Caring Medical - Where the world comes for ProlotherapyNon-surgical Treatment of Acetabular or Hip Labral Tears

Ross Hauser, MD  | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois

Non-surgical hip labral tear treatment

People can do very well with a hip labrum arthroscopic surgery. These are the people we usually do not see come into our clinics, 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.”

If you are here reading this article you have likely been to a doctor, a specialist/surgeon, and have been told that 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.

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 labrum 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.
  • 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 deterioration of already damaged joints.
    • 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)
  • 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 sport 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.”

These are usually not the people we see in our office, we see the people for who conservative care mentioned above did not help them get back to work or the game.

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 first hand, 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 the patient who does not want the surgery.

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.

Here is what the conclusion of a 2016 study in the American Journal of Sports Medicine (3) 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 the 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.

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 has 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 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:(3)

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 displacement 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, and ask us what is the recovery time of these surgeries? We point to the studies above and tell them, 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(4) This should concern patients over the age of 50 who had an MRI or MRA for suspected hip labral tears and were recommended to 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 and 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 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 is 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?

The hip labrum diagnosis and ultimate recommendation to 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 (5) September 2019

  • 11 professional rugby players and 10 professional ballet dancers, and 10 controls subjects completed activity and symptom questionnaires and underwent 3 T MRI 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 there MRI’s 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 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.”

The 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.

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 injury and labral tears can be caused by a sudden, specific injury or with repetitive motions that cause “wear and tear.” The difference between the men in the above study and the people we see in our clinics are symptoms. The patient with hip pain suspected to the hip labrum may describe a clicking, popping or a 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.

Labrum-Repair-CMThis 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 (6) from doctors at the University Hospitals of Geneva and University of Geneva, concern is expressed that there does not appear to be options for patients showing degenerative labrum hip tear symptoms: painful, 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 tissue that 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(7) 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 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.(8)

The points to consider:

  • how much damage occured 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 had hip labrum surgery in 1993, this patient was still be 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?

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 (9): 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:(10)

  • “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.(11)

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.

Regenerative Injection Therapy (Prolotherapy) for Hip Labrum Lesions: Rationale and Retrospective Study

Ross Hauser MD of Caring Medical and Rehabilitation Services 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 (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
    partial relief
  • 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 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.(12)

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, (13) Prolotherapy was found to provide connective tissue growth responses and provide clinical benefit 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 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 were 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.

Results:

  • 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.”

If you have questions about your Hip Labrum injury, You can get help and information from our Caring Medical staff

1 Krych AJ, Griffith TB, Hudgens JL, Kuzma SA, Sierra RJ, Levy BA.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. [Google Scholar]
2 Theige M, David S. Nonsurgical treatment of acetabular labral tears. Journal of sport rehabilitation. 2018 Jul 1;27(4):380-4. [Google Scholar]
3 Gupta A, Redmond JM, Stake CE, Dunne KF, Domb BG. Does primary hip arthroscopy result in improved clinical outcomes? 2-year clinical follow-up on a mixed group of 738 consecutive primary hip arthroscopies performed at a high-volume referral center. The American journal of sports medicine. 2016 Jan;44(1):74-82. [Google Scholar]
3 Zaffagnini S, Signorelli C, Bonanzinga T, Lopomo N, Raggi F, Di Sarsina TR, Grassi A, Marcheggiani Muccioli GM, Marcacci M. Soft tissues contribution to hip joint kinematics and biomechanics. Hip Int. 2016 May 14;26 Suppl 1:23-7. doi: 10.5301/hipint.5000407. Epub 2016 May 12. [Google Scholar]
4. Jayakar R, Merz A, Plotkin B, Wang D, Seeger L, Hame SL. Magnetic resonance arthrography and the prevalence of acetabular labral tears in patients 50 years of age and older. Skeletal Radiol. 2016 Apr 20. [Google Scholar]
5 Blankenstein T, Grainger A, Dube B, Evans R, Robinson P. MRI hip findings in asymptomatic professional rugby players, ballet dancers, and age-matched controls. Clinical radiology. 2019 Sep 30. [Google Scholar]
6 Miozzari HH, Celia M, Clark JM, Werlen S, Naal FD, Nötzli HP. No Regeneration of the Human Acetabular Labrum After Excision to Bone. Clin Orthop Relat Res. 2015 Apr;473(4):1349-57. doi: 10.1007/s11999-014-4021-z. [Google Scholar]
7 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. [Google Scholar]
8 Dwyer M, Tumpowsky C, Boone A, Lee J, McCarthy J. What Is the Association Between Articular Cartilage Damage and Subsequent THA 20 Years After Hip Arthroscopy for Labral Tears?. Clinical Orthopaedics and Related Research. 2019 May 1;477(5):1211-20. [Google Scholar]
9 Salata MJ, Vasileff WK. Management of Labral and Chondral Disease in Hip Preservation Surgery. Sports Med Arthrosc. 2015 Dec;23(4):200-4. [Google Scholar]
10 Groh MM, Herrara J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009 June; 2(2): 105–117. [Google Scholar]
11 Stubbs AJ, Howse EA, Mannava S. Tissue engineering and the future of hip cartilage, labrum and ligamentum teres. Journal of Hip Preservation Surgery. 2016;3(1):23-29. doi:10.1093/jhps/hnv051. [Google Scholar]
12 Hauser R, Orlofsky A. Regenerative injection therapy (prolotherapy) for hip labrum lesions: rationale and retrospective study. The Open Rehabilitation Journal. 2013 Oct 18;6(1). [Google Scholar]
13 Hauser R, Hauser M, A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Hip Pain at an Outpatient Charity Clinic in Rural Illinois. Journal of Prolotherapy. 2009;2:76-88. [Google Scholar]

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