Acetabular labrum tear

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Acetabular labrum tear
Figure 7. A complex labral tear. An arthroscopic probe is seen at the junction of the labrum and acetabular rim..png
A complex labral tear. An arthroscopic probe is seen at the junction of the labrum and acetabular rim.
Specialty Orthopedics

An acetabular labrum tear or hip labrum tear is a common injury of the acetabular labrum resulting from a number of causes including running, hip dislocation, and deterioration with ageing. Most are thought to result from a gradual tear due to repetitive microtrauma.

Contents

Causes

It is estimated that 75% of acetabular labrum tears have an unknown cause. Tears of the labrum have been credited to a variety of causes such as excessive force, hip dislocation, capsular hip hypermobility, hip dysplasia, and hip degeneration. [1] A tight iliopsoas tendon has also been attributed to labrum tears by causing compression or traction injuries that eventually lead to a labrum tear. [2] Most labrum tears are thought to be from gradual tear due to repetitive microtrauma. [1] Incidents of labrum tears increase with age, suggesting that they may also be caused by deterioration through the aging process. [1] Labrum tears in athletes can occur from a single event or recurring trauma. Running can cause labrum tears due to the labrum being used more for weight bearing and taking excessive force while at the end-range motion of the leg: hyperabduction, hyperextension, hyperflexion, excessive external rotation. [3] Sporting activities are likely causes, specifically those that require frequent lateral rotation or pivoting on a loaded femur as in hockey or ballet. [1] Constant hip rotation places increased stress on the capsular tissue and damage to the iliofemoral ligament. This in turn causes hip rotational instability putting increased pressure on the labrum. [3] Traumatic injuries are most commonly seen in athletes who participate in contact or high-impact sports like football, soccer, or golf. [4] The prevalence rate for traumatic hip injuries that causes a tear of the labrum is very low. Less than 25% of all patients can relate a specific incident to their torn labrum; however, they are often a result of a dislocation or fracture. [5] Falling on one's side causes a blunt trauma to the greater trochanter of the femur. Since there is very little soft tissue to diminish the force between the impact and the greater trochanter, the entire blow is transferred to the surface of the hip joint. [6] And since bone density does not reach its peak until the age of 30, hip traumas could result in a fracture. [6] Tears of the hip labrum can be classified in a variety of ways, including morphology, etiology, location, or severity. [4]

Anatomical modifications of the femur and or hip socket cause a slow buildup of damage to the cartilage. Femur or acetabular dysplasia can lead to femoral acetabular impingement (FAI). Impingement occurs when the femoral head rubs abnormally or lacks a full range of motion in the acetabular socket. [7] There are three different forms of FAI. The first form is caused by a cam-deformity where extra bone is present on the femoral head, which leads to the head being non-spherical. The second deformity is referred to as a pincer deformity and it is due to an excess growth of the acetabular socket. [4] The third type of FAI is a combination of the first two deformities. When either abnormality is present, it changes the position of the femoral head in the hip socket. The increased stresses that the femur and or acetabulum experience may lead to a fracture of the acetabular rim or a detachment of the overstressed labrum. [4]

Women are more susceptible to acetabulum labrum tears due to their pelvic anatomy. External Rotation at the pelvic girdle.JPG
Women are more susceptible to acetabulum labrum tears due to their pelvic anatomy.

Diagnosis

An acetabular labrum tear is assessed by physical examination followed by medical imaging. An MR arthrogram is more reliable than magnetic resonance imaging. A full confirmation can be made using arthroscopy. [8] [9] [10]

Epidemiology

In the United States acetabular labrum tears usually occur in the anterior or anterior-superior area, possibly due to a sudden change from labrum to acetabular cartilage. [2] The most common labrum tears in Japan are in the posterior region, likely due to the customary practice of sitting on the floor. Posterior labrum tears in the Western world usually occur when a force drives the femoral head posteriorly which transfers shear and compressive forces to the posterior labrum. [4]

Rehabilitation

There is little evidence for the benefit of physical therapy for the acetabular labrum. [11] Some studies though report that physical therapy could be of benefit in restoring "sports-ready" capabilities. [1] Following surgery, crutches will be needed for up to six weeks and physical exercise such as running, curtailed for at six months. [12]

There are usually four phases in the rehabilitation process: "Phase I: initial exercises (weeks 1–4), Phase II: intermediate exercises (weeks 5–7), Phase III: advanced exercises (weeks 8–12), and Phase IV: return to sports (weeks 12+)". [11] Therapy programs need to be personalised. [13]

In phase I the first objective is to minimize pain and inflammation. A symmetrical gait pattern is essential so as not to create an imbalance in the muscles of the hip. Aquatic therapy enables more gravity-free movement.

In phase II more flexibility in the soft tissue is promoted, with an emphasis on strength training basics. [ citation needed ]

In phase III the focus is to begin building functional strength, using single leg exercises to build the muscle and challenge the strength of the hip.[ citation needed ]

Phase IV is the final stage where further exercise is prescribed until returning to sports. [11] Complex movements like squatting, kicking, and running, will be promoted until symmetrical pain free movements are achieved. [1]

Prevention

An acetabular labrum tear can occur in a variety of ways such as frequent twisting movement, direct trauma, or degeneration. [1] But many hip labral tears are not directly related to any specific action, [4] making it difficult to prevent such an injury. It may be possible to lower the risk by strengthening the gluteus, stretching before exercise, and discontinuing the use of repetitive twisting activities.[ citation needed ]

One way to prevent a hip labrum tear is to decrease the pressure on the anterior labrum region. The labrum is about 2 to 3 mm thick but is wider and thinner in the anterior portion. Studies have found that in the United States and European countries, hip labral tears are commonly found in the anterior region. [1] Muscular imbalance of the pelvis can develop lower crossed syndrome. It is caused by tight hip flexors and erector spinae with inhibited weak gluteals and abdominals. [11] Imbalance of the muscles can lead to an anterior pelvic tilt, increased hip flexion, and lumbar hyperlordosis of the lumbar spine. This increases the pressure in the anterior labrum. [4] Weak gluteals during hip extension have also shown increased joint pressure in the anterior labrum. [14] Muscles that help with balance need to be strengthened, or stretched to prevent a hip labrum tear. Exercises include strengthening the gluteus by abducting the hip whilst lying on the side with legs together. The top leg is raised keeping the knee and hip straight; especially effective where there is an anterior pelvic tilt. [11] A tight hip flexor may be stretched by using a kneeling hip flexor stretch that targets the iliopsoas.[ citation needed ]

Stretching before exercise will affect the cartilage through "creep". It will place a constant load on the labrum, allowing fluid the leak out and deform to the applied load. This is significant for the viscoelasticity of the labrum. [15] The hip labrum acts as a shock absorber, joint lubricator, stabilizer and pressure distributor. [1] A warm-up using body weight squats can induce creep before exercise to help prevent a hip labrum tear.[ citation needed ]

See also

Related Research Articles

<span class="mw-page-title-main">Human leg</span> Lower extremity or limb of the human body (foot, lower leg, thigh and hip)

The leg is the entire lower limb of the human body, including the foot, thigh or sometimes even the hip or buttock region. The major bones of the leg are the femur, tibia, and adjacent fibula.

<span class="mw-page-title-main">Acetabulum</span> Cavity where the thigh bone (femur) articulates with the pelvis

The acetabulum, also called the cotyloid cavity, is a concave surface of the pelvis. The head of the femur meets with the pelvis at the acetabulum, forming the hip joint.

<span class="mw-page-title-main">Knee</span> Leg joint in primates

In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia, and one between the femur and patella. It is the largest joint in the human body. The knee is a modified hinge joint, which permits flexion and extension as well as slight internal and external rotation. The knee is vulnerable to injury and to the development of osteoarthritis.

An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is also used to correct a coxa vara, genu valgum, and genu varum. The operation is done under a general anaesthetic.

<span class="mw-page-title-main">Posterior cruciate ligament</span> One of four major ligaments of the knee

The posterior cruciate ligament (PCL) is a ligament in each knee of humans and various other animals. It works as a counterpart to the anterior cruciate ligament (ACL). It connects the posterior intercondylar area of the tibia to the medial condyle of the femur. This configuration allows the PCL to resist forces pushing the tibia posteriorly relative to the femur.

<span class="mw-page-title-main">Gluteus minimus</span> Smallest of the three gluteal muscles

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<span class="mw-page-title-main">Piriformis muscle</span> Hip muscle in the lateral rotator group

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<span class="mw-page-title-main">Iliopsoas</span> Joined psoas and iliacus muscles of the hip and thigh

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<span class="mw-page-title-main">Hip dislocation</span> Orthopedic injury

A hip dislocation is when the thighbone (femur) separates from the hip bone (pelvis). Specifically it is when the ball–shaped head of the femur separates from its cup–shaped socket in the hip bone, known as the acetabulum. The joint of the femur and pelvis is very stable, secured by both bony and soft-tissue constraints. With that, dislocation would require significant force which typically results from significant trauma such as from a motor vehicle collision or from a fall from elevation. Hip dislocations can also occur following a hip replacement or from a developmental abnormality known as hip dysplasia.

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<span class="mw-page-title-main">SLAP tear</span> Medical condition

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<span class="mw-page-title-main">Acetabular labrum</span> Ring of cartilage that surrounds the acetabulum of the hip

The acetabular labrum is a fibrocartilaginous ring which surrounds the circumference of the acetabulum of the hip, deepening the acetabulum. The labrum is attached onto the bony rim and transverse acetabular ligament. It is triangular in cross-section.

<span class="mw-page-title-main">Meniscus tear</span> Rupturing of the fibrocartilage strips in the knee called menisci

A tear of a meniscus is a rupturing of one or more of the fibrocartilage strips in the knee called menisci. When doctors and patients refer to "torn cartilage" in the knee, they actually may be referring to an injury to a meniscus at the top of one of the tibiae. Menisci can be torn during innocuous activities such as walking or squatting. They can also be torn by traumatic force encountered in sports or other forms of physical exertion. The traumatic action is most often a twisting movement at the knee while the leg is bent. In older adults, the meniscus can be damaged following prolonged 'wear and tear'. Especially acute injuries can lead to displaced tears which can cause mechanical symptoms such as clicking, catching, or locking during motion of the joint. The joint will be in pain when in use, but when there is no load, the pain goes away.

<span class="mw-page-title-main">Femoroacetabular impingement</span> Medical condition

Femoroacetabular impingement (FAI) is a condition involving one or more anatomical abnormalities of the hip joint, which is a ball and socket joint. It is a common cause of hip pain and discomfort in young and middle-aged adults. It occurs when the ball shaped femoral head contacts the acetabulum abnormally or does not permit a normal range of motion in the acetabular socket. Damage can occur to the articular cartilage, or labral cartilage, or both. The condition may be symptomatic or asymptomatic. It may cause osteoarthritis of the hip. Treatment options range from conservative management to surgery.

<span class="mw-page-title-main">Medial patellofemoral ligament</span> Ligament of the knee

The medial patellofemoral ligament (MPFL) is one of several ligaments on the medial aspect of the knee. It originates in the superomedial aspect of the patella and inserts in the space between the adductor tubercle and the medial femoral epicondyle. The ligament itself extends from the femur to the superomedial patella, and its shape is similar to a trapezoid. It keeps the patella in place, but its main function is to prevent lateral displacement of the patella.

<span class="mw-page-title-main">Hip arthroscopy</span>

Hip arthroscopy refers to the viewing of the interior of the acetabulofemoral (hip) joint through an arthroscope and the treatment of hip pathology through a minimally invasive approach. This technique is sometimes used to help in the treatment of various joint disorders and has gained popularity because of the small incisions used and shorter recovery times when compared with conventional surgical techniques. Hip arthroscopy was not feasible until recently, new technology in both the tools used and the ability to distract the hip joint has led to a recent surge in the ability to do hip arthroscopy and the popularity of it.

<span class="mw-page-title-main">Hip pain</span>

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<span class="mw-page-title-main">Labral reconstruction</span> Medical procedure

Labral reconstruction is a type of hip arthroscopy in which the patient's native labrum is partially or completely removed and reconstructed using either autograft or allograft tissue. Originally described in 2009 using the ligamentum teres capitis, arthroscopic labral reconstruction using a variety of graft tissue has demonstrated promising short and mid-term clinical outcomes. Most importantly, labral reconstruction has demonstrated utility when the patient's native labral tissue is far too damaged for debridement or repair.

<span class="mw-page-title-main">Deep gluteal syndrome</span> Medical condition

Deep gluteal syndrome describes the non-discogenic extrapelvic entrapment of the sciatic nerve in the deep gluteal space. In simpler terms this is sciatica due to nerve irritation in the buttocks rather than the spine or pelvis. It is an extension of non-discogenic sciatic nerve entrapment beyond the traditional model of piriformis syndrome. Where sciatic nerve irritation in the buttocks was once thought of as only piriformis muscle, it is now recognized that there are many other causes. Symptoms are pain or dysthesias in the buttocks, hip, and posterior thigh with or without radiating leg pain. Patients often report pain when sitting. The two most common causes are piriformis syndrome and fibrovascular bands, but many other causes exist. Diagnosis is usually done through physical examination, magnetic resonance imaging, magnetic resonance neurography, and diagnostic nerve blocks. Surgical treatment is an endoscopic sciatic nerve decompression where tissue around the sciatic nerve is removed to relieve pressure.

References

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  2. 1 2 Smith, Matthew V.; Panchal, Hemang B.; Ruberte Thiele, Ramon A.; Sekiya, Jon K. (2011). "Effect of Acetabular Labrum Tears on Hip Stability and Labral Strain in a Joint Compression Model". The American Journal of Sports Medicine. 39 (1_suppl): 103–110. doi:10.1177/0363546511400981. ISSN   0363-5465. PMID   21709039.
  3. 1 2 Rylander, Lucas; Froelich, John M.; Novicoff, Wendy; Saleh, Khaled (2010). "Femoroacetabular Impingement and Acetabular Labral Tears". Orthopedics. 33 (5): 342–350. doi:10.3928/01477447-20100329-21. ISSN   0147-7447. PMID   20507038.
  4. 1 2 3 4 5 6 7 Groh, Megan M.; Herrera, Joseph (2009). "A comprehensive review of hip labral tears". Current Reviews in Musculoskeletal Medicine. 2 (2): 105–117. doi:10.1007/s12178-009-9052-9. ISSN   1935-973X. PMC   2697339 . PMID   19468871.
  5. ↑ Bohannon Mason, J. (2001). "Acetabular Labral Tears in the Athlete". Clinics in Sports Medicine. 20 (4): 779–790. doi:10.1016/S0278-5919(05)70284-2. PMID   11675886.
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  7. ↑ Aly, Abdel Rahman; Rajasekaran, Sathish; Obaid, Haron (2013). "MRI morphometric hip comparison analysis of anterior acetabular labral tears". Skeletal Radiology. 42 (9): 1245–1252. doi:10.1007/s00256-013-1652-1. ISSN   0364-2348. PMID   23760571.
  8. ↑ Liu, Yuwei; Lu, Wei; Ouyang, Kan; Deng, Zhenhan (2021). "The imaging evaluation of acetabular labral lesions". Journal of Orthopaedics and Traumatology. 22 (1): 34. doi: 10.1186/s10195-021-00595-7 . ISSN   1590-9921. PMC   8346610 . PMID   34357462.
  9. ↑ Su, Tiao; Chen, Guang-Xing; Yang, Liu (2019-01-20). "Diagnosis and treatment of labral tear". Chinese Medical Journal. 132 (2): 211–219. doi:10.1097/CM9.0000000000000020. ISSN   0366-6999. PMC   6365273 . PMID   30614856.
  10. ↑ Guanche, Carlos A. (2009-11-01). Hip and Pelvis Injuries in Sports Medicine. Philadelphia: Lippincott Williams & Wilkins. p. 100. ISBN   978-0-7817-7771-1.
  11. 1 2 3 4 5 Garrison, J. Craig; Osler, Michael T.; Singleton, Steven B. (2007). "Rehabilitation after arthroscopy of an acetabular labral tear". North American Journal of Sports Physical Therapy: NAJSPT. 2 (4): 241–250. ISSN   1558-6162. PMC   2953303 . PMID   21509143.
  12. ↑ Clohisy, John C.; McClure, J. Thomas (2005). "Treatment of anterior femoroacetabular impingement with combined hip arthroscopy and limited anterior decompression". The Iowa Orthopaedic Journal. 25: 164–171. ISSN   1541-5457. PMC   1888771 . PMID   16089092.
  13. ↑ Hunt, Devyani; Clohisy, John; Prather, Heidi (2007). "Acetabular labral tears of the hip in women". Physical Medicine and Rehabilitation Clinics of North America. 18 (3): 497–520, ix–x. doi:10.1016/j.pmr.2007.05.007. ISSN   1047-9651. PMID   17678764.
  14. ↑ Lewis, Cara L.; Sahrmann, Shirley A.; Moran, Daniel W. (2007). "Anterior hip joint force increases with hip extension, decreased gluteal force, or decreased iliopsoas force". Journal of Biomechanics. 40 (16): 3725–3731. doi:10.1016/j.jbiomech.2007.06.024. ISSN   0021-9290. PMC   2580726 . PMID   17707385.
  15. ↑ Mak, A. F. (1986). "The apparent viscoelastic behavior of articular cartilage--the contributions from the intrinsic matrix viscoelasticity and interstitial fluid flows". Journal of Biomechanical Engineering. 108 (2): 123–130. doi:10.1115/1.3138591. ISSN   0148-0731. PMID   3724099.
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