When we see patients in clinic, we figure out where their pain is coming from. One cause of hip pain within the hip joint itself is hip impingement or femoroacetabular impingement, and the labral tears that oftentimes occur within the hip because of it.
Hip Anatomy
The hip is a ball and socket joint. The ball is the femoral head, on the leg, and the socket, on the pelvis, is called the acetabulum. Around the rim of the socket there is a soft tissue called the labrum, which is a piece of cartilage that forms a seal around the ball and helps maintain good health within the joint itself as well as nerve feedback for the joint. When we have injuries to the labrum itself, those injuries may cause pain.
What is hip impingement?
Hip impingement is a condition in which there is a slight asymmetry in how the bone was formed at the junction between the ball and the neck, which is part of the femur.
There are two types of impingement:
- Cam impingement: A bump on the femoral side that can rub the edge of the socket when you move your hip.
- Pincer impingement: A socket that is deeper than normal or rotated slightly, causing the ball to rub against the socket when you move your hip.
Who gets hip impingement?
Hip impingement patients are usually twenties to forties, but it can happen from your teens to your fifties or sixties.
What are hip impingement symptoms?
Patients will often report pain that they feel deep in the front of the hip or groin, particularly with specific positions or activities like squatting, going up and down stairs, prolonged sitting, getting out of a car, or twisting and rotating.
How do you diagnose a hip impingement or labral tear?
Most of the evaluation comes from the initial clinic visit. By talking to the patient, we can understand when the pain began, what types of activities, movements or positions may cause their pain and what types of treatments they have undergone.
During the physical exam, there are certain maneuvers that can be very indicative of hip impingement or labral tear.
We look at specific x-rays to look at the overall bony alignment of the hip to see if we can see the hip impingement on the x-ray, as well as making sure that there’s not another issue like arthritis that could be contributing to symptoms.
An MRI can be useful for evaluating the overall health of the cartilage within the joint and to see if there is evidence of a labral tear within the hip joint.
Finally, we may do a diagnostic injection, where numbing medication and a small amount of steroid are injected into the hip itself to see if the pain is reduced.
How do you treat hip impingement and labral tears?
Non-operative treatment is tried first.
- Modifying offending activities, although there is a balance between modifying and not being able to do activities you enjoy.
- Physical therapy to identify any areas of weakness around the hip or the core, with a focus on hip strengthening, core strengthening and some overall flexibility.
- Anti-inflammatory medications.
- Injections.
If you have significant improvement with non-operative treatments, you may not need additional treatment. However, if you have ongoing symptoms that are causing significant dysfunction in your overall activities and it happens frequently enough you can’t do the things you want to do, we’ll discuss if surgery would be appropriate.
The surgery is a hip arthroscopy, also called a hip scope. In this same-day surgery, the surgeon goes in through a couple of small incisions around the hip joint into the joint itself. The focus of the surgery is twofold: to fix the labral tear and to take care of the underlying bony impingement that’s causing some of the pain and may have caused the labral tear.
How do you recover from a hip arthroscopy?
After a hip arthroscopy, you’re on crutches for 3-4 weeks to let some of the tissues around the hip joint heal properly. Within a week to ten days after surgery you’ll start physical therapy to work on range of motion and gentle strengthening. Most patients are allowed to get on a stationary bike within the first three to four weeks. At around eight weeks, you’ll transition to more strengthening and possibly an elliptical machine. There’s usually no impact running or jumping for the first three months, but after three months most patients are allowed to slowly progress and add back in activities as they tolerate and as their surgeon and physical therapist allow. Most patients will see an overall full recovery around the five-to-six-month mark.
Frequently asked questions
Is it common to need a hip replacement after having a labral repair?
Usually not. If we look at the overall studies that look at hip arthroscopy, hip impingement and labral tears, there is a thought process that patients who have underlying hip impingement can create damage of the cartilage within the joint and that can place them at higher risk for future arthritis within the joint, which could then lead to a hip replacement. Part of the thought process in our treatment of hip impingement is to hopefully make patients less symptomatic and more functional today and improve the overall health of their hip over their lifespan. The vast majority of patients who undergo a hip arthroscopy do not need any further hip surgeries in the future.
What is the difference between an impingement and a bone spur?
A bone spur is a reactive condition that is a response to underlying arthritis. Bone spurs occur because of loss of cartilage within a joint and the associated inflammation. The hip impingement is related to an underlying formation of the bone while you’re a child.
Do hip impingements usually happen in one hip or both hips?
Since we’re made symmetrically, most people who have a bump on one hip will have it on the other hip. However, not everybody who becomes symptomatic in one hip will have the other hip be a problem. Even if we see the bump on the x-ray, we let the patient’s symptoms guide us in terms of if we need to treat something.
I have patients that end up having hip impingement and a labral tear in both hips that we address surgically in both hips, but I have a fairly high subset of patients that have one hip that becomes symptomatic and the other hip never bothers them.
Can someone have a labral tear after they’ve had a total hip replacement?
No. Patients don’t have a labrum anymore after a total hip arthroplasty, because the joint is replaced with the metal and plastic parts. Hip pain after a total hip replacement would have a different cause.
How long after the labral repair surgery does the pain stop?
Most patients have soreness the first few weeks after surgery, but they’re often pleasantly surprised that it’s not as painful of a recovery as they had anticipated. Within the first month, most patients notice a difference in the daily symptoms they were having. Usually within three to four weeks the majority of patients are off their crutches, walking normally and feeling confident in how their hip is responding.