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Psoas impingement causing labrum tear: a series from three tertiary hip arthroscopy centers.

BACKGROUND

The iliopsoas tendon has been implicated as a cause of hip pain in a variety of conditions. The classic syndrome, termed coxa saltans interna, occurs when the iliopsoas tendon catches on the iliopectineal eminence or snaps across the femoral head with hip motion from flexion to extension. (1,2) The iliopsoas tendon can also impinge upon the acetabular component following a total hip arthroplasty. (3,4) The role of the iliopsoas tendon as a possible cause for symptomatic labral tears is gaining increasing attention; (6-9) whereas, the understanding of labral tears as a cause of hip pain due to bony architecture abnormalities such as femoroacetabular impingement and hip dysplasia is relatively well described. (11) Recent anatomic studies and reviews of revision arthroscopy have shed light on the role of the psoas as a source of impingement and possible cause of labrum pathology in the pre-arthritic hip. (5,12) Sporadic reports over the decades of abnormal psoas morphology causing impingment upon other anatomical structures exist, but none define what constitutes normal or hypertrophic psoas or iliacus morphology or its relationship to the hip labrum. (13,14)

Coxa saltans interna, or internal snapping of the psoas, is thought to occur as the iliacus and psoas muscles converge and fuse together as they pass through a groove between the iliopectineal eminence and the anterior inferior iliac spine. (1,2) The musculotendinous junction occurs consistently at the level of this "psoas groove," with the remainder of the tendon being inferior to the bony pelvis. The tendon is located most laterally when the hip is in full flexion, abduction, and external rotation and located most medially when the hip is in extension, adduction, and internal rotation and normally remains in the groove. (1,2) During the movement from flexion to extension, it moves over the femoral head. In the majority of symptomatic cases of coxa saltans interna, it is this back-and-forth motion over the femoral head that causes the snapping. Additionally, a prominent iliopectineal ridge or exostoses can cause snapping. In some patients, a discrete tendinous slip can arise from a position superior to the bony pelvis, (2) and this slip may snap on the iliopectineal ridge. Patients with coxa saltans interna will feel a snap, and an audible sound may be heard during flexion and extension of the hip. Labral tears with coxa saltans interna have not been widely described. (15)

While labral tears in FAI have been described typically from the 10 to 2 o'clock position, labral tears more medially have been noted, especially during revision arthroscopy. (10) These more medial tears are also noted to be adjacent to the iliopsoas tendon, separated only by the joint capsule. (5) It has been theorized that the psoas tendon can apply a pathologic amount of pressure to the more medial labrum. (5) This pressure could cause a symptomatic condition, including labrum tearing and psoas inflammation that can impair athletic performance.

This paper describes a series of these more medial tears in young, athletic patients without significant bony abnormality that improved after arthroscopic treatment, which included psoas tendon release and labrum repair. There is much yet to learn regarding this entity, and this preliminary description of a series of cases and potential treatment will hopefully spur further discussion and awareness.

MATERIALS AND METHODS

Seven hundred hip arthroscopies by three surgeons in different centers were performed between 2009 and 2010. Patients with symptomatic labrum tears from the two to three o'clock position were evaluated for inclusion in the study. Patients with osteoarthritis, crossover sign, CAM lesion, or coxa saltans were excluded. The authors were the primary surgeons and are fellowship trained hip arthroscopists working in tertiary hip referral centers. Pre- and postoperative Harris Hip scores were obtained.

Preoperative management

Patients received a course of rest and physical therapy, either prescribed by the authors or referring physician. All patients who continued to complain of pain despite rest or physical therapy had an MR arthrogram with a pain test, an anesthetic, and with or without a steroid.

Surgical method

Patients were placed supine, and general anesthesia was induced. Examination under anesthesia was performed. Counter traction was placed on contralateral hip; distraction was placed across operative hip under direct visualization. After prepping and draping, two standard portals were utilized --the first was the anterolateral (viewing portal) and the second, mid-anterior portal (working portal). A diagnostic arthroscopy was performed. Capsulotomies were performed. The labral tear was identified at the two to three o'clock position on a right hip and the 9 to 10 o'clock position on the left side. Often, bruising and hemorrage were noted on the torn labrum. A motorized burr was used to create a small bleeding bed of bone at the 2:30 position, just inferior to the psoas tendon and superior to the tear; an acetabuloplasty was not performed. A loaded suture anchor was used to perform a secure labrum repair, with the suture either looped around or passed through the labrum. In most cases, only one anchor was used due to the small size of the tear. The psoas tendon was released in all patients at the level of the capsule via a transcapsular approach. The psoas tendon was located by identifying the distinct bulge created in the capsule.

There was associated synovitis on the capsule between the psoas tendon and the labrum. The tendon was released using a combination of a beaver blade, arthroscopic biter, motorized shaver, and/or electrocautery. Care was taken to release only tendon tissue and not muscle. Other pathology, such as synovitis and ligamentum teres partial tears, were then addressed. A dynamic analysis was performed off traction to determine the extent, if any, of any CAM lesions. A capsule repair was not ordinarily done. Portals were closed and marcaine with epinephrine injected into the portals and joint. The patient was awakened from anesthesia and moved to the post anesthesia unit with a TED stocking on both legs and both feet in internal rotation boots with the peroneal post pillow between the feet.

Postop

Flexion was restricted beyond 70-90 degrees for three weeks. Internal rotation pillow and boots were used for one to three weeks at night when not using the continuous passive motion machine (CPM). CPM was used four to eight hours a day for 7-14 days. Crutches and partial weight bearing were used for at least two weeks. Postoperative medications included aspirin for DVT prophylaxis, naproxen for heterotopic bone prophylaxis for six weeks, and a proton pump inhibitor to prevent gastrointestinal complications due to the six weeks of anti-inflammatory medication. Lovenox was used instead of aspirin for DVT prophylaxis if the patients had any coagulation risk factors. Physical therapy began day of surgery and continued two to three times a week for 8-12 weeks. Jogging was permitted at nine weeks, and full release to sports was usually at four months.

RESULTS

Twenty-two patients (26 hips, four bilateral) who underwent arthroscopy were identified as athletes with a labrum tear apparently caused by psoas impingement and had no other significant hip abnormalities. All but one were female. Average age was 19 (12-25 years). All were competitive athletes at the high school or college level.

Sports represented were sprinting, distance running, dancing, cheerleading, and soccer. There was one male football player. All but two patients had varying amounts of relief from the intra-articular pain test. Labral repairs were performed in all but two patients. Average anchors used were 1.2 per hip. Pre- and postoperative Harris hip scores were obtained with a minimum follow-up of six months for 16 patients. Average Harris hip score improved from 70 preoperatively (range 66 to 81) to 94 postoperatively (range 81 to 100). There were no significant complications identified. Minor, temporary complications included ankle and/or knee pain and lateral femoral cutaneous nerve paresthesias. Mild hip flexor pain consistent with rectus tendinitis commonly developed postoperatively for a variable amount of time and was treated with conservative management, including physical therapy and non-steroidal anti-inflammatories. There was one revison performed at 18 months postoperatively for repair of the labrum that was not addressed at the initial surgery.

DISCUSSION

Psoas pathology as a source of pain is sparsely described in the literature, especially in the young, otherwise normal hip. Coxa saltans interna has been implicated as a source of pain particularly in the young female. Labral pathology has not been described with coxa saltans. It is likely that repetitive snapping of the psoas tendon could cause labral tears in the more medial position, as described in this study, and that coxa saltans is a more dynamic version of non-arthroplasty psoas impingement. We sought to exclude patients who reported snapping either audible or palpable as confounding factors with this diagnosis. It is possible that psoas impingement might even be considered as a silent or non-snapping coxa saltans.

Another finding that could confound this diagnosis is the presence of pincer lesions from femoroacetabular impingement. Pincer lesions are usually diagnosed by the pelvis X-ray as acetabular retroversion from the crossover sign or as coxa profunda from a deep socket. (16) Tears associated with pincer lesions tend to be from the 10 to 2 o'clock position, as opposed to the more medial tears associated with psoas impingement. We excluded any patient that had radiographic signs of pincer abnormality. Another diagnostic entity encountered in the athletic population with hip pain is hip laxity. Hip laxity is a complex diagnosis, and we excluded any patients with significant hip laxity that underwent capsular plication from this study. (2,13) The authors rarely perform capsule placation or repair in patients without pathologic laxity and instead use internal rotational boots at night for three weeks. With capsule laxity, as with acetabular anatomy and pincer lesions, there is a continuum of variation, and it is difficult to say where normal variation ends and pathology begins. A recent study demonstrated the surprisingly poor interobserver agreement between experienced hip experts when attempting to diagnose hip laxity and FAI. (17) These factors can confound the diagnosis, and it is possible that some patients with labrum tears due to psoas impingement could have a mild pincer lesion, capsular laxity, or even coxa saltans interna.

It is important for the surgeon to recognize this entity because of the increased difficulty in placing more medial anchors for labrum repair. Visualization of the two to three o'clock position, where these tears tend to occur, is more difficult than visualizing the more common 10 to 2 o'clock position in FAI. This is true even for experienced hip arthroscopists. Also, placement of anchors is made more difficult because of the angle of the bony architecture encountered more medially. Thus, knowledge of this entity and recognizing the potential patient with this entity is important for the inexperienced hip arthroscopist so that appropriate informed consent to include the psoas release and appropriate referral might be considered. The theory of labrum tear due to psoas impingement as a distinct entity was originally suggested by surgeons during revision arthroscopies. (12) Leaving the more medial labrum tear or non-arthroplasty psoas impingment lesion untreated could be a potential source of continuing hip pain and failed initial hip arthroscopy. (12)

The maintenance or return of flexion strength after psoas tendon release at three months is consistent with the literature. (4,15) Loss of flexion strength has been described immediately postoperatively, but full return to play is expected after psoas tendon release, both at the capsular level and at the lesser trochanter. (18-20) Releasing the tendon at the joint level only affects about half of the psoas muscle and none of the iliacus muscle, while releasing the psoas tendon at the level of the trochanter leaves the iliacus insertion on the proximal femur intact. (5,20,21) Care should be taken to release only the tendinous portion of the psoas without causing unnecessary muscle damage and iatrogenic weakness. Unnecessary muscle damage can also lead to bleeding, compromised visualization, and potential need for increased pump pressure. Pump pressure has been associated with hip arthroscopic complications. (22,23) It is helpful to use the shaver to pull the tendon into the joint while releasing the tendon. This approach seems to work well to removed bubbles that may be created, avoiding unwanted muscle damage and bleeding and protecting the neurovascular structures. Alternatively, an arthroscopic biter or thermal device may be used.

The fact that all but one patient in this study were female may be a function of the patient population of the authors. All young athletic males but one operated on for labrum tears by the authors during the collection period of this series of patients had either a traumatic episode, Perthes, or FAI and did not have labrum tears in the two to three o'clock position.

Limitations to this study include the inherent difficulty and low intraobserver agreement for FAI, capsular laxity, and non-arthroplasty psoas impingement. (17) The recognition of this entity evolved during the patient collection process and was based on the recognition of these more medial labrum tears and the close proximity of the psoas tendon. This was not a randomized study, and this study does not disprove that an isolated psoas release, an isolated labrum repair, or even a debridement could have improved the patients' symptoms. This is only one approach and other surgical or non-surgical approaches could also provide relief and need to be evaluated.

It is worth noting that the vast majority of patients were seen by multiple doctors and or therapists/trainers prior to being evaluated by the authors. Patients also received a course of therapy and an intraarticular injection of marcaine, lidocaine, and steroid usually given at the same time as the MRI arthrogram dye.

Hip arthroscopy has proven to be a safe procedure. Its effectiveness leaves room for improvement, however. (8,12,24,25) Recognition of labrum tears due to psoas impingement as a unique cause of hip pain requiring unique treatment could improve patient outcomes and decrease revisions.

CONCLUSION

Labrum tearing due to psoas impingement is a relatively newly described entity. Arthroscopic treatment including a psoas tendon release and a more medial labrum repair can provide relief with no significant complications in the short term.

REFERENCES

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(16.) Siebenrock KA, Kalbermatten DF, Ganz R. Effect of pelvic tilt on acetabular retroversion: a study of pelves from cadavers. Clin Orthop Relat Res 2003:241-8.

(17.) Martin RL, Kelly BT, Leunig M, et al. Reliability of clinical diagnosis in intraarticular hip diseases. Knee Surg Sports Traumatol Arthrosc 2010;18:685-90.

(18.) Hoskins JS, Burd TA, Allen WC. Surgical correction of internal coxa saltans: a 20-year consecutive study. Am J Sports Med 2004;32:998-1001.

(19.) Ilizaliturri VM, Jr., Camacho-Galindo J. Endoscopic treatment of snapping hips, iliotibial band, and iliopsoas tendon. Sports Med Arthrosc 2010;18:120-7.

(20.) Ilizaliturri VM, Jr., Chaidez C, Villegas P, Briseno A, Camacho-Galindo J. Prospective randomized study of 2 different techniques for endoscopic iliopsoas tendon release in the treatment of internal snapping hip syndrome. Arthroscopy 2009;25:159-63.

(21.) Polster JM, Elgabaly M, Lee H, Klika A, Drake R, Barsoum W. MRI and gross anatomy of the iliopsoas tendon complex. Skeletal Radiol 2008;37:55-8.

(22.) Fowler J, Owens BD. Abdominal compartment syndrome after hip arthroscopy. Arthroscopy 2010;26:128-30.

(23.) Ladner B, Nester K, Cascio B. Abdominal fluid extravasation during hip arthroscopy. Arthroscopy 2010;26:131-5.

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(25.) Shu B, Safran MR. Case report: Bifid iliopsoas tendon causing refractory internal snapping hip. Clin Orthop Relat Res 2011;469:289-93.

Dr. Cascio is Director of the Sports Medicine Program at Lake Charles Memorial Hospital and Clinical Assistant Professor of Orthopaedics and Sports Medicine at the Louisiana State University School of Medicine in New Orleans. Dr. King is an Orthopaedic Joint Specialist with King Orthopaedics in St. Louis. Dr. Yen is a Clinical Instructor in the Department of Orthopaedic Surgery at Boston Children's Hospital.
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Author:Cascio, Brett; King, David; Yi-Meng Yen
Publication:The Journal of the Louisiana State Medical Society
Article Type:Report
Geographic Code:1USA
Date:Mar 1, 2013
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