Imaging_Group Presentation- Acetabular Labral Tears

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Acetabular Labral Tears:

Acetabular Labral Tears June 10, 2012 Group members: Christina Melendreras , Radhika Patel, Alexandra Roger

Acetabular Labrum:

Acetabular Labrum Innervated by free nerve endings 1 Vascularized Provides stability by deepening acetabulum 22%. 1 Distributes load by increasing surface area by 28%. 1 Provides proprioceptive information. 2

Incidence:

Incidence 74% have no specific event/structural deficits 3 86 % of tears are located in anterior quadrant. 1 55% of patients with mechanical hip pain of unknown etiology had labral tears. 3 22% of athletes who report groin pain have a labral tear 3

Signs and Symptoms:

Signs and Symptoms Clicking (100 % sensitive, 85% specific) 4 58% of people with tears report locking, catching 5 Instability, and/or stiffness 5 >90% report sharp pain in anterior hip/groin –anterior tear 3 Pain referral to buttock with posterior tear 3

Physical Therapy Diagnosis:

Physical Therapy Diagnosis History Female > Males 3 Most common 18-40 yrs old 6 Traumatic vs. Insidious onset 61% of patients-insidious onset ROM Accessory- possible hypermobility of an anterior glide 2 Possible hypomobility secondary to muscle guarding 1 Possible blocks in motion due to pieces of labral tears 1 Most reported limitations: rotation, hip flexion, adduction, abduction 1 Dependent on location of the tear

Physical Therapy Diagnosis:

Special Test - FABER 88% sensitive for intra- articular hip pathology, but not specific for labral tears -Fitzgerald test -IR/Flexion/Axial Compression maneuver 75% sensitive, 43% specific for acetabular labral tears 7 -Anterior hip impingement test- positive 1 pt supine, hip flexion 90°, knee flexion 90° IR with adduction force + is pain in anterolateral hip or groin Physical Therapy Diagnosis

Impact of Functioning:

Impact of Functioning 89% of patients with labral tears demonstrate an antalgic gait 1 67% require upper extremity support to ascend/descend stairs 1 46% have decreased tolerance to prolonged ambulation 1 25% unable to sit for >30 minutes 1 Increased symptoms with pivoting and impact activities 1

Role of Imaging in Diagnosis and Management:

Role of Imaging in Diagnosis and Management First step in diagnostic imaging is a hip radiograph Helps determine if structural abnormalities are present, such as: degeneration, impingement, and retroversion 1 Gold standard of imaging for diagnosis of labral tear is MRI arthrogram ( Mra ) with intra- articular gadolinium (contrast dye) 8 90% sensitivity 8 91% accurate 8 Assists with differential diagnosis by ruling out other pathologies such as: synovitis , avascular necrosis, stress fracture, bursitis 9 Imaging is important to obtain an accurate diagnosis so we as therapists are able to appropriately educate and treat the patient

MRI arthrogram:

MRI arthrogram Gold standard of imaging for labral tears 8 “the principle of this procedure relies upon capsular distension, which outlines the labrum with contrast and fills any tears that may be present” 1

PowerPoint Presentation:

Hip Radiograph, A/P view

Hip Radiograph:

Hip Radiograph Findings Pincer type impingement Indicated by excessive coverage of femoral head by acetabulum (see arrow) Deeper acetabular space Decreased femoral acetabular joint space Biomechanical/physical impairments Impaired ROM, specifically: flexion, adduction, IR 10

MRI arthrogram:

MRI arthrogram

MRI arthrogram:

MRI arthrogram Findings Dye extrusion indicates a superior, anterior labral tear Biomechanical/Physical findings -Flexion ROM decreased -Clicking with movement -Poor hip proprioception is possible - Antalgic gait

Prognosis:

Prognosis Lewis reports that appropriate PT interventions can be beneficial 3 Groh recommends focused PT interventions in conjunction with anti inflammatory and pain medication, and rest to temporarily reduce pain 1 If conservative management fails, surgery is indicated 1

Questions:

Questions Based on your analysis of the radiograph image, how would a Pincer type impingement contribute to the development of an acetabular labral tear? Why do you think an MRI would not be as sensitive or accurate as an MRa in diagnosing an acetabular labral tear?

References:

References Groh M, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med . 2009;2:105-117. Ferguson et al. J Biomech . 2000. Lewis C, Sahrmann SA. Acetabular Labral Tears. Phys Ther . 2006;86:110-121. Narvani AA, Tsiridis E, Kendall S, et al. A preliminary report of prevalence of acetabular labrum tears in sports patients with groin pain. Knee Surg Sports Traumatol Arthrosc . 2003;11:403-408. Martin RL, Enseki KR, Draovitch P, Trapuzzano T, Philippon MJ. Acetabular labral tears of the hip: examination and diagnostic challenges. JOSPT. 2006; 36(7):503-515 Sizer P. The Hip: Physical therapy patient management utilizing current evidence. Current Concepts of Orthopaedic Physical Therapy. La Crosse, WI Cleland J, Koppenhaver S. Netters orthopaedic clinical examination: an evidence-based approach . 2 nd ed. Philladelphia , PA: Saunders Elsevier; 2011. Czerny C, Hoffman S, Neuhold A, et al. Lesions of the acetabular labrum: accuracy of MR imaging and MR arthrography in detection and staging. Radiology. 1996;200:225-230. Chan YS, Lien LC, Hsu HL, Wan YL, Lee MS, Hsu KY, Shih CH. Evaluating hip labral tears using magnetic resonance arthrography : a prospective study comparing hip arthroscopy and magnetic resonance arthrography diagnosis. Journal of Arthroscopic and Related Surgery. 2005; 21(10):1250e1-1250e8. Banarjee P, Mclean C . Femoroacetabular impingement: a review of diagnosis and management. Curr Rev Musculoskelet Med. 2011;4:23-32.

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