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• W2799355536 abstract "The labrum has been recognised to play an important role in the hip in regard to stability, fluid regulation, decreasing contact forces, proprioception and nociception. These functions are all important for normal joint homeostasis in a well-functioning hip and can be responsible for increasing joint pain, damage, instability and dysfunction when compromised. The labrum has been studied intently in the last few decades to better understand its role in the normal and the pathologic hip and how best to treat pathology that causes debilitating hip pain and dysfunction. This current concept review discusses and summarises the current literature on labral anatomy, biomechanics, pathology, clinical exam and imaging. The labrum has been recognised to play an important role in the hip in regard to stability, fluid regulation, decreasing contact forces, proprioception and nociception. These functions are all important for normal joint homeostasis in a well-functioning hip and can be responsible for increasing joint pain, damage, instability and dysfunction when compromised. The labrum has been studied intently in the last few decades to better understand its role in the normal and the pathologic hip and how best to treat pathology that causes debilitating hip pain and dysfunction. This current concept review discusses and summarises the current literature on labral anatomy, biomechanics, pathology, clinical exam and imaging. From 1999 to 2009, the number of hip arthroscopies performed by orthopaedic surgeons has increased 18-fold in the USA.1Colvin AC Harrast J Harner C Trends in hip arthroscopy.J Bone Joint Surg Am. 2012; 94: e23-1-510.2106/JBJS.J.01886Crossref PubMed Scopus (247) Google Scholar This has led to and been a result of increasing literature on hip arthroscopy. The labrum has been a structure of great interest during this time period, as it is often noted to be injured at the time of arthroscopy. There has been a multitude of studies examining the labrum from both a basic science standpoint and from a diagnostic and treatment standpoint. The purpose of this current concept review article is to discuss labral biomechanics, pathoanatomy, imaging, clinical diagnosis of pathology and labral treatments including debridement, repair and reconstruction. The acetabular labrum is a fibrocartilaginous structure that attaches to both the anterior and posterior aspects of the transverse acetabular ligament and is then securely tethered to the hyaline cartilage of the acetabular periphery through a transition zone.2Grant AD Sala DA Davidovitch RI The labrum: structure, function, and injury with femoro-acetabular impingement.J Child Orthop. 2012; 6: 357-37210.1007/s11832-012-0431-1Crossref PubMed Scopus (27) Google Scholar It is a triangular shaped structure in cross section that forms a soft tissue seal around the articulation of the femoral head with the acetabulum. The collagen at the junction between the articular cartilage and the labrum is oriented perpendicular to the junction in all regions except for the anterosuperior region where the collagen runs parallel.3Türker M Kılıçoğlu Ö Göksan B et al.Vascularity and histology of fetal labrum and chondrolabral junction: its relevance to chondrolabral detachment tears.Knee Surg Sports Traumatol Arthrosc. 2012; 20: 381-38610.1007/s00167-011-1566-1Crossref PubMed Scopus (6) Google Scholar The parallel orientation of the collagen fibres at the anterosuperior region of the chondrolabral junction decreases the strength of the labral attachment and creates a relative weakness at this junction where most labral tears occur. The labrum has been shown to be richly embedded with nerve fibres for both nociceptive and proprioceptive functions.4Gerhardt M Johnson K Atkinson R et al.Characterisation and classification of the neural anatomy in the human hip joint.Hip Int. 2012; 22: 75-8110.5301/HIP.2012.9042Crossref PubMed Scopus (73) Google Scholar These nerves are more densely populated in the anterior-superior and posterior-superior regions of the acetabulum, which may explain why labral tears can be so painful to patients.5Alzaharani A Bali K Gudena R et al.The innervation of the human acetabular labrum and hip joint: an anatomic study.BMC Musculoskelet Disord. 2014; 15: 4110.1186/1471-2474-15-41Crossref PubMed Scopus (51) Google Scholar Most of the innervation to the hip joint comes from the nerve to the quadratus femoris and the obturator nerve.6Hosokawa O [Histological study on the type and distribution of the sensory nerve endings in human hip joint capsule and ligament].Nihon Seikeigeka Gakkai Zasshi. 1964; 38: 887-901PubMed Google Scholar The labrum receives its vascular supply mainly from superior and inferior gluteal arteries with small contributions from the medial and lateral femoral circumflex arteries.7Kalhor M Horowitz K Beck M et al.Vascular supply to the acetabular labrum.J Bone Joint Surg Am. 2010; 92: 2570-257510.2106/JBJS.I.01719Crossref PubMed Scopus (39) Google Scholar These vessels form a periacetabular vascular ring. The radial vessels in this vascular ring were noted to be in slightly higher concentration posteriorly than anteriorly. This relatively decreased blood supply anteriorly, in combination with the usual anterolateral location of bony impingement and the parallel collagen fibres at the labral junction, may contribute to the anterosuperior labrum being the most often location for tears. Vascular supply to the labrum has been demonstrated to be denser along the capsular side compared with the articular side. This is consistent with the glenoid labrum and the meniscus because the circulation feeds from the capsular side inward towards the articular side.8Kelly BT Shapiro GS Digiovanni CW et al.Vascularity of the hip labrum: a cadaveric investigation.Arthroscopy. 2005; 21: 3-1110.1016/j.arthro.2004.09.016Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar It has been noted in animal models that the last portion of the hip labrum to heal after repair is the transitional zone between labrum and hyaline cartilage, further reinforcing the idea that it is a relatively hypovascular zone.9Philippon MJ Arnoczky SP Torrie A Arthroscopic repair of the acetabular labrum: a histologic assessment of healing in an ovine model.Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2007; 23: 376-38010.1016/j.arthro.2007.01.017Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar The size of the labrum usually varies depending on the bony morphology noted on radiograph. It is currently theorised that dysplastic acetabulums experience increased shear forces in the anterior and lateral weightbearing zones due to instability, which places greater demand on the labrum and soft tissues during development and necessitates hypertrophy for stability. This is hypothesised to be the reason hypertrophic labrums are more prevalent in the dysplastic population and has been supported by several studies that have looked at MRI measurements of acetabular coverage and labrum size.10James S Miocevic M Malara F et al.MR imaging findings of acetabular dysplasia in adults.Skeletal Radiol. 2006; 35: 378-38410.1007/s00256-006-0082-8Crossref PubMed Scopus (29) Google Scholar Domb et al demonstrated that all four quadrants of the acetabular labrum are hypertrophic in patients with radiographic evidence of dysplasia.11Gupta A Chandrasekaran S Redmond JM et al.Does Labral Size Correlate With Degree of Acetabular Dysplasia?.Orthop J Sports Med. 2015; 3 (232596711557257)10.1177/2325967115572573Crossref PubMed Scopus (32) Google Scholar Patients with more acetabular coverage have not been shown to have hypoplastic labrums compared with those with normal radiographic measurements of acetabular coverage. One of the many important functions of the labrum is to increase the stability of the hip. This is accomplished by both increasing the depth of the acetabulum and by creating a negative pressure suction seal of the hip joint. Finite element analysis models have demonstrated significant contributions from the labrum in hip stability with normal activity and to a greater extent with more extreme hip motions.12Bonner TF Colbrunn RW Bottros JJ et al.The contribution of the acetabular labrum to hip joint stability: a quantitative analysis using a dynamic three-dimensional robot model.J Biomech Eng. 2015; 137061012 10.1115/1.4030012Crossref PubMed Scopus (6) Google Scholar When the labrum and capsule were sectioned in the laboratory, a significantly larger amount of external rotation and anterior translation was noted compared with the intact state.13Myers CA Register BC Lertwanich P et al.Role of the acetabular labrum and the iliofemoral ligament in hip stability: an in vitro biplane fluoroscopy study.Am J Sports Med. 2011; 39: 85-91Crossref PubMed Scopus (232) Google Scholar However, the amount of external rotation and translation only changed when the labrum was sectioned in combination with the capsule. This would suggest that the labrum has a significant role in stabilising the hip in conjunction with the capsular ligaments. In the intact state, the labrum has been shown to create a negative pressure by sealing off fluid in the central compartment from the peripheral compartment.14Cadet ER Chan AK Vorys GC et al.Investigation of the preservation of the fluid seal effect in the repaired, partially resected, and reconstructed acetabular labrum in a cadaveric hip model.Am J Sports Med. 2012; 40: 2218-222310.1177/0363546512457645Crossref PubMed Scopus (77) Google Scholar This negative pressure acts as a suction seal to increase the stability of the hip further, and is lost with significant labral tearing. The suction seal helps to regulate the amount of fluid that moves in and out of the central compartment of the hip and maintains a very thin layer of fluid between the femoral head and the acetabulum.14Cadet ER Chan AK Vorys GC et al.Investigation of the preservation of the fluid seal effect in the repaired, partially resected, and reconstructed acetabular labrum in a cadaveric hip model.Am J Sports Med. 2012; 40: 2218-222310.1177/0363546512457645Crossref PubMed Scopus (77) Google Scholar This fluid film allows for weightbearing with much less contact force and a lower coefficient of friction between opposing cartilage surfaces than there would be without this fluid layer. Loss of this fluid film is one of the possible causes of premature osteoarthritis of the hip.14Cadet ER Chan AK Vorys GC et al.Investigation of the preservation of the fluid seal effect in the repaired, partially resected, and reconstructed acetabular labrum in a cadaveric hip model.Am J Sports Med. 2012; 40: 2218-222310.1177/0363546512457645Crossref PubMed Scopus (77) Google Scholar Labral tears are most commonly located in the anterosuperior aspect of the acetabulum and this is usually associated with either instability or hip impingement from cam, pincer or most commonly mixed pathology. Anterior labral tears at the three o'clock position may be caused by tightness of the iliopsoas tendon against the anterior capsulolabral structures which causes snapping of the iliopsoas with rotational movement of the hip.15Alpert JM Kozanek M Li G et al.Cross-sectional analysis of the iliopsoas tendon and its relationship to the acetabular labrum: an anatomic study.Am J Sports Med. 2009; 37: 1594-159810.1177/0363546509332817Crossref PubMed Scopus (63) Google Scholar Posterior labral tears are much less common and can be caused by contrecoup lesions when the hip impinges anteriorly and levers the head out posteriorly, by posterior instability, or by posterior hip impingement. There are several labral tear classifications used in the literature currently.16Seldes RM Tan V Hunt J et al.Anatomy, histologic features, and vascularity of the adult acetabular labrum.Clin Orthop Relat Res. 2001; 382: 232-24010.1097/00003086-200101000-00031Crossref PubMed Scopus (494) Google Scholar, 17Lage LA Patel JV Villar RN The acetabular labral tear: an arthroscopic classification.Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 1996; 12: 269-27210.1016/S0749-8063(96)90057-2Abstract Full Text PDF PubMed Scopus (228) Google Scholar One classification system uses both aetiological (traumatic, degenerative, idiopathic or congenital) and morphological (radial flap, radial fibrillated, longitudinal peripheral or unstable) characteristics of the tear.17Lage LA Patel JV Villar RN The acetabular labral tear: an arthroscopic classification.Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 1996; 12: 269-27210.1016/S0749-8063(96)90057-2Abstract Full Text PDF PubMed Scopus (228) Google Scholar The most common classification used currently is Seldes. This classification is based on cadaveric dissection and histologic review of labra.16Seldes RM Tan V Hunt J et al.Anatomy, histologic features, and vascularity of the adult acetabular labrum.Clin Orthop Relat Res. 2001; 382: 232-24010.1097/00003086-200101000-00031Crossref PubMed Scopus (494) Google Scholar This histologically based classification has been adapted to be used at the time of arthroscopy based on morphologic characteristics of the tear seen at the time of arthroscopy. Type I is when the chondrolabral junction has been disrupted and type II is when there is an intrasubstance tear of the labrum (figure 1). Surgeons have also created a third type which demonstrates features of both and is termed a combined tear type. Based on mechanics of how the tears were created some have postulated that cam impingement would primarily cause Seldes type I tears because the cam pushes the labrum aside when it enters the joint. As repetitive impingement occurs between the femoral head-neck junction and the acetabulum, the chondrolabral junction is disrupted. In pincer impingement, the overcovering socket and labrum are crushed between the normal head-neck junction and the overcovering acetabulum causing a type II tear. Neither of these classifications have been predictive of outcomes with repair. Patients with true intra-articular hip pain will often report to the physician deep groin pain with a positive C-sign (figure 2).18Byrd JW Femoroacetabular impingement in athletes, part 1: cause and assessment.Sports Health. 2010; 2: 321-33310.1177/1941738110368392Crossref PubMed Scopus (37) Google Scholar Men and women have similar histories with the exception that men tend to have a more traumatic onset to their pain from labral pathology than women.19Lindner D El Bitar YF Jackson TJ et al.Sex-Based Differences in the Clinical Presentation of Patients With Symptomatic Hip Labral Tears.Am J Sports Med. 2014; 42: 1365-136910.1177/0363546514532226Crossref PubMed Scopus (21) Google Scholar Some patients may convey a history of mechanical catching, locking and popping in the hip. Labral tears from impingement will often cause pain with sitting for long periods of time; twisting manoeuvres, especially internal rotation; cutting or pivoting; running, especially up hill; and anything that requires increased flexion of the hip. Labral tears from instability can demonstrate pain from the above position as well. In addition, patients with anterior instability may have pain when they place their legs into extension and external rotation, whereas patients with posterior instability may have posterior pain when they place their legs into flexion, adduction and internal rotation. There are several clinical exam manoeuvres that have been used for diagnosis of labral tears in the hip. These tests are meant to replicate impingement or instability over the area of labral tearing and cause pain in this area. Objective weakness is present in flexion and abduction in almost 50% of patients with a diagnosed labral tear.20Beighton P Solomon L Soskolne CL Articular mobility in an African population.Ann Rheum Dis. 1973; 32: 413-41810.1136/ard.32.5.413Crossref PubMed Scopus (1183) Google Scholar Research on examination manoeuvres used to diagnose labral tears has been lacking and of poor quality.21Reiman MP Goode AP Cook CE et al.Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis.Br J Sports Med. 2015; 49: 81110.1136/bjsports-2014-094302Crossref PubMed Scopus (112) Google Scholar The first exam manoeuvre that should be used to test for bony impingement is range of motion. Restricted internal rotation with the hip at 90° of flexion is indicative of cam and/or pincer morphology and less so for soft tissue non-compliance.22Wyss TF Clark JM Weishaupt D et al.Correlation between internal rotation and bony anatomy in the hip.Clin Orthop Relat Res. 2007; 460: 152-15810.1097/BLO.0b013e3180399430Crossref PubMed Scopus (117) Google Scholar The most popular tests currently used attempt to pinch the labrum between the impinging bone to replicate symptoms and include the following list: the flexion, adduction, internal rotation (FADIR) test (figure 3); the flexion, abduction, external rotation (FABER) test; the abduction impingement test (figure 4); the extension and external rotation test; and the bilateral squat test. The type and location of the impingement and labral pathology dictate which tests are positive.Figure 4Abduction impingement test. The patient lies supine on the examination table as the examiner stands on the ipsilateral side and brings the hip into direct abduction with the leg in neutral rotation. Replication of hip pain suggests lateral impingement of the cam lesion onto the lateral aspect of the acetabulum.View Large Image Figure ViewerDownload (PPT) The FADIR test brings the hip into 90° of flexion followed by adduction and internal rotation in an attempt to irritate the labrum at the area most commonly impinged upon. A positive test is when the patient conveys pain. This test has been shown to have a high specificity (89%) and positive predictive value (96%), but a low sensitivity (51%).23Hananouchi T Yasui Y Yamamoto K et al.Anterior impingement test for labral lesions has high positive predictive value.Clin Orthop Relat Res. 2012; 470: 3524-352910.1007/s11999-012-2450-0Crossref PubMed Scopus (25) Google Scholar The FABER test can be positive secondary to intra-articular hip pain as well as sacroiliac (SI) joint pain. This makes describing the location of the pain paramount as most intra-articular hip pain will be deep groin pain whereas SI joint pathology will be localised more posteriorly to the SI joints. A labral tear secondary to impingement can be nearly ruled out in patients with no history of groin pain and a negative FABER and FADIR test with physical exam.24Tijssen M van Cingel RE de Visser E et al.Hip joint pathology: relationship between patient history, physical tests, and arthroscopy findings in clinical practice.Scand J Med Sci Sports. 2017; 27: 342-35010.1111/sms.12651Crossref PubMed Scopus (23) Google Scholar Instability should be checked for in patients with hip pain as well. Beighton score is one way to classify the ligamentous laxity in a patient.20Beighton P Solomon L Soskolne CL Articular mobility in an African population.Ann Rheum Dis. 1973; 32: 413-41810.1136/ard.32.5.413Crossref PubMed Scopus (1183) Google Scholar Beighton score assesses ligamentous laxity on a 9-point scale with a single point given for each side that displays metacarpophalangeal hyperextension of the fifth finger,2Grant AD Sala DA Davidovitch RI The labrum: structure, function, and injury with femoro-acetabular impingement.J Child Orthop. 2012; 6: 357-37210.1007/s11832-012-0431-1Crossref PubMed Scopus (27) Google Scholar elbow hyperextension >10°,2Grant AD Sala DA Davidovitch RI The labrum: structure, function, and injury with femoro-acetabular impingement.J Child Orthop. 2012; 6: 357-37210.1007/s11832-012-0431-1Crossref PubMed Scopus (27) Google Scholar knee hyperextension >10°,2Grant AD Sala DA Davidovitch RI The labrum: structure, function, and injury with femoro-acetabular impingement.J Child Orthop. 2012; 6: 357-37210.1007/s11832-012-0431-1Crossref PubMed Scopus (27) Google Scholar ability to touch the radial aspect of the thumb to the forearm2Grant AD Sala DA Davidovitch RI The labrum: structure, function, and injury with femoro-acetabular impingement.J Child Orthop. 2012; 6: 357-37210.1007/s11832-012-0431-1Crossref PubMed Scopus (27) Google Scholar and the ability for a patient to touch their palms to the floor with their knees fully extended.1Colvin AC Harrast J Harner C Trends in hip arthroscopy.J Bone Joint Surg Am. 2012; 94: e23-1-510.2106/JBJS.J.01886Crossref PubMed Scopus (247) Google Scholar Any score over 4 would suggest joint hypermobility. To test for posterior instability, the hip is brought into flexion, adduction and internal rotation, and a posteriorly directed force is applied. Posterior hip pain from this manoeuvre can be an indicator of posterior hip instability. To check for anterior instability, the hip is extended and externally rotated (figure 5). Anterior groin pain from this manoeuvre can be an indicator of anterior hip instability. Another test to elicit anterior instability symptoms is the extension external rotation test with an anterior drawer placed on the posterior hip (figure 6).Figure 6Extension and external rotation test with an anterior drawer. The patient is in the prone position and the knee is bent to 90°, the leg is levered to maximal external rotation of the hip which also slightly extends the hip, and then an anterior directed force is placed on the posterior aspect of the proximal femur. Anterior pain is indicative of anterior instability.View Large Image Figure ViewerDownload (PPT) There is a multitude of exam manoeuvres used and these are explained in greater detail in table 1. Overall, the clinician should use a combination of history, physical exam, radiographs and advanced imaging to best decipher a patient's pathology and tailor a treatment programme specifically for their needs. Despite all of these, sometimes the clinical diagnosis may remain elusive. A diagnostic injection can be of use in this scenario. The diagnostic injection is very helpful in distinguishing between hip and non-hip pathology. If a patient does respond to a diagnostic injection this does not indicate they will respond to surgery as it will make multiple pathology feel better, both treatable and non-treatable problems.25Byrd JW Jones KS Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients.Am J Sports Med. 2004; 32: 1668-167410.1177/0363546504266480Crossref PubMed Scopus (287) Google Scholar A non-response to injection has been shown to lead to lesser surgical outcome with hip arthroscopy, possibly due to misdiagnosis.26Lynch TS Steinhaus ME Popkin CA et al.Outcomes After Diagnostic Hip Injection.Arthroscopy. 2016; 32: 1702-171110.1016/j.arthro.2016.02.027Abstract Full Text Full Text PDF PubMed Scopus (26) Google ScholarTable 1Exam manoeuvers for diagnosing labral pathology with name, description of exam, and clinical significance.Exam nameDescriptionClinical significanceFADIR38Klaue K Durnin CW Ganz R The acetabular rim syndrome. A clinical presentation of dysplasia of the hip.J Bone Joint Surg Br. 1991; 73: 423-42910.1302/0301-620X.73B3.1670443Crossref PubMed Google ScholarPatient is supine, the hip and knee are flexed to 90° and the hip is then adducted and internally rotated. Groin pain indicates a positive test.Groin pain signifies anterosuperior impingement and possible labral tear.FABER (Patrick's test)39Nepple JJ Prather H Trousdale RT et al.Clinical diagnosis of femoroacetabular impingement.J Am Acad Orthop Surg. 2013; 21: S16-S1910.5435/JAAOS-21-07-S16Crossref PubMed Scopus (67) Google ScholarPatient is supine, the ipsilateral foot is placed on the contralateral leg with the knee flexed to 90°, and the hip is abducted and externally rotated maximally. A positive test is either pain or decreased motion compared with the contralateral side.Decreased motion and pain can be associated with anterolateral impingement, labral tear or iliopsoas impingement. Posterior pain can denote SI joint pathology.Twist test40Ochiai DH Adib F Donovan S The twist test: a new test for hip labral pathology (SS-37).Arthrosc J Arthrosc Relat Surg. 2011; 27: e5010.1016/j.arthro.2011.03.042Abstract Full Text PDF Google ScholarStanding on the affected leg with the knee bent to 30° the patient twists as much as possible in and out. A positive test is pain or apprehension in the hip or gross differences between right and left hips.Labral tearSuperolateral impingement test (Butterfly Goalies test)41Tramer JS Deneweth JM Whiteside D et al.On-Ice Functional Assessment of an Elite Ice Hockey Goaltender After Treatment for Femoroacetabular Impingement.Sports Health. 2015; 7: 542-54710.1177/1941738115576481Crossref PubMed Scopus (6) Google ScholarThe hip is brought into flexion, abduction and internal rotation. A positive test is groin pain.Superolateral hip impingementDynamic internal rotatory impingement test42Martin HD Palmer IJ History and physical examination of the hip: the basics.Curr Rev Musculoskelet Med. 2013; 6: 219-22510.1007/s12178-013-9175-xCrossref PubMed Scopus (36) Google ScholarThe contralateral hip is held in 90° of flexion, the examined hip is brought into 90° of flexion and passively taken into a broad motion of adduction and internal rotation.Labral tear/impingement corresponds to the clockface of where the patient had pain.Dynamic external rotatory impingement test42Martin HD Palmer IJ History and physical examination of the hip: the basics.Curr Rev Musculoskelet Med. 2013; 6: 219-22510.1007/s12178-013-9175-xCrossref PubMed Scopus (36) Google ScholarThe contralateral hip is held in 90° of flexion, the examined hip is brought into 90° of flexion and passively taken into a broad motion of abduction and external rotation.Labral tear/impingement corresponds to the clockface of where the patient had pain.Posterior impingement test42Martin HD Palmer IJ History and physical examination of the hip: the basics.Curr Rev Musculoskelet Med. 2013; 6: 219-22510.1007/s12178-013-9175-xCrossref PubMed Scopus (36) Google ScholarWith the contralateral hip held in a flexed position, the hip is extended and externally rotated. A positive test is when the patient gets buttock pain.Posterior pain suggests posterior impingement with possible posterior labral tear.Lateral rim impingement test42Martin HD Palmer IJ History and physical examination of the hip: the basics.Curr Rev Musculoskelet Med. 2013; 6: 219-22510.1007/s12178-013-9175-xCrossref PubMed Scopus (36) Google ScholarWith the leg in neutral rotation the hip is maximally abducted. A positive test is lateral hip pain.Lateral impingement/labral tearAnterior apprehension test (prone external rotation test)43Domb BG Stake CE Lindner D et al.Arthroscopic capsular plication and labral preservation in borderline hip dysplasia: two-year clinical outcomes of a surgical approach to a challenging problem.Am J Sports Med. 2013; 41: 2591-259810.1177/0363546513499154Crossref PubMed Scopus (207) Google ScholarPatient is in the prone position, the knee is flexed to 90° and the hip is placed in maximal external rotation. The examiner then applies an anterior directed force to the buttock. A positive test is apprehension with firing of gluteal muscles or anterior groin pain that is better when posterior pressure is removed.Anterior instability and possible labral tearAnterior instability44Shu B Safran MR Hip instability: anatomic and clinical considerations of traumatic and atraumatic instability.Clin Sports Med. 2011; 30: 349-36710.1016/j.csm.2010.12.008Abstract Full Text Full Text PDF PubMed Scopus (137) Google ScholarThe contralateral hip is held in 90° of flexion. The hip is then brought into extension and external rotation. A positive test is anterior groin pain.Anterior instability and possible labral tearFABER, flexion, abduction, external rotation test; FADIR, flexion, adduction, internal rotation test; SI, sacroiliac. Open table in a new tab FABER, flexion, abduction, external rotation test; FADIR, flexion, adduction, internal rotation test; SI, sacroiliac. The labrum is not visualised on most radiographs unless it is calcified. The bony morphologic changes often associated with labral tears from either impingement or dysplasia are noted on plain radiographs. These changes are best demonstrated on a combination of supine anteroposterior (AP) pelvis, false profile, 45° or 90° Dunn view, frog leg and/or a cross-table lateral (figure 7) (table 2).27Clohisy JC Carlisle JC Beaulé PE et al.A systematic approach to the plain radiographic evaluation of the young adult hip.J Bone Joint Surg Am. 2008; 90: 47-6610.2106/JBJS.H.00756Crossref PubMed Scopus (752) Google Scholar In general, the AP of the pelvis and false profile are the images that are best at identifying acetabular morphology and joint spacing, while the frog leg, Dunn views and lateral are best at demonstrating proximal femoral anatomy. Up to 95% of athletes have at least one sign of femoroacetabular impingement on plain radiographs and few of these individuals express symptoms.28Kapron AL Anderson AE Aoki SK et al.Radiographic prevalence of femoroacetabular impingement in collegiate football players: AAOS Exhibit Selection.J Bone Joint Surg Am. 2011; 93: e11110.2106/JBJS.K.00544Crossref PubMed Scopus (156) Google Scholar It should also be noted that 87% of patients who are diagnosed with a labral tear have at least one bony abnormality as" @default.
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• W2799355536 title "Biomechanics, anatomy, pathology, imaging and clinical evaluation of the acetabular labrum: current concepts" @default.
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