We just finished reviewing hip and pelvic disorders in my fellowship right now and I have to say, it is really hitting home for me! I've wanted to write about this for a long time, but I never had enough time to dedicate to it until now. If you want to skip my lame story and read about labral variants and so on, scroll down about half-way.
I dealt with anterior hip pain for probably too long before proceeding with surgical intervention for femoroacetabular impingement (FAI). When I was in the Army, and many years prior to that (starting in middle school), I was an athlete - running, olympic lifting, competitive rowing, consistent yoga practice, basketball, soccer. Here's some pictures, just to reminisce:
I always had some orthopedic complaints from high school onward - ankle sprains, PFPS, low back/SI joint pain, but never anything in my hip until I started rowing again in grad school. I started having inconsistent deep anterior hip pain with rowing, running,
squatting, and really anything that would put my hip into a loaded flexed position. Over time, and after 2 pregnancies, that pain became more prominent, consistent and bothersome with everyday activities - like sitting in a regular chair. A 28 y/o (and everyone at every age, for that matter) should be able to sit without pain, right? Face palm #1.
At the time, I was a busy Army PT and mom to 2 babies under 2, so time was not something I really had, BUT, I was pretty desperate. I did my due diligence and had several friends (PT and ortho) examine me and I even did a full course of PT, because you can't be objective with yourself (at least I can't!). It always improved/calmed down, but I was never able to recover my ability to run and squat (and other things) without creating a flare up. Remember, I was in the Army at the time, so this was a huge issue for me. I ultimately decided to get out of the Army, for more reasons than this, but here's what pushed me over the edge with my stupid hip: my older son, Hunter, had just turned 2 and Jimmy was 5 months old. Little ones require a lot of floor-sitting activities. I started noticing that just sitting on the floor and sitting with my thighs touching was recreating that pinch sensation in my hip and I couldn't tolerate it. I called an ortho surgeon friend and he encouraged me to get it fixed. Side note: he had actually told me to get it fixed several years prior to this point, but you know, I was a new grad PT and thought PT/conservative care fixes everything so.... face palm #2. You get the point.
Jan 30, 2019, my surgery date rolls around. I have the surgery, wake up, and my friend comes in and says "yeah, so you have weird anatomy"... or something along those lines! Exactly what you want to hear following surgery... 3rd face palm of this story. So here's what he meant (excerpt from the op report - excuse the poor picture quality! I took a snap shot of the paper copy that's been sitting around for 2+ years).
I apparently have/had an itty bitty, "extremely diminutive" labrum:
For comparison, here he is normal-sized labrum (1). Please note, although this is normal in size, it's not totally normal. This labrum is a bit more brittle and degenerated (68 y/o) and sort of detached from the acetabular rim. The arrows point to a sublabral cleft. Pretty different from my situation. If interested, you can review this case in the reference below. It's actually pretty interesting.
Now, I know these are different views of different people at different times by different surgeons, but the comparison is just so you can appreciate the size difference.
People need well-functioning labrums! The labrum maintains the fit and congruency of the
hip joint and ensures that a good negative suction is maintained in the intra-articular space. This keeps the synvovium and chrondral surfaces healthy. It also helps maintain stability of the hip, so that there is normal translation of the coxafemoral junction throughout a full functional range of motion. My insufficient labrum wasn't doing what I needed it to do and it was clinically apparent - with long axis traction (which is something I made my husband do for me to get some relief), I could feel my femoral head come way too far out of it's socket. Not normal!
I am not a surgeon, but after having this done, I've spent a lot of time studying labrums (looking at scope pictures and images, reading a ton of studies, commentaries and review articles) and I think that the "extremely diminutive" description was pretty darn justified in my case. What caused this? Who knows?! Mom and Dad, and... in-utero development malfunction... or whatever? No one can really say. All I know is, my mom remembers me sitting with my whole right leg turned inward in a long-sit position as a child. I never had any gait deviations, however.
All I have to say is, thank goodness for healthy cartilage! So my surgeon ends up doing something somewhat novel - a "labralization"(2) of the hip. He bundles up some of the redundant articular cartilage and creates a super awesome, robust, pretty sexy-looking "pseudo-labrum", with my itty bitty (and also worthless) labrum tucked up in there somewhere. Between that, the acetabuloplasty, femoroplasty and capsule closure, I had(have) a pretty darn good outcome. Lots of ups and downs in the rehab process, but overall, much better than pre-op. It took me 2 years to get back to trail running comfortably, but I find that very acceptable, considering I had symptoms for 5 years before surgery and thought I would never run again. Looking back, I wish I would have done it sooner. I do think that I have some long-lasting biomechanical issues from waiting too long, however small, but anywho...
Now, why am I writing about this? I am NOT a surgeon, so I'm not going to talk about the technique or surgical decision-making. If you want to know more about that, read Dr. Matsuda's paper! He goes into detail about technique. There's a link to the full text in my references below.
BUT, I am a DPT and I often see patients with hip pain as a first-contact provider. When indicated, I make referrals to orthopedic surgeons. My little labrum was pretty atypical, but it's still a possibility in the spectrum of FAI/hip disorders, and it was never appreciated or visualized until I got under a scope. So how can non-surgical clinicians be cued in to these potential structural abnormalities that DO contribute to a problem when imaging doesn't capture it? In my next blog post, I'm going to talk about clinical decision making from a first-contact diagnostic perspective. Stay tuned...
Studler, U. et al. “MR arthrography of the hip: differentiation between an anterior sublabral recess as a normal variant and a labral tear.” Radiology 249 3 (2008): 947-54 .
Matsuda DK. Arthroscopic labralization of the hip: an alternative to labral reconstruction. Arthrosc Tech. 2014 Jan 31;3(1):e131-3. doi: 10.1016/j.eats.2013.09.009. PMID: 24749033; PMCID: PMC3986659. Full text link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3986659/