Overview of hip labral tears

Original Editor - Margaret Layden

Top Contributors - Margaret Layden  

Clinically Relevant Anatomy

The hip is one of the largest joints in the body and is a very stable ball and socket joint.  The labrum is a fibrocartilaginous structure which attaches to the acetabulum and functions to deepen the acetabulum which increases the stability of the hip joint.  The labrum is normally triangular in shape but may be be round, flat or irregular.[1][2][3]  Although the vascular supply is controversial it is generally believed to be primarily avascular with some authors reporting blood supply to only the periphery.[4][5]  Nerve endings and nerve end organs have been identified by Kim and Azum suggesting that injury to the labrum may lead to pain in the hip.[6]

In addition to increasing the stability of the hip, the labrum also acts as a shock absorber and aids in lubricating the joint and provides for distribution of pressure.

Mechanism of Injury / Pathological Process

A labral tear can be caused by trauma as in a motor vehicle accident, a fall or injury during a sporting activity or it may be the result of repetitive microtrauma.  Groh and Herrera report findings by Kelly et al. and Philippon et al. of  "at least five etiologies of labral tears--trauma, FAI (femoroacetabular impingement), capsular laxity/hip hypermobility, dysplasia and degeneration."[1][7][8]
Trauma - results in subluxation or dislocation of the hip damaging the labrum

FAI - results in pinching of the labrum between the acetabulum and the femoral head

Capsular laxity - may lead to labral injury as the result of a decrease in the stability of the joint causing increased pressure on the labrum

Dysplasia - any bony abnormality in the acetabulum or the femoral head or neck can lead to increased stresses on the acetabulum and/or the labrum

Degeneration - any abnormality in the joint will lead to increased stress and injury of the labrum, the cartilage and the bone.

Clinical Presentation

Unless there is a traumatic injury the problem may go undiagnosed for years.[1]  Symptoms usually include anterior hip and groin pain.  Patients may also complain of buttock pain.  At times there is a complaint of clicking (most common), giving way and locking.  

On physical examination, the patient will normally have a positive anterior hip impingement test.[1] 
Functionally the patient will have difficulty with prolonged walking or sitting, pivoting, climbing stairs and impact activities.[1]  The patient usually will have dull aching pain with intermittant sharp pain.

Diagnostic Procedures

Radiographs are normally obtained first to screen for bony abnormalities.  These should include an anteroposterior view, a cross-table lateral view and a false profile view.[1]

The diagnostic test of choice is the magnetic resonance arthroscopy to assess the labrum and to rule out other disorders.[1]

Outcome Measures

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Management / Interventions

Conservative treatment of rest, anti-inflammatory medication, pain medication and physcial therapy for 12 weeks is recommended.

If there has been a traumatic injury, the patient may be advised to restrict weight bearing.[1]

Focus is on strengthening and gait training (assessing and treating the whole lower extremity) as indicated.  Treatment is progressed to weight-bearing, proprioceptive and balance exercises and functional activities.[1]

Manual techniques to restore range of motion are also recommended.[1]

According to Lewis et al. the goal of treatment is to "optimize the alignment of the hip joint and the precision of joint motion, particularly avoiding excessive forces into the anterior hip joint".[2]

If conservative measures fail to relieve the patients symptoms and improve function, referral to a surgeon is recommended.

Differential Diagnosis

Differential diagnoses when considering labral tears include: "stress fractures, neoplasm, avascular necrosis, osteitis pubis, synovitis, ligamentum teres rupture and other extraarticular soft tissue abnormalities". [1] It is also important to evaluate the lumbar spine and sacroiliac joint as well as the knee.

Key Evidence

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Resources

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Case Studies

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Recent Related Research (from Pubmed)


References

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  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med 2009;2:105-117.
  2. 2.0 2.1 Lewis CL, Sahrmann SA. Acetabular Labral Tears. 2006;86(1):110-121.
  3. Magee DJ. Orthopedic Physical Assessment. United States of America: W.B. Saunders, 1987.
  4. McCarthy JC, Noble PC, Schuck MR, et al. The Otto E. Aufranc Award: the role of labral lesions to develoopment of early degenerative hip disease. Clin Orthop 2001;393:25-37.
  5. Petersen W, Petersen F, Tillmann B. Structure and vascularization of the acetabular labrum with regard to the pathogenesis and healing of labral lesions. Arch Orthop Trauma Surg 2003;123:283-288.
  6. Kim YT, Azuma H. The nerve endings of the acetabular labrum. Clin Orthop 1995;320:176-181.
  7. Kelly BT, Weiland DE, Schenker ML, Philippon MJ. Arthroscopic labral repair in the hip:surgical technique and review of the literature. Arthroscopy. 2005;21:1496-504
  8. Philippon MJ, Martin RR, Kelly BT. A classification system for labral tears of the hip. Arthroscopy. 2005;21(suppl):e36.abstr.