Hip Labral Tear and FAI Articles

Acetabular Labral Tears
by Cara L Lewis and Shirley A Sahrmann
PHYS THERVol. 86, No. 1, January 2006, pp. 110-121
Anterior hip or groin pain is a common complaint for which people are referred for physical therapy, with the hip region being involved in approximately 5% to 9% of injuries in high school athletes.1 Although anterior hip pain is known to result from a number of musculoskeletal and systemic pathologies, a tear of the acetabular labrum is a recent addition to the list that is of particular interest to physical therapists. This mechanically induced pathology is thought to result from excessive forces at the hip joint2,3 and has been proposed as part of a continuum of hip joint disease that may result in articular cartilage degeneration.2 Although the number of recent articles in the orthopedic literature identifying acetabular labral tears as a source of hip pain is increasing, labral tears often evade detection, resulting in a long duration of symptoms, greater than 2 years on average, before diagnosis.4–8 Studies have shown that 22% of athletes with groin pain9 and 55% of patients with mechanical hip pain of unknown etiology2 were found to have a labral tear upon further evaluation. In order to provide the most appropriate intervention for patients with anterior hip or groin pain, physical therapists should be knowledgeable about all of the possible sources and causes of this pain, including a tear of the acetabular labrum and the possible factors contributing to these tears. Therefore, the purpose of this article is to review the anatomy and function of the acetabular labrum and present current concepts on the etiology, clinical characteristics, diagnosis, and treatment of labral tears.


Acetabular Labral Tears of the Hip: Examination and Diagnostic Challenges
RobRoy L. Martin, Keelan R. Enseki, Peter Draovitch, Talia Trapuzzano, Marc J. Philippon
J Orthop Sports Phys Ther. 2006:36(7):503-515. doi:10.2519/jospt.2006.2135

The purpose of this clinical commentary is to provide an evidence-based review of the examination process and diagnostic challenges associated with acetabular labral tears of the hip. Once considered an uncommon entity, labral tears have recently received wider recognition as a source of symptoms and functional limitation. Information regarding acetabular labral tears and their association to capsular laxity, femoral acetabular impingement (FAI), dysplasia of the acetabulum, and chondral lesions is emerging.
Physical therapists should understand the anatomical structures of the hip and recognize how the clinical presentation of labral tears is difficult to view isolated from other hip articular pathologies. Clinical examination should consider lumbopelvic and extra-articular pathologies in addition to intra-articular pathologies when assessing for the source of symptoms and functional limitation. If a labral tear is suspected, further diagnostic testing may be indicated. Although up-and-coming evidence suggests that information obtained from patient history and clinical examination can be useful, continued research is warranted to determine the diagnostic accuracy of our examination techniques.
Video of Hip Exam from this Article


The Hip Joint: Arthroscopic Procedures and Postoperative Rehabilitation
Keelan R. Enseki, Peter Draovitch, Bryan T. Kelly, RobRoy L. Martin, Marc J. Philippon, Mara L. Schenker
J Orthop Sports Phys Ther. 2006;36(7):516-525. doi:10.2519/jospt.2006.2138

Recent technological improvements have resulted in a greater number of surgical options available for individuals with hip joint pathology. These options are particularly pertinent to the relatively younger and more active population.
The diagnosis and treatment of acetabular labral tears have become topics of particular interest. Improvements in diagnostic capability and surgical technology have resulted in an increased number of arthroscopic procedures being performed to address acetabular labral tears and associated pathology. Associated conditions include capsular laxity, femoral-acetabular impingement, and chondral lesions. Arthroscopic techniques include labral tear resection, labral repair, capsular modification, osteoplasty, and microfracture procedures.
Postoperative rehabilitation following arthroscopic procedures of the hip joint carries particular concerns regarding range of motion, weight-bearing precautions, and initiation of strength activities. Postoperative rehabilitation protocols that have been typically used for surgeries such as total hip arthroplasty are often not sufficient for the population of patients undergoing arthroscopic procedures of the hip joint. Postoperative rehabilitation should be based upon the principles of tissue healing as well as individual patient characteristics. As arthroscopic procedures to address acetabular labral tears and associated pathology evolve, physical therapists have the opportunity to play a significant role through the development of corresponding rehabilitation protocols.

Video of Hip Arthorscopy from this article


Acetabular Labral Tears

J Bone Joint Surg Am. 2009;91:701-710. doi:10.2106/JBJS.H.00802
Paul E. Beaulé, Michelle O'Neill and Kawan Rakhra
Acetabular labral tears rarely occur in the absence of a structural osseous abnormality.
Labral tears are frequently associated with lesions of acetabular cartilage such as delamination.
Hip arthroscopy is the preferred operative approach in the treatment of labral injuries in the absence of substantial structural osseous abnormalities.

see a later posting for more on this article

What My Readers Symptoms of FAI or Labral Tear Were

Ok, so this is not a scholarly peer reviwed journal or anything, but I have found it helpful to know what other people have experienced, and I assume you do too, or you wouldn't be reading this. In the past, I have polled my readers to find out what their symptoms of FAI and or labral tear were, here is what they have shared. Feel free to add your own in the comments section, or email them to me and I can edit this post.
Here were my pre-op symptoms: Groin pain, deep deep groin pain, not always excruciating, but so annoying I felt like cutting off my leg, tight hip flexors, pain with sitting, pain with walking uphill, pain with pushing my stroller. I did not have radiating pain down my legs, all the hip pain was anterior medial.
This is what my readers had to say:
-At original onset of pain, I had acute, sharp pain along with a deeper pain in the anterior (non-PT term - front) hip. Once the acute pain subsided, I was left with a persistent but not 100% constant deep ache (only way I can describe it is comprable to early labor pains, or really bad menstrual cramps, or, in other words, not bad enough to put me in bed, but bad enough to ruin my day - but deep in my hip joint) along with the occasional "catching" of my hip. I would be walking and suddenly it would pinch and hurt too much to walk normally. I would usually stretch or range my hip and that would sometimes work. Otherwise I'd just have to wait it out, and later that day, the ache would be particularly bad. Now (3 + years post op) I'm at the achy stage, with occasional catching and occasional pain that is bad enough to keep me from sleeping, ie: can't find comfortable position, even with pillow between legs, must get up and take 600-800 mg Advil and wait. Those have been my symptoms to date. Hope this helps. I am eager to read about other people's symptoms - knowledge is power. (This reader had a scope a few years ago for a labral tear, her symptoms came back, she ended up being diagnosed with FAI and had an open surgery to address it)

-Clicking, catching (especially when changing direction when walking or getting in and out of car), deep aching. Now post op (scope with labral debridement of fibrillated labral tear) and still have aching (especially with sitting for long periods), nerve pain in thigh and butt, episodes of the hip giving way (though less frequent now). Pain is better with rest and worse with increased activity. Am now six months post op. Wish I had just broke it lol

-My symptoms started with groin pain, which seemed both deep and also superficial, and sometimes radiated up to my lower right pelvic/abdominal area. After awhile, I developed pain over my greater trochanter and in my piriformis muscle. Before my first scope I had SI joint discomfort as well, and also IT band tightness and soreness down my thigh to my knee. At first my pain was intermittent, but over time it became constant; it would get better or worse, but there was always a baseline amount of pain. Driving was horrible. Groin pain was always the worst symptom. Yuck!

Thats what friends are for....

As I have previously mentioned, I got together this week with my 'hip friend' Amy, who has had her left hip scoped twice by Dr. Kelly and will be having her IT band released in the next few weeks/ months. I asked her to write a guest blog post.

Susie asked me to write a guest spot for her blog.... Hmmmm.. what to say?!?! I met Susie as a result of posts on the labralicious and FAI listserves. We had been talking as she had decided to see Dr. Kelly and I had experienced surgery with him. We talked quite a bit on-line and by phone. When I flew up to NYC on March 21st, the day before my surgery, we decided to meet. Needless to say, we clicked. My ride home to my friend's apartment in the city fell through because of complications with getting my surgery started, and Susie came to my rescue just two weeks after her own surgery. She drove in to New York Presby to pick me up and take me to my friend's place. Of course, meeting her two adorable kids in the car on the way home from the hospital sealed the deal!! We are forever "joined at the hip!" On my next trip up, we met and went to the Central Park Zoo together. I had a blast with Susie and her kids and it was a welcome afternoon of fun for both of us. Being able to jump in puddles with L and JK was the highlight of my day!! As a result of meeting on the listserves, we have become friends with this horrible hip problem in common. We have been through each other's ups and downs and frustrations. .... and the "emotionally unstable:" e-mail subject line on multiple occasions. It is wonderful to have the support of someone who is going through the same thing... and with the same doctor. It also doesn't hurt that she is a PT either, and I have picked her brain on multiple occasions!!! This last trip up was just as much fun as it was frustrating... I flew in to NYC on Tuesday afternoon and met up with Susie and the kids. We went to the swimming pool and chilled out for a while. I had a blast taking pictures of all of the kids at the pool, and it has cemented my feeling that maybe I should consider getting back into photography for a living... That evening, we went to see Xanadu with my best friend, Marni. The three of us had a blast at the show, but looked like the walking wounded headed away from the theater! But, for that 90 minutes that the show was on (with us seated on the stage), we were feeling no pain! Well, except for when one of the cast members hit me on the head with a rubber mallet! The frustrating part was the visit to Dr. Kelly. I hate waiting in doctor's offices. It seems like you wait for hours and then get to see the doctor for a few minutes. I think that Dr. Kelly really didn't want to deal with me, because Susie's appointment was 20 minutes after mine and he saw her before me!! He agreed that I need to have my IT Band released but that it should be done back home in Pittsburgh by Dr. Gruen as an open surgery because he has never done an IT Band as messed up as mine with a scope. At least he admitted to is limitations. That is a big thing for a surgeon. As you have already read in Susie's blog, he admitted to missing part of her impingement in the original surgery. We are in the same boat there, as he did not address impingement in my first surgery either. It is a very frustrating thing to deal with to say the least. I did have the opportunity to strangle him playfully when he mentioned our last "argument' over the phone and I was telling him that both of my hips hurt now!! So, for all of you who have wanted to strangle your doctor (Kelly or other) I did it for you too!! I had a happy mood swing that afternoon when I took L to Wave Hill for a "supermodel photo shoot." We had so much fun, and L posed beautifully for me. Her Mom never gets pictures like that... always the "cheese" face, never the cute stuff!! It ended too soon as I had to catch a flight home. It truly amazes me how friendships can develop out of adversity. Heck, I even told Susie that if she has to have another surgery and her Mom gets sick of being there I would come up and help her out. (Provided I am on my own two feet at the time.) After all, That's what friends are for!

The Appointment

Ahhh, the dreaded/ anticipated appointment. I went with my friend Amy, also a two timing hipster, so I had someone to hang out with in the waiting room. I met a blog reader (Lakewood) who said "Susie, as in Susie711?" It was nice to see there are actually real people who are reading this that I can meet!! I didn't catch your name though, but I hope your appt went well, if you have any more questions feel free to email me suzq613 @ aol . com (take out spaces).
So, I waited about an hour. Dr. Kelly came in with Arianna, we discussed the injection, and what happened with the right hip and what is going on with it now. He quickly checked my ROM, nothing else really, and said he is not really sure of what is going on. I mentioned that I had gone over the radiology reports and noticed that there is cam impingement in that hip (thanks Rachel), he sighed and said "I know" in a concerned tone. Then he sat down. Let's see what happens with the injection, if it is an inflammatory reaction, then the cortisone from yesterday should take care of it, call us in 2 weeks and we can talk about it. He also said that when he was in the joint with the scope, he didn't think the labrum had torn from the cam, since the lesion didn't look 'peeled back', it looked to be consistent with the pincer impingement, that's why he left it. Then he looked at me and said "you don't look too convinced", I said no, I'm not, I have always had residual pinching, even from the very beginning, with the second surgery, I had great ROM from the very beginning, so looking back, something has been not right with the right. I have pain with flexion, IR and adduction, so no, I am not convinced that this is inflammatory. So he said, sometimes, he does need to go back in a second time to correct more impingement, this did not make me at all happy. Then he said, you know what, call early next week instead of in 2 weeks so we can figure this out and figure out what the next step is. So this is where I stand, no concrete answers yet, but the possibility of a third surgery looms.

Incompetencies

I am now waiting to get my MRI results. Having experienced many times the way Dr Kelly's office staff works, I anticipate this to be a long and drawn out process. Nothing huge has ever happened with them, but so many little things, it makes you wonder.
-When I called to make my first appointment ever, the receptionist didn't want to give me one as my injury was not 'sports related'...how many of you actually tore your labrum playing sports? Luckily, I insisted on speaking with his PA who said "definitely come in"
-His PA called me with my first MRI results, I really wanted to speak with him, I left 2 messages....heard nothing, until I sent him an email, heard within 45 minutes (it was nice to bypass his office staff)
-When I was being discharged from the hospital after my first surgery, my Gameready was nowhere to be found...someone forgot to order it for me
-I scheduled my post-op appointment at the same time I scheduled my surgery, when I arrived at 12 days post-op, on crutches, brace, and soaked from an icy rain, I was informed that he was in his 'other' office, 2 blocks away. When I arrived there, they could not find my appointment for the day, and were unsure of what to do, as his schedule was booked. I informed the man at the desk that I was not leaving until someone removed my sutures!
-After my second MRI, it took 3 phone calls to get through to him to call me with the results
-I wanted a copy of the MRI report, it took 3 days to have it faxed over, and multiple phone calls
-Luckily, all of my pre-op requests for my second surgery went through, including time of surgery, anesthesia and post-op meds
-I am eligible for temporary disability, but your doctor must fill out some paperwork. His PA did it for me the first time, and there was no issue, this time, I specifically faxed it to her, but it was intercepted by his office manager, who called to ask me, 4 days post-op, when I was going back to work, so she would know how long to write on the form. I explained that I was hoping to be back in 4 weeks, but Arianna had filled it out for 3 months last time, so she should do the same, just in case 4 weeks was not enough. She answered me with a snotty "well, then we can fill out an extension". Why bother with more paperwork, just fill it out for 3 months, and we don't have to worry about it anymore. The story doesn't end here (are you surprised). In my fax, I had included a note that said please fax back to me. A fax never showed up at my office. So I called, sigh, they couldn't find it, so they 'must have' mailed it to me. It never showed up in my mailbox, sigh, so another phone call, I am going to fax it to you, again, please have it ready for me, I will be in the office tomorrow, to which I got a reply of "I will do my best", as opposed to "I am so sorry I never filled your request, it will be ready tomorrow". I arrived at the office, and it was ready, filled out for 4 weeks of disability. I did end up going back to work at 4 weeks, but, sigh, nonetheless!!
-To schedule my 3rd MRI, at first, they tried scheduling it in the wrong facility, then, gave me an appointment almost a week later. I ended up calling the MRI department and rescheduling myself.
-When I arrived for my MRI, they had forgotten to fax over the prescription
-2 weeks to get the message through to call me with my 3rd MRI results
-When I finally decided that I wanted an injection (right side, 6 months out), I left a message and the office manager called me to see "how she could help me", uh, not at all, please have the dr call me
-At the time of this post, almost 24 hours have passed since I called to have the dr office schedule my injection, waiting to hear back from them
-Another injection nightmare, when we decided to inject my psoas, I got a call from the receptionist early the next day, I was impressed, they took initiative. I told her when I wanted it, she said she would call back with a time. 2 days went by, I called her back, she was going to have the other receptionist call me bc she is actually the one who books it with the radiologist, another day, I called back and asked to speak with receptionist #2, she was surprised I was calling bc receptionist #1 told her she had called me and confirmed the appt. Plus it was the wrong date. She corrected the error, and I thought everything was all good. Until the radiologist called and left me a message saying he wanted to make sure I wanted the 'other' appt, bc there had been some reschedulings done, it worked out and I got the day I wanted.
-So...sigh, nothing huge, but a lot of little things which add up to a lot of frustration!

All in a Day's work

I made it. I am exhausted. But I did it!! Yay!!! I feel so accomplished. Did it hurt? Yes, but it was sooooo worth it!! I am back to work! Luckily, I had a light schedule today. There were a few "issues" involving my work performance, that I had not anticipated. First, I was working with a lady who preferred to be on a low table, so in order to stretch her, I was kneeling, sitting back on my heels, I suddenly developed that deep, gnawing groin pain, and had to find another position to work in. The other issue came from left field. I work in an outpatient orthopaedics facility, with mostly surgical and orthopaedic conditions. We also have a pool. I had a new patient, wheelchair bound, who wanted to use the pool, and needed to be transferred from her wheelchair to the table. This almost never happens, my patients are usually higher level functioning. There was no way in hell I could pull this off, probably even on a good day!!! After some discussion and shuffling, I got the situation under control!!!

Besides for that, everything was going pretty well, until my SI joint decided to give me trouble. Yes, again, when it rains it pours. Interestingly, my dysfunction was a posterior inominate on the right, normally, I get an anterior inominate, I assume it is from the hip flexors tightening up and pulling it forwards. Today it was posterior. P hypothesized that maybe it went that way bc the hip flexors are weak? I muscle tested a 4,4+/5 on that side.....so who knows. He corrected it with a MET, he said I was "stuck" on that side. He also released (sigh, again) my iliacus and psoas, which REALLY hurt. I stood up and felt great, walked to my computer, sat down, and had groin pain (sigh). I am beyond frustarted at this point, I don't even know what to think anymore.

The rest of the day was uneventful,, the kiddies slept late, until almost 5:00, so we did not do anything this afternoon, other than a short trip around the block, L on her bike and Jk in the stroller. What a sight it was, since L is not great at riding, me pulling her with one hand and pushing Jk with the other! As I sit here and blog, my hip pain is back with a veangence, and just in time for my Target excursion!!

If you have gotten this far in my post, I want to try something. One of the hardest things I found when my hip journey began was finding a list of symptoms correlated to a labral tear and FAI. If you would like to help, I want to compile a list of people's sympotms in the "comments" of this post, and in a week or so, publish it as a posting, so others have a place to compare notes.

Here were my pre-op symptoms: Groin pain, deep deep groin pain, not always excruciating, but so annoying I felt like cutting off my leg, tight hip flexors, pain with sitting, pain with walking uphill, pain with pushing my stroller. I did not have radiating pain down my legs, all the hip pain was anterior medial.

Timeline

I know that my blog, up until now, has been out of order and maybe confusing at times, so I would like to make a timeline of events to make it clear what led up to 3 surgeries.
November 2005- Jk was born (2nd child, boy) via VBAC, I felt hip pain, but what didn't hurt! Pain went away on its own.
November 2006- Hip pain came back, ignored it for 2 weeks, on Jk's birthday (how ironic) pain was AWFUL, had 3 different PT's work on it, PT only made it worse
Dec 2006- Exercise makes my hip hurt more, manual therapy makes my hip hurt more, time to look into seeing a hip specialist
Dec 2006- Don't get to bed until after midnight, for weeks as I am doing tons of hip research and investigating specialists, come across 2 articles in JOSPT that are encouraging. Found hip labral tear and FAI web forums, learn a ton from other people's experiences
Dec 2006- Choose hip doc, get an appt one month later (see earlier post)
Jan 2007- See hip doc, agrees with self diagnosis, order's MRI (no injection, he believes his MRI machine is good enough to pick up a labral tear without contrast)
Jan 2007- Receive call form hip doc's PA, MRI showed tear and FAI, go get diagnostic injection and make an appt to see hip doc 2 weeks after
Jan 2007- Have injection (see earlier post), injection provides immediate relief
Jan 2007- Go to Disney World!!!!
Feb 2007- See hip doc again, he is pleased that I got relief with injection, lets hold off on surgery, maybe the injection was enough. I don't agree, I want to get this over and done with, as long as he feels comfortable operating. He says "oh, I feel comfortable, I just didn't know if you did!!"
Feb 2007- Schedule first hip scope for March 5
March 2007- First post-op visit, 1 1/2 weeks later, things seem to be going well, I mention that my other hip hurts, he says its compensation, we leave it at that, he wants to see me in 6 weeks
April 2007- 2nd post-op visit, at this point, the other hip is becoming a major issue, I make it very very clear to him, most importantly, it is affecting my rehab on the operated hip, so I want it injected, just for pain relief, he agrees and wants an MRI too
May 2007- 7am MRI followed by 12pm injection, relief with second injection
May 2007- doc calls, MRI positive, looks identical to MRI on other hip. He generally will operate a second time 8-12 weeks out from the first
May 2007- after 3 sleepless nights, I schedule the second surgery, they will be 17 weeks apart
June 28 2007- Twisting motion while applying make-up causes loud, painful pop in right hip
July 2 2007- Left hip arthroscopy, findings: torn labrum, cam and pincer impingement,loose bodies
July 18 2007- 1st post-op appointment, right hip pain is compenastion, left is doing fine
July 26 2007- Right hip is unbearable, call doc, decide to schedule MRI
July 31 2007- Right hip MRI- shows farying of labrum anteriorly and Cam impingement, doc says it is nothing to worry about, do I want injection? I will think about it
August 28 2007- Finally have arthrogram (intra-articualr injection), got 3 painfree hours
August 29 2007- See doc, discuss cam impingement in right hip, he tells me that sometimes he needs to do revision surgeries in cases like this
September 2007- Discuss situation with doc, he believes it may be my psoas as well, schedule CT scan, scan inconclusive
October 2007- Doc strongly suspects psoas involvement, I still disagree, we agree to try a psoas injection, bad reaction, mild pain relief
October 2007- See doc post-psoas injection, beg him to put me out of my misery, we agree to set a tentative date for surgery and wait 1 week to see how I fare with injection
October 2007- Injection did not help, Nov 12 2007 date set for Right hip revision arthroscopy
November 12 2007-Right Revision Hip Arthroscopy, cam impingement, scar tissue, synovectomy
April 2008- Get pregnant with Zk
January 2009- Zk is born, once again via VBAC (drugless too)
June 2009- After sitting in Indian Style for 30 minutes, I procees to stand up and hip is too painful to stand on
June 2009- MRI of R hip shows increased signal in capsule
July 2009- Intra-articular injection of right hip gives approximately 2 days of relief
September 2009- PRP injection of the joint capsule gives no relief
September 2009- BK tells me he thinks I need exploratory surgery (this will be surgery #4)
September 2009- I freak out, BK agrees to try one more injection
October 2009- Synvisc + Cortisone injection scheduled for right hip
November 2009-Schedule Hip Arthroscopy #4 (#3 for right side)
November 2009- Hip Arthroscopy #4 for possible HO, labral tear and capsular shift
February 2010 Hip begins to feel unstable, joint pain becomes awful at times
February 2010 I begin to become concerned that I have a TON of hip ER, despite capsular shift
March 2010 MRI to see what the issue is (this time...sigh)
March 2010 BK thinks it may be my psoas or capsule or scar tissue
March 2010 Discuss possibility of dynamic ultrasound and/or dynamic CT scan