Hip labral tears

Original Editor - Juliana Doyle

Top Contributors - Juliana Doyle, Scott Buxton and Admin  

Clinically Relevant Anatomy

The hip labral complex is a fibrocartilaginous structure that lines the acetabular socket and increases its surface area by 28%.¹ 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 thought to be  more highly innervated anteriorly and superiorly via free nerve endings.¹

Mechanism of Injury / Pathological Process

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

Clinical Presentation

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

Diagnostic Procedures

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 

hip Outcome Measures

Harris Hip score

Management / Interventions

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

Differential Diagnosis

There are a variety of other pathologies that are potential causes of hip pain including hip OA, piriformis syndrome,snapping hip,AVN,SCFE,referred lumbosacral pain, tumor, fracture,bursitis, muscle strain, hernia, septic arthritis, and Legg - Calves -Perthes disase. ^1,2

Key Evidence

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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