Part 1 discussed the risk factors associated with developing a tear, common mechanisms of injury and the prevalence in the general population, sporting populations and dancers. Notably, while a labral tear is present in almost every hip with Femoralacetabular (FAI) symptoms, it's also an exceedingly common finding in hips without symptoms and not an indication of future hip pain. Furthermore, hip pain may not be caused by a labral tear even if one is present (Vahedi, 2019).
If a labral tear isn't the source of my hip pain, then what is?
Symptomatic tears usually occur in the anterior/ superior portion of the labrum. A labral tear is likely if anterior hip, thigh and groin pain is associated with clicking, locking or catching. Anterior labral tears tend to present as most painful with internal rotation (knee turns in) and flexion (forward bend)(Martin, 2006).
Other common sources of anterior hip, thigh and groin pain local to the hip include osteoarthritis (OA), inflammatory arthritis (e.g. rheumatoid arthritis), chondral defects (cartilage damage), hip flexor strain, iliopsoas bursitis and joint capsule / ligamentous injury. Sources that commonly refer pain into the anterior hip, thigh and groin (and may not present as painful themselves) include the knee, lumbar spine, pubic symphysis (pubic bone), inguinal hernias and gynaecological conditions (e.g. endometriosis) (Ahuja, 2020)
It's common for any of these conditions to co-occur with a labral tear and be the primary source of pain. That is why a thorough assessment by a team of health professionals is required to ensure the best management of the complaint.
When is labral surgery indicated?
Once a labral tear is confirmed as the primary source of persistent hip pain (MRA +/ - diagnostic anesthetic injection and management of other co-occurring conditions), labral surgery (usually repair or replacement) works best for young (under 45) active people with minimal hip arthritis and cartilage damage, after a period of 3 months to a year of active rehabilitation / conservative management. The decision to operate is not based on the tear's location, type or size but on symptoms and the likely success of the surgery Vs risk of adverse outcomes. Different labral surgeries have unique risk-benefit profiles that are considered before surgery (Harris, 2016).
What is conservative management, and where does it fit?
Conservative management for labral tears includes all non-surgical interventions such as rest, activity modification, medications, injections, manual therapies and exercise rehabilitation. Conservative management aims to restore/ improve hip function, manage symptoms and improve quality of life regardless of whether surgery is planned. Good conservative management improves surgical outcomes and post-surgical rehabilitation (Harris, 2016).
Initially, management should focus on minimising symptoms and preventing further damage. Rehabilitation should be guided by 'LOVE', principles for managing soft-tissue injuries (labral tear is a soft-tissue injury). The acronym stands for L-load, O- Optimism, V- vascularisation and E- exercise and highlights the importance of graded activity, education and addressing psycho-social factors to enhance recovery (BJSM, 2019).
More specifically, exercise rehabilitation for labral tears includes core strength, control and stability and aims to improve range, function and strength of the hip and lower body (Harris, 2016). Effective rehabilitation is graded, relevant and meaningful to the individual. Use of goal setting, objective outcome measures and subjective outcome measures (client specific, condition specific and/or global) help track progress, provide motivation and can highlight the need for medical intervention/referral.
If exercise is helpful, can I just continue training as I like?
Continuing training 'as usual' with symptoms of a labral tear (confirmed or not) is usually unhelpful. Not only does it risk worsening the tear (meaning longer rehabilitation and increased risk of poor outcome following surgery), it aggravates symptoms, regardless of the state of tissue health. This means more pain, symptoms and restriction to activities, despite no change to the injury or tissue damage. Conservative management is likely to fail unless activity modification occurs (You can't continue the same way and expect a different outcome).
Guidelines for exercise and training with a labral tear
NB: This advice is general and does not override guidance your managing professionals provide.
- Avoid provocative activities such as jumping, hopping and loaded pivoting for 1-3 months
- Be cautious with loading the hip into extension and external rotation (stretches the sore tissue) and flexion and internal rotation (compresses the sore tissue).
- Use symptoms to guide your training and recovery. Ensure pain stays at a mild / tolerable level during training (e.g. approx 3-4/ 10), and reduces after the activity has ceased. If pain remains elevated for days or at a level where daily activities are impacted, this is too much too soon. Pain management and active recovery techniques such as medications, heat, and soft tissue techniques may be used to help keep symptoms at a manageable level. Ideally, symptoms should return to your baseline (not necessarily pain-free) before training or exercising again.
- Focus on activities that you enjoy and are meaningful to you within the above recommendations.
- Pacing and graded loading is challenging. Mistakes will be made. Be patient with yourself and your body.
- If pain or other symptoms increase over time, let your health care provider know, as this indicates your management needs to change.
Flexibility-specific guidelines for training with a labral tear
- Prioritise sub max strength through range and focus on gradually restoring limitations in range.
- Be cautious with hip rotation, particularly near the end of range and/ or loaded hip extension and rotation - This describes the back hip in a front split.
- Ensure you are controlled and smooth moving in and out of stretches. Minimise the risk of slip/falls.
- Be mindful and listen to your body when you are training. Pay attention to when your hip flexors are tensing, as this is how your body will try to avoid overloading your anterior labrum.
- Less is more. Remember any training is only as good as your recovery.
Ahuja V, Thapa D, Patial S, Chander A, Ahuja A. Chronic hip pain in adults: Current knowledge and future prospective. J Anaesthesiol Clin Pharmacol. 2020 Oct-Dec;36(4):450-457.
Harris JD. Hip labral repair: options and outcomes. Curr Rev Musculoskelet Med. 2016 Dec;9(4):361-367.
Martin, RobRoy & Enseki, Keelan & Draovitch, Peter & Trapuzzano, Talia & Philippon, Marc. (2006). Acetabular Labral Tears of the Hip: Examination and Diagnostic Challenges. The Journal of orthopaedic and sports physical therapy. 36. 503-15. 10.2519/jospt.2006.2135.
Vahedi H, Aalirezaie A, Azboy I, Daryoush T, Shahi A, Parvizi J. Acetabular Labral Tears Are Common in Asymptomatic Contralateral Hips With Femoroacetabular Impingement. Clin Orthop Relat Res. 2019 May;477(5):974-979.