Mr Araz B. Massraf

Consultant Orthopaedic Surgeon
MBCHB, FRCSI, FRCS (Orth & Trauma)

Femoro-acetabular impingement and labral tear.(Articular causes)

Femoroacetabular impingement is a condition of too much friction in the hip joint creating damage to the articular cartilage or the labrum or both. Ganz et al. and Lavigne et al. have identified femoroacetabularimpingement as the predominant cause of labral tears in the non dysplastic hip. Abnormal hip morphology can limit motionand result in repetitive impact of the proximal portion of the femoral neck against the acetabular labrum and its adjacentcartilage.


Clinical Presentation

Pain is usually around hip area which might get worse with movements, especially standing, sitting and perhaps changing direction while walking or jogging. The greatest clue to the diagnosis is in the history because athletes can usually describe the motion that reproduces the pain.

It is important to differentiate between intra-articular and extra-articular hip disorders so that the treatment strategiescan be accurately focused.

Other causes of referred hip pain,such as conditions of the lumbar spine, sacroiliac joint, or intra pelvic structures.

Diagnosing hip pain in an athlete can be complicated further by the presence of concomitant injuries to the surrounding soft tissues.

The history should focus on the exact location of pain, the qualitative nature of the discomfort (such as catching, clicking,instability, stiffness, weakness, or decreased performance), the timing of the onset of symptoms, and the precipitating causeof the symptoms. Patients with labral tears typically point to the groin as the area of pain.

A complete examination of the surrounding structures is necessary to fully evaluate patients presenting with hip pain.

The general examination shouldcarefully assess gait, the abdomen (with an emphasis on pubicpain), lumbar spine abnormalities (including a neurologic evaluation), the sacroiliac joint, the knee, and lower-limb lengths.

Although thereis no universally accepted "correct" comprehensive hip examination,a positionally based examination, as described by Martin etal., helps to limit missed diagnoses. With this method,the patient is examined in five different positions, includingstanding, seated, supine, lateral, and prone. Within each position, fives pecific tests are administered.


Traumatic Instability

The spectrum of traumatic hip instability ranges from gross instability associated with a high-energy dislocation to a moresubtle hip subluxation. While hip dislocations most commonly result from motor-vehicle crashes, they have also been reported in athletic competition, secondary to a forward fall on the knee while the hip is flexed or to a blow from behind whilethe player is down on all four limbs.

The immediate managementof a hip dislocation involves rapid reduction in order to minimize long-term complications, such as osteonecrosis of the femoralhead. The secondary phase of treatment focuses on the definitivecare of injured structures. Due to the low-energy mechanism,most hip dislocations sustained during athletic competitionare a pure dislocation without any associated acetabular rim fractures. Thus,open reduction and internal fixation is often not warranted,and active and passive range of motion can begin as soon as tolerated by the patient.

Posterior subluxation of the hip is more subtle in presentationbecause it involves less energy and may be misdiagnosed as asimple hip sprain or strain. Thus, even following minor trauma,the physician should have a high index of suspicion for an intra-articularinjury. The mechanism of subluxation is often similar to thatof hip dislocation: a fall on a flexed knee and hip with a posteriorly directed force.



Etiology

The main causes of labral tears include:
1. femoroacetabular impingement,
2. trauma,
3. dysplasia,
4. degeneration,
5. psoas impingement,and
6. hypermobility.


Dysplasia

Labral tears can also occur in association with hip dysplasia.


Degenerative Joint Disease

Osteoarthritis of the hip may affect the cartilage as well as the health of the labrum.


Psoas Impingement

Labral tears typically occur anterosuperiorly in association with femoroacetabular impingement or dysplasia.


Hypermobility and/or Ligamentous Laxity

Atraumatic hip instability may arise from overuse injuries leading to microinstability or from generalized ligamentous laxity.Overuse injuries are common in athletes who participate in sports that involve repetitive axial hip-loading and rotation, suchas figure skating, golf, martial arts, gymnastics, and ballet.



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Tel 079809989421
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