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Figure 1. Anteroposterior radiograph of pelvis.
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Figure 2. Sagittal MR arthrogram.
A 20-year-old woman presents to the office with a 6-month history of right hip pain. She is an avid runner and has been training for a marathon for the past year. Over the last 6 months, she reports having sharp hip pain with prolonged walking, running, and squatting. She has tried 2 months of rest without running and anti-inflammatory medications, followed by a 3-month course of physical therapy for the hip without significant relief. In addition, the patient received an intra-articular cortisone injection 3 months ago, which provided 100% relief of pain for 2 to 3 weeks. Anteroposterior hip radiograph (Figure 1) and sagittal magnetic resonance arthrogram (Figure 2) show a small anterior superior labral tear. On physical examination, the patient has sharp pain with flexion, abduction, and internal rotation of the hip (FADIR impingement).
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The hip labrum is a soft tissue bumper around the acetabulum that contributes to hip stability. The labrum can become damaged with repetitive sports and in patients with hip dysplasia and femoroacetabular impingement. Hip labral tears can also be found in a high percentage of asymptomatic patients; therefore, a careful physical examination and history must be included with imaging findings to determine the etiology of hip pain. In 1 study, 69% of asymptomatic patients between the ages of 15 and 66 years had a hip labral tear.1
In patients with MRI evidence of a hip labral tear who have failed conservative treatment (rest, NSAIDS, physical therapy), a reasonable first treatment approach is to perform an intra-articular injection into the hip joint. A short period of relief from the injection helps confirm the diagnosis of an intra-articular source of hip pain such as a labral tear.
Patients with a labral tear who have failed 3 months of conservative treatment are candidates for arthroscopic labral repair vs debridement. In young active patients, the current literature supports arthroscopic labral repair over debridement. Labral debridement alone has been found to be associated with a significantly higher risk of progression of hip arthritis compared with labral repair. If the labrum has viable tissue and a good vascular supply, then labral repair is favored in young active patients without arthritic changes.2
A typical rehabilitation protocol for a labral repair includes 2 to 4 weeks of partial weight-bearing with crutches, avoidance of deep hip flexion beyond 90 degrees for 6 weeks, and 2 to 3 months of physical therapy.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopaedics for Physician Assistants.
References
1. Register B, Pennock AT, Ho CP, Strickland CD, Lawand A, Philippon MJ. Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. Am J Sports Med. 2012;40(12):2720-2724. doi:10.1177/0363546512462124
2. Domb BG, Hartigan DE, Perets I. Decision making for labral treatment in the hip: repair versus débridement versus reconstruction. J Am Acad Orthop Surg. 2017;25(3):e53-e62. doi:10.5435/JAAOS-D-16-00144
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