Interviewer: If you or someone you know is experiencing persistent joint pain in the hip or maybe a catching sensation or just a general instability, it may be the result of a labral tear. This is a very common hip injury, but it can significantly impact a person's ability to move and live their lives. If left untreated, it has the potential to lead to more complications such as arthritis later in life.
To help us better understand what a labral tear is and what we can do to treat them, we're joined by orthopedic surgeon Dr. Stephen K. Aoki, who is a professor and the chief of sports medicine at University of Utah Health.
The Role of the Labrum in Hip Function and Stability
Now, Dr. Aoki, what exactly is the labrum in the hip? What is it doing? And what happens when it gets torn?
Dr. Aoki: Sure. That's a great start. If we look at the labrum, think of the labrum almost like a gasket, where you have this little soft tissue ring around the hip joint. And so the hip is made out of a ball and a socket, and those two bones move together to allow your hip to move in different directions and be functional. The labrum is a ring of tissue that surrounds the cup or the socket of the joint, it's a soft tissue stabilizing structure that adds support, helps to unload the joint, and helps with the stability of the joint.
Causes and Risk Factors of Labral Tears
Interviewer: So what can cause, say, a tear to this gasket of the hip, like you were explaining to me?
Dr. Aoki: Sure. So the labral tear usually is loaded in a way, like anything, right? If you have a structure and if you put enough force through it . . . if you hit your car, at some point if there's enough energy, it's going to break or dent your car. Same sort of deal with a labral tear. If there's enough energy that gets thrown through that tissue, it can get injured, and it can tear or at least get loaded in a way that can cause some damage.
That can be an effect of activity, so if you're doing really aggressive cutting, twisting, pivoting, jumping-type activities where you're putting a lot of force through the hip joint.
But it can also be affected . . . and particularly this is very common and probably the most common issue related to labral tears, is that there's some sort of underlying bony problem of the hip, or bony variation to the hip that makes the hips so that the ball and socket don't fit together perfectly.
If you have the ball and socket concept, if a ball fits really well and is machined in a way that it fits perfectly into that cup, then it moves really nicely. If that ball is more egg-shaped, then as a hip moves, if you're trying to roll an egg in a round socket, it doesn't fit.
And so when you have something that doesn't fit, then it loads the edge. On the edge of that tissue is the labrum. And so oftentimes in the young healthy individual who gets a labral tear, there's an underlying shape problem to the hip that leads to or that makes you more susceptible to having a labral tear.
Interviewer: So I'm hearing that if you're moving a whole lot, if you're causing a lot of force on that particular joint, that can cause it, but also just shape. If your body is a little different, it might cause some issues. Does that mean that there are particular types of people that are more likely to get a labral tear, or is this something that affects a whole lot of people across different ages?
Dr. Aoki: It affects a lot of people at different ages, but typically the individuals that we see come in that are younger that have this issue, they're typically individuals that are more aggressive with their activities and they have some sort of underlying shape problem that loads the hip joint in a way that's maybe not ideal.
Interviewer: So I'm assuming we've got athletes. Are there any other types of people that you see this a lot in?
Dr. Aoki: Mainly athletes, but I think anyone actually. I mean, the challenge with labral tears and the shape problem . . . which actually the term for it is called femoroacetabular impingement, or FAI for short. It's typically a shape issue where the ball isn't round. It's just a way that it formed as you were going through those growing years. Typically we see it more frequently in athletes because there's a growth plate around the hip that gets stimulated that causes a little bit of extra bone to form.
Interviewer: Oh, wow.
Dr. Aoki: And that shape issue ends up pinching in the hip joint, and it pinches directly on that labrum.
Common Symptoms of Labral Tears
Interviewer: So if someone experiences a labral tear, how do they know? What are some of the symptoms that they're feeling? What do they first notice that even send them to the doctor?
Dr. Aoki: Sure. Most of the time when you have a hip injury or a labral tear, the first symptom is usually groin pain. And it's right in that . . .
Interviewer: Oh, really?
Dr. Aoki: . . . crease between your pelvis and your thigh. So right where you sit, where you form that crease in the joint or in the leg, that's right where people tend to feel the discomfort. And so it's an aching pain in the front of the hip.
It can radiate to the back, so you might get this radiating pain that goes back into the buttock region, but most of the time it's in the front.
Interviewer: Okay. And I also had heard about a catching sensation. Is that pretty typical, or is that kind of rare with something like this?
Dr. Aoki: It can happen where it's more mechanical. Most of the time, individuals will have more discomfort with deep squatting or more aggressive twisting, pivoting-type activities. You can have pain with prolonged sitting, which is another common complaint.
Diagnosis and Evaluation of Labral Tears
Interviewer: Oh, interesting. So they go to their doctor, they're like, "Hey, my hip is bothering me," etc. What is it that finally gets them the diagnosis of a labral tear and then gets sent to a surgeon like you?
Dr. Aoki: Yeah. I mean, any time you have this type of discomfort, when it first starts off, most of the time it's kind of a reasonably tolerable discomfort that sets in. And if it is the femoroacetabular impingement problem with the underlying labral tear, usually what happens is that the period of rest, a period of activity modification, trying to do things from a non-surgical standpoint, initially usually it feels better when you take a break from activity.
Interviewer: Oh, okay.
Dr. Aoki: However, the return to activity, if the pain continues to return when you go back to the things in life that you like to do, that's when I would start looking at trying to get in to see someone to get an evaluation.
Typically it's coming in, and like most medical problems, hearing a patient's story gives you a lot of information and kind of keys you into a diagnosis. And then that, on top of an exam and usually getting some X-rays to look at the shape of the hip, as well as potentially moving towards getting an MRI to look for that labral tear.
Interviewer: So they got their MRI, they have been diagnosed with a labral tear, and they come into your office. What are patients coming in expecting? As a layperson when I hear, "Oh, no, there's a part of me that has been torn," I immediately think, "Hey, I need to go get this stitched up." Well, that might be a little too crass, but just like, "Hey, I need to get this fixed." Is that the right approach to take? Or what do you tell patients when they come in and they know they have a labral tear?
Dr. Aoki: Absolutely. And that's probably one of the most challenging issues that we deal with in a hip clinic where we're dealing with MRIs that are read as a labral tear.
It's interesting because the read of a labral tear on an MRI is not the same as what we see with a lot of different orthopedic problems where something gets torn and broken, right? Oftentimes what we see with a hip labral tear is that when radiologists and when we're looking at MRIs, we're looking at these changes to the tissue, or there's a signal. It's looking at a color on the MRI and it gives us an idea of an injury.
I almost like the term labral injury better than labral tear, because tear just to the layperson makes you feel like you have to get it fixed in order to get better. And that's not always true.
Probably the more important issue with someone who's coming in with hip pain that has an underlying MRI that is read as a labral tear is the clinical picture. How long have you been dealing with this? How much does it slow you down? Have you tried non-surgical options first?
Because there are some people who just get better. If you give them a period of rest, if you give them a period of activity modification, work with a therapist potentially, let things calm down, oftentimes there will be individuals that just get back to what they want to do and things are okay.
It's the individual that has that recurrent pain. They took that time off, they gave it a good try, and then as they started to increase their activity, the pain just crept back in. That's the person where we start thinking about doing something from the standpoint of heading to the surgical route.
And I try to explain the issue of the labral tear to patients in a sense that there are papers out there that look at people who have no hip pain, and they get MRIs and they send them to experienced radiologists, and 40% to 80% of them are read in these papers as labral tears.
So a read on an MRI may not necessarily mean that that's the pain generator. While it can be, it may not be the pain generator in everyone. So it's very important to make sure that you take that time to make sure you go through that non-surgical treatment first before you start committing your body to surgery.
Non-Surgical Treatment Options for Labral Tears
Interviewer: So that's really the first approach. Even if you're diagnosed with a labral tear, we start with conservative approaches, I guess like ice compression and elevation. Is that the standard for joints, or is that a little much?
Dr. Aoki: Yeah. Maybe a little bit different with the hip because it's a little hard to elevate that hip unless you stand on your head. But yeah, I think that probably the priority is taking a little bit of time and modifying that activity for a period and just letting things calm down. Let the discomfort settle and then start regrouping and getting back into what you want to do.
Recurrent pain, pain that creeps back in with activity and is limiting you, that's when you start thinking about heading in the other direction towards potentially considering surgery for a problem.
Interviewer: All right. So a patient has tried rest. They've tried the typical stuff. They've worked with a physical therapist to try to ease their pain, but they're still experiencing it. Now they're in your office. What are the options available? What is the next step if those more conservative approaches do not work?
Dr. Aoki: Sure. Now getting back to that conservative time period, I would probably throw in that even on the 6- to 12-week window, that's still relatively short, although that's kind of when we start thinking about potentially heading the other direction if things are not improving.
But it is around 6 to 12 weeks before you want to start sort of committing yourself to think of a different pathway because it does take that amount of time for some injuries to just get better and for modification of activity or pain from an injury to calm down and to allow potentially a therapy program to be effective.
Surgical Considerations for Labral Tears
But if you're not getting better, then it's looking at potentially seeing an orthopedic surgeon that specializes in hip, and sitting down and having a discussion and particularly looking through or having a discussion with them about what is bothering you. Where is your discomfort? What activities tend to cause discomfort? Do your physical exam and evaluate your studies.
I think the other thing to think about when you're dealing with hip pain is that there are a lot of other problems that can mimic hip joint pain. And so you just need to make sure someone who is experienced in hip problems can help sort that out.
Interviewer: Say there's a patient out there and they've done everything they're supposed to and it's maybe time to look into a surgery. What is it that you tell them? What can a patient expect if they go out and they seek treatment for a labral tear? Are things going to get better? Or is this something that they just have to deal with?
Dr. Aoki: Yeah, I think probably the best thing to do if you're at the point where you're not improving from non-surgical options, then it's time to start looking at trying to find someone to see.
There are a lot of educational resources out there. We have some on our University of Utah Health website where you could go to the orthopedics page and search "hip labral tear." But there's also a lot of other educational information that you can look at as well that can help you understand this process a little bit more.
But if you're at the point where you're frustrated and your level of activity and function is bothersome to a point where you are not happy with what you're doing in life, then it's time to get in and see someone. We have a lot of great individuals who can help take care of you at the University of Utah.
Interviewer: One last question before we kind of wrap things up here is say they're not here in Utah and can go to a place like the University of Utah Health. What kind of doctor are they looking for? What kind of clinic are they looking for to get this type of treatment?
Dr. Aoki: Yeah, for your initial evaluation, I would try to see a non-operative sports provider. There are a lot of individuals who specialize in sports medicine who can do the initial screening.
And then from there, if you need a referral, typically most individuals who are non-operative sports medicine providers know of individuals who can help you from there if you need to pursue the surgical route.
I would try to find someone who specializes in hip problems and make sure that you get in to see them. Again, most people have good websites that can help direct you to see what their specialty is in orthopedics.
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