Acetabular Labral Tears and Hip Scope Rehab Webinar Handout

Labral
tear and hip

arthroscopy
An outline of surgery and post-operative physiotherapy
Nichole Hamilton
www.synergyphysio.com.au
Copyright N Hamilton 2015
Summary
● What can contributes to labral tear and anterior hip
impingement biomechanically? Discussed last lecture
● What contributes to impingement and labral tear
structurally?
● Prevalence, signs and symptoms of labral tear
● How to test for labral tear
● Surgical management of labral tear
● Post-operative rehabilitation and exercise prescription
to improve hip centring and motor control
2
Acetabular Labrum
● Fibrocartilage, mostly
triangular
● Length 4-7 mm (longer ant-
sup)
● Attachment to bone via
zone of calcified cartilage
● Continuous with transverse
acetabular lig
● Relatively avascular
● Innervated
● Anterior-superior tears
most common
Labral Tear- Mechanism of Injury
1) Trauma (twisting sports, falls)

2) Repetitive microtrauma on
anterior- superior labrum with
biomechanical dysfunction
3) Abnormal hip or acetabular
morphology contributing to
femoral-acetabular impingement
(compressive)
Ganz, Parvizi, Beck et al 2003
4
FAI- Cam and Pincer (Lavigne et al 2004)
● Loss of IR ROM evident
especially with hip flexed.
● Bony end feel
● CAM deformity more
common in men
● CAM and Pincer (abnormal
bony morphology) does not
mean you have
symptomatic FAI
 
femoral head neck offset
Head-neck
offset
Loss of IR in hip flexion

Tannast, M. et al. Am. J. Roentgenol. 2007;188:1540-1552
Primal pictures
6
Cam impingements normal head-neck offset
Decreased femoral head–neck offset (OS‘)

Schematic (left) and radiographic (right)

presentations of focal anterior overcoverage
8
Hip Dysplasia
Acetabular Labral Tears

● Most common cause of mechanical hip symptoms
● Females more common than males
● Anterior superior most common
● All ages, increasing with age related changes
● Poorly defined injury rather than specific trauma more
common (up to 74%) (Santori & Villar, 2000)
10
“Clinical Presentation of Patients with
Tears of the Acetabular Labrum”- Retrospective
Study JBJS
66 Hips records reviewed retrospectively-

● 92% presented with groin pain
● 86% describe sharp pain, 80 % dull pain
● 71% female
● 61% insidious onset
● 89% describe mechanical locking
● 91% describe activity related pain (pivoting, walking)
● 92% tears anterior or ant-sup
Stephen, Burnett, Della Rocca et al (2006)
11
Tests for Labral Tear

● MRI (36% accurate), MRa (91% accurate. Czerny et

al 1996),
● MRI= MRA (Yoon, 2007)

● Q or flexion/add/IR

(75 % sens, 43% spec, Narvani et al 2003)
● F/Abd/ER (Byrd et al 2005, Mitchell et al 2003))

● Subjective history- clicking
sensation (100% sens, 85% specific predictor.
Narvani et al 2003)
12
Patient Presentation
● Description of Pain
● Location of Pain
?
● Agg Factors
● Clues
● Differential Dx
● Tests
● Further Investigation
13
Conservative management?
Acute trauma vs biomechanical dysfunction vs structure
Address underlying biomechanical cause for anterior
hip load including:
❖ Daily habits that load the anterior hip (posture)
❖ Underlying patterns of hip overload in foot, pelvis or
thorax
❖ Muscle imbalance in the hip, manual therapy to areas
of hypertonicity and functional strengthening for areas
of deficiency: common patterns
14
Surgical management: 
Hip Arthroscopy
● Lateral and Anterolateral Portals

● GA
● Traction Table
● Image Intensifier
● Day only or overnight
● Potential Complications
15
16
17
18
19
FAI: Surgical management

● CAM Impingement
● Pincer Impingement
(Ref: Dr Damian Griffin)
20
Indications for Arthroscopic Hip Surgery
● Symptomatic labral tears not responding to

conservative management 3-6 months
● Positive Pain Provocation/MRI
● Symptomatic FAI
● Loose bodies/Post-traumatic
21
Contra-Indications & Precautions

for surgery
● The immature skeleton (precaution)
● The Aging Skeleton (precaution)
● Early OA- in the presence of subchondral cysts and bone oedema
inferior outcomes (Krych et al 2015)
● Established Arthritis (CI)
● Asymptomatic FAI- lack of evidence to prevent OA
● Dysplasia
● Borderline Dysplasia- Portal cut IF lig and can result in increased
FH translation (Dr Marc Safran), surgery that best preserves the
labrum and closes the capsule preferable to restore passive
stability (Domb et al 2013)
22
Post-Op Summary and Rehab
Phase one: Weeks 1 and 2
Restore gait, ROM within tolerance, start stability training
Phase two: Weeks 3-6
Address contributing factors to labral tear, increase stability
training to include functional gluts control
Phase Three: Weeks 6-12
Increase proprioception, increase glut challenges, return to
sport
CONSERVATIVE MANAGEMENT OR PREOP: START
FROM PHASE TWO!
23
Phase One
● Reduce swelling and pain
● Regain ROM within
tolerance
● Restore normal gait pattern
● Restore normal standing
and sitting postural
alignment- mirrors help
● Start basic activation
exercises of inner unit
24
Exercise Rehab-Phase one 
Inner Unit Control
● Basic core/inner unit activation: (transversus,
pelvic floor, multifidis) Watch for individual
compensation strategies (eg.EO or butt grip). Try
shoelace analogy- gentle force in correct location.
Not too little, not too much!
● Basic QF activation: QF ISM hold in sidelying
● Basic Deep Hip flexor activation: Supine
● Inner Unit with Hip Movements: Supine: basic
core activation with controlled hip movements,
(closed chain preferably)
25
Inner Hip Control Supine

● Cue to allow femoral head to
“sink” into acetabulum, with
core engaged
● Palpate TFL/rectus to ensure
not overactive as lifting foot
off floor to flex hip in
comfortable range
● Progress to hip flexion and
extension with cues to
maintain connection of
femur into acetabulum
26
Phase One-Two Exercise Rehab
Functional Inner Unit
Squats with core
activation and hip
centred- not too deep
Emphasis on low load and
high reps to retrain motor
control
Watch gripping strategy
(toes, butt, thorax)
27
Phase Two:- Weeks 3-6

Start addressing any factors that may have
contributed to labral tear;
● Lumbar Spine/SIJ
● Thorax
● Foot/lower limb chain
● Hip stability/ motor control
28
Pathways to Labral Tear- Clinical
Observations
● Thorax posterior ● Articular SIJ or lumbar
● Hypermobility or long dysfunction and/or
inhibited psoas ● Poor motor control strategy
● Reduced hip stability & ● Hypertonic posterior hip
motor control
● Restricted posterior hip glide
● Increased translation
during flexion
femoral head in extension
● Increased load anterior hip ● Anterior hip impingement
structures compressive with flexion
Labral Tear
29
Phase two manual therapy

● Assessed on individual basis
● For hip: STR to individual areas of hypertonicity could
include TFL/ITB, piriformis, OI, hamstrings
● For posterior thorax, rigid thorax or asymmetric
thoracic rotation that might be a contributing factor:
STR, joint mobilisation, home stretches, breathwork
● For SIJ: STR to areas of joint compression
● For foot: STR to forefoot, mid or rearfoot, joint
mobilisation, home ball rolling.
30
Phase Two Exercise Rehabilitation
● Dynamic QF
progressions with
core control
● Dynamic closed
chain deep hip
flexor activation
31
Phase Two Exercise Rehabilitation
● Open chain gluteal work more likely to recruit TFL- closed chain preferable
● Functional inner unit introducing gluts control (quarter and half squats with
weight transfer)
● Lunges (split squats) with accurate core activation. Watch for foot, knee and
hip alignment
● Increase challenges with weight transfer including toe taps, step ups, steps
downs, crab walk (trunk flexed to encourage gluteal activation- Berry et al 2015)
● Utilise theraband to encourage gluts activation with squats, lunges, crab walk
32
Phase Three Rehabilitation
● Addition of air cushion or spin discs to squats and lunges

and include theraband and weights
● Addition of balance work, progressing to air cushion
33
Phase Four- 12 weeks onward
● Improve functional gluts strength and endurance with

increased single leg challenges, maintaining inner unit
● Sports specific training and return to sport
34
35
Summary Post-Op
● Phase 1: Check plumb line, check gait, inner unit
activation, ism QF, gentle hip ROM with centered hip
● Phase 2: Check LS & SIJ,TS and Lower Limb- manual
therapy if required. Check hip recruitment patterns. Is
there dominance in TFL? Rectus? OI? Piri? Hs?
Increase functional QF and gluts exercises:- lunges,
weight transfer, step ups.
● Phase 3: Continue manual therapy. Increase balance
and proprioception. Sports specific ideas.
36
Hip Pain
Psychol, Articular
Posture, Lumbar Thorax? Motor
Emotions, Structural
Daily Habits Spine, Pelvis Lower Limb? Control
Beliefs changes?
37
Thank you
I hope the ideas presented have helped in understanding
the hip is a complex area, and needs to be assessed on a very
individual basis.
Addressing each individuals cause for anterior hip overload

is essential in recovery. This means more than local hip
control, but also addressing daily habits, postures in life and
sport, other joints in the chain and your patients psychology
and beliefs to ensure optimum return to patient goals
Nichole Hamilton
www.synergyphysio.com.au
38
References
● Domb B, Phillipon M, Giodano B (2013) Arthroscopic capsulotomy, capsular repair, and capsular
plication of the hip: relation to atraumatic instability. Arthroscopy 2013 Jan;29(1):162-73.
● Domb B, Stake C, Linder D, El-bitar Y, Jackson T (2013) Arthroscopic capsular plication and labral
preservation in borderline hip dysplasia: two-year clinical outcomes of a surgical approach to a
challenging problem. Am J Sports Med 2013 Nov;41(11):2591-8.
● Ellison JB, Rose SJ, Sahrmann SA 1990 Patterns of hip rotation range of motion: a comparison between
healthy subjects and patients with low back pain. Physical Therapy 70(9): 537-41
● Ganz R, Parvvizi J, Beck M etal (2003) Femoralacetabular impingement: a cause for osteoarthritis in
the hip. Clin Orthop 417: 112-120
● Grimaldi A (2006) Dynamic Stabilisation of the Hip and Pelvis: The Importance of Specificity in
Maximising Stability. Evening Lecture Series.
● Grimaldi A, RichardsonC Stanton W etal (2009) The association between degenerative hip joint
pathology and size of the gluteus maximus and tensor fascia lata muscles. Manual Therapy 14:605-10
● Harding L, Barbe M, Shepard K, Marks A, Ajai R, Lardiere J, Sweringa H 2003 Posterior-anterior glide
of the femoral head in the acetabulum: a cadaver study. Journal of Orthopaedic and Sports Physical
Therapy 33(3)
● Hatton A, Kemp J, Brauer S, Clark R, Crossley K (2014) Impairment of Dynamic Single Leg Balance
Performance in Individuals with Hip Chondropathy. Arth Care and Research 66 (5) 709-716
39
References
● Lewis CL Sahrmann SA (2009) Effect of Position and alteration in synergist muscle
force contribution on hip forces when performing hip strengthening exercises.
Clinical Biomechanics 24(1): 35-42 Jan
● Krych A, King A, Berardelli R, Sousa P, Levy B (2016) Is Subchondral Acetabular Edema or
Cystic Change on MRI a Contraindication for Hip Arthroscopy in Patients With
Femoroacetabular Impingement? Am Jour Sports Med Feb;44(2):454-9.
● Lewis CL, Sahrmann SA, Moran DW (2007) Anterior Hip Joint Forces Increases with Hip
Extension, Decreased Gluteal Force, or Decreased Iliopsoas Force. J Biomech 40(16):
3725-3731
● Sahrmann S 2003. Proceedings of the MACP AGM. The Hip and Groin: A Neglected
Region. Movement impairment syndromes of the hip.
● Seldes R, Tan V, Hunt J, Katz M, Winiarsky R, Fitzgerald R 2001 Anatomy, Histologic
Features, and Vascularity of the Adult Acetabular Labrum. Clinical Orthopaedics 382:
232-240.
● Pirouzi, Soraya MS; Hides, J; Richardson C; Darnell, R; Toppenberg, R 2006 Low Back Pain
Patients Demonstrate Increased Hip Extensor Muscle Activity During Standardized
Submaximal Rotation Efforts Spine. 31(26):E999-E1005, December 15
● Wall P, Fernandez M, griffin D, Foster N. Nonoperative treatment for femoroacetabular
impingement: a systematic review of the literature. PM R. 2013 May;5(5):418-26..
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Labral

tear and hip

Copyright N Hamilton 2015

Copyright N Hamilton 2015

Copyright N Hamilton 2015

Labral Tear- Mechanism of Injury

1) Trauma (twisting sports, falls)

Copyright N Hamilton 2015

Copyright N Hamilton 2015

Loss of IR in hip flexion

Decreased femoral head–neck offset (OS‘)

Schematic (left) and radiographic (right)

Tannast, M. et al. Am. J. Roentgenol. 2007;188:1540-1552

Copyright N Hamilton 2015

Copyright N Hamilton 2015