/grind test - With the patient in a supine position, the examiner passively flexes the patient's hip to 100°, and then rotates the subject’s hip from internal rotation to external rotation while pushing along the axis of the femur through the knee to elicit ‘grind’ (see video below).
• Fitzgerald Test - For assessment of the anterior labrum. The patient's hip is acutely flexed and then extended while internally rotated and in full abduction.
• Patrick test - For assessment of the posterior labrum. The patient's hip is flexed and then extended while in abduction and external rotation.

Medical Management

Arthroscopy

Repair of the acetabular labral lesion can be preformed in either the supine or lateral position. In the supine position, a stand fracture table is used with an oversized perinal post to apply traction. The affected hip is placed into slight extension/adduction to allow approach to the joint. During traction it is important that there is a minimized pressure in the perineal area to avoid neurologic complications. The procedure is under the guidance of fluoroscopy. If the distraction is obtain a 14 or a 16 gauge spinal needle is inserted into the joint to break the vacuum seal and allow further distraction. Three portals are used (the anterolateral, anterior and the distal lateral accessory).
For repair of a detached labrum, the edges of the tear are delineated and suture anchors are placed on top of the acetabular rim in the area of detachment. If the tear in the labrum has a secure outer rim and is still attached to the acetabulum, a suture in the mid substance of the tear can be used to secure.

Physical Therapy Management

Movements that cause stress in the area need to be avoided. The rehabilitation protocol following acetabular labral debridement or repair are divided into four phases.

Phase 1 - Initial Exercise (Week 1-4)

The primary goals following a acetabularlabral debridement or repair are to the minimize pain and the inflammation, and initiate early motion exercises. This phase initially consists of isometric contraction exercises for the hip adductors, abductors, transverse abdominals and extensor muscles. Following a labral debridement, closed-chain activities such as low-level leg press or shuttle can begin with limited resistance. Assistive device for those with increased pain with weight bearing. Active movements within painful limits. Transversus abdominis and multifidus isolated contraction and associated light exercises, such as bridging and crouching close to the floor on hands and knees

Weight bearing protocol following a debridement is 50% for 7 to 10 days, and non-weight bearing or toe-touch weight bearing for 3 to 6 weeks in case of a labral repair. Unnecessary hypomobility will limit progress in future phases, thus it is important to ensure that the patient maintains adequate mobility and range during this phase.

Treatment modalities:

• Aquatic therapy is a suitable treatment approach - movement in the water allows for improvement in gait by allowing appropriate loads to be placed on the joint without causing unnecessary stress to the healing tissue. For example, the patient may perform light jogging in the water using a flotation device. It is import to know that the patient's range of motion precautions, as these may vary in debridement or repair.
• Manual therapy for pain reduction and improvement in joint mobility and proprioception. Considerations include gentle hip joint mobilizations contract-relax stretching for internal and external rotation, long axis distraction, and assessment of lumbo-sacral mobility.
• Cryotherapy
• Appropriate pain management through medication.
• Gentle stretching of hip muscle groups including psoas, quadriceps, hamstring muscles with passive range of motion.
• Stationary bike without resistance, with seat height that limits the hip to less than 90°
• Exercises such as: water walking, piriformis stretch, ankle pumps.

To progress to phase 2, ROM has to be greater or equal to 75%.

Phase 2 - Intermediate Exercise (Week 5-7)

The goal of this phase is to continue to improve ROM and soft tissue flexibility . Manual therapy should continue with mobilization that is more aggressive, passive ROM exercises should become more aggressive as needed, for external- and internal rotation. Discontinuation of assistive device is done.

• Flexibility exercises involving the piriformis, adductor group, psoas/rectus femoris should continue
• Stationary bike with resistance
• Maitland’s manual mobilization (grades 3 and 4) and combined movements
• Pelvic rotation maneuver
• Sacroiliac distraction
• Sidestepping with an abductor band for resistance
• Core strengthening (lumbopelvic stabilization exercises added to moderate exercises, such as lateral bridge and mini squat, and to light sensory motor training)
• Non-competitive swimming
• Exercises such as wall sits with abductor band, two leg bridging
• Standing hip flexion and extension (progressive load), 3 × 10 reps • Standing hip abduction and adduction, with elastic resistance near a support bar (progressive load), 3 × 10 reps • Lunge (progressive load), 3 × 10 reps • Shuttle machine (progressive load), 3 × 10 reps, 70% MR • Knee flexion-extension on chair (progressive load), 3 × 10 reps, 70% MR • Sidestepping gait with an elastic band over midfeet, 3 × 1 min • Dynamic valgus control with single-limb squat, 3 × 1 min
• To improve balance• Balancing • Balance board • DynaDisc • Jumping board

To progress to the third phase it is important that the patient has a normal gait pattern with no Trendelenburg sign. The patient should have symmetrical and passive ROM measurement with minimal complaints of pain.

Phase 3 - Advanced Exercise (Week 8-12)

• Manual therapy should be performed as needed
• Flexibility and passive ROM interventions should become slightly more aggressive if the limitations persist (if the patient has reached his full ROM or flexibility, terminal stretches should be initiated)
• Strengthening exercises: walking lunges, lunges with trunk rotations, resistend sportcord, walking forward/backwards, plyometric bounding in the water. Muscle strength maintenance (progressive load) and address any persisting muscular imbalance.
• Core (lumbopelvic stabilization exercises) added to Swiss ball exercises and advanced sensory motor training
• Exercises such as core ball stabilization, golf progression, lunges

To progress to the fourth phases it is important that there is symmetrical ROM and flexibility of the psoas and piriformis.

Phase 4 - Sport Specific Training (Week 12-*)

In this phase it is important to return safely and effectively back to competition or previous activity level. Manual therapy, flexibility, and ROM exercises can continue as appropriate.

It is important the the patient has good muscular endurance, good eccentric muscle control, and the ability to generate power.

The patient can be given sport specific exercises and has to have the ability to demonstrate a good neuromuscular control of the lower extremity during the activities.

Exercises such as: sport specific drills, functional testing

Key Research

• Greaves LL, et al. Effect of acetabular labral tears, repair and resection on hip cartilage strain: a 7T MR study. J Biomech. 2010 Mar 22;43(5):858-63. doi: 10.1016/j.jbiomech.2009.11.016. http://www.jbiomech.com/article/S0021-9290(09)00652-6/abstract (accessed 27 January 2014)
  
• Springer BA, et al. Acetabular labral tears: diagnostic accuracy of clinical examination by a physical therapist, orthopaedic surgeon, and orthopaedic residents. N Am J Sports Phys Ther. 2009 Feb;4(1):38-45. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953315/pdf/najspt-04-038.pdf (accessed 27 January 2014).
  
• Nishii T, et al. Acetabular labral tears: contrast-enhanced MR imaging under continuous leg traction. Skeletal Radiol. 1996 May;25(4):349-56.