This document describes the case of a 22-year-old collegiate male athlete who presented with a right hip labral tear. He reported a history of pain and paresthesia in his right hip exacerbated by internal rotation. MRI and radiographs did not reveal any abnormalities, but diagnostic arthroscopy confirmed a superior labral tear and synovitis. He underwent arthroscopic surgery and followed up with a rehabilitation program focusing on strengthening and functional activities. By 3 months post-op, he had fully recovered and was able to return to athletic activities with no pain or instability. The case demonstrates the importance of a thorough history and physical exam for hip injuries and limitations of diagnostic imaging for labral tears.
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Right Hip Labral Tear in a 22 Year-Old Collegiate Male
1. Right Hip Labral Tear In A 22
Year-Old Collegiate Male
Ruby L. Floyd, ATS
Jill A. Manners, MS, MPT, LAT, ATC, PT
Western Carolina University, Cullowhee, North Carolina
3. Case Background
22 year-old collegiate male, recreational athlete
Previous medical history
Falling off a horse and being dragged by his right leg
Current mechanism of injury:
Reaching forward in a seated position
4. Anatomical Review
Femoroacetabular Joint
Head of femur
Acetabulum
Joint Stability
Capsule
Ligaments
Acetabular labrum
The American Orthopaedic Society for Sports Medicine. Hip Arthroscopy. 2010.
http://orthoinfo.aaos.org/figures/A00571F01.jpg. Accessed March 7, 2012.
5. Blood Supply
Blood Supply
Artery to the head of the
femur
Medial and lateral femoral
circumflex arteries
Avascular Necrosis
Ellis H and Mahadevan V. Clinical Anatomy: Applied Anatomy for Students
and Junior Doctors.12th ed. West Sussex, UK: Wiley-Blackwell; 2010: 233.
6. Initial Clinical Evaluation
History
Complaints of:
Range of Motion
Passive Internal Rotation
Strength Testing
Radiating pain
Parethesia
Night pain
Hip Flexion
Special Tests
Grind (Scouring) Test
7. Differential Diagnosis
Snapping hip syndrome
Iliopsoas bursitis
Osteoarthritis
Femoral fracture
Avascular necrosis of the femoral head
Acetabular labral tear
Hip subluxation
Hip dislocation
8. Physician Evaluation
Follow-up with orthopedist for further
evaluation
Diagnostic testing
Radiographs
MRI
Negative
Negative
Diagnostic Arthroscopy
9. Surgical Diagnosis
Arthroscopic
diagnosis
Tear of the superior
labrum
Synovitis
McDermott I. Acetabular Labral Tears. Sports Orthopaedics UK. 2010.
http://www.sportsortho.co.uk/article.asp?article=66. Accessed March 7, 2012.
10. Post–Surgical Rehabilitation
Immediate post surgical
Rest
Ambulate 50% PWB
Heel-toe gait pattern
Hip precautions
Strengthening
4 weeks post surgical
Weight bearing as tolerated
AROM to end-range
11. Continued Rehabilitation
3 months post surgical:
Strengthening
CKC proprioceptive exercises
Functional activities
Jogging progression
13. Uniqueness of This Case
Mechanism of injury
Time lapse between initial onset and
surgical repair
Diagnostic imaging
Baber YF, Robinson AHN, Villar RN. Is diagnostic arthroscopy of the hip
worthwhile? J Bone Joint Surg [Br] 1999; 81-B:600-603.
http://web.jbjs.org.uk/content/81-B/4/600.full.pdf. Accessed March 7, 2012.
14. MRIs
Standard MRI
Arthrogram MRI
Rakhra KA. Magnetic resonance imaging of acetabular labral tears. J Bone Joint Surg Am. 2011;
93(Supplement 2):28-34. doi:10.2106/jbjs.j.01722.
Ziegert AJ, Blankenbaker DG, De Smet AA, Keene JS, Shinki K, Fine JP. Comparison of standard hip MR
arthrographic imaging planes and sequences for detection of arthroscopically proven labral tear. AJR. 2009;
192:1397–1400. doi:10.2214/AJR.08.1609.
15. Relevance to Athletic Training
Evaluation and management
Full history
Accuracy of diagnostic images
16. References
1.
2.
3.
4.
5.
6.
The American Orthopaedic Society for Sports Medicine. Hip Arthroscopy.
2010. http://orthoinfo.aaos.org/figures/A00571F01.jpg. Accessed March 7,
2012.
Ellis H and Mahadevan V. Clinical Anatomy: Applied Anatomy for Students
and Junior Doctors.12th ed. West Sussex, UK: Wiley-Blackwell; 2010: 233.
McDermott I. Acetabular Labral Tears. Sports Orthopaedics UK. 2010.
http://www.sportsortho.co.uk/article.asp?article=66. Accessed March 7, 2012.
Baber YF, Robinson AHN, Villar RN. Is diagnostic arthroscopy of the hip
worthwhile? J Bone Joint Surg [Br] 1999; 81-B:600-603.
http://web.jbjs.org.uk/content/81-B/4/600.full.pdf. Accessed March 7, 2012.
Rakhra KA. Magnetic resonance imaging of acetabular labral tears. J Bone
Joint Surg Am. 2011; 93(Supplement 2):28-34. doi:10.2106/jbjs.j.01722.
Ziegert AJ, Blankenbaker DG, De Smet AA, Keene JS, Shinki K, Fine JP.
Comparison of standard hip MR arthrographic imaging planes and sequences
for detection of arthroscopically proven labral tear. AJR. 2009; 192:1397–
1400. doi:10.2214/AJR.08.1609.
Thank you for introducing me. As she stated, I am Ruby Floyd, a rising senior in the athletic training program at Western Carolina University, and I am presenting to you about a right hip labral tear in a 22 year-old collegiate male.
The objective of this case is to educate athletic trainers regarding the evaluation of a unique presenting right hip labral tear with synovitis in a collegiate male.
The patient in this case is a 22 year-old collegiate male who is a recreational athlete with complaints of occasional right hip pain for the previous five years. The patient’s past medical history reveals the onset of symptoms secondary to falling off of a horse and being “dragged” by his right leg. Symptoms have included feelings of instability and pain which typically resolve within 24 hours. Due to the transient nature of the symptoms and his minimal level of discomfort, the patient did not seek medical attention during this five year period. Then, while reaching forward in a seated position, the patient experienced an immediate intense pain and instability of his hip. Typically his symptoms would resolve, but two weeks after this most recent incident, the frequency and intensity of his symptoms prompted him to seek medical attention.
As we all know, the hip is, generally, a very stable joint. Hip dislocations account for a very small percentage of dislocations in the body. Relevant anatomy in this case involves the femoroacetbular joint which includes the articulation of the head of the femur and the acetabulum.
Stability of the hip is provided by the joint capsule, ligaments, and acetabular labrum. Compromise to any of these structures can result in pain, instability, and dysfunction.
The blood supply of the femur includes the artery to the head of the femur and the medial and lateral circumflex femoral arteries. Due to the fragile blood supply at the femoroacetabular joint, compromise of these arteries could lead to detrimental effects such as avascular necrosis. This limb-threatening condition, if not thoroughly evaluated and treated, will result in permanent bone death beginning with the femoral head and neck that typically requires a bone graft surgery for repair.
Upon initial evaluation, the patient reported severe pain in the anterior aspect of the hip and groin, with occasional radiating pain and parethesia into his anterior thigh. He also reported that the pain frequently woke him at night. The patient initially ambulated into the ATR PWB on crutches. Visual inspection was unremarkable, and a grind test revealed crepitus and pain deep into the joint without referral. Pain was present during passive internal rotation of the right hip in a seated position, while no significant pain was noted with passive external rotation. There was also mild pain with resisted hip flexion without a reproduction of symptoms.
At this time the differential diagnosis in this patient includes snapping hip syndrome, iliopsoas bursitis, osteoarthritis, femoral fracture, avascular necrosis of the femoral head, acetabular labral tear, hip subluxation and hip dislocation. The patient was subsequently referred to an orthopedist for further evaluation and diagnosis.
The physician evaluation resulted in similar findings to those of the athletic trainer. Diagnostic testing ordered at that time included plain radiographs and a MRI without contrast, which were negative for both fracture and joint pathology. The patient subsequently underwent a right hip diagnostic arthroscopy.
During the arthroscopy, the physician identified a superior labral tear with synovitis of the right hip . The surgeon then performed a partial synovectomy and debridement of the involved labrum. In this picture, you can note the femoral head inferiorly, the acetabulum superiorly, and the labrum superiorly. This white flap is a superior labral tear, which if not torn, it would be tacked down along the acetabulum.
Following the surgical repair, the patient was instructed to rest and ambulate with a 50% partial weight-bearing gait emphasizing a heel-toe symmetrical pattern. Although typically recommended, this patient did not undergo a supervised rehabilitation program involving early passive motion to promote healing and decrease pain. Usual precautions at this time include limiting flexion to 90 degrees, abduction to 25 degrees and extension to 10 degrees in order to decrease the compression of the acetabular labrum during the first two weeks post-surgery. Strengthening during initial rehabilitation typically includes isometric contractions with progression to no weight isotonics. Four weeks following surgery, the patient was allowed weight-bearing as tolerated and began AROM exercises in all directions, to end-range. At this time, the patient demonstrated no pain with ADL, but complained of increased discomfort towards the end of the day. PROM was within normal limits, with only ERP in internal rotation. Strengthening exercises at this time consist of hip and core musculature in order to build strength, stability, and endurance.
Three months post-op, the patient reports no hip pain and is completing a comprehensive rehabilitation program including strengthening, closed-kinetic chain proprioceptive exercises, and functional activities. At this time the patient is now cleared to initiate jogging since he has achieved FWB.
Sixteen weeks post surgery the patient was cleared for a full return to activities with no limitations. Follow-up evaluation at this time presented with full function, no pain or joint instability. The timeline demonstrated by this patient is similar to the return to activity of a competitive athlete.
This case is unique due to the mechanism of injury from falling off of a horse and being “dragged” by his right leg and the subsequent mechanism of reaching forward while sitting. Along with this, the extended period of time, a total of five years, between initial onset and surgical repair is unusual.
Finally, this case is considered unique because of the negative plain radiographs and negative MRI. Due to the patient’s high level of discomfort and longevity of symptoms, in addition to the physician's search for an accurate diagnosis, a diagnostic arthroscopy became essential. One study of over 300 subjects found that 19% of patients presenting with idiopathic hip pain receive an arthroscopy to make a diagnosis.
In this case, the physician ordered a standard MRI without contrast. This image is shown on the left. Most physicians order an Arthrogram MRI, shown on the right, which contrasts the labral tear with an injectable dye. These versions of MRIs are noted to be 91% accurate in diagnosing a labral tear, whereas a standard MRI does not contrast the labral tear as well making it difficult to diagnose. The red arrows indicate the superior labral tear in both images as seen here .
It is necessary for athletic trainers to be familiar with the evaluation and management of acetabular labral tears. It also reinforces that a full history should be noted in any evaluation, and that injuries may occur under a variety of unique circumstances. This case is also relevant to athletic training as it is important to remember that diagnostic images may present with false negatives.
At this time I would like to thank the MAATA Selection committee and Jill Manners, Program Director and faculty advisor at Western Carolina University.
Thank you for listening and do you have any questions at this time?
