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Hip pain is miserable making walking across the room almost impossible at times.  What is a hip labrum?  Are there other causes of hip pain down leg besides a hip labral tear?  Does the presence of hip labral tear with pain down leg mean I need surgery?   What are the treatment options for hip labrum tears?  Let’s dig in.

What is Hip Labrum?

The hip is a complex ball and socket joint.  The top portion of the thigh bone is shaped like a ball that fits into a socket.  The socket is called the acetabulum. The hip labrum is a ring of fibrocartilage that is attached to the acetabulum.  It provides stability and deepens the joint.  The labrum increases the joint surface area by 22% (1).  The hip labrum is susceptible to injury and can tear.   Tears are thought to be from gradual wear and tear, trauma, congenital malformation (dysplasia), impingement and joint laxity (2).

Hip Labral Tear with Pain Down Leg?

A tear in the hip labrum can cause a number of different symptoms.  The most common is anterior hip or groin pain which may radiate down to the level of the knee (3).  Pain develops gradually and typically is dull in character made worse with walking, pivoting and running.  Hip labral tears are easily seen on MRI.  Unfortunately, it’s importance as a source of pain must be questioned.  Why?  Research has demonstrated that many patients with no hip pain have labral tears on MRI (4-5).   In one study, Duthon et al demonstrated that 69% of patients without hip pain had labral tears.

What Causes Hip Pain that Radiates Down the Leg?

Does the combination of a hip labral tear with pain down leg necessarily mean that the labral tear is causing the pain? Given that labrum tears are present in patients without hip pain it is important to understand the other causes of anterior thigh and hip pain.  The major causes include

Muscles

The quadriceps, hamstrings and inner thigh muscles and tendons can be injured causing anterior thigh and hip pain.

Ligaments

Ligaments are thick bands of connective tissue that connect bone to bone.  The hip joint has multiple ligaments which can be injured and cause anterior thigh and hip pain

Blood Vessels

Blood clots in the upper leg can cause swelling and pain.

Irritation of Low Back Nerves

Disc protrusions, disc herniations, small joint overgrowth, and disc slippage can cause nerve irritation resulting in the anterior thigh and hip pain.

Sacroiliac Joint

The sacroiliac joint (SI) is an important joint in the low back that is formed by your waist bone (iliac crest) and the base of your lumbar spine (sacrum).  It functions to transfer the forces of the upper body to the lower extremities. The joint is susceptible to injury with pain in the anterior thigh, groin, buttock and posterior thigh.

Treatment Options for Hip Labral Tears

Treatments will vary from patient to patient based upon the severity of the injury, pain level, level of disability, findings on physical examination and MRI.  Treatment options include

Conservative Care

Rest, activity modification, PT, and safe anti-inflammatory medications such as fish oil and curcumin.

Injections

When conservative care fails, steroid injections into the hip joint are oftentimes recommended.  Steroids like cortisone are powerful anti-inflammatory agents that may reduce inflammation but are very toxic to orthopedic tissue like cartilage (6).  Research has shown that steroid injections will increase the loss of normal cartilage in a joint.  Steroids injections should be avoided.

Surgery

Hip labrum surgery is major surgery.  It involves the insertion of a narrow-gauge camera and operating instruments into the hip joint.  This is called arthroscopy and allows the surgeon to visualize structures inside of the hip joint including the labrum.   Aside from hip replacement, hip arthroscopy is the most common hip surgery in America.   In a 4 year period, the number of hip arthroscopes has increased by 600% (7).  Complications can occur.  The most common complication of hip labrum surgery is nerve damage with an incidence of 16.5% (8)

Is surgery of hip labral tears successful?  One of the largest high-level studies to date comparing hip arthroscopy to physical therapy demonstrated no difference between the outcomes of the two groups (9).  Yes, that is correct.  Hip labrum surgery outcomes were no different than those treated with PT.

Meet JB

JB is a 55 yr old female who presented to Centeno-Schultz Clinic last week with a 2-year history of left anterior thigh and groin pain that was progressive in nature, dull in character aggravated by sitting and prolonged standing.  The onset of pain was not associated with any trauma or activity.  Treatment had included physical therapy, stretching, oral NSAID and a steroid injection.  She was scheduled for hip labrum repair the following week and wanted a second opinion.  Her examination was significant for a full range of motion of the hip, tenderness in the left low lumbar spine and left SI joint.  Her inner thigh muscles and pubic bone were painful to the touch.   Low back x-ray was significant for disc injury at the lowest level.  Ultrasound of the hip and groin demonstrated arthritis in pelvis and inflammation of the inner thigh tendons.  Hip MRI and ultrasound were significant for very minor wear and tear of the labrum with NO tears.

If you are a hammer everything looks like a nail. Beware of the diagnosis of labrum tears and the need for surgery.  Correct diagnosis is key even if you have a hip labral tear with pain down leg.  JB did not need hip labrum surgery for her right thigh and hip pain as she had irritation of her low back nerves, inflammation of inner thigh muscles, and sacroiliac and pelvic joint dysfunction.

At the Centeno-Schultz Clinic, we are experts in the management and treatment of low back, hip, muscle and ligament injuries.  We use the SANS approach which utilizes a comprehensive approach to common musculoskeletal injuries.  Precise ultrasound and x-ray injections of PRP and bone marrow concentrate are effective nonsurgical options for many conditions.  JB canceled her hip labrum surgery and is scheduled for PRP injections next week.

In Conclusion

The hip is a complex ball and socket joint.  The labrum is a ring of fibrocartilage that provides stability for the hip joint.  Labral tears can occur with anterior thigh and groin pain.  The significance of hip labrum tears on MRI has been questioned as patients with no hip pain have labral tears on MRI.  There are many other causes of anterior thigh and groin pain which include injury to muscles, tendons, ligaments, low back nerve irritation, and sacroiliac joint dysfunction.  Treatment options include conservative care, steroid injections, and surgery.  Steroids are toxic to cartilage and should be avoided.  Hip labrum surgery outcomes were no different than physical therapy.  If you are experiencing the issue of hip labral tear with pain down leg, beware of the recommendation for hip labrum surgery as in many cases it is not indicated as was the case with JB.  PRP and bone marrow concentrate are effective nonsurgical treatment options without risk surgery or extensive rehabilitation.


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6.. McAlindon TE, LaValley MP, Harvey WF, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017;317(19):1967–1975. doi:10.1001/jama.2017.5283.

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8. Larson CM, Clohisy JC, Beaulé PE, et al. Intraoperative and Early Postoperative Complications After Hip Arthroscopic Surgery: A Prospective Multicenter Trial Utilizing a Validated Grading Scheme. Am J Sports Med. 2016;44(9):2292-8.DOI: 10.1177/0363546516650885

9. Mansell NS, Rhon DI, Meyer J, Slevin JM, Marchant BG. Arthroscopic Surgery or Physical Therapy for Patients With Femoroacetabular Impingement Syndrome: A Randomized Controlled Trial With 2-Year Follow-up. Am J Sports Med. 2018 May;46(6):1306-1314. doi: 10.1177/0363546517751912.

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