Demystifying Labral Tears

I vividly remember my first class when, upon asking about any injuries, someone raised their hand and mentioned they had a labral tear in their hip.

*googles labral tear**

I had no idea what a labrum was, how it gets torn, how to modify movements for it, much less how to help someone who has it. I was not at all confident that I wouldn’t hurt them in class so I basically just avoided movements that loaded the hip and told them to avoid any discomfort they felt.

While this isn’t wrong, we can do better for our clients when we feel confident we understand some basic information. So let’s break down the anatomy of a labral tear, contraindications (if there are any), and how we can not only help our clients modify for sensitive positions but how we can help them gain the strength to support their joint so they can continue to do the meaningful activities in their life.

ANATOMY & BIOMECHANICS

The acetabular labrum is a non continuous fibrocartilaginous ring that surrounds the hip socket (acetabulum). Inferiorly, the incomplete ends of the labrum are joined by the transverse acetabular ligament crossing the acetabular notch where the soft tissue structures form a foramen (opening) where nerves and blood vessels pass through to supply the intraarticular structures of the hip (Standring, 2016). The labrum is pyramidal, arising from the rim of the hip socket like a mountain. Its base is continuous with adjacent cartilaginous structures and as it tapers to a thin peak it extends beyond the rim of the acetabulum, functionally extending the depth of the hip socket by 33% contributing to the inherent stability of the hip joint and contributing to the dissipation of large forces encountered during activities like running and jumping (Bowman et al., 2010). The labrum, along with the acetabulum, cover nearly half of the femoral head (Grant et al., 2012). In addition to extending the physical depth of the acetabulum the labrum provides a seal for interstitial fluid inside the joint. This seal allows increased hydrostatic fluid pressure which allows the fluid to continue to provide nutrients to the intra articular cartilage (Bowman et al. 2010, Grant et al. 2012).

The collagen fibers of the labrum are oriented differently on the anterior portion of the labrum than on the posterior portion. The collagen fibers on the front are arranged parallel to the bony edge of the acetabulum making them more susceptible to shear forces as opposed to the fibers on the back portion of the labrum, which are arranged perpendicular to the acetabulum making the labral attachment more resistant to shear forces (Grant et al., 2012).

The bottom line: The structure and function of the labrum dissipate high ground reaction forces from common activities as well as provide a stable yet elastic articulation at the femoral acetabular joint. In layman’s terms when we hit the ground at force the labrum takes some of the load off of the articulating cartilage in the hip socket.

LABRAL TEARS

A labral tear can occur as a result of femoral acetabular impingement (FAI), hip dysplasia, traumatic injury, repetitive use, or as a part of natural age-related changes to the joint structure. However, a torn labrum may not be the source of a painful hip even though the labrum is highly innervated (Berthelot et al. 2023). In a 2018 systematic review of the current literature, Heerey et al. found that labral tears are present in 42-54% of asymptomatic individuals and cartilage damage was present in 12-17% of individuals. Heeley et al. also found that 67% of symptomatic individuals did have a labral tear upon imaging where symptomatic individuals tend to be older and have additional degenerative changes to the joint structure. Tears can occur anywhere in the labrum, however, most tears occur in the anterior portion where the collagen fibers run parallel to the bony attachment at the acetabulum rather than perpendicular. So imagine if we draw an imaginary line from the center of the kneecap all the way up to where the thigh meets the pelvis we would then land on that anterior space.The perpendicular attachment creates a stronger bond between the soft tissue and and acetabulum and is able to resist shear forces more effectively than the parallel orientation (Grant et al.2012).

It is theorized that when the labrum is torn, significant stability to the hip joint is lost potentially resulting in higher loads on joint structures like muscles, tendons, and ligaments (Makovich et al. 2020). Symptoms can present in a wide range of structures from the joint itself to the surrounding musculature and even adjacent structures like the knee and there is some debate as to whether a torn labrum predisposes the individual to osteoarthritis (OA) (Makovich et al. 2020). It seems that the most consistent observation of a torn labrum is the loss of the suction mechanism around the femoral head and resultant potential for partial loss of femoral stability (Makovich et al. 2020). You may hear clients complain about pinching sensations when squatting below parallel or when doing high bar footwork, or pain around the entirety of the hip socket, or may even experience clicking or grinding when doing open chain leg exercises like the abdominal series on the mat. However, keep in mind that each client can have different sensations in the hip that may or may not relate to a labral tear.

Suitable Movement Modifications
The good news is that there are no big no no’s when working with labral tears and there are no specific contraindications. Rather than thinking of movements to avoid with this population, we want to think about modifying positions that are particularly problematic for the body in front of you. These may be different for different people. But a good rule of thumb is to either reduce the ROM (make the movement smaller until tolerable) and/or shorten the lever e.g. bend the leg.

RX

So, now that we know a thing or two about labral tears, what do we as movement professionals do with this population? Good question! Conservative management (exercise) and patient education is the first option that is generally presented to people who are symptomatic and show a labral tear upon imaging without the presence of advanced OA (Makovich et al. 2020).

Movement prescription should modify for sensitive positions temporarily while load tolerance is built over time (Makovich et al. 2020). An exercise program, like Pilates, should focus on building hip musculature and dynamic balance (Freke et al., 2016). For Pilates instructors load management and progressively loading hip musculature might look like initially doing footwork on tolerable loads and ranges of motion (deep flexion and internal rotation could produce painful sensations and we could modify footbar height to modify for this sensitive position), progressing to supported two-footed squatting or squatting to the reformer bed or short box, eventually progressing to a single leg unsupported squat. This progression could happen over weeks or even months to years with lots of progressive steps in between. The exact exercises aren't as important as load management (we must progress load to see strength gains) and modification for sensitive positions. Success of conservative management is dependent on lots of different factors like age, underlying tissue and metabolic health, as well as adherence to the exercise program.

Understanding what the client’s goals are and consistently moving them towards those goals will help develop a therapeutic alliance with your client and keep them coming back to your sessions even after their hip pain has subsided. A labral tear is nothing to be afraid of and Pilates can help your client create a different relationship with their pain and understanding of how the surrounding musculature can help support the damaged tissue.

So, go forth and help those folks let go of their fear and get back to doing what they love! 

Anatomy of Pilates helps Pilates instructors feel more confident teaching people with pain and injury through anatomy and post-rehab courses, workshops, and 1:1 coaching. 

References

1. Standring, S. (2016) Gray's Anatomy: The Anatomical Basis of Clinical Practice. Gray's Anatomy Series 41st edn.: Elsevier Limited.

2. Karl F. Bowman Jr.; Jeremy Fox; Jon K. Sekiya (2010). A Clinically Relevant Review of Hip Biomechanics. , 26(8), 0–1129. doi:10.1016/j.arthro.2010.01.027

3. Grant AD, Sala DA, Davidovitch RI. The labrum: structure, function, and injury with femoro-acetabular impingement. J Child Orthop. 2012 Oct;6(5):357-72. doi: 10.1007/s11832-012-0431-1. Epub 2012 Sep 6. PMID: 24082951; PMCID: PMC3468736.

4. Berthelot JM, Brulefert K, Arnolfo P, Le Goff B, Darrieutort-Laffite C. Update on contribution of hip labral tears to hip pain: A narrative review. Joint Bone Spine. 2023 Jan;90(1):105465. doi: 10.1016/j.jbspin.2022.105465. Epub 2022 Sep 20. PMID: 36150666.

5. Heerey JJ, Kemp JL, Mosler AB, Jones DM, Pizzari T, Souza RB, Crossley KM. What is the prevalence of imaging-defined intra-articular hip pathologies in people with and without pain? A systematic review and meta-analysis. Br J Sports Med. 2018 May;52(9):581-593. doi: 10.1136/bjsports-2017-098264. Epub 2018 Mar 14. PMID: 29540366.

6. Makovitch, Steven A.; Mills, Catherine A.; Eng, Christine (2020). Update on Evidence-Based Diagnosis and Treatment of Acetabular Labral Tears. Current Physical Medicine and Rehabilitation Reports, 8(4), 342–353. doi:10.1007/s40141-020-00295-z

7. Freke MD, Kemp J, Svege I, Risberg MA, Semciw A, Crossley KM. Physical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidence. Br J Sports Med. 2016 Oct;50(19):1180. doi: 10.1136/bjsports-2016-096152. Epub 2016 Jun 14. Erratum in: Br J Sports Med. 2019 Oct;53(20):e7. doi: 10.1136/bjsports-2016-096152corr1. PMID: 27301577.