nonsurgical treatment of acetabular labrum tears: a case ... · tears, there is a lack of...

346 | may 2011 | volume 41 | number 5 | journal of orthopaedic & sports physical therapy

[ case report ]

Interest in the etiology, diagnosis, and treatment of individuals with acetabular labral tears continues to increase. While there is available information for arthroscopic and postoperative management of labral tears, femoroacetabular impingement

(FAI), and hip instability,4,6,8,9,28,32 there is limited research regarding appropriate nonsurgical physical therapy intervention for those with suspected labral tears. As we become more aware of intra-articular

hip pathologies, information to help guide nonoperative rehabilitation pro-grams is needed.

Mechanical impingement and/or in-stability of the femoroacetabular joint are believed to be common causes of labral

TT STUDY DESIGN: Case series.

TT BACKGROUND: While the literature has em-phasized surgical treatment of acetabular labrum tears, there is a lack of information regarding conservative treatment. The purpose of this case series was to describe a nonsurgical program for those with clinical evidence of an acetabular labrum tear, that emphasized hip and lumbopelvic stabilization, correction of hip muscle imbal-ance, biomechanical control, and sport-specific functional progression.

TT CASE DESCRIPTION: The 4 patients in this se-ries had clinical evidence and magnetic resonance imaging confirmation of an acetabular labrum tear and underwent a similar treatment protocol con-sisting of 3 phases. Phase 1 emphasized pain con-trol, education in trunk stabilization, and correction of abnormal joint movement. Phase 2 focused on muscular strengthening, recovery of normal range of motion (ROM), and initiation of sensory motor training. And phase 3 emphasized advanced sen-

sory motor training, with sport-specific functional progression. ROM, flexibility, pain, special tests, and level of function were assessed, and strength was measured with handheld dynamometry.

TT OUTCOMES: All patients demonstrated decreased pain, functional improvement, and cor-rection of muscular imbalance. Increased muscle strength, primarily for the hip flexors (1%-39%), abductors (18%-56%), and extensors (68%-139%) was also noted.

TT DISCUSSION: All patients responded well to our program. This case series suggests that pa-tients with clinical evidence of an acetabular labral tear confirmed with MRI can show meaningful improvement with nonsurgical intervention.

TT LEVEL OF EVIDENCE: Therapy, level 4. J Orthop Sports Phys Ther 2011;41(5):346-353, Epub 18 February 2011. doi:10.2519/jospt.2011.3225

TT KEY WORDS: acetabulum, hip, labrum, rehabilitation

1Staff Physical Therapist, Irmandade da Santa Casa de Misericórdia de São Paulo, Rehabilitation Service, São Paulo-SP, Brazil. 2Associate Professor, Department of Physical Therapy, Duquesne University, Pittsburgh, PA; Staff Physical Therapist, University of Pittsburgh Centers for Sports Medicine, Pittsburgh, PA. 3Doctoral candidate, Associate Professor, Staff Physical Therapist, Irmandade da Santa Casa de Misericórdia de São Paulo, Rehabilitation Service, São Paulo-SP, Brazil. This work received approval from the Institutional Review Board of Irmandade da Santa Casa de Misericórdia de São Paulo. Address correspondence to Dr Thiago Yukio Fukuda, Physical Therapy Department, Rua Dr Cesário Motta Jr, 112, 01221-020, São Paulo-SP, Brazil. E-mail: [email protected]

PAULA M. YAZBEK, PT1 • VANESSA OVANESSIAN, PT, MS1 • ROBROY L. MARTIN, PT, PhD2 • THIAGO Y. FUKUDA, PT, PhD3

Nonsurgical Treatment of Acetabular Labrum Tears: A Case Series

chondral pathology.3,11,22,28 The 2 primary types of femoroacetabular impingement (FAI) are cam and pincer impingement. Cam impingement originates from ab-normal thickening of the femoral head-neck junction, while pincer impingement

originates from overcoverage of the ac-etabulum.10 Clinical signs of FAI have been found to be present in up to 95% of patients with a labral tear.5 The anterior-superior region of the joint is the most common location for a labral tear,33 the patient symptoms of which are provoked by combined hip internal rotation, ad-duction, and flexion.28

Labral chondral lesions may also re-sult from atraumatic hip instability, with or without mechanical impingement. Focal rotational instability is defined as localized laxity of select capsule-ligamen-tous structures that results from repeti-tive forceful hip rotation.22,29,31 The most common injury mechanism is excessive hip external rotation, leading to iliofemo-ral ligament laxity.22,31 Abnormal loading of the anterior-superior labrum can oc-cur in the presence of instability.29 The la-brum is important for joint stability and, therefore, capsule-ligamentous structures can come under additional stress when a labral tear occurs. Forceful loading of the hip joint may further compromise the in-tegrity of not only the passive stabilizing structures but the active joint stabilizers. Poor neuromuscular control of the hip and lumbopelvic regions may, therefore, exacerbate the pathology and symptoms associated with instability.

Pathologies that affect the neuromus-cular control of hip musculature can dis-rupt movement patterns and alter forces across the labrum and articular carti-

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journal of orthopaedic & sports physical therapy | volume 41 | number 5 | may 2011 | 347

from The Institutional Review Board of Irmandade da Santa Casa de Misericór-dia de São Paulo, and all participants gave informed, written consent prior to participation.

CASE DESCRIPTION

The 4 patients in this case series were evaluated at baseline, and at 4 months and 6 months after treat-

ment. For each patient, demographic, relevant history, primary symptoms, and results of magnetic resonance imaging (MRI) are provided in TABLE 1. Evalua-tion consisted of an assessment of range of motion, flexibility, pain, and level of function as assessed with the Lequesne Hip Score.17 Strength assessment was measured with handheld dynamometry.1 Potential sacroiliac joint, radiculopathy, piriformis, and anterior pelvic involve-ment were assessed, respectively, with the squish test (posterior pelvic pain during anterior-posterior pressure applied on the iliac bone), Lasegue’s straight-leg maneuver, the piriformis test (buttock or sciatica pain during hip medial rota-tion), and the grava test (pain during hip

(internal rotation) hip kinematics was found to decrease pain and improve function in a female individual with FAI.2 Lewis et al20 described a program that at-tempted to reduce stress on the anterior hip joint by improving force production of the gluteus medius, piriformis, gemel-lus, obturators, gluteus maximus, and iliopsoas, while minimizing excessive quadriceps femoris and hamstring activ-ity. Key elements of this program address positional and movement control, muscle force-generating capacity, muscle length, and activity modification.20

Anecdotally, it has been reported that modifying muscle recruitment and movement patterns during gait and functional activities is helpful. However, further investigation and descriptions of conservative intervention programs are needed. The conservative program out-lined in this study emphasized hip and lumbopelvic stabilization, correction of hip muscular imbalance, biomechani-cal control, and sport-specific functional progression. The aim of this paper was to report the outcome of 4 patients, as well as to describe the nonsurgical treatment protocol. This work received approval

lage.25 Gait deviations resulting from ab-normal recruitment patterns of the hip musculature have been documented in individuals with FAI.14 Also, decreased force contribution from the gluteal mus-cles during active hip extension and ilio-psoas during active hip flexion was found to result in greater anterior hip forces.20 Gluteus medius function is thought to be commonly impaired in those with hip pathology.8 Though compensation with excessive hip internal rotation can enhance gluteus medius function, it can negatively impact force generation of the gluteus maximus. Abnormal internal rotation may also increase anterior hip forces.36 If force-producing capacity and control of the muscles around the hip are improved, anterior hip forces and, there-fore, hip pain may potentially be reduced in those with labral or chondral lesions.

Although there is limited informa-tion regarding nonsurgical treatment of those with clinical evidence of a labral tear, interventions that attempt to nor-malize hip alignment and correct joint movement may be beneficial. The use of a hip-strapping device to reduce frontal plane (adduction) and transverse plane

TABLE 1 Patient Information

Abbreviation: MRI, magnetic resonance imaging.

Patient Age, y Gender Relevant History Complaints MRI Findings

1 27 Male • Professional indoor soccer player

• Partial labral resection 10 mo earlier

• 10 unsuccessful previous physical

therapy sessions

• Arthroscopic knee surgery 5 y ago

• Groin and lateral knee pain of the involved side

• Pain increased with walking, going up and down stairs,

running, and changing direction

• Duration of symptoms, 2 y

• Pincer femoroacetabular impingement

2 24 Male • Professional Jiu-Jitsu fighter • Groin and medial thigh pain of the involved side

• Duration of symptoms, 9 mo

• Anterior superior labral tear

• Bilateral adductor tendinitis

• Superior lateral chondral lesion

3 24 Female • Sedentary • Groin pain of the involved side

• Locking after periods of sitting

• Thigh pain with standing


• 10-d history of lateral leg paresthesia

• Anterior superior labral tear

• Partial ligamentum teres tear

• Gluteal medius and minimus tendinopathy

4 24 Male • Recreational soccer player

• Mild L5-S1 degenerative disc disease

• Normal electromyography tests

• Groin and right thigh pain

• Pain increased with sitting and soccer-related activities


• Partial anterior superior labral tear

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[ case report ]adductors and abdominal contraction in prone position).7 The following special tests for intra-articular hip pathology were also performed: flexion-adduction internal rotation impingement,18 Patrick or flexion-abduction external rotation (FABER),27 scour (pain during pressure applied down through the thigh into the hip joint, over a hip range of motion), and internal rotation (groin pain during passive hip internal rotation).21 The re-sults of these tests are provided in TABLE

2. Additionally, we tested the presence of femoral anteversion, according to the method described by Souza and Powers.34 None of the 4 patients presented with femoral anteversion; however, 1 patient showed a decrease of 15° in hip internal rotation in relation to the opposite limb. Only patients with clinical evidence of an acetabular labrum tear were included in the study. This includes patient 1, who, despite a previous partial labral resec-tion, showed signs of FAI with continued labral involvement.

As noted in TABLE 1, 3 of the 4 patients participated in sports, with 1 being seden-tary. All 4 individuals had MRI findings consistent with a labral tear. Addition-ally, all 4 patients had some positive signs and symptoms that would suggest a labral tear as a potential pathology. All 4 patients might have had concurrent extra-articular pathology, as well, which might have partially contributed to their complaints. Although case 1 presented with a status of post partial labral resec-tion, his symptoms, examination, and diagnostic testing suggested FAI with continued labral involvement as a poten-tial pathology.

Nonsurgical Treatment ProtocolThe conservative treatment protocol (TABLE 3) was developed for those with clinical evidence of an acetabular labrum tear and modified as needed for coexist-ing pathologies. Phase 1 consisted of pain control, education in trunk stabilization, and correction of abnormal movement. Patients also received instruction to cor-rect excessive dynamic valgus of the lower

extremity, with dynamic valgus defined as hip adduction and internal rotation that increased during single-limb support.30,33 Once a patient noted diminished pain with improved control of trunk stabili-zation and dynamic valgus, the patient could progress to phase 2. Phase 2 (FIGURE

1) focused on muscle strengthening, re-covery of normal range of motion (ROM), and initiation of sensory motor training.

The 4 patients in this report demon-strated muscular imbalance of the lower limbs, as demonstrated by differences in strength measurements between limbs. Once this imbalance was corrected (when the injured limb reached or exceeded the strength of the healthy limb), pa-tients could progress to phase 3 (FIGURE

2), which emphasized advanced sensory motor training, with sport-specific func-tional progression. Proper lower extrem-

ity alignment and stabilization were encouraged at all times during activity.

OUTCOMES

Special test results and pain lev-els are included in TABLE 2. The re-sults of the strength assessments are

provided in TABLE 4. All patients received 3 treatment sessions per week and were progressed through the 3 phases of the proposed protocol, in accordance with the outlined criteria.

Each patient generally progressed well through the treatment program. It should be noted that in patient 1, despite the partial acetabular labrum resection, symptoms continued. Biomechanical instability might have contributed to the patient’s prior lack of progress. This previous lack of progress might also have

TABLE 2Results of Clinical Tests and Functional

and Pain Scales for the Initial Evaluation and Re-evaluations (Discharge of Therapy)

Patient/Special Tests Involved Uninvolved Involved Uninvolved

Patient 1

Impingement + – + –

Patrick-FABER + – – –

Scour + – + –

Internal rotation + – – –

Squish – – – –

Lasegue – – – –

Piriform + – – –

Grava + – – –

VAS* 5 0

Lequesne† 10 5

Patient 2

Impingement + – – –

Patrick-FABER – – – –

Scour + – – –

Internal rotation – – – –

Squish + – + –

Lasegue – – – –

Piriform – – – –

Grava – – – –

VAS* 4 0

Lequesne† 5 1

Table continues on page 349.

AfterBefore

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been due to symptoms arising from FAI, as opposed to an isolated labral tear. For this patient, it was not possible to quan-tify hip strength on initial evaluation, because the dynamometer was not avail-able. This patient progressed to phase 2 after 2 weeks, phase 3 after 4 weeks, and was discharged after a total of 12 weeks of treatment.

Patient 2 progressed through the strengthening and functional-training activities relatively quickly, once pain was reduced. Being a professional athlete might have contributed to this patient’s rapid progress. He was able to progress to phase 2 after 2 weeks and phase 3 after 4 weeks. Following discharge, after a total

of 9 weeks of treatment, the patient was able to start a new competitive season.

Patient 3 presented with gluteal me-dius and minimus tendinopathy, in ad-dition to a potential labral tear, which was addressed with laser and electrical stimulation included in the intervention plan. According to our clinical experi-ence, both physical agents work well for tendinopathy in inferior limbs and focus especially on pain relief. It was felt that the tendinopathy did not influence efforts to correct muscular imbalances. Patient 3 started phase 2 after 5 sessions, with no pain or paresthesia. She progressed to phase 3 after 5 weeks. Once dynamic valgus control was maintained, she noted

that the locking episodes were no longer present. She was discharged after 13 weeks of treatment, with her only com-plaint being slight hip pain after wearing high-heeled shoes for prolonged periods. At the 6-month follow-up evaluation, the patient had returned to her normal daily activities but had not done any sports-related activities.

Patient 4 was unique, in that he was the only case to present with decreased hip internal rotation range of motion (right, 40°; left, 25°). Regaining this loss of motion was emphasized and addressed with joint mobilization techniques. The patient was able to progress to phase 2 after 3 weeks and phase 3 after 6 weeks. After 4 months of treatment, he was dis-charged with normal range of motion and symptom improvement.

DISCUSSION

Nonsurgical treatment for indi-viduals with suspected acetabular labral tears has not been described.

This case series outlines a conservative treatment program for individuals with clinical evidence of an acetabular labral tear, confirmed with MRI, that empha-sized hip and lumbopelvic stabilization. Over a 12-week period, the 4 patients who participated in this program noted decreased pain, increased strength, and improved function.

As noted in TABLE 2, after the treatment sessions, all patients reached a normal to moderate limitation of function, ac-cording to the Lequesne Hip Score. The Lequesne Hip Score was chosen because this scale was easily applicable and can be used to assess level of disability. Ac-cording to this scale, the level of handi-cap can be interpreted as follows: none (0 points), mild (1-4 points), moderate (5-7 points), severe (8-10 points), very severe (11-13 points), and extremely severe (14 or more points). Although the Lequesne Hip Score has not undergone psycho-metric testing to provide minimal clini-cally important difference (MCID) for changes in score, improvements in scores

TABLE 2

Results of Clinical Tests and Functional and Pain Scales for the Initial Evaluation and Re-evaluations (Discharge of Therapy)

(continued)

Abbreviation: VAS, visual analog scale.*0- to 10-cm scale, where 0 means “no pain” and 10 means “worst imaginable pain.”†0 to 22 points, where 0 means “normal function” and 14 or more points means “extremely severe dysfunction.”

Patient/Special Tests Involved Uninvolved Involved Uninvolved

Patient 3

Impingement + – + –

Patrick-FABER – – – –

Scour – – – –


Squish – – – –

Lasegue + – – –

Piriform + – – –

Grava – – – –

VAS* 6 0

Lequesne† 7 1

Patient 4

Impingement + – – –

Patrick-FABER + – + –

Scour + – + –


Squish + – – –

Lasegue + – + –

Piriform + – + –

Grava – – – –

VAS* 10 3

Lequesne† 14 5

Before After

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[ case report ]

obtained by this instrument were accom-panied by decreased pain and increased strength. Three patients had total pain relief, as measured with a visual analog scale, and all patients showed improved muscle strength of the hip flexors (1%-39%), abductors (18%-56%), and exten-sors (68%-139%).

On initial evaluation, lower limb strength imbalance was identified in the

patients. Gluteus medius, gluteus maxi-mus, and iliopsoas weakness can contrib-ute to increased anterior hip force. This weakness, combined with hip hyperex-tension, may be a contributing factor for an acetabular labrum tear.5,25,26 We have noted that patients with gluteus maxi-mus, gluteus medius, and iliopsoas weak-ness can report hip instability (anterior discomfort when performing activities

that require active extension, along with hip external rotation). Gluteus medius and maximus weakness can also lead to abnormal lower extremity positioning associated with excessive lower extrem-ity dynamic valgus (ie, femoral adduc-tion and internal rotation).30 In dynamic valgus, the hip is in a position that can cause or aggravate symptoms associated with a labral tear. The improvement that

TABLE 3Rehabilitation Protocol for Nonsurgical

Treatment of Acetabular Labrum Tears

Abbreviations: AROM, active range of motion; MR, maximal repetition; VAS, visual analog scale.*0- to 10-cm scale, where 0 means “no pain” and 10 means “worst imaginable pain.”†0 to 22 points, where 0 means “normal function” and 14 or more points means “extremely severe dysfunction.”

Parameter Phase 1 Phase 2 Phase 3

Progression criterion • Diagnosis of acetabular labrum tear • Significant decrease or absence of pain

complaint (VAS*, <4, or Lequesne†, <5)

• Good balance and proprioception and normal

muscle strength and range of motion

Gait • Assistive device for those with increased pain

with weight bearing

• Discontinue assistive device

Pain • Maitland’s manual mobilization (grades 1 and 2)

• Electrophysical agents: electrical stimulation

and laser

AROM • Active movements within painful limits • Maitland’s manual mobilization (grades 3 and 4)

and combined movements

• Pelvic rotation maneuver

• Sacroiliac distraction

Segmental stabilization • Transversus abdominis and multifidus isolated

contraction and associated light exercises, such

as bridging and crouching close to the floor on

hands and knees

• Core (lumbopelvic stabilization exercises) added

to moderate exercises, such as lateral bridge and

mini squat, and to light sensory motor training

• Core (lumbopelvic stabilization exercises) added

to Swiss ball exercises and advanced sensory

motor training

Muscle strength • Standing hip flexion and extension (progressive

load), 3 × 10 reps

• Standing hip abduction and adduction,

with elastic resistance near a support bar

(progressive load), 3 × 10 reps

• Lunge (progressive load), 3 × 10 reps

• Shuttle machine (progressive load), 3 × 10 reps,

70% MR

• Knee flexion-extension on chair (progressive

load), 3 × 10 reps, 70% MR

• Sidestepping gait with an elastic band over

midfeet, 3 × 1 min

• Dynamic valgus control with single-limb squat,

3 × 1 min

• Muscle strength maintenance (progressive load)

and address any persisting muscular imbalance

Sensory motor training • Balancing

• Balance board

• DynaDisc

• Jumping board

• Same equipment used in phase 2, combined

with sports movements (eg, kicking and

throwing)

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patients achieved as a result of this pro-gram may be attributed to the increase strength in the muscles that help to de-crease anterior hip forces, as well as to control dynamic valgus.

The treatment protocol outlined in this manuscript is focused on hip muscle imbalance and correction of abnormal biomechanics, and adds a more specific exercise prescription than the previously described program.19 Kapandji13 noted

a direct relationship between abduc-tor weakness of the involved limb and adductor weakness of the contralateral limb. The author labeled these findings as “cross-chain weakness.” During dou-ble-limb support, the pelvis is balanced by simultaneous and bilateral action of the hip abductors and adductors. When these antagonistic actions are balanced, the pelvis is stable in a symmetrical po-sition.9,36 When cross-chain weakness is

present, the dynamic stability of the pel-vis is impaired. This dynamic instabil-ity can contribute to an overload of the capsule, potentially leading to labral or chondral pathology.9 During single-limb standing, the pelvis is balanced by the ac-tion of the ipsilateral abductors. The glu-teus medius is primarily responsible for maintaining this balance, with contribu-tion from the gluteus minimus and ten-sor fascia lata. When abductor weakness occurs, the effect of gravity may not be conterbalanced, causing the hip to move into adduction. This cross-chain weak-ness was best observed in patient 3. This patient had hip extensors, hip abductors, and hip flexors weakness on the involved limb, with significant weakness of the ad-ductors in the contralateral limb.

Handheld dynamometry allowed for close monitoring of muscle imbalance during strengthening exercises. In the correction of abnormal mechanics, it was considered critical to strengthen those muscles identified as weak. At the begin-ning of treatment, the primary objective was to instruct patients on the impor-tance and techniques for proper lumbo-pelvic and hip stabilization, especially for athletes.6,36 At the same time, analgesic methods were used to reduce pain.

Stabilization during movement re-quires normal muscle activation patterns for proper movement coordination. It is debated whether joint instability or im-paired coordinated movement is a source of dysfunction. Adequate joint stability depends on contractile and noncontrac-tile elements. Therefore, improper coor-dination of movement patterns may play a large role in whether or not a patient experiences symptoms related to insta-bility.15 Studies have determined that, in healthy people, pelvic postural con-trol during lower limb exercises occurs through the simultaneous contraction of local and global muscles.12 In contrast, it was found that multifidus and transver-sus abdominis activation was impaired in individuals with pelvic injuries.35 Activi-ties to improve recruitment, activation, and timing of deep lumbopelvic muscu-

FIGURE 1. Phase 2 of rehabilitation protocol. (A) Gluteus maximus strengthening on equipment, (B) side-stepping using an elastic band around both midfeet, which promotes greater concentric and eccentric hip abduction and external rotation effort, and (C) control of dynamic valgus on a trampoline.

FIGURE 2. Phase 3 of rehabilitation protocol. (A) Core stabilization with perturbation forward, backward, and side-to-side, (B) single-limb sliding on straight board while controlling dynamic valgus, (C) sitting on Swiss ball, performing isometric hip adduction and ball throws, (D) Jiu-Jitsu sport movement with elastic resistance for hands and feet, and (E) movements with lower limbs holding a Swiss ball between legs.

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[ case report ]

REFERENCES

1. Andrews AW, Thomas MW, Bohannon RW. Normative values for isometric muscle force measurements obtained with hand-held dyna-mometers. Phys Ther. 1996;76:248-259.

2. Austin AB, Souza RB, Meyer JL, Powers CM. Identification of abnormal hip motion associ-ated with acetabular labral pathology. J Orthop Sports Phys Ther. 2008;38:558-565. http://dx.doi.org/10.2519/jospt.2008.2790

3. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of dam-age to the acetabular cartilage: femoroac-etabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br. 2005;87:1012-1018. http://dx.doi.org/10.1302/0301-620X.87B7.15203

lature, transversus abdominis, and mul-tifidus were implemented early in our program to improve movement coordina-tion. The goal during all our activities was to have the patients activate these deep muscles before and during the activation of muscles that produce hip motion.

It is the authors’ opinion that not only is this specific muscle strength training important to dynamic posture mainte-nance and control but also important for progressive sensory motor control. This was implemented in our protocol by first emphasizing lumbopelvic and hip stabi-lization, before progressing to functional activities. Visual feedback was provided to the patients throughout the progres-sion of activities and was considered a key component in teaching and learn-ing dynamic stabilization. But it should be noted that the passage of time might have contributed to some or all of the patients’ improvement. However, this is considered unlikely, given the long dura-tion of symptoms in our patients. There

is limited ability to accurately clinically diagnose a labral tear.16,22-24 In addition, even for patients with a confirmed labral tear on diagnostic imagining, it does not ensure that the pain arises from the tear.23 Therefore, we chose to use the term “clinical evidence of a labral tear” for our patients. The difficulty with the diagnos-tic process should not affect the interpre-tation of this study. The purpose of this paper was not to describe the diagnostic process but to describe a rehabilitation protocol that could be implemented for those with suspected hip labral tears.

CONCLUSION

This article reported on patients with clinical evidence of an acetab-ular labrum tear, confirmed with

MRI. All patients responded well to a nonsurgical program that emphasized hip and lumbopelvic stabilization, correc-tion of muscular imbalance, and sport-specific functional progression. This case

series suggests that patients with clinical evidence of an acetabular labral tear can show meaningful improvement with con-servative intervention. Further research is necessary to determine the short- and long-term effectiveness of this approach in the management of suspected labral injuries. t

TABLE4Muscle Strength Using Handheld Dynamometer

for Initial Evaluation and Discharge From Therapy*

Abbreviation: NA, not evaluated.*There are no values of case 1 because during his evaluation the dynamometer was not available yet.†6-month re-evaluation.‡4-month re-evaluation.

Involved Uninvolved Involved Uninvolved Involved Uninvolved

Hip flexors

Case 2† 41.9 46.4 52.3 57.4 25 24

Case 3† 19.5 22.8 19.6 22.8 1 0

Case 4‡ 17.5 22.2 24.0 24.0 39 7

Hip extensors

Case 2† 18.3 16.2 36.3 38.7 98 139

Case 3† 11.1 18.0 18.7 18.0 68 0

Case 4‡ 20.2 26.4 NA NA NA NA

Hip abductors

Case 2† 28.8 29.6 28.8 29.6 0 0

Case 3† 7.5 10.9 11.7 15.9 56 46

Case 4‡ 10.8 12.7 14.8 15.0 37 18

Hip adductors

Case 2† 13.4 11.3 13.4 15.6 0 38

Case 3† 9.1 7.2 12.3 11.4 35 58

Case 4‡ 17.7 18.3 17.7 18.3 0 0

Evaluation,kg Re-evaluation,kg Change,%

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