Labral tears and altered motion during loading.

"One might argue, that we sit the majority of our days with our femur and thus our femoral head pressed forward into the anterior and roof of the acetabulum. This becomes particularly suspect when in a conforming chair, such as a "bucket" seat in a car." -Shawn Allen

This article follows nicely with yesterday's post about hip joint control and anterior hip pain.

The premise behind this study referenced below was to determine if contact forces and electromyography (EMG) muscle amplitudes were altered during lunging activities in clients with painful labral tears compared to hose who are symptom free.
The unsurprising conclusions of this study ("contact forces and EMG muscle amplitudes are altered during the lunge for patients with symptomatic labral tears") are mostly predictable. But one should, we would hope, propose the chicken or the egg theory here.  Are these clients having pain because they are loading into the labral tear, or is the pain from poor joint stabilitation (and thus possible impaired normal mobility and motion) which incidentally lead to the labral loading and thus tear ?  We propose this one all the time. Why? Because we get a decent population of clients with typical "suspect" anterior hip labral pain and after rehabbing them, the pain resolves. So in these cases, was it a labral tear? Labral irritation? Or just a faulty loading response?
*However, we also get enough clients who present with an MRI in hand that confirms a labral tear, and we take them through the same process, and many of them also stabilize and have pain resolved. This then proposes the end question from them "So, was my pain from the labral tear at all? Or was it because had a poor stabilization capability, which lead to the tear/irritation?" 
And that folks, is the big question that has to be asked in all cases, and that is the unanswerable question.  But, should the process change regardless? If your client is going to head into surgery for the tear, should they not be fully rehabbed in the first place? And if the rehab works, is surgery even necessary ?  In the successful cases, we just stare openly at the client and smile, we let them answer the question. After all, they know the answer anyways.

Make no mistake. not everyone responds to our, or your, care. And, not every labral tear is incidental. Not every labral tear is undamaging to the femoral head and to the longer term health of the joint.  But, taking a few weeks and dedicating some good work into your client's skill, endurance, strength, power and loading responses often either give your client answers or prepare them for a great outcome post-operatively. 

In a nut shell, these can be tricky challenging cases. People sit and use the glutes as a cushion all day. We sit the majority of our days with our femur and thus our femoral head pressed forward into the anterior and roof of the acetabulum (depending on our sitting posture and chair choice).  They load similarly in their cars in challenged ways. They do not move well or often enough. They have weak glutes and abdominals and their ability to control the pelvis in safe loading is poor.  So many patients, and non-patients are on this bus, in fact, the majority of us are on it as well.  It feels like we are seeing more and more of these anterior hip problems, and we are not surprised as the average human moves less, is getting weaker and less durable and robust physically, and they sit more, and drive more.  This anterior hip pain clinical entity should really be no surprise to anyone anymore.
To be thorough, this study did "surface electromyography electrodes were placed over the gluteus medius, gluteus maximus, adductor longus, and rectus femoris muscles of the patients' involved limb and matched limb of asymptomatic controls."  This makes this an incomplete study with incomplete conclusions. As we said yesterday, without information on the mighty psoas and iliacus to name a few other big players, this study is somewhat suspect, but overall, we do not thing the results would come out too terribly different.

-Shawn and Ivo, the gait guys

Do Neuromuscular Alterations Exist for Patients With Acetabular Labral Tears During Function?
Arthroscopy. 2016 Jun;32(6):1045-52. doi: 10.1016/j.arthro.2016.03.016. Epub 2016 Apr 27.  Dwyer MK1, Lewis CL2, Hanmer AW3, McCarthy JC4.

https://www.ncbi.nlm.nih.gov/pubmed/27129378

“When you run up a hill, most of the cross over gait disappears. Runners will tend toward beautifully stacked lower limb joints.”- Dr. Allen

Are people running up a hill more likely to tend towards a cross over gait style, in other words tend toward a more narrow gait step or a wider gait step ?

Watch people run up hill closely. Even if they are cross over (narrow foot fall) runners, when running up hills a few things will negate much of the narrow foot fall.

1- Running up hill requires more gluteals, more power is needed for all that extra required hip extension to power up the hill. More gluteal max use can, and will, spill over into the posterior fibers of the gluteus medius and this will tend to abduct the leg/hip and reduce some of the cross over tendency.

2- When one runs up a hill, there is a forward pitch of the upper torso, often with a some degree of forward pitch occurring at the hips. More importantly, because one is running up hill, they are stepping up and so more than normal hip flexion is necessary than in normal running. The forward pitch of the body and the greater degree of hip flexion is the culprit here. If the hip/leg is adducted in a cross over style, adding this to a more than normal flexing hip, it will create a scenario for anterior hip impingement and risk of femoral acetabular impingement (FAI) syndromes. Go ahead, test it for yourself. Lie on your back and flex your hip, drawing your knee straight up towards your shoulder.  Pretty good range correct ?  Now, flex the hip drawing your knee towards your navel, adducting it a little across your body. Feel the abrupt range of motion loss and possible pinch in the front of the hip ?  FAI.  This is what would happen if you utilized a cross over gait, narrow foot strike gait. The goes for mountain/sleep hill hikers as well. 

This is why, if you are a narrow foot striker, a near-cross over type of runner, you will see it disappear when you run up hills.  

If you get anterior hip pain running up hills, force a wider step width and reduce the possible impingement at the anterior hip joint. Just make sure you have enough ankle dorsiflexion to tackle the hill in the first place. If not, you may welcome some foot and ankle stuff to the table along with the hip.  

Likely obvious stuff to most of the readers here, but sometimes it is nice to point out the obvious.  Hills, just because they are there, doesn’t mean you have the parts to run them safely.

Dr. Shawn Allen