Labral Tear of the Hip Joint

Hip joint is a joint form by head of femur and acetabulum of hip bone. The head of femur seats within socket of acetabulum. The head of femur is tightly placed within acetabulum by form grip of circular cartilaginous covering known as labrum and several ligaments attached to acetabulum and neck of femur. The ligaments are tough fibrous connective tissue. The internal surface of acetabulum is covered with tough cartilage. Ball shape head of femur is attached to neck of femur that protrudes at angle from body of femur. The femur is also known as thigh bone. Socket or acetabulum is a part of hip bone also known as ilium. Inner surface of socket is covered by smooth cartilages. The rim of cartilage protrudes outside the rim and known as labrum. Labrum holds femur bone. The labrum and ligaments are responsible for increasing the stability of the joint and firm anchoring of head into socket.^[1]

The joint is filled with synovial fluid. Synovial fluid lubricates the joint and with joint cartilage act as a shock absorber. The synovial fluid is continuously secreted as well as absorbed.^[2] The cartilage extends outside acetabulum known as labrum and holds the neck of femur. Labrum absorbs the impact caused by head of femur during activities and movement of head of femur. Upper body weight is transmitted through the hip joint to lower leg. The healthy labrum is essential to allow smooth rotational movements of head of femur in all direction within acetabulum as well as weight transmission. The direct impact as well as abnormal twist and turn of hip joint causes labral tear of the hip joint. A labral tear of the hip is characterized by partial or complete tear. Labral tear may involve ligamental tear or dislocation. Labral tear may extend through the joint cartilage.^[3]

A labral tear of the hip is very common in individuals who regularly participate in contact sports such as football, rugby, soccer, ice hockey, and basketball. The labral tear is also observed in individual who participate in noncontact sports like ballet, golf and snow skiing. In some cases, degenerative structural abnormalities of the hip and joint cartilages causes tearing of the hip labrum. A labral tear of the hip may also occur while running long distance, impact by moving object and impact caused by fall.^[4]

Penetrating or blunt impact of hip joint caused by motor vehicle accident also causes labral tear. Repeated activities result in overuse of joint. Risk of labral tear is increased in individual who are involved in repeated joint activities and simultaneous weight transmission. Repeated actions resulting in labral tear is observed in participants of long distance running, excessive kicking such as football, martial arts and cycling. Older individuals suffering with degenerative hip joint disease may developed sudden labral tear of the hip even with relatively trivial movements of hip joint.

Lack of coordination- Most activities involving hip joint needs excellent coordination between flexor, extensor, adductor and abductor muscles. Abnormal coordination is observed in individual suffering with malnourishment, generalized weakness, neurological disorders and following excessive activities. Patient suffering with lack of coordination of leg muscle has tendency to fall and twist leg that may result in labral tear.

Prior Injury- Individual recovering from prior injuries of lower extremity often sustained weakness in leg muscle. Patient suffering with leg muscle injury may sustained residual pain. Muscle stiffness or weakness and pain may cause postural deformity and abnormal ambulation. In few cases wrong twist and turn of hip joint as well as fall can cause labral tear.

Joint Stiffness- Joint stiffness is observed in few individual following prolonged illness. Lack of exercise or staying in bed or chair for prolong period can cause hip joint stiffness. Patient suffering with hip joint stiffness can fall or twist hip joint in wrong direction resulting labral tear.

Weakness in the muscles- Individual suffering with unilateral muscle weakness (polio) or bilateral muscle weakness of lower leg has tendency to fall or twist lower leg. Direct impact causes labral tear of outer surface of hip joint. Twist of lower leg causes abnormal pull of leg and stress on hip joint. Individual following forceful twist may sustain dislocation of hip joint or liberal tear.

Improper technique- Professional athletes are vigorously trained prior to participation of sporting activities. Labral tear is often seen in professional athletes who are not adequately trained and participate in professional or semiprofessional sports activities like soccer, football, basketball, wrestling and long distance.

Poor biomechanics of lower leg- Anatomical congenital abnormalities or improper healing of fracture or dislocation causes poor biomechanics of one or both legs. The deformity like scoliosis, short leg and limping gait causes poor biomechanics of lower leg. Poor biomechanics causes tripping and loss of balance. Fall or twist of leg causes labral tear in patient suffering with malnourishment, osteoporotic disease or generalized muscle weaknesses.

Extreme training- Labral fracture is observed in certain young healthy population who are undergoing extreme training when enrolled in army, law enforcement and professional sport.

Inappropriate footwear – Footwear should be properly fitting. Loose fitting shoes or slippers can cause slip, tripping and fall resulting in labral fracture.

Inadequate warm up- Most armature and professional athletes warm up prior to beginning of the game. Inadequate warming may cause poor tone and coordination of leg muscles. Contact and race to finish often causes tripping and fall results in Labral fracture.

Overweight– Obese or overweight patient often has a tendency to trip or fall. Fall over the hip joint causes labral fracture.^[5]

Neurological disorder- Individual suffering with cerebral palsy or Parkinson’s disease occasionally loose balance and fall. Frequent fall or fall resulting in impact over hip joint causes Labral Fracture.

Work accident– Manual work involves repetitive action, heavy weight lifting as well as twist and turn. Exaggeration of any of these action can cause labral tear in few cases. Manual worker may get hit by a moving solid object while at work, such impact also can cause labral Tear.

Auto accident– Car accident may cause head on or side impact. Chances of injury of hip joint or labrum is rare if driver or passenger is wearing seat belt. Penetrating or blunt injury of hip joint can caused labral tear.

Contact sports– Contact sport like American football, rugby, European football (soccer), basketball and wrestling often causes severe impact over hip joint that may cause labral tear.

Domestic fall- Hip injury and labral tear is seen in few domestic fall. Tripping over the carpet and staircase causes fall. Fall over the hip joint and obesity can cause severe injury and result in labral tear.

Twisting and repetitive movement- Twisting of hip joint and pelvis is common among professional dancers, golfer and manual worker. Loss of balance and concentration can cause loss of coordination between flexor and extensor muscles or abductor and adductor muscles. The lack of coordination, wrong twist and turn as well as fall can cause labral tear in golfer, dancer, manual worker and cleaners. Repetitive movement of pelvis and hip joint is also observed among martial art exercises, runner and individual participates in long distance cycling.

A labral tear of the hip is associated with abrupt catching sensation of sharp pain that is located over the hip joint. Occasional mild symptoms become severe pain when individuals continue participation in sports and manual work that needs repetitive movements. Patient suffering with osteoporosis and chronic progressive bone diseases may develop labral tear with minimum stress of hip joint. A detail history and complete examination is performed to diagnose labral tear of the hip joint. History of injury, history of past illnesses, history of medications, past surgeries and examination are considered subjective test.^[6]

Pain- Immediately following injuries severe intractable pain is felt in the groin and hip. Character of pain is burning and stabbing pain. Pain intensity increases when individual tries to move leg at hip joint on affected side.

Locking sound- Examination of hip joint is often difficult because of severe pain. Patient is uncooperative since pain intensity increases with movement of leg. Patient is given adequate NSAIDs or opioid for pain relief. Hip joint examination is performed after adequate pain relief. One of the sign observed is locking or clicking of hip joint when abduction, adduction, flexion and extension movement are attempted.

Joint Stiffness- Hip joint become stiff because of pain. Hip joint stiffness is caused by continuous contraction of muscles that supports hip joint movements. Continuous muscle contraction (muscle spasm) prevents any movement of the joint that may provoke pain.

Limited range of motion- The pain caused by labral tear restricts movement of head of femur within acetabulum. Patient voluntarily and involuntarily restricts the movement of the leg and hip joint. Limited range of movement continues until patient feels adequate pain relief.

Objective test includes radiological studies and lab studies. The most significant test for diagnosis of labrum tear are as follows-

WBC count is increased during infection. WBC study is performed if pain continues when NSAIDs and physical therapy fails to relieve pain. Inflammation and trauma may cause infection of cartilage and joint.

Radiological examination included X-Ray, CT Scan and MRI studies. Radiological studies are performed to rule out fracture and dislocation of hip joint. MRI and CT scan may show loose fragments and labrum fracture.

Ultrasound Study- Ultrasound probe is used to visualize hip joint and surrounding tissue. Examination shows the tissue swelling, blood clots and fragment.

Arthroscopy– Arthroscopy is performed when pain continues and finding of radiological examination are not conclusive. Arthroscopy is performed by using tubular tiny camera known as arthroscope. The camera is passed through skin into joint. The images are magnified and seen on television screen.^[7]

Treatment options of labral tear of the hip joint usually depends upon the severity. Conservative treatments help some patients to recover in few weeks whereas others may be treated with arthroscopic surgery to remove fragments of cartilages or repair the torn area of the labrum.

1. Medications: Labrum tear causes inflammation within the injured cartilage and capsule. Inflamed tissue secretes several chemicals like prostaglandin, histamine and bradykinin. Prostaglandin irritates pain receptors and pain carrying nerve fibers. Pain caused by inflammation is known as nociceptive pain and often moderate to severe in character.

   1. Nonsteroidal anti-inflammatory drugs (NSAIDs)- Pain and tissue inflammation caused by labral tear responds to treatment of Nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen and ibuprofen. NSAIDs not only help in relieve pain, but also decreases inflammation.
   2. Opioids- Opioids are prescribed for severe pain that is not responding to NSAIDs. Opioid treatment is preferably continued for 2 to 3 weeks. Opioid dependence and addiction is often seen if opioid medication is prescribed for longer than 3 to 4 weeks.

2. Antibiotics– In few cases infection may follow the initial inflammation when injury is ignored and appropriate treatment is not provided. Preventive antibiotics are prescribed if patient is suffering with pain, fever and increased white blood cell count. Infection is not common following labrum tear.

3. Corticosteroid Injection- Corticosteroids are anti-inflammatory and helps to relieve pain as well as inflammation when injected near or over the inflammatory tissue. Procedure is performed in surgical center under aseptic surrounding. Needle is place near the tear labrum of hip joint using X-Ray or ultrasound. Patient may be given mild sedation if pain is severe. Corticosteroid is injected around the torn labrum of hip joint directly following needle placement. Procedure helps to relieve pain immediately and also helps to treat inflammation.^[9]

4. Physical Therapy: Physical therapy for labral tear of the hip joint is important in speeding up the healing process. Physical therapy also decreases the likelihood of recurrences of pain in the future. Physical therapy helps to heal wound faster when inflammation is simultaneously treated with NSAIDs. Physical therapy prevents joint stiffness and improves joint mobility. Physical therapy includes most of the following treatment options:

   1. Massage Therapy– Massage therapy improves circulation, tone of the muscles, body immunity and joint mobility. Massage therapy is mostly focus over gluteal and hip joint muscles. Massage is performed twice a week. Initial few courses are mostly performed to treat superficial muscles and joint movements. Later deep massage therapy is performed to treat deeper muscles, joint tendon and ligaments.
   2. Cold and Heat Therapy- Cold therapy involves application of ice over the wounded area immediately following accident. The initial cold therapy immediately following injury helps to control bleeding. Cold therapy also helps to control mild to moderate pain during healing phase. Cold therapy causes vasoconstriction and reduces inflammatory tissue edema. Heat therapy is effective after wound is healed but pain continues. Heat therapy improves circulation around the wounded area and removes metabolites and chemicals like prostaglandin.
   3. Electrotherapy- Electrotherapy is performed to treat moderate and severe pain. Electrotherapy passes signals to spinal cord so pain impulses are blocked from transmitting to brain. There are several electrotherapies are recommended. Most scientific published study suggests transcutaneous electrical nerve stimulation (TENS) is useful to treat pain caused by inflammatory reaction following deep tissue injury. Other electrical therapy tried for chronic pain are Percutaneous electrical nerve stimulation (PENS), Electrical muscle stimulation (EMS), Interferential current (IFC), Pulsed electromagnetic field therapy (PEMF) and Galvanic stimulation (GS).
   4. Joint mobilization- Joint therapy includes active and passive joint movements. The joint movement is assisted by physical therapist to achieve optimum range of movement when individual is suffering with stiff joint. Patient is trained to performed joint mobilization exercises after completion of therapy at home.
   5. Joint Stretches- Physical therapist teaches patient various joint stretching exercises. Supervise joint stretching helps to prevent joint stiffness. Training of proper stretching is essential to prevent overstretching as well as wrong twist and turn of the joint.
   6. Dry needling– Dry needing is used instead cortisone injection in few cases. Irritation of muscles and subcutaneous tissue by dry needling helps to control pain. Dry needling triggers local endogenous peptide secretion. These peptide helps to relieve pain caused by irritation of pain receptors and sensory fibers.
   7. Biomechanical correction- Pain and muscle spasm often causes biomechanical problems. Patient may prefer to use certain group of muscles and avoid muscles that are causing pain. Physical therapist will evaluate the muscles that may need to be treated with massage and exercises. Crutches, cane or wheel chair is advised accordingly for ambulation. Patient is also advised to change or modify posture according to biomechanical problems.
   8. Hydrotherapy. Hydrotherapy treatment is performed under water. Hydrotherapy treatment includes underwater exercise of hip joint, water jet therapy over the hip joint, underwater massages and mineral bath. Water therapy is performed in indoor swimming pool or Jacuzzi. Hydrotherapy is also known as aquatic therapy. The treatment improves blood supply to the injure area by causing vasodilation. Vasodilation helps to reduce inflammation and remove metabolites that irritates the pain receptors and sensory fibers.
   9. Rehab therapy- Once the wound is healed and all treatment options are tired then patient is advised to consider rehab therapy. Rehab therapy will consider activity modification and some changes at home or work to accommodate patient’s need like special chairs, working tables and space to get in out of rooms or office. Patient is advised to consider appropriate weight loss with diet control.

5. Surgical intervention- Surgery is considered if NSAIDs, cortisone injection and physical therapy fails to relieve pain and inflammation. Non-surgical treatments are tried for 6 to 12 weeks. If pain continues after 8 to 12 weeks in spite of all non-surgical treatment, then diagnostic endoscopy is performed. In most cases, during diagnostic endoscopy certain causes of pain are treated with endoscopic surgery, like repair of labral tear and removal fragments of labral cartilages. Thus, choice of surgical treatment is open surgery or endoscopic (arthroscopy) surgery. Arthroscopic and open surgeries are performed under local anesthesia and sedation. Most patients recover within four to six weeks after the surgery.

   1. Endoscopic surgery- The endoscopic surgery involves 2 or 3 small skin incision of ½ cm or smaller. Following first skin incision, long tubular fiber optic camera is passed through the incision and slowly directed to hip joint guided by X-Ray or ultrasound. Once the camera is placed in or close to the joint, surgeon can actually see magnified images of the joint and damages of the cartilage. The images are projected over large television screen. Second skin incision is taken to insert surgical instruments. Surgery is performed to remove fragments of labrum (cartilages), repair tear of ligament and fracture labrum. Images of instruments and surgical field are observed over large television. Endoscopic surgery is performed under small incision.
   2. Open surgical procedure- Few labral tears are difficult to approach using endoscopy because of position of injured cartilage relation to the joint. Such cases may not be suitable for endoscopic surgery. In such cases open surgical procedure is performed. Open surgical procedure involves long and extended incision of skin that is extended into subcutaneous tissue, muscles and joint capsule. Sometime surgeon may use microscope or telescopic glasses to magnify the surgical field. The incision is extended to hip joint. Surgery involves removal of loose fragment of cartilages, repair of ligamental tear, correct tendon dislocation and repair labrum fracture under direct vision.

6. Exercises to prevent joint stiffness and improve joint mobility- Exercises described below helps to prevent permanent joint stiffness and fast recovery to near normal activities. The following exercises are not alternative therapy for physical therapy. Exercises performed during physical therapy sessions are supervised exercises.

1. Hip Flexion Exercise for Labral Tear of the Hip Joint:

   This exercise is performed in supine position. Lie down on back and keep both leg extended at hip and knee joint with heel touching the ground. Now gradually bring affected leg flex at hip and knee joint towards the chest as far as possible until a mild to moderate pain is felt in affected hip. Few individuals may not feel any pain that suggests scarring or muscle spasm is not significant. Slowly return the leg back to the initial position. Perform the exercise 10 to 20 times each side ensuring there is no exacerbation of the symptoms.

   

2. Hip Abduction Exercise for Labral Tear of the Hip Joint:

   This exercise is performed by lying down on back. Both the legs laid flat on exercise bed keeping the knee in a straight position. While breathing deep move the leg sideways as far as possible until a mild to moderate pain is felt at hip joint then return the leg back to the initial position. Make sure that the toes and the knee cap is facing the ceiling while performing this exercise. Perform the exercise 10 to 20 times on each side ensuring there is no exacerbation of symptoms.^[10]

   

3. Hip External Rotation Exercise for Labral Tear of the Hip Joint

   This exercise is performed by lying down on the back with foot flat on ground and knee bent. Now move the knee sideways away from body as far as possible until a mild to moderate pain is felt while stretching hip joint. Carefully return the feet and knee back to the initial position. Perform the test 10 to 20 times on each side if there is no significant pain or there is no exacerbation of symptoms.

   

   Please see physician if you have any of above discussed symptoms or sign, do not try over the counter medication unless the diagnosis is determined and medication is advised by physician.

References:

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