12/21/2012 Labrum Hip Labral Pathology From Diagnosis to Functional - PDF document

12/21/2012 Labrum Hip Labral Pathology – From Diagnosis to Functional The labrum is a ring of fibrocartilage (fibrous cartilage) that extends around the majority of the Rehabilitation acetabulum, increasing its depth. The labrum acts as a suction seal around the femoral head maintaining the joint fluid within. Josette Fisher, PT, ATC, CSCS The fluid protects the articular cartilage Director of Rehabilitation layers of the femur and acetabulum. The labrum does act as a stabilizer of the femoral head within the Jfisher@excelsiorortho.com acetabulum as well. Labral Tears are Typically the Result of Some Underlying Etiology Bony 1. Static overload ‐ femoral anteversion ‐ valgus femoral neck orientation ‐ acetabular dysplasia (ant/lat) 2. Dynamic Impingement ‐ CAM impingement ‐ femoral retroversion ‐ pincer impingement Soft Tissue 1. Psoas Impingement 2.Laxity – collagen disorders Traumatic 1 . Subluxation 2.Dislocation Objective Classification • Overview of labral tears AAOS Classification of labral tears • Stage 0 – labral contusion with synovitis • Hip impingement • Stage 1 – discreet labral tear with normal articular cartilage ‐ what does that mean? • Stage 2 – tear with focal articular damage to subjacent femoral head, no acetabular cartilage abnormality • Review of traditional exam • Stage 3A – tear with focal acetabular cartilage lesion <1cm • Stage 3B – tear with focal acetabular cartilage lesion >1cm • Treatment philosophy • Stage 4 – extensive acetabular labral tear with associated • How functional assessment can confirm diagnosis and drive treatment diffuse osteoarthritis plan 1

12/21/2012 Labral Tear Femoroacetabular Impingement Femoroacetabular Impingement (FAI) • Condition in which femoral head, acetabulum or both are shaped abnormally • Ball and socket do not fit perfectly • Damage may occur to articular cartilage or labral cartilage • Impingement can occur as a result of femoral sided impingement (CAM) • Acetabular rim impingement (pincer) • Combination of both Not Uncommon Impingement Syndromes Multiple cadaveric studies have shown CAM Impingement labral tears to be quite common. • Predominately affects the cartilage with in the hip joint McCarthy et al found 53 of 54 acetabular • Results in characteristic peeling of cartilage off the bone specimens to have at least one labral tear, while Seldes et al found 53 of 55 Pincer Impingement cadavers to have labral tears. • Refers to the “over cartilage” of the acetabulum in respect to femoral head In an additional study of 365 cadaveric hips, Byers et al found that the labrum • “Extra” bone of the acetabulum repetitively hits upon the femoral was detached from the articular surface neck, resulting in pinching of the labrum of the acetabulum in 88% of people over Combined the age of 30. • CAM lesions often coexist with pincer lesions Symptomatic acetabular labral tears are • CAM lesions lead to articular cartilage injury most common in the ages 25 ‐ 40 • Pincer lesions crush and tear the labrum (Burnett) and are of equal prevalence among men and women (Narvani). History Labral Management • Not all labral tears are the same • 92% of individuals complain of anterior groin pain with symptomatic labral tears • Conversely, it is a symptom that has a very low specificity for labral injury • Isolated labral tears are uncommon • 33% of individuals with a confirmed labral tear recalled a trauma that started their symptoms • Most have associated chondral damage ( Byrd & Jones, AAOS "02 ) • 66% of labral tears are suspected of being degenerative in nature • 56 ‐ 71% of people complain of night pain • Studies (MRI/MRA) best at detecting labral damage • 9 ‐ 89% of individuals reported limping • 67% reported clicking • >50% reported locking up or catching • Poor at detecting articular damage ( Byrd & Jones, AJSM '04 ) • Overuse activities is common in labral tears specifically external rotation, hyperabduction • Extent of chondral damage ‐ less favorable prognostic indicator 2

12/21/2012 How Does a Labral Tear Present? Traditional Exam • Labral tears commonly result in "groin" pain • AROM/PROM • Localized to anterior hip • Less commonly, posterior or lateral pain Normative ranges: • Pain described as deep and sharp ‐ hip flexion – 0 ‐ 120 degrees • Reproduced with high degrees of flexion and IR ‐ hip extension – 0 ‐ 30 degrees • Prolonged sitting can increase pain ‐ hip ER/IR – 0 ‐ 45 degrees • Activity can increase pain • Pain is Intermittent • Flexibility of muscles • Referred pain down the leg ‐ RF, PF, HS, ITB, Illiopsoas • Disturbed sleep secondary to pain • MMT • Referred pain and disturbed sleep tend to be more common in those with arthritis of the hip. • Joint mobility ‐ anterior/inferior/posterior capsule restrictions • SI screen Imaging Special Tests • x ‐ ray – standard/special views • FABER test ‐ hip flexion, abduction, ER Coronal fast ‐ spin ‐ echo magnetic resonance image of a patient • CT – 3D reconstruction • Thomas test – flex hips and lower affected leg with combined • MRI / MRI arthrogram femoroacetabular impingement • Impingement test – hip flexion, adduction, IR with a cam lesion (arrow) and ossification of a torn superior • Ober test – knee/hip extension, hip abduction portion of the labrum (arrowhead) consistent with • Lateral rim impingement – flexion ‐ >extension in abduction pincer ‐ type impingement. • Craig test ‐ rotate limb until greater trochanter is parallel to floor • Ely test – flex knee and draw lower leg to thigh Dunn lateral radiograph (elongated ‐ neck lateral view) of the hip, demonstrating an osseous offset (yellow arrow) at the femoral head ‐ neck junction, indicating a cam lesion. Physical Exam FABER TEST One study found FABER (Patrick) test to be positive in 88% of those tested. • Observation Seven studies evaluated Flexion/ Adduction/ Internal Rotation (FADIR) and • Gait pattern ‐ antalgic/ trendelenburg found sensitivities between 95 ‐ 100%, with positive predictive values • Palpation ‐ iliac crest height symmetry between 64 ‐ 100%. • AROM/PROM bilaterally into all planes • Strength FABER test FADIR / Internal Impingement test • Flexibility • Joint mobility • Special tests • Functional Tests 3

12/21/2012 Thomas Test Functional Exam • Therapist observes position • Lower extremity assessment incorporates tri ‐ planar movements of contralateral hip while patient holds flexed hip • Open and closed kinetic chain motions • Overall mobility and functionality • Positive test is indicated by the contralateral leg rising • Deficits identified drive the treatment plan from the table secondary to hip flexion contracture • 5 basic lower extremity tests assess hip ‐ core mobility and strength Internal Snapping Hip Functional Exam • Interesting phenomenon in which a portion of the tendinous area of • Core Motion / Hip Mobility the psoas, running outside the joint (in the majority of cases), becomes symptomatic, in that it tightens causing it to snap (internal snapping hip) across either the rim of the acetabulum or the femoral head. • Abdominal ‐ psoas relationship • The psoas itself can become painful from this repetitive motion. In • Functional squat other cases, the psoas compresses the labrum resulting in crushing and sometimes tearing of the labral tissue due to the close proximity of the two structures. • Single leg squat • Several patients do present with an internal snapping hip, over coverage of the acetabulum and labral tear, for which we have deemed the term "triple impingement." • Medial step down Core ROM Assesses all three planes • Rules out : ‐ Spinal deviations ‐ musculoskeletal restrictions ‐ capsular restrictions SP motion • Ideally enough motion to touch toes and extend 50 degrees • During SP motion fluid hip translation and minimal thoraco ‐ lumbar compensation should be present 4

12/21/2012 Transverse Plane Motion Sagittal Plane Motion Core ROM Abdominal ‐ Psoas Relationship • FP motion Hip mobility works in conjunction with eccentric abdominal ‐ psoas functionality • Lateral pelvis translation is evaluated ideal range 50 degrees or more from center • Poor control /deficits of eccentric motion can lead to excessive or • Limited FP motion can be due to restrictions in quadratus lumborum, restricted pelvis translation in all planes ilio ‐ psoas, and hip inferior capsule TP motion • Tri ‐ planar motions can be modified with poor balance/control • Focuses on symmetric trunk/pelvis rotation ideal range 50 degrees or more from center • Assessment of functional relationship looks at objective data • Shoulders and hips should move symmetrically • Minimal compensation at the lumbar ‐ thoracic regions Sagittal Abdominal ‐ Psoas Functional Frontal Plane Motion Relationship • Patient faces away from wall with heels 6 inches away • Single leg balance with raised hip and knee at 90 • Arms are crossed behind the head • Patient translates hips anteriorly and taps wall with back of hands • Returns to upright position while maintaining SLB for 20 sec • Time, repetitions, quality of motion are assessed 5