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Acetabular Labrum Tear

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(Redirected from Acetabular Labral Tears)

Other Names

  • Hip labral tear
  • Acetabular Labral Tear
  • Hip Paralabral Cyst

Background

History

  • First reported by Peterson in 1957 in association with irreducible posterior hip dislocation[1]
  • Altenberg reported the first atraumatic labral tear in 1977[2]
  • Arthroscopic description first published by Suzuki in 1986[3]

Epidemiology

  • Prevalence
    • In patients with hip or groin pain, reported between 22-55%[4]
    • In cadaveric studies, labral tears found in 93-96% of hips[5]
  • Time to diagnosis
    • there is on average greater than 2 years before diagnosis is achieved (need citation)

Introduction

Illustration of the hip joint including the acetabular labrum[6]
3D lateral view of the hip with the femur removed demonstrates a common method for dividing the acetabular labrum into segments.[7]

General

  • Description
    • The term labral tear implies a labrum split into at least two parts
    • However most tears involve detachment of the labrum from the hyaline cartilage or bony acetabulum
  • McCarthy et al: [8]
    • 73% of labral tears have associated chondral damage, and chondral damage is more severe in patients with labral lesions
    • 94% of patients articular damage occurs in the same zone as labral lesions
    • Isolated labral tear found more often in younger patients
    • Older patients: labral tear in conjunction with chondral lesions
  • Location
    • Most commonly occurs along the anterosuperior labrum

Etiology

  • Trauma
    • Uncommon as an isolated injury, often associated with Hip Dislocation or subluxation
    • Associated with injuries to the articular cartilage
    • Occasionally, acetabular tear can cause irreducible dislocation or recurrent dislocation[9]
    • Approximately 25% of labral tears are not associated with any specific injury or traumatic event with the underlying etiology thought to be repetitive microtrauma.
  • Femoroacetabular Impingement (FAI)
    • Abnormal abutment of femoral head or acetabulum due to morphological changes
    • Cam-type: damage to anterosuperior acetabular cartilage, separation between labrum and cartilage
    • Pincer-type: either localized or circumferential and peripheral
  • Hypermobility (capsular laxity)
    • Underlying collage dysfunction, hormonal influences predispose patients to labral injury
    • Associated with repetitive rotational sporting activities, leading to rotational instability of hip
    • Weakenig of the iliofemoral ligament can occur in sports such as golf, soccer and hockey
  • Acetabular Dysplasia
    • Abnormal relationship between acetabulum and femoral head, leading to joint incongruity and increased stress on the labrum
    • Most commonly, anterior labrum infringing upon anterior acetabulum leads to hypertrophy, tearing of labrum
    • McCarthy et al: 72% (of 170) hips had labral tears, 93% were anterior[10]
  • Degenerative
    • Often considered part of the natural history of aging joints

Anatomy of the Acetabular Labrum

  • Fibrocartilagenous structure which outlines the acetebular rim
  • Covers 170° of femoral head
  • Functions: shock absorption, joint lubrication, pressure distribution, stability
  • Horse-shoe shaped
  • Continuous with the transverse acetabular ligament
  • Articular side composed of fibrocartilage, capsular side composed of dense connective tissue

Associated Conditions

Risk Factors

  • Sports
    • Golf
    • Soccer
    • Ballet
    • Running
  • Other
    • Female gender

Differential Diagnosis

Differential Diagnosis Hip Pain

Differential Diagnosis Groin Pain

Clinical Features

Illustration of FABER test[11]

History

  • Patient may endorse having seen multiple providers
  • Onset is typically insidious
  • Patients usually report anterior hip or groin pain, less commonly buttock pain
  • Burnett et al using arthroscopy as the diagnostic standard, looked at pre-surgical pain patterns and found the following: groin pain (92%), anterior thigh pain (52%), lateral hip pain (59%), buttock pain (38%)[12]
  • They may report clicking, locking, giving way, snapping sensation
  • Pain is often described as constant dull pain with intermittent episodes of sharp pain that worsens with activity
  • Activities that make it worse walking, pivoting, prolonged sitting, and impact activities, such as running
  • 71% of patients endorse night pain[13]

Physical Exam: Physical Exam Hip

  • Range of motion limitations are reported in the literature, especially with internal/external rotation

Special Tests

Evaluation

AP view of right hip demonstrates subtle calcification of superolateral acetabulum suspicious for labral pathology
Axial cut of MRI arthrogram demonstrates full thickness tear of anterior labrum
T1w left hip MRA; coronal views. A) Labral tear (arrow); B) osteochondral loose bodies (arrow). figura 6.-T1w artro-RMN anca sinistra; proiezioni coronali. A) Lesione labbrale (freccia); B) corpi mobili intraarticolari (freccia).[14]
Ultrasound demonstrating needle trajectory (green arrow) and insertion into hypoechoic anterior paralabral cyst for needle fenestration (red arrow). A transparent needle illustration [9] is seen directly adjacent to the actual needle trajectory for ease of viewing.[15]

Radiographs

  • Standard Radiographs Hip
    • Useful initial imaging as many of the causes of labral tears have radiographic findings
  • Potential Findings
    • Degenerative changes
    • Evidence of dysplasia
    • Evidence previous surgery
    • Coxa Valga (angle between the femoral shaft and neck of >135°)
    • Aacetabular retroversion (the acetabulum faces posterolaterally)
  • Peele et al: 49% of patients with symptomatic labral tears have radiographic abnormality [16]
    • Confirmed arthroscopically
    • 17% acetablum, 14% femur, 18% both anatomic sites
  • Note, many of these findings can be found in asymptomatic individuals
    • The significance of this is unknown

CT

  • Helpful to evaluate osseous abnormalities
  • Does not visualize the labrum well
  • Arthrography
    • May help better visualize the labrum in patients who can not get an MRI
    • However, sensitivity is lower than MR Arthrography[17]

Ultrasound

  • May have a role in evaluating anterosuperior labral tears
  • Overall role is likely limited but not well described in the literature

MRI

  • Gold standard imaging modality for evaluating hip labrum
    • Arthroscopy is the diagnostic gold standard
  • Angiography
    • When performed on a 1.5T or larger machine, sensitivity increases for labral abnormalities[18]
    • Beaulé et al: MRA sensitivity 92-100%, accuracy 93-96% (compared to arthroscopy)[19]
  • 3T MRI
    • Increased availability of higher resolution MRI allows for opportunity to evaluate labrum without arthrography
    • Benefits: increase patient throughput, reduce costs for departments, improve patient experience[20]
    • Early literature suggests 3T MRI is superior to 1.5T MR Arthrography for evaluating labrum (need citation)
  • Pitfalls
    • Some individuals have a congenitally absent labrum, thought to be rare
    • Readers can misinterpret the high/ intermediate signal in the labrum
    • Cotten et al: 58% of asymptomatic labra examined on conventional MRI showed intermediate or high intra-labral signal intensity[21]
    • Normal paralabral rescess
    • Presence of a sublabral rescess
    • Bifid posterior labrum

Classification

  • Can be classified by
    • Location
    • Morphology
    • Etiology

Seldes Classification

  • General[22]
    • Surgical classification system
    • Based on anatomical and histological features
    • Histologically, show hyalinization of the fibrocartilage along the edges of the tear with increased microvascularity at the base of the labrum adjacent to the bony attachment.
    • Myxoid change with cyst formation is sometimes seen within the adjacent fibrocartilage.
  • Type 1
    • Detachment of the labrum from the articular surface
    • Occurs at the transition zone between the fibrocartilaginous labrum and the articular hyaline cartilage
    • These are perpendicular to the articular surfaces
    • Can extend down to the subchondral bone
  • Type 2
    • Defined by one or more cleavage planes of variable depth within the labral substance

Lage Classification

  • Surgical classification system
  • Radial flap[23]
    • Disruption of the free margin of the labrum
    • Subsequent formation of discrete flap
    • Most common tear pattern
  • Radial fibrillated
    • Appearance of a shaving brush
    • Hairy appearance at the free margin
    • Common in degenerative disease
  • Longitudinal peripheral
    • Variable length along the acetabular insertion of the labrum
  • Unstable
    • Subluxing labrum
    • No discrete morphological pattern

Czerny Classification

  • MR arthrography classification of labral tears[24]
  • Stage 0:
    • Homogeneous low signal intensity, triangular shape, continuous attachment to the lateral margins of the acetabulum without a notch or a sulcus.
    • A recess between the joint capsule and the labrum, which consists of a linear collection of the contrast material extending between the cranial margin of the acetabular labrum and the joint capsule
  • Stage 1A
    • Labra have an area of increased signal intensity in the center that does not extend to the margins, a triangular shape, and a continuous attachment to the lateral margin of the acetabulum without the sulcus.
    • A normal labral recess is also present
  • Stage 1B
    • Similar to stage 1A but are thickened and no labral recess is present
  • Stage 2A
    • An extension of contrast into the labrum without detachment from the acetabulum, triangular, and have a labral recess
  • Stage 2B
    • Like stage 2A but thickened, and the labral recess is not present
  • Stage 3A
    • Labrum is detached from the acetabulum but triangular in shape
  • Stage 3B
    • Like stage 3A but thickened

Blankenbaker Classification

  • MR arthrography classification of labral tears[25]
  • Type 1
    • Frayed: Irregular margins of the labrum without a discrete tear
  • Type 2
    • Flap tear: Contrast extending into or through the labral substance
  • Type 3
    • Peripheral longitudinal: Contrast partially or completely between the labral base and acetabulum labral detachment
  • Type 4
    • Thickened and distorted and thus likely unstable

Management

Nonoperative

Operative

  • Indications
    • Symptoms that have failed to improve with nonoperative modalities
  • Technique
    • Arthroscopic labral debridement
    • Arthroscopic labral repair

Rehab and Return to Play

Rehabilitation

  • 4 Phase Post-arthroscopic rehab proposed by Holling[28]
    • Phase 1 (0-4 weeks): emphasis on non-weight bearing modalities
    • Phase 2 (4-8 weeks): progressive weight bearing as tolerated
    • Phase 3 (8-12 weeks): dynamic movements, self stretching
    • Phase 4 (12+ weeks): sport specific movements

Return to Play

  • O'connor et al RTP criteria[29]
    • Timeline
    • Conditional criteria
    • Description of measurements assessing the conditional criteria
    • Specific rehabilitation protocol
  • Chen et al return to running after arthroscopy[30]
    • Three months of physical therapy
    • Demonstration good stability while performing 30 consecutive single leg squats
  • Kraeutler et al return to running[31]
    • Walking program
    • Quick response and plyometric routine with progression to a walk/jog program,
    • Return to distance running
  • Kuhn et al rehabilitation program[32]
    • Running at 16 weeks on anti-gravity treadmill
    • Running at 20 weeks on traditional treadmill

Prognosis and Complications

Prognosis

  • Arthroscopic debridement
    • Burnett et al: 89% of patients with continued ‘‘improved’’ status at an average of 16.5 months after arthroscopic debridement of a labral tear[12]
    • Farjo et al: 13/28 (46%) of patients reported being ‘‘better’’ or ‘‘much better’’ when monitored for at least 1 year following arthroscopic debridement[33]
    • Santori et al: at a mean of 3.5 years follow up, 39 (67.3%) reported being ‘‘pleased’’ with the results of the surgery, whereas 32.7% were not pleased[34]
  • Return to Play
    • Elwood et al: 94% of elite athletes return to play after an average of 6.8 months following arthroscopic repair[35]

Complications

See Also

Internal

External

References

  1. ↑ Dameron TB. Bucket handle tear of acetabular labrum accompanying posterior dislocation of the hip. J Bone Joint Surg. 1959;41A:131–134
  2. ↑ Altenberg AR. Acetabulur labrum tears: A cause of hip pain and degenerative arthritis. South Med J. 1977;70:174–175.
  3. ↑ Suzuki S, Away G, Okada Y, et al. Arthroscopic diagnosis of ruptured acetabular labrum. Acta Orthop Scand. 1986;57:513–515
  4. ↑ Narvani AA, Tsiridis E, Kendall S, Chaudhuri R, Thomas P. A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain. Knee Surg Sports Traumatol Arthrosc. 2003;11:403–408.
  5. ↑ Lewis CL, Sahrmann SA. Acetabular labral tears. Phys Ther. 2006;86:110–121.
  6. ↑ Image courtesy of https://pjsorthopaedics.com.au/
  7. ↑ Image courtesy of radsource.us
  8. ↑ McCarthy JC, Noble PC, Schuck MR, et al. The Otto E Aufranc Award the role of labral lesions to development of early degenerative hip disease. Clin Orthop. 2001;393:25–37.
  9. ↑ Paterson I. The torn acetabular labrum; a block to reduction of a dislocated hip. J Bone Joint Surg [Br] 1957;39-B(2):306–309.
  10. ↑ McCarthy JC, Lee JA. Acetabular dysplasia: a paradigm of arthroscopic examination of chondral injuries. Clin Orthop. 2002;405:122–128.
  11. ↑ Bernstein, Robert M., and Harold Cozen. "Evaluation of back pain in children and adolescents." American family physician 76.11 (2007): 1669-1676.
  12. ↑ 12.0 12.1 Burnett S, Della Rocca G, Prather H, et al. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am. 2006;88(7):1448–57.
  13. ↑ Hunt D, Clohisy J, Prather H. Acetabular tears of the hip in women. Phys Med Rehabil Clin N Am. 2007;18(3):497–520.
  14. ↑ Pogliacomi, Francesco, et al. "Anterior groin pain in athletes as a consequence of intra-articular diseases: etiopathogenesis, diagnosis and principles of treatment." Medicina dello Sport 67.3 (2014): 341-68.
  15. ↑ Bazzi, Michael O., et al. "A Novel Ultrasound-Guided Approach for the Management of an Anterior Paralabral Cyst of the Hip." Journal of Orthopaedics and Sports Medicine 5.2 (2023): 300-303.
  16. ↑ Keeney JA, Peelle MW, et al. Magnetic resonance arthrography versus arthroscopy in the evaluation of articular hip pathology. Clin Orthop Relat Res. 2004;429:163–169.
  17. ↑ Sutter R, Zanetti M, Pfirrmann CW. New developments in hip imaging. Radiology 2012;264(3):651–667
  18. ↑ Lazarus ML. Imaging of femoroacetabular impingement and acetabular labral tears of the hip. Dis Mon 2012;58(9):495–542
  19. ↑ Beaulé PE, O’Neill M, Rakhra K. Acetabular labral tears. J Bone Joint Surg Am 2009;91(3):701–710
  20. ↑ Robinson P. Conventional 3-T MRI and 1.5-T MR arthrography of femoroacetabular impingement. AJR Am J Roentgenol 2012; 199(3):509–515
  21. ↑ Cotten A, Boutry N, Demondion X, et al. Acetabular labrum: MRI in asymptomatic volunteers. J Comput Assist Tomogr 1998;22(1):1–7
  22. ↑ Seldes RM, Tan V, Hunt J, Katz M, Winiarsky R, Fitzgerald RH Jr. Anatomy, histologic features, and vascularity of the adult acetabular labrum. Clin Orthop Relat Res 2001;(382):232–240
  23. ↑ Lage LA, Patel JV, Villar RN. The acetabular labral tear: an arthroscopic classification. Arthroscopy 1996;12(3):269–272
  24. ↑ Czerny C, Hofmann S, Neuhold A, et al. Lesions of the acetabular labrum: accuracy of MR imaging and MR arthrography in detection and staging. Radiology 1996;200(1):225–230
  25. ↑ Blankenbaker DG, De Smet AA, Keene JS, Fine JP. Classification and localization of acetabular labral tears. Skeletal Radiol 2007;36(5): 391–397
  26. ↑ Hickman JM, Peters CL. Hip pain in the young adult: diagnosis and treatment of disorders of the acetabular labrum and acetabular dysplasia. Am J Orthop. 2001;30:459–67.
  27. ↑ De Luigi AJ, Blatz D, Karam C, Gustin Z, Gordon AH. Use of Platelet-Rich Plasma for the Treatment of Acetabular Labral Tear of the Hip: A Pilot Study. Am J Phys Med Rehabil. 2019 Nov;98(11):1010-1017. doi: 10.1097/PHM.0000000000001237. PMID: 31162277.
  28. ↑ Holling, Mark J., Scott T. Miller, and Andrew G. Geeslin. "Rehabilitation and return to sport after arthroscopic treatment of femoroacetabular impingement: a review of the recent literature and discussion of advanced rehabilitation techniques for athletes." Arthroscopy, Sports Medicine, and Rehabilitation 4.1 (2022): e125-e132.
  29. ↑ O’Connor, Michaela, et al. "Return to play after hip arthroscopy: a systematic review and meta-analysis." The American journal of sports medicine 46.11 (2018): 2780-2788.
  30. ↑ Chen, Austin W., et al. "Five-year outcomes and return to sport of runners undergoing hip arthroscopy for labral tears with or without femoroacetabular impingement." The American Journal of Sports Medicine 47.6 (2019): 1459-1466.
  31. ↑ Kraeutler, Matthew J., et al. "Return to running after arthroscopic hip surgery: literature review and proposal of a physical therapy protocol." Journal of hip preservation surgery 4.2 (2017): 121-130.
  32. ↑ Kuhns, Benjamin D., et al. "A four-phase physical therapy regimen for returning athletes to sport following hip arthroscopy for femoroacetabular impingement with routine capsular closure." International journal of sports physical therapy 12.4 (2017): 683.
  33. ↑ Farjo LA, Glick JM, Sampson TG. Hip arthroscopy for acetabular labral tears. Arthroscopy. 1999;15:132–7.
  34. ↑ Santori N, Villar RN. Acetabular labral tears: results of arthroscopic partial limbectomy. Arthroscopy. 2000;16(1):11–5.
  35. ↑ Elwood, R., et al. "Outcomes and rate of return to play in elite athletes following arthroscopic surgery of the hip." International Orthopaedics 45.10 (2021): 2507-2517.
Created by:
John Kiel on 5 July 2019 08:48:17
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Last edited:
27 May 2026 13:29:01
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