November 16, 2019

Hip Labral Tears→

November 16, 2019/ Pro Dynamic Physical Therapy Inc./ Travis Tanasse

What is a Hip Labral Tear?

A hip labral tear occurs when there is damage to the labrum (ring of cartilage) within the hip joint. The hip joint is where the thigh bone (femur) meets the pelvis (ilium). It is described as a ball-and-socket joint. This design allows the hip to move in several directions. The bony hip socket is surrounded by the labrum, which provides additional stability and shock absorption to the hip joint.

A labral tear results when a part of the labrum separates or is pulled away from the socket. Most commonly, a labral tear is the result of repetitive stress (loading) causing irritation to the hip, often due to long-distance running or performing repeated, sharp, sports movements, such as twisting and cutting.

Repetitive loading is more likely to result in injury to the labrum when there are bony abnormalities at the hip joint. For example, hip impingement is a condition resulting in hip pain due to abnormal bony contact between the ball and socket. As the hip is moved into specific positions, this bony contact can place greater stress on the labrum.

Hip labral tears may result from a combination of several different variables, including:

Bony abnormalities in the hip joint (hip impingement)
Hip muscle tightness
Hip muscle weakness
An unstable hip joint
Improper technique when performing repetitive activities
Participation in sports that require distance running, or repetitive twisting and cutting
Typical wear-and-tear over time

Once torn, the labral tissue in the hip does not have the ability to heal on its own. There are surgical procedures to remove or repair torn labral tissue; however, treatment for a labral tear often begins with a course of physical therapy.

Nonsurgical treatment efforts are focused on addressing symptoms by maximizing the strength and mobility of the hip to minimize the stress placed on the injured area. In some cases, patients are able to achieve a satisfactory level of activity without surgery.

Surgical interventions are available to clean out the hip joint, and repair or reconstruct the torn labral tissue. Following surgery, patients will complete several months of physical therapy to regain function of the hip.

How Does it Feel?

Many people have labral tears in the hip and do not experience symptoms; however, some labral tears can result in significant pain or limitations. Pain in the front of the hip or in the groin resulting from a hip labral tear can cause an individual to have limited ability to stand, walk, climb stairs, squat, or participate in recreational activities.

With a labral tear, you may experience:

A deep ache in the front of your hip or groin, often described by the "C sign." (People make a "C" with the thumb and hand, and place it on the fold at the front and side of the hip to locate their pain.)
Painful clicking or "catching" with hip movements; the feeling of something painful stuck in the hip or blocking hip motion.
Pain that increases with prolonged sitting or walking.
A sharp pain in the hip or groin when squatting.
Pain that comes on gradually rather than with one specific episode.
Weakness in the muscles surrounding the hip, or a feeling of the hip “giving way.”
Stiffness in the hip.

How Is It Diagnosed?

Your physical therapist will begin your evaluation by gathering information about your condition and medical history. Although a hip labral tear may be the result of a single injury, it most likely is a condition that develops as a consequence of repetitive irritation in the hip. Your physical therapist may ask you to describe:

Your current symptoms and how they affect your activities in a typical day
Any pain you are experiencing, its intensity and location, and how it may vary during the day
What activities you may be unable to do or have difficulty completing
What activities aggravate your symptoms, and how you reduce the level of your discomfort
Prior injury occurrences before your symptoms began
Other health care professional visits and any tests received

Your physical examination will focus on the region where your symptoms are occurring, but also include other areas that may have been affected as your body adjusted to pain. Your physical therapist may watch you walk, step onto a stair, squat, or balance on one leg.

Your physical therapist will gently but skillfully palpate (touch) the front, side, and back of your hip to determine exactly where it is most painful. The therapist will assess the mobility and strength of your hip and other regions of the body to determine the areas that require treatment.

Following the interview and physical examination, your physical therapist will discuss the findings with you and, through mutual collaboration, develop an individualized treatment program to begin your recovery.

Your physical therapist also may refer you to an orthopedic physician who specializes in hip injuries for diagnostic imaging (ie, X-ray, MRI). An X-ray helps to identify any bony abnormalities, such as those that occur with hip impingement, which may be contributing to your pain. An MRI helps to identify a labral tear.

How Can a Physical Therapist Help?

When you have been diagnosed with a hip labral tear, your physical therapist will work with you to develop a plan to help achieve your specific goals. To do so, your therapist will select treatment strategies in any or all of the following areas:

Education. Your physical therapist will work with you to identify and change any external factors causing your pain, such as exercise selection, footwear, or the amount of exercises you perform.

Pain management. Many pain-relief strategies may be implemented; the most beneficial strategy to alleviate hip pain is to apply ice to the area and to decrease or eliminate specific activities causing your symptoms. Your physical therapist will identify specific movements that aggravate the inside of your hip joint, and design an individualized treatment plan for you, beginning with a period of rest, and gradually adding a return to certain activities as appropriate. Physical therapists are experts in prescribing pain-management techniques that reduce or eliminate the need for medication, including opioids.

Manual therapy. Your physical therapist may apply hands-on treatments to gently move your muscles and joints to decrease your pain and improve motion and strength. These techniques often address areas that are difficult to treat on your own.

Movement reeducation. Your back and hip may be moving improperly, causing increased tension at the hip joint. Your physical therapist may teach you self-stretching techniques for the lower body to decrease tension and help restore normal motion in the back, hip, and leg. There are, however, certain hip motions to avoid following an injury to the hip labrum. Your physical therapist will carefully prescribe exercises that improve your range of motion while protecting the area that has the labral tear.

Muscle strengthening. Muscle weaknesses or imbalances can be the cause or the result of hip pain. Based on your specific condition, your physical therapist will design a safe, individualized, progressive resistance program for you, likely including your core (midsection) and lower extremity. You may begin by performing strengthening exercises while lying down, and advance to performing exercises in a standing position. Your physical therapist will choose what exercises are right for you.

Functional training. Once your pain, strength, and motion improve you will be able to safely transition back into more demanding activities. To minimize tension on the hip, it is important to teach your body safe, controlled movements. Based on your own unique movement assessment and goals, your physical therapist will create a series of activities to help you learn how to use and move your body correctly and safely. Your therapist also will discuss specific positions and activities that should be avoided or modified to protect your hip.

Can this Injury or Condition be Prevented?

Repetitive motion, such as sports or long-distance running, can create the risk of sustaining a labral injury. It is imperative to be aware of any hip pain that you experience, particularly with sitting and squatting, as these are signs of a potential hip injury. Identifying and addressing these injuries early is helpful in their treatment. A physical therapist can help an active individual learn proper body movements to lessen the possibility of injury.

After recovering from a hip labral tear, it is important to continue the lower-extremity mobility and muscle strengthening practices taught to you by your physical therapist, to help reduce the risk of further irritation or injury. In some cases, complete avoidance of the activity that contributed to the symptoms may be recommended.

Real Life Experiences

Erin is a 27-year-old accountant who is training for an upcoming half-marathon. She runs 5 days a week and also enjoys performing weight training and strengthening exercises 2 to 3 days a week. Over the past 2 weeks, Erin has begun to experience an achy pain in the front of her right hip. Her pain is worse after running, and while sitting in her car and at her desk. She also experiences occasional "catching" in her hip when reaching forward to pick up her 1-year-old daughter.

Erin is concerned about the pain she feels between runs and her inability to sit without discomfort. She is worried about her ability to perform daily activities, care for her daughter, and train for her upcoming race. She consults her physical therapist.

Erin’s physical therapist conducts a comprehensive assessment of her current symptoms and her health history. She assesses Erin’s motion, strength, balance, movement, and running mechanics. She skillfully palpates (touches) the front, side, and back of Erin’s hip to determine the precise location of her pain. Erin describes her typical daily running routine, her stretching routine, and her footwear. Based on these findings, her physical therapist suspects an injury to her labrum within her hip joint.

Because Erin’s hip is so tender, her physical therapist refers her to an orthopedic surgeon. The surgeon confirms the diagnosis of a hip labral tear. Erin and her surgeon discuss treatment options; the decision is made for nonoperative management of the condition, with a 2-month period of physical therapy.

Erin and her physical therapist work together to establish short- and long-term goals and identify immediate treatment priorities, including icing and activity modification to decrease her pain as well as gentle hip-strengthening exercises. Her physical therapist also teaches her a home-exercise program to perform daily to help speed her recovery.

Together, they outline a 4-week rehabilitation program. Erin sees her physical therapist 1 to 2 times each week; she assesses Erin’s progress, performs manual therapy techniques, and advances her exercise program as appropriate. She advises Erin on exercise and activity modifications that will enhance her recovery. Erin maintains her daily exercise routine at home.

After 6 weeks, Erin's hip no longer "catches" when she bends forward, and she only experiences periodic mild discomfort when sitting or running.

On the day of the half-marathon, Erin runs pain free—and is proud to high five her husband and her little daughter at the finish line!

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat a labral injury in the hip. However, you may want to consider:

A physical therapist who is experienced in treating people with hip labral injuries or tears, and hip impingement. Some physical therapists have a practice with an orthopedic or musculoskeletal focus.
A physical therapist who is a board-certified clinical specialist, or who completed a residency or fellowship in orthopedic or sports physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

Get recommendations from family and friends or from other health care providers.
When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have hip labral injury or hip impingement.
During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and describe what makes your symptoms worse.

Hip Impingement →

October 29, 2018/ Pro Dynamic Physical Therapy Inc./ Travis Tanasse

Hip impingement involves a change in the shape of the surface of the hip joint that predisposes it to damage, resulting in stiffness and pain. Hip impingement is a process that may precede hip osteoarthritis. It most often occurs in young, active people. A recent study found that 87% of teens and adults with hip pain showed evidence of hip impingement on diagnostic images taken of their hip joints. To treat hip impingement, physical therapists prescribe stretches and strengthening exercises to better balance the muscles around the hip to protect it, and use manual therapies to help restore range of motion and increase comfort.

What is Hip Impingement?

There are 2 types of hip impingement; they may occur alone or together.

Pincer-Type Impingement

In pincer-type impingement, the hip socket (acetabulum), which is usually angled forward, may be angled toward the back, or protruding bone may be present on the pelvis side of the hip joint making the socket a deeper recess that covers more of the ball or head of the femur bone.
The overgrown bone or incorrect angle of the socket causes the labrum, a rim of connective tissue around the edge of the hip socket, to be pinched. Over time, this extra pressure to the labrum when flexing (moving the leg forward) leads to wear and tear that can cause inflammation and could result in a tear. If this condition persists, eventually the cartilage that lines the hip joint can become worn and form holes.
This condition affects men and women equally; symptoms often begin early, appearing at any time between 15 to 50 years of age.

Cam-Type Impingement

In cam-type impingement, the shape of the bone around the head of the femur—the ball at the top of the bone in the thigh—is misshapen. It can vary from the normal round ball shape, or have overgrown bone formed at the top and front. The nickname “pistol grip” deformity is given to the appearance of the bony overgrowth on x-rays.
The overgrown or misshapen bone contacts the cartilage that lines the hip socket, and can cause it to peel away from the bone in the socket. The labrum can become worn, frayed, or torn as well.
This condition affects men to women at a ratio of 3 to 1; symptoms often manifest during the teen years and 20s.

Signs and Symptoms

Hip impingement may cause you to experience:

Stiffness or deep aching pain in the front or side of the hip or front of the upper thigh while resting.
Sharp, stabbing pain when standing up from a chair, squatting, rising from a squat, running, "cutting," jumping, twisting, pivoting, or making lateral motions.
Hip pain described in a specific location by making a "C" with the thumb and hand and placing it on the fold at the front and side of the hip, known as the "C-sign."
Pain that most often starts gradually, but can also remain after another injury resolves.
Pain that increases with prolonged sitting or forward leaning.
Feeling less flexible at the hips, including a decreased ability to turn your thigh inward on the painful side.

How Is It Diagnosed?

Your physical therapist will evaluate the range of motion (movement) of the hip and surrounding joints, and test the strength of the muscles in that area. Your therapist will feel the hip joint and surrounding muscles to evaluate their condition. The examination will include observing how you move, standing from a sitting position, walking, running, or squatting, as appropriate. Your physical therapist may perform special tests to help determine whether the hip is the source of your symptoms. For instance, the therapist may gently roll your leg in and out (the “log roll” test), or bend your hip up and in while turning the lower leg out to the side (the "FADDIR" test) to assess your condition.

If further diagnosis is needed, your doctor may order diagnostic tests to help identify any joint changes, including x-rays, magnetic resonance imaging (MRI), or diagnostic injections. Hip impingement can occur at the same time as low back, buttock, or pelvic pain, or from conditions such as bursitis or groin strain. The final diagnosis of hip impingement may take some time, especially when other conditions are present.

How Can a Physical Therapist Help?

Without Surgery

When an active person develops hip pain, but does not have severe symptoms or joint damage, the recommended treatment is physical therapy. The following interventions can help decrease pain, improve movement, and avoid the progression of hip impingement and the need for surgery:

Improving the strength of your hips and trunk. Strengthening of the hips and trunk can reduce abnormal forces on the already injured joint and help with strategies to compensate.
Improving hip muscle flexibility and joint mobility. Stretching tight muscles can reduce abnormal forces that cause pain with motion. Joint mobilization may help ease pain from the hip joint; however, these treatments do not always help range of motion, especially if the shape of the bone at the hip joint has changed.
Improving tolerance of daily activities. Your physical therapist can consider your job and recreational activities and offer advice regarding maintaining postures that are healthier for your hip and activity modification. Often this involves limiting the amount of bending at the hip to avoid further hip damage.

Following Surgery

Surgery for hip impingement is performed with arthroscopy. This is a minimally invasive type of surgery, where the surgeon makes small incisions in the skin and inserts pencil-sized instruments into the joint to repair damage. The surgeon may perform 1 or several techniques during your procedure as needed. The surgeon may remove or reshape the bone on the pelvis or femur side of the joint, and repair or remove the damaged labrum or cartilage of the hip joint.

Postsurgical physical therapy varies based on the procedure performed. It may include:

Ensuring your safety as you heal. Your physical therapist may recommend that you limit the amount of weight you put on the operated leg if there was a repair of the labrum. You may wear a brace to help limit the amount of bending at the hip. You might also use crutches to avoid overloading the leg if the bone on the femur was reshaped.
Improving your range of motion, strength, and balance. Your physical therapist will guide you through safe range-of-motion, strengthening, and balance activities to improve your movement as quickly as possible while allowing the surgical site to heal properly.
Instructions on returning to an active lifestyle. Most people return to normal daily activities about 3 months after surgery, and to high-level activities and sports 4 to 6 months after surgery. Your physical therapist will recommend a gradual return to activity based on your condition—research shows that 60% to 90% of athletes return to their previous playing ability depending on the surgical procedure performed and the sport.

Can this Injury or Condition be Prevented?

Currently there are no recommendations to prevent hip impingement. Despite a major increase in research to learn more about hip impingement, there is a great deal that is unknown. For instance, many active young people whose x-rays show hips as being abnormal do not have pain despite continuing to live active lives and participate in sports.

However, there is evidence that physical therapy interventions along with anti-inflammatory drugs can decrease pain, slow joint damage, and improve function. This is particularly important in those with mild hip impingement, those who are attempting to avoid surgery, and those who are not candidates for surgery.

Real Life Experiences

Lindsay is an active high school senior who plays shortstop for her school's softball team. Over the last several months, she has had progressively worsening pain on the front and side of her left hip. It started as an occasional sharp pain when she fielded ground balls at practice, and it eventually developed into aching and stiffness of the hip while resting. Lindsay occasionally develops hip pain while sitting in class or at the movies. In the past couple of weeks, she has found it hard to lean forward to tie her shoes. Her mom has been worrying about her pain and takes Lindsay to her physical therapist.

At the evaluation, the physical therapist finds that Lindsay has weakness around her hip and trunk muscles, decreased hip mobility, pain when flexing the hip, pain returning to a standing position after squatting, and decreased balance when standing on her affected leg. Her physical therapist diagnoses mild hip impingement in her left hip. Lindsay sees her physical therapist 1-2 times a week for the next 6 weeks.

Her treatments focus on developing a home program for strengthening her hips and trunk, and the therapist uses manual therapy for the hip to improve her comfort and allow her to perform more activities. The therapist works with Lindsay to change how she moves when standing from a seated position, and also to modify how she moves when playing the infield in softball. Lindsay also spends less time in the positions that bother her hip in the weight room and on the practice field, following recommendations from her physical therapist. After 3 weeks, the majority of her pain has subsided, and by 6 weeks, she is playing in games pain-free.

Lindsay meets her goal of finishing her senior year with the softball team. However, she is considering other ways to stay active after she graduates that don’t involve bending forward as much.

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat patients who have hip impingement. You may want to consider:

A physical therapist who is experienced in treating people with musculoskeletal problems. Some physical therapists have a practice with a sports or orthopaedic focus.
A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in sports or orthopaedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

General tips when you're looking for a physical therapist (or any other health care provider):

Get recommendations from family and friends or from other health care providers.
When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with hip impingement.
During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Pro Dynamic Physical Therapy Inc.

Pro Dynamic Physical Therapy Inc.

Blog

Pro Dynamic Physical Therapy Inc.

Hip Labral Tears→

What is a Hip Labral Tear?

How Does it Feel?

How Is It Diagnosed?

How Can a Physical Therapist Help?

Can this Injury or Condition be Prevented?

Real Life Experiences

What Kind of Physical Therapist Do I Need?

Further Reading

Hip Impingement →

What is Hip Impingement?

Pincer-Type Impingement

Cam-Type Impingement

Signs and Symptoms

How Is It Diagnosed?

How Can a Physical Therapist Help?

Without Surgery

Following Surgery

Can this Injury or Condition be Prevented?

Real Life Experiences

What Kind of Physical Therapist Do I Need?

Further Reading

Pro Dynamic Physical Therapy Inc.