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L Hip with previous labral tear surgery

Exit forum ID Forum Discussion L Hip with previous labral tear surgery

This topic contains 6 replies, has 1 voice, and was last updated by   William Brady, DC July 24, 2018 at 8:59 am.

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  • #5410

    Scott Glidden
    Participant

      40 year old female patient with lingering left lateral hip pain that ranges from 0/10 to a 6/10 ache that will cause her to wake up if she sleeps on it for too long, rest is palliative otherwise. No particular activity seems to really aggravate it when she is awake besides heavy amounts of barre class which she has ceased. I have twice now cleared out adhesion in the hip just for it to return 2 weeks later. Today her L SHF was 2 fingers/5-6 anterior pinch to 0F/0 post tx of the hip capsule. A few years ago she had a labral tear in her left hip corrected. I think that there is a possibility of a labral tear and/or joint morphology issue that irritates the local tissue, brings on inflammation and keeps laying down adhesion. With the continually reoccuring hip pain, should I consult with the surgeon who did the surgery or get an MR arthrogram of the hip to check for other pathology? I feel like at this point my treatment skills are on point with her, but this damn thing keeps popping back up.

      #5411

      William Brady, DC
      Participant

        She is still damaging/protecting the joint. First option is load manage to slow adhesion recurrence. Most likely there is a cam/pincer deformity that caused the first labrum tear and is now causing more trouble. If she can’t get her load low enough you will want to explore imaging (with a MSK radiologist) to determine presence/extent of cam/pincer. If present and extensive, refer for possible reduction surgery.

        #5412

        Scott Glidden
        Participant

          Since I’m on texting terms with the surgeon, I had him check out his notes on her and he said he did the following:

          -labral tear fix
          -cam/pincer fix
          -GT bursectomy

          From the sounds of it, she is pretty screwed going forward since everything that is supposed to help her body has been taken out. I think its going to be a tough conversation at her next appointment about load and her options going forward if its not properly managed.

          #5413

          Logan Reading

            I would look at her gait, foot mechanics, and hip motor control to see if the problem is somewhere else in the chain. Great work so far….

            #5414

            Carl Nottoli, DC
            Participant

              Logan, what do you mean by foot mechanics?

              If you’re assessing gait or hip motor control it will only show compensation for the peripheral pathology, so it wouldn’t prove to be of any long term value to try and fix a compensation.

              You had also mentioned looking somewhere else in the chain for the problem. While I agree about fixing any other dysfunction to help unload the hip, the root of the issue is still pathology in the hip itself and her high load environment that causes it to become damaged again.

              I’m curious to hear your thoughts. Thanks for responding to the thread.

              #5415

              Scott Glidden
              Participant

                She initially came in for lower back and we moved to the hip. Her lunge is pitiful and although she has near full ROM of her lumbar spine now (up from about 10%) she still has a persistent ache which I believe is due to her large breasts and a desk job (lumbar MRI= clean). She really has very few things that are persistently terrible from an objective standpoint. Her big issue is that she had a surgeon that went too far in removing a bursa sac and now she is paying the price for it.

                #5416

                William Brady, DC
                Participant

                  In the ID system we always have a tissue and pathology specific prioritized list for our diagnosis. This patients is complicated, but still possible. Here it will help to put it on a timeline.

                  1. Cam/pincer malformation (developmental or acquired or both)
                  2. This damaged the labrum (labrum taer)
                  3. These both required surgery. Surgery mitigates rather than fixes and sometimes makes things worse. The bursectomy was probably unnecessary but unless she has local symptoms there not her priority. (additional tissue alterations post surgical)
                  4. Conservative care has maxed out (reducing adhesion, strength and load management).

                  Here is the bit we never learned in school: respect pathology. When tissue is damaged and can’t be repaired- that’s a problem. Tissue has limits. Conservative care has limits. Any abnormality in gait or motor control is likely a compensation to unload the actual hip pathology. Still within the ID system we can assess the function of other body regions and determine relevance (assessing provocative motions in light of functional deficits).

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