Hip labral tears
Hip anatomy
The hip is a ball and socket joint comprising a femoral head and an acetabulum. These moving parts work in synchrony with surrounding muscles and tendons to ensure that your hip movements are flexible, painless and stable. The labrum is a soft cartilage around the edges of the acetabulum. It helps to stabilize the femoral head by deepening the hip joint, distributes pressures evenly and also helps lubricate the joint.
Labral tears and symptoms
Tears of the labrum may cause patients to develop hip pain, clicking and loss of function. Labral tear at the front of the acetabulum may cause anterior groin pain when sitting down or going up stairs. Tears at the back of the acetabulum may cause buttock pain when sitting down.
Causes
As mentioned above, labral tears cause pain and clicking. The tears themselves are often a symptoms of a larger problem. This could be due to developmental conditions such as the following:
- Femoral-acetabular impingement (FAI)
- Hip dysplasia
- Trauma
- Arthritis: degenerative or inflammatory
Femoral acetabular impingement (FAI)
The acetabulum and femoral head are designed to provide stability and yet flexibility of the hip joint. They are shaped and positioned in such a way that there is flexible range of motion when we go about our daily activities. Sometimes these bones are not shaped appropriately or develop bone spurs and this causes them to rub against one another. Some bony spurs form at the acetabulum and this is called a Pincer. Bone spurs that develop at the femoral head and neck are called CAMs. Some patients may develop both Pincers and Cams! The impingement phenomenon of FAI causes hip pain and a tear to the soft labrum.
Hip Dysplasia
This condition describes a hip joint that is unstable and keeps wanting to slip out of the socket. It may be due to a shallow or slightly vertical acetabulum or a femoral head that is facing the wrong way. This condition is developmental and often picked up during early childhood. Early detection of hip dysplasia allows treatment to be started earlier rather than later. However some hip dysplasia patients may not have been diagnosed and they experience hip instability, pain and loss of function in young adulthood.
Patients with shallow acetabulums will find that their femoral head tries to sublux out of th socket all the time. There is point pressure at the femoral head and the outer border of the acetabulum where the labrum is. Labral tears are very common in this group of patients. It is very important to diagnose the hip dysplasia in this group of patients with labral tears as just repairing the labral tear without addressing the dysplasia will cause recurrence of hip pain from a further labral tear in future.
Xray showing a normal right hip with a lateral centre edge angle (LCEA) of more than 30 degrees, while the left hip is dysplasic showing a LCEA of less than 20 degrees.
X-ray showing a dysplastic hip where the femoral head is pivoting over the lateral border of the shallow acetabulum. There is arthritis of the hip joint as well as labral tears.
Trauma
Major trauma of involving the hip may cause a labral tear as well as fractures or sprains around the hip. This may be a fall from height or road traffic accident. Like all hip cases, appropriate x-rays and possibly MRI scans will be done to investigate the cause of the hip pain.
Arthritis
Most arthritis is due to age related wear and tear. This is known as osteoarthritis. There is also inflammatory arthritis such as rheumatoid arthritis and ankylosing spondylitis that are autoimmune conditions. In both forms of arthritis, there is thinning and ulcers in the cartilage of the hip. This may also be accompanied by degenerative tears of the labrum. There are early and late stages of arthritis so treatment options will depend on the general state of the hip and not just the labral tear.
Right hip showing advanced arthritis with loss of joint space and subchondral cysts.
Diagnosis
Your orthopaedic surgeon will examine your walking gait, spine, leg lengths, both hips and knees for completeness. This is to ensure that your hip pain is truly coming from your hip and not a radiating pain from your spine or elsewhere.
Basic radiographic imaging such as appropriate x-rays and an MRI scan will help your orthopaedic surgeon come to an accurate diagnosis of the labral tear and what could be the cause of it.
Treatment options
There are conservative or non surgical options to treat hip pain and labral tears. We usually start with anti-inflammatory medication such as Arcoxia or Diclofenac to reduce pain and restore some function in our patients. If the labral tears are in the front of the hip, we advice patients to refrain from flexing their hip and knee beyond 90 degrees as this will worseng the tear even more.
Patients are sent for physiotherapy to strengthen the muscles around their hip such as the quadriceps, hip flexors, hip abductor and hip adductor muscles. They are also encouraged to strengthen their lower back and core muscles. This helps to protect the hip joint during daily activities.
In patients who fail these conservative methods, an intra-articular injection into the hip joint with anaesthetic and steroid may be considered. This helps to alleviate the hip pain as well as confirm that the pain is truly coming from the hip joint and not from somewhere else.
These injections into the hip joint are performed under x-ray guidance to ensure accuracy and effectiveness.
Same-Day Appointments Available
Prompt Examination And Diagnosis
Minimally-Invasive & Non-Surgical Options
Surgery Only When Necessary
Once the conservative or injection options have failed for these patients, surgery may be discussed. Surgery is aimed at repairing and reattaching the torn labrum back to the acetabulum. After the labral tear is debrided, sutures are passed around the labrum and anchored to the acetabulum using anchor sutures. At the same time, any bone spurs such as Pincers or CAMs are addressed through minimally invasive or key-hole techniques.
Intra-operative image of a repaired labrum with 2 anchor sutures
Hip replacement surgery
If patients have labral tears as well as advanced arthritis of their hip joint, just repairing the torn labrum will not bring about good pain relief or restroration of patients full function. Depending on their age, weight, level of physical activity, a total hip replacement may be a more appropriate surgical options for this group of patient.
Rehabilitation after labral repair surgery
The rehab and physiotherapy phase after surgery is extremely important for patient to regain their full function. In the initial 4 to 6 weeks, care is aimed at reducing the swelling around the hip joint and strengthening the hip and thigh muscles. Patients are also advised not to flex their hip beyond 90 degrees as this will undermine the repair which has not healed yet. We also provide patients with crutches to use while walking so they do not stress the area of repair.
After about 4 weeks, patients will increase their exercise and start rehab on stationary bicycles. This not only helps to increase their muscle strength but also break away any scar tissue around the front of the hip. After 6 weeks or so, physiotherapists will increase the range of motion of the hip joint.
Patients may look forward to jogging, cycling and brisk walking at about 3 months post op.
Summary
Labral tears of the hip may cause pain, clicking and loss of function. There are many reasons why the labrum may tear and it is important for the orthopaedic surgeon to identify its root cause. Treatment may be conservative, injections or even surgery to reattach the torn labrum. In cases of severe degenerate labral tears with advanced hip arthritis, a total hip replacement may be the treatment of choice.
