Hip Labral Tear
Hip Labral Tear
A hip labral tear is a painful condition that may require surgery. The labrum is a rubbery cartilage that has several important functions. One of these important functions is to help keep the ball part of the joint (which is the top of the femur bone) in the socket (part of the pelvis bone). There are several causes of labral tears. Some causes are a result of trauma. However, there are also several non-traumatic causes. Traumatic tears of the labrum most commonly occur during high impact sports or exercise. On the other hand, non-traumatic tears are usually attributed to several biomechanical factors. The treatment for tears will depend on a number of variables, including the cause and severity. Arthroscopic surgery is the best option in some cases; but not all cases. This article outlines how these tears can occur, some alternatives to surgery, what happens during arthroscopic repairs, as well as the risks, and expected recovery time after surgery.
Hip Labrum - What Is It and What Does It Do?
The hip joint is a ball and socket joint that is encased in a dense soft tissue capsule. The ball part of the joint is at the end of the thigh bone and is called the head of the femur. The socket part of the joint is called the acetabulum. The acetabulum is part of the pelvis. The labrum is dense soft tissue (like a rubbery cartilage) that attaches to the outside of the acetabulum (outside part of the socket) on the pelvis side of the joint. It is perhaps the most important part of the soft tissue structures that envelope the ball to keep it the right place. Some people have described the labrum as forming part of the ‘suction cup’ that helps to keep the ball in the socket. There quite a wide range in the shape and thickness of the labrum (and other structures of the hip) that naturally occurs in a normal population. However the labrum is generally thicker at the back (posterior) portion of the joint and thinner and wider at the front (anterior) portion of the joint.
Causes of Hip Labrum Tears
Medical professionals and researchers believe there are at five primary causes of labral tears. These causes include trauma, impingement of the labrum between the acetabulum and the head of femur, laxity of the hip capsule, hip dysplasia and degeneration.
Labral tears due to trauma usually occur during high velocity and impact events (such as a car accident or sporting injury) and are often associated with dislocations (or subluxations). If the hip dislocates in the backward (posterior) direction than the labrum tear will often be on the back (posterior) portion of the labrum.
Impingement occurs when the labrum is being pinched between the ball and socket during certain kinds of movements. This may happen due to certain biomechanical factors (such as the shape of the acetabulum or head of femur). Unfortunately the underlying biomechanical factors (shape of the pelvis or thigh bones) that cause this to occur in some people can be difficult to change (without surgery).
Similarly to impingement, laxity of the hip capsule is another cause of labral tears that is not easy to change. You may recall that the capsule refers to the soft tissue structures that keep the ball in socket. Certain hormone levels or soft tissue disorders can cause some people to have an increased risk of capsule laxity leading to labrum tears. Laxity in the capsule can lead to additional strain on the capsule tissues (such as the labrum); particularly during rotational activities (such as tennis). Capsule laxity can cause the head of the femur to be unstable during movement and rides forward and up (anterior and superior) in the socket. This instability and additional strain on the front-upper (anterior-superior) portion of the labrum may cause it to tear.
Illustration of Hip Dysplasia
Hip dysplasia is a developmental condition characterised by misformed or misaligned joint. This may commonly include a shallow socket or misshapen femoral head. It can cause a range of problems including damage to the joint surface. Labral tears are also a problem that have been observed to occur among people with hip dysplasia.
Like many structures in the body, the soft tissues around the hip can experience degeneration with age. The labrum is not immune to this and may tear as a result of degeneration in older age. People who develop labral tears in young or middle ages are more likely to have one of the other four causes described above.
Symptoms of Hip Labral Tears
The most common symptom of a labrum tear is pain at the front of the hip (anterior hip pain) or in the groin area. While this is the cast in a vast majority of cases (more than 90%), sometimes people with labrum tears complain of pain deep in their buttock, or on the sides. It is believed that people who have a labrum tear and report pain at the front are more likely to have a tear in the anterior (front) portion of the labrum. This is also where the labrum is thinner and more likely to tear. In contrast, people who report pain deep in the buttock region are considered more likely to have a tear in the posterior region of the labrum.
Other symptoms of a labral tear at the joint include clicking, locking, catching, or giving way. Sometimes women with a labrum tear may also report a sensation that feels like pain in their pelvic floor area. It is also common for labrum tears to cause referred pain to the inside of the knee. In other words, it may feel like there is pain on the inside of knee, but this is being caused by the tear at the hip. Because there are many potential causes of pain around the hip, it is not uncommon for people with labrum tears to see several health professionals over a period of time (perhaps a couple of years) before it is correctly diagnosed.
Video of Arthroscopic Labral Tear Surgery
Non-Surgical Treatments for Tears (Conservative Management)
People with labral tears may be advised to try a conservative approach at first. This may include avoiding any aggravating activities (such as sport), anti-inflammatory medications, pain medications, and perhaps most importantly undertaking physical therapy for approximately 12 weeks. For many people, the symptoms may subside with this approach only to return once they begin undertaking their usual activities. Steroid injections may be considered but are generally not the first treatment option for young people who otherwise do not have degeneration at the joint.
Surgery for Hip Labral Tears
If conservative management has not resulted in a suitable reduction in symptoms, surgery is sometimes considered. The earlier surgical techniques would simply cut awat the damaged portion of the labrum. However, the removal of labrum may contribute to instability and earlier onset of arthritis. Therefore, contemporary surgical approaches most often include arthroscopic repair of the hip labrum. This involves making several small incisions (also colloquially known as 'keyholes') and inserting surgical instruments to access the joint with minimal invasiveness. Although, it is worth noting that even arthroscopic labrum repairs (as with all surgery) is still an invasive procedure. Once the instruments are in place, the surgeon can use several techniques to tidy up the area and repair structural abnormalities. The purpose of arthroscopic treatment is to relieve pain by eliminating the unstable flap tear that causes the discomfort. In some cases open surgery may be required, this involves the surgeon cutting through the skin and soft tissues to directly access the joint and repair the affected structures. Open procedures are generally more invasive, painful and have a longer recovery time. For this reason they are typically only used when arthroscopic surgery is not viable or likely to be successful (not common for tears these days).
Risks of Surgery
No surgery is risk free. Some risks that have been reported for surgical labrum repairs include:
- Blood clot, most notably deep vein thrombosis (DVT)
- Damage to the cartilage on the joint surface
- Accidental nerve or blood vessel injury
There are also other risks associated with going under a general anesthetic including (this is not a comprehensive list):
- Nausia and vomitting
- Allergic reaction to anaesthetic
- Death (this is unlikely, something like 1 in 100000)
As always, if you are considering any treatment including surgery, you should discuss the potential risks of treatment with your doctor. Risks are not equal for all patients. Your doctor will be able to provide you with specific advice and more comprehensive details of risks that may arise in your specific circumstance.
Recovery After Surgery - What to Expect.
The first few days after arthroscopic hip labrum repairs will be quite uncomfortable. It is important that an appropriate medication schedule is in place to manage post-operative pain at this time. Patients will often be seen by a physical therapist in the first day or two following surgery who will be able to provide instructions for a staged exercise plan that is approved or recommended by the surgeon. Depending on the precise surgery that has been performed, some people will not be permitted to put all their weight on the affected leg for several weeks. Other people may use a walking aid in the first few days for comfort only and will be able to return to normal walking quite quickly. Although the hospital stay will most likely be quite short (generally ranging from one day to a few days), the recovery period will usually last for 6-12 weeks depending on the severity of the injury and repair. Return to sport or other high impact activities will depend on several factors. Some of these factors include the cause of the injury (and likelihood of re-injury), the severity of injury and the nature of the surgical repair technique. The surgeon will generally be able to provide some advice in this regard prior to the surgery being undertaken.
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