Hip Labral Disorders

Original Editor - Karolyn Conolty, Kenny Bosmans, Juliana Doyle,Alisha Lopez

Lead Editors- Scott Buxton

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Definition/Description

Hip labral disorders are pathologies which cause pain due to damage the acetabular labrum. In most cases this is caused by a tear in the labrum but it can also be caused by a dislocation, misalignment from bony structures ore a not optimal angle of the caput femoris.

Clinically Relevant Anatomy

The labrum of the hip is responsible for deepening the acetabulum to provide increased joint stability. It contains nerve endings to enhance proprioception, but may also be a source of pain.

The hip labral complex is a fibrocartilaginous structure that lines the acetabular socket&nbsp;and increases its surface area by 28%. It functions to increase joint stability and contibutes to propreoceptive feedback. The labrum works to maintain approriate synovial fluid pressure and keeps the fluid within the articular cartilage to decrease the forces of direct load between the femoral head and acetabular surfaces.The labrum is comprised of type I collagen and is typically between 2-3mm thick. It is thinner in the anterior region and is&nbsp;thought to be &nbsp;more highly innervated anteriorly and superiorly via free nerve endings.¹<br>

Epidemiology /Etiology

The labrum is susceptible to traumatic injury from shearing forces that occur with twisting, pivoting and falling. The most common mechanism is an external rotation force in a hyperextended position.In some cases pain develops over time. It is believed the microtraumata are responsible of the labral lasions in these cases.
Hip dysplasia is an important risk factor. Hip dysplasia is a general term used to describe certain abnormalities of the femur or the acetabulum, or both that result in inadequate containment of the femoral head within the acetabulum. A shallow acetabulum, a femoral or acetabular anteversion, and a decreased head offset or perpendicular distance from the center of the femoral head to the axis of the femoral shaft are a few of those bony abnormalities.

 

Mechanism of Injury

There are five possible etiologies of labral tears that are currently recognized: Femoroacetabular impingement (FAI),trauma,capsular laxity, dysplasia, and degeneration. ^1,2 FAI has been categorized into two types: cam and pincer. Cam type impingment exists with a large femoral head with resulting abdnormal junction between the femoral head and neck. This causes impingement between the femur and acetabular rim, particularly during hip flexion and internal rotation.¹
Pincer impingement occurs with an acetabular overcoverage, causing abutment of the femoral head into the acetabulum.Cam impingement is the proposed etiology of atererosuperior labral tears, and pincer type is thought to be on eof the causes posterioinferior chondral lesions.² Traumatic injury to the hip labum is thought to occur with a shearing force associated with twisting and falling. This can lead to joint instabililty resulitng in abnormal movment patterns with eventual degenerative changes and labral fraying.² Capsular laxity with resulting labral pathology is thought to occur in one of two ways; cartilage disorders (ie. Ehlers-Danlos syndrome) or rotational laxity resulting from excessive external rotation. These forces are often seen in certain sports including ballet,hockey,and gymnastics. ² Hip dysplasia occurs with development of a shallow acetabular socket resulting in decreased coverage of the femoral head. This places increased stress into the anterior portion of the hip joint, resulting in impingement and possible tears over time. ¹

Characteristics/Clinical Presentation

Patients with pain deep in the groin, instability of the hip, a "clicking" or "locking" feeling and stiffness of the hip might be suffering from an acetabular labral tear. These symptoms can increase when the patient's bearing weight or performing twisting movements of the hip. Pain may also occur while climbing stairs. Most patients (90%) diagnosed with acetabular labral tears have had complaints of pain in the anterior hip or groin. This can be an indication for an anterior labral tear, whereas buttock pain is more consistent with posterior tears and less common. 

Labral tears have been classified into 4 types:
- 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
- abnormally mobile: can result from a detached labrum

There is some variation in the presentation of hip labral tears.  Frequently patients present with anterior hip and groin pain, although some do present with GT, buttock, and/or medial knee pain. Mechanical symptoms associated with a tear are clicking, popping,giving way,catching,and stiffness. Patients offent describe a dull ache which increases with activities such as running or brisk walking. ¹
Some special tests performed are: FABER test,scour test, resisted SLR, and  anterior hip impingement test^1,2

Differential Diagnosis

A variety of pathologies have to be taken into account when facing hip pain. In most cases this pain is situated in the anterior hip or goin region. Some patients might also complain about pain in the lateral region or deep in the posterior buttocks, but this is less common. Pain in the hip region van be due to hip joint contusion, strain, athlethis pubalgia, osteitis pubis, inflammatory arthritis, osteoarthritis, septic arthritis, piriformis syndrome, snapping hip syndrome, bursitis, femoral head avascular necrosis, fracture, dislocation, tumor, hernia, slipped femoral capital epiphysis, Legg-Calve-Perthes disease, or referred pain from the lumbosacral and sacroiliac areas. 

The current gold standard for diagnosing labral tears is arthroscopy. There has been favorable results reported utilizing MRA, however studies have reported wide ranges of sensitivity from 60%- 100% and specificity from 44% - 100%. ² 

Diagnostic Procedures

Imaging from plain radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) are rather useless when identifying labral tears. The magnetic resonance arthrography (MRa) on the other hand is proven to be more succesful. MRa uses a dye injection into the hip capsule before imaging several planes with an MR. Although an MRa can give some indications for labral tears, studies have indicated that the sensitivity and specificity of the test varies. Diagnosis is there for best based on the combination of MRa, physical examination and arthroscopy. Arthroscopy is considered the golden standard and can be used for diagnostic as well as therapeutic means.

Outcome Measures

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hip Outcome Measures

Harris Hip score

Examination 

Hip labral disorders can be diagnosed during a thorough physical examination. In some cases the first signs can be spotted while observing the patient. During a brief walk the knee on the side of the affected hip might be slightly bend to absorb the shocks and lowering the weight bearing on that side. the step length of the affected leg may also be shortened to lower the pain. 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.

for the McCarthy test, both hips have to be in a flexed position. The affected hip needs to be brought into extension. If this movement reproduces a painful click, the patient is suffering from a labral tear.

The flexion-abduction-external rotation test(FABER) test elicates 88% of the patient with an articular pathology, But the FABER test didn’t find any correlation between the pisitive test result and the tipes of hip joint pathology.

To identify an 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.

A 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.

Medical Management

The most commen treatment uses anti-inflammatory drugs. Hip Labral Disorders can also be treated with débridement or with churgical ripair. There is a bioabsorbeble suture angor placed witch is needed to stabilize the fibrocartilaginous tissue back to the rim of the acetabulum when the labrum is detached from the bone. The goal of this artoscopic theatment is to releave the pain by eliminating the unstable flap tear that causes this discomfort. Pelvic osteotomies is a surgical treatment that is used when the alignment of the bone structures isn’t optimal. Due to this misalignment of the socket, witch is usually created by a disease during childhood the hip is going to wear out prematurely. When the angel of the caput femoris isn’t optimal a femoral osteotomy can be done. 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. As last resort an arthodesis can be used. Witch this churgical treatment an artificial induction of joint ossification is placed between two bones.

Conservative management includes rest,NSAIDS, physical therapy. There is not a great deal of evidnece supprting a speicifc protocol for PT, however it has been suggested to address joint motion, recruitment patterns of the hip musculature, avoiding pivoting and shearing motions across the hip joint, and analyzing/correcting gait patterns.²If conservative treatment fails arthroscopic treatment is often indicated. Procedures include labral repair, osteoplasty,rim trimming, microfracture, and capsular modifications. ³ A post operative course of phyiscal therapy has been suggested with intial restrictions in range of motion to allow for appropriate healing. Gradual motion, weightbearing, and strengthening is initiated based primarily on tissue healing times.³

Physical Therapy Management

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. 

Key Research

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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.

Resources

Groh M, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med 2009;2:105-117

Enseki K, Martin R, Draovitch P, Kelly B, Philippon M, Shunker M. The hip joint: Arthroscopic procedures and postoperative rehabilitation. J Orthop Sports Phys Ther. 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.

Resources

1. Groh M,Herrera J. A comprehensive review of hip labral tears.Curr Rev Musculoskelet Med 2009;2:105-117

2. 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

3. 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

Case Studies

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References

1. Groh M,Herrera J. A comprehensive review of hip labral tears.Curr Rev Musculoskelet Med 2009;2:105-117 

2. 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

3. 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

Recent Related Research (from Pubmed)

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References

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Martin R, Enseki K, Draovitch P, Trapuzzano T, Philippon M. Acetabular labral tears of the hip: Examination and diagnostic challenges. J Orthop Sports Phys Ther. 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. J Orthop Sports Phys Ther. 2006;36(7):516-525.