FAI or labral tear?

[Zaynah]

Hi everyone

I'm a final year physiotherapy student in South Africa (Stellenbosch). I started getting a stabbind pain in my L groin about 4 years ago when I did a deep squat to pick something up from the floor. When I tried to come back up, I couldnt' take weight on the leg and it took 5min of lying on the bed doing some quad stretches and weird poses to get the pain away. It didn't happen every day or week, only some months when I did something strange with my hip. I started dancing when I was 4 years old (ballet and then latin american) and during the time this first started I was training very hard for nationals. I'm very lax and hipermobile and I once felt my L hip sublux laterally without pain. I have osgood schlatters in my R knee since I was 12. The problem is that i stopped dancing last year due to breaking my R big toe and then I just couldnt dance in those heels anymore. Since March this year every time I sit down in a deep chair, squat, bend over to blowdry my hair, pick up stuff or get out of the car, I get that stabbing cathing pain in my L groin and then the giving away of the L leg. I cant' row or gym anymore. I can't do Pilates anymore. I did a self evaluation and I have almost no L hip internal rotation actively, painfull inpinge feeling when the L hip quadrant, clicking of the hip from F to E with pain. One leg standing L is painfull. My back is fine. I went to the doctor about a wrist injury (that's another story!) and he said I injured it in childhood, but I have no such history and I need a diagnosis! I'm seeing a orthopeadic surgeon next week for my wrist and I want him to take a look at it. Does this sound like a FAI or a labral tear!? :eek:

[Jean M]

Sounds like you may have a labral tear. Part of a good diagnosis would be to find out the CAUSE of the tear, possibly FAI. You need to find an OS who is specifically trained in dealing with this condition (if indeed this is applicable to you) and who can perform the necessary procedures arthroscopically. In Australia we have only two. Pre-surgery I had trouble getting in and out of a car, couldn't do a lot of normal household chores without a lot of discomfort. Stabbing pain usually occurred at night, usually when turning over (a deep stabbing pain in my hip). But I had a whole range of other symptoms too. When you've read enough of these posts you start to appreciate how different we all are. No 2 patients with labral tears/FAI will present with the exact same symptoms. I still have limited ROM on my R hip (I really miss sitting cross-legged) but soooo many of my referred pains have either disappeared or are greatly lessened. But I was lucky to get a great surgeon. Let us know how you get on in S. Africa - hopefully you'll find the right person to help you (it aint easy though, cos this condition hasn't been treated by the medical profession for all that long). I'm curious to know whether you found out about all this in your course???

[Zaynah]

Hey Jean

Thx for the reply... Our physio course over here is quite full... our curriculum changed in my 3rd year to the group-work case study approach and we did injuries at every joint aswell as systemic, resp, cardio and neuro cases. Our clinical blocks were 6week blocks with theory and practicals after every block, so the evaluation is continues!

The problem here in SA is that u cant go to see a ortopeadic surgeon without a referral! So luckily I got a referral from my doctor for my wrist, so next week Teusday (:eek: ) i'm going to see the doc and ask him to look at my hip. I think the labral tear or primarily, maybe FAI, is propably due to overuse, splits, lots of external rotational movements and extreme hip positions. I have no incident history of trauma or such. In Cape Town we have a orthopeadic clinic at the Sport Sciences Institute of SA where our national and provincial sport teams are treated. I'm thinking of contacting them if I don't get a proper referral from the hand-specialist. :confused:

[Liz Browne]

I am a physiotherapist working in Johannesburg, South Africa. I have a particular interest in hip injuries and am finding it more and more fascinating the more I read and the more patients I treat or assess.
The only way to diagnose a labral tear and/or FAI with certainty is with an MRI scan, CT scan and arthrogram. The symptoms you are presenting with appear to indicate some internal derangement, but it would be advisable to consult a specialist orthopaedic surgeon who does hip arthroscopy. Both labral tears and FAI may be due to hip dysplasia. There is also a relationship between joint hypermobility syndrome and associated hip joint problems. If your hip joint anatomy is altered, you will potentially present with symptoms. Your history of dancing and putting your joints in extreme positions have most probably caused some damage along the way.
I work with a fantastic surgeon who would be able to refer you to a Dr in Stellenbosch or Cape Town. His name is Dr Cakic and he works from the Carstenhof clinic and Rosebank centre for sports medicine and orthopaedics.
My advice would be to contact him and get your hip assessed and managed properly.

[Zaynah]

Hi Liz

Thnx for the info. I will definately contact him after my app next week. I just don't want a doctor to tell me to manage my hip problem conservatively, when that's what i've been doing ever since! So i'll see how things go at Dr.Wells (hand OS) and then i'll hear what he says and suggests. I have to get this sorted now, as I start with my Zuma community service early January and then I won't have time to be a patient! Will let you know how it went.

[soccermom]

Hi Liz:
You talked about hypermobility of the hip....can you explain a little more? briefly, i had 2 neg mra's but 2 hip scopes that debrided labral tears. both hips have been painful and catching for 10 yrs now. the first hip scope just debrided a tear...surgeon didn't believe in fai. 2nd hip scope debrided the tear and reshaped the femoral head....better more experienced and well known surgeon. after my first scope, though...surgeon said my hip was really loose and that was a good thing. appearently was very easily distracted for the surgery. i have continued to have pain in that hip despite the surgery to remove the labral tear (remember, no boney work on that hip). that hip also does a lot of snapping...but no further catching. curious as to what you think about a really loose hip?
soccermom

[Zaynah]

hey

hip laxity is where the ligaments and capsule around the joint is lax and able to stretch far beyond normal without pain, feeling a pop at the end of the hipermobile movement and as it goes back. the hip joint has more movement but is unstable. For example, if you stand on the one leg and sit into that hip, you can feel your hip trying to pop out at the side of your buttock! So it's good for surgery, coz the docs get easy entry, but it's bad for the biomechanics of your joint and make you prone to injury and early joint surface degeneration. Usually with joint laxity the muscles are also flexible. You need to train the muscles to act as stabilisers for your joint, cos the ligaments that are suppose to do the stabilising are weak.

[Zaynah]

I had my consult with my hand OS today, had MRI and more XR done... I posted the results on the wrist forum. I got referred to an awesome hip OS at the same medi-clinic, and he took some XR today. Suprisingly on my XR's I have osteitis pubis, more on the L side... :eek: I have no hip dysplasia or visible 'bone' abnormalities!:D And everything else is good. He says i have an extremely small pelvic area and my pelvis is turned inward like a male pelvis. He says that the female pelvis is usually turned outward with broad ilia's and a big internal pelvic area. The pubic symfises was tender when he pressed on that area, but he says that OP is more to the pubic area and my groin pain is specific to intra-articular hip pathology. He says that many sports people have OP without even knowing it, and if not symptomatic, no need for intervention. He examined me further and concluded that I might have a acetabular labrum tear, and if not, iliopsoas bursitis or tendinitis. I'm having a MRI done on thursday and then we'll know what's the diagnosis and plan of action. He has a college who has experience with arthroscopy, so he'll refer me to him if needed. So i'm quite happy knowing that i'm on my way getting diagnosed. I'm sure the MRI will show the soft tissue abnormalities and stop my worrying! :)

[Liz Browne]

Soccermom,
There are many reasons why a joint can be hypermobile - your genetic make-up may be that your ligament structure is intrinsically lax (the actual fibrous tissue constituting the ligaments can be lax in some individuals), or if you are/were a gymnast, dancer, athlete that requires flexibility to perform extreme joint movements, the body will have "memory" of this and the tissue naturally assumes this form even after ceasing the activity.
There is a specific syndrome called joint hypermobility syndrome in which the connective tissue in all the body is hyperlax and it is problematic as the individuals with this syndrome generally do take up sports where flexiblity is a plus, but their muscles are unable to support the very lax joints and they keep re-injuring themselves and have to give up that sport.
I am no expert in hip diagnosis and management, but there are a number of reasons why a joint and particularly the hip could be lax. The ligamentum teres that joins the femoral head to the acetabulum may have torn, thus rendering the inate stability given by this ligament null. There is no cure for this and one can continue normal activity with a torn ligamentum teres, but people generally are symptomatic and consult an Orthopod regarding the symptoms. Clicking and snapping in the hip can also be caused by a number of different scenarios - tendinitis of tendons surrounding the hip, bursitis,torn labrum, FAI,chondral damage, arthritis...
My advice to you would be to consult a hip specialist orthopaedic surgeon and have the appropriate conservative examinations, and then potentially further assessments such as MRI, CT scan, arthrogram etc. if deemed necessary. Hip research has come along in leaps and bounds in the last 20 or so years and even though it lags behing the medical advances done in the knee to date, there is so much that can be done conservatively and if necessary, surgically with excellent results. Finding the right surgeon is the age old question, but if you are in South Africa, I would advise consulting Dr JN Cakic in Johannesburg - even if he can refer you to someone else in S.A. or internationally, as he is world-renowned.

I trust this has helped you and I am sorry you have had such a long history of hip problems. My empathy is with you and I trust you will find a solution to this problem

[soccermom]

thanks liz:
i doubt i have a ligamentum teres tear as that hip has been scoped and the labral tear debrided. i do have a great snapping psoas that seems to aggrevate the hip!!! honestly, i think i have fai in it also and that just wasn't addressed by the previous surgeon or my current one. the current one really doesn't want to talk about the previous one at this time. don't know why my hip is loose, but apparently it distracted way too easily. it no longer catches, but it does still pop. i did gymnastics as a kid, but stopped when i was an early teen. i don't consider myself flexible...i just must have a loose joint !

i had my 1 mo post op appt. he told me to quit limping :) yah, i would if i could! overall things are fine...just hanging out and will start pt. my right (previous scope) is killing me so i hope that pt will strengthen it as well. see him again in jan...then he said we will talk about my other hip (yeah, right....that is what he says every time. :) )

anyway...thanks for the info...i appreciate it.
soccermom

[Zaynah]

i just have a question.
i don't have medical aid, coz they exclude my asthma so i only have a hospital plan. thus i'm paying for all the XR and MRI's... which is mad! i read up on the different types of MRI scans for diagnosing a labral tear, and it seems that unenhanced normal MRI does miss labral tears most of the time. apparentely the enhanced MRI with the contrast injected, has a high specificity to diagnose labral tears and is the best way to go. i'm schedueled for a MRI on the hip on thursday, and was wondering, can i ask for the contrast MRI as i'm paying for it. i don't want to have a unenhanced MRI showing nothing and then another MRI with the contrast to make the diagnosis or have arthroscopy done when there is no labral tear...?????

[soccermom]

i just have a question.
i don't have medical aid, coz they exclude my asthma so i only have a hospital plan. thus i'm paying for all the XR and MRI's... which is mad! i read up on the different types of MRI scans for diagnosing a labral tear, and it seems that unenhanced normal MRI does miss labral tears most of the time. apparentely the enhanced MRI with the contrast injected, has a high specificity to diagnose labral tears and is the best way to go. i'm schedueled for a MRI on the hip on thursday, and was wondering, can i ask for the contrast MRI as i'm paying for it. i don't want to have a unenhanced MRI showing nothing and then another MRI with the contrast to make the diagnosis or have arthroscopy done when there is no labral tear...?????
the dye injection must be done by a radiologist (doctor) and it must be guided. so where you are going must be a bit more specialized to do it. Call first.
Soccermom