By now, if you have been dealing with chronic hip pain or had an acute onset of pain related to an injury, you likely have heard of the hip labrum. And perhaps have wondered if you have a labral tear of your hip.
What is this labrum? Where is it located, and what does it do?
The hip’s labrum is a ring of fibrocartilage–think dense, rubbery ring–that lines the socket (acetabulum) portion of the hip’s ball-and-socket joint. The socket is part of the pelvis. The labrum acts as a shock absorber and aids in joint lubrication. It provides stability to the joint by deepening the socket to provide a seal that keeps the ball of the femur rooted in the acetabulum.
Prevalence of Labral Tears:
Research reports that the prevalence of labral tears in patients with hip or groin pain is as high as 22-55%.1,2,3,4 Reports from one study concluded that a labral tear was detected upward of 41% of male and 43% of female subjects with an asymptomatic (pain-free) hip and no history of a hip problem5. With that understanding, we must consider that just because an imaging report (i.e., MRI with contrast dye) discovers a labral problem, it does not mean it’s the cause of hip pain. A comprehensive clinical examination can help determine if a patient’s pain behaves labral-like.
Causes of Labral Tears:
Labral tears can occur for a multitude of reasons, with the most common being trauma. Acute injury to the hip labrum can occur through traumatic events such as car accidents, falls, or playing contact sports.
Hip labral tears also occur due to structural abnormalities of the hip joint’s bony structure (known as a ‘Pincer’ or ‘Cam’ lesion) and soft tissue laxity and hypermobility.
Overuse and repetitive motion can put excessive torsional forces across the hip joint and labrum, leading to tearing. Athletes that repetitively perform rotational movements at the hip such as soccer, hockey, golf, and dance are at increased risk for injury.
Lastly, degenerative osteoarthritis sometimes called the “wear and tear” arthritis, can erode the cartilage in the hip joint and lead to labral tears.
Symptoms:
Labral tears are a frequent cause of anterior hip and groin pain and often go undiagnosed for extended periods. Symptoms may include:
- Anterior hip and groin pain, often made worse with prolonged walking, standing, and sitting. Pain may be dull at rest and sharp with activity.
- Mechanical symptoms including, clicking, locking, and catching with the occasional feeling of “giving out of the hip.”
- Stiffness and decreased range of motion, most notably with rotation at the hip.
- Walking with a limp if the pain is severe enough.
Diagnosis:
It’s not uncommon that a hip labral tear goes undiagnosed for an extended period. Multiple health care providers often see patients before obtaining a definitive diagnosis. A thorough subjective exam–a conversation between the patient and the physical therapist–is essential and consists of detailed history on a patient’s problem, including the mechanism of injury and pain-inducing and relieving factors.
At Rose City Physical Therapy, our physical therapists will perform a comprehensive clinical physical exam that assesses the range of motion, flexibility, strength, functional movement, and load tolerances of the hip. Also evaluated is the patient’s gait (walking or running if applicable) to look for deviations, compensations, or other deficits. Special tests are also completed, which can rule out the clinical suspicion of a hip labral lesion. These include:
- Hip Impingement Test: With the patient supine, the hip is passively flexed to 90°, then internally rotated, and finally ADDucted.
- Scour (Internal Load/Grind) Test: With the patient supine, axial compression is applied along the femur’s long axis while the hip is passively internally and externally rotated.
- Patrick’s (FABER) Test: With the patient supine, the hip is passively flexed, then ABDucted, and finally externally rotated.
- McCarthy Sign: With the patient supine, both hips are brought forward into full flexion. The patient keeps one hip flexed (knee held to chest). Simultaneously, the physical therapist passively extends the other hip back down toward the treatment table and then passive fully external and then fully internally rotates the hip.
- Fitzgerald Test:
- Anterior Labrum: With the patient lying on their side opposite the hip testing, the involved hip is passively flexed, externally rotated, and ABDucted (test starting position) and then passively internally rotated and ADDucted while bringing the hip into extension
- Posterior Labrum: With the patient lying on their side opposite the hip testing, the involved hip is passively flexed, internally rotated, and ADDucted (test starting position) and then passively externally rotated and ABDucted while bringing the hip into extension.
- Resisted Straight Leg Test: With the patient in long-sitting, the involved hip is actively flexed to 30° with the knee straight, then a downward pressure is applied just above the knee.
Imaging:
Not everyone with a hip problem needs imaging. Research shows that even in people with no history of a hip injury or issue, and pain-free, imaging will likely show a certain degree of hip joint or labral integrity changes. It’s a matter of relevance based on the clinical presentation if imaging results are correlated to one’s problem. For the patient with persistent hip pain that is unresponsive to conservative care, imaging becomes necessary. X-rays, MRI, or a contrast MRI (known as an MRA) are the most common images. The latter is much more sensitive to detecting labral tears of the hip and the test of choice for surgeons suspecting a labral pathology.
Treatment:
Treatment of hip labral tears consists of either conservative treatment with relative rest (protection and avoiding adverse pain provoking activity), use of ice in the acute stages of injury, and physical therapy. At Rose City Physical Therapy, our hip specialists use evidence-informed decisions in the choice of treatment and exercise progression used in rehab. If a patient fails to respond to conservative treatment attempts, surgical intervention may be necessary for labral tears.
Physical Therapy includes the following:
- Education! Paramount in the success of care. Understanding the purpose and function of the labrum is essential, and ways to protect the injured area while remaining active, mobile, and strong.
- Gait (ambulation) and functional movement retraining and avoiding movements that cause increased stress on the hip.
- Flexibility and motion restoration: Identifying areas of adverse muscle tension, hip capsule (tissue surrounding the hip joint) tightness, and inflexibility and teaching patients self-stretching.
- Muscle strengthening, including addressing muscle imbalances and areas of weakness,
- Manual therapy to help decrease pain and to regain normal ROM and hip mobility.
Surgery:
Someone may require surgery to address structural abnormalities that can contribute to labral tears, repair a torn labrum, or debride (clean up) the joint and labral tissue. Surgery may be performed either arthroscopically or by traditional open surgery. In either case, patients typically will be prescribed physical therapy to help return to daily activities, and recreational activities, including sports, in a timely and safe manner. Recovery times from labrum surgery typically take 4–6 months.
Contact us at 503.966.8563 to talk with one of our hip specialists to get answers to your questions or set up a free 20-minute consultation to screen your hip and help guide you in the right direction for care.
References:
- McCarthy JC, et al. The Otto E Aufranc Award the role of labral lesions to the development of early degenerative hip disease. Clin Orthop. 2001
- Lewis CL, Sahrmann SA. Acetabular labral tears. Phys Ther. 2006
- McCarthy JC, Busconi B. The role of hip arthroscopy in the diagnosis and of hip disease. Orthopedics. 1999
- Narvani AA, et al. A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain. Knee Surg Sports Traumatol Arthrosc. 2003
- Vahedi H, et al. Acetabular Labral Tears Are Common in Asymptomatic Contralateral Hips With Femoroacetabular Impingement. Clin Orthop Relat Res. 2019