HIP LABRAL TEARS
Anterosuperior Most Common | Associated with FAI
Tear Locations
Critical Must-Knows
- Anterosuperior location most common (85%), usually FAI-related
- Labrum seals hip joint and distributes load
- FADIR test reproduces pain (anterior impingement)
- MR arthrogram is gold standard imaging
- Labral repair superior to debridement for outcomes
Examiner's Pearls
- "Labrum increases acetabular depth 22% and surface area 28%
- "Contains free nerve endings - important for proprioception
- "Cam FAI causes outside-in delamination at labral-chondral junction
- "Address underlying cause (FAI, dysplasia) with labral surgery
Clinical Imaging
Imaging Gallery
Critical Hip Labral Tear Exam Points
Function
Labrum functions: Seals joint (suction seal), stabilizes femoral head, distributes load, increases depth (22%) and surface area (28%). Contains proprioceptive nerve endings.
Location
Anterosuperior (85%): Usually FAI-related. Posterior: Dysplasia or trauma-related. Location guides surgical approach and prognosis.
Associated Pathology
Must identify underlying cause: FAI (cam/pincer), dysplasia, instability. Treating labrum alone without addressing morphology leads to failure.
Repair vs Debridement
Labral repair preferred over debridement. Multiple studies show better outcomes with repair. Preserves sealing function and proprioception.
At a Glance
Hip labral tears predominantly occur in the anterosuperior location (85%) and are most commonly associated with femoroacetabular impingement (FAI)—cam morphology causes outside-in delamination at the labral-chondral junction. The acetabular labrum serves critical functions: it increases acetabular depth by 22% and surface area by 28%, creates a suction seal to contain joint fluid, and provides proprioceptive feedback through free nerve endings. Clinical diagnosis relies on the FADIR test (flexion, adduction, internal rotation reproducing anterior impingement pain), with MR arthrography serving as the gold standard imaging modality. Surgical management favors labral repair over debridement, as multiple studies demonstrate superior functional outcomes when the labrum is preserved. Critically, underlying morphologic abnormalities (FAI, dysplasia) must be addressed concurrently—treating the labral tear in isolation without correcting the bony pathology leads to predictable failure.
SSSDLabral Function
Memory Hook:SSSD = Seal, Stabilize, Surface area, Depth - labral functions!
FAD-TLabral Tear Causes
Memory Hook:FAD-T = FAI, Acetabular dysplasia, Degeneration, Trauma!
Overview and Anatomy
The acetabular labrum is a fibrocartilaginous structure attached to the rim of the acetabulum. It extends the coverage of the femoral head, increases joint stability, and contributes to the sealing function of the hip joint.
Anatomy
The labrum is triangular in cross-section, attached to the acetabular rim. It is continuous with the transverse acetabular ligament inferiorly. Blood supply is from the capsular side (peripheral). The labrum contains free nerve endings and is important for proprioception.
Function
The labrum creates a suction seal maintaining negative intra-articular pressure. It increases acetabular depth by approximately 22% and surface area by approximately 28%. Labral damage compromises this seal and alters joint mechanics.
Clinical Presentation
History
Patients present with groin pain (most common), though may also describe anterior thigh, buttock, or lateral hip pain. Pain is typically activity-related and may be accompanied by mechanical symptoms (clicking, catching, locking). Prolonged sitting may aggravate symptoms. Athletes often report difficulty with sport-specific activities.
Examination
FADIR Test (Anterior Impingement Test): Flexion, Adduction, Internal Rotation reproduces groin pain. Most sensitive clinical test.
FABER Test: Flexion, Abduction, External Rotation may reproduce pain or indicate SI pathology.
Range of Motion: May be reduced, particularly internal rotation in flexion if FAI is present.
Gait: Usually normal unless significant pain or associated pathology.
Log Roll: May reproduce pain with minimal stress on the hip.
Diagnosis
Plain Radiographs: Assess for underlying morphology (FAI, dysplasia, osteoarthritis). AP pelvis, lateral hip. Measure alpha angle, lateral center-edge angle.
MRI: Shows labral pathology. Standard MRI may miss some tears.
MR Arthrogram (MRA): Gold standard. Intra-articular gadolinium improves sensitivity and specificity for labral tears. Shows tear location, size, and associated cartilage damage.
CT: For detailed bony morphology assessment if planning surgery.
Management
Activity Modification: Avoid provocative positions and activities.
Physiotherapy: Hip stability, core strengthening, range of motion exercises.
Analgesia/NSAIDs: Symptomatic relief.
Intra-articular Injection: Local anesthetic/corticosteroid. Diagnostic (confirms hip as source) and therapeutic (temporary relief).
Conservative treatment may provide symptomatic relief but does not heal labral tears.
Evidence Base
- Labrum contributes 22% of acetabular depth
- Labrum increases surface area 28%
- Sealing function demonstrated
- Foundation for understanding labral importance
- Labral repair vs debridement comparison
- Repair group had better outcomes
- Higher satisfaction with repair
- Lower re-operation rate
- Hip arthroscopy outcomes for labral tears
- Good results in athletes
- High return to sport rate
- Patient selection important
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Hip Labral Tear
"A 30-year-old woman with groin pain has an anterosuperior labral tear on MR arthrogram. How do you manage her?"
Scenario 2: Posterior Labral Tear with Hip Dysplasia - Complex Decision-Making
"You are seeing a 24-year-old recreational runner with a 12-month history of deep buttock and posterior hip pain. She describes a sensation of hip instability, particularly when walking on uneven ground, and occasional painful clicking. Her FADIR test is negative, but she has a positive posterior rim impingement test and apprehension with external rotation in extension. Plain X-rays show a lateral center-edge angle (LCEA) of 18° (normal greater than 25°), Tonnis angle 15° (normal less than 10°), and no cam morphology (alpha angle 42°). MR arthrogram demonstrates a posterior labral tear (zone 4-5) with adjacent chondral thinning (Outerbridge grade II) and anterior subluxation of the femoral head on dynamic imaging. How do you counsel this patient about management options?"
Scenario 3: Failed Labral Repair - Recurrent Symptoms and Revision Decision-Making
"You are seeing a 32-year-old man who underwent right hip arthroscopy with labral repair and cam osteochondroplasty 14 months ago. He initially improved for 4-5 months post-operatively but has had gradual recurrence of groin pain over the past 6 months. He now has similar symptoms to pre-operatively: groin pain with prolonged sitting, FADIR test positive, reduced internal rotation (15° vs 25° on left). You obtain his pre-operative imaging which shows an alpha angle of 72° with an anterosuperior labral tear. His new plain X-rays show the joint space is preserved (3mm), no progression of osteoarthritis (Tonnis 0), but the post-operative alpha angle measures 58° (inadequate correction - should be less than 50°). A new MR arthrogram shows re-tear of the repaired labrum at the same anterosuperior location with contrast extravasation, and Outerbridge grade II cartilage in the anterosuperior acetabulum (unchanged from pre-op). The patient is frustrated and asking about revision surgery. How do you assess this patient and what are the management options?"
MCQ Practice Points
Location
Q: What is the most common location for hip labral tears? A: Anterosuperior (85%). Usually associated with FAI (cam or pincer morphology).
Imaging
Q: What is the gold standard imaging for hip labral tears? A: MR arthrogram (MRA). Intra-articular gadolinium improves sensitivity and specificity.
Treatment
Q: Is labral debridement or repair preferred? A: Repair is preferred. Multiple studies show better outcomes with repair. Preserves labral function and proprioception.
Australian Context
Clinical Practice: Hip labral tears are commonly diagnosed and treated in Australia. MR arthrography is widely available. Hip arthroscopy is performed at specialized centers.
HIP LABRAL TEARS
High-Yield Exam Summary
Labral Function (SSSD)
- •Seal (suction seal)
- •Stabilize femoral head
- •Surface area increase (28%)
- •Depth increase (22%)
Key Facts
- •Anterosuperior 85% (FAI-related)
- •FADIR test positive
- •MR arthrogram gold standard
- •Repair preferred over debridement
Causes (FAD-T)
- •FAI (cam/pincer)
- •Acetabular dysplasia
- •Degeneration
- •Trauma
Treatment Principles
- •Address underlying morphology
- •Repair if possible
- •Debridement for irreparable tissue
- •Incomplete correction leads to failure