Mike Jones, PT, MHS, OCS, MTC Ari Kaplan, PT, DPT, CSCS, Cert MDT Tim Lonergan , PT, DPT

1. GROUP ALPHA HIP PROJECTCurrent Best Evidence for Select Hip Disorders: Acetabular Labral Lesions Mike Jones, PT, MHS, OCS, MTC Ari Kaplan, PT, DPT, CSCS, Cert MDT Tim Lonergan, PT, DPT Lindsay Rambo, PT, DPT Mindy Riley, PT, MPT, CSCS Pierre Rougny, PT, OCS, MTC

2. Objectives • Examine the epidemiology, anatomy, and pathology associated with acetabularlabral lesions • Discuss evidence-based diagnosis of this disorder • Present current best treatment options for this disorder

3. Acetabular Labral Lesions: Epidemiology • In a study of 436 patients with mechanical hip pain, 55.3% were found to have acetabularlabral tears1 • Average patient age was 37.4 years with a range of 14-72 years with 95% of the patients being younger than 55 years • No patient exhibited radiographic evidence of significant hip arthrosis • All patients had undergone a 6-month course of failed conservative treatment • Each patient underwent diagnostic hip arthroscopy

4. Acetabular Labral Lesions: Functional Anatomy • The acetabular labrum, a fibrocartilaginous structure which is typically 2 to 3 millimeters thick, outlines the bony rim of the acetabulum of the hip joint2 From Ithaca College Department of Physical Therapy website3

5. Acetabular Labral Lesions: Functional Anatomy • Peripherally, the labrum attaches to the hip joint capsule extending 2 to 3 millimeters beyond the margins of the acetabulum2 From Lewis and Sahrmann4

6. Acetabular Labral Lesions: Functional Anatomy • By deepening the acetabulum, the labrum promotes stability and reduces joint surface stresses within the hip4 • The labrum also increases the area of contact within the acetabulum upon the femoral head thereby distributing compressive forces and reducing surface area contact stress4

7. Acetabular Labral Lesions: Functional Anatomy • In serving to effectively seal the hip joint, the labrum also acts to distribute load within the hip joint by maintaining a pressurization of the intra-articular fluid, which can act to prevent direct surface contact between the surfaces of the femoral head and the acetabulum4,5

8. Acetabular Labral Lesions: Pathology • Tears in the acetabular labrum have been found to typically occur at the interface between the labrum and the bony rim of the acetabulum rather than at the junction with the joint capsule1 Arthroscopic evaluation of a displaced anterior labral tear From Bharam2

9. Acetabular Labral Lesions: Pathology • Additionally, the majority of tears have been found to occur anteriorly (86%) though some have been found to occur laterally (3%) and posteriorly (11%)1 Arthroscopic evaluation of a posterior labral tear From Bharam2

10. Acetabular Labral Lesions: Etiology • Five primary causes have been recognized in association with the occurrence of acetabularlabral tears6 • Trauma • Hip joint hypermobility • Hip dysplasia • Femoroacetabular impingement (FAI) • Degeneration

11. Acetabular Labral Lesions: Etiology • FAI is a pathomechanical condition that is typically associated with morphological osseous abnormalities of the acetabulum and/or femoral head and neck7 • These abnormalities can be classified as leading to either “cam” or “pincer” types of impingement7

12. Acetabular Labral Lesions: Etiology • With cam-type deformities, impingement occurs secondary to the presence of a non-spherical femoral head or a lack of offset between the head and the neck of the femur7 Cam-type deformity Adapted from Cobb et al8

13. Acetabular Labral Lesions: Etiology Pincer-type deformity Adapted from Cobb et al8 • With pincer-type deformities, impingement occurs secondary to a maloriented or excessively deep acetabulum7

14. Acetabular Labral Lesions: Etiology • FAI has been shown to have a high association with the occurrence of labral tears9,10 • Additionally, labral lesions have been demonstrated to frequently occur in the area of impingement along the acetabular rim10 Zone of damage associated with FAI represented in red From Tannast et al10

15. Acetabular Labral Lesions: Etiology • Both acetabularlabral tears1 and FAI11 have been associated with the early onset of osteoarthritis of the hip joint • Hence, reliable and valid examination measures as well as effective interventions are essential to the progression of morbidity

16. Acetabular Labral Lesions: Diagnosis – Clinical Presentation • Groin pain (92%) of insidious onset(61%) are among the most prominent features with labral injuries12 • Hip impingement, which is considered as a possible cause of labral lesions, also shows high percentages of insidious onset (65%) and groin pain (83%)13 • Differentiating between impingement and labral tears may be difficult, as an impingement may be a precursor to a labral tear14 • Although pain is usually confined to the groin, it may refer to the greater trochanter or buttock15,16

17. Acetabular Labral Lesions: Diagnosis – Clinical Presentation • Interestingly, pain is described as both sharp and dull in the Burnett study12 • The Burnett study’s participants considered themselves active or athletic (98%) • The following was also found • Pain was exacerbated by activity (91%) such as running or pivoting • Painful mechanical locking was often experienced (89%). • A limp of some degree was often present (89%)

18. Acetabular Labral Lesions: Diagnosis – Clinical Presentation • Differential diagnosis includes the following17 • Bursitis • Piriformis syndrome • Snapping hip syndrome • Femoral head OA • Avascular necrosis • Septic arthritis • Fractures • Tumors • Slipped femoral capital epiphysis • Legg-Calve Perthes disease • Pain referred from the lumbosacral area among others

19. Acetabular Labral Lesions: Diagnosis – Key Clinical Tests • Key clinical tests include FABER or Patrick test, scour test, and resisted SLR18 • Most of the tests described in the literature provide more general information regarding the potential for lumbosacral spine, intra-articular, and/or extra-articular hip pathology18 • It is important to identify the specific location of symptoms • A positive test does not confirm necessarily confirm involvement of the labrum, but rather an intra-articular pathology

20. Acetabular Labral Lesions: Diagnosis – Key Clinical Tests • Intra-articular Hip Pathology could include the following18 • Acetabular labral tears • Chondral lesions • Osteoarthritis • Synovitis • Loose bodies • Avascular necrosis • Osteonecrosis • Inflammatory arthritis

21. Acetabular Labral Lesions: Diagnosis – Key Clinical Tests • FABER (Patrick) test18 • Hip flexion, abduction, & external rotation • Measure distance from knee to table • Pain in anterior hip • Decrease in range of motion on the involved side may indicate either capsular tightness or psoas spasm • Mitchell et al19 reported that hip pain during the FABER test was 88% sensitive for intraarticular hip pathology, but not specific as to which pathology

22. Acetabular Labral Lesions: Diagnosis – Key Clinical Tests • Scour test18 • Passively moving the femur through an arc of motion incorporating hip flexion/adduction and extension/abduction • Compressive force is applied moving counter and clockwise • Assess for reproduction of hip pain and/or intra articularjoint clicking

23. Acetabular Labral Lesions: Diagnosis – Key Clinical Tests • Resisted Straight Leg Raise18 • Thought to load the hip joint anterosuperiorly and to reproduce anterior groin pain when an intra-articular lesion is present • Performed at approximately 30° of hip flexion

24. Acetabular Labral Lesions: Diagnosis – Key Clinical Tests • Confirming a potential labral tear18 • If history, symptoms, and signs are consistent with a labral tear, assess for potential associated factors including the following • Capsular laxity • Articular cartilage degeneration • Femoral Acetabular Impingement (FAI)

25. Acetabular Labral Lesions: Diagnosis – Key Clinical Tests • Clinical tests for FAI18 • The most common test for FAI combines flexion, IR, and adduction • Similar to the Fitzgerald Test, this movement engages femoral head/neck into the anterior superior labrum and acetabular rim20 • Log roll • Long axis distraction • Tests for general ligamentous laxity • Hip ROM

26. Acetabular Labral Lesions: Diagnosis – Key Clinical Tests • While clinical tests for acetabularlabral lesions have been found to exhibit limited specificity, many have been found to be highly sensitive21 • By definition, if these tests are found to be negative, the likelihood of a labral tear is low21

27. Acetabular Labral Lesions: Diagnosis – Imaging Studies • Ziegert et al.22 • Magnetic Resonance Arthogram is 97% effective in diagnosis of acetabularlabral tears when compared to diagnosis by arthroscopy • Zlatkin et al.23 • Compared MRI to MR arthrogram in diagnostic accuracy versus arthroscopy • MRI was 85% accurate, MR arthrogram was 100% accurate

28. Acetabular Labral Lesions: Intervention – Non-surgical • Poor evidence exists, although promising results from 2 Case Series • Possible Regional Interdependence

29. AcetabularLabral Lesions:Intervention – Non-surgical • Case Study, Emara 201124 • 37 patients treated non-surgically • 4 went onto surgery • 6 of the remaining 33 had recurrent hip pain but did not go onto surgery • Conservative management:  • avoidance of aggravating activities and NSAIDs • PT 2-3 weeks for stretching to increase hip ER and abduction • No effect on ROM; Harris hip score increased from 72 to 91 (at 2 years).   • Pain on VAS went from 6 to 2 (at 2 year follow up)

30. AcetabularLabral Lesions:Intervention – Non-surgical • Case Study, Yazbek 201125 • Case Series on 4 patients: 3 phase rehab program      • Length of treatment prior to D/C: 3x/week for 12, 9, 13 weeks, and 16 weeks for each of the 4 patients • 10 point Mean Pain VAS Prior to Tx: 6.25 • 10 Point Mean Pain VAS Post Tx: .75 (3 of the 4 patients reported 0/10

31. AcetabularLabral Lesions:Intervention – Non-surgical • Yazbek: 25 description of phases • Phase 1: Pain control, education in trunk stabilization and correction of abnormal movement • Phase 2: Progressed to phase 2 when patient noted diminished pain and improved control of trunk and decreased dynamic valgus (IR and add of hip) focus shifted to muscle strengthening and recovery of normal ROM and initiation of motor training;  Patients showed side-to-side differences in strength • Phase 3: Progressed to when patients showed equal side-to-side strength measurements: Sport specific progression with proper lower extremity alignment

32. AcetabularLabral Lesions:Intervention – Non-surgical • Regional Interdependence • Association between low back pain and hip ROM differences26 • Hip ROM was found to be one of 5 predictors for LBP that responded to LB/Spinal manipulation.27

33. AcetabularLabral Lesions:Intervention – Non-surgical • Regional Interdependence, Cibulka 199328 • 20 athletic subjects with anterior hip pain and no evidence of OA. • Inclusion criteria also required 3 of 4 positive SI tests: long sit, seated PSIS, prone knee bend, and standing flexion • Source of anterior hip pain not specified • No imaging was noted • Randomly Assigned: SI manipulation group or Hip Mobilization group.1 treatment performed and then followed up • SI Manipulation decreased pain by 3.8 out of 10.   • Hip mobilization group decreased by .8 out of 10 

34. Acetabular Labral Lesions: Intervention – Surgical • Labral Debridement29 • Objective is to remove loose flap of labrum.  Additionally will remove possible Cam or Pincer abnormalities • 10 year follow up shows:  • Median 29 point improvement on Harris Hip Scale • At 10 years, 15 of the 18 patients who did not show arthritic changes at surgery still had 18 or greater points of improvement on HHS • At 10 years, 7 of the 8 patients who showed arthritis at surgery had been converted to THA at a mean of 63 months later.  • Conclusion: Good response to debridement at 10 year follow up for patients who did not show arthritic changes at time of surgery

35. AcetabularLabral Lesions:Intervention – Surgical • Labral Repair30 • Tissue is debrided • If labrum is detached from the bone, a bioabsorbable suture anchor is use to stabilize the labral tissue to the acetabulum. • Intrasubstance tears are repairable if it is well fixed to the acetabulum and has a stable outer rim • Can result in altered load bearing ability of labrum, increase load on cartilage, and decrease joint stability

36. Acetabular Labral Lesions: Intervention – Post-surgical • Little has been published in regards to the rehabilitation management of patients following surgical procedures for the treatment of acetabularlabral lesions • Published works on this topic include case studies31 and clinical commentaries32,33 rather than clinical trials

37. Acetabular Labral Lesions: Intervention – Post-surgical • Binningsley31 has described the surgical and post-surgical management of an acetabularlabral tear in an 18 year-old male elite-level rugby player http://commons.wikimedia.org/wiki/File:Kcblues_player2.jpg

38. Acetabular Labral Lesions: Intervention – Post-surgical • Assessed outcomes • Isokinetic strength of the hip and knee • Return to sport • Intervention • Surgical intervention • Arthroscopic debridement of anterior labral tear Arthroscopy identifying a tear in the anterior portion of the labrum From Binningsley1

39. Acetabular Labral Lesions: Intervention – Post-surgical • Intervention • Post-operative rehabilitation • Between 4 to 6 weeks of activity restriction prior to initiating functional progression recommended by physician • Non-weightbearing for 5 days post-operatively • Proprioceptive exercises and unresisted lower body cardiovascular exercise as well as upper body and torso training initiated 5 days after surgery • Aquatic exercise initiated10 days after surgery

40. Acetabular Labral Lesions: Intervention – Post-surgical • Intervention • Post-operative rehabilitation • Functional progression and isokinetic strength training initiated at 5 weeks post-operatively and continued for 4 weeks • Jogging progressed to running • Elements of speed training, endurance, agility, plyometric, and advanced proprioceptive skills including ball handling work continuously progressed • Isokinetic strengthening of hip flexion/extension, hip abduction/adduction, and knee flexion and extension

41. Acetabular Labral Lesions: Intervention – Post-surgical • Intervention • Post-operative rehabilitation • Full sport training initiated at 10 weeks post-operatively and continued for 2 weeks prior to reinitiating full sport participation • Results • Isokinetic strength measures of the operative lower extremity either met or exceeded measures performed on the uninvolved lower extremity • The patient successfully returned to full sport participation at 12 weeks post-operatively

42. Acetabular Labral Lesions: Intervention – Post-surgical • Limitations • Case study • Age and gender of patient • Patient status as an elite athlete • Associated pre-morbid physical performance and health status • Access to exceptional care

43. Acetabular Labral Lesions: Intervention – Post-surgical • Enseki and colleagues32 have offered general guidelines recommended for the rehabilitation of patients having undergone arthroscopic surgical intervention for acetabularlabral lesions

44. Acetabular Labral Lesions: Intervention – Post-surgical

45. Acetabular Labral Lesions: Intervention – Post-surgical

46. Acetabular Labral Lesions: Intervention – Post-surgical • Garrison and colleagues33 have outlined specific programs recommended for the rehabilitation of patients attempting to return to sport activities following arthroscopic labral debridement or repair

47. Acetabular Labral Lesions: Intervention –Post-surgical Labral Debridement (Adapted from Garrison et al33)

48. Acetabular Labral Lesions: Intervention –Post-surgical Labral Repair (Adapted from Garrison et al33)

49. Thank you! • Please help us with the discussion of this project by posting in the forum

50. References • McCarthy JC, Noble PC, Schuck MR, Wright J, Lee J. The Otto E. Aufranc Award: The role of labral lesions to development of early degenerative hip disease. ClinOrthopRelat Res. 2001;(393):25-37. • Socket for head of femur. Ithaca College Department of Physical Therapy web site. Available at: Http://www.ithaca.edu/faculty/lahr/LE2000/hip%20pics/8acetabularlig.jpg, Accessed January 15. 2012. • Bharam S. Labral tears, extra-articular injuries, and hip arthroscopy in the athlete. Clin Sports Med. 2006;25(2):279-292. • Lewis CL, Sahrmann SA. Acetabular labral tears. Phys Ther. 2006;86(1):110-121. • Hlavácek M. The influence of the acetabular labrum seal, intact articular superficial zone and synovial fluid thixotropy on squeeze-film lubrication of a spherical synovial joint. J Biomech. 2002;35(10):1325-1335. • Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2(2):105-117.