Your Hips Don’t Lie – Treating Labral Tears by Mr Parag Kumar Jaiswal
6th December 2019
Hip pain in young adults is not normal and it’s important to recognise the signs of hip problems so that they can be diagnosed and addressed clinically before they become a bigger issue.
Patients are often surprised to hear that hip pain is felt in the groin and can radiate down the thigh to the knee. Frequently, patients attribute their groin pain to muscle strain (even older patients with arthritis). Furthermore, athletes often put their groin pain down to a muscle strain or sports injury. However, many people are unaware that a tear in the labrum (the soft cartilage surrounding the hip socket) can also cause groin pain.
How does a healthy hip work?
Your hip is a ball and socket joint with some unique features. The ball is the femoral head (the top of the thigh bone) and is normally spherical; the socket is the acetabulum, which is part of the pelvis. Both are lined with cartilage, which is the most incredible structure engineered by nature: it provides friction-free load-bearing on joint surfaces to allow for smooth movement without joint pain. Synovial fluid within the joint helps even further. In most joints in the body, articular cartilage lasts for 7 decades or more but it is the wear and tear of this that leads to arthritis.
The ball and socket joint is sealed by soft tissue – the labrum – which creates a vacuum seal and suction effect, keeping the synovial joint fluid in place and protecting your joint cartilage during physical activity. It also maintains the stability of your hip joint. This is particularly important in patients with poorly developed hip joints which is known as hip dysplasia.
How do labral tears occur and what does it feel like?
Tears in the labrum often occur in patients in which there are pre-existing structural abnormalities (such as femoroacetabular – i.e. hip impingement or hip dysplasia). They can also occur after trauma, or through overuse during high intensity repetitive activities such as in pivoting sports (eg football, tennis or golf) or ballet – although this is less common.
Left unchecked, labral tears can progress to the point that the hip joint cartilage starts to peel off, leading to further damage within the joint and, eventually, arthritis. If you have a labral tear you may experience sharp, knife-like groin pain. This tends to occur in activities such as squats and lunges or getting in and out of a low car. The pain is usually activity related initially but can be severe and disabling, affecting work, parenting and leisure pursuits. As tears and symptoms progress, walking or standing for prolonged periods becomes more problematic.
Pain while sitting is another characteristic feature of labral tears. This could manifest itself in an inability to drive or cope with long distance air travel. In one case, for example, a patient became depressed as he was no longer able to visit the cinema. Other symptoms can include a catching sensation or clicking, as well as your hip ‘giving way’. In some cases pain may be located in other areas such as the buttocks, in front of the thigh or the side of the hip.
Let’s take a closer look at the conditions that can predispose you to labral tears.
Femoroacetabular impingement (FAI)
Impingement is another problem seen frequently. It can be caused by excess bone around the ball, a hip socket that is too deep, or a combination of the two. Both can cause labral tears and damage to the cartilage lining the joints. 80% of patients with FAI complain of groin pain and it usually affects active individuals between 30 to 45 years of age but it can also affect athletes and dancers in their teenage years or twenties.
Developmental dysplasia of the hip (DDH)
In DDH, the socket is shallow and does not completely cover the ball which means the ball can partially or completely slip out of the socket. DDH can be present at birth or develop during childhood. In milder forms, the condition is diagnosed in adulthood when the hip becomes painful (often with labral tears).
Diagnosis and treatment for labral tears
The diagnosis of labral tears is based on a thorough clinical history and examination as well as X-rays, MRI and CT scans. By far, most labral tears are associated with the above conditions, so treatment involves addressing the underlying cause as well as the labral tear. In a General Practice study, 50% of young adults (aged 18-55) presenting with groin pain were suspected to have FAI.
Initial management involves rest, activity modification and anti-inflammatory medication. After symptoms have settled, physiotherapy is especially important to stretch and strengthen muscles around the hip. Injections into the hip joint are frequently performed, allowing the surgeon to assess how much of the pain is coming from the hip joint and give the patient a pain-free interval to enable more effective physiotherapy.
If symptoms persist then surgery may be necessary. This is usually in the form of keyhole surgery (arthroscopy), whereby the torn labrum can be removed (debrided) or repaired. Recent scientific work has shown better results following repair of labrum rather than removal. Addressing the underlying cause involves removing the extra bone causing impingement or stabilising the labrum in hip dysplasia.
The most important advice one can give to patients considering treatment for their hip condition is to seek out a well-trained young-adult hip specialist who can explore in detail patients’ expectations and together devise a personalised plan to achieve the best possible outcome.
Parag Kumar Jaiswal is a Consultant in Trauma and Orthopaedics with an interest in lower limb arthroplasty (hip and knee replacements) and a subspeciality interest in sports injuries of hips and knees, in particular Hip Arthroscopy. After spending two years as a Consultant at Guy’s Hospital as part of the young adult hip unit, he now runs a large NHS practice at The Royal Free London NHS Foundation Trust. He is setting up the Young Adult Hip Unit. Parag’s private practice is mainly based at Hospital of St. John’s & St. Elizabeth.
To book an appointment contact the hospital on 0207 078 3811 or call Mr Jaiswal’s secretary on 07539 645794