Hip and pelvic arthropathies and labral tears

Author(s): William Micheo, MD, Brenda Castillo, MD, Belmarie Rodriguez, MD, and Coral Candelario, MD

Originally published:09/20/2013

Last updated:02/13/2018

1. DISEASE/DISORDER:

Definition

The spectrum of hip and pelvic arthropathies alter the joint and adjacent muscles leading to structural and functional failure of the joint, which in turn causes pain, stiffness, swelling, disability, and reduced quality of life.1

Etiology

Hip pain is a common symptom with a number of possible causes. Femoroacetabular impingement (FAI) is characterized by symptomatic, motion related clinical disorder caused by a premature contact between the acetabulum and the femoral head or head-neck junction causing repetitive microtrauma, which eventually may result in labral injury.2  Hip labral tears are disruption of the fibrocartilaginous acetabular labrum, which functions as a shock absorber for the hip joint.3 Aforementioned conditions may both lead to degeneration of the hip joint, which is described as a chronic condition that involves gradual loss of the articular cartilage and inflammation of the synovium.4

Epidemiology including risk factors and primary prevention

Radiographic abnormalities associated to FAI have been identified in up to 35% of the general population. Cam-type impingement is more prevalent in young active males, while pincer-type impingement is more common in middle-aged athletic females. Risk factors include protrusio acetabuli, coxa profunda, acetabular retroversion and a prominent posterior acetabular rim, developmental hip dysplasia, femoral retrotorsion and coxa vara.2  Hip labral tears are estimated to be present in 66% of those with mechanical hip pain and in 39% of asymptomatic patients. Risk factors include an acute traumatic event, chronic impingement, and idiopathic or congenital etiologies. Age-standardized prevalence of symptomatic radiographic hip OA has varied from 1% to 10% in large population-based prevalence surveys. Risk factors include aberrant hip joint morphology, increasing age, BMI, hip musculature imbalances, female gender, and high impact physical activity. 5

Patho-anatomy/physiology

Three type of morphologic abnormalities may be present in FAI. Cam-type is described as an aspherical femoral head-neck junction leading to increased pressure at the acetabular rim during flexion and internal rotation. Pincer-type involves an overcoverage of the femoral head by the acetabulum resulting in abnormal contact of the acetabular rim on the femoral neck.2,6 Mixed-type includes a combination of the two previous mentioned morphologies. Hip labral tears develop secondary to excessive loading over the acetabular labrum producing direct wearing and tearing of the labral surface.7 Hip OA may develop due to repetitive shear stress at the hip articular surface causing cellular and molecular changes, which include decreased type II collagen and proteoglycans in the articular cartilage, increased release of pro-inflammatory mediators, and increased apoptotic cellular changes.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

It is considered that untreated patients with FAI will experience a gradual deterioration of symptoms, but the long-term outlook is still unknown.2 Patients with damage to the labrum will develop worsening of the hips biomechanical function, leading to accelerated development of hip OA. Pathological biomechanical stress caused by hip OA progressively disrupt the homeostatic equilibrium between joint tissue synthesis and degradation, ultimately resulting in end-stage OA.5

2. ESSENTIALS OF ASSESSMENT

History

It is important to assess timing, sport or vocational history, precipitating factors, pain location, pain irradiation, mechanical symptoms, and associated symptoms, such as low back pain. One must assess previous history of childhood conditions such as Legg-Calvé-Perthes disease.9 Patients with FAI commonly present with insidious onset of a dull, aching hip pain, which is mainly localized to the anterior groin area. Pain may be exacerbated with athletic activity, certain hip movements, and prolonged sitting and/or walking. Patients may as well refer a sensation of catching.10 Labral tears frequently cause insidious anterior hip/groin pain worsened with prolonged periods of standing or sitting. Patient may refer clicking, locking, catching, instability, giving way, and/or stiffness.  Pain may radiate to the anterior groin, buttock, greater trochanter, thigh, and/or medial knee with irradiation of pain to the buttock.3 Patients with hip OA refer morning joint stiffness, which usually lasts for less than 30 minutes. Pain usually increases with activity and subsides with rest, but as joints become unstable, pain may become present even at rest.11

Physical examination

FAI patients present with restricted hip motion, especially while in flexion from 90 to 110 degrees with adduction and internal rotation. Weakness on hip flexors, external rotators, hip adductors, and hip abductors may be present as well.9 Labral tears cause pain with hip extension and external rotation (Posterior Impingement test). 9,12 FAI and labral tears are difficult to distinguish from physical exam and may coexist. When the patient has an isolated labral tear, instability may be present and pain will be reproduced with hip extension.5 Hip OA resents with tenderness at the joint, limited ROM, pain/crepitus with ROM, and joint enlargement 2ry to synovial fluid accumulation.11

Functional assessment

Patients with hip arthropathies have difficulty with walking, standing, bending, and/or athletic activities. Patients may present antalgic gait with limping due to painful stance phase and will show limitations on weight-bearing activities.2 Decrease sagittal plane ROM during walking and stair ambulation is often visible, which leads to slower cadence. On dynamic assessment, pain may be reproduced with deep squatting. 13,14

Laboratory studies

Serology is not generally used diagnostically, unless an inflammatory or rheumatologic process is involved.11

Imaging

When history and physical exam findings do not give a certain diagnosis, imaging can help in the assessment of the diagnosis. Plain radiographs in patients with hip OA may demonstrate asymmetric narrowing of the joint space, often at the superior lateral part of the hip. New bone formation, osteophytes, and/or loose bodies can also be seen, but no erosive changes should be noted. Radiographs may also reveal cam or pincer deformities demonstrating a flattened head-neck junction or pistol-grip deformity at the proximal femur, respectively. Magnetic resonance arthrography (MRA) has become the standard investigative tool in FAI, best demonstrating nonsphericity of the femoral head, head-neck offsets, herniation pits, and rim ossification.11 On evaluation for labral tears, plain radiographs may show findings of chronicity with evidence of labral calcifications. MRI and MR angiography have better sensitivity and specificity than radiographs for evaluation of labral tears, being MRA the most sensitive.10

Early predictions of outcomes

Weight loss can decrease symptoms and progression of OA by providing a decrease in joint forces. An adequate response to intra-articular injection with corticosteroids or viscosupplementation has shown to delay the need for hip surgery.  Once hip surgery is performed, early ambulation results in better post-operative outcome. For labral tears, physical therapy is recommended through three phases, including pain reduction, strengthening and the transition to sports or work related activities. The tolerance and achievement of each phase will affect how soon the patient can return to work or sports.9

Environmental

Various environmental factors contribute to hip pathology, particularly repetitive motion injury arising from occupational and athletic endeavors. Repeated and unusual stresses placed on the joint can tear at the labrum, cause the femoral head to flatten/malalign, and predispose the patient to degenerative changes.

Professional Issues

Progressive hip and pelvic arthropathies often lead to lost work time, as well as problems for athletes returning to play. A comprehensive approach, developed by the physician in charge of the patient’s care, should comprehensively work to maximize patient function over time.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

Treatment is directed towards; educating patients about the nature of the disorder and its management, reducing pain, stiffness, disability, handicap and progression of disease, while improving joint mobility and health-related quality of life.15

At different disease stages

Optimal management requires a combination of non-pharmacological and pharmacological modalities. Patients should be educated about the objectives of treatment and the importance of changes in lifestyle, exercise, pacing of activities, weight reduction, and other measures that will help in unloading the damaged joint. Rehabilitation aims to reduce patients symptoms by improving hip stability, neuromuscular control and movement patterns. Goal of physical therapy is to improve hip ROM, hip muscle strength, and lumbopelvic dissociation. Regular aerobic exercises are also recommended, and for those with pain, exercises in water can be effective. Oral analgesic/anti-inflammatory agents, and/or intra-articular injections (corticosteroids and viscosupplementation) can be used for pain control. Walking aids (cane) and biomechanical interventions (footwear, insole, ect.) can help improve joint congruence and reduce hip loads, leading to reduction in pain levels. When the combination of non-pharmacological and pharmacological treatment does not provide adequate pain control, surgery may be considered.2,15

Coordination of care

A successful treatment of a hip or pelvic arthropathy requires a competent evaluation by the physician, which includes a complete and thorough history and physical exam. Once a diagnosis has been reached, the physician will be able to direct care, either through conservative management (medications, physical therapies, lifestyle modifications, etc.) or a more invasive approach, such as surgery.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

Complementary and alternative therapies, such as acupuncture, moxibustion, transcutaneous electric nerve stimulation, and percutaneous electric nerve stimulation, have favorable evidence, suggesting they are efficacious in treating painful OA.16

Recent studies of platelet-rich plasma (PRP), as an autologous biologic agent, suggest it may hold promise in treating hip OA and other hip pathologies.17-19 However, evidenced-based research regarding treatment with PRP is scant; the scientific literature on PRP is in its infancy, and PRP cannot be considered a standard of care until further research establishes such standards.18

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Mardones et al. study demonstrated a promising treatment option through the use of a PRP clot in hip chondral lesions in patients with FAI, but little has been published to support its current use in practice. In another study, Mardones et al. described the use of intra-articular injections of expanded mesenchymal stem cells (MSC) for the treatment of OA. Currently, even though strong evidence indicates that clinical use of MSC is feasible and safe, they’re clinical efficacy still remain controversial.20

REFERENCES

  1. Bennell, K. Physiotherapy management of hip osteoarthritis. Journal of Physiotherapy.2013; 59:145-157.
  2. Griffin DR, Dickenson EJ, O’Donnell JM, et al. Infographic. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med 2016;50:1169–76.
  3. Groh GM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2:105-117.
  4. Loeser, R., Goldring, S., Scanzello, C., and Goldring, M. Osteoarthirtis: A Disease of the Joint as an Organ. Arthritis Rheum 2012;64(6):1697-1707.
  5. Murphy, N. J., Eyles, J. P., & Hunter, D. J. (2016). Hip Osteoarthritis: Etiopathogenesis and Implications for Management. Advances in Therapy, 33(11), 1921–1946. http://doi.org/10.1007/s12325-016-0409-3
  6. Crawford, JR, Villar RN. Current concepts in the management of femoroacetabular impingement. J Bone Joint Surg Br. 2005;87:1459-1462.
  7. Groh GM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2:105-117.
  8. Murphy, N. J., Eyles, J. P., & Hunter, D. J. (2016). Hip Osteoarthritis: Etiopathogenesis and Implications for Management. Advances in Therapy, 33(11), 1921–1946. http://doi.org/10.1007/s12325-016-0409-3
  9. Banerjee P, McLean CR. Femoroacetabular impingement: a review of diagnosis and management. Curr Rev Musculoskeletal Med. 2011;4:23-32.
  10. Pun, S., Kumar, D., and Lane, N. Femoroacetabular Impingement. Arthritis Rheumatol.2015;67(1):17–27.
  11. Cuccurullo SJ, ed. Physical Medicine and Rehabilitation Board Review. 2nd ed. New York, NY: Demos Medical Publishing; 2010.
  12. Kivlan BR, Martin RL, Sekiya JK. Response to diagnostic injection in patients with femoroacetabular impingement, labral tears, chondral lesions, and extra-articular pathology. Arthroscopy. 2011:27:619-627.
  13. Beatty T. Osteitis pubis in athletes. Curr Sports Med Rep. 2012;11:96-98.
  14. Troelsen A, Mechlenburg I, Gelineck J, Bolvig L, Jacobsen S, Soballe K. What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics? Acta Orthop. 2009;80:314-318.
  15. McAlindon, T., Bannuru, R., Sullivan, M., Arden, N., Berenbaum, F., Bierma-Zeinstra, S., Hawker, G., Henrotin, Y., Hunter, D., Kawaguchi, H, Kwob, K., Lohmander, S., Rannou, F., Roos, E., and Underwood, M. OARSI guidelines for the non-surgical management of knee Osteoarthritis. Osteoarthritis and Cartilage.2014;22.
  16. De Luigi AJ. Complementary and alternative medicine in osteoarthritis. PM R. 2012;4(5 Suppl):S122-133.
  17. Gordon AH, Karam CS, De Luigi AJ. Intra-articular injection of platelet rich plasma (PRP) relieves pain induced by hip labral tear. Poster presented at: Second Annual Symposium on Regenerative Rehabilitation; November 12-13, 2012; Pittsburgh, PA.
  18. Nguyen RT, Borg-Stein J, McInnis K. Applications of platelet-rich-plasma in musculoskeletal and sports medicine: an evidence-based approach. PM R. 2011;3:226-250.
  19. Sanchez M, Guadilla J, Fiz N, Andia I. Ultrasound-guided platelet-rich plasma injections for the treatment of osteoarthritis of the hip. Rheumatology. 2012;51:144-150.
  20. Mardones, R. and Larrain, C. Cartilage restoration technique of the hip. Journal of Hip Preservation Surgery.2015 1(3):30–36.

Original Version of the Topic

Arthur J. De Luigi, DO, Andrew H. Gordon, MD, PhD. Hip and pelvic arthropathies and labral tears. 09/20/2013.

Author Disclosures

William Micheo, MD
Nothing to Disclose

Brenda Castillo, MD
Nothing to Disclose

Belmarie Rodriguez, MD
Nothing to Disclose

Coral Candelario, MD
Nothing to Disclose

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