The hip is the largest joints in your body and provides stability for your leg where it connects to your hip and upper body. Inside your hip joint there is a hard type of cartilage that is called the labrum of the hip. The labrum acts like an O-ring seal to stabilize your hip. It can be injured or torn during sport or with a fall or an accident. A hip labrum tear typically cause hip pain and a feeling that your hip is ‘clicking’ or ‘stuck’ in one position.
Let’s take a look at what the labrum is, what exactly it does and how a labral tear of the hip happens.
What is the hip joint and labrum made up of?
The hip joint is called a ball-and-socket joint, the same as your shoulder. Your thigh bone (femur) connects to your hip bone (acetabulum) through your hip joint. The top part of your femur forms a round ball that fits into the socket of the acetabulum. Thus the name ball-and-socket joint. There is cartilage in your hip joint, the same as in all of your other joints. The labrum can be described as an extra layer of cartilage. It sits on the rim of the acetabulum, right where your femur fits into it. The labrum helps to keep the head of the femur inside of the acetabulum, almost like a rubber ring that seals the hip joint and keeps the femur in place. It varies in form and thickness in each person.
Because the labrum is made up of a type of cartilage, it does not get good blood supply. This means that it takes longer to heal. There is some parts of the labrum that have nerve endings innervating it. So, with an injury or if you have a hip labrum tear, these nerves will transmit messages to your brain that can cause you to feel pain in your hip.
In & around your hip joint
There are many other structures, each playing a role in the functioning of your hip joint. Cartilage and joint fluid inside the hip joint reduces friction and allows the ball and socket to smoothly move past one another. The hip joint capsule is a layer of tissue covering the hip joint and it keeps the structures on the inside together. Ligaments in and around the hip joint provide stability. Muscles around the hip joint provide stability and mobility, as your hip joint has quite a big range of movement. With any hip labrum tear, other structures around your hip will be involved as well. Each patient is different and the type of injury will influence which other structures are involved.
What is the function of the labrum in your hip joint?
- Increases the stability of your hip joint.
- Increases the depth of the hip joint which makes your femur fit snugly into your acetabulum.
- Acts as a shock absorber when impact goes through your hip joint.
- Helps to distribute pressure through your hip joint.
- Decreases friction between the cartilage surfaces in your hip joint.
- Increases the significant range of motion of your hip joint.
- Helps to maintain the alignment of the hip’s ball and socket.
- Helps to keep the joint fluid inside the hip joint capsule.
How does a hip labrum tear happen?
A hip labrum tear can happen due to an injury or by simply doing a normal daily activity. Think of the labrum as a rubber seal that helps to seal the hip joint, by making sure the femur fits perfectly into the acetabulum. Now imagine you do a hard twisting movement with your leg, like doing a turn in ballet. Just like a rubber seal would tear if you keep twisting and pulling on it, your labrum can tear as well.
When your labrum tears, it usually tears away from the bone in your hip socket. Now, each time you move or lift your leg, the labral tear gets pinched and you feel pain. Each time you twist or turn your leg, a torsion type of force is put on your labral tear, causing you pain. The labral tear can be classified in many ways, according to where it is located or how badly it is torn.
Type of Labral tears
- Anterior labral tear: This is a tear located at the front of the hip joint and is the most common. Repeated stress on the hip joint like repetitive twisting or pivoting can lead to an anterior hip labral tear.
- Posterior labral tear: This is a tear located toward the back of the hip joint and it is less common. These types of tears are associated with movements that put stress on the back of the hip joint, such as frequent squatting.
With a labral tear in the hip joint, there won’t be excessive inflammation. Due to the fact that the labrum does not get good blood supply. The pain will probably be more mechanical of nature. Meaning that certain movements will be painful or impossible to do. The injury will however cause other structures in the area to overcompensate, by trying to provide extra stability to your hip joint. This leads to a vicious cycle of pain. The pain will prevent you to move, which in turn leads to weakness and stiffness, which in turn leads to more pain.
Causes and risk factors of a hip labrum tear
Causes
- Sports or activities which involve sudden stop and turn movements.
- Sudden jumping and landing movements.
- Sports that require extreme flexibility of your hip like; ballet or gymnastics.
- Motor vehicle accidents that cause a direct hit and injury to your hip.
- Dislocating or partially dislocating your hip can lead to a labral tear in your hip as well.
- A fall that leads to an injury in your hip.
- A slip or fall that leads to a split type of movement with your leg.
- Repetitive microtrauma due to your leg and hip being forced into extreme positions, like in ballet and gymnastics.
Risk factors
People of any age can get a hip labrum tear. There are a few risk factors that can predispose someone into getting a hip labrum tear.
- Acetabular dysplasia: An abnormality of your femur and acetabulum. In this case, your acetabulum is too shallow. It does not form a proper socket that the femur can fit into and it leads to an unstable hip joint. Usually it is an abnormality that someone has from birth. Add extra trauma, injury or overuse to the hip joint and it can lead to a torn labrum.
- Degeneration: Repeated previous injuries to the hip joint can lead to degeneration in the joint. Degeneration is also a normal part of ageing. With time the surface of the joint becomes less smooth, the cartilage becomes thinner and the mobility of the joint decreases.
- Capsular laxity and hip hypermobility: One person might be more flexible than the next or certain sports might lead to repeated ‘overstretching’ of the hip joint. However, hypermobility can lead to your hip joint and joint capsule becoming lax. This leads to decreased stability of the hip joint and adds extra load and pressure on the labrum.
- Femero-acetabular impingement: Pinching of the labrum between the acetabulum and the femoral head. Hip impingement can occur when the bones that form the hip joint grow excess bone, like a bone spur, causing there to be abnormal friction and impingement between them. With time, hip instability and increased stress on the joint can contribute to a labral tear.
How bad is my hip labrum tear?
Hip labrum tears can be classified according to the severity of the tear:
- Radial flap tear: This is the most common type of tear. The edge of the rim of the labrum gets torn towards the acetabulum.
- Radial fibrillated tear: The edge of the rim of the labrum gets frayed, associated with degenerative joint disease (like osteoarthritis).
- Longitudinal peripheral tear: Least common type of tear. This type of tear happens lengthwise in the labrum, keeping the edge of the labrum intact.
- Unstable/Abnormally mobile tear: This type of tear is very dangerous and usually goes together with a hip dislocation. The labrum completely tears away from the bone (acetabulum).
Although the classification of these hip labral tears can be used as a guideline, it can only really be visualised by a scan or a surgical procedure. Working on the severity of your symptoms and functional impairment is a better way for us to determine the severity of your injury.
Diagnosis
Physiotherapy evaluation
Physiotherapists can accurately diagnose your hip labrum tear and diagnose other associated injured structures. We know and understand the anatomy of the hip and we know which structures could be injured with a hip labral injury or tear. We take into account the the intricacy of the biomechanics of hip, lower back and pelvis movements. During your physiotherapy evaluation, we determine how bad your labrum injury is by stretching and stressing the hip joint, surrounding ligaments and the labrum itself.
The following tests are used to test for a hip labrum tear:
- Faber test
- Hip flexion, adduction and internal rotation test
- Thomas test
- Anterior hip impingement test
- Resisted straight leg raise test
- Fitzgerald test
We will also be look at other structures in and around your hip that could have been injured as well. We also test:
- The movements of your ankle, knee and hip (and how they interact with each other)
- Movement of your lumbar and sacral vertebrae
- Movements of your pelvis (forwards and backwards tilt)
- Muscles surrounding the hip joint
- Core muscle control and pelvic floor muscles
- All the thigh muscles that attach onto the Femur (Quadriceps, Hamstrings, Adductors)
- The Sciatic and Femoral nerves
We can reach a conclusive diagnosis by testing muscle strength and length, range of movement and measuring swelling in the area of your hip. This is why our physiotherapists are the best at diagnosing this type of problem.
X-rays
X-rays will only show any abnormalities to the bones that form the hip joint. With an x-ray, the position of the femur can be seen as well as signs of degeneration to the joint or the formation of any bone spurs. These bone spurs can contribute to cause femoro-acetabular impingement. A stress x-ray will confirm any pinching of the femoral head. However, an x-ray will not show you any soft tissue structures. The labrum will not be visible on an x-ray.
Your physiotherapist will refer you to get an x-ray taken if deemed necessary.
MRI
An MRI or CT scan will be the best test to visualize a labral tear or any other accompanying soft tissue injuries. However, these scans are very expensive and you can only get a scan done via a referral from a specialist.
Your physiotherapist will refer you to the necessary specialist to get a scan done if deemed necessary.
Why is the pain from my hip labrum tear not going away?
A hip labrum tear takes a long time to heal due to poor blood circulation to the area, especially if there is repetitive microtrauma to the labrum. A hip labral tear can worsen from a small tear to an unstable tear if it is not managed the right way from the start.
It disrupt the foundation of your hip joint. The negative pressure of the fluid in your hip joint helps to keep the femur head in the socket. So, with a labral tear, this stability is disrupted and the position of the femur changes. The femur wiggles around inside the socket that interferes with effective transfer of forces through your hip.
Your body forms scar tissue around the area of a labrum tear. This scar tissue can become thick over time as your body is trying to repeatedly heal the injured area that is repeatedly being scraped over. When you then walk or take weight on your leg, this scar tissue is being broken down.
An underlying hip labrum tear that is not treated or managed well can lead to degeneration. The cartilage becomes worn out, bone spurs form and a chronic cycle of inflammation causes pain that comes and goes. Degeneration is not something that can be reversed.
To rest might improve your pain and other symptoms, but it won’t help the labrum tear to heal faster. To ignore your pain and push through it is also not the answer. You will need to find a good balance between rest and movements that are safe to do. It will require you to modify your sport, your daily activities and your exercise.
What NOT to do
What you SHOULD do
Making it worse
A big problem we see with hip labrum tears and injuries
A big problem we see with hip labral tears, is that patients tend to wait too long before they see a physiotherapist. By the time they seek help, the condition has become much worse. By simply ignoring the pain and hoping it will go away, you could be increasing the damage to the labrum and you end up hurting other muscles or joints in the surrounding area as well.
Over time, repetitive microtrauma to the labrum can lead to degeneration in your hip joint. Degeneration is not reversible. Do not continue training or exercising if it worsens the pain that you feel in your hip or groin.
On the other hand, it is not wise to simply rest either. Pain will prevent you to move and will hold you back. Over time, it leads to you getting weaker and your hip joint getting very stiff.
Treatment of a hip labrum tear will need to address not only your pain, but also your lifestyle, goals, training and work routine. If you have had treatment, but that only included taking medication, that will not be enough. You will need to strengthen muscles around your hip and buttock and you will need to adapt your lifestyle or training for a while. Looking at the bigger picture and addressing all the problem areas, will be the best way to go.
Seek help sooner rather than later. Call us, as we will be able to guide and advise you every step of the way while working through your recovery process.
Physiotherapy treatment
We are confident that we provide the best possible treatment that leads to faster recovery. Usually, patients are anxious to get back to their normal activities, and that is why we are here to provide guidance and answers. However, it’s important that you commit to the treatment plan as this improves your chances of successful long-term recovery.
The basic structure of our treatments:
- Determine which structures is involved in your injury
- How bad is your injury
- Protect it from further injury
- Help accelerate the healing
- Strengthen muscles in the surrounding area
- Do a re-evaluation to monitor your progress
We will look at different aspects like muscle strength, range of motion, flexibility and stability. Treatment techniques include: soft tissue massage, joint mobilisations, dry needling, strapping, laser therapy, nerve mobilisations and prescribing exercises.
Come and see us for comprehensive rehabilitation. We work on all the phases of healing until we get you back to where you were before your injury.
Phases of rehabilitation
1st Phase: Protection & initial Healing
Protect
We have found that patients tend to continue walking on the injured leg with a limp. Your hip joint still has to carry the load every time you put weight on your leg. It might be an option for you to use crutches. The main concern is to prevent your injured hip labrum from tearing even further.
Rest
Rest from activities that is worsening your pain. As soon as there’s no pain, don’t test it out. Give it time to heal.
Ice or Heat
Ice has a numbing effect and can reduce pain to the area where you apply it. Always make sure the ice is covered in a wet towel, so that it doesn’t hurt your skin.
Heat has a pain relieving effect by relieving stiffness and muscle tightness. If you apply heat, make sure it doesn’t burn your skin.
Support
Use strapping to keep your hip joint supported. Supporting the hip joint helps to relieve pain.
2nd Phase: Establish a pain-free range of movement
During your examination, it’ll become clear which movements you are able to do and which ones you should avoid. We identify factors that contribute to your pain, specific to your case. The exercises that we give you, will be in your pain-free range. On completion of this phase you should be able to perform movements within your limits of pain.
As your rehabilitation progresses, we aim for you to gain a bigger pain-free range of movement of your hip and spine, while your painful range becomes less intense.
3d Phase: Tissue healing
We monitor the progress of your pathology, inflammation and scar tissue healing of your injury. We’re able to accelerate the healing that takes place in your hip joint and surrounding tissues.
4th Phase: Tissue Stress & ability to heal
During each session we will re-evaluate to see if you are achieving the necessary targets for your hip labrum to be able to handle tensile, elastic and compression forces. Taking weight through your hip joint, puts strain on the labrum. However, you should be able to take weight on your affected leg as it is part of normal daily activities like standing and walking. Doing exercises with added compression or weightbearing helps to improve your hip labrum and hip joint’s ability to handle these forces.
5thPhase: Muscle Strength
Muscles around your hip joint give you the ability to move your leg, but also improve the stability of your hip. With a hip labrum tear, some of the muscles around your hip becomes deconditioned and weak. By improving your muscle strength, your pain will improve. Initially, we will give you exercises that won’t put a lot of strain on your labrum and hip joint. With time, these exercises will be progressed.
6rd Phase: Full range of motion
A very important component of rehabilitation, is to regain full range of movement of your hip joint and spine. The scar tissue that forms inside your hip joint and around the labrum tear needs to be broken down. This way you can regain your full range of motion. We will do mobilisations of your hip joint and gradually get your joint into end range positions. This way we help to break down any adhesions and scar tissue, to make the inside of your hip joint smoother.
On completion of this phase you should be able to lift your leg forward, sideways and backwards and be able to rotate your leg.
7th Phase: Hip stability and control
Working together, all the muscles around your hip give you the stability and control you need to do simple everyday tasks like climbing stairs. As your muscle strength improves, it becomes easier for you to control hip movements. Your strengthening exercises will be progressed during this phase and will include eccentric exercises as well as working on your balance. Your physiotherapist will guide and monitor your muscles’ reaction to normal activities like walking and climbing stairs.
8th Phase: Testing for return to activity
Gradual build up into your previous intensity of normal activities and training to determine if your labrum injury is able to withstand the repetitive loading without flare-ups. Your physiotherapist guides you to re-engage in safe increments, and adjust where necessary. We’ll follow your progress and adapt where needed.
9th Phase: High Speed, Power, Proprioception
The ability of your hip joint and labrum to take high loads and move with speed will be tested to ensure that it will be able to keep up with the demand of your body. During this phase your physiotherapist will guide you to return to normal activities. This includes challenging your joint and muscles past their ‘normal’ boundaries to determine how they react to different forces. Ultimately we prepare you to return to participating in your sport.
Whatever must be done – we’ll get you there. Jumps, Landing, Sprints, and much more.
10th Phase: Sport Specific Training
This is the final stage of rehabilitation. Your physiotherapist will still continue with myofascial release, trigger point release and electrotherapy modalities where needed, but functional rehabilitation is most important during this phase.
Depending on your sport, your physiotherapist will tailor specific exercises that will help strengthen the muscles pertaining to your sport. A successful outcome is when you have gained knowledge throughout the rehabilitation program and can participate at full power and speed, not to mention the benefits of minimizing your chance of future injury.
Recovery Time
During your first session and evaluation, your physiotherapist will discuss a treatment plan with you. The severity of your symptoms and injury will greatly determine the recovery time. You will usually see an improvement in a hip labral tear within 4 – 6 weeks. With acute pain, you will probably need treatment twice a week for the first two weeks, after which it will be decreased to once a week for another 2 – 4 weeks or as needed. The level of sport or training that you want to return to, will lead to a longer recovery process. The overall recovery process and return to sport can take 2 to 4 months.
Other forms of treatment for a hip labrum tear
- Biokineticist: A biokineticist will assist you with long-term rehabilitation and sport-specific training and endurance. Your physiotherapist will refer you during your recovery if it is deemed necessary.
- Cortisone Injections: This might help to decrease inflammation in the hip joint and surrounding area and decrease your pain, but is not good for the integrity of the joint. It will not be the best long-term solution to help improve the stability of your hip joint.
- Anti-inflammatory medications: Your doctor might prescribe anti-inflammatory or pain medication. It might even get to a stage where you use these medications chronically. However, it will not help the labrum tear to heal, even though it might decrease your pain. Taking these medications on a long-term basis, will not be good for your health.
- Chiropractor: With a hip labral tear, you might feel the need to get your hip ‘clicked back in’. The fact that it is already ‘clicking’ or ‘getting stuck’ is not reason for a manipulation. Getting a manipulation done on your hip or back is not going to fix the labral tear in your hip. It could actually worsen the labrum tear.
Is surgery an option?
Depending on the Orthopaedic surgeon, the severity and location of the tear, an arthroscopy is best. This is a minimum invasive procedure where two scopes are inserted with minimal damage to the soft tissue structures surrounding the hip joint. During the surgery the Orthopaedic surgeon aims to repair the tear and stimulate new cartilage growth.
After surgery to your hip, you will need to follow your rehabilitation protocol. Depending on your orthopaedic surgeon’s protocol, you will have to use crutches and rest and recover for the first 6 weeks. After 6 weeks you will probably start to go back to your normal routine. Then it will take another 6 weeks to 3 months to fully recover and get back to where you were before your injury.
What else could it be?
- Hip joint pain or Osteoarthritis of the Hip joint – pain and stiffness of the hip, especially in cold weather, in the mornings and after increased activity.
- Gluteus muscle strain, Quadriceps muscle tear, Groin muscle tear or Hamstring muscle tear – muscular pain that worsens with movement and improves with rest.
- Quadriceps tendinitis, Gluteal tendinitis or Hamstring tendinitis – pain located over the tendon that feels worse after exercise or the next day.
- Hip Bursitis – localised pain over the side of your hip that feels worse when you try to sleep on your side.
- Pinched nerve (sciatic or femoral) – Sharp, electric type of pain with pins and needles and weakness of your leg.
- Femur Fractures, Avultion fractures or Stress fracture of Femur Head – usally painful when you take weight on your sore leg, like standing or walking. Usually there is trauma (like a fall) involved or even severe osteoporosis.
- Iliotibial band syndrome – pain along the side of your hip, leg and/or knee that feels worse when you run, walk or clim stairs with repetitive movement of your knee and hip.
