|
|
acetabular labral tears
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
acetabular labral tears - March 4, 2005 10:38:00 AM
|
|
|
bonmar
Posts: 137
Joined: August 15, 2000
From: Boston, MA
Status: offline
|
I saw a patient for the first time today. HPI includes severe hip/groin/buttock pain for the past 6 months. The pt is a 33 yo, active, mother who was walking on the beach last summer and her left leg got suddenly painful and gave away. There has been no resolution of her problems since that time. She has had gyn issues (removal of an ovarian cyst, right, 11/04). She states that after the sx to remove the cyst, her left hip felt great for 2 wks (she was basically NWB at that time)but the pain resumed once she was up and about again. Her gyn thought her hip pain (on the left) would resolve with the removal of her right ovarian cyst.
Presently, she is unable to get up from sitting while wt bearing on her left leg w/o significant pain and giving out. When her leg does give out, she experiences tingling into her thigh. Hip xrays were normal. She also experiences clicking in her left hip. Passive ROM reveals extreme pain with flexion past 90 degrees, and less pain (but painful still) with IR/ER equally as well as abduction and extension. No LBP or reproduction of pain with passive LB ROM. She is extremely tender on the lateral to anterior hip joint region.
I spoke to the patient's primary care MD re: ? acetabular labral tear. He is ordering an MRI next week.
From my understanding and from experience in the past with a pt with an hip labral tear, MRI is not always conclusive.
Research that I have done states patients with hip labral tears can get better with PT. My only other experience was a patient who underwent a hip scope with repair of the labral tears. She did rehab nicely once the repair was done.
Does anyone have any experience with this? Any other insight into this problem?
Thanx in advance, Bonnie
|
|
|
|
|
Re: acetabular labral tears - March 4, 2005 12:16:00 PM
|
|
|
ericm
Posts: 171
Joined: March 13, 2003
From: Nanaimo, BC
Status: offline
|
In my only experience with a labral tear, the patients MRI was negative. The tear was only detected during the scope. While the tear was repairable in this case, the forces involved in tearing the labrum also resulted in joint surface damage. I'm afraid I didn't get very far with that patient but that may have been due to overwhelming psychosocial issues in this guys life at that time. good luck.
eric
|
|
|
|
|
Re: acetabular labral tears - March 4, 2005 1:33:00 PM
|
|
|
PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
I have a lot of experience in the area, as some of the leading surgeons in this field have been from the Pittsburgh area.
Unfortunately, even a wonderful article published here in the Pittsburgh Orthopaedic Journal, by surgoen Marc Phillipon, indicates you often have to go by gut feel....."if it smells like a rat, looks like a rat"
Check FABER position, MMT painful for hip flexion, pain with passive hip IR/flexion/adduction. As you guys mention, standard MRI will most likely be negative. MR arthrography is the one with the highest sensitivity and specificity at detecting chondral lesions of the hip.
One must also rule out lower abdominal tear/injury. It can be researched more by reading:
MANAGEMENT OF SEVERE LOWER ABDOMINAL OR INGUINAL PAIN IN HIGH PERFORMANCE ATHLETES. The American Journal of Sports Medicine, Vol. 28, No. 1, 2000.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: acetabular labral tears - March 4, 2005 2:20:00 PM
|
|
|
bonmar
Posts: 137
Joined: August 15, 2000
From: Boston, MA
Status: offline
|
Thank you both for the replies.
John, I agree with the "rat" statement. My gut today was telling me there is something more than just a hip "sprain".
Due to the mechanism of injury (if that is what you want to call it....walking on a beach and sudden leg pain/giving out) or lack of, I do not feel this patient has an abdominal tear. I am questioning if while walking on the sand, she just stepped and twisted the "wrong" way thereby tearing the labrum.
I have also treated patients (although few) with abdominal tears and this pt is not presenting the same.
I have this patient(with the hip problem) on hold until MRI results come in. I did speak to the MD (primary) and he did not have any experience with labral tears. I did tell him that from my research, they were difficult to diagnose and often times not viewed with MRI results. He agreed that he would refer this patient to an ortho in Boston who I know specializes in hips/hip scopes when the results of the MRI come in.
John, have you treated pts with hip labral tears that did not require sx? What was your treatment/success?
Thank you, Bonnie
|
|
|
|
|
Re: acetabular labral tears - March 4, 2005 3:32:00 PM
|
|
|
eam
Posts: 293
Joined: February 5, 2004
From: New York, NY 10028
Status: offline
|
Bonnie-
Labral tears can be tricky. I have a couple of patients right now with "diagnosed" labral tears and are doing well with PT. I also had a patient who had a diagnosed tear on MRI (without contrast) and they went in and scoped him and found nothing. As John mentioned, pain on flex,add will be a sign. Depending on the presentation, they can do well with PT. I have found some of the Sahrmann corrective exercises (quadruped sit backs, passive hip flexion, etc ) helpful with these types of patients in addition to mobilization. One of the referring physicians I spoke with, thinks it is a red herring and wants to try PT first. Also, I have a couple of patients right now with significant restrictions in IR (young -labral tears on MR) and am finding it difficult to maintain carryover of IR to the next treatment session. I have done traditional mobs, Mulligan, more belt mobs, frustrating to say the least.
You can try a few other types of assessment techniques in addition to the FABER etc. For example, try having them sit back on their heels and see if there is less hip flexion and/or pain on the involved side. If so, have them abduct and ER that side and see if it symptoms are better.
If so, give that to them as a home exercise program. Just my thoughts, good luck!
Erica
|
|
|
|
|
Re: acetabular labral tears - March 4, 2005 3:43:00 PM
|
|
|
bonmar
Posts: 137
Joined: August 15, 2000
From: Boston, MA
Status: offline
|
Thanx so much Erica. That was just what I was looking for! I was wondering if people do get better often without surgical intervention.
I am not familiar with Sahrmann exercises, however. Are they the quadraped sit backs, passive hip flexion exercises that you are referring to in your post?
Keep me posted on anything more you may have found helpful in your treatments. The above examples are a great start. Bonnie
|
|
|
|
|
Re: acetabular labral tears - March 5, 2005 12:53:00 AM
|
|
|
PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Well, the "success" of the PT program depends on how we view "success". If it means relieving the pain your patinet is experiencing and getting them back to some function, yes, PT can work. Most of my cases involved higher level athletes, and their goals were pretty high. I was almost always able to relieve their initial pain/symtoms and restore close to normal motion/strength. However, return to aggressive activity always had some issues...some minor, some more severe.
Where the labral injury has occurred also helps predict future problems. This was another nice article I had once read:
THE WATERSHED LABRAL LESION: ITS RELATIONSHIP WITH EARLY ARTHRITIS OF THE HIP. The Journal of Arthroplasty, Vol. 16, No.8, Suppl. 1, December 2001.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: acetabular labral tears - March 5, 2005 1:25:00 AM
|
|
|
bonmar
Posts: 137
Joined: August 15, 2000
From: Boston, MA
Status: offline
|
Thank you, John. I read the abstract of the above mentioned article as well as others. Based on the research and the difficulty in diagnosing labral tears, I would think early intervention would assist in the delay of arthritis. (Interestingly enough, Dr. J. McCarthy is the surgeon I recommended for follow up to the primary MD for this particular patient.)
I have been practicing PT for 20 years now and have only, knowingly, come across 1 labral tear prior to this patient. It appears more common than I originally thought.
I have put this pt on hold until we have the results of the MRI. I am wondering if I acted in haste and should be treating her. I do have to say that she is in significant pain and cannot weight bear fully. Any thoughts on this?
Thanx, Bonnie
|
|
|
|
|
Re: acetabular labral tears - March 6, 2005 7:14:00 AM
|
|
|
Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
Status: offline
|
Bonnie, how hard did you look at the lumbar spine? If you are not getting anywhere with the hip I would certainly start treating the lumbar spine. Good luck, keep us posted.
_____________________________
Alex Brenner, PT, MPT, OCS
|
|
|
|
|
Re: acetabular labral tears - March 6, 2005 1:47:00 PM
|
|
|
PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Consider unilateral hip distraction...if a fragment of labrum is pinched, you may free it. I have done a similar technique for a lot of knees with a flapped bucket handle tear. Some just re-flap again, others are able to progress with a normal program.
Also, make sure someone rules out AVN of the hip.
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: acetabular labral tears - March 6, 2005 2:14:00 PM
|
|
|
eam
Posts: 293
Joined: February 5, 2004
From: New York, NY 10028
Status: offline
|
Hi Bonnie-
The quadruped exercise I use is indeed sitting back on your heels. I find it very useful. Duffy's suggestion re: hip distraction is a good one as I find distraction (I use a belt) helpful as well. I have a nasty hip myself and as a patient the belt mobs feel great and have helped me personally. Sahrmann has some good prone hip extension and supine slr tests where you palpate the greater trochanter to monitor movement when you perform these tests. They make sense to me but in practice I find them difficult to do depending on the patient. Good luck!
I also just rec'd a new patient who as diagnosed labral tear on MR and wants to run the 1/2 marathon in London in May!
Erica
|
|
|
|
|
Re: acetabular labral tears - March 6, 2005 2:28:00 PM
|
|
|
coloradojulie
Posts: 413
Joined: November 10, 2002
From: colorado usa
Status: offline
|
Along the lines of the abdominal strain...check differential diagnosis for hernia...either inguinal or femoral. Also psoas abcesses can mimic these symptoms.
Given the gyn history and surgery could be connected. Has she seen an internist?
Does she have a left ovarian cyst? I don't think the referral pattern for pain would be to the contralateral side? Worth a check. The symtoms seem more serious than musculoskeletal...and the mechanism of injury is pretty light...
_____________________________
PRC
|
|
|
|
|
Re: acetabular labral tears - March 7, 2005 5:48:00 AM
|
|
|
bonmar
Posts: 137
Joined: August 15, 2000
From: Boston, MA
Status: offline
|
Thank you all for the replies...definitely helpful.
Duffy, I was not thinking along the lines of the labrum being "pinched", just torn. That is why distraction did not seem helpful to me at first. Also, I would think Mulligan techniques would assist as well. As far as AVN, I believe the xray would have shown abnormality...her hip xray was negative.
Army, I did not do a great clearing of the lumbar spine (A/P ROM only).If I do see her again and am still in the dark, I will certainly head in that direction.
Julie, her internist did check for hernias...that is what he thought it was, initially. He ordered an abd CT scan and subsequently found the right ovarian cyst. She does not have a cyst on the left ovary. Also, she was symptomatic prior to her sx.
I know I have written that I felt I may have acted in haste in not treating her until further testing but I realize from all these postings that I will stick with my original "gut" feeling. I do not often avoid treatment and I need to trust my intuitive sense on this one and hold off. The patient/MD will keep me posted on the results of the MRI (whatever they may be) and I will keep you all posted.
Thanx so much, Bonnie
|
|
|
|
|
Re: acetabular labral tears - March 11, 2005 2:37:00 AM
|
|
|
PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Bonnie and others:
For those interested in reading more about labral injuries and acetabular/anterior hip impingement, consider these articles:
SURGICAL TREATMENT OF FEMOROACETABULAR IMPINGEMENT: EVALUATION OR THE EFFECT OF THE SIZE OF THE RESECTION. Journal of Bone and Joint Surgery, Vol. 87-A, No. 2, February 2005.
Anterior Femoro-Acetabular Impingement Due to Acetabular Retroversion , Journal of Bone and Joint Surgery, February 2003.
The Young Adult With Hip Pain: Diagnosis and Medical Treatment, Circa 2004.
Clinical Orthopaedics & Related Research. (418):9-17, January 2004
Anterior Femoroacetabular Impingement: Part I. Techniques of Joint Preserving Surgery.
Clinical Orthopaedics & Related Research. (418):61-66, January 2004.
Anterior Femoroacetabular Impingement After Femoral Neck Fractures.
Journal of Orthopaedic Trauma. 15(7):475-481, September/October 2001.
HIP ARTHROSCOPY: CURRENT INDICATIONS, TREATMENT OPTIONS, AND MANAGEMENT ISSUES. The Pittsburgh Orthopaedic Journal, Vol. 15, 2004.
Each provides unique ideas/tips, and also provide additional sources to back reference for even more material. It appears this topic is becoming hot, and everybody is investigating deeper for treatment options.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: acetabular labral tears - March 11, 2005 10:04:00 AM
|
|
|
bonmar
Posts: 137
Joined: August 15, 2000
From: Boston, MA
Status: offline
|
Thank you so much, Duffy. I plan on reading these articles and passing any pertinent info onto the primary care MD. He just asked me for any info that may help him in diagnosing labral tears since this is something he is not very familiar with either. Bonnie
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.094
|
Printable Version
