The Injury Clinic - The Bradford Injury

Well, thankfully its been a while but unfortunately its time for another Injury Clinic write-up.

Earlier this week it was revealed that TB Allen Bradford has a labral tear in his hip. This is a NEW injury in regards to its name recognition but it has been around for a while.This is the same injury that has also affected a number of other SC players recently.

The orthopedic community has done a much better job at identifying the injury and the treatment options has significantly improved.

So, lets take a look at it.

First, the Anatomy...


The acetabular labrum is a ring of fibrocartilage that attaches to the circular outer edge of the acetabulum (hip socket). It is made of alternating layers of Type I collagen fibres and hyaline cartilage matrix orientated in the direction of functional stress. A spur of bone extends from the acetabulum into the labrum to increase stability. The labrum has a highly variable shape and three surfaces:

- - a basal surface which connects the labrum to the acetabular bony rim

- - an internal articular surface which is in continuation with the articular surface of the acetabulum

- - an external surface where the hip joint capsule attaches.

A network of blood vessels enter the outer third of the labrum on the external surface only. The lack of blood supply to the inner two-thirds is thought to impede healing after injury. Free nerve endings are found throughout the acetabular labrum but are most densely packed in the anterior and superior quadrants.

The main function of the acetabular labrum is to improve hip joint stability in two ways. Firstly it deepens the hip socket, providing it with extra structural support. Secondly it partially seals the joint to create a negative intra-articular pressure which counteracts any distractive (pulling-apart) forces.

A second important function of the acetabular labrum is to increase joint congruity. After removal of the labrum the frictional force between the femoral and acetabular articular surfaces is increased by up to 92%, showing that the labrum plays an important role in the even distribution of forces across the articular surface.

This is not the same type of injury as say a meniscal tear in the knee. That sort sort of injury is usually the direct result of a traumatic twisting of knee.

From the Mayo Clinic's website.

A tear in your labrum, known as a hip labral tear or acetabular labral tear, can result from injury, repetitive movements that cause wear-and-tear on your hip joint, or degeneration, such as from osteoarthritis.In many cases, a hip labral tear causes no signs or symptoms and doesn't require treatment. Occasionally, however, a hip labral tear may cause pain or a "catching" sensation in the hip joint.

Many hip labral tears cause no signs or symptoms. Occasionally, however, you may experience one or more of the following:

  • A locking, clicking or catching sensation in your hip joint
  • Pain in your hip or groin
  • Stiffness or limited range of motion in your hip joint

The labral tear in the hip is not something that just happens because of repetitive motion or join reaction forces. It is usually caused by Femoro-acetabular impingement (FAI). Other reasons for FAI are capsular laxity, dysplasia, and trauma.

From the Hospital for Special Surgery website.

Femoro-acetabular impingement (FAI) occurs when the ball (head of the femur) does not have its full range of motion within the socket (acetabulum of the pelvis).

Impingement itself is the premature and improper collision or impact between the head and/or neck of the femur and the acetabulum. This causes a decreased range of hip joint motion, in addition to pain. Most commonly, FAI is a result of excess bone that has formed around the head and/or neck of the femur, otherwise known as "cam"-type impingement. FAI also commonly occurs due to overgrowth of the acetabular (socket) rim, otherwise known as "pincer"-type impingement, or when the socket is angled in such a way that abnormal impact occurs between the femur and the rim of the acetabulum.

The reason orthopedic surgeons have become better at diagnosing and treating this injury is because of better MRI capabilities. Once they have identified it they then can address a specific course of treatment.

Gr1-med_medium  Fai_2_medium

 

Symptoms and Diagnosis:

The presentation of acetabular labral tears is very inconsistent but the most common complaint is a sharp groin pain after trauma. Other possible sites of pain are the anterior thigh, greater trochanter and buttock region. Other symptoms include clicking, locking and ‘giving way’ of the hip. The pain may be reproduced in sport by weight-bearing activities that require twisting, such as kicking a football.

Examination of the hip is often entirely normal with a full range of movement. There are specific tests for a labral tear. The impingement test (flexion, adduction and internal rotation of the hip joint) commonly produces pain or a clicking sensation when an antero-superior tear is present. The McCarthy test involves flexing both hips and then extending the affected hip patients with a labral tear will feel a catch. Passive hyperextension, abduction and external rotation elicit pain with a posterior tear.

Treatment- Non-Surgical:

Non-surgical treatment is always the first choice in treating these types of injuries Many labral tears may become asymptomatic, and these do not need specific treatment. However, for athletes with persistent pain from labral tears, there are many treatment options. Physical therapy is used to improve hip range of motion and strengthen the muscles around the hip joint. Pain medications such as anti-inflammatories can be used to decrease inflammation around the labrum and provide pain relief.

Treatment- Surgical:

Hip Arthroscopy

If non-surgical treatment is not effective then surgery is often indicated. The most effective way to address this injury is Hip Arthroscopy. This is very similar to the technique of Knee Arthroscopy but the set up and and actual procedure is much more involved.

Surgery_setup_smaller_medium

As you can see, this is a little more involved than a typical knee arthroscopy. From HSS

From the Arthroscopy Association of North America (AANA)

Arthroscopic management consists of debridement and repair. The goal of arthroscopic debridement of a torn hip labrum is to relieve pain by eliminating the unstable flap tear that causes the observed hip discomfort. The surgical technique of a hip labral tear repair depends on the nature of the labral injury. There are at least two distinct types of acetabular labrum tears.

Type I consist of a detachment of the labrum at the zone of transition to the articular hyaline cartilage and require reattachment to the acetabular rim, usally with anchor.

On the other hand,Type II tears are intrasubstance splits with one or more cleavage planes can be repaired with a suture lasso technique and a bioabsorbable suture.

Images of the arthroscopic repair.

Figure1_medium Figure2_medium Figure1_medium

This is a great video of the procedure.

From the Southern California Orthopedic Institute (SCOI)

Post-operative Care:

After the surgery, the patient will be on crutches for two to six weeks; this is determined on a case by case basis. Physical therapy is used to improve the hip range of motion and muscle strength around the hip. Once a patient is free of symptoms and has regained their strength, they can return to play, which is usually between two and six months, depending on the extent of the injury.


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