Hip Labral Tear

A hip labral tear involves the ring of cartilage, called the labrum, that follows the outside rim of the socket of your hip joint.

The labrum adds to the stability of the hip by deepening the socket and protects the joint surface. The labrum can tear as the result of an injury.

The labrum can also tear when there is osteoarthritis in the hip, as a part of the overall degeneration of the joint. When there is a labral tear due to osteoarthritis, treatment is usually geared towards treating the arthritic joint as a whole. 

Pain in the front of the hip (most often in the groin area) accompanied by clicking, locking, or catching of the hip are the main symptoms of hip labral tears.

Joint stiffness and a feeling of instability where the hip and leg seem to give away are also common. The pain may radiate (travel) to the buttocks, along the side of the hip, or even down to the knee.

Symptoms get worse with long periods of standing, sitting, or walking. Pivoting on the involved leg is avoided for the same reason (causes pain). Some patients walk with a limp or have a positive Trendelenburg sign (hip drops down on the right side when standing on the left leg and vice versa).

The pain can be constant and severe enough to limit all recreational activities and sports participation.

It was once believed that a single injury was the main cause of labral tears (running, twisting, slipping). But with improved radiographic imaging and anatomy studies, its clear now that abnormal shape and structure of the acetabulum, labrum, and/or femoral head can also lead to the problem.

Injury is still a major cause for labral tears. Anatomical changes that contribute to labral tears combined with repetitive small injuries lead to a gradual onset of the problem.

Athletic activities that require repetitive pivoting motions or repeated hip flexion cause these types of small injuries, the most common one being called femoral acetabular impingement (FAI). With FAI, there is decreased joint clearance between the junction of the femoral head and neck with the acetabular rim.

When the leg bends, internally rotates, and moves toward the body, the bone of the femoral neck butts up against the acetabular rim pinching the labrum between the femoral neck and the acetabular rim. Over time, this pinching, or impingement, of the labrum causes fraying and tearing of the edges.

A complete rupture is referred to as an avulsion where the labrum is separated from the edge of the acetabulum where it normally attaches.
Changes in normal hip movement combined with muscle weakness around the hip can lead to acetabular labrum tears.

Other causes include capsular laxity (loose ligaments), hip dysplasia (shallow hip socket), traction injuries, and degenerative (arthritic) changes associated with aging.

Anyone who has had a childhood hip disease (such as Legg-Calve Perthes disease, hip dysplasia, slipped capital femoral epiphysis) is also at increased risk for labral tears.

The history and physical examination are the first tools the physician uses to diagnose hip labral tears. There may or may not be a history of known trauma linked with the hip pain. When there are anatomic and structural causes or muscle imbalances contributing to the development of labral tears, symptoms may develop gradually over time.

One common test is the impingement sign. This test is done by bending the hip to 90 degrees (flexion), turning the hip inward internal rotation) and bringing the thigh towards the other hip (adduction).

Labral tears are frequently misdiagnosed at first. That's because there are many possible causes of hip pain. The pain associated with labral tears can be hard to pinpoint.

Your doctor must rely on additional tests to locate the exact cause of the pain. For example, injecting a local anesthetic agent (lidocaine) into the joint itself can help determine if the pain is coming from inside (versus outside) the joint.

X-rays provide a visual picture of any changes out of the ordinary of the entire structure and location of the hip position. Magnetic resonance imaging (MRI) gives a clearer picture of the soft tissues (e.g. labrum, cartilage, tendons, and muscles).

One other test called a Magnetic Resonance Arthrography (MRA) is now considered the gold standard for diagnosis. Studies show that MRA is highly sensitive and specific for labral tears. This test may replace arthroscopic examination as the main diagnostic tool.

Arthroscopic examination is still 100 per cent accurate but requires a surgical procedure. With MRAs, contrast dye (gadolinium) is injected into the hip joint. Any irregularity in the joint surface will show up when the dye seeps into areas where damage has occurred. MRAs give the surgeon an excellent view of the location and extent of the tear as well as any bony abnormalities that will have to be addressed during surgery.

Several treatment methods exist for hip labral tear.

Non-Surgical treatment:

• When surgery is not recommended for the treatment of a labral tear, physical therapists or athletic trainers develop a rehabilitation plan, starting with a comprehensive examination to identify factors contributing to hip pain. This is followed by a customized treatment plan to address muscle imbalances, pelvic position, posture and movement patterns, which can put increased stress on the hip joint. Activity modification or rest from sports is common to decrease stress on the hip joint.

Conservative treatment may include:

• Gentle hip joint mobilizations for pain relief
• Stretching and range-of-motion exercises
• Exercises to increase strength

Although most labral tears are unlikely to heal fully due to a lack of blood supply, conservative treatment can reduce symptoms and pain, and progressive exercise programs may make returning to sports and other activities possible.

Surgical (Hip Arthroscopy) treatment:

• For hip labral tears that do not respond to non-operative treatment, hip arthroscopy may be required. This is a minimally invasive outpatient procedure performed under general anesthesia.

        The common course of the procedure includes:

• Placing the hip in traction to open up the hip joint.
• Making a small incision into the hip joint to insert an arthroscope with a camera to display the inside of the hip on a television monitor.
• Performing two or three other incisions to insert the surgical instruments used for removing labral tears, loose bodies and bony prominences that contact the bones of the hip joint (impingement).

Post-operative Rehabilitation:

After arthroscopic hip surgery, rehabilitation with a physical therapist or athletic trainer focuses on regaining normal motion, strength and movement patterns at the hip. Rehabilitation also focuses on addressing any other factors that may be causing injury and identifying strategies to prevent future injury.

General points about rehabilitation:

• Crutches may be required for about two weeks (sometimes longer) after surgery.
• Exercises start soon after surgery.
• Rehabilitation progresses as certain criteria is met with the goal to return to full activities, including sports.
• Return to high-impact sports usually takes eight to twelve weeks after surgery.

Maintaining appropriate lower-extremity mobility and muscular strength are the best methods for preventing a hip labral tear. Unfortunately, the way the hip and pelvis bones of some individuals are structured, the risk of sustaining a labral injury can increase.

It is imperative to be aware of any hip pain that you experience, particularly with sitting and squatting, as these are signs of a potential hip injury. Identifying and addressing these injuries early is helpful in their treatment.

There are several risks and complications associated with hip labral tear.

There seems to be a significant association between labral tears and arthritis in the hip – that is to say, no study demonstrates a direct cause of arthritis by labral tears. It is impossible to predict who will develop symptomatic arthritis and who will not.

Complications are uncommon but include the following:

• Deep Venous Thrombosis (blood clot) – aspirin is given post-operatively
• Infection – antibiotics are given post-operatively
• Heterotopic ossification – (abnormal bone formation in soft tissues) – NSAIDs are given post-operatively
• Nerve injury (Sciatic, LFCN, Pudendal)
• Scarring/Adhesions