- Among 52 patients with hip labral tears, one year of nonsurgical management was associated with significant improvement in functional outcomes, regardless of whether femoroacetabular impingement (FAI) was present
- Still, many patients reported persistent pain (48%), limitation of activities (69%) or continued interest in surgery (40%)
- The best candidates for nonsurgical management are probably patients with minimal FAI who are willing to alter their lifestyle and accept occasional discomfort
Hip labral tears are usually treated surgically, given the limited healing potential of the labrum, the contributing anatomic defects and the potential for progression to osteoarthritis. Some surgeons start with a trial of physical therapy, anti-inflammatory medications, intra-articular injections and activity modification. However, there have been few studies of these modalities.
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To formally evaluate them, Scott D. Martin, MD, director of the Joint Preservation Service within the Department of Orthopaedics Sports Medicine Center at Massachusetts General Hospital, and colleagues reviewed the records of patients with labral injury who pursued nonsurgical treatment for at least one year. They report in The American Journal of Sports Medicine that patients with and without femoroacetabular impingement (FAI) experienced functional improvement, but many reported residual pain, limitation of activities and interest in surgery.
The researchers selected 52 patients of Dr. Martin from a prospective database who had been suspected of having a hip labral tear and met the key inclusion criteria:
- Symptomatic labral injury confirmed by magnetic resonance imaging or magnetic resonance arthrography
- Hip/pelvis radiographs available
- Nonsurgical treatment for at least one year from the date of injection
- Completion of functional assessment questionnaires at the time of injection and one year later
Average symptom duration at presentation was 19 months, 58% of patients were female, average age was 39 and average body mass index was 26.
Patients initially received a fluoroscopically guided intra-articular injection with an anesthetic and methylprednisolone for diagnostic and therapeutic purposes. After injection, patients were advised to limit activities that substantially stress the hip joint or put the hip at extremes of motion (e.g., squats, deadlifts, lunges and distance running). They were also advised to wait two weeks before beginning physical therapy, to allow the methylprednisolone to take full effect.
Physical therapy targeted the lumbar spine, surrounding hip and core musculature, sacroiliac joint and pubic symphysis, as well as the hip itself. These areas are likely to be overloaded in patients with FAI, the researchers note, as a compensatory response to loss of motion at the hip joint.
Patients were advised to gradually progress in their activities, as tolerated, aiming to return to full activity at a minimum of six months after the injection. Anti-inflammatory medications were recommended as needed.
The primary outcome measure was the modified Harris Hip Score (mHHS). After average follow-up of 16 months, there was significant improvement in the overall cohort on the mHHS and on all secondary functional outcome measures: Hip Outcome Score (Activities of Daily Living and Sports subscales), level of function during activities of daily living, level of function during sports-related activities and the International Hip Outcome Tool–33.
The researchers then split the cohort into those with or without FAI. Both groups demonstrated significant improvement on the mHHS and on most of the secondary outcomes. The exceptions were that level of function during sports-related activities did not improve significantly in the FAI group, and level of function during activities of daily living did not improve significantly in the non-FAI group.
At presentation, 23 patients (44%) rated their hip as either normal or nearly normal, and 29 (56%) rated it abnormal or severely abnormal. At follow-up, 37 patients (71%) rated their hip as normal or nearly normal, 14 (27%) rated it abnormal and one (2%) rated it severely abnormal.
Attitudes Toward Nonsurgical Treatment
Despite the significant improvement in function, at follow-up 36 patients (69%) said they felt limited in their activities, 25 (48%) reported no improvement in their pain, 21 (40%) were considering surgery and 10 (19%) had sought a second opinion.
The researchers conclude that the patients best suited to nonsurgical management are probably those with minimal FAI who are willing to alter their lifestyle and accept occasional discomfort.
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