Hip Labral Tears: what, why, how and treatment

What is the labrum in the hip, and what does it do?

To understand what is a hip labral tear is let us first understand what the hip labrum is. The acetabular labrum is a fibrous ‘fringe’, a ring of cartilage that attaches around the rim of the hip socket (the acetabulum). It is most commonly triangular in shape, 2-3 mm thick and extends out from the acetabular socket 6-10mm. The labrum has a number of key functions.

The hip labrum:

Deepens the hip socket joint
Provides a seal for the joint, creating a vacuum that helps hold the ball (head of the femur) into the socket
Traps synovial fluid (normal joint lubricant) between the ball and the socket This means that when walking and running, much of the landing forces are absorbed by fluid, rather than the joint cartilage
Assists with flow of synovial fluid, important for cartilage nutrition within the hip joint

As the acetabular labrum is a structure at the edge of the hip joint, in most people the labrum only absorbs 1-2% of total joint load when standing.¹ The main cartilage surfaces of the ball and socket take almost all of this load, and this is why it is common for people to have tears in their hip labrum without even knowing about it – more on that below.

How common is a labral tear of the hip and do they always hurt?

You might be surprised to learn that at least 50% of people without hip pain have a tear in the acetabular labrum, compared with around 62% of those with hip pain!² So while it can cause pain, because the labrum does contain sense receptors,³ it doesn’t always become painful.

It often depends on what you are doing with your hips, and the natural bone shape of your ball and socket may play a role. If you’re regularly moving your hip into the very end of its range e.g., deep squats, lunges, splits or forced rotation, the labrum will absorb more load and a labral tear is more likely to become painful.

The labrum may also be exposed to higher loads in those with certain bone shapes – cam or pincer shape, or acetabular dysplasia (shallow socket). Read more about this in the next section.

This brings up 2 key points

Just because a labral tear is detected on a hip scan, it doesn’t mean it is the source of pain. A good clinical assessment by a health professional experienced with hip pain is required. They can help determine whether the labral tear is likely to be relevant to your hip problem.
Labral tears can be painfree. If you do have hip pain related to a labral tear, physical therapy (physiotherapy) can assist in helping you reduce time spent in irritating positions and improving how you control movement at the hip to alleviate pain related to the labrum.

Symptoms of a hip labral tear

Common symptoms of a hip labral tear include:

deep pain at the front (groin pain), or around the front, outer side of the hip,
sharp catches of pain in a deep squat position or pivoting on the hip,
aching deep in the front of the hip with prolonged sitting or driving,
aching pain at night, particularly after activity,
limping when the pain is bad

What causes a hip labral tear?

The labrum can sometimes be injured traumatically, most commonly with a sudden twist or pivot or during an extreme movement to the end of the joint range. However, medical researchers have discovered that acute trauma is the least likely cause of hip labral injury.

It is much more common that individual variations in bony and ligament structure increase the risk of micro-trauma to the labrum. Repeated small insults to the labrum over time may eventually result in a visible tear on Magnetic Resonance Imaging (MRI scan).

The development of an acetabular labral tear likely depends on your hip shape and what you are doing with your hips.

Bone shapes that may increase the risk of a hip labral tear

Acetabular dysplasia (a shallow hip socket)

Some people are born with a smaller or shallower hip socket that doesn’t provide as much bony coverage or support for the ball at the top of the femur (thigh bone). This is called acetabular dysplasia.

Less bone allows for greater flexibility and so it is not uncommon to find dancers, gymnasts and circus performers with this bone shape. However, less bone in the hip socket does mean that the acetabular labrum will need to do a little more work.

Remember we said that the labrum normally absorbs only 1-2% of total joint load? In those with acetabular dysplasia, the labrum absorbs 4-11% of total hip joint load,¹ which is a dramatic increase.

The shallower socket also allows more gliding of the ball in the socket, which also needs to be controlled by the labrum. These extra loads may contribute to development of acetabular labral tears in people with acetabular dysplasia, and sometimes this may lead to pain. Again, what you do with your joint and how, will also influence the likelihood of developing pain.

Read more about the development, symptoms and treatment of acetabular dysplasia by clicking on the pink text.

Femoroacetabular Impingement (FAI)

Femoral acetabular Impingement (FAI) is a mismatch of the ball and socket of the hip joint, which may result in increased loads on the labrum of the hip.

Variation in the shape of the ball and/or the socket results in the bones coming together a little earlier than normal (femoroacetabular impingement) during hip flexion (knee to chest) or inward rotation of the hip. As the labrum is on the edge of the socket, it may be exposed to greater compression or shear force, particularly in extremes of joint motion.

Cam shape of the femoral head

Cam shape is where the ‘neck’ of the femur just below the head (ball) is thicker than average. This shape develops in adolescence and appears to be a natural response to higher levels of participation in weightbearing sports that involve change of direction.

The neck of the femur becomes thicker and stronger, but the extra bone means the thicker neck will impinge against the socket earlier in hip motion, increasing load on the labrum.

Pincer shape of the hip socket

Pincer shape is where the socket is deeper or facing slightly less forward than typical. This means there is relatively more bone at the front of the socket and so once again, the bones come together earlier with more potential load on the labrum.

However, while there are links with cam shape and increased risks of developing hip pain, the relationship between pain and pincer morphology is not strong.

Mixed FAI

A mix of cam and pincer shape that results in early bony impingement is called “mixed FAI”.

Other possible contributors to hip labral tears

The research has shown that although people with acetabular dysplasia and FAI may be at higher risk of developing hip pain associated with a tear of the hip labrum, only some people with these bone shapes ever develop a problem.

Why is that? Well, it’s because it is not just about bone shape and we probably don’t fully understand all the possible factors and their relative importance yet.

But what you do with your hip and how you control hip movement are thought to be 2 important factors.

People that repetitively force their hips into the very end of their range, particularly with added load or at higher speeds, may overload the labrum. Reduced muscle strength and co-ordination around the hip may also result in higher loads being transmitted across the joint and the labrum.

Pair one or both of these things with one of the bony variations we’ve mentioned, dysplasia or FAI, and the risks of pain related to a labral tear are likely to be substantially increased.

Diagnosis of a painful hip labral tear

To diagnose a labral tear, a health professional will first ask you about the location, type and behaviour of your pain, the history of your condition, what types of activities you do normally and which of these appears to aggravate your hip.

The health professional will also assess your hip range of motion (flexibility) and perform some special tests that provide some guidance as to whether you are likely to have a labral tear.

Often the final diagnosis is made on imaging (scans), however, remember these are not a great way to make a diagnosis by themselves (because lots of people have labral tears without hip pain. The clinical assessment by a health professional (interview and physical examination) can help to figure out if a labral tear seen on imaging is likely to be the source of your problem.

Scans should not be used alone to diagnose a painful labral tear

This is only one part of the assessment – the diagnosis is only the beginning. The health professional then needs to perform other assessments of the hip, your whole lower limb, the way you move and how your muscles are functioning.

They may also want to assess your sporting technique and/or ask some detail about your normal training routine and any recent changes to your training schedule.

All of this additional information helps to build a picture of the factors that are most likely to have contributed to the development of your hip pain.

What is the usual treatment for a hip labral tear?

What can you do about a labral tear? Lots of people with a labral tear can continue in life without issues, even competing in sport to a high level.

If pain does develop, the first thing to try is a program of rehabilitation, usually with a physical therapist (physiotherapist). Just having a tear, does not mean you need to jump straight to a surgical treatment, as a labral tear can settle and become painfree again with rehabilitation. For those who continue to have problems, there are additional medical options.

Physical therapy treatment for a hip labral tear

The 2 main components of a rehabilitation program for a painful labral tear are education around hip care, and an individualized exercise program.

Learning to care for your hip

Learning to care for your hip and how to reduce unnecessary load on your labrum is one of the most important components of any rehabilitation plan. You can do all the exercises you like, but if you don’t understand why your labrum is becoming painful and how to control this, you are likely to continue experiencing flares of pain.

The advice will be a little different, depending on what the health professional has discovered in your examination about your likely bone shape, work environment, car, sport or recreation, training habits etc, etc. Getting individualized advice will be most helpful.

Often the best places to start is in modifying things that you might be doing a lot – sitting, walking, running. Simple modifications to these high-duration positions or high-volume activities can often make a big difference.

You can find some great advice in other blogs on this site about:

Exercise for a labral tear

Your physical therapist, physio or exercise physiologist may develop a specific exercise program with hip exercises to help reduce your pain and regain your normal function in your hip.

This rehabilitation program will also be most effective when tailored to the individual. For example, a program for someone with a labral tear and acetabular dysplasia will be a little different to that for someone with FAI. A program for an athlete will also be a little different to that for someone who has lower levels of physical activity.

Generally, the program will involve helping you to move in ways that avoid repetitive overload of the labrum, and teach you the best exercises to help address any specific weaknesses or reduced coordination you may have in the muscle around your hip. Ensuring good strength, endurance and control around the trunk, knee and ankle is also often important to help reduce excessive loads crossing the hip. You will be guided in flexibility exercises to help, as well as those to avoid that may irritate the hip labral tear symptoms further.

Deep muscles around the hip will be important to provide support to the joint, and the gluteals, hip flexors, thigh, calf and abdominal muscles will also be important in better sharing loads across the hip joint and across the whole lower half of the body.

Other physical therapy treatments

Hands-on treatments, or manual therapy, to relieve muscle tension may be provided and acupuncture or needling techniques are also sometimes used to help reduce pain. These treatments may be effective for some people in achieving some short-term relief while they work on the 2 main strategies – hip care and an exercise program.

A physical therapy rehabilitation program for a painful labral tear is more likely to be successful when developed by a physical therapist or physiotherapist who understands labral tears and can develop an individualized program to suit your situation.

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When you use our Find a Hip Pain Professional Search, have a closer look at the results. Each Hip Pain Professional will specify which hip pain management they provide from the above list.

Medical treatment of a painful hip labral tear

Medications and injections

A doctor will usually refer to a physical therapist or physiotherapist for rehabilitation of a painful hip labral tear. They may also prescribe some medication to help with pain management where necessary.

If the pain is more severe and is not settling adequately with hip care strategies and exercise, an injection may be suggested, most commonly a cortisone injection or a platelet rich plasma (PRP) injection.

While cortisone can provide some short-term relief, the pain usually returns if the underlying contributing factors have not been addressed. There are also some concerns about the safety of cortisone injections, particularly multiple injections. PRP injections are still somewhat controversial, with mixed results shown in the literature. Discuss the possible risks and benefits for you with your medical practitioner.

Hip labral tear surgery

If all other non-surgical, conservative treatment options have been exhausted and hip labral tear pain persists, referral to a hip specialist orthopaedic surgeon may be provided. The surgeon will discuss the relative risks and potential benefits you may gain from surgery, if they consider you to be a surgical candidate. After surgery you will still need to follow a specific rehabilitation protocol attending physical therapy sessions to support you through this.

Surgical intervention needs to be considered with care. Surgery should not be considered a complete ‘fix’. While surgery can reduce pain and improve function, the literature has shown that most people still have ongoing symptoms even 2 years after surgery.

For some people, symptoms may become worse after surgery. This is why the surgeon needs to weigh up the relative risks for you. Those with acetabular dysplasia, global hypermobility syndromes like hypermobile Ehlers Danlos Syndrome, and those who already have some arthritic change in their joint, have been shown to have a higher risk of poor outcomes after surgery.

This is why surgical interventions should only be considered after first trialing a non-surgical approach. Your treatment plan should include an individualized education and exercise program from a professional who knows and understands hips. You can look for a therapist near you in our Hip Pain Professional directory by clicking HERE

Surgery for a labral tear is performed with hip arthroscopy – keyhole surgery. There are 4 main surgical approaches to this arthroscopic surgery.

Arthroscopic labral debridement

This is the most commonly performed type of labral surgery. Debridement refers to trimming or tidying up the tear. This often does reduce pain in the short term, but does not ‘fix‘ the labrum or repair the tear.

Debridement leaves you with less labrum then you had before, and research has shown that this can result in significant reductions in labral function – lower levels of function than with the tear.^4,5

If you are having a labral debridement then, it is important to commit to a good rehabilitation program afterwards, to optimise the way you move and muscle support around the joint. This may help achieve best results in the short and longer term.

Arthroscopic acetabular labral repair

This is the preferred labral surgery approach for a hip labrum tear as it aims to preserve the labrum and helps to maintain its function in hip joint protection and stability.

Whether the surgeon is able to perform a repair depends on the type of tear and health of the remaining tissue. For example, a clean split in the labrum with healthy edges is easier to repair. However, with a degenerative tear where the edges of the tear are frayed, it is very difficult to sew the tear together securely.

As a high proportion of tears are degenerative, this is why labral debridement is the most common surgical technique – it is much easier to trim off a degenerative tear than try to repair it.

Arthroscopic reconstruction of the acetabular labrum

In cases where the torn labrum is too difficult to repair, due to the complex or degenerative nature of the tear, some surgeons will offer labral reconstruction. This involves removing part or all of the labrum from the edge of the socket and trying to rebuild it with other tissue – often a small piece of tissue from somewhere around your own hip (e.g., a piece of the iliotibial band or quads tendon).

Reconstructive hip labral surgery is still relatively new and is only performed by select surgeons around the world. Because it is much less common, we don’t have enough information yet on how successful this type of surgery is.

Basic science research shows that reconstruction of the labrum helps restore the normal protective function of the labrum.^4,5 Surgical technique is likely to continue to progress over time to improve outcomes, and if successful, more surgeons will learn to perform these procedures.

Bone remodelling surgery

Where the labral tear is related to FAI or dysplasia, the surgeon may recommend that the underlying bony issue is addressed with bone remodelling surgery (osteoplasty).

Surgeons can trim excess bone away from the neck or the femur in those with a cam shape femoral head (femoral osteoplasty), or trim the acetabulum in those with pincer shape sockets (acetabuloplasty). The labral tear is then debrided or repaired at the same time.

Once again, these surgeries may for many people provide some moderate pain relief and improved function, but this does not restore a normal painfree hip. Some people may also have poor outcomes and be worse after such a procedure.

Surgery needs to be carefully considered and weighed up. Discuss with your surgeon about the relative risks and benefits for your particular situation.

There are also bony remodeling procedures for those with acetabular dysplasia – periacetabular osteotomy. This is a large surgery involving cutting the pelvis in 3 places around the hip socket and reorienting the socket to better cover the head of the femur.

Periacetabular osteotomy is performed open rather than via arthroscopy. It comes with much higher risks and is therefore only considered in those with more severe dysplasia and hip instability. For those people, this surgery can be very effective, but requires 6-12 months of rehabilitation.

We hope this information has been helpful in your journey of understanding and recovery.

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