Torn Hip Labrum Repair
Ross Hauser, MD
- New research says that patients, forty-five years of age or older, who had arthroscopic labral surgery had a relatively high re-operation rate and minimal overall improvement with small clinical benefit.1
- In patients with pain from femoral acetabular impingement (FAI) and labral tear, intra-articular cortisone injection has limited clinical benefit.2
In this article Ross Hauser MD explains that when thinking through the root cause of chronic pain and sports injury, Treatments such as Stem Cell Therapy, Platelet Rich Plasma Therapy, and Prolotherapy should make sense as the first line treatment in hip labral tear.
A torn acetabular (hip) labrum is a common sports injury which can quickly, and unnecessarily, land an athlete on the surgical table. The labrum is a smooth ring of fibrocartilaginous tissue that provides hip joint stability for the head of the femur. When this tissue is damaged, a person may experience clicking, pain, or weakness in the hip. But some people have no distinct symptoms.
The labrum has a poor blood supply, which makes a tear or injury difficult to treat with traditional approaches, such as pain medicine or rest. These particular recommendations have very little long term appeal, especially for an active person who does not want to take mediation long term. Physical therapy may also be recommended for rehabilitation. While physical therapy can help the surrounding muscles, it does nothing to help repair the labrum itself and little to prevent further instability of the hip joint. Consequently, labral tear cases are quickly referred to surgeons for potential surgery to try and repair or remove the damaged tissue. Surgical intervention involves risks, as well as extended time off for rehab. This is not an ideal option for an athlete who wishes to return to the game quickly. The surgical prognosis is often guarded as to if the athlete would be able to return fully to his or her sport, especially if labral tissue is removed.
Unfortunately standard treatments for chronic pain injuries ignore the root cause, going after the symptoms and potentially causing more injury and pain. Labral tears are one of these injuries. An article published in Current Reviews in Musculoskeletal Medicine conducted a comprehensive review of hip labral tears that pointed out some crucial facts about these tears1. In short, the hip surgeries that remove or debride the hip labrum are taking away from the vital function of the labrum.
Hip labral repair
Most structures of the body have significant function and purpose. Removing a natural structure of the body is almost never a good thing. Take the hip labrum. Its function is shock absorption, joint lubrication, pressure distribution and hip stability. It resists the movement of the femoral head in the acetabulum. It also acts as seal to maintain the synovial fluid, thereby lowering the stresses and strains in the hip joint.
Hip labral tear
When looking at the function of the hip labrum it is clear that a tear is more than significant. Damage to the labrum, typically caused by trauma, hypermobility or degeneration, is linked to osteoarthritis (OA). It is known that the anterior and superior aspects of the labrum contain free nerve endings and sensory nerve organs; meaning damage produces pain, pressure and deep sensation.
Treatments for hip labral tears
With the advance of medical technology, hip labral tears are diagnosed more often than in the past. While conservative treatments such as rest, nonsteroidal anti-inflammatory medications, and physical therapy are done, surgery is almost always performed. Removal of the labrum used to be the surgical treatment of choice, but with the knowledge of how important the labrum is, surgical treatment now involves arthroscopy to remove the unstable flap that causes the hip pain or discomfort. In some cases, repairs are made with cadaver grafts. These also can prove unsuccessful and lead to complications and pain after surgery.
Problems with surgery for hip labral tear
The study mentioned above points out the problem with completely removing the labrum but also points to problems with tears:
Doctors recognize that without the labrum, the articular cartilage must withstand significantly increased pressure, and a compromise of this system could lead to early joint deterioration. Research noted that a tear in the labrum would also likely destabilize the hip joint. This explains why there is an association between acetabular labral tears and early onset osteoarthritiis.”3
Treatment for hip labral tears
Unfortunately removing any part of the labrum will lead to further degeneration and most likely osteoarthritiis. Since the labrum is vital to hip joint function, both doctors and patients should desire to preserve the hip labrum. While standard treatments prove unsuccessful, Comprehensive Prolotherapy is an excellent alternative to surgery for hip labral tears. Specifically, Platelet Rich Plasma and Stem Cell Therapy can be greatly beneficial in delivering growth factors to the damaged labrum.
Platelet Rich Plasma Therapy treatment for hip labrum tear
Platelets play a central role in blood clotting and wound healing. Tissue repair begins with clot formation and platelet degranulation, which release the growth factors necessary for wound repair. Platelet-derived growth factors are biologically active substances that enhance tissue repair mechanisms.
After platelets are activated at a wound site, proteins are released that directly and indirectly influence virtually all aspects of the wound healing cascade. Studies have shown a direct correlation between the platelet concentration and the level of secretory proteins, as well as the amount of proliferation involved in the wound healing.
In basic terms, PRP involves the application of concentrated platelets, which release a supra-maximal quantity of growth factors which stimulate recovery in non-healing injuries. PRP causes a mass influx of growth factors, such as platelet-derived growth factor, transforming growth factor and others, which exert their effects of fibroblasts causing proliferation and thereby accelerating the regeneration of injured tissues. Specifically PRP enhances the fibroblastic events involved in tissue healing including chemotaxis, proliferation of cells, proteosynthesis, reparation, extracellular matrix deposition, and the remodeling of tissues. Bottom line here is that tissues can heal faster with PRP! 4-8
In our own research, Prolotherapy for hip labral tears was curative in 54% of the patients (no pain at all after Prolotherapy) and overall relieved 80-85% of their pain, which in our experience will end up much better than surgical procedures, because the hip is now stable. We do not feel surgical labrum removal is the best option for first line treatment, nor do we agree with surgeons inserting titanium stables in the hip for so-called “repair.” What do you think the long-term consequences of titanium staples in the hip will be? We believe it will cause long-term osteoarthritis. So in a nutshell, in our experience, Prolotherapy is the best long-term solution for hip labral tears. Typically four or five treatments are needed. Often we use Platelet Rich Plasma Therapy (PRP) as the proliferant inside the hip and utilize Comprehensive dextrose Prolotherapy to the ligaments.
1. Wilkin G, March G, Beaulé PE. Arthroscopic Acetabular Labral Debridement in Patients Forty-five Years of Age or Older Has Minimal Benefit for Pain and Function. J Bone Joint Surg Am. 2014 Jan 15;96(2):113-8. doi: 10.2106/JBJS.L.01710.
2. Krych AJ, Griffith TB, Hudgens JL, et al. Limited therapeutic benefits of intra-articular cortisone injection for patients with femoro-acetabular impingement and labral tear. Knee Surg Sports Traumatol Arthrosc. 2014 Apr;22(4):750-5. doi: 10.1007/s00167-014-2862-3. Epub 2014 Feb 1.
3. Groh MM, Herrara J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009 June; 2(2): 105–117.
4. Pietrzak WS, Eppley BL. Platelet rich plasma: biology and new technology. Journal of Craniofacial Surgery. 2005; 16:1043-1054
5. Crane D, Everts P. Platelet Rich Plasma Matrix Grafts. Practical Pain Management. 2008; Jan/Feb: 12-26.
6. Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Current Reviews in Musculoskeletal Medicine. 2008; 3:165-174.
7. Rabago D, Best TM, Zgierska A, et al. A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet rich plasma. British Journal of Sports Medicine. 2009; 43:
8 Sanchez A, Nurden AT, Zalduendo MM, et al. Platelet-released growth factors enhance the secretion of hyaluronic acid and induce hepatocyte growth factor production by synovial fibroblasts from arthritic patients. Rheumatology. 2007;46:1769-1772.