Surgery for Hip Labral Problems
Between the years of 2004 and 2009, hip arthroscopy rates in the U.S. increased by over 365%! So, does this mean that during this time frame, there was a huge increase in the general population sustaining labral injuries? Probably not. But, what likely did happen, is that the development of a surgical solution for something led to the over-diagnosis of the "condition" to be "fixed." Now, this would not be concerning if there was good data to show that the surgical procedure was better than more conservative care. When this surgery started being performed, we did not have this data. Through the years though, we are beginning to collect information on surgical outcomes.
A study published in 2016 by Filbay et al, found that participants who underwent hip arthroscopic surgery had poorer health-related quality of life and greater anxiety 12-24 months following surgery compared to age-matched, pain-free controls. In addition, patients reported greater impairment in hip related quality of life due to poor hip confidence, participation restrictions, difficulty maintaining fitness, and greater concern about pain during sport or recreational activities.
Another study published in 2018 by Thorborg et al, showed that hip arthroscopy for labral tears helped with pain and symptoms fairly quickly. However, the patients ability to participate in sport and desired physical activities and their quality of life are still markedly reduced 1 year after surgery. Further more, a large majority of individual patients do not seem to reach the level of the population with healthy hips.
Add to the outcomes from these studies the fact that a high proportion of hip arthroscopy patients (37%) will undergo a total hip replacement within 10 years following surgery (Kemp et el, Br J Sports Med, 2013), and we see why going into surgery for a hip labral problem should not be taken lightly and should be a last resort if your goal is to get back to physical activity and sport participation. Now, I am not saying that surgery should never be done as it does help some people and they do very well. However, given the research showing that there is a risk to not being able to get back to the things that may have caused you to consider surgery in the first place and there is a risk for future problems, I would recommend trying everything you can to avoid the surgery.
Labral Problems and Imaging
Like a lot of other conditions, imaging done on people without hip pain, show many of the things that are explained as the cause of pain. Tresch et al (2107) showed that patients with FAI (femeroacetabular impingement) and people without hip pain had the same percentage of hip labral tears (44%). Blankenstein et al (2020) showed that 87% of rugby players, ballet dancers, and age-matched controls without symptoms had labral pathology in imaging. Lastly, Mayes et al (2016) looked at the hips of ballet dancers and other sporting participants. They found 51% had labral pathology. However, these findings were not associated with clinical measures such as pain, functions scores, or range of motion. As we see, hip labral "problems" are seen in many healthy, active people without hip pain, so we have to be cautious in identifying things from MRI, as the sole cause of pain.
So, Why does it hurt so much?
The question that likely is coming to mind if you are struggling with hip pain and have been diagnosed with something that is fairly common in high functioning people without pain is "why does it hurt so much?" This is a difficult thing to answer in a Blog because everyone is different and one answer does not fit all individuals. I will lay out here some general things which I consider with all of my patients based on the research that we know about ongoing pain. Again, some or none of these may apply to you, but they are things that need to be considered.
First, there are definitely some physical factors that can contribute to ongoing hip pain. Repeatedly doing activities or sports that aggravate it, sometimes can be found. Doing "stretches" that seem to feel like should help, but are actually making it worse, is something that I commonly see. Not doing physical activities or exercises that could help because you do not know what to do, you are afraid they will make it worse, or you do not have the proper dosing to keep the hip from flaring up are other common things that can make the hip stay painful.
Also, based on what we know about ongoing pain conditions, we have to consider "non-physical" factors that could make your hip stay painful and sensitive. These can include not sleeping well, stress, worry, and anxiety not only related to your hip, but in regard to life in general. Also, being diagnosed with the labral problem can have a profound psychological impact on your thoughts, concerns, worry, and fear about your hip which can also make your hip stay painful and sensitive. In treating you as a "whole" person, these other factors need to be considered.
What does good "conservative" care look like?
Like most other painful musculoskeletal conditions, the basic treatment philosophy is to calm the symptoms down and then build the area back up. Calming symptoms down can include education on what activities or movements need to be modified temporarily to take the stress off sensitive tissue structures. It can also include some hands-on manual therapy to the hip joint to help relieve symptoms so that it is more tolerant to movement and tissue loading.
Probably the most important aspect of managing this is to build the area back up-get to moving the hip and loading the muscles around the hip and entire lower extremity. This needs to be individualized to each person as a one-size-fits-fits all "cookie cutter" approach will not work!. In addition the the gradual progression of individualized exercise, clear, concise education about pain and what it means, how much symptoms are ok, and how to know if you are doing too much or too little, needs to be given.
In my practice, by doing these things and tailoring this to each individual, I find that many people are able to get past the pain they are experiencing and become active and doing the things they want without having to take the surgical step.
Please feel free to reach out if you have any questions,
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