Labral tears and altered motion during loading.

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"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

More anterior hip pain dialogue.

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On a recent podcast we discussed complex hip problems, particularly hip stability and mobility issues lending themselves to anterior hip pain.
We have often mentioned ankle rocker being important in the discovery of hip pain, insufficient rocker can cause some impairments and abilities to get to ample hip extension function and range.
Here, this slightly older article mirrors a discussion we had on a recent podcast. We discussed the need for balance in the hip. More so, that focusing only on the glutes and hip extension can get one into trouble. One needs to also consider hip flexion skill, endurance and strength. The glutes and the hip flexors are a team to help maintain hip stability, mobility, and centration of the opposing joint surfaces during roll and glide motions. This is some of Shirley Sahrman's work, and others of course. When these component parts are not in harmony, and a loading force potentiates the femoral head towards the anterior labrum, it is the job of the glutes and hip flexors, to name two of the big players, to centrate that femoral head and keep it from impinging, and applying a forward load especially when this occurs during end motion loading into hip flexion and extension. I came across an article a while back that suggested these anterior directed movement risks are greater when the limb is loaded from being externally rotated, such as when making a strong power move or "cut" off the stance leg into the contralateral direction (we are looking for that source).
The bottom line is pretty simple, create sufficient stability to endure the loading challenge, but have enough strength and skill to still enable safe mobility. That being said, it is the diagnostics and the remedy that can be the tricky and challenging part of this game.

Anterior hip joint force increases with hip extension, decreased gluteal force, or decreased iliopsoas force. Lewis CL1, Sahrmann SA, Moran DW. J Biomech. 2007;40(16):3725-31. Epub 2007 Aug 17.

"Abnormal or excessive force on the anterior hip joint may cause anterior hip pain, subtle hip instability and a tear of the acetabular labrum.

We found that decreased force contribution from the gluteal muscles during hip extension and the iliopsoas muscle during hip flexion resulted in an increase in the anterior hip joint force. The anterior hip joint force was greater when the hip was in extension than when the hip was in flexion."

Podcast 73: Cross Fit and Squatting. Knees out ?

Podcast 73: Femoral and Tibial Torsions and Squatting: Know your Squatting Truths and Myths

*Show sponsor: www.newbalancechicago.com

Lems Shoes.  www.lemsshoes.comMention GAIT15 at check out for a 15% discount through August 31st, 2014.

A. Link to our server: http://traffic.libsyn.com/thegaitguys/pod_74f.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-73-cross-fit-squatting-knees-b. out

iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

1. Bioengineers create functional 3D brain-like tissue   http://www.nih.gov/news/health/aug2014/nibib-11.htm

2.  A Novel Shear Reduction Insole Effect on the Thermal Response to Walking Stress, Balance, and Gait
 
3.  Hi Shawn and Ivo, There is a lively debate in the Crossfit community about “knees out” during squatting. I have attached a blog post. It might be a good blog post or podcast segment. 
 
4. Shoe Finder ?
 
5.  Michael wrote: “I know this is too broad a topic for facebook, but I was wondering what your general recommendation would be for someone with flat feet and exaggerated, constant over-pronation. I’ve tried strengthening my calves and ankles, but have seen no noticeable reduction in the automatic "rolling in” of my feet whenever walking or standing. I can consciously correct the over-pronation, of course, but as soon as I stop tensing my arch muscle, everything flops back down.“
Got Hip Pain ? Attention Runners and Athletes with Hip Pain.  
 Compensatory joint motions are quite often a source of a person’s pain. Shirley Sahrmann named her hip syndromes for the direction of the movement most consistently associated with pain. In a recent CME presentation we did for    www.onlineCE.com    we discussed the accessory movements found with the hip. 
  Lets look at the known normal biomechanical facts:  
 During hip flexion the accessory motion is posterior glide of the femoral head. 
 Hip extension: accessory motion is anterior glide of the femoral head. 
 Hip medial (internal) rotation: accessory motion is posterior glide of the femoral head. 
 Hip lateral (external) rotation: accessory motion is anterior glide of the femoral head. 
 Hip abduction: accessory motion is inferior glide of the femoral head. 
 Hip adduction: accessory motion is superior glide. 
 Impairment, either from joint/bony deformation (ie. torsions) or from functional muscular asymmetry, can lead to impairment of the accessory motions (compensation) that are necessary for clean joint function.  This can lead to pain.  
 For you clinicians out there, knowing your hip torsions and versions will impact the amount/degree of these accessory motions. This is why we harp on knowing your fixed anatomic variants.  (You can find discussions on these in our prior blog posts and on previous recorded  www.onlineCE.com  teleseminar presentations.) For example, reduced medial rotation at the hip (usually met with increased external rotation) is often seen in people with retrotorsion of the femur. Said another way, when your client has impaired medial or lateral hip rotation you must go beyond looking at the muscles at some point and consider whether they have a form of ante or retro torsion. 
 Hip extension is a critical part of normal human ambulation, whether you are walking or running.  Normally the hip, when moving into extension during the final propulsive phase of ambulation, allows for the femoral head of the hip to glide anterior in the socket (acetabulum). This reduces labral RIM pinch (RIM Syndromes) and allows for greater safe extension range. If hip extension range is impaired then this accessory motion of anterior glide can be impaired and lead to compensation and pain. 
  Think about this:  
 What if the quadriceps are tight ? 
 What If the Glutes are weak ? 
 What if rotational muscles are short ? 
 What if ankle rocker (dorsiflexion) is impaired ? 
 What if there is neuro-inhibition from joint pain (ie. osteoarthritis or joint mal-centration etc) ? 
 What if there is imbalance and weaknesses about the hip ? 
 What if there are other faulty movement patterns ? 
 What if there is one of the femoral torsions present ? 
 Much of this is “chicken or the egg”, who came first ?  These “what ifs” are what make practicing medicine difficult and a real challenge. Some of these issues can be found during functional movement assessments, but some of them will be missed if that is all you are doing. These issues may be what separates the good clinician, therapist, coach or trainer from the “not so good”. Knowing if a person has an impaired rolling pattern (see here  http://youtu.be/dqnR0EcW2YY ) is great to know, but knowing if the lower limb driver is off because the hip cannot internally rotate is even greater. Merely giving the person the homework of practicing and repeating the rolls on the impaired driver side without assessing all of the parts (for example some of the issues above) may cause you to miss the boat, or to engrain a new faulty motor pattern.   
   Knowledge is prince, application of knowledge is king.   
 Next week we will begin a blog post a week on the biomechanics of the hip. We hope you will join us. 
 Shawn and Ivo 
   Here are some of our prior blog posts to add and deepen this dialogue:  
   http://thegaitguys.tumblr.com/post/7493909435/the-hip-part-1-hip-labral-tears-the-rim-syndromes  
  http://thegaitguys.tumblr.com/post/7533986761/ars-acetabular-rim-syndromes-hip-pain-some  
  http://thegaitguys.tumblr.com/post/7573791535/the-hip-part-3-more-on-hip-rim-syndromes-and-labral

Got Hip Pain ? Attention Runners and Athletes with Hip Pain.

Compensatory joint motions are quite often a source of a person’s pain. Shirley Sahrmann named her hip syndromes for the direction of the movement most consistently associated with pain. In a recent CME presentation we did for www.onlineCE.com we discussed the accessory movements found with the hip.

Lets look at the known normal biomechanical facts:

During hip flexion the accessory motion is posterior glide of the femoral head.

Hip extension: accessory motion is anterior glide of the femoral head.

Hip medial (internal) rotation: accessory motion is posterior glide of the femoral head.

Hip lateral (external) rotation: accessory motion is anterior glide of the femoral head.

Hip abduction: accessory motion is inferior glide of the femoral head.

Hip adduction: accessory motion is superior glide.

Impairment, either from joint/bony deformation (ie. torsions) or from functional muscular asymmetry, can lead to impairment of the accessory motions (compensation) that are necessary for clean joint function.  This can lead to pain. 

For you clinicians out there, knowing your hip torsions and versions will impact the amount/degree of these accessory motions. This is why we harp on knowing your fixed anatomic variants.  (You can find discussions on these in our prior blog posts and on previous recorded www.onlineCE.com teleseminar presentations.) For example, reduced medial rotation at the hip (usually met with increased external rotation) is often seen in people with retrotorsion of the femur. Said another way, when your client has impaired medial or lateral hip rotation you must go beyond looking at the muscles at some point and consider whether they have a form of ante or retro torsion.

Hip extension is a critical part of normal human ambulation, whether you are walking or running.  Normally the hip, when moving into extension during the final propulsive phase of ambulation, allows for the femoral head of the hip to glide anterior in the socket (acetabulum). This reduces labral RIM pinch (RIM Syndromes) and allows for greater safe extension range. If hip extension range is impaired then this accessory motion of anterior glide can be impaired and lead to compensation and pain.

Think about this:

What if the quadriceps are tight ?

What If the Glutes are weak ?

What if rotational muscles are short ?

What if ankle rocker (dorsiflexion) is impaired ?

What if there is neuro-inhibition from joint pain (ie. osteoarthritis or joint mal-centration etc) ?

What if there is imbalance and weaknesses about the hip ?

What if there are other faulty movement patterns ?

What if there is one of the femoral torsions present ?

Much of this is “chicken or the egg”, who came first ?  These “what ifs” are what make practicing medicine difficult and a real challenge. Some of these issues can be found during functional movement assessments, but some of them will be missed if that is all you are doing. These issues may be what separates the good clinician, therapist, coach or trainer from the “not so good”. Knowing if a person has an impaired rolling pattern (see here http://youtu.be/dqnR0EcW2YY) is great to know, but knowing if the lower limb driver is off because the hip cannot internally rotate is even greater. Merely giving the person the homework of practicing and repeating the rolls on the impaired driver side without assessing all of the parts (for example some of the issues above) may cause you to miss the boat, or to engrain a new faulty motor pattern. 

Knowledge is prince, application of knowledge is king.

Next week we will begin a blog post a week on the biomechanics of the hip. We hope you will join us.

Shawn and Ivo


Here are some of our prior blog posts to add and deepen this dialogue:

The Hip, Part 3: More on Hip Rim Syndromes and Labral Tears

Tomorrow, in Part 4 (the last part), we will talk about functional hip problems in runners and cyclists but today we will finish up this little topic on some of the internal hip derangements. For tomorrow, remember our key words from the other day, INTERNAL HIP ROTATION range……. it is important stuff when we discuss gait and the hip problems that result from pathologic gait patterns.

________________________________

Labral detachments and tears are the most common clinically significant abnormalities to be identified.  To date it still seems that evaluation of the patient with chronic mechanical hip pain remains somewhat of a diagnostic dilemma for physicians.  The differential diagnosis is diverse including common entities such as osteoarthritis, fracture, and avascular necrosis, as well as less common entities including pigmented villonodular synovitis, synovial osteochondromatosis, snapping hip syndrome, and hemorrhage into the ligamentum teres.  Childhood disorders such as Perthes disease and dysplasia also need to be considered with adolescents. Similar to findings in the knee and shoulder, radiographs appear normal in the vast majority of patients with internal derangement as a cause for hip symptoms. In one study, labral lesions were identified at arthroscopy in 55% of patients with intractable hip pain. 

Imaging: As with other joints in the body, magnetic resonance (MR) arthrography of the hip has emerged as a technique for diagnosis of internal derangement of the hip.  In addition to depicting labral lesions, MR arthrography may also depict intraarticular loose bodies, osteochondral abnormalities, and abnormalities of the supporting soft-tissue structures. Radiographs in patients with labral tears are typically unremarkable. If early osteoarthritic disease is present, the pain is out of proportion to the radiographic changes.

Labral lesions have a strong correlation with symptoms such as:  anterior inguinal pain, painful clicking, transient locking. “giving way” of the hip. Pain may be reproduced with flexion and internal rotation of the hip. An audible click may also be present at times. The patient history usually does not reveal significant trauma. The onset of pain may be related to sports and may involve a mild twisting or slipping injury.  Major trauma such as dislocation may result in labral tear.


Patients with developmental dysplasia of the hip are at increased risk for labral tears and abnormalities of the labral rim. The Rim syndromes are categorized by two types of acetabular dysplasia;  one being the incongruent oval shaped acetabulum the other being the congruent, spherical acetabulum with poor lateral coverage of the femur head which leads to fatigue fractures of the acetabulum socket and articular and interosseous cyst formation. In patients with developmental dysplasia, the acetabular rim and the labrum are placed under increased stress. 
The possibility of a pathologic labral condition should be considered in individuals with developmental dysplasia of the hip in whom the pain is disproportionate to the radiographic changes, as well as in patients who have not experienced significant improvement after osteotomy. The fact that a detached labrum increases the risk of failure of treatment has been recognized.

Summary:
Mechanical hip pain can be a real enigma unless your doctor really knows their stuff. Not many studies talk about neuromuscular support, muscular function and movement patterns of the hip largely because the education in this area is poor, in our opinion.  Physician skill level with years of experience is also a real challenge when dealing with mechanical hip pain and the causes (as we have discussed here) of anatomic pathology that might occur when the normal hip mechanics are challenged.  Add an abnormal gait pattern to the mix and it is no wonder why some hip problems go undiagnosed in the early stages of problem.
A pathologic labral conditions, detachments or tears, are a common cause of chronic hip pain, and MR arthrography of the hip is the imaging procedure of choice for identifying an abnormal labrum.  Detachments are more common than tears and are identified on the basis of the presence of contrast material interposed at the acetabular-labral junction. 

_________________________________________________________
There is not a ton of literature out on the Rim syndromes, since some of you have been asking about it.  Here is an article we found. Link for article purchase is at the header of today’s blog.
J Bone Joint Surg Br. 1991 May;73(3):423-9.
The acetabular rim syndrome. A clinical presentation of dysplasia of the hip.
Klaue K, Durnin CW, Ganz R.
Abstract
The acetabular rim syndrome is a pathological entity which we illustrate by reference to 29 cases. The syndrome is a precursor of osteoarthritis of the hip secondary to acetabular dysplasia. The symptoms are pain and impaired function. All our cases were treated by operation which consisted in most instances of re-orientation of the acetabulum by peri-acetabular osteotomy and arthrotomy of the hip. In all cases, the limbus was found to be detached from the bony rim of the acetabulum. In several instances there was a separated bone fragment, or ‘os acetabuli’ as well. In acetabular dysplasia, the acetabular rim is subject to abnormal stress which may cause the limbus to rupture, and a fragment of bone to separate from the adjacent bone margin. Dysplastic acetabuli may be classified into two radiological types. In type I there is an incongruent shallow acetabulum. In type II the acetabulum is congruent but the coverage of the femoral head is deficient.