Ligamentum Teres Injury

Other Names

• Injuries to the Ligamentum Teres
• Ligamentum Teres Tear
• LT Tear

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Background

• This page refers to injuries related to the Ligamentum Teres (LT), an intra-articular ligament within the medial hip joint

History

• Ligamentum teres first described by Egyptian surgeon Hegetor in 100 BC (need citation)

Epidemiology

• Incidence of rupture during hip arthroscopy is approximately 9%
• Rupture is reported as the third most common cause of hip pain in the athlete
• In another study, tears were identified in 8 to 51% of patients undergoing hip arthroscopy
• Prevalence of LT tear in asymptomatic cohort reported to be as low as 2.2%]]
• In patients undergoing hip arthroscopy, LT pathology ranges from 30% to 90%

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Introduction

Illustration of a ligamentum teres tear

Frontal section of the hip joint with the ligament of the head of the femur marked

General

• Ligamentum teres is a complex and not well understood intra-articular structure of the hip joint
• Limited literature exists on its role as a source of pain and instability
• Pain associated with these tears can dramatically impact ADLs and sporting activities
• It is difficult to distinguish between LT pathology as a primary or secondary source of pain

Pathophysiology

• Mechanism of injury/ etiology of LT tears is not well understood or described

Controversy

• Some controversy about the clinical significance of ligamentum teres tears
• Reports of asymptomatic individuals with a congenitally absent ligamentum teres
• Similarly, skepticism exists whether these tears lead to instability of the hip

Anatomy of the Ligamentum Teres

• Pyramidal shaped structure
• Origin: from the posteroinferior acetabular fossa
• Insetion: on the femoral fovea capitis
• Surrounded by a thin synovial lining intimately tied to a posterior branch of the Obturator Artery
• Encompasses an undefined central sensory nerve supply
• Function
  • Much remains unknown about the purpose and function of the ligament
  • Believed to serve as a secondary stabilizer of the hip
• Notably, it is congenitally absent in 18.67% of hips in one study

Biomechanical Function of the LT

• Source of much scholarly debate
• Many surgeons have historically considered it a vestigial structure, promoting excision during hip surgery
• More recent anatomical, biomechanical, clinical studies suggest notable biomechanical and neurological properties

Associated Conditions

• Damage to the Articular Cartilage
  • Inferior medial acetabular cartilage damage, apical cartilage damage to femoral head
• Hip Osteoarthritis
  • Lodhia showed acetabular osteophytes have markedly higher cartilage damage and LT tears compared to controls

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Risk Factors

Nonmodifiable

• Female sex
• Advanced age
• Ligamentous laxity
• Structural hip abnormalities (hip dysplasia, acetabular morphology)

Modifiable

• Sports: Ballet, Gymnastics, Martial Arts
  • Thought to increase risk due to increased range of motion

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Differential Diagnosis

Differential Diagnosis Hip Pain

• Fractures And Dislocations
  • Pelvic Fracture
  • Hip Fracture
  • Acetabular Fracture
  • Femoral Neck Stress Fracture
  • Pelvic Stress Fracture
  • Hip Dislocation
• Arthropathies
  • Osteitis Pubis
  • Avascular Necrosis of the Hip
  • Hip Osteoarthritis
  • Femoroacetabular Impingement
  • Transient Osteoporosis of the Hip
  • Hip Microinstability
  • Osteochondral Defect of the Hip
• Muscle and Tendon Injuries
  • Hip Flexor Tendonitis
  • Piriformis Syndrome
  • Hamstring Strain
  • Proximal Hamstring Tendinopathy
  • Adductor Strain
  • Greater Trochanteric Pain Syndrome
• Bursopathies
  • Iliopsoas Bursitis
  • Ischial Bursitis
• Ligament Injuries
  • Acetabular Labrum Tear
• Neuropathies
  • Meralgia Paresthetica
• Other
  • Snapping Hip Syndrome
  • Septic Arthritis
  • Gout
  • Leg Length Discrepancy
• Pediatric Pathology
  • Transient Synovitis of the Hip
  • Developmental Dysplasia of the Hip (DDH)
  • Legg-Calve-Perthes Disease
  • Slipped Capital Femoral Epiphysis (SCFE)
  • Avulsion Fractures of the Ilium (Iliac Crest, ASIS, AIIS)
  • Ischial Tuberosity Avulsion Fracture
  • Avulsion Fractures of the Trochanters (Greater, Lesser)
  • Iliac Apophysitis (AIIS, ASIS, Iliac Crest)
  • Idiopathic Chondrolysis of the Hip

Differential Diagnosis Groin Pain

• Intra-articular / Hip Etiology
  • Femoroacetabular Impingement
  • Acetabular Labral Tears
  • Injuries to the Ligamentum Teres
  • Hip Osteoarthritis
  • Avascular Necrosis of the Femoral Head
  • Osteochondral Defect of the Hip (Loose Bodies)
  • Hip Microinstability
• Extra-articular Causes
  • Pelvic Stress Fracture
  • Osteitis Pubis
  • Sports Hernia (Athletic Pubalgia)
  • Avulsion Fractures of the Pelvis
  • Snapping Hip Syndrome
  • Iliopsoas Tendinopathy
  • Rectus Femoris Strain
  • Rectus Abdominal Strain
  • Myositis Ossificans
  • Iliac Apophysitis (AIIS, ASIS, Iliac Crest)
  • Inguinal Hernia
  • Femoral Hernia
  • Adductor Tendonitis
  • Adductor Strain
• Neuropathic/ Nerve Entrapment Syndromes
  • Obturator Neuropathy
  • Femoral Neuropathy
  • Iliohypogastric Nerve Injury
  • Genitofemoral Nerve Injury
  • Ilioinguinal Nerve Injury
  • Meralgia Paresthetica (Lateral Femoral Cutaneous Nerve)
  • Pudendal Neuralgia
• Axial/Spinal Etiology
  • Lumbar Disc Disease
  • Facet Arthropathy
  • Sacroiliitis
  • Sacroiliac Joint Dysfunction
• Pediatric Considerations
  • Legg Calve Perthes Disease
  • Slipped Capital Femoral Epiphysis
  • Transient Synovitis of the Hip
  • Idiopathic Chondrolysis of the Hip
• Intra-abdominal Considerations
  • Abdominal Aortic Aneurysm
  • Appendicitis
  • Diverticulitis/ Diverticulosis
  • Lymphadenitis
  • Inflammatory Bowel Disease
• Genitourinary Considerations
  • Ovarian/Testicular Torsion
  • Ectopic Pregnancy
  • Nephrolithiasis
  • Epididymo-Orchitis
  • Ovarian Cyst
  • Pelvic Inflammatory Disease
  • Round ligament pain
  • Urinary Tract Infection
  • Endometriosis
  • Prostatitis
  • Testicular cancer

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Clinical Features

Demonstration of the ligamentum teres (LT) test

History

• Pain in the hip, groin or thigh
• Catching, popping, locking or giving way
• Important to ask about history of hip pathology, injuries, sporting activities
• Pain in certain positions

Physical Exam: Physical Exam Hip

• Use the Beighton Score to evaluate for generalized ligamentous laxity
• Evaluate for hip joint stability

Special Tests

• Ligamentum Teres Test: flex hip/knee, internally/externally rotate hip
• Anterior Shuck Test of the Hip:
• Posterior Shuck Test of the Hip:

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Evaluation

Normal appearance of ligamentum teres on MRI arthrogram

Arthroscopy confirmed ligamentum teres tear

CT confirms an acute avulsion fracture of the left femoral head medially at the superoanterior aspect of the fovea capitis where the ligamentum teres inserts

Radiographs

• Standard Radiographs Hip
  • First line imaging, typically normal
  • Useful to exclude other causes of hip pain
• May have findings of
  • Developmental Dysplasia of the Hip
  • Cam impingement from Femoroacetabular Impingement

MRI

• Imaging modality of choice
• Less 2% of LT tears are diagnosed on pre-operative MRI
• Arthrography improves diagnostic yield (need citation)
• Normal LT appearance
  • Smooth edges, normal insertion,
  • Homogenous hypointense signal on T1- and T2-weighted images
• Partial tear: irregularity and partial discontinuity of the fibers with frayed margins and a hyperintense T2 signal
• Complete tear:no normal fibers are present in the expected location and insertion sites
• Other potential findings
  • Bone edema at the fovea of the femoral head
  • Hip plicae which may be mistaken for an LT
• Accuracy
  • Overall, 64% without arthrography
  • Chang et al: 95% accuraccy in a 1.5T MRI with arthrography
  • Pooled data for MR arthrography is 82.2% sensitive, 88.6% specific

Arthroscopy

• Remains the gold standard for evaluation of the ligamentum teres

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Classification

Table of classifications

Gray and Villar Classification

• Type 1 (complete)
• Type 2 (partial)
• Type 3 (degenerative)

Botser and Domb Classification

• Divides partial tear (type 2) into two groups
• Group I: partial LT tear visualized to be of <50% (low grade)
• Group II: partial LT tear of >50 % (high grade)
• Group III: full-thickness LT tear

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Management

Nonoperative

• Indications
  • First line management in most LT tears
• Consider
  • Activity modification
  • Physical Therapy
  • NSAIDS
  • Hip Joint Injection

Operative

• Indications
  • There are no evidenced based guidelines for surgical management
  • Typically, individuals who have exhausted conservative treatment with persistent pain or instability
• Technique
  • Ligamentum teres reconstruction
  • Ligamentum teres debridement

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Rehab and Return to Play

Rehabilitation

• Postoperative
  • Some surgeons have used a hip abduction brace for 4-6 weeks
  • Partial weight-bearing for 4-6 weeks
  • Avoid external rotation to minimize tension on graft
  • 2 weeks of NSAIDS for Heterotopic Ossification prophylaxis

Return to Play/ Work

• Needs to be updated

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Prognosis and Complications

Prognosis: Surgical Outcomes

• Case series included both debridement and reconstruction techniques
  • There was a notable improvement in patient reported outcomes, pain, return to sports
• Recurrence
  • Haviv and O'Donnell reported a 17% recurrence and need for revision debridement

Complications

• Hip Osteoarthritis
• Need for Total Hip Arthroplasty

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See Also

Groin

• Groin Anatomy Main
• Groin Pain Main
• Physical Exam Groin

Hip

• Hip Pain Main
• Hip Anatomy Main
• Physical Exam Hip

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