Physical Therapy Management of Hip Labral Tears

Physical Therapy Management of Hip Labral Tears
A hip labral tear is a mechanically induced pathology that could predispose one to develop osteoarthritis at the joint. Joint abnormalities or excessive forces at the joint from sudden or repetitive twisting and pivoting motions are known to cause a labral tear. Patients often present with hip or groin pain but differential diagnosis is necessary to confirm the presence of a labral tear. Treatment for a labral tear is dependent on the severity of the symptoms. Conservative management can be beneficial for some patients while arthroscopic surgery might be indicated for others to repair or remove the torn labrum. Potential impairments seen in patients with a labral tear are as follows: • Pain • Decreased ROM • Decreased muscle strength • Posture dysfunction • Impaired muscle performance • Limited function • Knowledge deficit regarding condition, self-management, home program, prevention Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction* Expected range of number of visits per episode of care: 3 to 36 Pattern 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery* Expected range of number of visits per episode of care: 6 to 70 *APTA membership required to gain full access to the guide online. Rehabilitation The goals for physical therapy management is specifically designed in accordance to individual patient symptoms. Below listed are the overarching goals usually identified for patients with a hip labral tear: Independent self-management of pain, posture, joint protection. Decrease pain Increase ROM Increase strength Improve gait efficiency and quality Maximize function and return to previously active lifestyle Independence with home exercise program PT interventions should correspond to the goals identified for each individual patient. It may include the following: Aerobic capacity/endurance conditioning or reconditioning Balance Body mechanics and postural stabilization Flexibility exercises including stretching and range of motion exercises Gait and locomotion training Relaxation Strength, power, and endurance training Avoid sitting - with knees lower than hips - with legs crossed or sitting on legs so that the hip is rotated - on the edge of the seat and contracting the hip flexor muscles - with pressure on the femur, which can cause forces into the hip joint; instead, the pressure should be on the ischial tuberosity. A pad may be placed under the ischial tuberosities to correct the problem of increased pressure on the femurs. Patients who are overweight and who have large thighs should be encouraged to lose weight to avoid the altered alignment of the femur in sitting. When getting up from a chair that is behind a desk or out of a car, patients should avoid pushing or rotating the pelvis on a loaded femur When walking on a treadmill, patients must be careful not to let the moving tread contribute to excessive hip hyperextension Patients should avoid weight training of quadriceps femoris and hamstring muscles and avoid any exercises causing hip hyperextension. Patients should avoid active straight leg raises or any type of trunk curl with the hip in flexion greater than 90° to avoid undue compression of the anterior labrum. Any exercises requiring hip extension beyond neutral, such as prone hip extension exercises or lunges, in which the hip on the stance side is hyperextended, also should be avoided. The appropriate physical therapy intervention for a patient with an acetabular labral tear has yet to be established. However, several studies have shown that physical therapy can be beneficial when used appropriately. The goals of physical therapy should focus on reducing forces on the hip by addressing the patterns of recruitment of muscles that control hip motion, by correcting the movement patterns during exercises and during gait, and by instruction in the avoidance of pivoting motions in which the acetabulum rotates on the femur, particularly under load. Gait training with an assistive device (e.g., cane, crutch) may be necessary to temporarily reduce the amount of loading on the affected hip. A rehabilitation protocol for nonsurgical treatment of acetabular labrum tear by Yazbek et al. is included below. This protocol addresses the potential impairments from a labral tear in three phases over a period of 12 weeks. Phase 1 of the protocol consisted of pain control, education in trunk stabilization, and correction of abnormal movement. Phase 2 focused on muscle strengthening, recovery of normal range of motion, and initiation of sensory motor training. Phase 3 emphasized on advanced sensory motor training, with sport-specific functional progression. Image source: Nonsurgical treatment of acetabular labrum tears: A case series. Most prevalent impairments after an arthroscopy includes inflammation, pain, swelling, decreased joint mobility, altered muscle extensibility, impaired muscle strength, altered proprioception, and decreased muscular endurance. Rehabilitation protocols should be designed to address these impairments. Physical therapists should note the location and size of the labral tear, and also the phase of tissue healing to guide the intervention strategies. Weight bearing restrictions indicated by the physician should be followed to allow healing to occur without re-injury. Modalities such as ice, heat, and TENS may be used to reduce pain and swelling. Gentle stretching and flexibility exercises of hip muscle groups including piriformis, psoas, quadriceps, and hamstring muscles should begin with passive range of motion exercises, respecting the patient's pain threshold and by abiding to physician dictated precautions. Strengthening exercises for the hip adductors, abductors, and extensors are introduced at first isometrically with the operated limb in a neutral position, and advanced as tolerated and with regard to weight-bearing status. Strengthening exercises should include core stabilization activities to improve trunk strength in addition to hip muscle strength. Gait training may be necessary to restore normal movement patterns as the individual transitions from using an assistive device to ambulating independently. Balance and proprioception exercises are introduced as hip strength returns, and as weight bearing status allows. Rehab after surgical repair consists of four phases. The goals for each phase as described by Stalzer et. al. is included in the chart below. Additional Protocols The use of electrophysical modalities in the management of hip labral tear is intended to minimize inflammation by decreasing pain and swelling around the injury and by increasing circulation to the joint. Knowledge on the tissue healing process is required to apply these modalities appropriately. Below are the suggested modalities according to the Guide to PT practice. Electrotherapeutic Modalities: Electrical stimulation (Reduces pain, promotes neuromuscular re-education and initiates muscle contractions) electrical muscle stimulation (EMS) functional electrical stimulation (FES) high voltage pulsed current (HVPC) neuromuscular electrical stimulation (NMES) transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Physical agents may include: Cryotherapy (Decreases pain and swelling) cold packs ice massage vapocoolant spray Hydrotherapy (Allows mobilisation without compression through the joint) whirlpool tanks contrast bath pools pulsatile lavage Thermotherapy (Helps to relax and loosen tissues, and to stimulate blood flow to the area) dry heat hot packs paraffin baths Sound agents (Pain management) phonophoresis ultrasound Mechanical modalities may include: Compression therapies (Promote venous return and reduce swelling) compression bandaging compression garments taping vasopneumatic compression devices Mechanical motion devices : (Improve and maintain ROM) continuous passive motion (CPM) The appropriate physical therapy intervention including the use of modalities for a patient with an acetabular labral tear has yet to be established. Since there is little evidence in the current literature to support rehabilitative procedures performed on labral tear patients, the best approach of treatment is adapted based on the physical therapist's clinical experience on what was shown to be beneficial to the patient population. Original article and pictures take http://morphopedics.wikidot.com/physical-therapy-management-of-hip-labral-tears site