IADMS New York 2002   [back to the Category]

Anterior Labral Tear in the Dancer: Etiology, Treatment, Rehabilitation   [read the french version]

Author :   Douglas Padgett, MD, & al.

Anterior Labral Tear in the Dancer:
Etiology, Treatment, Rehabilitation

Douglas Padgett, MD, Hospital for Special Surgery

Peter Marshall, PT, American Ballet Theater
William Hamilton, MD, American Ballet Theater, New York City Ballet
Marika Molnar, PT, Westside Dance Physical Therapy
New York, New York, USA


It is often difficult to establish a clear diagnosis of hip joint problems. Often hip pain and dysfunction will cause sacroiliac joint and lumbar spine dysfunction, with the pain in these regions masking the true pathology. Dancers often complain of pain in the anterior hip joint which is often evaluated as iliopsoas tendonitis. Another structure has been recently found to be the culprit of some of this hip pain, based on manual testing as well as diagnostic MRI reports. The anterior portion of the labrum has been found to be torn in several cases of hip and back pain in dancers, probably de to its association with the hip joint capsule and the extreme ranges of motion the hip is put through.

The hip flexion/adduction test has proven to be a positive indicator of labral problems and when surgically treated, has given a good prognosis. Dancers often require 6-8 weeks of rehabilitation following surgery before resuming class. This interactive lecture will aim at presenting the information necessary to rule out this pathology as well as the treatment that has so far proven successful in returning the dancers to the stage.


Introduction: Hip pain in the young dancing population is quite common. Traditionally, the diagnosis has included tendonopathies of the abductors or hip flexors in addition to degenerative disease of the hip due to hip dysplasia. While injuries to the hip labrum are not a new diagnosis, they were often not considered largely due to the difficulty in the ability to image the hip labrum. However, recent advances in the detection of hip labral injuries using high resolution, non contrast MR techniques have greatly improved our ability to diagnose these disorders. While MRI accuracy is high, the role of MR in the evaluation of patients with hip pain is not entirely clear. Do all patients with hip pain need an MRI? MRI is expensive, time consuming and does it necessarily correlate with the proximate cause of the patients’ pain?

Unfortunately, the clinical signs of labral pathology are not well described. Some authors describe hip pain during passive extension of the hip while others have noted pain during flexion and external rotation. Over the past several years, the authors of this study have noted a consistent pattern of pain during supine hip flexion coupled with adduction of the hip. In cases of isolated anterior labral tears of the hip, it has been our observation that other provocative maneuvers failed to elicit pain. The goal of our study was to prospectively evaluate the efficacy of the flexion adduction sign in predicting the presence of anterior labral tears of the hip comparing our findings with the results of high resolution non-contrast MRI of the hip.


Methods: A prospective, consecutive series of patients referred to us for evaluation of anterior hip pain was performed. While anterior groin pain with high degrees of flexion was the most common complaint, anterolateral and lateral hip pain was occasionally observed. Symptoms of locking and clicking were recorded as were functional deficits related to activities of daily living and any restrictions in dance or athletic endeavor.

All patients were evaluated using a hip examination algorithm which attempted to distinguish the four most common clinical entities associated with hip pain: anterior labral tears, hip arthritis, abductor tendonitis, or psoas tendonitis. Clinical examination included recording range of motion as well as provocation of pain during maneuvers associated with these entities:
flexion adduction
prone rotation
figure 4 external rotation
resistive hip flexion

Radiographic imaging included the HSS hip clinic series: anteroposterior radiograph of the pelvis, AP and lateral of the affected hip. In addition, all patients underwent high resolution non-contrast MR imaging with the use of surface coil according to HSS protocol. The results of the MR were interpreted by a single radiologist, blinded to the results of the clinical examination.

Results: Between 1996 and 2000, 73 consecutive patients were evaluated by the senior authors. The mean age of patients was 30.7 years (range 14-47) with a chief complaint of anterior groin pain, occasional clicking and occasional catching of the joint. The mean duration of symptoms ranged from 1-4 years. In some cases, a specific traumatic event was the proximate cause of referral although in the majority, symptoms were attributable to chronic repetitive injury often during dance related activities.

In eleven patients, symptoms of anterior groin pain occurred during rotation in both the supine and prone position. Radiographs demonstrated early evidence of degenerative joint disease, which was confirmed on magnetic resonance imaging.

Of the remaining 62 patients, 61 had a positive flexion/adduction sign which reproduced their symptoms. In one patient, symptoms were diffuse and not reproducible with any hip specific maneuver.

The results of MR imaging demonstrated anterior labral tears in 60 of the 62 patients. In correlating the clinical findings with those of MR, there were two false positive examinations: one patient with a snapping iliopsoas tendon over a pectineal prominence and one patient with an acute avulsion of the ligamentum teres. There was one false negative examination: a patient with an equivocal flexion/adduction sign but a positive



MR demonstrating an anterior labral tear. The labral tear was confirmed at the time of hip arthroscopic surgery. Sixty one of the seventy three patients in this group underwent hip arthroscopic surgery. The findings at surgery correlated with the MR findings in all cases.

In this study, the flexion adduction sign yielded a sensitivity of 98.3%, specificity of 84.6%, and accuracy of 95.8% and a positive predicative value of 96.7% in determining the presence of anterior labral tears of the hip.

Discussion: Hip pain in the young patient is often a difficult diagnosis especially in the dance population. Many patients are treated as having some form of tendonopathy with anti-inflammatory medications, physical therapy and often having to stop participation in sports and dance. In many instances, labral tears are not considered.

While conservative management is a very reasonable first step in the management of younger patients with hip disorders, we feel it is essential to establish a diagnosis. It has been our experience that many labral tears of the hip do not respond simply to rest and other non-operative modalities. The presentation of persistent anterior groin pain occurring during activities in which the hip is flexed is often a key symptom in patients. The symptoms of locking and clicking are often variable.

Our investigation demonstrates that the flexion adduction sign correlates highly with the presence of tears of the anterior hip labrum. We feel that this is an excellent screening tool for clinicians and other health care providers to utilize prior to the ordering of more definitive studies such as a high resolution, non contrast magnetic resonance scan.