Non-surgical Treatment of Acetabular or Hip Labral Tears
Ross Hauser, MD.
Non-surgical hip labral tear treatment
If you are here reading this article you have likely been to a doctor, a specialist/surgeon, and have been told that catching/locking, popping/clicking noise in your hip is a result of a hip labrum tear. This was likely confirmed by an x-ray or MRI of the hip. You may have been recommended to have surgery sometime in the future. People can do very well with hip labrum arthroscopic surgery. These are the people we usually do not see at our center, we see the people that did not do well or may not be good candidates at this time for a surgical procedure because the “damage is not significant enough.”
- Hip labral tear conservative treatments.
- The complexity of hip labrum tear diagnosis and surgical recommendations.
- This study then helps us understand that for some people, groin pain was the actual problem and not the hip labrum.
- Abnormal hip and low back MRI findings are common- MRI doesn’t always show the real cause of pain.
- One of the main questions we are often asked is what are hip labral tear surgery success rates?
- The typical non-surgical approaches to treating a hip labrum tear will likely send you to hip labrum surgery.
- The more hip labrum you can leave behind after surgery, the better.
- Hip labral tear surgery. Are staples stabilizers?
- Research offers concern to patients thinking of surgery for the removal of their hip labrum.
- Another study: Concerns about hip labrum MRI and surgical recommendation.
- Was your MRI even accurate? Do you even have a labrum tear? If you do have a labrum tear, is that what is causing your problems?
- Is a hip replacement the ultimate destiny for patients who had a hip labrum arthroscopic procedure? Surgeons say yes in 40% of patients.
- The risk of revision hip replacement in patients with hip arthroscopic surgery history.
- “The conversion rate from hip arthroscopy performed in Medicare osteoarthritis patients to total hip arthroplasty (replacement) within two years is unacceptably high.
Only two joints in the body have labrums: the shoulder and the hip. The shoulder joint is the most mobile peripheral joint, whereas the hip joint has slightly less motion, as it has to bear the weight of the body. During a normal day, there may be thousands more pounds of pressure placed on the hip as compared to the non-weight bearing shoulder. To support this anatomically, the hip joint has a very deep socket. (The shoulder has a very shallow socket). The normal hip joint is designed to maintain stability during movement and weight bearing and this stability is dependent primarily on its configuration and relationship between the bony and soft tissue structures, including the labrum.
The acetabular labrum has many functions including shock absorption, joint lubrication and pressure distribution. The labrum is a joint stabilizer and enhances joint stability by deepening the acetabulum and acting as a seal to maintain negative intra-articular pressure. This seal helps retain a layer of pressurized intra-articular fluid, which has a suctioning effect on the femoral head decreasing its ability to translate. When a labral tear is present, the labrum’s ability to act as a buttress to prevent excessive movement and to act as a seal is compromised, placing increased stress on the surrounding joint capsule and ligaments.
The semi-circular depression of the acetabulum is deepened by the acetabular labrum and transverse acetabular ligament, which together encompass almost the entire head of the femur. These tissues have different histological and functional features, but together they form a continuous encasement that extends the depth of the acetabulum and surrounds more than half of the femoral head. The joint capsule and the iliofemoral, ischiofemoral, and pubofemoral ligaments then surround these two structures.
The anterior (front of body part) labrum is especially vulnerable to tears in part because the anterior labrum itself is thinner and wider is comparison to the entire labrum. Anatomically, this makes the anterior labrum weaker and less resistant to shear forces. It also has a poor vascular supply, making it more susceptible to wear without the ability to regenerate. Lastly, the greatest contributor to its vulnerability is that the anterior region is subjected to higher forces and greater stresses than any other area of the labrum
Diagnosing labral tears can be difficult. However, there are specific features and patterns clinicians can look for and testing that can be confirmative. The diagnosis of labral tears is best done by physical exam and by taking a careful patient history. More than 90 percent of people with labral tears complain of anterior hip, thigh, and groin pain and sometimes report pain deep in the buttock or radiating to the knee. They often have mechanical symptoms, such as locking, clicking, and weakness or feeling of giving way. Their pain is typically described as dull with intermittent periods of sharp stabbing pain.
Physical examination may reveal a Trendelenberg gait or limp. In addition, the affected hip very often displays a positive ‘impingement test’ that places the hip in 90 degree of flexion, adduction, and internal rotation and produces groin pain upon rotation.
Nearly all people with labral tears report their pain gets worse with activity such as walking, pivoting, sitting, putting on socks and shoes, or climbing stairs. Nearly three out of four people with labral tears will have night pain that interferes with sleep, half are limited in the distance they can walk, half must use the support of the banister to climb stairs and one out of four may only be able to sit for 30 minutes at the time. (23)
Hip labral tear conservative treatments
If it has been decided that you only have a minor tear or that you do not want the arthroscopic surgery usually recommended and prescribed for a hip labral tear, you will be recommended to a course of conservative treatments. This will include:
- Anti-inflammatory medications. (This is not something we recommend. Please see our article When NSAIDs make the pain worse, in which we explain why chronic non-steroidal anti-inflammatory drug (NSAIDs) usage can make the pain worse in the long term and accelerate the need for joint replacement.)
- Stronger pain medications. This particular recommendation has very little appeal, especially for an active person who does not want to take medication long-term.
- In patients with pain from femoral acetabular impingement (FAI) and hip labral tear, intra-articular cortisone injection has shown limited clinical benefit as pointed out in research from the Mayo Clinic. (1) Corticosteroids/cortisone or steroid injection. (This is also a treatment we do not recommend. Please see our article by Ross Hauser MD Alternative to cortisone shots, in which he examines new research that is providing more warnings that cortisone does not heal and, in fact, accelerates the deterioration of already damaged joints.
- Physical therapy may also be recommended for rehabilitation. Your doctor may send you to physical therapy or Yoga to strengthen the hip muscles. For hip muscles to strengthen they require resistance provided by strong hip tendons and ligaments. Please see our article Exercise and physical therapy fail to restore muscle strength in hip osteoarthritis patients where we show research that four months of physiotherapist-supervised, progressive, moderate, and strength training was less effective than thought for improving muscle strength and power in patients with hip osteoarthritis.
- Rest and Ice, recommendations we usually will not suggest to a patient. Please see our article Rest ice compression elevation | Rice Therapy and Price Therapy for our reasoning.
Some patients can do very well with this course of treatment as well as suggested by July 2018 research in the Journal of Sports Rehabilitation. (2) Here researchers asked:
“To what extent can nonsurgical treatment produce symptomatic or functional improvements in athletes with an acetabular labral tear?” The answer they found? “The research discussed in this review agreed that conservative management of acetabular labral tears produced measurable improvements in pain and function among the athletes studied, including their ability to participate in sports activities. Based on these findings, it appears that conservative management is effective at rehabilitating athletes with acetabular labral tears. However, this method should not be applied to every athlete based on the low strength of current research. Treatment plans should be decided upon on a case-by-case basis.”
A March 2019 report in The American Journal of Sports Medicine (22) found that “Patients with symptomatic labral tears can experience functional improvement after a minimum of one year of nonsurgical treatment in the presence and absence of femoroacetabular impingement. However, many report residual pain, alteration in their activities, and interest in surgery. This information is important when patients are counseled in the treatment options for this injury.”
The complexity of hip labrum tear diagnosis and surgical recommendations
For those of you who have been told that arthroscopic hip surgery is recommended, you may have received a lidocaine injection to help with the pain and to give your surgeon a clue that the surgery will be successful for you. Below we will discuss how to take these injections one step further to help you avoid surgery and heal soft tissue damage in the hip.
This study then helps us understand that for some people, groin pain was the actual problem and not the hip labrum.
A January 2021 study (3) explains how a lidocaine injection into your hip helps diagnose what is actually happening in your hip. This goes beyond an MRI in that you are getting treatment to help pinpoint your hip pain. In this group of patients hip and groin pain was a problem and lidocaine was given to suggest if groin pain should be addressed as well in the surgery.
In this study, lidocaine was given to people who had a hip labrum tear and also suffered from groin pain. The lidocaine was given into the hip joint.
- Intra-articular lidocaine injections have been used to confirm the hip damage and may be used to predict the effectiveness of arthroscopic surgery.
- Surgeons routinely give lidocaine injections as a surgical indicator. If the patient has a degree of pain relief, this is an indication that the surgery would be successful.
- Our note: It should be pointed out that lidocaine is a painkiller it is not repairing anything. Where the lidocaine is injected and pain relief is obtained offers a target area for the surgeon.
- The aim of this study was to assess the effectiveness of these diagnostic intra-articular lidocaine injections on groin pain in patients with labral tears involving early osteoarthritis.
- A total of 113 patients were included in this study.
- All patients received one injection of 10 ml of 1% lidocaine into the hip joint under fluoroscopy.
- The duration and effectiveness of the injection were assessed 2 weeks after the injection and at a minimum of 1 year of follow-up.
- The effect of the injection was graded as:
- 0: unchanged or worse; 19 patients (16.8%)
- 1: an effect only on the day of injection; 30 patients (26.5%)
- 2: the effect lasted a few days; 38 patients (33.6%)
- 3: the effect lasted about a week; 13 patients (11.5%)
- 4: symptom remission; 13 patients (11.5%)
- Seventy-two patients (63.7%) underwent hip arthroscopic surgery.
This study then helps us understand that for some groin involvement is not a trigger point for pain as demonstrated by the patients who were not helped by the injection. For some, the injection determined that groin pain was the actual problem and not the hip labrum and the pain went away.
In other words, hip labrum tear diagnosis and surgical recommendations can be tricky and may sometimes lead to a surgery that does not help. We will let orthopedic surgeons present this evidence below in the medical research presented. Let’s point out that many people get a great benefit from hip labrum surgery. These are typically not the people we see at our center.
The typical non-surgical approaches to treating a hip labrum tear will likely send you to hip labrum surgery
In what you have just read, you have seen and most likely experienced firsthand, that the typical non-surgical approaches to treating a hip labrum tear will likely send you to hip labrum surgery. The articles that we have highlighted above contain research similar to what we will present in this article showing that leading medical centers around the world are documenting the problems and the dilemmas facing health care providers in treating a hip labrum tear for a patient who does not want the surgery.
Abnormal hip and low back MRI findings are common- MRI doesn’t always show the real cause of pain
In the video below, Ross Hauser, MD discusses some very common MRI findings in asymptomatic patients and why MRI can lead to surgery even when that may not be the true pain-producing structure.
In this research, the MRI is read by a radiologist without knowledge of the patient’s history, so they are “blinded” from making any pre-determined judgment based on the patient’s history. The key to this study is that the MRIs the radiologists are looking at are people who are all asymptomatic.
- What the radiologist found in these asymptomatic patients is that:
- 69% had a hip labral tear. So what can be conferred here is that you can’t rely on MRI in discovering what are the issues you are having with your hip pain because if you had a labral tear, as these people did, and you started to have a new onset of pain that could be caused by the low spine or some other injury or problem in the hip – the doctors would focus on the labral tear. This is not to say that the labral tear had not finally tore enough to cause pain, but what it does suggest is that a hip labral tear does not automatically cause pain.
- 24% had cartilage defects meaning the onset of osteoarthritis that remains pain-free.
- 20% Osseous bumps on bone form most commonly atop the femoral head and these “spurs” tear at the hip cartilage inside the “socket” or acetabulum.
- 16% had a bone cyst
- 13% had a labral cyst and
- 11% had acetabular bone edema
- The researchers also found study participants over 35 years old were 13.7 times more like to have a chondral defect (a cartilage problem) and 16.7 times more likely to have a subchondral cyst.
- The point of this review study is that these people had no symptoms, but the MRI found many things wrong with them. All these defects were not producing pain for the study subjects. Then what causes hip pain? The stretching of ligaments in the hip. The ligaments are abundant in nerve endings. It is the hip ligaments sending back messages to the brain when the ligaments are stretched.
In the above research, all the patients with all the MRI findings did not have pain, so in their cases, the labral tear, the bone spurs, and the cartilage defects were not pain-producing structures or had not advanced enough to cause pain. What we see in our office is that someone may take a fall or injure themselves in such a way that they now have acute pain. An MRI may reveal abnormalities that were already present. In many cases, the fall caused hip ligament damage. The hip ligament damage, not seen on MRI or not given enough credence to calling it the source of pain, gives way to the more obvious diagnosis of hip labral tear, advancing osteoarthritis, or more prevalently seen MRI interpretation, as mentioned above.
One of the main questions we are often asked is what are hip labral tear surgery success rates?
This is a question we cannot answer because we do not perform surgery. Let’s let the research from hip surgical specialists and let’s take the words of a very positive surgical study into account to answer the question of what is considered successful hip labrum surgery.
Orthopedic surgeons want people to think that surgery is the best option for a labral tear because they are going to repair it. They may say the labrum ‘doesn’t repair itself’ and use that as a basis to perform surgery on it. It is important to note though that blood vessels enter the labrum from the adjacent joint capsule. What is going to happen to the blood vessels piercing the joint capsule if the joint capsular ligaments are injured? Likely, the blood vessels will get injured also and disrupt blood flow in the joint. The labrum has a limited blood supply already, but combined with capsular injury, this blood flow can be further compromised unless the capsule is healed. This is why labral repair surgeries are not successful long term.
Here is what the conclusion of a 2016 study in the American Journal of Sports Medicine (4) states:
“Primary hip arthroscopy for all procedures performed in aggregate had excellent clinical outcomes and patient satisfaction scores at short-term follow-up in this study. More studies must be conducted to determine the definition of a successful outcome. There was a 6.1% minor complication rate, which was consistent with previous studies. Patients should be counseled regarding the potential progression of degenerative change leading to arthroplasty as well as the potential for revision surgery..”
Excellent clinical results included:
During this research study period between April 2008 and October 2011, data were collected on all patients who underwent primary hip arthroscopy. A total of 595 patients were included in the study.
- Forty-seven (7.7%) patients underwent revision hip arthroscopy, and
- 54 (9.1%) patients underwent either a total hip replacement or a hip resurfacing procedure during the study period.
- Nearly 17% of the patients who had hip arthroscopy went in for a second surgery within two years. Two surgeries – two years.
The researchers of this study were right to point out: More studies must be conducted to determine the definition of a successful outcome.
The more hip labrum you can leave behind after surgery, the better
You may say to yourself that is a 2016 study, things must have changed in five years? The one thing that is changing is the idea that surgeons should try to repair the labrum instead of removing it. When you remove the labrum, as demonstrated in research, you accelerated the need for a hip replacement.
A study with a publication date of March 2021 (5) led by the Hospital for Special Surgery Sports Medicine Institute offers this observation:
“Advances in hip preservation surgery have to lead to increased utilization of hip arthroscopy. With this, there has also been a growth in the understanding of various hip conditions, therefore, leading to an increase in hip conditions amenable to arthroscopic intervention. The acetabular hip labrum has been at the forefront of arthroscopic advances in the hip. The labrum is important for hip stability, provision of the suction seal, and joint proprioception (keeping the leg in normal alignment).
Given the labrum’s central role in hip biomechanics, there is increasing emphasis on labral preservation in the form of debridement and repair.
In revision settings (a surgery following a primary surgery to fix and go in and fix what was missed in the first surgery), advanced techniques such as labral augmentation and reconstruction may play a role in the management of labral pathology. Appropriate management of the hip labrum at the time of surgery can be an important mediator of the outcome.” (In other words the more hip labrum you can leave behind after surgery, the better.)
In this video, Ross Hauser, MD discusses hip labrum surgery and non-surgical options
- Caring Medical published research (the study is detailed later in this article) demonstrated that 2 out of the 3 patients in our study came to us after they had already been recommended for hip labrum surgery. We were able to successfully help them without surgery.
- While many people do benefit from this surgery, we see many people for whom surgery was not a good long-term option.
- The challenges with stapling or tacking the labrum are that the labrum tissue is designed to be resilient and flexible
- In some patients, because of the severity of the tear, we would recommend Prolotherapy and PRP treatments. (These treatments are explained below).
These are usually not the people we see in our office, we see the people whose conservative care mentioned above did not help them get back to work or the game.
Alice had a hip labral tear. After months of visiting the chiropractor with limited results, Alice had an MRI that revealed a hip labral tear. She was able to avoid surgery with Prolotherapy treatments. The significance of her tear required 7 Prolotherapy treatments. Results of Prolotherapy treatments vary among patients. Prolotherapy will not be effective for everyone.
Hip labral tear surgery. Are staples stabilizers?
It should be obvious that we are not big fans of surgery, but this is because we see many patients after surgery have failed to provide functional improvements and sustained pain relief. It is backed up by the medical literature as we outline below. If you take the hip meniscus or the hip labral tissue out you are taking out tissue that the body needs for stability. The surgery will leave the patient less stable. Some patients believe the titanium staples used in these surgeries will provide the stability and support they need for their hips. The labrum is a very pliable tissue. Simply tacking it in place will restrict all the movement the hip was designed to do. It also indicates that the tear found in the labrum was the isolated reason for the patient’s pain. This is simply not the case. Tissue tears are not isolated injuries. Any type of injury affects all structures of the joint.
Research offers concern to patients thinking of surgery for the removal of their hip labrum
If the above research was not enough, listen to what doctors at the Rizzoli Orthopaedic Institute in Italy published in the medical journal Hip International:(6)
In their research, the Italian researchers wanted to examine the kinematic behavior of the hip joint (how the hip moved) with a particular interest in the contribution of the periarticular soft tissues (tendons, ligaments, labral tissue) to hip stability. In essence to examine what happens to the hip when the acetabular labrum is damaged and then surgically repaired.
- After a series of tests to manipulate the hip through its natural range of motion, the doctors found that the “ball” of the ball and socket hip joint, the femoral head, was displaced in all directions and rotated into and out of its socket.
- Further, as surgery removed more tissue, the more unstable and “dislocated,” the hip became.
The study showed that after hip labrum surgery, the hip no longer acts as a ball-and-socket joint (meaning it is unstable and unsupportive for the rest of the body) and the femoral head anatomical displacement is strongly affected by the removal of periarticular soft tissues, labral repair as well as labrectomy.
If the labrum is not there the hip bone “floats” and causes hip instability which can lead to further degeneration of the hip which will lead to hip replacement.
- So, when a patient tells us that they are considering hip labrum surgery or hip labrectomy, ask us what is the recovery time of these surgeries? We point to the studies above and tell them, that there is no recovery from hip labrum surgery.
Another study: Concerns about hip labrum MRI and surgical recommendation
If the above research was not enough, listen to what doctors at the David Geffen School of Medicine at UCLA wrote in the medical journal Skeletal Radiology. (7) This should concern patients over the age of 50 who had an MRI or MRA for suspected hip labral tears and were recommended for surgery.
- Arthroscopy for acetabular labral tears has minimal impact on pain and function in older patients, especially in the setting of concomitant osteoarthritis. Still, many physicians seek this diagnosis with magnetic resonance arthrography (MRA). . . “
Basically, the surgeons wanted to do hip labrum surgery, and are seeking an MRA (A more advanced imaging than MRI where contrast is used), to justify the surgery.
The radiologists of this study said this:
- “Given the high frequency of labral pathology and the questionable efficacy of an arthroscopic surgical intervention in older patients, MR arthrography should be primarily for those with minimal arthritis on radiograph and potential to benefit from surgery. If further imaging beyond radiographs is necessary for these patients, standard MRI may be a more appropriate imaging tool.”
In other words, in patients over 50, advanced imaging and surgery are not supported.
Please see our article Options and alternatives to hip preserving arthroscopic surgery
Was your MRI even accurate? Do you even have a labrum tear? If you do have a labrum tear, is that what is causing your problems?
When a patient presents with clicking, locking and giving way in the hip, an immediate response may be to suspect a hip labral tear and order an MRI. While this may be helpful, it doesn’t provide a clear picture of what is really occurring in the joint or the best way to treat it. Also, it may provide a false positive or false negative result. Up to 25% of asymptomatic people may have MRI evidence of a labral tear. In cases where labral tears are present on MRI, yet the patient is asymptomatic, surgery may still be suggested. For these people who have no preceding trauma and are considering labral surgery, I would exercise extreme caution. There is a good chance the surgery could be a disaster long-term. Clicking, locking, popping and giving way are also symptoms of hip joint instability due to ligament laxity that is often missed on MRI. However, if the person has a definite known trauma and immediately after has popping, clicking and/or grinding in the joint, a true labral tear is likely, as well as ligament and capsular injury. MRI findings can also be correlated to physical exam findings with various labral stressor maneuvers.
The hip labrum diagnosis and ultimate recommendation for surgery can be even more so. Doctors in the United Kingdom addressed the confusion in non-problematic or asymptomatic hip labral tears in professional rugby players and male ballet dancers. This research appeared in the journal Clinical Radiology (8) September 2019
- 11 professional rugby players and 10 professional ballet dancers, and 10 control subjects completed activity and symptom questionnaires and underwent 3 T MRIs of their self-declared dominant hip.
- Each scan was independently scored by two musculoskeletal radiologists for multiple features, including joint morphology, acetabular labrum appearance, cartilage loss, and capsular thickness.
The people in this study had no complaints. But their MRIs were suggesting something else.
- Labral tear prevalence was 87% with no significant difference between groups.
- Rates of paralabral cysts were significantly higher in ballet dancers (50%), compared to rugby players (0%) and controls (10%).
- Acetabular cartilage loss was present in 54% with no significant differences between groups.
- Superior capsular thickness was significantly greater in ballet dancers (5.3 mm) compared to rugby players (3.8 mm) and controls (3.8 mm).
The researchers concluded: “Despite the difference in the type of activity between groups, there were equally high rates of labral tears and acetabular cartilage loss, questioning the role that sport plays in the development of these findings and their relationship to symptoms.”
In other words, in this study, rugby players, ballet dancers, and a control group of men all had significant NON -Pain causing labral damage on MRI. What could this mean to you? Read the conclusion again: “(results are) questioning the role that sport plays in the development of these findings and their relationship to symptoms.”
Participation in the sport of activity may not be the cause of your hip labrum problems. Then what could it be? You were told that you have a hip labrum tear.
The use of magnetic resonance arthrography (MRA) to evaluate labral tears has become the gold standard. Magnetic resonance arthrography is enhanced by the intra-articular injection of gadolinium-based contrast media that improve the visibility of internal body structures in magnetic resonance imaging (MRI).
Labral hip tears are grouped into four classifications
- anterior superior labrum hip tear (front of the hip)
- posterior superior labrum hip tear (front and top of the hip)
- superior labrum hip tear (towards the rear of the hip)
- posterior labrum hip tear (the rear of the hip)
Some hip labrum injuries and labral tears can be caused by a sudden, specific injury or repetitive motions that cause “wear and tear.” The difference between the men in the above study and the people we see in our clinic are their symptoms. The patient with hip pain suspected to the hip labrum may describe a clicking, popping, or locking sensation in the hip. The men in the study above had no symptoms but seemingly similar damage. So what is going on? Simply? It may not be the labrum at the cause of the problem, it may be total hip instability.
What are we seeing in this image?
This is an arthroscopic picture showing the aftermath of a hip labrum repair with a cadaver graft. Full-thickness tears of the cartilage are seen, even after the hip surgery. The unsolved instability and mechanical problems of the hip remained after the hip labrum surgery. This caused the continued degenerative disease of the hip and continued pain and instability for the patient.
This may be why surgery was not the answer some had hoped they would get. The surgery addressed the damaged hip labrum without addressing what was damaging the hip labrum in the first place. This is why new surgical procedures are being sought, there is a problem.
In a recent study published in Clinical Orthopaedics and Related Research (9) by doctors at the University Hospitals of Geneva and the University of Geneva, the concern is expressed that there do not appear to be options for patients showing degenerative labrum hip tear symptoms: pain, torn, irreparable, or completely ossified (calcified) acetabular labrum short of reconstruction with grafts.
What is being suggested here is that there was a thought that if you shaved away the damaged labrum and tissue regeneration of the acetabular labrum was possible. But studies are inconclusive and one study says it does not happen.
The Geneva team concluded: “Resection (removal) of a non-repairable acetabular labrum does not stimulate regrowth of tissue. . . patients who underwent this procedure had neither results in regrowth nor the restoration of consistently high hip function.”
The damaged labrum did not repair after the surgery.
Doctors at The Ottawa Hospital in Canada found similar findings in their research published in The Journal of Bone and Joint Surgery. (10) They too cast a harsh light on hip labral procedures in patients over 45:
- “Arthroscopic labral debridement in patients forty-five years of age or older was associated with a relatively high reoperation rate and a minimal overall improvement in joint-specific and quality-of-life outcome measures.
- Although differences in some outcome measures were statistically significant, most did not reach the level of the minimum clinically important difference.
- Arthroscopic debridement of labral tears in this patient population must be approached with caution as the overall clinical benefit was small.”
Is a hip replacement the ultimate destiny for patients who had a hip labrum arthroscopic procedure? Surgeons say yes in 40% of patients
You are a patient being sent to hip labrum surgery. You are told that within 20 years 40% of all patients getting surgery will need a hip replacement. We get it, many of you will think, I will worry about that 20 years from now. Some of you may be concerned that if a hip replacement is in my future, that means that my hip may get really bad over the next couple of years. This is one of the challenges patients face, the short-term vs. the long-term solution.
Here are some things to consider from a May 2019 study from the Department of Orthopaedics, Massachusetts General Hospital, and Tufts University School of Medicine published in the journal Clinical Orthopaedics and Related Research. (11)
The points to consider:
- how much damage occurred in the hip post-arthroscopic surgery.
- what caused this damage?
Quick points to help understand the study:
- Between 1989 and 2000, one surgeon performed 552 arthroscopic hip procedures for symptomatic labral tears, with or without associated articular cartilage damage.
- Between the years 2004 and 2015, 73% of these patients (404 hip procedures) were still being monitored. A minimum of 15 years after their initial hip labrum procedure.
So for example, the patient who had hip labrum surgery in 1993, this patient was still monitored in 2008 (a minimum of 15 years after the procedure and possibly all the way to 2013, the 20-year cut-off point of this study.)
- The patients who did not need or refused conversion to hip replacement at 20 years was 59%
- Factors that affected survival included age, patients older than 40 years old, and the presence of combined femoral head and acetabular chondral damage.
- Patients should be counseled as to the increased probability of conversion to total hip replacement, depending on the health of their articular cartilage after surgery.
So, after the hip labrum surgery, 4 out of 10 patients suffered significant hip damage over the course of years that ultimately lead to a hip replacement within 20 years.
- Would it be fair to say the hip labrum surgery did not prevent hip degeneration?
- Would it be fair to say removing parts of the labrum caused degenerative hip disease?
The risk of revision hip replacement in patients with hip arthroscopic surgery history. “the conversion rate from hip arthroscopy performed in Medicare osteoarthritis patients to total hip arthroplasty (replacement) within two years is unacceptably high.
The idea of hip arthroscopic patients in older or aging patients was introduced as a “joint preserving surgery.” The arthroscopic procedure obviously is less invasive and far from a total hip replacement.
A March 2020 study in the journal Hip International: The Journal of Clinical and Experimental Research on Hip Pathology and Therapy (12) comes to us from the Department of Orthopaedic Surgery, Hospital for Special Surgery, New York. In this paper, the doctors examined the possible risks hip arthroscopy may cause in leading to adverse outcomes after total hip arthroplasty (replacement). The purpose of this study was to (1) determine the 2-year conversion rate of hip arthroscopy done for osteoarthritis to total hip replacement and (2) explore the relationship between hip arthroscopy performed in patients with hip osteoarthritis and the risk of revision total hip replacement within 2 years of the main or primary arthroplasty.
What were the results?
- The two-year conversion to total hip replacement rate for hip arthroscopy in patients with osteoarthritis was 68.4%.
- Hip osteoarthritis patients who underwent hip arthroscopy prior to total hip replacement were at an increased risk of revision surgery, periprosthetic joint infection, and aseptic loosening within 2 years of total hip replacement.
Conclusions: “Analysis of a large insurance database found the conversion rate from hip arthroscopy performed in Medicare osteoarthritis patients to a total hip replacement within 2 years is unacceptably high. Hip arthroscopy prior to total hip replacement also significantly increased the risk of total hip replacement revision within 2 years after index total hip replacement. These results suggest that arthroscopic hip surgery should not be performed in patients with a diagnosis of osteoarthritis as conversion rates are high and revision rates post total hip replacement are significantly increased.”
There had been previous concerns about offering hip arthroscopic surgery to older patients
This is not exactly new information. There had been previous concerns about offering hip arthroscopic surgery to older patients. In 2017 doctors at the Department of Orthopaedic Surgery, School of Medicine, Kitasato University in Japan wrote in the Journal of Orthopaedic Surgery and Research (13) about the high conversion to total hip replacement, but, selecting the right patients for hip arthroscopy could reduce the high conversation rate.
In this study, the doctors investigated the clinical outcomes of arthroscopic surgery for the treatment of labrum tear and/or osteoarthritis in patients over 50 years of age. Overall, although the clinical outcomes generally improved, they contained cases in which conversion to total hip replacement occurred at a constant rate. One paper reported that patients aged 50 years or older could have hip arthroscopy if they were carefully screened as the results of this study did not see more conversations to hip replacement. However, nearly 35% of the successful hip arthroscopic procedures showed
Let’s turn to two other surgical studies:
Surgeons discuss saving the hip labrum
Doctors at the Ohio State University Wexner Medical Center say in their research in the Sports Medicine and Arthroscopy Review (14): that the techniques utilized for the management of articular cartilage and hip labral injuries during hip preservation surgery have changed dramatically because doctors need to figure out a way to preserve the hip labrum so as to achieve the goal of providing labral treatment that restores native functions of the labrum to allow for more normal biomechanical function.
In 2009, Dr. Megan M. Groh of the Physical Medicine & Rehabilitation, Mount Sinai Hospital, New York. conducted a comprehensive review of hip labral tears that pointed out that hip surgeries that remove or debride the hip labrum are taking away from the vital function of the labrum and indeed motion of the hip. Writing in the Current Reviews in Musculoskeletal Medicine:(15)
- “Without the labrum, the articular cartilage must withstand significantly increased pressure, and a compromise of this system could lead to early joint deterioration. A study testing a labrum-free model of the hip showed that, without the labrum, contact stress may increase by as much as 92%. 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 osteoarthritis.”
It all comes back to saving the hip labrum, as documented by the research
Research out of Wake Forest University School of Medicine published in the Journal of Hip Preservation Surgery suggests that an awareness of how biomaterials, among them, stem cells would make the future of hip arthroscopy exciting. Cartilage injuries can be managed with a higher level of restorative techniques. These cartilage restoration techniques have evolved rapidly as well and may include the use of scaffolds, allograft cartilage cells, and other stem-cell-related procedures. (16)
Pain after arthroscopic surgery
In an April 2020 editorial in the medical journal Arthroscopy (17) doctors from Cambridge University Hospital in England wrote:
“Pain after hip arthroscopy is a significant and challenging issue as is evidenced by the number of publications on this subject. Various analgesic strategies to circumvent this issue have been tried, with variable results. The central problem is that pain experienced by patients after hip arthroscopy is multifactorial in origin.”
Prolotherapy for Hip Labrum Tears
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.
Prolotherapy is an injection technique utilizing simple sugar or dextrose.
Regenerative Injection Therapy (Prolotherapy) for Hip Labrum Lesions: Rationale and Retrospective Study
Ross Hauser MD of Caring Medical and Amos Z. Orlofsky, Ph.D. of Albert Einstein College of Medicine published the above study in The Open Rehabilitation Journal research describing the effectiveness of Prolotherapy for a hip labral tear and groin pain. The study concluded Prolotherapy for acetabular labral tear appears to be a safe and potentially effective treatment.
Here are learning points from that research:
- The results of the study were encouraging, as all 19 patients reported pain reduction, and all reported improvement in at least one of two functional categories.
- All patients expressed a positive view of their treatment on a (self-reported) questionnaire. Improvements appeared to
be stable during at least the first two years post-treatment, as judged by the lack of time dependence for pain reduction.
- (Prolotherapy) was well tolerated and no adverse events were observed.
- The study results are notable for the high frequency of posttreatment reports of complete symptomatic relief, rather than
- Hypertonic dextrose potentially has multiple effects that may enhance labral healing, including the induction of growth factor production and proliferative responses as well as the possible elicitation of inflammatory changes that may promote healing responses.
- The nature of healing responses in the labrum is still poorly understood, but earlier studies suggest that considerable
spontaneous healing occurs and that therapies that focus on amplifying and optimizing this spontaneous process may have merit.
- Given the poor efficacy of the current conservative treatment of labral tear, and the risks, failure rate, and expense associated with arthroscopy, regenerative therapy may be viewed as a potential adjunct to conservative management. (17)
A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Hip Pain at an Outpatient Charity Clinic in Rural Illinois
In this research published in the Journal of Prolotherapy, (18) Prolotherapy was found to provide connective tissue growth responses and provide clinical benefits with low risks in musculoskeletal conditions. Further, Prolotherapy can be a cost-effective alternative to surgery for patients with hip pain and labral tear.
We examined Sixty-one patients, representing 94 hips, who had been in pain for an average of 63 months We treated these patients quarterly with dextrose Prolotherapy.
This included a subset of 20 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of eight patients who were told by their doctor(s) that surgery was their only option.
The patients have been contacted an average of 19 months following their last Prolotherapy session and asked questions regarding their levels of pain, physical and psychological symptoms, and activities of daily living, before and after their last Prolotherapy treatment.
- In these 94 hips, pain levels decreased from 7.0 to 2.4 after Prolotherapy;
- 89% experienced more than 50% of pain relief with Prolotherapy;
- more than 84% showed improvements in walking and exercise ability, anxiety, depression, and overall disability;
- 54% were able to completely stop taking pain medications.
We concluded: “Prolotherapy used on patients who presented with over five years of unresolved hip pain were shown in this retrospective pilot study to improve their quality of life even 19 months subsequent from their last Prolotherapy session.
The 61 patients with 94 hips treated reported significantly less pain, stiffness, crunching sensation, disability, depressed and anxious thoughts, medication and other pain therapy usage, as well as improved walking ability, range of motion, sleep, exercise ability, and activities of daily living. This included patients who were told there were no other treatment options for their pain or that surgery was their only option. The results confirm that Prolotherapy is a treatment that should be highly considered for people suffering from chronic hip pain.”
Regenerative Injection Therapy (PRP) for Hip Labrum Tears
Platelet Rich Plasma or PRP therapy is one of the injection treatments that may have been recommended to you by your orthopedic surgeon or that you came upon in your research. You may have even asked your orthopedist about “PRP” injections and you were told: “They do not work, they are not covered by insurance.”
Well, that is probably enough to chase anyone away. Except for one thing. There is a lot of research that when administered correctly by a doctor experienced in the treatment, PRP can work well. At our center, we offer PRP in conjunction with Prolotherapy treatments. As outlined above Prolotherapy injections help stabilize the hip, it helps stop unnatural grinding movements that can cause impingements, wear and tear, and further soft tissue damage in many patients. PRP is given to help patch up and fill in tears and other joint “erosions,” Will working together the two treatments are prioritizing a different kind of fix.
Growth and healing factors in PRP. This is what makes PRP work
A paper in the journal Clinical Cases in Mineral and Bone Metabolism (19) describes the growth, healing, and repair factors found in platelet-rich plasma. These are the healing factors and what they do:
- PDGF (Platelet-derived Growth Factor) initiates connective tissue healing through the promotion of collagen and protein synthesis.
- The primary effect of PDGF seems to be its mitogenic activity on mesoderm-derived cells such as fibroblasts (produce collagen a building block of new cartilage),
- Vascular muscle cells (new blood vessels to bring healing factors to the injury).
- Glial cells (protects nerves) and chondrocytes (the stuff cartilage is made of – see our article on Extracellular Matrix).
- The most important specific activity of PDGF is the creation of cartilage.
- VEGF (Vascular Endothelial Growth Factor) is the major regulator of vasculogenesis and angiogenesis and plays an important role in tissue regeneration. It does so by creating new highways of blood vessels for the healing factors to get to the site of the injury.
- Transforming Growth Factor (TGF) including TGF-b1 stimulates chondrocyte (Cartilage growth) and decreases catabolic activity (the breakdown of cartilage). There is also research to suggest that TGF-bi stimulates stem cell activity in the injured area.
So the concept is here. These healing growth factors in your blood are taken and “spun,” to separate out a platelet-rich plasma solution filled with these healing and growth factors, and then the solution is injected into your knee.
PRP is not a single-shot miracle cure for hip labrum tears and hip pain. The effectiveness of PRP is in how many times the treatment is given
PRP is not a single-shot miracle cure for hip labrum tears and hip pain. While for the rare patient a single shot may work for them, we have seen in our clinical experience, that PRP not to be as effective as a stand-alone, single-shot treatment.
Research on the use of PRP in hip labrum tears
A November 2019 study led by the Mayo Clinic and published in the American Journal of Physical Medicine & Rehabilitation (20) reviewed whether ultrasound-guided injection of platelet-rich plasma can safely and effectively treat symptoms associated with acetabular hip labral tears. This was a study on eight patients who have previously failed conservative management and received an ultrasound-guided injection of platelet-rich plasma at the site of the hip labrum tear.
After the injection, (this is one injection treatment) the patient’s pain reduction and functional ability (using standard scoring systems) were assessed at baseline and then 2 weeks, 6 weeks, and 8 weeks after injection.
- Results: Statistically significant differences in Harris Hip Score (standard functionality scoring system) were seen at 2 weeks after injection, 6 weeks after injection, and 8 weeks after injection as compared with baseline. Corresponding improvements were seen on the visual analog scale (standard pain scoring system with 0 being no pain to 10 being severe pain) seen at 2 weeks after injection at rest and with activity, 6 weeks after injection at rest and with activity, and 8 weeks after injection at rest and with activity compared with baseline.
Conclusions: “Ultrasound-guided injection of platelet-rich plasma holds promise as an emerging, minimally invasive technique toward symptom relief, reducing pain, and improving function in patients with hip labral tears.”
Summary and contact us. Can we help you?
When traditional treatments such as physiotherapy, medications, electrical stimulation, manipulation, exercise, rest, or massage do not work, then consider that you may have a labral tear. If you externally rotate your hip while lying on the ground and keep your foot off of the ground and then run it next to your opposing leg from the groin down to the foot and this increases your pain and you feel a clicking, grinding, or popping sound, this correlates highly with the diagnosis of a hip labral tear. If this is the case, then consider receiving Prolotherapy.
We hope you found this article informative and it helped answer many of the questions you may have surrounding your hip problems and hip instability. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
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This page was updated July 22, 2022