Hip Labral Tears: Everything You Need to Know About Hip Pain, Injections, Surgery, and Functional Training Solutions.
If you’re experiencing hip pain, you might be wondering if it’s a symptom of joint damage and a labral tear. Read on to learn what the science says on the correlation between pain and labral tears, how to figure out what may be causing your discomfort, and ways to work toward pain relief.
Table of Contents
- What are Hip Labral Tears?
- How do You Know if You Have a Labral Tear?
- Do Hip Labral Tears Cause Hip Instability?
- What are Treatment Options for Labral Tears?
- Recap: What You Should Do if You Think You Have a Labral Tear in Your Hip
Maybe your doctor has said you have a labral tear in your hip, or maybe you’re experiencing hip pain and wondering if it’s related to a tear.
Hip pain is becoming an extremely common complaint in the age of desk work and constant sitting. It’s also becoming very common for people to get diagnosed with a hip labral tear.
In this article, I’ll take a deep look at the research around hip pain, labral tears, when to consider surgery (hardly ever), and how functional training can help. If you’re in hip pain, you’ll have a better sense of whether or not you might have a tear, and if you do, whether you should take action, and how.
But first, what is a labral tear?
What are Hip Labral Tears?
A labral tear is damage to the little cartilaginous ring around the joint. Orthopedic surgeons may tell you that this can lead to catching, clicking, and irreversible damage to the hip joint. They may tell you that when the labral cushion deteriorates, it can cause movement problems and eventually arthritis.
This is what a labral tear looks like.
I’ve worked with a lot of clients who have hip issues, and I have put a lot of thought and energy into understanding both the myths and facts around hip pain, hip labral tears, and other hip joint pathologies. I always want to make sure that what I’m doing with clients makes sense and won’t make things worse.
Many doctors think that less movement is the only logical prescription. That can be a pretty disempowering perspective, and it can also lead to more problems down the road.
In my experience, even if you have a labral tear, movement is the path toward better mobility and less pain, while conventional treatments for a labral tear can cause even more discomfort.
In this article I’ll explain why movement can be so helpful and why a labral tear diagnosis itself is untrustworthy and harmful to your hip health. I’ll also share what to really expect from common medical treatments for hip labral tears and what you can do to improve your hip pain and function in the long run.
How do You Know if You Have a Labral Tear?
If you’re reading this, a doctor probably told you that you have a labral tear. You probably have hip pain, and a magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA) may have come back with a positive result for a labral tear.
So it’s time to stop all movement and schedule surgery, right? Not so fast.
If you’re experiencing hip pain, watch this video on the warning signs of an actual labral tear:
The Reliability of MRI and MRA for Diagnosing Labral Tears
In reality, research shows that MRI and MRA have very high false positive rates, making the findings ambiguous.
A 2011 study on acetabular labral tears looked at MRI and MRA accuracy. Researchers evaluated 19 published papers that covered 881 hips. They found that MRI had a specificity of 79 percent and MRA had a specificity of 64 percent. The lower the specificity, the greater the chance you’ll be diagnosed positive, even if you’re not! So, in this case, your chance of a false positive could be as high as 36 percent!
These two imaging strategies for diagnosing labral tears proved to be unreliable, but the study concluded that MRA is a bit better than MRI at finding tears (since it has fewer false negatives).
Consider, however, that according to this study, if you’re told MRA results confirm a labral tear, there could be as high as a one in three chance that they actually don’t.
Another study on MRA and acetabular labral tears, this one from 2012, found that depending on the radiologist, the false positive rate could be from 25 percent to as high as 50 percent!
Some surgeons point to this 2017 study published in the Egyptian Journal of Radiology and Nuclear Medicine, which looked at the accuracy of MRI and MRA.
The authors claimed MRA was 96 percent accurate during their study in diagnosing labral tears! This is suspicious given what we have seen in other studies.
It’s important to note that the study design in this case had a high risk of bias, with a small sample size, no control group, and no randomization.
All 50 patients had hip pain complaints, and all 50 were slated for surgery to address their hip pain. The patients had imaging done, then surgeons went in to investigate, “fix” the pain, and confirm that the imaging was accurate.
One of the problems was that the surgeons had already committed to surgery as the solution. This introduced a high risk of “assessment bias,” which is when researchers might evaluate the patients differently (radiographic measurement, side effects, etc) if they think one treatment is not as effective as another,” according to an article on study design in the journal Clinical Orthopaedics and Related Research.
In the study published in Egyptian Journal of Radiology and Nuclear Medicine, it seems no other treatment options outside of surgery were considered. Once the surgeons cut open the patients, it might follow that they worked hard to find a justification for their preferred solution.
As illustrated by the 2012 study mentioned above, imaging results are fairly unreliable. Results can vary dramatically depending on who is reading them. With the Egyptian Journal of Radiology and Nuclear Medicine study, it appears that the surgeons themselves interpretted the images, not radiologists, and that there wasn’t any independent verification of the image results.
It makes sense that the surgeons would more aggressively interpret results as positive when they had already decided that surgery was the best solution.
Even if MRA is as accurate as the authors claim at detecting labral tears, there is an even bigger question to address: Does a hip labral tear even cause hip pain?
We’ll dive into that after we discuss physical tests (sometimes called “special tests” for labral tears).
The Reliability of Physical Tests for Diagnosing Labral Tears
Sometimes doctors and therapists use physical tests to determine whether your hip problems are caused by labral tears. The idea is that if you move someone’s hip joint in specific ways and you run into specific movement limitations, you can say someone has a labral tear.
A 2010 study put this idea to the test. Researchers examined the sensitivity, specificity, and accuracy of four different hip maneuvers that are supposed to tell you whether pain is from labral tears or other intra-articular sources.
All four hip tests had specificity ratings worse than a coin toss. The best specificity score was with the Stinchfield test, which looks at the relationship between hip flexor engagement and pain, and even that was accurate just 32 percent of the time. That means that positive results for labral tears on these tests have a very high risk of being false positives.
Sometimes doctors claim that using multiple tests will increase the certainty of the result. In a way, they’re right.
In this study, combining multiple tests led to a guaranteed “positive” result, even if the patient didn’t have a labral tear or other hip joint pathology.
So when you combine MRI or MRA, which have high false positive risk, with physical tests, which have extremely high false positive risk, you’re basically guaranteed to be told you have a labral tear.
The bottom line? With tests this unreliable, the only way to see and confirm a labral tear is to cut into your body and look inside, but that’s not a good idea unless you’re 100 percent sure a hip labral tear is actually causing your hip pain! As we’ll see, this is actually harder than it sounds.
See also : RIIPS: Why Rest, Ice, Injections, Pills, and Surgery Shouldn’t be Your Only Options
The Reliability of Anesthetic Injections for Diagnosing Labral Tears
Often, hip injections are offered as a reliable way to identify the cause of hip pain.
The idea is that if you’re in pain and suspect a labrum tear, an anesthetic injection will temporarily stop the pain. The assumption is that the pain is a symptom of a labrum tear, which we know isn’t usually the case.
For example, in a 2008 study, the authors looked at 105 patients to see if anesthetic injections could help them identify who had pathologies like labral tears in their hips.
The researchers used patient symptoms and MRI to see if they could find a correlation between symptoms, the imaging findings, the injections, and labral tears.
The researchers considered a 50 percent reduction in pain symptoms as a positive response to an injection. If a patient got a positive response, then it meant their pain was coming from something like a labral tear (or other joint pathology).
However, 39 percent of patients with confirmed labral tears had a positive response to an injection. Plus, 45 percent of patients with possible, unconfirmed, tears did not respond to the injection. Basically, injections were marginally better than guessing when it came to diagnosing labral tears.
In other words, you couldn’t tell anything from these injections.
The researchers checked to see if other physical tests could help identify tears, but concluded that none of the tests they tried, including injections and physical manipulation, had reliable results.
If you’d like to read more studies on labral tears and pain, you can check out this post.
In short, there is currently no way to reliably determine that a person’s hip pain is coming from joint pathology.
Watch this case study of a patient with hip pain resolving her discomfort with functional training, not surgery or injections:
Joint Popping, Snapping, and Clicking and Labral Tears
Maybe you’ve heard your hip pop or snap and are worried that sound is a symptom or sign of a labral tear.
This is a belief that is echoed all over the internet and is extremely common to hear from doctors.
For many reasons, it seems unlikely that popping, snapping, and clicking sounds are indicators of a labral tear.
The top reason this is unlikely is that the labrum itself is not stiff enough to catch on anything to make a loud clicking sound. The labrum is like a small cushion in your joint. Imagine sitting on a pillow and trying to make a snapping sound by rubbing your butt on it. No matter how hard you rub, you will not get a clicking or popping sound.
Watch this video for a visual breakdown:
Now you’ve seen that MRIs, MRAs, physical tests, and diagnostic injections for hip labral tears are unreliable and highly likely to give you false positives.
But even if the tests and images are correct, and you really do have a hip labral tear, does that mean the labral tear is causing your hip pain? Let’s find out.
Hip Pain and Labral Tears
A lot of the information you find on the internet also seems to be saying that labral tears are always associated with pain.
But in fact, many studies have shown little to no correlation between labral tears and pain, even disability!
These MRI studies look at the hip health of asymptomatic people.
In a pioneering study, in 1998, researchers studied 52 asymptomatic hips (meaning hips with no problems or reports of pain) to examine the relationship between hip labral tears and hip pain.
They found that the majority of study subjects had some level of labral tear or lesion, or variation.
In a similar study in 2012, 85 percent of asymptomatic volunteers had hip labral tears. And in 2015, another study set up in the same way revealed that 39 percent of asymptomatic people had labral tears.
That means that out of 70 people in the study, nearly half had some kind of joint “pathology,” but no symptoms.
The authors of the 2015 study concluded: “Given the high prevalence of labral pathology in the asymptomatic population, it is important to confirm that a patient’s symptoms are due to the demonstrated abnormalities when considering surgery.”
In short, hip labral tears may be common, but they are likely not the cause of your hip pain, and they likely don’t require surgery for you to find relief and mobility!
Do Hip Labral Tears Cause Hip Instability?
Nobody likes instability. Credit: Stock Unlimited
For years, surgeons have believed that labral tears cause instability in the hip joint. This instability supposedly can only be “fixed” by either cutting out or securing loose labrum tissue via surgery.
In 2011 study, a group of researchers tested the idea that a labral tear would lead to joint instability by using finely tuned instruments and hip joints from human cadavers. They created labral tears and then measured the effect on joint stability.
Their findings were almost the exact opposite of what they expected to find. They tested circumferential tears and radial tears (basically different orientations of tears) to see if the kind of tear mattered. They also tested hip joint stability after labrectomies (a treatment for labral tears that simply removes pieces of the labrum).
Even big tears in the labrum did not result in more instability in the hip joint.
There was no significant difference in stability after a radial tear or a one-centimeter partial labrectomy, compared with an intact labrum.
On the other hand, a two-centimeter partial labrectomy, or removal of parts of the labrum, significantly decreased stability.
Their conclusion: Even big tears in the labrum do not result in more instability in the hip joint. Removing pieces of the labrum increases instability.
So do hip labral tears cause hip instability? Generally no. In fact, the research shows that surgery may lead to more instability.
What are Treatment Options for Labral Tears?
If you have been diagnosed with a labral tear, your doctor may have recommended surgery. I’m here to present the science behind that option, as well as offer up a different solution, related to functional training.
Movement and functional training can serve you if you have an official hip labral tear, are experiencing pain, or just want more range of motion in your hips.
Do Surgeries for Hip Labral Tears Work?
When you do research on surgery for hip labral tears, you’ll find the vast majority of medical information sites tell you that this is the only option for repair.
Occasionally you’ll run across physicians who believe other approaches make sense before even thinking about surgery.
As you’ve already read, the justifications for surgery on labral tears ar shaky. Labral tears don’t increase instability and aren’t related to pain.
One of the most popular treatments for hip labral tears in the last decade has been labral debridement (or labrectomy), in which a surgeon goes into your hip and cuts away the “loose” bits of your labrum. As noted previously, removing pieces of labrum actually increases instability. So, it’s not surprising that a study on the results of labrectomy, published in 2014, showed dismal results for debridements or labrectomies.
The researchers found that nearly half of the 57 patients who had undergone labral debridement ended up with poor results.
It gets better: The study proposes that the reason patients got bad results from the labrectomies is that the surgeons didn’t also cut away bone.
It’s like saying, “We fixed your flat tire by removing a nail, but the tire is still flat because we need to remove more of the damaged tire.”
See also : Why you DON’T Need Orthopedic Surgery for Joint Pain
The other surgical option for a labral tear is refixation, where the “damaged” labrum pieces are reattached.
According to this 2009 study that looked at the difference between debridement and refixation, refixation seemed to have better outcomes than debridement.
So, there’s some evidence that refixation may be better than debridement or labrectomy, but there is ambiguity about whether the reported improvements are a result of the surgery. As with many orthopedic surgeries, there have been very few (if any) comparisons between the surgical approach to more conservative approaches.
One study, published in 2021, did attempt to compare surgery with physical therapy for labral tears. Researchers ran a randomized controlled trial and concluded that surgery was better than physical therapy with a 12-month follow-up.
However, when you dig deep into the study, you see that it's plagued with methodological problems and massive bias.
First of all, all the patients were recruited through a hip surgery clinic, meaning the patients were highly likely to prefer surgery from the outset. Once recruited into the study, they were required to go through a "conservative treatment" period where they were told not to do anything to aggravate their hip pain, do no flexibility or strength training, and follow a poorly designed physical therapy protocol. They may have also received hip joint injections to numb the pain. If the patients didn't improve from this misguided conservative care protocol for a few months, they could participate in the actual trial and be randomized to either surgery or more physical therapy.
If assigned to surgery, the patient got surgery. If not, the patient was assigned to more pointless and poorly designed physical therapy.
The physical therapy protocol disallowed any serious flexibility or targeted strength training. It also included thorough "patient education" to ensure that patients believed they had a bone problem that could not be fixed with exercise. Furthermore, physical therapists and doctors in the study reiterated that any movement that was uncomfortable in the hips was to be avoided to prevent further hip damage.
But the most problematic issue is they told patients if they didn't see progress in physical therapy after a few months, they could switch in to the surgery group! Unsurprisingly, the trial was unable to maintain two distinct groups for comparison. A whopping 63% of the patients in the "physical therapy" group actually ended up getting surgery halfway through the study.
In any independent and dispassionate analysis, this would completely disqualify this study as a well-designed randomized controlled trial.
But the researchers employed multiple statistical analysis tricks and highly biased scoring systems to claim that surgery came out significantly ahead of physical therapy.
In reality, the scoring systems they used, the iHot-33 and the Harris Hip Score, showed only minor differences between surgery and physical therapy that can be explained almost entirely by the bias within the scoring systems themselves.
Watch this video for a thorough, detailed breakdown of the study and the scoring systems.
So, to recap: Surgery may sound promising initially when your doctor presents it as an option, but many people who go through surgery actually discover that their pain doesn’t go away, and their range of motion is worse.
Based on my experience as a functional trainer who has seen hundreds of clients with hip pain, pre- and post-surgery, I don’t recommend surgery as a first step.
Here’s why: Surgical treatments for hip, back, shoulder, and knee pain may have been invented by well-intentioned surgeons, but rigorous scientific investigation routinely debunks orthopedic surgeries and other conventional Western treatments for joint pain.
There’s often an emphasis on quick short-term “fixes” and financial incentives from insurance companies, and a total mismatch of what "success" means to a patient and what it means to a surgeon. For patients, success is measured by the ability to return to daily life and any specific athletic endeavors that they love. It's not just about surviving the surgery with minimal scarring.
In fact, surgery comes with a whole host of recovery issues. The required period of rest after surgery leads to atrophy. More simply put: if you don't use your muscles, you lose them.
And there's another catch to be aware of: Many people I’ve talked with have been told that they should never go back to high-impact, high-intensity activities after surgery. That’s not a great outcome for anyone who's active.
Here’s another case study, of someone with hip pain who found relief through functional training, NOT surgery:
Functional Training for Hip Mobility and Hip Pain
If you’re experiencing pain or less range of motion in your hips, restoring mobility and control gradually and progressively (through functional training) can save you thousands of dollars and months of bed rest.
And while the process is not a quick fix, it’s a solution that gives you the power to get rid of pain and increase your ability to enjoy all the activities you love, even the high-impact, high-intensity ones!
As a functional trainer, I want to keep you moving, and am always looking for ways to improve your range of motion, comfort level, and overall athletic competency.
If you think you have a labral tear and, as a result, a one-way ticket to arthritis, your doctor may suggest moving less (and then surgery).
That’s a pretty disempowering perspective. It’s also one I think you should be careful to educate yourself about.
See also : How to Identify Muscle Imbalances and Muscle Dysfunction
In fact, I think people are better off completely ignoring the advice to NOT move.
I’ve seen people with pretty severe hip pain regain full function of their hips without surgery, so we know that there’s definitely room for a different perspective on hip pain than what the medical world currently provides.
I’ve also seen people get hip surgeries to repair labral tears, only to have the pain remain the same or get worse.
This is where movement plays a key role. Proper retraining of the muscles around the hip will actually get rid of the pain and restore function to the hip in a way that surgery doesn’t!
If you’re still not sure, here’s another client story, from someone who needed to recover from hip pain AFTER surgery:
Recap: What You Should Do if You Think You Have a Labral Tear in Your Hip
First, let’s assume you have been told you have a labral tear. What should you do? First, don’t take this as medical advice. It’s coming from a non-medical perspective, and the ideas offered here are decidedly not medical.
If you have been told you have a labral tear that is the cause of your pain, think about these major questions and considerations:
- Is there any way to know whether you have a labral tear? Without surgery, there’s no definitive way to know.
- Is there any way to know that the labral tear is actually causing your hip pain? Based on the research, NO! People with hip pain in research studies often don’t have labral tears, and vice versa. Remember: Just because a doctor believes something is true does not actually mean it's true.
- What’s the likelihood that surgery will fully fix your hip pain? Read papers like the ones you find here so you understand the history of surgeries to “cure” pain. A surgeon saying, “surgery is guaranteed to fix your hip pain,” is well-intentioned and may truly have your best interests in mind, but the research doesn’t back them up.
I’ve worked with people with hip labral tears who want to avoid surgery, and I’ve also worked with people after surgery. From what I’ve seen, repairing or ripping out the labrum is not the most important factor to fixing hip pain. The fact that the labrum may be torn doesn’t even seem to be an important factor, based on the science.
The most important factor is training your hip muscles to work in unison gradually and carefully.
That is a process that requires time, learning, and patience. I strongly encourage people to acknowledge their fears and anxieties around labral tears, recognize that there’s very little evidence that labral tears actually are the definitive cause of pain, and focus on the muscles around the hips.
You can control your muscles better. You can retrain muscles with stretching, self-massage, and carefully executed exercises.
See also: How to Fix Muscle Imbalances and Muscle Dysfunction
Here is what I suggest, if you’re experiencing hip pain or think you have a labral tear:
- Find a trainer, coach, or a physiotherapist who can coach you to move with good form in new ranges of motion. Please don’t jump into high-intensity interval training or some kind of boot camp, group class, or Crossfit situation until you’ve worked with a professional.
- Use your own sensations as guidance. At first you may interpret sensation as threatening, but with practice, you’ll learn what your sensations mean (and they aren’t always warning signs that something is horribly wrong). Get curious. Strive for strength.
- Identify areas that aren’t moving well and work to improve them.
- Always think muscles! Learn more about how and why pain you feel in your joints is likely really due to muscle imbalance and dysfunction.
- Identify muscles that are weak and build strength.
- Learn how to stretch properly and appropriately for your body and your life.
- Identify positions you find difficult and carefully work to make those positions more comfortable (by training the muscles there).
- Aim to improve on something every single day.
- Don’t stress! Labral tears are not related to symptoms, thus there is nothing specific about them that you need to worry about. Hip pain and dysfunction is related to muscle function, therefore addressing the muscle dysfunction that causes your pain will help you start to feel better and more in control.
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If you are experiencing hip pain, read my article on muscle dysfunction: ATM Theory: Your Joint Pain May Actually be Muscle Pain
Still not convinced? Why you DON’T Need Orthopedic Surgery for Joint Pain
