Hip Labral Tear: Difference between revisions
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The acetabular labrum seals the central hip joint from the periphery, keeps the synovial fluid within the central compartment, and creates a negative pressure within the joint. The negative pressure helps to resist subluxation of the femoral head and increases stability. Any disruption of the labrum can negatively affect articular cartilage health and joint stability.<ref name="uptodate">Johnson, R. Approach to hip and groin pain in the athlete and active adult. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2020.</ref> | The acetabular labrum seals the central hip joint from the periphery, keeps the synovial fluid within the central compartment, and creates a negative pressure within the joint. The negative pressure helps to resist subluxation of the femoral head and increases stability. Any disruption of the labrum can negatively affect articular cartilage health and joint stability.<ref name="uptodate">Johnson, R. Approach to hip and groin pain in the athlete and active adult. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2020.</ref> | ||
==Epidemiology== | |||
Labral tears are present in 22% of athletes with groin pain and 55% of those with mechanical symptoms.<ref name="brukner"/> | |||
==Pathogenesis== | |||
There are two general mechanisms of injury to the acetabular labrum.<ref name=uptodate/> | There are two general mechanisms of injury to the acetabular labrum.<ref name=uptodate/> | ||
#A single event of significant trauma. This normally involves forced resistance of hip flexion while kicking or running (for example in Rugby). | #A single event of significant trauma. This normally involves forced resistance of hip flexion while kicking or running (for example in Rugby). | ||
#Repetititve injury and microtrauma in an osteoarthritic, dysplastic hip or in a hip with [[Femoroacetabular Impingement|FAI]]. | #Repetititve injury and microtrauma in an osteoarthritic, dysplastic hip or in a hip with [[Femoroacetabular Impingement|FAI]]. | ||
== | Pathology normally occurs in the weightbearing anterosuperior aspect of the labrum.<ref name="uptodate"/> There are several thoughts as to the reasons for this prediliction. There is reduced thickness of the anterior labrum. Femoroacetabular impingement normally causes anterior impingement. Repetitive twisting and pivoting is a factor. Owing to anteversion of the acetabulum, there is reduced bony support anteriorly which may also increase the shear forces on the labrum. Increased forces are also placed on the anterior labrum during the final stages of the stance phase of gait and in more than 5 degrees of hip extension.<ref name="brukner">Brukner. Clinical Sports Medicine. 4th Edition. McGraw-Hill. 2012</ref> | ||
Healing of the labrum has been demonstrated in animal studies.<ref>{{#pmid:15094141}}</ref> | |||
==Classification== | |||
Type I tears are a detachment of the labrum from the acetabular rim cartilage. Type II is a cleavage tear within the labrum substance. The tear location in respect to vascular supply is important when considering healing potential.<ref name="brukner"/> | |||
==Clinical Features== | ==Clinical Features== | ||
The most common symptom is groin pain that is exacerbated by athletic activity. Pain is normally located in the anterior hip or groin, and is often described as sharp. Uncommonly it can can cause mechanical symptoms such as catching or locking. Pain can occur in particular with activities involving aggressive hip flexion such as jumping or sprinting. Pain can sometimes occur when fatigued such as during a long distance run, or running up hill. Some patients may report groin pain with sitting, transitioning between standing from sitting, or when descending stairs. Some activities of daily living may be affected such as putting on shoes or stockings while sitting. | The most common symptom is groin pain that is exacerbated by athletic activity. Pain is normally located in the anterior hip or groin, and is often described as sharp. Uncommonly it can can cause mechanical symptoms such as catching, clicking, or locking. <ref name=uptodate/>Some patients may describe buttock pain.<ref name="brukner"/> Pain can occur in particular with activities involving aggressive hip flexion such as jumping or sprinting. Pain can sometimes occur when fatigued such as during a long distance run, or running up hill. Some patients may report groin pain with sitting, transitioning between standing from sitting, or when descending stairs. Some activities of daily living may be affected such as putting on shoes or stockings while sitting. <ref name=uptodate/> | ||
Examination | Examination has poor sensitivity and sensitivity.<ref name="brukner"/> Features are pain with hip flexion and anterior impingement tests. No test is specific for labral injury, and signs and symptoms overlap with FAI. Some useful tests are repeated hip flexion, hip flexion against resistance, FABER, and FADDIR testing. Reduced internal rotation may suggest [[Hip Osteoarthritis|hip joint osteoarthritis]].<ref name=uptodate/><ref name="brukner"/> | ||
==Imaging== | ==Imaging== | ||
MRA is the most accurate imaging modality, but the gold standard remains the arthroscopic exam<ref name="brukner"/>. Xrays can be helpful, and should include standing anteroposterior, cross-table lateral or Dunn lateral, and a false profile view. An intraarticular injection of local anaesthetic with or without a glucocorticoid can aid in the diagnostic process if pain is ablated following injection. If an MRA is performed then anaesthetic can be injected along with the contrast and a pain diary can be ascertained. | |||
==Management== | ==Management== | ||
An initial trial of non-operative management is recommended | An initial trial of non-operative management is recommended,<ref name="brukner"/> and physical therapy is the mainstay of conservative management. Strengthening of the pelvic girdle can aid in stabilising the hip joint, correct abnormal pelvic tilt, and rectify abnormal load on the labrum.<ref name=uptodate/> Exercises should start unloaded and progress with more load added. Gait retraining can also be considered in order to reduce excessive hip extension at the end of the stance phase of gait.<ref name="brukner"/> | ||
Activity modification should also be discussed. The patient should be advised to avoid repetitive hip flexion, adduction, abduction, and rotation at end range. | |||
Arthroscopic surgery can be considered upon failure of conservative management. Where possible the labrum should be restored rather than excised in order to restore normal hip joint function. | Arthroscopic surgery can be considered upon failure of conservative management. Where possible the labrum should be restored rather than excised in order to restore normal hip joint function. In athletes with FAI, surgery can be considered early if their sport requires a range of motion not achieved before impingement symptoms occur. | ||
[[Category:Pelvis, Hip & Thigh]] | [[Category:Pelvis, Hip & Thigh]] | ||
==References== | ==References== | ||
Revision as of 18:17, 14 July 2020
The acetabular labrum seals the central hip joint from the periphery, keeps the synovial fluid within the central compartment, and creates a negative pressure within the joint. The negative pressure helps to resist subluxation of the femoral head and increases stability. Any disruption of the labrum can negatively affect articular cartilage health and joint stability.[1]
Epidemiology
Labral tears are present in 22% of athletes with groin pain and 55% of those with mechanical symptoms.[2]
Pathogenesis
There are two general mechanisms of injury to the acetabular labrum.[1]
- A single event of significant trauma. This normally involves forced resistance of hip flexion while kicking or running (for example in Rugby).
- Repetititve injury and microtrauma in an osteoarthritic, dysplastic hip or in a hip with FAI.
Pathology normally occurs in the weightbearing anterosuperior aspect of the labrum.[1] There are several thoughts as to the reasons for this prediliction. There is reduced thickness of the anterior labrum. Femoroacetabular impingement normally causes anterior impingement. Repetitive twisting and pivoting is a factor. Owing to anteversion of the acetabulum, there is reduced bony support anteriorly which may also increase the shear forces on the labrum. Increased forces are also placed on the anterior labrum during the final stages of the stance phase of gait and in more than 5 degrees of hip extension.[2]
Healing of the labrum has been demonstrated in animal studies.[3]
Classification
Type I tears are a detachment of the labrum from the acetabular rim cartilage. Type II is a cleavage tear within the labrum substance. The tear location in respect to vascular supply is important when considering healing potential.[2]
Clinical Features
The most common symptom is groin pain that is exacerbated by athletic activity. Pain is normally located in the anterior hip or groin, and is often described as sharp. Uncommonly it can can cause mechanical symptoms such as catching, clicking, or locking. [1]Some patients may describe buttock pain.[2] Pain can occur in particular with activities involving aggressive hip flexion such as jumping or sprinting. Pain can sometimes occur when fatigued such as during a long distance run, or running up hill. Some patients may report groin pain with sitting, transitioning between standing from sitting, or when descending stairs. Some activities of daily living may be affected such as putting on shoes or stockings while sitting. [1]
Examination has poor sensitivity and sensitivity.[2] Features are pain with hip flexion and anterior impingement tests. No test is specific for labral injury, and signs and symptoms overlap with FAI. Some useful tests are repeated hip flexion, hip flexion against resistance, FABER, and FADDIR testing. Reduced internal rotation may suggest hip joint osteoarthritis.[1][2]
Imaging
MRA is the most accurate imaging modality, but the gold standard remains the arthroscopic exam[2]. Xrays can be helpful, and should include standing anteroposterior, cross-table lateral or Dunn lateral, and a false profile view. An intraarticular injection of local anaesthetic with or without a glucocorticoid can aid in the diagnostic process if pain is ablated following injection. If an MRA is performed then anaesthetic can be injected along with the contrast and a pain diary can be ascertained.
Management
An initial trial of non-operative management is recommended,[2] and physical therapy is the mainstay of conservative management. Strengthening of the pelvic girdle can aid in stabilising the hip joint, correct abnormal pelvic tilt, and rectify abnormal load on the labrum.[1] Exercises should start unloaded and progress with more load added. Gait retraining can also be considered in order to reduce excessive hip extension at the end of the stance phase of gait.[2]
Activity modification should also be discussed. The patient should be advised to avoid repetitive hip flexion, adduction, abduction, and rotation at end range.
Arthroscopic surgery can be considered upon failure of conservative management. Where possible the labrum should be restored rather than excised in order to restore normal hip joint function. In athletes with FAI, surgery can be considered early if their sport requires a range of motion not achieved before impingement symptoms occur.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Johnson, R. Approach to hip and groin pain in the athlete and active adult. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2020.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Brukner. Clinical Sports Medicine. 4th Edition. McGraw-Hill. 2012
- ↑ Miozzari et al.. Effects of removal of the acetabular labrum in a sheep hip model. Osteoarthritis and cartilage 2004. 12:419-30. PMID: 15094141. DOI.
