Transcript The Acetabular Labrum

The Acetabular Labrum
BLAIRE CHANDLER
VIRGINIA COMMONWEALTH UNIVERSITY PHYSICAL THERAPY
DECEMBER 1, 2015
Prevalence
2010 Review8:
“Unprecedented growth” in the number of hip arthroscopies over
the last decade
Acetabular labral tears are the leading indication for hip
arthroscopy
Anatomy & Function
Structure
Horseshoe-shaped structure
2 parts
 Capsular: dense connective tissue
 Articular: fibrocartilage, blends with the
acetabular rim
Widest anteriorly and thickest superiorly
Vascularity: no intrinsic vasculature
Innervation: multiple types of nerve endings
 Mechanoreceptors (proprioception?)
Biomechanics
↑ articular surface area and acetabular
volume
Creates a seal of the central compartment
that opposes flow of synovial fluid
 Negative pressure acts as a suction cup 
improved stability
 Maintains amount of joint fluid  uniform
distribution of pressures to articular surfaces
Labrum provides greatest stability at extremes
in ROM
Labral Tears
Etiologies
Traumatic Injuries
 North America – anterosuperior tears associated
with sudden twisting or pivoting motions
 Asia – posterior tears associated with
hyperflexion
Dysplasia
 Shallow acetabular socket
 Decrease coverage of femoral head anteriorly
and laterally  increased stress on anterior
capsule and labrum
Femoral acetabular impingement (FAI)
Capsular laxity
Reported 74.1% of tears are not associated
with a known event or cause7
Femoral Acetabular Impingement (FAI)
FAI = ↓joint clearance between the acetabulum and femur
2 types – Cam and Pincer
Cam impingement:
 Abnormally large radius of femoral head
 Abnormal contact with acetabulum, especially in flexion with adduction and IR
 More common in young, athletic males
Pincer impingement:
 Abnormal acetabulum with overcoverage
 More common in middle-aged, active women
Capsular Laxity
Traumatic vs. Atraumatic
 Traumatic = s/p dislocation or subluxation
 Atraumatic  global or focal rotational
Global Capsular Laxity
 Connective tissue disorders
 Down’s, Marfan’s, Ehlers-Danlos
Focal Rotational Laxity
 Results from excessive, forceful hip ER
 Golf, ballet, gymnastics, martial arts, hockey,
baseball
 Leads to iliofemoral ligament insufficiency  less
force absorption  increase force transferred to
labrum
Types of Tears
(most common)
Radial
Fibrillated
Longitudinal
Peripheral
Abnormally
Mobile
Radial Flap
Location of Tears
Dependent on geographic region
Prevalence of anterior tears:
 ? Poorer vascular supply
 Mechanically weaker tissue
 Higher localized forces
Most
common
Study
Patients
Undergoing
Surgical
Treatment (n)
Country of
Study
Suzuki et al
5
Japan
0%
60% posterior
60% posterosuperior
0%
Ikeda et al
7
Japan
14% anterosuperior 86% posterosuperior
0%
Hase & Ueo
10
Japan
20%
50%
10%
Farjo et al
28
United States 61%
25%
15%
Fitzgerald
49
United States 92%
8%
0%
Santori &
Villar
58
67%
28%
5%
McCarthy et
al
241
United States 86%
11%
3%
England
Anterior
Table 2. Locations of acetabular labral tears across studies.7
Posterior
Superior or
Lateral
Other
20%
posterior &
anterior
Clinical Assessment
History & Symptoms
Most common traumatic MOI = ER force in a
hyperextended position
Symptoms – pain, clicking, locking, catching,
instability, giving way, stiffness
 Pain location = anterior groin, buttock, greater
trochanter, thigh, and/or medial knee
 Anterior groin pain is NOT specific to labral tear
Symptom localization – C-sign
Clinical Characteristics of Symptomatic
7
Labral Tears
Sex: females > males
Symptoms:
 Anterior hip pain or groin pain
 Clicking, locking, catching
 ROM limitations: rotation*, flexion, abduction,
adduction
Symptom duration: average of >2 years
Symptom
Anterior groin
pain
Keeney, et al
96% with diagnosed tear
McCarthy & Busconi
Narvani, et al
100% with diagnosed tear
No correlation between anterior
groin p! and labral tear (r=0.16,
P=0.41)
Anterior thigh
pain
34% with diagnosed tear
Lateral hip pain
38% with diagnosed tear
Buttock pain
17% with diagnosed tear
Locking or
catching
58% with diagnosed tear
Inguinal clicking
Correlated to labral tears
(r=0.70, P=<0.0005)
Giving way
Correlated to labral tears
(r=0.41, P=<0.002)
100% sensitivity and 85%
specificity, +LLR 6.67
Physical Examination
Inspection
 Standing posture
 Sitting posture
 Gait
Palpation – usually to rule out other disorders
Special Tests – Intra-Articular Pathology
No single special test associated with labral
tear specifically!
 All tests are for INTRA-ARTICULAR hip pathology
FABER/Patrick’s – flexion, abduction, and ER
 Pain provocation + ROM
Scour Test – flexion/adduction to
extension/abduction with compression and
ER/IR
Resisted Straight Leg Raise – apply resistance
at ~30° of hip flexion
Log Roll Test – best test for just intra-articular
symptoms1
Special Tests – Associated Conditions
Tests used to determine presence of
associated pathologies/conditions
Impingement Test/FADIR – forced flexion,
adduction, and IR
 + for FAI
General ligament laxity
Log Roll Test – with hip in neutral position,
IR/ER leg
 Compare side to side for capsular laxity
JOSPT Key Examination
7
Elements
1) Positions and movement tests
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Standing alignment, esp. hip hyperextension
Precision of active and passive hip flexion
Precision of active hip extension (contribution of hamstrings vs. gluteals)
Pattern and range of hip IR/ER in prone
Quadruped – effect on symptoms, alignment
2) Muscle strength and pattern of control
3) Muscle length and stiffness
4) Gait assessment – esp. lack of appropriate knee flexion, excessive time in foot flat, hip
hyperextension
5) Modification of functional activities – sitting mechanics
Hip Pain “Red Flags”
Acute hip pain with:
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Fever
Malaise
Night sweats
Weight lost
Night pain
IV drug use
History of cancer
Compromised immune system
Could indicate tumor, infection, septic
arthritis, osteomyelitis, or an inflammatory
condition
Corticosteroid or alcohol use = risk of
avascular necrosis
Potential indicators of fracture:
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Significant trauma
Pain with any/all movement
Inability to walk/bear weight
Shortened, externally rotated lower extremity
Diagnosis
Diagnosed via MRI with arthrogram
Kahlenberg et al:
 Average number of healthcare providers: 4
($315.05)
 Average number of diagnostic tests: 3.4
($837.01)
 Average number of conservative treatments: 3.1
($1375.44)
Differential Diagnosis
Common Symptoms
Clinical Examination
Extra-Articular pathology
 Superficial groin, lateral hip, or
posterior hip pain
 Lateral or anterior snapping
 Tenderness to palpation
 Pain with stretching and/or resistance to
involved structures
Intra-articular pathology
 Groin pain
 Clicking, giving way
 Groin pain/limited ROM FABER test
 Groin pain and/or clicking with Scour
test
 Groin pain with SLR test
FAI
 Anterior pinching pain with sitting
 Anterior pinching pain with
impingement/FADIR test
Degenerative changes
 Medial thigh pain
 Morning stiffness
 Painful and/or limited IR ROM
 Limited flexion ROM
Capsular laxity
 Instability
 General hypermobility
 Increased ER ROM with log roll test
Table 1. Martin, et al.
Treatment
Medical Management
Protected weight bearing
Nonsteroidal anti-inflammatory drugs
Physical therapy
Intra-articular cortisone injections
 Limited benefit
Physical Therapy (Pre-Op)
“Physical therapy has not proved to be of
Key muscles to target:
significant benefit and is not recommended for
 Hip abductors
patients with a labral tear”
 Deep external rotators
Goal: reducing anteriorly directed forces on
the hip
 Address patterns of recruitment of muscles that
control hip motion
 Correct movement patterns
 Education re: provocative positions, etc.
 Gluteus maximus
 Iliopsoas
Surgical Management
Goal: “anatomically restore labral
function in order to preserve or
restore stability of the joint, decrease
joint contact pressure on the articular
cartilage, and ultimately restore painfree function”10
3 options:
 Debridement or excision
 Repair
 Reconstruction
Other pathology often corrected
simultaneously
Post-Op Rehabilitation
Rehabilitation After Hip Arthroscopy
No evidence exists to support
Generally broken down into 3-4
specific post-op rehab guidelines phases:
Lots of variability
 MD dependent
 Different surgical components
*Protocols should be tailored to
the individual patient
 Phase I – Initial Exercises
 Phase II – Intermediate Exercises
 Phase III – Advanced Exercises
 Phase IV – Sport-Specific Exercises
General Guidelines
Protected weight bearing
 50% WB x 4 weeks
 TTWB x 3 weeks
 WBAT with use of crutches x 4 weeks
 Variable…
ROM limitations (~6 weeks)
 No hip flexion past 90°
 Avoid external rotation
 No hip extension past 0-10° (most variable)
 Limited abduction
Avoid hip flexor activity
Limit ROM based on pain initially
Gentle circumduction should be
started early to maintain joint mobility
and decrease the likelihood of
adhesions
Phase 1
Post-op weeks ~0-4
Goals:
 Protect repaired tissue
 Restore ROM within limitations
 Control pain
 Restore muscle control and prevent muscle
inhibition
Phase 2
Post-op weeks ~5-7
Goals:
 Protect repaired tissue
 Increase ROM
 Normalize gait
 Increase muscle strength
Phase 3
Post-op weeks ~8-12
Goals:
 Restore muscle endurance/strength
 Restore cardiovascular endurance
 Optimize neuromuscular
control/balance/proprioception
Phase 4
Post-op weeks ~12+
Goals:
 Running progression
 Sport-specific drills
 Return to sport
References
1)
Byrd, T. (2007). Evaluation of the Hip: History and Physical Examination. North American Journal of Sports Physical Therapy, 2(4), 231-240.
2)
Edelstein, J., Ranawat, A., Enseki, K., Yun, R., & Draovitch, P. (2012). Post-operative guidelines following hip arthroscopy. Current Review of
Musculoskeletal Medicine, 5, 15-23.
3)
Garrison, J., Osler, M., & Singleton, S. (2007). Rehabilitation After Arthroscopy of an Acetabular Labral Tear. North American Journal of Sports
Physical Therapy, 2(4), 241-250.
4)
Kahlenberg, C., Han, B., Patel, R., Deshmane, P., & Terry, M. (2014). Time and Cost of Diagnosis for Symptomatic Femoroacetabular
Impingement. Orthopaedic Journal of Sports Medicine, 2(3).
5)
Krych, A., Griffith, T., Hudgens, J., Kuzma, S., Sierra, R., & Levy, B. (2014). Limited therapeutic benefits of intra-articular cortisone injection for
patients with femoro-acetabular impingement and labral tear. Knee Surgery, Sports Traumatology, Arthroscopy, 22, 750-755.
6)
Lewis, C., & Sahrmann, S. (2006). Acetabular Labral Tears. Physical Therapy, 86(1), 110-121.
7)
Martin, R., Enseki, K., Draovitch, P., Trapuzzano, T., & Philippon, M. (2006). Acetabular Labral Tears of the Hip: Examination and Diagnostic
Challenges. Journal of Orthopedic & Sports Physical Therapy, 36(7), 503-515. doi:10.2519/jospt.2006.2135
8)
Safran, M. (2010). The Acetabular Labrum: Anatomic and Functional Characteristics and Rationale for Surgical Intervention. Journal of the
American Academy of Orthopaedic Surgeons, 18(6), 338-345.
9)
Edelstein, J., Ranawat, A., Enseki, K., Yun, R., & Draovitch, P. (2012). Post-operative guidelines following hip arthroscopy. Current Review of
Musculoskeletal Medicine, 5, 15-23.
10)
Wolff AB. Mantell M. Gerscovich D. Haines C. “Arthroscopic Management of the Labrum: Debridement, Repair, and Stitch Configurations”
Chapter 11 with accompanying video in *The Hip: Arthroscopy Association of North America Advanced Arthroscopic Surgical Techniques. In
Press.