Conservative Management of Acetabular Labral Tears for Return to Sport

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Conservative Management of Acetabular Labral Tears for Return to Sport

Yana I. Ginzburg, SPT

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Background

I have a special interest in sports medicine rehabilitation and injury prevention. This project grew out of my initial curiosity as to the prospects of return to sport for a specific case of a runner with a labral tear. This led to the completion of a Critically Appraised Topic (CAT) in the fall of 2018, comparing conservative and surgical management on long term outcomes for a return to running for a patient with a labral tear. The clinical bottom line was as follows: “Current research suggests that physiotherapy may be more effective than surgical management for return to sport after an acetabular labral tear, although no information exists regarding long term joint damage with either intervention. Evidence for this topic is lacking in quality, specific patient characteristics potentially affecting outcomes, as well as long-term data.”

Additionally in the fall of 2018, I had the pleasure of taking the Teacher-Scholar elective and assisting with components of the Musculoskeletal II course for the second year SPTs in the UNC DPT program. As part of the course requirements, I worked with Jon to develop a short lecture on a selected topic of interest. My topic of choice was “Labral Tears and Femoral Acetabular Impingement (FAI)”. Thus, I further familiarized myself with the literature for this condition, but from a different perspective than my (at the time) concurrent CAT project. The lecture presentation that I ultimately delivered to the DPT2’s featured information tailored to a novice clinician about hip anatomy, risk factors for labral tears, incidence/prevalence, information about examination, and potential preliminary treatment ideas.

Simultaneously completing my CAT and Teacher-Scholar lecture presentation, I began to acknowledge that while conservative management is potentially of benefit for this population, there is extremely limited information regarding what specific treatments or types of treatments are effective. Furthermore, there is no literature for treatment trajectories for an athlete with intentions of return to sport with this condition. This led to conversations with clinicians working with patients with labral tears, who acknowledged the limited research in this area as well as challenges with rehabilitation for this population. These dialogues further convinced me of the significant utility of a project creating a treatment paradigm for an athlete with an acetabular labral tear and intentions of return to sport.

Equipped with thorough background knowledge as well as a personally vested interest in the topic, I began my research project outlining a multi-faceted and evidence-based rehabilitation program for this population.

Purpose

There is a paucity of high-quality evidence based information regarding conservative management for hip acetabular labral tears. The majority of the pertinent research in this domain is contained in low level evidence of case series, case studies, and expert opinion. Additionally, much of this data is present in those who concurrently have Femoral Acetabular Impingement (FAI). While those with FAI make up a large percentage of individuals with acetabular labral tears, there is also a subset of people who solely have labral tears without associated FAI. Labral tear etiologies other than FAI include trauma, dysplasia, degeneration, and excess hip mobility/micro instability.¹ The effects of these latter etiologies can be compounded with the repetitive forces secondary to certain athletic activities. Thus, the purpose of this project is to explore labral tears from a clinical perspective – seeking the information concerning these injuries in specific sports, as well as synthesizing a summary of a rehabilitation program for return to sport for this population.

Project overview

I began developing this project by conducting a literature review of hip anatomy and biomechanics, predisposing risk factors for acetabular labral tears, and common examination and evaluation findings upon clinic presentation. Successively, I began investigating the influence of sport participation on the development of an acetabular labral tear without associated FAI. The most frequently affected sports were soccer, hockey, ballet, golf, gymnastics, baseball, martial arts, and running. I looked specifically at studies researching the prevalence of this injury in the specific sport population, as well as what particular biomechanics or sport specific movements may be injurious.

I compiled a list of all available evidence for conservative management of an acetabular labral tear. The final list of evidence (updated most recently in April 2019), ranked from highest to lowest on the quality of evidence pyramid,² featured:

• CPG for non-arthritic hip pain (level 1 evidence)
  • 2014, non-specific to acetabular labral tears³
• 2 case series (level 4 evidence)
  • 2018, six subjects⁴
  • 2011, four subjects⁵
• 4 case studies (level 5 evidence)
  • 2014, one figure skater subject⁶
  • 2015, one hockey player subject⁷
  • 2015, one ballet subject⁸
• Expert opinions and clinical commentary (level 5 evidence)
  • 2006 and 2007, Lewis and Sahrmann^9,10
  • 2008, Brigham and Women’s Hospital¹¹

Subsequently, I synthesized various components of all of the material to create a multi-faceted rehabilitation program. This program was revised with the clinical practice expertise from committee members. It includes –

1) Pain control

2) Biomechanical corrections

3) Maintenance of endurance

4) Mobility

5) Neuromuscular control

6) Strengthening

7) Sport specific functional progression and utilizing the return to play decision making (StARRT) framework

This information will be delivered as a presentation at an in-service at the Duke Sports Medicine Physical Therapy clinic this summer. This is an outpatient sports/orthopedic clinic with a large athletic population. It has a close relationship with several of the local high schools, so many of the high school aged athletes in Durham and Cary seeking sports therapists choose this clinic for their services. Thus, there is a large influx of young athletes seeking conservative management for their musculoskeletal conditions. As acetabular labral tears are theorized to account for upwards of half of the pathologies causing hip and/or groin pain,¹² it is likely that this patient population is presenting in this clinic.

Products

The main product of this capstone project is a presentation, titled “Conservative Management of Acetabular Labral Tears for Return to Sport”. It is presented here in its thorough entirety but will be tailored and shortened to fit the time and content needs of my in-service attendees.

Additionally, I have created a patient education handout, titled “Hip Labral Tears: A Patient’s Guide”. It is intended as a resource to address common patient questions and concerns about an acetabular labral tear.

Evaluation

I deliberately seek feedback and thrive on receiving information both as to the content of my presentations as well as my presentation skills. Thus, I developed a Capstone Presentation Feedback Form that I will print and hand out to the attending individuals at my in-service. It features a quantitative numerical rating scale for assessment of specific characteristics of my presentation, as well as includes room for additional qualitative comments.

I anticipate attendance of 30-40 therapists so this will likely provide me with a significant amount of feedback. Adjunctively, I have made a spreadsheet to compile and organize the information from these reviews. I can utilize it to calculate the areas for most improvement. In the future, I can use this information to improve both my presentation content as well my professional presentation skills.

Reflection

I chose this topic for my capstone because the information to guide clinical decision making for this population is severely limited. While we often speak of the benefit of physical therapy, the generalities (and sometimes altogether vagueness) of its benefit can be frustrating for a clinician. My goal was to provide an evidence based treatment guideline with concrete ideas for treatment, as well as treatment variations, that can be tailored to diverse types of athletes and numerous clinical presentation dysfunctions. I look forward to encouraging further dialogue of other therapists’ experiences during my in-service, as well as incorporating their feedback into future variations of this presentation.

In the coming months, I will be starting a sports medicine residency and likely seeing this patient population frequently. I hope that this presentation, as well as all of its associated materials, can be of benefit not only for me but also for my current and future colleagues.

I am very much looking forward to seeing new research developments in this area over the coming years.

Acknowledgements

Firstly, I would like to thank my advisor, Michael Gross, PT, PhD, FAPTA, for his evaluations of this project from inception to finish. He generously made himself available to answer my multitudes of both generalized and pointed questions, as well as provided valuable benefit as to the direction that this project should take. I greatly appreciate his ambition in potentially looking to get this synthesis published.

The contributions of Jon Hacke, PT, DPT, MA, are not only those of a committee member but also those of a mentor. My interest for this topic began to take serious shape during my work with him during the Teacher-Scholar elective last fall. I am forever indebted to him for his allowing me to pick labral tears as my topic of interest for the creation of my MSKII lecture, which eventually led me to the realization of my sincere curiosity about this topic. Ultimately of course, this evolved into my capstone. The process of its formation was not without some discrepancies between the literature and clinical practice (tolerance for ambiguity!!) and thus I greatly appreciate his critical thought and its application to my synthesis. His generosity with his time, forever present patience and wisdom, as well as genuine skill in mentorship, will forever stay with me as I begin my professional career in just a few short months.

This project would not have been possible without the clinical expertise of Nicole Durand, PT, DPT, OCS. Her firsthand knowledge of this injury, stemming from her time at Brigham and Young Hospital where this population was frequently seen for conservative management, was invaluable in the development of this synthesis. I cannot thank her enough for her time in reviewing of my materials, sharing of resources, and additionally taking the time to meet and discuss the content thoroughly. I am so genuinely grateful (and incredibly impressed!!) for the time that she dedicated to this project despite a full time clinical load and active pursuit of an additional graduate degree. I look forward to doing an in-service together at UNC.

An additional note of thanks to Dr. Ellen Shanley, PT, PhD, OCS, who during my residency interview allowed our conversation to flow into a digression about formulating clinical decisions for allowing an athlete to return to sport. This came at an opportune time, as I had been somewhat stumped as to how to incorporate decision making for return to play (after the course of acetabular labral tear rehabilitation) into my treatment paradigm. It is thanks to her that I was initially introduced to Ian Shier’s StAART framework and was ultimately able to utilize it as a component of my capstone project.

Lastly, to anyone and everyone who has heard me (passionately) chatter about this topic (and an extra shout-out of gratitude to Alex and Liv for the volume of this that they have tolerated) – thank you for your kindness and patience in allowing me to express my thoughts. I am incredibly thankful for your time and never-ending encouragement.

Overall, I cannot thank these individuals enough for their countless words of wisdom and the amount of time that they have spent in providing support as well as guiding me in the development of this project.

Direct links

Critically Appraised Topic (CAT)

“Labral Tears and Femoral Acetabular Impingement (FAI)” Teacher-Scholar elective presentation

“Conservative Management of Acetabular Labral Tears for Return to Sport” Capstone presentation

“Hip Labral Tears: A Patient’s Guide” Capstone patient education handout

Capstone Presentation Feedback Form and spreadsheet for evaluation

References

1. Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2(2):105-117.
2. Portney LG, Watkins MP. Foundations of clinical research : applications to practice.2nd ed. Upper Saddle River, N.J.: Prentice Hall Health; 2000.
3. Enseki K, Harris-Hayes M, White DM, et al. Nonarthritic hip joint pain. J Orthop Sports Phys Ther. 2014;44(6):A1-32.
4. Narveson JR, Haberl MD, Nathan Vannatta C, Rhon DI. Conservative Treatment Continuum for Managing Femoroacetabular Impingement Syndrome and Acetabular Labral Tears in Surgical Candidates: A Case Series. Int J Sports Phys Ther. 2018;13(6):1032-1048.
5. Yazbek PM, Ovanessian V, Martin RL, Fukuda TY. Nonsurgical treatment of acetabular labrum tears: a case series. J Orthop Sports Phys Ther. 2011;41(5):346-353.
6. Liem BC, Loveless MS, Apple EL, Krabak BJ. Nonoperative management of acetabular labral tear in a skeletally immature figure skater. PM R. 2014;6(10):951-955.
7. MacIntyre K, Gomes B, MacKenzie S, D’Angelo K. Conservative management of an elite ice hockey goaltender with femoroacetabular impingement (FAI): a case report. J Can Chiropr Assoc. 2015;59(4):398-409.
8. Khoo-Summers L, Bloom NJ. Examination and treatment of a professional ballet dancer with a suspected acetabular labral tear: A case report. Man Ther. 2015;20(4):623-629.
9. Lewis CL, Sahrmann SA, Moran DW. Anterior hip joint force increases with hip extension, decreased gluteal force, or decreased iliopsoas force. J Biomech. 2007;40(16):3725-3731.
10. Lewis CL, Sahrmann SA. Acetabular labral tears. Phys Ther. 2006;86(1):110-121.
11. Brigham-and-Women’s-Hospital. Standard of Care: Acetabular Labral Tears (Non-Operative Treatment). 2014.
12. Reiman MP, Mather RC, 3rd, Hash TW, 2nd, Cook CE. Examination of acetabular labral tear: a continued diagnostic challenge. Br J Sports Med. 2014;48(4):311-319.

*Header image courtesy of: https://hipdysplasia.org/adult-hip-dysplasia/related-adult-hip-disorders/torn-labrum/