What is the best course of treatment for a patient with a left hip labral tear?

Management of Left Hip Labral Tear

For a patient with a left hip labral tear, begin with a minimum 6-month trial of conservative management including physical therapy, activity modification, and NSAIDs; if symptoms persist after this period, proceed to arthroscopic labral repair using suture anchors, which has become the standard surgical approach. 1, 2

Initial Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis with appropriate imaging:

• MR arthrography is the gold standard for diagnosing labral tears, with the highest rating (9/9) from the American College of Radiology 3, 4
• Direct MR arthrography using intra-articular injection of dilute gadolinium solution (1:200) provides superior visualization compared to standard MRI 5
• If MR arthrography is contraindicated, CT arthrography (rating 7/9) is an acceptable alternative 4
• High-resolution 3T MRI without contrast may be sufficient in some cases and can obviate the need for arthrography 5, 4

Key clinical examination findings that support the diagnosis include:

• Positive anterior hip impingement test (FADIR test) - the most consistent physical finding 3, 2
• Pain with internal rotation at 90° hip flexion 6
• Pain with axial compression when hip is flexed 90° and slightly adducted 6
• Tenderness posterior to the greater trochanter 6

Conservative Management Protocol (First-Line Treatment)

All patients should undergo conservative management initially, as this is the mandatory first step in the treatment algorithm 7, 2:

• Duration: Minimum 6 months before considering surgical intervention 1
• Components of conservative treatment:
  • Physical therapy focused on hip stabilization and core strengthening 2
  • NSAIDs for pain and inflammation control 7, 2
  • Activity modification and rest from aggravating movements 2
  • Partial weight-bearing if initiated early may be beneficial 8
  • Pain medications as needed 2
  • Diagnostic/therapeutic intra-articular injection with anesthetic and corticosteroid (rating 5/9) if uncertainty exists about intra-articular pain origin 4, 1, 2

Important caveat: Early diagnosis and treatment initiation is critical, as untreated labral tears may progress to cartilage damage and osteoarthritis 4, 8

Prognostic Factors to Consider

Before proceeding with any treatment plan, assess these prognostic factors that affect surgical success (unanimous consensus among experts) 1:

• Patient age (younger patients have better outcomes)
• Pain severity and functional limitation
• Presence of hip dysplasia
• Degree of degenerative changes on imaging
• Size of associated cartilage lesions

Surgical Management (When Conservative Treatment Fails)

If symptoms persist after 6 months of conservative management, arthroscopic labral repair is indicated 7, 1, 2:

Surgical Technique

• Arthroscopic repair using suture anchors is the current standard approach 7
• This minimally invasive technique allows direct visualization and repair of the torn labrum 4, 7
• The labrum should be repaired rather than debrided when possible, as the labrum provides critical joint stability and load distribution 7

Surgical Options Based on Tear Characteristics

• Small tears with small cartilage lesions (<3 cm²): Debridement followed by microfracture or repair 4
• Larger associated cartilage lesions (>3 cm²): More complex management required 4
• Degenerative tears: May require partial labrectomy, though long-term outcomes need further study 8

Expected Outcomes

• Prompt pain relief is typical after arthroscopic partial limbectomy or repair 6
• Eight of 10 patients in one series were symptom-free at latest follow-up after arthroscopic treatment 6
• Patients treated conservatively without surgery had persistent symptoms 6

Post-Treatment Considerations

After surgical intervention:

• Allow minimum 6 months before reinvestigation for persistent symptoms 1
• Return to sport-specific training timing achieved unanimous consensus among experts, though specific timeframes vary by activity level 1
• There is no consensus on postoperative range of motion restrictions, weight-bearing protocols, or hip brace usage - these should be individualized based on surgeon preference and tear characteristics 1

Common Pitfalls to Avoid

• Do not delay diagnosis: Labral tears may progress to osteoarthritis if left untreated 8
• Do not proceed directly to surgery: Conservative management must be attempted first for at least 6 months 1, 2
• Do not use standard MRI alone: MR arthrography provides significantly better visualization of labral pathology 5, 3, 4
• Do not ignore associated pathology: Always assess for femoroacetabular impingement, dysplasia, and cartilage damage, as these commonly coexist with labral tears 2
• Recognize the steep learning curve: Hip arthroscopy requires proper technique to minimize morbidity 7