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Review Article
Acetabular Labral Tears in the Dancer
A Literature Review
Marika Hartog, P.T, Jo Stnith, P.T., B.Sc.RT, and Andrea Zujko, P.T., D.P.T.
Abstract
Acetabular labral tears are recognized as a
source
of
hip pain in the
general,
athletic and
dance populations. The complicated, often
end-range movement patterns required of
dancers make them especially susceptible to
hip injury. Labral
tears
at
the
hip
can
signifi-
candy impact the success
of
a dancer's
career.
Gurrendy there is little research regarding
acetabular labral tears in the dance popula-
tion.
This
literature
review highlights
current
knowledge of labral structure and function,
the epidemiology and etiology of tears,
and conservative and surgical treatment.
According to the literature, labral tears are
found most ofi:en in the anterior quadrant
of the labrum. Both traumatic and non-
traumatic mechanisms
of injury
are
reported,
of either minimal or significant severity.
Physical therapy tests have poor specificity
to diagnose labral
tears.
The majority of
re-
viewed studies
show positive
outcomes post
arthroscopy in the general population and
in athletes. Further research is necessary to
investigate
optimum rehabilitation and long-
term outcomes of conservative and surgical
treatment for the dance population.
H
ip injuries are relatively com-
mon in dancers, making up
7%
to 11% of all injuries
in professional ballet and modern
dancers.''^ Labral tears are a com-
mon source of intractable hip pain
in the general population, as well
as in recreational and professional
athletes.^'^ Increasingly, labral tears
are being recognized as a source of
hip pain within the dancer popula-
tion.^ However, to date there is little
research examining labral tears in the
dancer. Dancers of all disciplines per-
form intricate patterns of movement,
often at the extremes of physiological
range, placing them at high risk for
hip injury. These physical deisands
may separate the dancer population
from both the general public and
from other elite athletes in presenta-
tion of injury, speed of rehabilitation,
and treatment outcome. This review
examines the structure and function
of the acetabular labrum, investigates
the epidemiology and etiology of
labral tears as well as the current con-
servative and surgical treatment. It is
important to understand these aspects
of acetabular labral injury in order for
the physical therapist to provide spe-
cific care to this unique population.
The review was conducted using the
Medline and PEDro databases using
the keywords "hip injury," "labrum,"
and "labral tear." Additional articles
Marika Hartog, P.T, is a physical therapist at Westside Dance Physical Therapy.
Jo Smith, P.T., B.Sc.P.T., is a physical therapist at Westside Dance Physical
Therapy. Andrea Zujko, P.T, D.P.T, is a physical therapist at Westside Dance
Physical Therapy and at the School of American Ballet. She is also a certified
Pilates Instructor.
Correspondence:
Andrea Zujko, P.T, D.P.T, Westside Dance Physical Therapy,
53 Golumbus Avenue, Suite 4, New York, New York 10023.
were reviewed through the citations
found in the retrieved articles.
Anatomy of Labrum
The acetabular labrum is a fibrocarti-
laginous rim composed of longitudi-
nally oriented type-I collagen fibers.
It attaches to the hyaline cartilage of
the acetabulum through a transition
zone of
1
to 2 mm of calcified carti-
lage.^'
It is triangular in cross-section,
thinner antero-inferiorly, thicker and
rounded posteriorly and merges with
the transverse acetabular ligament at
the inferior border of the acetabular
rim."*
A narrow synovium-lined recess
separates the labrum from the joint
capsule.^
Overall, the labrum has relatively
poor vascularity. The inner articular
surface of the labrum is entirely hy-
povascular."* Three to four small blood
vessels are located circumferentially
on the outer surface adjacent to the
synovial lined recess.'' McCarthy
and colleagues found these vessels to
reach a depth of only 0.5 mm.' In
contrast, the synovial lined recess is
highly vascularized.'
The obturator, femoral, sciatic, and
superior gluteal nerves innervate the
hip joint.'" In the labrum, the superior
and anterior quarters are the most
highly innervated.'^
Function
Similar to the glenoid labrum, the
acetabular labrum deepens the
articular surface by extending the
51
52 Volume 10, Numbers
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border of the osseous acetabulum.
However, this deepening plays a
lesser role in hip stability due to
the inherent congruency at the
joint. The labrum does contrib-
ute to joint stability by creating
a negative intra-articular pressure
upon joint distraction." This seal-
ing mechanism augments the fluid
film lubrication, decreases the rate
of cartilage layer consolidation and
allows an even distribution of load
across the cartilage surface." Similar
to the knee menisci, the labrum may
also be involved in nociceptive and
proprioceptive mechanisms due to
its abundant neural supply.•'•"' How-
ever, this has yet to be confirmed.
Type and Classification of Tears
Reports in the literature classify
labral tears by location, etiology,
and morphology. Labral tears are
most often seen in the anterior
quadrant of the labrum. In a series
of 412 arthroscopic procedures,
Santori and Villar found that 76
patients had labral tears: 39 ante-
rior, 16 posterior, and 3 superior.'^
A retrospective review conducted by
McCarthy and associates found 241
labral tears in 436 patients undergo-
ing hip arthroscopy.'' All tears were
found at the articular junction of
the labrum. Two hundred twenty
Five patients had anterior quadrant
tears,
29 patients had posterior
tears,
and 7 lateral. The discrep-
ancy between incidences of labral
injury in these two studies may
be due to differences in reporting.
Santori and Villar reported cases
where the labral tear was the main
diagnosis and McCarthy included
all incidences of labral injury re-
gardless of other structural damage
present.'''^
Labral tears are also more frequent
anteriorly in the athletic population.
McCarthy and colleagues found that
of 13 labral surgeries performed on
the hips of elite athletes, 11 labral tears
were in the anterior quadrant while 2
were both anterior and posterior.'' This
data suggests that the anterior labrum
may be compromised first, with sub-
sequent tearing of other quadrants
either in response to the acute injury
or with overstressing of the remaining
intact labrum with repetitive move-
ments.
Lage and coworkers defined dis-
tinct etiological and morphological
classifications of labral tears.'^ Tears
can be categorized morphologically
as radial fiap (disruption of the free
margin of the labrum with a separate
fiap), radial fibrillated (with a "hairy"
appearance), longitudinal peripheral
(at the acetabular insertion of the
labrum) or congenital/unstable.'^ The
authors defined the etiology of tears
as follows:
Traumatic
tear:
tears with a clear
traumatic mechanism of injury
without signs of degenerative
change elsewhere in the hip
joint.
Degenerative tear: tears with de-
generation of either the labral
or articular cartilage.
Idiopathie tear: tears without a
clear mechanism of injury or
degenerative changes.
Congenital
tear:
usually attributed
to a functional abnormality
such as repetitively subluxing
labra."
Mechanisms of Injury
Labral tears are associated with both
traumatic and insidious mecha-
nisms of injury. Approximately
one-quarter to one-half of patients
report an acute provoking event,
which may be relatively minor.'^'''"'^
Various mechanisms of injury have
been described in cases of traumatic
labral tears. Traumatic anterior
labral tears are associated with ro-
tation of the hip, with or without
hyperextension.''"'* These injuries
may involve the hip being forcibly
hyper-rotated or may be following
an apparently benign twisting move-
ment."* •'' Mason described a ballet
dancer with an acute labral tear fol-
lowing a high kick into abduction
and external rotation.^ In contrast,
traumatic posterior labral tears are
associated with axial loading of the
femur when the hip is flexed. For
example, following a motor vehicle
accident, subluxation or dislocation
of the joint may occur. ''•'''^
Idiopathie anterior labral tears
are linked to repetitive twisting
movements."* Mason suggested that
during hyperextension with external
rotation the femoral head may sublux
anteriorly and shear against the ante-
rior labrum.'' This leads to excessive
loading of the labrum and possible
impingement at end range hip move-
ment.^ In addition to classical ballet,
football, soccer, basketball and hockey
are other sports that require this kind
of repetitive twisting and pivoting."*
Several investigators have identi-
fied muscle imbalance patterns that
may contribute to the development
of anterior labral tears. Sahrmann
described a "femoral anterior glide
syndrome" that is seen in association
with activities involving excessive
hip extension." In this condition,
there is increased anterior transla-
tion of the femoral head during hip
extension resulting in impingement
of anterior structures including the
labrum. Excessively long and weak
iliopsoas and relative predominance
of the hamstrings over gluteus
maximus during hip extension also
leads to increased forward femoral
translation." Similarly, Nicholls
suggested that the dominance of
the hip external rotators over the
internal rotators may contribute
to excessive anterior sliding of the
femoral head.'"
Epidemiology
There is little evidence in the cur-
rent literature regarding the relative
incidence of labral tears in males
and females. In several series of pa-
tients treated with arthroscopy for
intractable hip pain caused by labral
tears there were slightly more females
than males.'^'"''^ McCarthy noted in
his series that females presenting for
arthroscopy tended to be younger
than males, but this was not assessed
in other studies.' The average age of
patients undergoing arthroplasty for
labral tears was in the late 3O's to early
405.^""
However, in most series there
was substantial age range. Athletic
populations tended to present at a
younger age.^'^" There is currently no
Journal of Dance Medicine ef Science • Volume 10, Numbers
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&2, 2006 53
evidence comparing incidence in male
and female dancers.
Concomitant Factors
The literature suggests that a relation-
ship exists between labral tearing and
articular cartilage degeneration of the
hip.
McCarthy and colleagues found
that of 436 patients with mechanical
hip symptoms, 73% of patients with
labral tearing or fraying had associ-
ated chondral damage.** The major-
ity (94%) had labral and chondral
damage in the same quadrant of the
acetabulum. The anterior quadrant
had the greatest amount of associ-
ated labral and chondral lesions.''
Overall, chondral damage was more
severe in patients with labral lesions
than without. McCarthy and col-
leagues also found that although the
incidence of labral lesions remained
similar throughout all age groups,
the incidence of cartilage lesions
increased with age by approximately
40%.*^
Morphologically, radial fibril-
lated tears were most associated with
concurrent degenerative changes.'^
Dysplasia has been investigated as
a concomitant factor in acetabular
labral pathology. Many investiga-
tors have reported that patients with
acetabular dysplasia have a higher
incidence of anterior labral tearing
than those without dysplasia.'^ Dys-
plastic hips were found to have labral
detachment and hypertrophied and
bulbous anterior labral quadrants.
These changes suggest increased load
bearing through this region. Lage
and associates reported that the labra
they classified as congenital and un-
stable were in two teenage females
who presented with a click upon
examination and who had associated
generalized ligamentous laxity.'^ It has
been hypothesized that the presence
of acetabular dysplasia may be more
prevalent in dancers as this allows for
greater range of motion at the hip.
This may place dancers at a higher risk
of acetabular labral injury.*
Diagnosis
Labral tears are difficult to accurately
diagnose. Byrd and Jones noted that
intra-articular hip pain may be mis-
diagnosed as extra-articular pathology
such as bursitis and tendonitis.^" In
their series, only 40% of intra-articu-
lar hip pain cases were accurately diag-
nosed as such after initial evaluation.
Labral tears may be the underlying
cause of chronic symptoms commonly
attributed to hip flexor or adductor
pathology. Patients may present with
sharp,
catching pain and mechanical
clicking or locking.'' Since dancers
commonly experience clicking and
popping during movements of the
hip,
it is important to differentiate
between possible labral tear and the
usually more benign iliotibial or ilio-
psoas snapping syndromes.'•''•'^ Danc-
ers with labral tears may also present
with diflxise, dull pain, increased by
activity and relieved by rest.'' Pain is
usually localized to the anterior groin,
but may also be experienced at the
greater trochanter or buttock. Range
of motion may be preserved or mildly
Several diagnostic tests have been
described. Pain from anterior tears
may be provoked by a combination
of hip flexion, adduction and internal
rotation, with or without compres-
.''*'^''^^ This test has a specificity of
43%
and sensitivity of
75%.^^
Several
investigators identified the Thomas
test (hip extension from flexion) as a
test for labral tear.'"'^^ However, Nar-
vani and coworkers did not find a sig-
nificant correlation between positive
Thomas test and labral pathology in
their series of
18
athletes.^'' McCarthy
described a variation of the Thomas
test.^^ Both hips are flexed and then
the affected hip is extended, first in
external and then in internal rotation.
The patient's pain is reproduced in the
presence of a labral tear. Fitzgerald
described a method of differentiating
between anterior and posterior tears.'^
To diagnose anterior tears, the hip is
brought from a position of flexion,
external rotation and abduction, into
extension, adduction and internal
rotation. For a posterior tear, the hip
is first flexed, adducted and internally
rotated, and then extended, abducted
and externally rotated. In either case, a
positive test is indicated by pain. The
sensitivity and specificity of these tests
for labral tears has not been reported.
In the Fitzgerald series, the test was
positive in 54 of 55 patients with
labral tears.'^
Radiographs are of limited use in
diagnosing labral tears. However, they
may be used, particularly in pediatric
and adolescent dancers, to exclude
other sources of hip pain such as
slipped capital epiphysis, avulsions,
and stress fractures. Evidence of even
mild hip dysplasia on radiograph
may increase the suspicion of labral
tear."* Magnetic resonance imaging
(MRI) has a high incidence of false-
negative results with a sensitivity
of 80% and specificity of
65%."''''
MRI arthrography using gadolinium
increases the sensitivity of detection
of capsulo-labral pathology (sensitiv-
ity of
95%,
accuracy of
65%),^'*
In a
recent study, the use of a small pixel
size and a fast spin-echo sequence in
non-contrast MRI resulted in similar
accuracy in detecting labral lesions as
MRI arthrography,^^
Treatment
There is limited information in the
literature on the success of conserva-
tive treatment of acetabular labral
tears,
and what this nonoperative
care involved. Most studies men-
tioned various combinations of rest,
traction, ambulatory support with
crutches, non-steroidal anti-inflam-
matory drugs, activity modification,
and physical therapy, but specifics are
not defined.^'-'^'f'-'^^'^fi Information
on specific postoperative rehabilita-
tion protocols is also minimal. Sev-
eral investigators have advocated early
minimal weightbearing and range of
motion exercises that avoid external or
internal rotation for at least 3 weeks,
with avoidance of straight leg raise for
4 weeks. Aquatic, proprioceptive, and
other strengthening exercises were also
Binningsley provided more detail
in his rehabilitation of an 18-year-
old British footballer who underwent
arthroscopy and debridement for an
anterior tear.^' Treatment included
non-weightbearing on crutches for 5
days,
followed by the addition of up-
per extremity and abdominal exercises
54 Volume 10, Numbers
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Science
and early proprioceptive work. At day
10,
pool exercises, cycling without
resistance, and a general conditioning
program were implemented. Run-
ning, isokinetic strengthening, plyo-
metric functional rehabilitation drills
that focused on speed, endurance, and
agility, and advanced proprioception
were included at 5 weeks.•^^
A small number of subjects in two
studies reviewed responded well to
conservative intervention. Ikeda and
associates described three adolescent
athletes with posterior labral tears who
returned to full athletic activity after
a period of non-weightbearing with
crutches for 6 to 12 weeks.^° Fitzger-
ald reported that 7 out of
55
patients
experienced complete symptom relief
after injection of marcaine and cele-
stone, and partial weightbearing on
crutches for 4 weeks.'''
Aside from these two examples, the
majority of the literature highlights a
subject population who experienced
varied levels of symptom resolution
after hip arthroscopy.'''^"'-'^'^^'^^ Stud-
ies include case reports, small samples
of athletes, and larger studies on the
general population. Success was mea-
sured subjectively via questionnaire or
objectively using a modified version of
the Harris Hip Score (HHS). Origi-
nally designed to measure a patient's
progress after total hip arthroplasty
(THA),
the modified HHS omits
questions on the level of deformity
and range of motion restriction in
order to better serve a population of
patients who are at a higher level of
function than those usually approved
for THA.^' Fitzgerald reported suc-
cessful subjective outcomes in 42 out
of 48 patients, with 26 being able to
return to previous athletic activities
without residual symptoms.'^ O'Leary
and associates reported success in 20
out of 22 patients post-arthroscopy
according to subjective report with
a 30-month follow-up.^'' Hase and
coworkers reported positive results
through follow-up examinations
over two years postoperatively in 10
patients treated arthroscopically.''*
Additional studies highlighted the
success of arthroscopy for a labral tear
in high-level athletes. Case studies
include adolescent, collegiate, and
professional athletes who were able
to return to their pre-injury level in
sports, including softball, running,
and soccer.'*''^'^^'^'-' Mason described a
professional female ballet dancer who
returned to performing 3 weeks after
arthroscopic
surgery."*
In a study of 12
professional athletes, McCarthy and
colleagues reported on patients who
were able to successfully return to
their pre-injury levels in competitive
football, baseball, hockey, and
golf.''
Byrd and Jones found that improve-
ment in patients treated arthroscopi-
cally for labral tears had the second
highest median score behind patients
treated for loose bodies.^' They also
discovered that the most significant
improvement occurred within the
first month of rehabilitation, with a
plateau by the third month that con-
tinued for up to five years.^^
In contrast, Farjo and associates
found only 13 good results out of a
sample of 28 patients according to
subjective report on pain level, ability
to perform activities of daily living,
work and sport participation."^ San-
tori and Villar reported positive modi-
fied HHS scores in only 39 out of 76
patients after arthroscopic surgery for
a labral tear.'^ Poor results were also
reported in case studies by Beissel and
Byrd.'^'^' Overall, poor results after
arthroscopic surgery seemed to be
associated with concomitant factors
such as arthritis.'^•"'•'^'^'
Discussion
Acetabular labral injury is increas-
ingly being recognized as a source of
hip pain in dancers.* This literature
review highlights current evidence
regarding the assessment and treat-
ment of this injury. Although there
is minimal research regarding labral
injury specifically in dancers, the
information currently available high-
lights several relevant factors that aid
in the understanding of labral tears in
this population.
From a review of the current lit-
erature, it is difficult to determine the
incidence of labral tears in patients
presenting with hip pain. This may be
due to the lack of clinical diagnostic
tests with high specificity and the
inaccuracy of current imaging tech-
niques.^''^' In addition, the incidence
of labral tears diagnosed through
arthroscopy varies widely between
studies, possibly due to differences
in the reporting of data.*^'^ It may
be that, similar to other pathologies
such as disc herniations and rotator
cuff tears, asymptomatic labral tears
are present in many individuals. The
literature does indicate that individu-
als with dysplastic hips may be more
susceptible to anterior labral injury.*'^
As highlighted by Teitz, it is possible
that dancers are more likely to have
acetabular dysplasia than the general
population as this permits greater hip
range of motion. This may put them
at greater risk of developing labral
tears.'
This possibility warrants further
research.
There
is
a consensus in the literature
regarding the poor intrinsic mechani-
cal properties of the anterior labrum.
The labrum is thinner anteriorly and
has almost no vascular supply in its
inner articular portion.'*'* This may
help to explain why most tears occur
anteriorly and are difficult to rehabili-
tate.
With respect to dance, positions
requiring turnout and hyperextension
of the hip place the femoral head more
anteriorly in the acetabulum. This
may expose the anterior quadrant
of the labrum to excessive repetitive
stress.
Therefore, when treating a
patient with a labral tear, Lewis and
Sahrmann suggested eliminating
faulty postural and gait habits that
contribute to hip hyperextension,
and limiting functional activities that
involve compression of the head of the
femur into the acetabulum.^'' Closed
chain pivoting movements should
be avoided during the early stages
of rehabilitation in order to decrease
the anterior forces on the hip.^*" In
dancers, it may also be important to
initially limit end-range turnout and
hip extension during rehabilitation.
Several studies highlighted the
importance of the labrum for hip and
pelvic proprioception, as it has an
abundant neural supply.^'" Impair-
ment in proprioception post-labral
tear or arthroscopic debridement may
Journal of Dance Medicine ef
Science
• Volume 10, Numbers
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£^2, 2006 55
result in uneven load distribution
and muscle imbalance in the dancer.
This may present a problem in the
later stages of rehabili^ajtipn when the
dancer is moving into end-range hip
movements or performing dynamic
multi-joint movements. Nicholls
noted the importance of introducing
neutral, closed chain, proprioceptive
and isometric exercises in the early
stages of treatment.'" This will help
to combat muscular weakness, caused
by pain or effusion, and to maximize
proprioceptive input.'"
Two articles discussed the possible
impact of muscle imbalance patterns
on hip dysfunction.'"'^'' Prolonged or
repetitive hip extension and external
rotation posturing may lead to these
muscle imbalance patterns. Altered
femoral head accessory movement
within the acetabulum can be caused
by the dominance and increased
stiff-
ness of the two joint muscles crossing
the hip, including the TFL, rectus
femoris, and hamstrings, and relative
weakness of the hip abductors, deep
lateral rotators, gluteus maximus, and
iliopsoas. An over-dominance of the
hip lateral rotators over the medial
rotators may also lead to excessive
anterior force on the labrum during
knee flexion or straight leg raise."
Therefore it would be beneficial to as-
sess and treat these abnormal muscular
recruitment patterns in a dancer with
a labral injury. As stressed by Nicholls,
it is also vital to integrate aerobic and
core strengthening activities into an
athlete or dancer's rehabilitation pro-
gram.'" This can help maintain overall
general fitness and positive mental
health during limited sport or dance
participation.'"
From the review of the literature, it
appears that surgical debridement of a
torn labrum is a successful alternative
to failed conservative care.^'' The best
results postoperatively were in patients
without hip dysplasia or osteoarthri-
tis.
Positive results were reported in
studies that focused on small groups
of athletes who were able to return to
their previous level of athletic activ-
ity
4,7,15,20,2331
Unfortunately, there
is only one published case study on
a dancer. In the case of the female
professional ballet dancer reviewed
by Mason,'' the surgery resolved the
sharp,
catching pain in the hip; how-
ever, it did not resolve her symptoms
completely. Mason attributed this to
the presence of chondral damage in
the joint.''
Future research investigating con-
servative or surgical management of
labral tears in dancers will require
an outcome measure that is sensitive
to change in this population group.
The modified HHS that is widely
used post-arthroscopy may not be
high-level enough to accurately re-
flect outcomes in dancers.^" The
score categories are divided into gait
(with questions about the presence
of
a
limp, use of ambulatory aid, and
walking distance) and functional ac-
tivities (with questions regarding the
ability to climb stairs, don and doff
shoes and socks, sit, and use public
transportation). The lack of sensitivity
may be refiected in the fact that when
Byrd and Jones measured the outcome
of athletes using the modified HSS,
they found the most significant im-
provement within the first month of
rehabilitation with a plateau by the
third month.^" The activities measured
by the modified HSS are not reflective
of the range of motion, strength, or
proprioceptive demands of the hip
at a high level of sport or dance. The
Short Form-36 (SF-36) may be a more
appropriate outcome measure for use
in athletes. As discussed by Potter and
colleagues, the SF-36 correlates well
with results from the modified HSS,
with the advantage of having a greater
emphasis on patient satisfaction and
general wellness.^^ The SF-36 allows
the patient to rate their limitations
to performing at a higher level of
functional activity. The SF-36 has
been used previously with professional
dancers and has shown correlation
with injury.^'
Conclusion
It is important to consider the pos-
sibility of a labral tear when treating
dancers with intractable hip pain. This
is a condition that may have a large
impact on a dancer's career. Current
research indicates the possibility of full
return to dancing following hip ar-
throscopy. There is limited published
work on the conservative treatment
of labral tears. Further research in this
area will be valuable to the treatment
of dancers who do not want surgery
or have less severe symptoms.
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