Within 1 week, I examined 2 women with the diagnosis of lumbar pain who each happened to mention having a hip labral tear. Of course, neither woman volunteered information about the pelvic floor dysfunction she has lived with since having children. When I took the extra step and openly asked if they had any “issues” in the pelvic floor region, both women initially looked surprised and then relieved as they shared (perhaps for the first time) the problems they’ve had. I started to wonder about the contribution of pelvic floor dysfunction to acetabular labral tears, or vice versa, and I knew each problem had to be addressed for the referring diagnoses to be treated completely and effectively.
Considering the anatomy of the acetabular labrum in relation to the pelvic floor structures, there is undeniably a connection. A thorough review of pelvic anatomy is given in the Functional Applications in Pelvic Rehabilitation course by Kathe Wallace. Just briefly, the acetabulum is the depression in the pelvis (os coxae) where the femoral head articulates. The labrum sits in the acetabulum, which faces anteriorly along with the femoral head, requiring the anterior aspect of the labrum to stabilize this portion of the hip that lacks bony contact. The obturator internus muscle, which is a deep hip external rotator and abductor, attaches to the posterior aspect of the obturator foramen and inserts on the medial surface of the greater trochanter. When this muscle is in spasm or inhibited, the pelvic floor and the hip can suffer.
In 2009, Groh and Herrera published a review of hip labral tears, and the general consensus was that labral tears “occur more frequently in women than in men.” The fact that women have more hip dysplasia than men has been suggested as a cause for this finding; however, many of the women with labral tears do not have concomitant hip dysplasia. Alas, Hunt et al (2007) pointed out that women have a generally higher incidence of pelvic-floor pain, which could contribute to the higher incidence of labral tears.
Interestingly, in a study by Brooks and Domb (2012), 10 women over 2 years presented post-partum with anterior hip pain and required labral surgery. The excessive hip external rotation needed for natural delivery was implicated in the pathology, and the authors encouraged obstetricians to have women evaluated prior to delivery and mobilized properly so they could prevent the tears. Hormonal changes in the ligaments as well as the posture assumed by pregnant women with increased lordosis placing more shearing on the anterior aspect of the hip are also factors to consider. Not to mention, the pelvic floor connection to the acetabular labrum certainly seems a reasonable culprit for making the labrum more susceptible to injury during pregnancy and/or delivery.
With the improved technology to diagnose acetabular labral tears, more are being found and treated surgically. The higher incidence of labral pathology in women makes the contribution of pelvic floor dysfunction a serious possibility to consider. If the labrum gets fixed but the pelvic floor is still an issue, becoming completely asymptomatic is less likely. Seeing 2 patients in 1 week who each presented with low back pain, labral tear, and pelvic floor dysfunction when I only work part time makes me think we cannot deny the importance of our subjective examination in uncovering all the possible causes of any suspected tissue in lesion.
Herman & Wallace faculty member Ginger Garner teaches an excellent course called "Extra-Articular Pelvic and Hip Labrum Injury: Differential Diagnosis and Integrative Management" which explores acetabular labral tears in depth. Join Ginger next May in Rochester, NY to learn some great evaluation and treatment techniques!
References:
Groh, M. M., & Herrera, J. (2009). A comprehensive review of hip labral tears.Current Reviews in Musculoskeletal Medicine, 2(2), 105–117. doi:10.1007/s12178-009-9052-9.
Hunt D, Clohisy J, Prather H. (2007). Acetabular tears of the hip in women. Phys Med Rehabil Clin N Am.,18(3):497–520.
Brooks AG, Domb BG. (2012). Acetabular labral tear and postpartum hip pain. Obstet Gynecol. 120(5):1093-8.