Case Study: Hip pain with Pathology
An acetabular labral tear is a far too often surgical diagnosis. If you tear your labrum you do not have to necessarily undergo the knife to alleviate the pain and restore your function. Conservative management can be highly effective in avoiding the knife. It can also promote performance enhancement if approached with respect to human physiology and kinesiology.
Here is a recent real example of how I helped a patient avoid surgical intervention and achieve a higher level of function prior to her injury.
Case Background:
Susan is a 60 year old, Caucasian female, who lives a very active lifestyle. She enjoys working out regularly and hopes to resume this as well as other recreational/sporting activities, pain-free. Her hip had been bothering her for months before she came to see me in January. Her greatest complaints were that she could not rotate her left hip, squat, run, or sleep without pain. She also noted an audible pop/click with hip flexion with rotation in either direction. She had a MRI to confirm the presence and location of her labral tear, it was superior anterior.
During her examination I cleared the lumbar spine as well as knee and ankle to ensure there was no other pathology existing or contributing to her hip pain. My examination specific to her hip provided the following findings:
PRI Assessment:
Adduction Drop Test (Modified Ober's): R: - L: +
Extension Drop Test (Thomas Test): R: + L: +
Straight Leg Raise: R: + L: +
Seated ER MMT: R: 4+/5 L: 4/5
Seated IR MMT: R: 4+/5 L: 4/5
HAdLT: R: 2/5 L: 2/5
Functional squat: 2/5
Apical Expansion: R: + L: +
Special Tests:
FABER: R: -, L: +
FADIR: R: -, L: +
Stork: R: +, L: +
Pain: 7/10
Let's pause for a moment to gain a better understanding of the labrum.
The labrum is one of many intra-articular structures that can become problematic and limiting during activity. But what exactly is it and its' function?
The labrum is considered a triangular fibrocartilagenous structure that is attached to the rim of the acetabulum. It is important to note that it is not continuous with itself, but is connected inferiorly by the transverse ligament to provide added support. Overall the function of the labrum is to enhance hip stability. The orientation of the labrum not only deepens the acetabulum creating a pressurized system for stability, but also creates increased femoral head coverage. This in turn increases the congruency between the femur and acetabulum and allows optimal hip mechanics to occur.
But what happens when this homeostatic relationship becomes stressed or disrupted?
To understand this we have to give consideration to its' local physiology: fascial and vascular elements. From the fascial perspective we must consider how the collagen is orientated in relation to the articular cartilage. It is known that the anterior aspect of the labrum is comprised of fibers orientated parallel to the articular cartilage creating a marginal and weak site of attachment; whereas the posterior region interdigitates with this cartilage at a perpendicular angle creating a strong attachment. It's this histological feature that is believed to predispose the anterior aspect of the labrum to more tears than the posterior region.
With regards to the vascular supply to the labrum we find that it is inconsistent and changes throughout. The capsular side of the labrum is highly vascular and believed to hold healing potential; whereas the articular side is more avascular wth less regenerative potential. Thus location and fullness of a labral tear matters and will influence the healing capacity as well as the rehabilitation process.
Before I explain what we did to achieve her goals of a pain-free life without limitation, we have to understand normal mechanics of the hip.
To ensure mechanics are sound we must achieve a position at the pelvis and thorax that will support optimal performance of the hip. As the most mobile joint type, ball and socket, the hip functions freely in each plane of motion. In the sagittal plane: flexion/extension, frontal plane: abduction/adduction, transverse plane: external/internal rotation. However to perform these movements efficiently the hip relies on more than 20 muscles with direct control. This is not counting the numerous muscles that indirectly influence the hip/hemipelvis via their femoral actions. In other words consideration must be given to muscles moving the acetabulum on femur and vice versa.
This demands we leverage the levers about the hip to function optimally.
To avoid getting lengthy with an anatomy review check out this article to gain an understanding of what this means and what the primary hip flexors, extensors, abductors, adductors, and rotators are as well as their roles based on position.
So what did we actually do?
I saw her 6 times over the course of 4 weeks. Our primary focus was to improve her pelvic and thorax position through what I designate as the 5 P's of Performance Physical Therapy:
1) prepare
2) position
3) prime
4) perform
5) parasympethics
Preparation of the tissues was achieved initially primarily by thermal agents as well as Active Release Techniques (ART). This stimulated blood flow to bring healing substrate into the region of the hip. From there we worked on obtaining a neutral/optimal pelvis through repositioning techniques from the PRI world.
Initial positioning program was prescribed 2x/daily and included:
1) 90/90 hip lift with resisted right glute max
2) Right sidelying left adductor pullback
3) Left sidelying knee toward knee
These exercises changed her objective measures to:
PRI Assessment:
1) Adduction Drop Test (Modified Ober's): R: - L: -
2) Extension Drop Test (Thomas Test): R: - L: -
3) Straight Leg Raise: R: - L: +
Special tests:
1) FABER: R: -, L: -
2) FADIR: R: -, L: -
3) Stork: R: +, L: -
This lead into the priming aspect of her program. Here I began to purposefully extend her by facilitating her sympathetic nervous system. We worked from the ground up:
1) 90/90 ISO bridge
2) quadruped alternating hip extension
3) sidelying to oblique sit
These were performed only on days that performance exercises were performed.
From here we worked on the performance of her squat. We only worked on one movement the first 2 weeks to develop proficiency:
1) counterweight squat to parallel.
This was performed 4x/week.
Finally her parasympathetic nervous system was stimulated to initiate the recovery process:
1) All 4s belly lift with bilateral FAIR.
This program was performed for the first 2x/weeks and then she was progressed into the following:
Prepare:
1) Inclined walking with ART as needed.
Position:
1) Paraspinal Release w/ left hamstrings
2) Left sidelying right glute max with left FAIR
3) Right Sidelying supported semi 90-90 with left AGM
4) Standing Right lunge w/ Right trunk rotation
Prime:
1) alternating single leg 90/90 bridge
2) side plank
3) counterweight squat
Perform:
1a) Reverse slider lunge
1b) Suitcase carry
2a) hip hinge from elevated surface
2b) SB rollout
Parasympathetics:
1) Supported functional squat with respiration
The outcome?
PRI Assessment:
Adduction Drop Test (Modified Ober's): R: - L: -
Extension Drop Test (Thomas Test): R: - L: -
Straight Leg Raise: R: - L: -
Seated ER MMT: R: 5/5 L: 5-/5
Seated IR MMT: R: 5/5 L: 5/5
HAdLT: R: 4/5 L: 4/5
Functional squat: 5/5
Apical Expansion: R: - L: -
Special Tests:
FABER: R: -, L: -
FADIR: R: -, L: -
Stork: R: +, L: -
Pain: 0/10
This demands we leverage the levers about the hip to function optimally.
By paying attention and working to optimize position we leveraged her levers and we were able to return her to all of her recreational activities pain-free. She stated that she felt stronger than she has in years and excited to be active again.
Don't settle if you have musculoskeletal pathology present: hip, low back, shoulder, etc, because it does not have to hurt nor does it necessitate surgery. Find a healthcare provider that understands and respects this fact and you will be in good hands.
As always remember you must position to perform.
