1. No category

[
case report
]
PAULA M. YAZBEK, PT1 • VANESSA OVANESSIAN, PT, MS1 • ROBROY L. MARTIN, PT, PhD2 • THIAGO Y. FUKUDA, PT, PhD3
Nonsurgical Treatment of Acetabular
Labrum Tears: A Case Series
I
nterest in the etiology, diagnosis, and treatment of individuals
with acetabular labral tears continues to increase. While there
is available information for arthroscopic and postoperative
management of labral tears, femoroacetabular impingement
(FAI), and hip instability,4,6,8,9,28,32 there is limited research regarding
appropriate nonsurgical physical therapy intervention for those with
suspected labral tears. As we become more aware of intra-articular
hip pathologies, information to help
guide nonoperative rehabilitation programs is needed.
Mechanical impingement and/or instability of the femoroacetabular joint are
believed to be common causes of labral
TTSTUDY DESIGN: Case series.
TTBACKGROUND: While the literature has em-
phasized surgical treatment of acetabular labrum
tears, there is a lack of information regarding
conservative treatment. The purpose of this case
series was to describe a nonsurgical program
for those with clinical evidence of an acetabular
labrum tear, that emphasized hip and lumbopelvic
stabilization, correction of hip muscle imbalance, biomechanical control, and sport-specific
functional progression.
TTCASE DESCRIPTION: The 4 patients in this se-
ries had clinical evidence and magnetic resonance
imaging confirmation of an acetabular labrum tear
and underwent a similar treatment protocol consisting of 3 phases. Phase 1 emphasized pain control, education in trunk stabilization, and correction
of abnormal joint movement. Phase 2 focused on
muscular strengthening, recovery of normal range
of motion (ROM), and initiation of sensory motor
training. And phase 3 emphasized advanced sen-
chondral pathology.3,11,22,28 The 2 primary
types of femoroacetabular impingement
(FAI) are cam and pincer impingement.
Cam impingement originates from abnormal thickening of the femoral headneck junction, while pincer impingement
sory motor training, with sport-specific functional
progression. ROM, flexibility, pain, special tests,
and level of function were assessed, and strength
was measured with handheld dynamometry.
TTOUTCOMES: All patients demonstrated
decreased pain, functional improvement, and correction of muscular imbalance. Increased muscle
strength, primarily for the hip flexors (1%-39%),
abductors (18%-56%), and extensors (68%-139%)
was also noted.
TTDISCUSSION: All patients responded well to
our program. This case series suggests that patients with clinical evidence of an acetabular labral
tear confirmed with MRI can show meaningful
improvement with nonsurgical intervention.
TTLEVEL OF EVIDENCE: Therapy, level 4. J
Orthop Sports Phys Ther 2011;41(5):346-353, Epub
18 February 2011. doi:10.2519/jospt.2011.3225
TTKEY WORDS: acetabulum, hip, labrum,
rehabilitation
originates from overcoverage of the acetabulum.10 Clinical signs of FAI have
been found to be present in up to 95% of
patients with a labral tear.5 The anteriorsuperior region of the joint is the most
common location for a labral tear,33 the
patient symptoms of which are provoked
by combined hip internal rotation, adduction, and flexion.28
Labral chondral lesions may also result from atraumatic hip instability, with
or without mechanical impingement.
Focal rotational instability is defined as
localized laxity of select capsule-ligamentous structures that results from repetitive forceful hip rotation.22,29,31 The most
common injury mechanism is excessive
hip external rotation, leading to iliofemoral ligament laxity.22,31 Abnormal loading
of the anterior-superior labrum can occur in the presence of instability.29 The labrum is important for joint stability and,
therefore, capsule-ligamentous structures
can come under additional stress when a
labral tear occurs. Forceful loading of the
hip joint may further compromise the integrity of not only the passive stabilizing
structures but the active joint stabilizers.
Poor neuromuscular control of the hip
and lumbopelvic regions may, therefore,
exacerbate the pathology and symptoms
associated with instability.
Pathologies that affect the neuromuscular control of hip musculature can disrupt movement patterns and alter forces
across the labrum and articular carti-
Staff Physical Therapist, Irmandade da Santa Casa de Misericórdia de São Paulo, Rehabilitation Service, São Paulo-SP, Brazil. 2Associate Professor, Department of Physical
Therapy, Duquesne University, Pittsburgh, PA; Staff Physical Therapist, University of Pittsburgh Centers for Sports Medicine, Pittsburgh, PA. 3Doctoral candidate, Associate
Professor, Staff Physical Therapist, Irmandade da Santa Casa de Misericórdia de São Paulo, Rehabilitation Service, São Paulo-SP, Brazil. This work received approval from the
Institutional Review Board of Irmandade da Santa Casa de Misericórdia de São Paulo. Address correspondence to Dr Thiago Yukio Fukuda, Physical Therapy Department, Rua
Dr Cesário Motta Jr, 112, 01221-020, São Paulo-SP, Brazil. E-mail: [email protected]
1
346 | may 2011 | volume 41 | number 5 | journal of orthopaedic & sports physical therapy
41-05 Yazbek.indd 346
4/20/2011 2:30:12 PM
TABLE 1
Patient Information
Patient
Age, y
Gender
1
27
Male
Relevant History
Complaints
MRI Findings
• Professional indoor soccer player
• Groin and lateral knee pain of the involved side
• Pincer femoroacetabular impingement
• Partial labral resection 10 mo earlier
• Pain increased with walking, going up and down stairs,
• 10 unsuccessful previous physical
therapy sessions
running, and changing direction
• Duration of symptoms, 2 y
• Arthroscopic knee surgery 5 y ago
2
24
Male
• Professional Jiu-Jitsu fighter
• Groin and medial thigh pain of the involved side
• Anterior superior labral tear
• Duration of symptoms, 9 mo
• Bilateral adductor tendinitis
• Superior lateral chondral lesion
3
24
Female
• Sedentary
• Groin pain of the involved side
• Anterior superior labral tear
• Locking after periods of sitting
• Partial ligamentum teres tear
• Thigh pain with standing
• Gluteal medius and minimus tendinopathy
• Duration of symptoms, 1 y
• 10-d history of lateral leg paresthesia
4
24
Male
• Recreational soccer player
• Groin and right thigh pain
• Partial anterior superior labral tear
• Mild L5-S1 degenerative disc disease • Pain increased with sitting and soccer-related activities
• Normal electromyography tests
• Duration of symptoms, 3 y
Abbreviation: MRI, magnetic resonance imaging.
lage.25 Gait deviations resulting from abnormal recruitment patterns of the hip
musculature have been documented in
individuals with FAI.14 Also, decreased
force contribution from the gluteal muscles during active hip extension and iliopsoas during active hip flexion was found
to result in greater anterior hip forces.20
Gluteus medius function is thought to
be commonly impaired in those with
hip pathology.8 Though compensation
with excessive hip internal rotation can
enhance gluteus medius function, it can
negatively impact force generation of the
gluteus maximus. Abnormal internal
rotation may also increase anterior hip
forces.36 If force-producing capacity and
control of the muscles around the hip are
improved, anterior hip forces and, therefore, hip pain may potentially be reduced
in those with labral or chondral lesions.
Although there is limited information regarding nonsurgical treatment of
those with clinical evidence of a labral
tear, interventions that attempt to normalize hip alignment and correct joint
movement may be beneficial. The use of
a hip-strapping device to reduce frontal
plane (adduction) and transverse plane
(internal rotation) hip kinematics was
found to decrease pain and improve
function in a female individual with FAI.2
Lewis et al20 described a program that attempted to reduce stress on the anterior
hip joint by improving force production
of the gluteus medius, piriformis, gemellus, obturators, gluteus maximus, and
iliopsoas, while minimizing excessive
quadriceps femoris and hamstring activity. Key elements of this program address
positional and movement control, muscle
force-generating capacity, muscle length,
and activity modification.20
Anecdotally, it has been reported
that modifying muscle recruitment and
movement patterns during gait and
functional activities is helpful. However,
further investigation and descriptions of
conservative intervention programs are
needed. The conservative program outlined in this study emphasized hip and
lumbopelvic stabilization, correction of
hip muscular imbalance, biomechanical control, and sport-specific functional
progression. The aim of this paper was to
report the outcome of 4 patients, as well
as to describe the nonsurgical treatment
protocol. This work received approval
from The Institutional Review Board of
Irmandade da Santa Casa de Misericórdia de São Paulo, and all participants
gave informed, written consent prior to
participation.
CASE DESCRIPTION
T
he 4 patients in this case series
were evaluated at baseline, and at 4
months and 6 months after treatment. For each patient, demographic,
relevant history, primary symptoms, and
results of magnetic resonance imaging
(MRI) are provided in TABLE 1. Evaluation consisted of an assessment of range
of motion, flexibility, pain, and level of
function as assessed with the Lequesne
Hip Score.17 Strength assessment was
measured with handheld dynamometry.1
Potential sacroiliac joint, radiculopathy,
piriformis, and anterior pelvic involvement were assessed, respectively, with the
squish test (posterior pelvic pain during
anterior-posterior pressure applied on
the iliac bone), Lasegue’s straight-leg
maneuver, the piriformis test (buttock
or sciatica pain during hip medial rotation), and the grava test (pain during hip
journal of orthopaedic & sports physical therapy | volume 41 | number 5 | may 2011 | 347
41-05 Yazbek.indd 347
4/20/2011 2:30:13 PM
[
adductors and abdominal contraction in
prone position).7 The following special
tests for intra-articular hip pathology
were also performed: flexion-adduction
internal rotation impingement,18 Patrick
or flexion-abduction external rotation
(FABER),27 scour (pain during pressure
applied down through the thigh into the
hip joint, over a hip range of motion),
and internal rotation (groin pain during
passive hip internal rotation).21 The results of these tests are provided in TABLE
2. Additionally, we tested the presence
of femoral anteversion, according to the
method described by Souza and Powers.34
None of the 4 patients presented with
femoral anteversion; however, 1 patient
showed a decrease of 15° in hip internal
rotation in relation to the opposite limb.
Only patients with clinical evidence of an
acetabular labrum tear were included in
the study. This includes patient 1, who,
despite a previous partial labral resection, showed signs of FAI with continued
labral involvement.
As noted in TABLE 1, 3 of the 4 patients
participated in sports, with 1 being sedentary. All 4 individuals had MRI findings
consistent with a labral tear. Additionally, all 4 patients had some positive
signs and symptoms that would suggest
a labral tear as a potential pathology. All
4 patients might have had concurrent
extra-articular pathology, as well, which
might have partially contributed to their
complaints. Although case 1 presented
with a status of post partial labral resection, his symptoms, examination, and
diagnostic testing suggested FAI with
continued labral involvement as a potential pathology.
Nonsurgical Treatment Protocol
The conservative treatment protocol
(TABLE 3) was developed for those with
clinical evidence of an acetabular labrum
tear and modified as needed for coexisting pathologies. Phase 1 consisted of pain
control, education in trunk stabilization,
and correction of abnormal movement.
Patients also received instruction to correct excessive dynamic valgus of the lower
case report
TABLE 2
]
Results of Clinical Tests and Functional and Pain Scales for the Initial Evaluation and Re-evaluations (Discharge of Therapy)
Before
Patient/Special Tests
Involved
After
Uninvolved
Involved
Uninvolved
Patient 1
Impingement
+
–
+
–
Patrick-FABER
+
–
–
–
Scour
+
–
+
–
Internal rotation
+
–
–
–
Squish
–
–
–
–
Lasegue
–
–
–
–
Piriform
+
–
–
–
Grava
+
–
–
–
VAS*
5
0
Lequesne†
10
5
Patient 2
Impingement
+
–
–
Patrick-FABER
–
–
–
–
–
Scour
+
–
–
–
Internal rotation
–
–
–
–
Squish
+
–
+
–
Lasegue
–
–
–
–
Piriform
–
–
–
–
Grava
–
–
–
–
VAS*
4
0
Lequesne†
5
1
Table continues on page 349.
extremity, with dynamic valgus defined as
hip adduction and internal rotation that
increased during single-limb support.30,33
Once a patient noted diminished pain
with improved control of trunk stabilization and dynamic valgus, the patient
could progress to phase 2. Phase 2 (FIGURE
1) focused on muscle strengthening, recovery of normal range of motion (ROM),
and initiation of sensory motor training.
The 4 patients in this report demonstrated muscular imbalance of the lower
limbs, as demonstrated by differences in
strength measurements between limbs.
Once this imbalance was corrected (when
the injured limb reached or exceeded
the strength of the healthy limb), patients could progress to phase 3 (FIGURE
2), which emphasized advanced sensory
motor training, with sport-specific functional progression. Proper lower extrem-
ity alignment and stabilization were
encouraged at all times during activity.
OUTCOMES
S
pecial test results and pain levels are included in TABLE 2. The results of the strength assessments are
provided in TABLE 4. All patients received
3 treatment sessions per week and were
progressed through the 3 phases of the
proposed protocol, in accordance with
the outlined criteria.
Each patient generally progressed
well through the treatment program. It
should be noted that in patient 1, despite
the partial acetabular labrum resection,
symptoms continued. Biomechanical
instability might have contributed to
the patient’s prior lack of progress. This
previous lack of progress might also have
348 | may 2011 | volume 41 | number 5 | journal of orthopaedic & sports physical therapy
41-05 Yazbek.indd 348
4/20/2011 2:30:14 PM
TABLE 2
Results of Clinical Tests and Functional
and Pain Scales for the Initial Evaluation
and Re-evaluations (Discharge of Therapy)
(continued)
After
Before
Patient/Special Tests
Involved
Uninvolved
Involved
Uninvolved
Patient 3
Impingement
+
–
+
–
Patrick-FABER
–
–
–
–
Scour
–
–
–
–
Internal rotation
+
–
–
–
Squish
–
–
–
–
Lasegue
+
–
–
–
Piriform
+
–
–
–
Grava
–
–
–
–
VAS*
6
0
Lequesne†
7
1
Patient 4
Impingement
+
–
–
–
Patrick-FABER
+
–
+
–
Scour
+
–
+
–
Internal rotation
+
–
–
–
Squish
+
–
–
–
Lasegue
+
–
+
–
Piriform
+
–
+
–
Grava
–
–
–
–
VAS*
10
3
Lequesne†
14
5
Abbreviation: VAS, visual analog scale.
*0- to 10-cm scale, where 0 means “no pain” and 10 means “worst imaginable pain.”
†
0 to 22 points, where 0 means “normal function” and 14 or more points means “extremely severe
dysfunction.”
been due to symptoms arising from FAI,
as opposed to an isolated labral tear. For
this patient, it was not possible to quantify hip strength on initial evaluation,
because the dynamometer was not available. This patient progressed to phase 2
after 2 weeks, phase 3 after 4 weeks, and
was discharged after a total of 12 weeks
of treatment.
Patient 2 progressed through the
strengthening and functional-training
activities relatively quickly, once pain
was reduced. Being a professional athlete
might have contributed to this patient’s
rapid progress. He was able to progress to
phase 2 after 2 weeks and phase 3 after 4
weeks. Following discharge, after a total
of 9 weeks of treatment, the patient was
able to start a new competitive season.
Patient 3 presented with gluteal medius and minimus tendinopathy, in addition to a potential labral tear, which
was addressed with laser and electrical
stimulation included in the intervention
plan. According to our clinical experience, both physical agents work well for
tendinopathy in inferior limbs and focus
especially on pain relief. It was felt that
the tendinopathy did not influence efforts
to correct muscular imbalances. Patient
3 started phase 2 after 5 sessions, with
no pain or paresthesia. She progressed
to phase 3 after 5 weeks. Once dynamic
valgus control was maintained, she noted
that the locking episodes were no longer
present. She was discharged after 13
weeks of treatment, with her only complaint being slight hip pain after wearing
high-heeled shoes for prolonged periods.
At the 6-month follow-up evaluation, the
patient had returned to her normal daily
activities but had not done any sportsrelated activities.
Patient 4 was unique, in that he was
the only case to present with decreased
hip internal rotation range of motion
(right, 40°; left, 25°). Regaining this loss
of motion was emphasized and addressed
with joint mobilization techniques. The
patient was able to progress to phase 2
after 3 weeks and phase 3 after 6 weeks.
After 4 months of treatment, he was discharged with normal range of motion and
symptom improvement.
DISCUSSION
N
onsurgical treatment for individuals with suspected acetabular
labral tears has not been described.
This case series outlines a conservative
treatment program for individuals with
clinical evidence of an acetabular labral
tear, confirmed with MRI, that emphasized hip and lumbopelvic stabilization.
Over a 12-week period, the 4 patients
who participated in this program noted
decreased pain, increased strength, and
improved function.
As noted in TABLE 2, after the treatment
sessions, all patients reached a normal
to moderate limitation of function, according to the Lequesne Hip Score. The
Lequesne Hip Score was chosen because
this scale was easily applicable and can
be used to assess level of disability. According to this scale, the level of handicap can be interpreted as follows: none (0
points), mild (1-4 points), moderate (5-7
points), severe (8-10 points), very severe
(11-13 points), and extremely severe (14
or more points). Although the Lequesne
Hip Score has not undergone psychometric testing to provide minimal clinically important difference (MCID) for
changes in score, improvements in scores
journal of orthopaedic & sports physical therapy | volume 41 | number 5 | may 2011 | 349
41-05 Yazbek.indd 349
4/20/2011 2:30:15 PM
[
case report
]
Rehabilitation Protocol for Nonsurgical Treatment of Acetabular Labrum Tears
TABLE 3
Parameter
Phase 1
Phase 2
Phase 3
Progression criterion
• Diagnosis of acetabular labrum tear
• Significant decrease or absence of pain
• Good balance and proprioception and normal
complaint (VAS*, <4, or Lequesne†, <5)
Gait
• Assistive device for those with increased pain
muscle strength and range of motion
• Discontinue assistive device
with weight bearing
Pain
• Maitland’s manual mobilization (grades 1 and 2)
• Electrophysical agents: electrical stimulation
and laser
AROM
• Active movements within painful limits
• Maitland’s manual mobilization (grades 3 and 4)
and combined movements
• Pelvic rotation maneuver
• Sacroiliac distraction
Segmental stabilization • Transversus abdominis and multifidus isolated
• Core (lumbopelvic stabilization exercises) added
• Core (lumbopelvic stabilization exercises) added
contraction and associated light exercises, such
to moderate exercises, such as lateral bridge and
to Swiss ball exercises and advanced sensory
as bridging and crouching close to the floor on
mini squat, and to light sensory motor training
motor training
hands and knees
Muscle strength
• Standing hip flexion and extension (progressive
load), 3 × 10 reps
• Muscle strength maintenance (progressive load)
and address any persisting muscular imbalance
• Standing hip abduction and adduction,
with elastic resistance near a support bar
(progressive load), 3 × 10 reps
• Lunge (progressive load), 3 × 10 reps
• Shuttle machine (progressive load), 3 × 10 reps,
70% MR
• Knee flexion-extension on chair (progressive
load), 3 × 10 reps, 70% MR
• Sidestepping gait with an elastic band over
midfeet, 3 × 1 min
• Dynamic valgus control with single-limb squat,
3 × 1 min
Sensory motor training
• Balancing
• Same equipment used in phase 2, combined
• Balance board
with sports movements (eg, kicking and
• DynaDisc
throwing)
• Jumping board
Abbreviations: AROM, active range of motion; MR, maximal repetition; VAS, visual analog scale.
*0- to 10-cm scale, where 0 means “no pain” and 10 means “worst imaginable pain.”
†
0 to 22 points, where 0 means “normal function” and 14 or more points means “extremely severe dysfunction.”
obtained by this instrument were accompanied by decreased pain and increased
strength. Three patients had total pain
relief, as measured with a visual analog
scale, and all patients showed improved
muscle strength of the hip flexors (1%39%), abductors (18%-56%), and extensors (68%-139%).
On initial evaluation, lower limb
strength imbalance was identified in the
patients. Gluteus medius, gluteus maximus, and iliopsoas weakness can contribute to increased anterior hip force. This
weakness, combined with hip hyperextension, may be a contributing factor for
an acetabular labrum tear.5,25,26 We have
noted that patients with gluteus maximus, gluteus medius, and iliopsoas weakness can report hip instability (anterior
discomfort when performing activities
that require active extension, along with
hip external rotation). Gluteus medius
and maximus weakness can also lead to
abnormal lower extremity positioning
associated with excessive lower extremity dynamic valgus (ie, femoral adduction and internal rotation).30 In dynamic
valgus, the hip is in a position that can
cause or aggravate symptoms associated
with a labral tear. The improvement that
350 | may 2011 | volume 41 | number 5 | journal of orthopaedic & sports physical therapy
41-05 Yazbek.indd 350
4/20/2011 2:30:16 PM
FIGURE 1. Phase 2 of rehabilitation protocol. (A) Gluteus maximus strengthening on equipment, (B) side-stepping
using an elastic band around both midfeet, which promotes greater concentric and eccentric hip abduction and
external rotation effort, and (C) control of dynamic valgus on a trampoline.
FIGURE 2. Phase 3 of rehabilitation protocol. (A) Core stabilization with perturbation forward, backward, and
side-to-side, (B) single-limb sliding on straight board while controlling dynamic valgus, (C) sitting on Swiss ball,
performing isometric hip adduction and ball throws, (D) Jiu-Jitsu sport movement with elastic resistance for hands
and feet, and (E) movements with lower limbs holding a Swiss ball between legs.
patients achieved as a result of this program may be attributed to the increase
strength in the muscles that help to decrease anterior hip forces, as well as to
control dynamic valgus.
The treatment protocol outlined in
this manuscript is focused on hip muscle
imbalance and correction of abnormal
biomechanics, and adds a more specific
exercise prescription than the previously
described program.19 Kapandji13 noted
a direct relationship between abductor weakness of the involved limb and
adductor weakness of the contralateral
limb. The author labeled these findings
as “cross-chain weakness.” During double-limb support, the pelvis is balanced
by simultaneous and bilateral action of
the hip abductors and adductors. When
these antagonistic actions are balanced,
the pelvis is stable in a symmetrical position.9,36 When cross-chain weakness is
present, the dynamic stability of the pelvis is impaired. This dynamic instability can contribute to an overload of the
capsule, potentially leading to labral or
chondral pathology.9 During single-limb
standing, the pelvis is balanced by the action of the ipsilateral abductors. The gluteus medius is primarily responsible for
maintaining this balance, with contribution from the gluteus minimus and tensor fascia lata. When abductor weakness
occurs, the effect of gravity may not be
conterbalanced, causing the hip to move
into adduction. This cross-chain weakness was best observed in patient 3. This
patient had hip extensors, hip abductors,
and hip flexors weakness on the involved
limb, with significant weakness of the adductors in the contralateral limb.
Handheld dynamometry allowed for
close monitoring of muscle imbalance
during strengthening exercises. In the
correction of abnormal mechanics, it was
considered critical to strengthen those
muscles identified as weak. At the beginning of treatment, the primary objective
was to instruct patients on the importance and techniques for proper lumbopelvic and hip stabilization, especially for
athletes.6,36 At the same time, analgesic
methods were used to reduce pain.
Stabilization during movement requires normal muscle activation patterns
for proper movement coordination. It is
debated whether joint instability or impaired coordinated movement is a source
of dysfunction. Adequate joint stability
depends on contractile and noncontractile elements. Therefore, improper coordination of movement patterns may play
a large role in whether or not a patient
experiences symptoms related to instability.15 Studies have determined that,
in healthy people, pelvic postural control during lower limb exercises occurs
through the simultaneous contraction of
local and global muscles.12 In contrast, it
was found that multifidus and transversus abdominis activation was impaired in
individuals with pelvic injuries.35 Activities to improve recruitment, activation,
and timing of deep lumbopelvic muscu-
journal of orthopaedic & sports physical therapy | volume 41 | number 5 | may 2011 | 351
41-05 Yazbek.indd 351
4/20/2011 2:30:19 PM
[
]
Muscle Strength Using Handheld Dynamometer for Initial Evaluation and Discharge From Therapy*
TABLE 4
case report
Evaluation, kg
Involved
Re-evaluation, kg
Uninvolved
Involved
Uninvolved
Change, %
Involved
Uninvolved
Hip flexors
Case 2†
41.9
46.4
52.3
57.4
25
24
Case 3†
19.5
22.8
19.6
22.8
1
0
Case 4‡
17.5
22.2
24.0
24.0
39
7
Hip extensors
Case 2†
18.3
16.2
36.3
38.7
98
Case 3†
11.1
18.0
18.7
18.0
68
139
0
Case 4‡
20.2
26.4
NA
NA
NA
NA
Hip abductors
Case 2†
28.8
29.6
28.8
29.6
0
0
Case 3†
7.5
10.9
11.7
15.9
56
46
Case 4‡
10.8
12.7
14.8
15.0
37
18
Hip adductors
Case 2†
13.4
11.3
13.4
15.6
0
38
Case 3†
9.1
7.2
12.3
11.4
35
58
Case 4‡
17.7
18.3
17.7
18.3
0
0
Abbreviation: NA, not evaluated.
*There are no values of case 1 because during his evaluation the dynamometer was not available yet.
†
6-month re-evaluation.
‡
4-month re-evaluation.
lature, transversus abdominis, and multifidus were implemented early in our
program to improve movement coordination. The goal during all our activities was
to have the patients activate these deep
muscles before and during the activation
of muscles that produce hip motion.
It is the authors’ opinion that not only
is this specific muscle strength training
important to dynamic posture maintenance and control but also important for
progressive sensory motor control. This
was implemented in our protocol by first
emphasizing lumbopelvic and hip stabilization, before progressing to functional
activities. Visual feedback was provided
to the patients throughout the progression of activities and was considered a
key component in teaching and learning dynamic stabilization. But it should
be noted that the passage of time might
have contributed to some or all of the
patients’ improvement. However, this is
considered unlikely, given the long duration of symptoms in our patients. There
is limited ability to accurately clinically
diagnose a labral tear.16,22-24 In addition,
even for patients with a confirmed labral
tear on diagnostic imagining, it does
not ensure that the pain arises from the
tear.23 Therefore, we chose to use the term
“clinical evidence of a labral tear” for our
patients. The difficulty with the diagnostic process should not affect the interpretation of this study. The purpose of this
paper was not to describe the diagnostic
process but to describe a rehabilitation
protocol that could be implemented for
those with suspected hip labral tears.
CONCLUSION
T
his article reported on patients
with clinical evidence of an acetabular labrum tear, confirmed with
MRI. All patients responded well to a
nonsurgical program that emphasized
hip and lumbopelvic stabilization, correction of muscular imbalance, and sportspecific functional progression. This case
series suggests that patients with clinical
evidence of an acetabular labral tear can
show meaningful improvement with conservative intervention. Further research
is necessary to determine the short- and
long-term effectiveness of this approach
in the management of suspected labral
injuries. t
REFERENCES
1. A
ndrews AW, Thomas MW, Bohannon RW.
Normative values for isometric muscle force
measurements obtained with hand-held dynamometers. Phys Ther. 1996;76:248-259.
2. Austin AB, Souza RB, Meyer JL, Powers CM.
Identification of abnormal hip motion associated with acetabular labral pathology. J Orthop
Sports Phys Ther. 2008;38:558-565. http://
dx.doi.org/10.2519/jospt.2008.2790
3. Beck M, Kalhor M, Leunig M, Ganz R. Hip
morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early
osteoarthritis of the hip. J Bone Joint Surg
Br. 2005;87:1012-1018. http://dx.doi.
org/10.1302/0301-620X.87B7.15203
352 | may 2011 | volume 41 | number 5 | journal of orthopaedic & sports physical therapy
41-05 Yazbek.indd 352
4/20/2011 2:30:19 PM
4. B
edi A, Chen N, Robertson W, Kelly BT. The
management of labral tears and femoroacetabular impingement of the hip in the young, active
patient. Arthroscopy. 2008;24:1135-1145. http://
dx.doi.org/10.1016/j.arthro.2008.06.001
5. Burnett RS, Della Rocca GJ, Prather H, Curry M,
Maloney WJ, Clohisy JC. Clinical presentation of
patients with tears of the acetabular labrum. J
Bone Joint Surg Am. 2006;88:1448-1457. http://
dx.doi.org/10.2106/JBJS.D.02806
6. Byrd JW, Jones KS. Hip arthroscopy for labral
pathology: prospective analysis with 10-year
follow-up. Arthroscopy. 2009;25:365-368.
http://dx.doi.org/10.1016/j.arthro.2009.02.001
7. Cohen M, Abdalla R. [Sports Injuries: Diagnosis,
Prevention and Treatment]. Rio de Janeiro, Brazil: Revinter; 2002.
8. Enseki KR, Martin R, Kelly BT. Rehabilitation
after arthroscopic decompression for femoroacetabular impingement. Clin Sports Med.
29:247-255, viii. http://dx.doi.org/10.1016/j.
csm.2009.12.007
9. Enseki KR, Martin RL, Draovitch P, Kelly BT,
Philippon MJ, Schenker ML. The hip joint:
arthroscopic procedures and postoperative
rehabilitation. J Orthop Sports Phys Ther.
2006;36:516-525. http://dx.doi.org/10.2519/
jospt.2006.2138
10. Ganz R, Leunig M, Leunig-Ganz K, Harris WH.
The etiology of osteoarthritis of the hip: an
integrated mechanical concept. Clin Orthop
Relat Res. 2008;466:264-272. http://dx.doi.
org/10.1007/s11999-007-0060-z
11. Guevara CJ, Pietrobon R, Carothers JT, Olson
SA, Vail TP. Comprehensive morphologic
evaluation of the hip in patients with symptomatic labral tear. Clin Orthop Relat Res.
2006;453:277-285. http://dx.doi.org/10.1097/01.
blo.0000246536.90371.12
12. Hodges PW, Richardson CA. Contraction of the
abdominal muscles associated with movement
of the lower limb. Phys Ther. 1997;77:132-142;
discussion 142-134.
13. Kapandji A. [Articulate Physiology. Volume 2:
Lower Limb]. 5th ed. Sao Paulo, Brazil: Guanabara Koogan Guanabara Koogan; 2001.
14. Kennedy MJ, Lamontagne M, Beaule PE. Femoroacetabular impingement alters hip and pelvic
biomechanics during gait walking biomechanics
of FAI. Gait Posture. 2009;30:41-44. http://
dx.doi.org/10.1016/j.gaitpost.2009.02.008
15. Key J, Clift A, Condie F, Harley C. A model of
movement dysfunction provides a classification
system guiding diagnosis and therapeutic care
in spinal pain and related musculoskeletal syn-
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
dromes: a paradigm shift-Part 1. J Bodyw Mov
Ther. 2008;12:7-21. http://dx.doi.org/10.1016/j.
jbmt.2007.04.005
Leibold MR, Huijbregts PA, Jensen R. Concurrent
criterion-related validity of physical examination
tests for hip labral lesions: a systematic review.
J Man Manip Ther. 2008;16:E24-41.
Lequesne MG, Mery C, Samson M, Gerard P. Indexes of severity for osteoarthritis of the hip and
knee. Validation--value in comparison with other
assessment tests. Scand J Rheumatol Suppl.
1987;65:85-89.
Leunig M, Ganz R. [Femoroacetabular
impingement. A common cause of hip complaints leading to arthrosis]. Unfallchirurg.
2005;108:9-10, 12-17. http://dx.doi.org/10.1007/
s00113-004-0902-z
Lewis CL, Sahrmann SA. Acetabular labral tears.
Phys Ther. 2006;86:110-121.
Lewis CL, Sahrmann SA, Moran DW. Anterior
hip joint force increases with hip extension,
decreased gluteal force, or decreased iliopsoas
force. J Biomech. 2007;40:3725-3731. http://
dx.doi.org/10.1016/j.jbiomech.2007.06.024
Magee D. [Musculoskeletal Assessment]. 4th
ed. Sao Paulo, Brazil: Manole; 2005.
Martin RL, Enseki KR, Draovitch P, Trapuzzano
T, Philippon MJ. Acetabular labral tears of the
hip: examination and diagnostic challenges. J
Orthop Sports Phys Ther. 2006;36:503-515.
http://dx.doi.org/10.2519/jospt.2006.2135
Martin RL, Irrgang JJ, Sekiya JK. The diagnostic
accuracy of a clinical examination in determining intra-articular hip pain for potential
hip arthroscopy candidates. Arthroscopy.
2008;24:1013-1018. http://dx.doi.org/10.1016/j.
arthro.2008.04.075
Martin RL, Kelly BT, Leunig M, et al. Reliability of clinical diagnosis in intraarticular
hip diseases. Knee Surg Sports Traumatol
Arthrosc. 18:685-690. http://dx.doi.org/10.1007/
s00167-009-1024-5
Neumann DA. Kinesiology of the hip: a focus
on muscular actions. J Orthop Sports Phys
Ther. 40:82-94. http://dx.doi.org/10.2519/
jospt.2010.3025
Neumann M, Cui Q, Siebenrock KA, Beck M.
Impingement-free hip motion: the ‘normal’
angle alpha after osteochondroplasty. Clin
Orthop Relat Res. 2009;467:699-703. http://
dx.doi.org/10.1007/s11999-008-0616-6
Philippon M, Schenker M, Briggs K, Kuppersmith
D. Femoroacetabular impingement in 45 professional athletes: associated pathologies and
return to sport following arthroscopic decom-
28.
29.
30.
31.
32.
33.
34.
35.
36.
pression. Knee Surg Sports Traumatol Arthrosc.
2007;15:908-914. http://dx.doi.org/10.1007/
s00167-007-0332-x
Philippon MJ. New frontiers in hip arthroscopy:
the role of arthroscopic hip labral repair and
capsulorrhaphy in the treatment of hip disorders. Instr Course Lect. 2006;55:309-316.
Philippon MJ. The role of arthroscopic thermal
capsulorrhaphy in the hip. Clin Sports Med.
2001;20:817-829.
Powers CM. The influence of abnormal hip
mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 40:42-51.
http://dx.doi.org/10.2519/jospt.2010.3337
Schenker M, Martin R, Weiland D, Philippon M.
Current trends in hip arthroscopy: A review of
injury diagnosis, techniques and outcome scoring. Curr Opin Ortho. 2005;16:89-94.
Sekiya JK, Martin RL, Lesniak BP. Arthroscopic
repair of delaminated acetabular articular
cartilage in femoroacetabular impingement.
Orthopedics. 2009;32:http://dx.doi.
org/10.3928/01477447-20090728-44
Smith CD, Masouros S, Hill AM, Amis AA, Bull
AM. A biomechanical basis for tears of the
human acetabular labrum. Br J Sports Med.
2009;43:574-578. http://dx.doi.org/10.1136/
bjsm.2008.053645
Souza RB, Powers CM. Concurrent criterionrelated validity and reliability of a clinical test to
measure femoral anteversion. J Orthop Sports
Phys Ther. 2009;39:586-592. http://dx.doi.
org/10.2519/jospt.2009.2996
Stevens VK, Vleeming A, Bouche KG, Mahieu
NN, Vanderstraeten GG, Danneels LA. Electromyographic activity of trunk and hip muscles
during stabilization exercises in four-point
kneeling in healthy volunteers. Eur Spine J.
2007;16:711-718. http://dx.doi.org/10.1007/
s00586-006-0181-1
Ward SR, Winters TM, Blemker SS. The architectural design of the gluteal muscle group:
implications for movement and rehabilitation.
J Orthop Sports Phys Ther. 2010;40:95-102.
http://dx.doi.org/10.2519/jospt.2010.3302
@
MORE INFORMATION
WWW.JOSPT.ORG
journal of orthopaedic & sports physical therapy | volume 41 | number 5 | may 2011 | 353
41-05 Yazbek.indd 353
4/20/2011 2:30:21 PM