Wednesday, July 30, 2008

Missing in Action: The Diagnosis of Acetabular Labral Tears
I recently had an interesting hip case come through the clinic. After practicing only six years, I've discovered there are some joints for which I have more clinical intuition, and the hip certainly isn't one of them. As a result I found the need to do some catching up.

Unfortunately, the referring physician was not much help in this case with a referring diagnosis of "hip pain". While interviewing the patient, he revealed the physician had spent approximately three minutes with him and performed no physical exam. The only diagnostic puzzle-piece we had was that he did not have any signs of OA on plain film.

During the examination the patient had focal hip pain that I gradually suspected was intraarticular in nature. I recently posted the case on if you'd like to see it in more detail.

In researching the case, I found a very good article from the Journal of Bone and Joint Surgery on acetabular labral tears. The authors retrospectively examined sixty-six individuals with confirmed labral tears via arthroscopy to determine what clinical variables were most closely associated with the pathology. The clinical findings were as follows:

  • 86 percent of the cases reported moderate to severe pain

  • 92 percent reported symptoms localized to the groin and that activity worsened symptoms

  • Only 39 percent had a Trendelenberg sign or observable limp

  • 95 percent had a positive impingement sign of the hip

Although the clinical features of acetabular labral tears were useful, a more telling set of statistics emerged from this report:

  • Nearly 20 percent of the patients were referred for a surgical procedure to a uninvolved site

  • The patients were seen by an average of 3.3 providers prior to establishing a definitive diagnosis

  • The average duration of symptoms from onset to successful diagnosis of the tear was 21 months

The findings of this study were directly applicable to this case. He and I had been discussing the likelihood that this was not a simple muscle strain as postulated during his initial visit. After a underwhelming four week follow-up experience with the referring orthopedist, I referred the frustrated patient to a physician known for performing an actual physical exam. An immediate MRA to the hip was ordered.

Not surprisingly, the MRA was positive for significant intraarticular pathology including a subchondral defect, moderate OA, and a fatty tumor encroaching upon the posterior branch of the obturator nerve. Labral pathology is questionable. The orthopedist suspects one may be present and will investigate this intraoperatively along with a surgical oncologist.

I think this provides a good example of how physical therapists can be a potential diagnostic gateway for our patients. Unfortunately, we can't take for granted the referring physician always brings their A-game to the exam room. Also if we are angling to be direct access providers, our clinical diagnostic skills will need to remain sharp. In this case, my exam certainly wasn't specific for the myriad of pathology present in this gentleman's hip. However it was sensitive enough to detect that there was certainly more to the story. Hopefully this story will have a happy ending.

Burnett, R.S. (2006). Clinical Presentation of Patients with Tears of the Acetabular Labrum. The Journal of Bone and Joint Surgery, 88(7), 1448-1457. DOI: 10.2106/JBJS.D.02806

Saturday, July 19, 2008


After traveling to a small Central American country and seeing what honest and hardworking folks have to do to eek out a living, you can imagine my disgust at firing up my homepage this morning to find this article. I had no idea that not wanting to work was a disability, but apparently it is slightly more en vogue than I had previously appreciated. I feel sorry for any family or significant other he is likely dragging through this process along with him. Nice going Albert...

We've all seen bogus or marginally-valid disability claims and the behavior can be both pitiful and appalling to our profession. Physical therapists should wholeheartedly support and advocate for those with legitimate disabilities. However, we should be equally vigilant in guarding against the abuse of a system designed to aid those with true physical disability.

This topic has even caught the attention of Newt Gingrich who is a spokesperson for the Institute for Healthcare Improvement. Regardless of what you may think about Newt's politics, he brings the issues to the table in a logical, albeit sometimes controversial, manner.

I am not aware of any APTA-based initiatives to ensure the proper use of our federal disability system, but there may be one out there. It might be a good idea to keep this on our radars as well. It would be interesting to see just how much money CMS could be saving preventing fraudulent disability claims instead of focusing on alienating the rehabilitation profession through ever-tightening regulatory guidelines.

More research-based blogging to come later this week! Have a great weekend.

Friday, July 18, 2008

Back from Belize!

Hey all. Just got back from an incredible trip down to Belize with my beautiful wife for our 10-year anniversary. If you've never been, I strongly recommend it! Our experiences couldn't have been better. We didn't let any grass grow under our feet with lots of diving, snorkeling, fishing, bike riding, and even a little spearfishing local-style.

The time spent away from television was a real joy to sit back and reflect on our marriage, our careers, and our future. It also made me realize that those of us in health care and education (my wife) need to make sure we take some time to truly get a way from the daily grind to charge the batteries as we all tend to burn the candle from both ends. A good trip away from television, iPods, and email did both of us some good. Now we are back home on terra firma and BOTH locked and loaded for the next ten years of our lifelong adventure together.

I promise not to morph this into a blog about my personal life, but just couldn't hold back my enthusiasm and energy on the heels of such a great trip. It looks like we've got some good things in the scientific literature to discuss and even a few political topics to take on! For example: Was the recent Medicare bill really a victory for physical therapists? We'll talk about that later.

Thanks everyone for hanging in during this brief pause in the blog. I will be kicking-out posts on later this week.