Our previous blog (click HERE) explained some of the background around the use of cartilage and bone marrow cells and the current evidence. We felt it would be useful to provide an update on our experience. The Manchester Hip Clinic is a national centre for hip arthroscopy and we have carried out nearly 1400 in total. Of these, we have carried out over 110 complex surgeries using cartilage and bone marrow cells since we started in 2017.
The aim of the primative cells (which we harvest from the patients’ thigh bone and centrifuge to form Bone Marrow Aspirate Concentrate (BMAC)) is to regenerate damaged joint surface cartilage. When we first started, we simply combined it with Tisseal (a biological glue) and dripped it onto the damaged area (see previous blog). However, that does not give it structural stability, our technique then progressed so that we either combined it with a biological scaffold (Hyalofast) or used the patients own cartilage. While it is a more challenging procedure to do, recent research has suggested that the use of these scaffolds leads to improved and longer lasting patient benefit.
Preparing the graft site
The ideal candidate seems to be someone with localised areas of damage and with good quality surrounding joint surface (see image). If the damage is too extensive, then the graft is not supported and is more likely to fail. Older patients (>55) and those with damage on the ball of the hip seem to do badly so we tend to recommend robotic assisted hip replacements (click HERE) to them.
The recovery period after a “normal” hip arthroscopy is usually up to six months. For patients who have cartilage treatment, that recovery can take up to 12 months with more extensive physiotherapy needed. This increased recovery period is probably due to the level of damage present and the muscle wasting/inflammation that patients develop before surgery. A useful way to think about it is that the surgery is to correct the damage, the physiotherapy is to strengthen the muscles afterwards and then we often recommend Pilates/Yoga to maintain that improved core/hip girdle strength and flexibility. The surgery/stem cell treatments seem to improve patients by 85-90% on average so it is more about improving a damaged hip rather than an absolute cure. After recovery, we normally recommend patients switch to non-impact cardio-vascular exercise afterwards such as cycling, swimming, cross-training or spin. The small number of patients that have remained symptomatic after treatment, tend to carry out impact exercise such as road running, squash, impact gym work etc. If we see these patients and they really wish to continue these activities, we often recommend Mako robotic hip replacement (click HERE) rather than hip preserving surgery.
Total hip replacement is one of the most successful operations that you can have. A successful one can literally be transformational. It can take a patient who is living with constant pain, dependent on strong pain killers, with very limited mobility and overnight, cure their pain and allow them to lead a fulfilling life. Because of the National Joint Registry, here in the UK, we can track patients after their surgery and see how long the implants last. We know that on average, if you have a well-designed implant (such as an Exeter), over 96% will still be in place and functioning well at 14 years. It is reasonable to predict that those implants will last 20 to 30 years. However, we know that if the components are not put in correctly or if the leg length or soft-tissue balance is not right, it can have a significant impact on the complication rate or how well the implant functions. This has led to the development of robotic hips.
Mako robot
Recently, some work has been done on what people are doing with their hip replacements after surgery. One paper published in 2019 showed that while all their patients returned to activity, there was a general move from high to low impact exercise. Another showed that after 10 years, 89% remained active but again there was a significant decrease in high impact sport. What is not clear is was that because patients were told to reduce their activity by their doctor/surgeon or was it because they themselves did not want to wear the new joint out? Perhaps by improving the accuracy of surgery and the muscle balance, we can have the confidence to enable people to maintain their desired level of activity?
The market leader by far in robotic assisted hip surgery is Stryker and the MAKO robot. They have well in excess of 500 machines around the world and over 40 in the UK. At the Manchester Hip Clinic and Spire Manchester, we started doing MAKO procedures in 2018 and are now the highest volume centre in the UK. Essentially, what MAKO does, is use CT scans to accurately map the shape of the patients own hip so that the new artificial one mirrors it exactly and then the robotic element ensures that the surgeon puts it in perfectly. Recent publications have shown that when using this technology, there is increased accuracy, improved patient function and quicker recovery.
Mako surgical planning
The use of MAKO has transformed how we do hip replacements. We see a lot of younger patients who have abnormally shaped hips that would previously have been very challenging to replace. With MAKO, we now have the confidence to know that we are choosing the correct implant and putting it in in the best possible position. That confidence allows us to encourage patients to return to sport and a range of different activities. If I was having a hip or knee replacement, I would definitely have it done using MAKO!
Modern Hip resurfacing was introduced in 1997 by a Birmingham surgeon called Derek McMinn, who basically looked at two old prostheses, the Judet hip from the 1950s, and the McKee-Farrar metal-on-metal hip replacement of the 1960s and combined the two to make the modern hip resurfacing. It is still a hip replacement, but unlike “traditional” replacements, it consisted of a metal cup in the pelvis and a metal cap on the head of the thigh bone. It is sometimes referred to as a partial hip replacement but in reality, it is a complete hip replacement.
A resurfacing is a ‘metal-on-metal’ (MOM) implant. This refers to the two surfaces that rub against each other when the joint moves. Historically, for its time, the McKee-Farrar had very good survivorship, and so the idea was that metal bearings would last much longer than the other bearings of the time (metal-on-plastic or ceramic). Resurfacing tends to be more stable as the head which goes on the femur is very large, so the risk of ‘dislocation’ was less. This reduced wear and increased stability opened up the option of hip replacements to younger active patients, as the feeling at the time was that this type of implant would reduce the need for revision or repeat surgery, which is more complex, higher risk and likely to have a poorer result than a first-time replacement. What was not appreciated, was that the neck (which is much wider than the neck of a standard hip replacement) could still catch against the cup and cause damage, which is essentially what happens with hip impingement.
Significant numbers were implanted in the late 1990s and early 2000s. Other companies saw they were missing out and so all the major implant manufacturers released a version (but all had to be slightly different due to patents). The original Birmingham hip resurfacing has done the best of all the various versions but unfortunately, some of these new designs did very badly. Actually, compared with standard hip replacements, they all had worse long-term results. This was because the metal-on-metal bearing actually wasn’t as safe as thought. Back in the 1960s, patients were not as active as now, and were in much worse condition prior to their hip replacement (which at the time was considered ‘major’ surgery) and so the issues with MOM didn’t really occur. Over time, it became clear that while the resurfacing did not produce as much wear as the traditional types, it did produce large amounts of very small metal particles which could cause very significant soft-tissue reactions and damage.
The problems associated with the MOM bearing became apparent around 2006 and as a result most companies dropped it and versions of it around 2007-8. The numbers of replacements implanted in the UK fell significantly.
Numbers of hip replacements implanted in UK by type
The current scenario is that a lot of NHS and private hospitals will not allow any form of MOM hip replacements (resurfacing or otherwise) to be performed. There are a few surgeons who still perform them as they believe that the failure rate is associated with the implantation technique, which is true to an extent but not wholly so. This situation continued until Andy Murray had his resurfacing early last year, which led to an increase in interest once again.
Technology has moved on since 1997, there are now far better contemporary styles of hip replacement which have all of the benefits of a resurfacing without the downsides and so the indications for resurfacing over anything else have essentially gone away. We specialise in hip replacements (with ceramic on highly cross-linked polyethylene) using robotics as I believe that technology produces the best outcome with the least complications and longest survival. For comparison, the revision risk of the type of implants we use at 14 years ranges from 3.77 to 5.28% compared to 14.78% for all ages of resurfacings, which rises to 22% in those under 55 years (see NJR).
At the Manchester Hip Clinic, we use either Accolade 2 uncemented stems or Exeter cemented stems (depending on age or bone shape) with Tritanium cups, all of which are made by Stryker, one of the big global orthopaedic companies. The bearing surfaces are ceramic on polyethylene, which has the least wear and best long-term survival on the National Joint Registry and we use Mako robotics to make sure they go in perfectly which gives excellent muscle balance and allows early return to function.
Most patients are in 2-3 days and off crutches by 2-4 weeks, exercise bike by 2 weeks and gradual increase in activity over 6-12 weeks. The dislocation risk is highest until at least 12 weeks but the hip will continue to improve for 10-12 months post-surgery. The fitter and stronger you are pre-surgery has a big effect on your recovery afterwards. We treat a lot of high-level athletes for both arthroscopy and replacement, so we are very pro-active with rehabilitation. It is important for us to liaise with your physio locally so we can monitor your recovery. If that is not possible, we can arrange physio supervision over Skype with our own team or one of our partner practices.
Who does this affect? Hip impingement is a relatively common condition in which there is a structural abnormality in either the femoral head (ball of the hip) or the pelvic cup. Normally, as the hip bends up, the bony cup and flexible cartilaginous rim (Labrum) sit into the concave femoral neck.
However, some patients have either a bump on their femoral head (cam impingement) or an over-hanging cup (pincer impingement) and this causes damage to the labrum and eventually the joint surface.
Symptoms Patients with hip impingement present with deep seated groin pain, usually worse on bending and may be present on both sides. There may be an associated deep click, which can be either due to a torn rim cartilage, or more commonly, an inflamed tendon running over the front of the hip (Psoas Tendon). If the condition has been present for some time, there may also be inflammation of the tissues surrounding the hip such as the outer hip (trochanteric bursitis), the groin muscles (adductor tendonitis) or inflammation of tendons in front of the hip (sartorius tendonitis). Eventually, as the damage continues, the patient may begin to develop more arthritic symptoms such as a dull ache in the groin and increasing stiffness. Hip-related pain is not always felt directly over the groin, it may also be felt on the outer aspect of the thigh, the buttock or traveling down the leg. Occasionally, the pain you do feel in the hip may actually be the result a problem in your back, a hernia or other diagnoses.
Causes Hip impingement is caused by bony abnormalities on the acetabular or pelvic rim, the femoral head (ball of the hip) or a combination of the two. Using a combination of plain x-rays and CT scans with 3-D reconstructions, it is possible to very accurately identify where the abnormality is and what needs to be removed at the time of surgery. The routine use of 3D CT has made a real difference to the success of the surgery and the eventual outcome for the patient.
Pure CAM deformity In a CAM deformity, there is an abnormal bump at the junction between the head/ball of the femur and the neck. This is evident on the image above. This area can be accessed from within the joint and shaving carried out using a small burr until the appropriate shape has been created.
Pure PINCER deformity In a PINCER deformity, there is an overhanging cup. This can be seen on both the plain x-rays and the CT reconstructions. Depending on the severity, the bony rim can be trimmed back leaving the soft cartilaginous rim in place (peri-labral rim recession), if it is a mild deformity or in more severe cases, by removing it, shaving back the bony rim and then reattaching the labrum using special bony anchors.
Mixed CAM/PINCER deformity In the majority of patients, there is a combination of CAM and PINCER impingement. In these cases both sides may need to be addressed if the patient is to get the best result. This can often be achieved by doing a peri-labral rim recession and a femoral head reshaping, thereby leaving the labrum in place and allowing for early mobilisation.
Investigations All patients undergo specialized x-rays of the hip as well as more complex scans such as CT and Magnetic Resonance Arthrography (MRA). These scans are used to confirm the soft-tissue damage and to accurately map out the bony deformity. This is very important when planning the surgery.
Non-surgical Treatment Professor Fehily has designed a specialized hip rehabilitation program. This was done in conjunction with his specialist hip physiotherapists. This was initially developed for patients following key-hole hip surgery but it is now being used for general hip rehabilitation. Other therapies such as painkillers, anti-inflammatory drugs, for example, liquid thc, as a more natural approach, and modification of activity can also be tried.
Surgical Treatment If the hip impingement is due to an underlying bony abnormality and physiotherapy has not cured the pain then surgery is recommended. The aim is to correct the bony deformity before there is irreversible joint damage. This is usually done by hip arthroscopy (keyhole surgery) where the deformity is shaved back via 2 or 3 small incisions. Occasionally some patients with pincer impingement do not simply have an overhanging front rim, instead, the entire cup is rotated backward (acetabular retroversion). If this is the case, then a simple rim trimming will not solve the problem and by decreasing the amount of head coverage, may actually speed up the onset of arthritis. These cases may need more significant pelvic surgery to alter the position of the cup (peri-acetabular osteotomy).
Hip arthroscopy is highly specialised and technically difficult surgery but can achieve excellent results if carried out correctly and on the right patient. Based on Professor Fehilys’ own experience and that of the wider orthopaedic community, certain patients do not do well from hip arthroscopy e.g. patients with significant hip arthritis, patients with severe childhood hip disease (hip dysplasia) or patients with inflammatory hip disease (e.g. rheumatoid arthritis). Occasionally, the bony deformity may be so large that an adequate bony reshaping is not possible using key-hole surgical techniques. In those cases the operation is done using an open technique. In some cases, the damage caused to the joint by the impingement may be so severe that the only reliable option is a joint replacement. However, if at all possible, we will try to preserve the joint using a combination of techniques such as micro-fracture and stem cell treatment (see Stem Cell Therapy). All patients are different and the advantages and disadvantages of the various treatment options can be discussed at the time of your consultation.
Hip arthroscopy is an innovative procedure that allows access to the hip joint using minimally invasive surgical techniques. It has been carried out episodically for some years, but in its current form has only been practiced over the last 5 to 10 years. It was pioneered by surgeons in the UK, Australia and the US and since then the indications have rapidly expanded. Initially it was used to remove loose bodies, take tissue samples and to investigate joint pain. However, since the concept of impingement has become clearer, it has been used to reshape both the pelvic cup (acetabular) rim and the femoral head/neck.
Investigations
Prior to surgery, all patients undergo specific x-rays of the hip as well as more complex scans such as CT and Magnetic Resonance Arthrography (MRA). These scans are used to confirm the soft-tissue damage and to accurately map out the bony deformity. This is very important when planning the surgery.
Each patient undergoes a general anaesthetic and the procedure takes approximately 1.5 to 2 hours to carry out. The patient is on their side and traction is placed on the leg. This distracts the hip and allows access to the joint. Using a combination of hollow needles and tubes, a camera is inserted into the joint.
Once there both the cartilaginous labrum and the joint surface cartilage are assessed. If the labrum is torn, it is repaired if possible as there is good evidence in the orthopaedic literature that this has a significant effect on long-term outcome. Occasionally the quality of the torn labrum is too poor for repair so it is debrided. If there is a defect in the joint surface cartilage then it is either debrided back or treated with specialised techniques such as micro-fracture or stem cell therapies.
Once the rest of the joint is inspected, the traction is released and access is made to the outer part of the hip joint. Once there, the abnormal bump is identified and removed using an arthroscopic shaver until it no longer catches.
Following the surgery, the patient undergoes a specialist hip rehabilitation program. This works on restoring range of movement and core stability. The patient initially remains partial weight bearing for between one and four weeks, depending on the surgery carried out, patients either go home on the day of surgery or the following day and are followed up by a dedicated therapist. They are reviewed in out-patients at six weeks and six months where their progress is carefully monitored.
Patient recovery can vary significantly following the operation. Most will return to normal day to day activities by six weeks, however, functional activity will continue to improve between six and nine months following the surgery. Occasionally, a small group of patients will remain uncomfortable following surgery and in these patients, a steroid injection into the hip joint can be very useful.
Compared to open surgery, the risks of hip arthroscopy are far less.There is a small risk of infection, blood clots, temporary nerve injury and groin bruising. Patients are routinely given antibiotics and a blood thinning drug to minimise some of these risks.
The outcome of hip arthroscopy is good, so long as the appropriate procedure is carried out. Professor Fehily has pioneered the use of 3D CT scans to accurately map out each patients bony deformity which then allows bespoke surgery, tailored to each individual patient. All patients undergo functional scoring both pre and post surgery and are then followed up long-term. A prospective database is kept of all patients and this has allowed us to identify who does and does not benefit from this surgery. On the whole, the majority of patients are significantly better following this procedure and this benefit is maintained into the long-term.
Professor Fehily carries out over 160 of these procedures per year and over 1300 in total. He is one of the highest volume surgeons for this procedure in the UK. He is an Honorary Professor at Salford University on soft-tissue hip problems, teaches physicians and physiotherapists about hip arthroscopy and is a regular member of faculty on both national and international courses teaching these advanced techniques to orthopaedic surgeons.
A painful hip can be through a one off injury but more commonly in clinic at Altius Healthcare we see pain that has come on gradually over a period of months and got worse. Patients describe a deep pain in either their groin or buttock or both and don’t recount a particular event. Their pain tends to vary in severity and is aggravated by certain movements that compress the joint surfaces including prolonged sitting. Combining physical therapy with other avenues can help people deal with the pain in a better manner. Medical marijuana has been known to aid in pain relief and depending on how you consume it, you can go and look at pipes and bongs online to find the best one for you. Alternatively, you can speak to your doctor if you are interested in using medical marijuana for pain management. Some doctors can write a prescription for you, which allows you to buy cannabis online to help give you pain relief.
Often these patients are scanned and the results of the imaging don’t match their pain presentation. Some have a large amount of damage in their hip but are relatively pain free and others are very painful with little to report on the scan. The majority of patients (regardless of their scan results) have muscular inhibition, as a result of the pain they are in and which we can address with home exercises which almost always helps them with their pain.
Patients with painful hips tend to keep going on them until they have picked up a poor movement pattern (limp) which sets off a cascade of events that if you don’t address with treatment and rehabilitation they continue to gradually get worse.
Once you are feeling pain the important thing to do initially is to identify the things that aggravate your pain and avoid them. This may sound like common sense but you would be surprised how many people try to push through the pain only to make it worse. For instance, if prolonged sitting is a problem, record how long it takes in sitting for you to get to 4/10 severity and then use this a s a guide to make sure that you don’t exceed this pain threshold in any one day.
Do take medication as well. People will not take medication because they think it will numb them so they do not know when they are making things worse. Once you know that without medication you can only sit for 40 mins then once you are taking medication stick to this rule of not sitting for longer than 40 mins for 3 days and then reassess your progress.
A person who has had hip pain for a month or longer will normally always have inhibition in their gluteal muscles (buttocks) and adductors (groins). In clinic, we would normally always prescribe exercises to help wake these muscles up. I often suggest a single leg bridge and a ball squeeze as a good place to start. Patients with hip pain also tend to have poor trunk strength, often worse on their painful side so we would also teach a modified plank exercise in three positions to strengthen the natural corset which is so important in stabilising the spine on the pelvis and off-loading the hips.
At the same time as addressing muscular inhibition, we also encourage patients to work on their spasm. We often find in clinic if the gluteals and adductors aren’t working properly, their default is to go into spasm to stop you moving which causes you more pain. We find teaching you deep pressure techniques with a foam roller can reduce spasm and pain and be a great thing to do before you do your strengthening rehab.
Regarding how much and how often. Obviously most patients are busy people and struggle to get anything done regularly just as some patients can over do it and aggravate things further. Therefore finding a balance is important and listening to your hip and how it is feeling, is of up most importance. I always suggest doing rehab Monday, Wednesday and Friday is a good place to start. The body needs to rest and recover from the strengthening you are doing and normally I say if you are sore (less than 4/10) during the exercises and and/or afterwards, that needs to be monitored and if you haven’t recovered by the next day and you are still 4/10 pain then you are doing too much of the wrong thing for you at that stage. During each rehab session I ask people to repeat each exercise three times until fatigue with a minutes rest between sets.
Catching hip pain early and treating it aggressively before you pick up a poor movement pattern is essential for a speedy recovery. Do not leave things for a month before you do something about it. Early intervention is key in managing any injury. So in summary, the devil is in the detail. We see many patients who make fantastic recoveries from severe hip pain with a huge amount of damage on a scan. The patients who do best are those who catch the pain early and make time to do the rehab properly and listen to their symptoms and don’t train with too much pain.
If in doubt and before you start doing the wrong thing it is important to get an accurate diagnosis. You should always get in to see an experienced physio or specialist sports medicine doctor with a special interest in the hip and groin as it is a specialist area and requires often a multi-centred approach.
If you would like further information or would like to send us a question please feel free to get in touch and we will help you as much as we can.
As a sports physiotherapist I work in a number of diverse settings which gives me access to a wide range of clients from the elite professional footballer to the office worker who is a keen triathlete at the weekends. For each client the need is the same “how can I get the most out of my sporting hip and groin following injury in order to improve my performance.” Pain at the hip and groin region particularly can be very debilitating for the athlete, quite often it is very poorly understood area and as a consequence the problem can become chronic and result in an extended period on the sideline’s.
Diagnostics & Collaborative working Diagnostics play an important role as the hip and groin is a very complex area and problems can be difficult to diagnose. Orthopaedic consultant opinion together with radiographic imaging and specialist reporting is important in pinning down the correct diagnosis. A collaborative approach in assessment from leading specialists in Sports Medicine and the Sports Physiotherapist is the most effective route in treating the athlete in terms of getting them back to action as soon as is safely possible and providing a solution to ensure their long term fitness.
Focused & Progressive Rehabilitation First of all it is important to educate the athlete about their injury, the mechanism of injury often involving video analysis and the rehabilitation plan that will allow them to return to sport and avoid any injury reoccurrence. It requires a ‘buy in’ from both the therapist and the athlete to commit to a rehabilitation programme which will allow them to return to full fitness. Hip and groin injury can be multifactorial in nature but it is important to focus targeted rehabilitation at the region initially and then progress to more dynamic loading as symptoms improve. I have found the following progressive stages of rehabilitation to be most effective within the sporting population:
Intersegmental control and strength (such as a deadlift or double leg squat)
Linear mechanics and running load (such as barbell/overhead running and leg change drills)
Multidirectional mechanics and sprinting (such as a lateral shuffle or Zig Zag cutting)
Within these 3 phases the therapist encourages correct execution in technique and correct lumbo-pelvic form. Furthermore, a gradual increase in load progression, speed intensity and multi-directional movement patterns is also encouraged. Other treatment methods may also be incorporated if deemed necessary, such as improving the mobility of the lower extremities and spine with manual therapy and sports yoga, application of strength and conditioning principles, Shockwave therapy and clinical Pilates.
It is also important to keep the athlete focused and interested within rehabilitation. In order to achieve this outcome the therapist must make rehab specific to their sport; jointly develop drills with the athlete to mirror scenarios encountered within a game situation and make rehab proprioceptively demanding in order to retrain reaction timing and load response.
Profiling & injury prevention There is now a growing trend towards profiling of the athlete to highlight any injury risk factors and movement dysfunction that may predispose the athlete to injury. A specific screening tool devised by the therapist specific to the demands of the sport and/or the athletes overall physical capabilities is generally used twice a year in both a squad environment or on an individual basis to measure athletic performance. The screen may broadly include the following battery of tests:
Range of motion eg. Shoulder mobility
Strength testing eg. Adductor Squeeze test
Balance testing eg. Single leg landing
Work Capacity testing eg. Push up to failure
Movement Patten analysis eg. Squat form
Outcome measure eg. Triple hop for distance
Data produced from the screen allows us to flag up any potential weaknesses that could be a contributing factor to injury and have an adverse effect on overall physical performance. In order to nullify these weaknesses the athlete who presents as a high injury risk is given outlined bespoke action points to work on and then they are assessed more regularly, every few months throughout the year on key tests relevant to their profiling findings. This detailed monitoring allows us to prevent potential injury occurrence in key area’s such as the hip and groin and ensures the athlete remains fit, strong and pain free in order to achieve optimal performance.
Mike Kennedy MSc BSc (Hons) MHCPC MCSP MACPSEM
Manchester United Football Club Academy Physiotherapist Lead Physiotherapist, Mike Kennedy Chartered Physiotherapy & Pilates Highly Specialist Musculoskeletal & Sports Physiotherapist, Spire Perform Manchester Consultant Physiotherapist to the Professional Footballers’ Association (PFA) Associate Research Physiotherapist to the FASHIoN trial – Studying Hip Impingement
The demands on any sportsperson in the groin region is huge but particularly so in football given the volume of change of direction work involved. The fact that there are 45 muscles which attach to the pelvis in a variety of directions gives us a snap shot of the different forces involved in this region and why groin injuries are so common.
One thing that we used to frequently discover in football and the same in clinic now is that whenever people seemed to have pain or pathology in the hip and groin, there would be some kind of muscular weakness. There is strong evidence to suggest that reduced adductor strength is related to the incidence of groin pain and the development of groin injuries and yet people generally take the approach of stretching and releasing muscles (which may be relevant but not always) rather than combining this with a strength programme.
A nice simple way to strengthen your adductors can be to follow the “Copenhagen Protocol” which has been shown to significantly improve the strength in the adductors (even when performed during mid season competition). This would start with 2 sets of 6 in week 1 done twice per week and volume increase weekly very gradually. By 8 weeks you should be competent to perform 3 x 15 twice per week. To perform the exercise, adopt the position shown below and bring the lower leg towards your weight bearing leg and lower it back down again. If this is too hard then just hold the position to start the strengthening process.
This is of course only one dimension to a complex region of the body which quite often requires a more detailed assessment and rehabilitation programme.
Dave Williams, physiotherapist of Harris & Ross Physiotherapy at Wilmslow and Wigan clinics following 8 years working in elite sport at the Manchester City F.C Academy. During his time at MCFC, he was lead Physio for the hugely successful Youth team boasting players such as Phil Foden, Jadon Sancho and Kieran Trippier amongst many others.
Who does this affect? Labral tears usually occur in patients who have femero-acetabular impingement. These patients have either an abnormal bump on their femoral neck or an overhanging pelvic cup. In both these cases, the soft cartilaginous cup rim (labrum) gets damaged (figure 1) as the hip bends up. Initially the rim is simply peeled back but eventually it becomes torn and occasionally shredded. Patients are typically younger and very active, often taking part in sports such as running, kick-boxing, mountain biking and horse riding. Occasionally it can occur due to a severe and traumatic injury e.g. hip dislocation while playing rugby.
Symptoms Patients with labral tears present with deep sharp groin pain, which may only occur on full hip bending. They may or may not be an associated deep click, which can be either due to the torn labrum, or more commonly, an inflamed tendon running over the front of the hip. If the condition has been present for some time, there may also be inflammation of the tissues surrounding the hip such as the outer hip (trochanteric bursitis), the groin muscles (adductor tendonitis) or infammation of tendons in front of the hip (sartorius tendonitis).
Investigations All patients undergo specialised x-rays of the hip as well as more complex scans such as CT and Magnetic Resonance Arthrography (MRA). The MR arthrogram involves injecting dye into the hip joint prior to the scan. This allows identification of the torn cartilage. CT scans are used to accurately map out the bony deformity. This is very important when planning the surgery.
Non-surgical Treatment Not everyone needs surgery so we initially treat patients with physiotherapy, painkillers, anti-inflammatory drugs and modification of activity. However, if they have a proven labral tear and physiotherapy has not cured their symptoms, then it is recommended that they undergo key-hole hip surgery (hip arthroscopy) first to address both the torn cartilage and bony abnormality, then undergo our specialist rehabilitation afterwards. A patient who has a painful hip and a proven tear is unlikely to settle without surgical intervention.
Surgical Treatment The treatment of choice is hip arthroscopy. This allows access to both the true hip joint itself and the front of the femoral head where the bony abnormality is often located. Most patients do not have frank labral tears, rather the labrum is peeled back from the acetabular rim. In those patients where there is a gross tear, there is good evidence to show that patients do better long term if the tear is repaired. Occasionally the labrum is frayed and is simply debrided back until it is stable. Once that is carried out, the rest of the joint surfaces are inspected and treated as required. If the joint surface is damaged, it can be trimmed back if minor or if more severe, then specialist techniques can be carried out to encourage new cartilage growth, such as stem cell grafting.
If there is an underlying bony abnormality on either the femoral head or the bony pelvic cup, then that is also addressed at this stage. This is technically difficult surgery but can achieve excellent results if carried out correctly and on the right patient. Based on Professor Fehily’s own experience and that of the wider orthopaedic community, certain patients do not do well from hip arthroscopy e.g. patients with significant hip arthritis, patients with severe childhood hip disease (hip dysplasia) or patients with inflammatory hip disease (e.g. rheumatoid arthritis). Occasionally, the bony deformity may be so large that an adequate bony reshaping is not possible using key-hole surgical techniques. In these cases the operation is done using an open technique and the labral tear can be addressed at the same time. In some cases, the damage caused to the joint by the impingement may be so severe that the only reliable option is a joint replacement. However, all patients are different and advantages and disadvantages of the various treatment options can be discussed at the time of your consultation with Professor Fehily.
The Manchester Hip Clinic is committed to helping all kinds of people with hip problems to be free from pain and often to resume near-normal levels of physical activity – even those who may have thought that such relief would never be possible.
