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Physyour

  /  Hip   /  Hip Labral Tear

Hip Labral Tear

A hip labral tear involves the ring of cartilage (labrum) that follows the outside rim of the hip joint socket. Besides cushioning the hip joint, the labrum acts like a rubber seal or gasket to help hold the ball at the top of the thighbone securely within the hip socket.

Athletes who participate in sports such as ice hockey, soccer, football, golf and ballet are at higher risk of developing hip labral tears. Structural problems of the hip also can lead to a hip labral tear.

Hip labral tears are more common in people who play certain sports or who have structural problems of the hip. If conservative treatments don’t help, a health care provider may suggest surgery to repair the torn labrum.

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:

  • Internal articular surface : adjacent to the joint (avascular).
  • External articular surface: contacting the joint capsule (vascular).
  • 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

Symptoms

Many hip labral tears cause no signs or symptoms. Some people, however, have one or more of the following:

  • Pain in the hip or groin, often made worse by long periods of standing, sitting or walking or athletic activity.
  • A locking, clicking or catching sensation in the hip joint.
  • Stiffness or limited range of motion in the hip joint.

Risk factors

  • Acetabular dysplasia.
  • Degeneration.
  • Capsular laxity and hip hypermobility.
  • Femeroacetabular impingement.

Causes

The cause of a hip labral tear might be:

  • Trauma: Injury to or dislocation of the hip joint — which can occur during car accidents or from playing contact sports such as football or hockey — can cause a hip labral tear.
  • Structural problems: Some people are born with hip issues that can accelerate wear and tear of the joint and eventually cause a hip labral tear. This can include having a socket that doesn’t fully cover the ball portion of the upper thigh bone (dysplasia) or a shallow socket, which can put more stress on the labrum.

Extra bone in the hip, called femoroacetabular impingement (FAI), can also cause pinching of the labrum, which can lead to tearing over time.

  • Repetitive motions. Sports-related and other physical activities — including long-distance running and the sudden twisting or pivoting motions common in golf or softball — can lead to joint wear and tear that ultimately result in a hip labral tear.

Categories

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.

Investigations

In individuals with acetabular labrum tears, plain radiography and computed tomography may detect hip dysplasia, arthritis, and acetabular cysts; still, these tests are helpful in ruling out other hip pathologies. The diagnosis of acetabular labral tears is aided by MRI.

  • 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 treatment

Includes some relaxation, anti-inflammatory drugs, and painkillers if required. paired with a rigorous 10- to 12-week physical therapy program. During this time, the patient’s pain may reduce, but it’s probable that once he resumes his regular activities, the pain will come back. Surgical intervention may be considered if conservative treatment fails to control the patient’s symptoms.

Examination

  • Specific tests are done to diagnose hip labral tears. The test is considered positive if one or more of theImpingement 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:

In either the supine or lateral positions, the acetabular labral lesion can be repaired. 

A stand fracture table is utilized with an enlarged perinal post to deliver traction to patients who are lying flat. To facilitate access to the joint, the afflicted hip is slightly extended or abducted. To prevent neurologic problems, it’s critical to keep the perineal area under minimal pressure during traction. Fluoroscopy is used as the procedure’s guiding tool. In order to breach the vacuum seal and enable further distraction, a 14 or 16 gauge spinal needle is introduced into the joint if the distraction is successful. The anterior, anterolateral, and distal lateral auxiliary portals are employed.

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

Phase 1 (week 1-4): Initial exercises

    • Minimize pain 
    • Reduce inflammation
    • Initial exercises:  isometric contractions for abductors, adductors, transverse abdominis and hip extensors. All of the activity should be performed in a pain free range.
    • Closed chain exercises can be performed with slight resistance if pain is not present.
    • Weight bearing: if only debridement is done, weight bearing can occur 7 to 10 days post surgery. If labral repair is performed, weight bearing  is not recommended before 3 to 6 weeks.
    • Mobility exercises 

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 (week 5-7): Intermediate exercises

This phase’s objective is to maintain and enhance soft tissue elasticity and range of motion. Aggressive mobilization should continue in manual therapy, and passive ROM activities for external- and internal-rotation should become more aggressive as needed. The use of assistive device has been discontinued.

Intermediate exercises should start in this phase including:

    • Flexibility exercises involving the piriformis, adductor group, psoas/rectus femoris should continue.
    • Stationary bike with resistance.
    • Non-competitive swimming.
    • Exercises such as wall sits with abductor band, two leg bridging.
    • Standing hip flexion and extension (progressive load).
    • Improve balance 

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 (week 8-12): Advanced exercises

    • 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, resisted sport cord, walking forward/backwards, plyometric bounding in the water. Muscle strength maintenance (progressive load) and address any persisting muscular imbalance.
    • Core (lumbo-pelvic 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 (from week 12): Sport specific training

In this phase, it is crucial to progress in exercises intensity and to manage the treatment plan based on the patient’s type of activity or sport. Simulation exercises, high intensity and plyometrics are done in this phase to prepare the patient for his comeback.

Good muscle endurance, eccentric control, explosive power and good neuromuscular control should be observed.

Sport specific drills, functional testing and training, explosive exercises should be done.

References:

 

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