Hip labral tears: what you should know and what your doctor won't tell you

Hip labral tears: what you need to know and what your doctor won’t tell you

Why are hip labral tears important to talk about?

Hip pain is becoming an extremely common complaint in this age of desk work and constant sitting. It’s also becoming very common for people to get the diagnosis of a hip labral tear.

But what does it mean to tell people they have hip labral tears?

What do doctors think it means?

And what does it mean for how you approach hip pain?

client doing a stretch

Hip labral tears in a training context

We work with a lot of clients with hip issues in our training facility. From the very beginning, we’ve worked very hard to understand the myths and facts around hip pain and hip labral tears and other hip joint pathologies. We always want to make sure what we’re doing with our clients makes sense and won’t make things worse.

We’ve seen people with pretty severe hip pain regain full function of their hips without surgery, so we know that there’s definitely room for a different perspective on hip pain than what the medical world currently provides.

In the conventional medical understanding of a hip labral tear, damage to the little cartilaginous ring leads to catching, clicking, and irreversible damage to the hip joint. The little cushion deteriorates and is believed to cause movement problems and eventually arthritis.

But in a training environment, we’re trying to improve people’s range of motion, comfort levels, and overall athletic competency. If a labral tear is a one-way ticket to arthritis, then less movement is the only prescription.

That’s a pretty disempowering perspective. It’s also one we think you shouldn’t take too seriously. In fact, we think people are better off ignoring that advice completely.

We’ve seen people with pretty severe hip pain regain full function of their hips without surgery, so we know that there’s definitely room for a different perspective on hip pain than what the medical world currently provides.

We’ve also seen people get hip surgeries to repair labral tears – only to have the pain remain the same or get worse. Proper retraining of the muscles around the hip actually gets rid of the pain and restores function to the hip in a way that surgery doesn’t!

A lot of what I’ve just said may be a bit controversial, especially if you’ve read conventional opinions and textbook answers about hip labral tears. Some people get quite agitated when reading things like this, so I’m going to ask you to take a breath, settle in, and get ready.

In this article, we’re going to look very deeply at the research around hip pain, labral tears, and surgery for labral tears.

Do you even have a hip labral tear?

This question may seem odd. If you’re reading this, a doctor probably told you that you have a labral tear, so why bother even thinking about this? You probably have hip pain, and an MRI or MRA probably came back with a positive result for a labral tear.

Case closed, right?

In reality, MRI and MRA appear to have very high false positive rates, making the findings ambiguous.

Several studies have compared the accuracy of MRI and MRA to surgical findings, and the results are much worse than you would think.

Based on these three studies, if you have an MRA report that tells you that you have a hip labral tear, there’s as high as a 50% chance that you DON’T have a labral tear!

A 2004 study showed that MRA had total accuracy of only 69% – and that it only identified true negative findings 44% of the time. This is a number known as “specificity.” That means out of a group of 100 people with no labral tears, the MRA would show that 56 had a labral tear. Those are bad numbers.

Now, that’s an older study. A 2011 study on acetabular labral tears looked at MRI and MRA’s accuracy again. They looked at 19 published papers that covered 881 hips.

They found that MRI had a specificity of 79% and MRA a specificity of 64%. That means MRI’s false positives were fewer (21%), and the MRA’s false positives were at 36%. MRI had false negatives of 34% and MRA false negatives of 13%.

You basically have two tests that are extremely unreliable, but this study concludes that MRA is a bit better than MRI at finding labral tears (since it has fewer false negatives).

Consider, however, that according to this study, if you are told you have a labral tear as a result of an MRA there could be as high as a one in three chance that you DON’T.

Now:

If I told you I am 66% sure that you have a cavity and that the best way to find out if I’m right would be to drill into your tooth (thus giving you 100% chance of tooth damage), would you want me as your dentist?

Another study on MRA and acetabular labral tears in 2012 found some more interesting numbers. MRA had false negatives of only 14% (so it was good at finding people with labral tears). However, its specificity was 50-75% depending on the radiologist reading the MRA! With one radiologist, the false positive rate was at 50%! The other radiologist managed to get a C grade at 75%.

So depending on the radiologist, your odds of having a false positive in this study could have been as bad as 50-50! 

The bottom line?

Based on these three studies, if you have an MRA report that tells you that you have a hip labral tear, there’s as high as a 50% chance that you DON’T have a labral tear!

RESEARCH UPDATE

A study in 2017 looked at the accuracy of MRI and MRA in the the Egyptian Journal of Radiology and Nuclear Medicine. 

The authors claim MRA was 96.15% accurate in diagnosing labral tears. This is extremely suspicious given what we have seen in other studies. What makes it more suspicious is that the authors do not clarify who read the scans. 

One major problem is that every person in this study was known to have hip pain at the beginning. The doctors/surgeons involved in the study were strongly biased to identify hip joint damage in all the scans and thereby justify subsequent surgeries. 

Imagine being a hip surgeon treating hip pain in a study like this. Imagine you go into a hip joint and find NO damage at all. Would you look a little harder to see something that appears more damaged? If you see something during surgery that wasn't in the scans, would you go back to the scans and look harder? 

As we saw earlier, who reads the scans and what they know about the patient make a big difference.

What about special tests / physical tests for hip pathology?

Sometimes doctors and therapists will say that physical tests can determine whether your problems are caused by labral tears. The idea is that if you move someone’s hip joint in specific ways and you run into specific movement limitations, you can definitively say someone has a labral tear.

A 2010 study put this idea to the test.

In the paper Diagnostic Validity of Hip Provocation Manuevers to Detect Intra-articular Hip Pathology, researchers looked at four very common physical tests for hip pathology.

They examined the sensitivity, specificity, and accuracy of four different hip maneuvers that are supposed to tell you whether pain is from labral tears or other intraarticular sources. FABER, Stinchfield, Scour, and Internal Rotation with Over Pressure were all included.

All four hip special tests had specificity ratings WORSE than a coin-toss. The BEST specificity score was with the Stinchfield test, and that scored only 32%! That means that positive results for labral tears on these tests have a very high risk of being false positives.

But what if you combined multiple tests? Sometimes doctors claim that using multiple tests will increase the certainty of the result.

In a way, they’re right.

In this study, combining multiple tests led to a guaranteed “positive” result. If you did not have a labral tear or other hip joint pathology, you were still 100% guaranteed to get a false positive.

Combining multiple tests with a high risk of false positives leads to an extremely high risk of getting a positive result. So when you combine MRI/MRA (with high false positive risk) with physical tests (with extremely high false positive risk), you’re basically guaranteed to be told you have a labral tear.

The bottom line?

With tests this unreliable, the only way to see and confirm a labral tear is to cut into your body and look inside. But before you consider that, we need to think of an even more important question.

Do labral tears cause hip pain?

When you read articles on the internet, it seems like labral tears have been definitively shown to cause you pain and that nothing but surgery could possibly help you.

What you will only rarely see is the fact that labral tears have not been shown to definitively cause pain. In fact, many studies have shown little to no correlation between labral tears and pain and disability! 

Sound crazy?

To look at the relationship between hip labral tears and hip pain, researchers need to look at populations with no symptoms of hip problems. If labral tears do cause pain, then you shouldn’t find them in high numbers in people with no hip problems.

Why is it important to test things this way?

You could argue that nearly 100% of all people with cancer have ten fingers, but that does not establish a causal link. By looking at asymptomatic people, you can see whether the suspected cause has a causal link with having symptoms.

Well, if you believed that having ten fingers caused cancer, you would want to get a sample of people with no cancer and see if there are people with ten fingers in your sample. Of course you would quickly find that there is a pretty weak causal correlation between having ten fingers and getting cancer. The fingers are just not the determining factor.

Remember:

Correlation does NOT equal causation.

You could argue that nearly 100% of all people with cancer have ten fingers, but that does not establish a causal link. By looking at asymptomatic people, you can see whether the suspected cause has a causal link with having symptoms.

One of the first examples of this investigation was in 1998 by Cotten et al. They studied 52 asymptomatic hips to examine the relationship between hip labral tears and hip pain. 

They found that “the MR appearance of the hip labrum is varied in asymptomatic volunteers. Intralabral increased signal intensity and absent anterosuperior labra are especially frequent and may represent asymptomatic lesions or normal variations.

Schmitz et al. in 2012 also investigated labral tears in the asymptomatic population. Out of 42 asymptomatic volunteers, 36 (85.7%) had hip labral tears.

The authors came to a very similar conclusion as the Cotten paper: “These data demonstrate that labral tears can occur without symptoms.”

Then in 2015, Lee et al. studied the prevalence of labral tears in 70 asymptomatic volunteers. They found hip labral tears in 27 volunteers (38.6%); these were an isolated finding in 16 (22.9%) and occurred with other intra-articular abnormalities in the remaining 11 volunteers.”

To summarize, out of 70 people, nearly half had some kind of joint “pathology” and had absolutely no symptoms. The authors concluded: “Given the high prevalence of labral pathology in the asymptomatic population, it is important to confirm that a patient’s symptoms are due to the demonstrated abnormalities when considering surgery.”

The bottom line?

Multiple studies demonstrate that there is not a strong relationship between labral tears and hip pain. Many people without any symptoms at all have hip labral tears.

Do hip labral tears cause popping and snapping in the hip joint?

This is a belief that is echoed all over the internet and is extremely common to hear from doctors. For many reasons, it seems unlikely that hip labral tears are the cause of popping, snapping, and clicking sounds.

The top reason this is unlikely to be true is that the labrum itself is not stiff enough to catch on anything to make a loud clicking sound. It’s like a small cushion in your joint.

Imagine sitting on a pillow and trying to make a snapping sound by rubbing your butt on it. No matter how hard you rub, you will not get a clicking or popping sound.

Watch this video for a visual breakdown.

How can you tell if a labral tear is causing your hip pain?

Hip labral tears are clearly quite common, so before operating on torn labrums, it would be prudent to figure out whether a person’s labral tear is causing their hip pain.

Unfortunately there is currently no way to reliably determine that a person’s symptoms are coming from joint pathology. Often, hip injections are offered as a reliable way to identify the cause of hip pain. The studies that allegedly prove this, however, are quite problematic.

And the studies that put this belief to the test demonstrate that injections don’t actually give you good information.

In 2008, Martin et al., the authors looked at 105 patients and to see if anesthetic injections could help them identify who had intraarticular pathology and who didn’t. The researchers went in believing that injections would help them identify who had things like labral tears in their hips.

They used patient symptoms and MRI arthrograms to see if they could find a correlation between symptoms, the imaging findings, and the injections. They considered a positive response to injection as greater than 50% relief of the symptoms. If a patient got a positive response, then it meant their pain was coming from something like a labral tear (or other joint pathology).

Here’s the kicker:

The results were not great for injections. For patients who had definite labral tears, 39% did not have a positive response to injection. For those who had possible tears, 45% did not respond. Basically, injections were marginally better than guessing. 

They checked to see if other physical tests could help them identify the responders and non-responders, but they found “Groin pain, clicking, pinching pain with sitting, lateral thigh pain, flexion abduction external rotation test, flexion-internal rotation-adduction test, and trochanteric tenderness were not useful in identifying those with greater than 50% pain relief from those with 50% relief or less.”

Their conclusion: “The symptoms and signs investigated in this study did not accurately or consistently identify subjects with primary intra-articular pain sources. Furthermore, candidates for hip arthroscopy with a labral tear identified on MRI arthrogram had varied responses to anesthetic intra-articular injection.”

The bottom line?

Based on studies like this, the most that one can say is that even if you have a labral tear, it’s going to be VERY difficult to determine whether it has anything to do with your hip pain.

If you’d like to read more studies on labral tears and pain, you can check out this post.


Do hip labral tears cause hip instability?

example of instability

Nobody likes instability.

Before we even look at the efficacy of surgeries like labral debridement, it’s a good idea to examine the underlying theories around surgery for labral tears.

For years, surgeons have believed that labral tears cause instability in the hip joint. This instability is supposedly a result of the labral tear and can only be “fixed” by either cutting out loose labrum tissue or securing the loose tissue.

But do the labral tears actually cause instability?

In 2011, a group of researchers tested the idea that a labral tear would lead to joint instability by using finely tuned instruments and hip joints from human cadavers. They created precisely measured and created labral tears in their setup. They then measured the effect on joint stability.

Their findings were almost the exact opposite of what they expected to find.

They tested circumferential tears and radial tears (basically different orientations of tears to see if it mattered). They also tested hip joint stability after labrectomies (a treatment for labral tears that simply removes pieces of the labrum).

In plain English, even big tears in the labrum do not result in more instability in the hip joint.

There was no significant difference in stability ratio after a radial tear or a 1-cm partial labrectomy compared with the intact labral state.

A 2-cm partial labrectomy significantly decreased the stability ratio. This is important as labrectomies for a while have been the solution offered for labral tears!

Their conclusion: “The findings suggest that the acetabular labrum continues to function to resist femoral head translation despite chondral-labral separation and that labral preservation, particularly with larger tears, may be important for maintaining hip stability.”

In plain English, even big tears in the labrum do not result in more instability in the hip joint. Removing pieces of the labrum increases instability.

The bottom line?

If labrum tears don’t actually result in increased instability and labrum tears do not appear to be related to pain, then does it make sense to address the labral tears surgically at all?

Do surgeries for hip labral tears work?

When you do research on surgery for hip labral tears, you’ll find the vast majority of medical information sites tell you that the only treatment for a labral tear is surgery. Occasionally you’ll run across physicians who believe other approaches make sense before even thinking about surgery.

As you’ve already seen, the justifications for surgery on labral tears is already shaky. Labral tears don’t increase instability and aren’t related to pain. But maybe the surgery works anyway?

Suppose surgery for labral tears does improve hip pain. Then maybe it’s worth doing anyway.

...they found that nearly half of the 57 patients who had undergone labral debridement ended up with poor results.

One of the most popular treatments for hip labral tears in the last decades has been labral debridement (or labrectomy), wherein a surgeon goes into your hip and cuts away the “loose” bits of your labrum. This is a surgery that has been regularly recommended for people with hip labral tears (and still regularly gets suggested).

As noted in the previous section, removing pieces of labrum actually increases instability.

So, it’s not surprising that a study on the results of labrectomy published in 2014 by Krych et al. showed dismal results for debridements/labrectomies.

In their study, they found that nearly half of the 57 patients who had undergone labral debridement ended up with poor results.

It gets better:

The study proposes that the reason patients got bad results from the labrectomies is that the surgeons didn’t ALSO cut away bone. It’s like saying “we fixed your flat tire by removing nail, but the tire is still flat because we need to remove more of the damaged tire.”

The other option for a labral tear is refixation, where the “damaged” labrum pieces are reattached. Is it a much more effective surgery than labrectomy?

According to this study done in 2011 by Schilders, et al., there is a marginal difference of 7.3 points out of 100 possible points. For those who take the time to read the study, it’s important to note that the Harris Hip Score mentioned in that study is a rather inaccurate tool.

There's more:

Another study by Larson and Giveans in 2009 looked at the difference between debridement and refixation, and found that refixation seemed to have better outcomes than debridement. They concluded that “although other variables could have influenced these outcomes, these preliminary results indicate that labral refixation resulted in better HHS (Harris Hip Score) outcomes and a greater percentage of good to excellent results compared with the results of labral debridement in an earlier cohort.”

So there’s a some evidence that refixation may be better than debridement/labrectomy, but there is ambiguity about whether those improved results are a result of the surgery. As with many orthopedic surgeries, there have been very few (if any) comparisons between the surgical approach to more conservative approaches.

The bottom line?

It seems like labral debridement doesn’t get great results. When it fails to get good results, some surgeons believe it’s because you haven’t cut away enough pieces of your body. 

Refixation may preserve more hip joint stability, but then again, the labral tear itself seems unlikely to be the root cause of hip pain and instability (as we looked at earlier).

If you have a hip labral tear, what should you do?

Let’s assume you have been told you have a labral tear. What should you do?

Before we go further, don’t take this as medical advice. It’s coming from a very non-medical perspective, and the ideas offered here are decidedly not medical.

If you have been told you have a labral tear that is the cause of your pain, think about these major questions:

  1. Is there any way to know whether you have a labral tear? Without surgery, there’s no definitive way to know.
  2. Is there any way to know that the labral tear is actually causing your hip pain? Based on the research – NO! Labral tears are very commonly found in people with absolutely not symptoms. Remember: just because a doctor believes something is true does not actually mean it is.
  3. What’s the likelihood that surgery will fully fix your hip pain? Read studies like the ones you find here. A surgeon saying “the surgery is guaranteed to fix your hip pain” is well-intentioned and may truly have your best interests in mind. However, many well-intentioned surgeons strongly recommended spinal fusions to “cure” back pain for decades. Research eventually showed that spinal surgery was a WORSE option for patients than conservative treatments like exercise and massage.

We’ve worked with people with hip labral tears avoid surgery, and we’ve also worked with people after surgery. From what we’ve seen, repairing or ripping out the labrum is not the most important factor. The fact that the labrum may be torn doesn’t even seem to be an important factor.

The most important factor is training your hip muscles to work in unison gradually and carefully.

That is a process that requires time, learning, and patience. We strongly encourage people to acknowledge their fears and anxieties around the labral tears, recognize that there’s very little evidence that labral tears actually are the definitive cause of pain, and focus on the muscles around the hips.

You can control your muscles better. You can retrain muscles with stretching, self-massage, and carefully executed exercises.

Here is what we suggest:

  1. Find a trainer, coach, or a physiotherapist who can coach you to move with good form in new ranges of motion. Please don’t jump into high intensity interval training or some kind of boot camp / group class / Crossfit situation.
  2. Identify areas that aren’t moving well and work to improve them.
  3. Learn how to stretch properly and appropriately for your body and your life.
  4. Identify muscles that are weak and build strength.
  5. Identify positions you find difficult and carefully work to make those positions more comfortable (by training the muscles there).
  6. Aim to improve on something every single day.

But isn't surgery the best option for hip labral tears?

Based on the evidence - no! 

Surgery sounds quite promising. Many people believe surgery will give them full function back, only to discover that retraining muscles becomes even more important after a long period of rest after the surgery. 

That period of rest leads to atrophy. More simply: if you don't use the muscles, you lose them. 

And there's another catch to be aware of.

Many people we’ve talked with have been told that they should never go back to high impact, high intensity activities ever again after surgery. That’s not a great outcome for anyone who's active.

Restoring hip mobility and control gradually and progressively can save you thousands of dollars and months of bed rest. 

And while the process is not a quick fix, it’s a solution that gives you the power to get rid of pain and increases your ability to enjoy all that activities that you love in life – even the high impact, high intensity ones (once you’re ready!).


Been told you have hip impingement / FAI that is causing your labral tears and hip pain?

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About the Author

Matt Hsu is a trainer and orthopedic massage therapist. He fought a long battle with chronic pain all over his body and won. He blends the principles he learned in his journey, empirical observations with clients, and relevant research to help others get their lives back.