The spectrum of hip and pelvic arthropathies that alter the joint and adjacent muscles lead to structural and functional joint failure. These arthropathies can lead to pain, stiffness, swelling, disability, and reduced quality of life.1
Hip pain is a common symptom with several potential causes. Three commonly encountered causes of hip pain include femoroacetabular impingement (FAI), hip labral tear, and hip osteoarthritis. FAI is characterized by a premature contact between the acetabulum and the femoral head or head-neck junction causing repetitive microtrauma, which eventually may become symptomatic or result in labral injury.2 Hip labral tears are disruption of the fibrocartilaginous acetabular labrum, which functions as a shock absorber for the hip joint.3 The aforementioned conditions may lead to hip joint degeneration, causing gradual articular cartilage loss and synovial inflammation.4 Hip osteoarthritis is a degenerative process where continued cartilage breakdown results from mechanical overload, causing secondary bony and synovial changes.5
Epidemiology including risk factors and primary prevention
The prevalence of adults with FAI is about 10-15% with symptomatic athletes around 55%.32 About 43-53% of asymptomatic people have FAI.36 There are three types of FAI: cam-, pincer-, and combined impingement. Cam-type impingement is more prevalent in young active males, while pincer-type impingement is more common in middle-aged athletic females. Many patients have the mixed type. Proposed risk factors include pediatric hip diseases, high-impact athletic activities during growth, and genetics. SCFE has been proposed to be a risk factor for development of cam type FAI and in some cases surgical over-correction of a hip dysplasia may lead to a pincer type FAI. Recently, there have been reports that athletes with excessive participation in high-impact sports during adolescence when the skeleton matures have a higher prevalence of FAI when compared to non-athletes.6 Other risk factors include protrusio acetabuli, coxa profunda, acetabular retroversion, prominent posterior acetabular rim, developmental hip dysplasia, femoral retrotorsion and coxa vara.2
Hip labral tears are estimated to be present in 66% of those with mechanical hip pain and in 39% of asymptomatic patients.34,35 Generally, acetabular labral tear is secondary to FAI, trauma, dysplasia, capsular laxity, congenital etiologies, and degeneration.7
Age-standardized prevalence of symptomatic radiographic hip OA has varied from 1% to 10% in large population-based prevalence surveys. Incidence of symptomatic hip OA is 88 per 100,000 per year.33 Risk factors are divided into modifiable and non-modifiable categories. Modifiable risk factors include trauma, BMI, muscle weakness, and high impact activities. Non-modifiable risk factors include female gender, increased age, genetics, and developmental or acquired deformities of the lower extremities.8,32
Three types of morphologic abnormalities may be present in FAI. Cam-type is described as a non-spherical femoral head-neck junction leading to increased pressure at the acetabular rim during flexion and internal rotation. Pincer-type involves an over coverage of the femoral head by the acetabulum resulting in abnormal contact of the acetabular rim on the femoral neck.2,6,10 Mixed-type includes a combination of the two previously mentioned morphologies.
Hip labral tears develop secondary to excessive loading over the acetabular labrum producing direct wearing and tearing of the labral surface.7,11 Hip OA may develop due to repetitive shear stress at the hip articular surface causing cellular and molecular changes, which include decreased type II collagen and proteoglycans in the articular cartilage, increased release of pro-inflammatory mediators, and increased apoptotic cellular changes.8,12
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
It is considered that untreated patients with FAI will experience a gradual deterioration of symptoms, but the long-term outlook is still unknown.2 Patients with labral damage will develop worsening hip biomechanical function leading to accelerated development of hip OA. Pathological biomechanical stress caused by hip OA progressively disrupt the homeostatic equilibrium between joint tissue synthesis and degradation, ultimately resulting in end-stage OA.5,9
Essentials of Assessment
It is important to assess timing, sport or vocational history, precipitating factors, pain location, pain irradiation, mechanical symptoms, and associated symptoms, such as low back pain. One must assess previous history of childhood conditions such as Legg-Calvé-Perthes disease.13
Patients with FAI commonly present with insidious onset of a dull, aching hip pain, which is mainly localized to the anterior groin area. Groin pain may also radiate to lateral hip and anterior thigh.25 Patients with FAI may also have concomitant posterior hip pain which is under-recognized.30 Pain may be exacerbated with athletic activity, certain hip movements, and prolonged sitting and/or walking. Patients’ pain may refer a catching sensation.14
Labral tears frequently cause insidious anterior hip/groin pain worsened with prolonged periods of standing or sitting. There may be a history of trauma or repetitive injury to the hip. Patients may refer clicking, locking, catching, instability, giving way, and/or stiffness. Pain may radiate to the anterior groin, buttock, greater trochanter, thigh, and/or medial knee with irradiation of pain to the buttock.3
Patients with hip OA refer morning joint stiffness, which usually lasts for less than 30 minutes. Pain usually increases with activity and subsides with rest, but as joints become unstable, pain may become present even at rest.15
FAI patients present with restricted hip motion, especially while in flexion from 90 to 110 degrees with adduction and internal rotation. Weakness on hip flexors, external rotators, hip adductors, and hip abductors may be present as well.13 The FABER (flexion, abduction, and external rotation of hip), FADIR (flexion, adduction, and internal rotation of hip), FIR (flexion, internal rotation of hip), log roll, and straight leg raise with resistance (Stinchfield) tests may help with the diagnosis of FAI.25,29 The Thomas test could also be used as a screening tool, although not proven, to test for FAI to reproduce hip extension which places great pressure over the hip joint and indirectly causing hip joint impingement.29
Labral tears cause pain with hip extension and external rotation (Posterior Impingement test).13,16 FAI and labral tears are difficult to distinguish from physical exam and may coexist. When the patient has an isolated labral tear, instability may be present and pain will be reproduced with hip extension.9 Special tests, such as FABER, FADIR, and Thomas, can point the pain towards a possible labral pathology.25,30
Hip OA presents with tenderness at the joint, limited ROM, pain/crepitus with ROM, and joint enlargement to synovial fluid accumulation.15 FABERE (flexion, abduction, external rotation, and extension of hip) and resisted hip abduction tests may help in diagnosing possible hip OA.30
Patients with hip arthropathies have difficulty with walking, standing, bending, and/or athletic activities. Observing patients may cup their hip with a “C sign” indicating an intra-articular hip pathology.25 Gait analysis may reveal a Trendelenburg gait, ankle pronation/supination, or leg length discrepancies.25 Patients may have an antalgic gait with limping due to painful stance phase and will show limitations on weight-bearing activities.2 Decrease sagittal plane ROM during walking and stair ambulation is often visible, which leads to slower cadence. On dynamic assessment, pain may be reproduced with deep squatting. 17,18 Deep squatting may be more difficult for those with FAI.27
Serology is not generally used diagnostically, unless an inflammatory or rheumatologic process is involved or suspected.15
When history and physical exam findings do not give a certain diagnosis, imaging can aid in the assessment of the diagnosis.
Radiographs may reveal cam or pincer deformities demonstrating a flattened head-neck junction or pistol-grip deformity at the proximal femur, respectively. A Dunn view (with hips flexed at 45 or 90 degrees and 20 degrees abduction) on radiograph can also be useful in evaluating for femoral head-neck junction morphology aiding in diagnosis of FAI.25,26
Plain radiographs in patients with hip OA may demonstrate asymmetric narrowing of the joint space, often at the superior lateral part of the hip. New bone formation, osteophytes, and/or loose bodies can also be seen, but no erosive changes should be noted.
Magnetic resonance arthrography (MRA) has become the standard investigative tool in FAI, best demonstrating non-sphericity of the femoral head, head-neck offsets, herniation pits, and rim ossification.15On evaluation for labral tears, plain radiographs may reveal chronicity with calcifications in the labrum. MRI and MR angiography have better sensitivity and specificity than radiographs for evaluation of labral tears, being MRA the most sensitive.14,25
Early predictions of outcomes
Weight loss can reduce symptoms and progression of OA by providing a decrease in joint forces.31 An adequate response to intra-articular injection with corticosteroids or viscosupplementation has shown to delay the need for hip surgery. Once hip surgery is performed, early ambulation results in improved post-operative outcome. For labral tears, physical therapy is recommended through three phases, including pain reduction, strengthening and the transition to sports or work related activities. The tolerance and achievement of each phase will affect how soon the patient can return to work or sports.13
Various environmental factors contribute to hip pathology, particularly repetitive motion injury or heavy mechanical loading arising from occupational and athletic endeavors.28 Repeated, and unusual stresses placed on the joint can tear the labrum, causing the femoral head to flatten or malalign, and thus predispose the patient to degenerative changes. These very same repeated motions, such as heavy lifting, squatting, or knee bending can be a risk factor for hip (as well as knee) OA.31
Progressive hip and pelvic arthropathies often lead to lost work time, as well as problems for athletes returning to play. A comprehensive approach, developed by the physician in charge of the patient’s care, should comprehensively work to maximize patient function over time.
Rehabilitation Management and Treatments
Available or current treatment guidelines
Treatment is directed towards; educating patients about the nature of the disorder and its management, reducing pain, stiffness, disability, handicap, and progression of disease, while improving joint mobility and health-related quality of life.19
At different disease stages
Optimal management requires a combination of non-pharmacological and pharmacological modalities. Patients should be educated about the objectives of treatment and the importance of changes in lifestyle, exercise, pacing of activities, weight reduction, and other measures that will help in unloading the damaged joint. Rehabilitation aims to reduce patients’ symptoms by improving hip stability, neuromuscular control, and movement patterns. Goal of physical therapy is to improve hip ROM, hip muscle strength, and lumbopelvic dissociation. Regular aerobic exercises are also recommended, and for those with pain, exercises in water can be effective. Oral analgesic/anti-inflammatory agents, and/or intra-articular injections (corticosteroids and viscosupplementation) can be used for pain control. Walking aids (cane) and biomechanical interventions (footwear, insole, etc.) can help improve joint congruence and reduce hip loads, leading to reduction in pain levels. When the combination of non-pharmacological and pharmacological treatment does not provide adequate pain control, surgery may be considered.2,19
Coordination of care
A successful treatment of a hip or pelvic arthropathy requires a competent evaluation by the physician, which includes a complete and thorough history and physical exam. Once a diagnosis has been reached, the physician will be able to direct care, either through conservative management (medications, physical therapies, lifestyle modifications, etc.) or a more invasive approach, such as surgery.
Cutting Edge/Emerging and Unique Concepts and Practice
Cutting edge concepts and practice
Complementary and alternative therapies, such as acupuncture, moxibustion, transcutaneous electric nerve stimulation, and percutaneous electrical nerve stimulation, have favorable evidence, suggesting they are efficacious in treating painful OA.20
Recent studies of platelet-rich plasma (PRP), as an autologous biologic agent, suggest it may hold promise in treating hip OA and other hip pathologies.21-23 A pilot study of patients with hip labrum tears who failed conservative treatment were given ultrasound-guided injection of PRP showed statistically significant difference in Harris Hip Score after injection compared with baseline.21 Evidenced-based research regarding treatment with PRP is still limited. There are a variety of factors such as method of preparation, composition, medical condition of the patient, anatomic location of the lesion, and tissue type that can alter the outcome.37 PRP cannot be considered a standard of care until further research establishes such standards.23
Gaps in the Evidence-Based Knowledge
Mardones et al. study demonstrated a promising treatment option using a PRP clot in hip chondral lesions in patients with FAI, but little has been published to support its current use in practice. In another study, Mardones et al. described the use of intra-articular injections of expanded mesenchymal stem cells (MSC) for the treatment of OA. Currently, even though strong evidence indicates that clinical use of MSC is feasible and safe, the clinical efficacy remains controversial.24
- Bennell, K. Physiotherapy management of hip osteoarthritis. Journal of Physiotherapy.2013; 59:145-157.
- Griffin DR, Dickenson EJ, O’Donnell JM, et al. Infographic. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med 2016;50:1169–76.
- Groh GM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2:105-117.
- Loeser, R., Goldring, S., Scanzello, C., and Goldring, M. Osteoarthirtis: A Disease of the Joint as an Organ. Arthritis Rheum 2012;64(6):1697-1707.
- Tibor L.M., Ganz R. (2015) Hip Osteoarthritis: Definition and Etiology. In: Nho S., Leunig M., Larson C., Bedi A., Kelly B. (eds) Hip Arthroscopy and Hip Joint Preservation Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-6965-0_9
- Pun S, Kumar D, Lane NE. Femoroacetabular impingement. Arthritis Rheumatol. 2015;67(1):17-27. doi:10.1002/art.38887
- Su T, Chen GX, Yang L. Diagnosis and treatment of labral tear. Chin Med J (Engl). 2019;132(2):211-219. doi:10.1097/CM9.0000000000000020
- Plotnikoff R, Karunamuni N, Lytvyak E, et al. Osteoarthritis prevalence and modifiable factors: a population study. BMC Public Health. 2015;15:1195. Published 2015 Nov 30. doi:10.1186/s12889-015-2529-0
- Murphy, N. J., Eyles, J. P., & Hunter, D. J. (2016). Hip Osteoarthritis: Etiopathogenesis and Implications for Management. Advances in Therapy. 33; 11 : 1921–1946. http://doi.org/10.1007/s12325-016-0409-3
- Crawford, JR, Villar RN. Current concepts in the management of femoroacetabular impingement. J Bone Joint Surg Br. 2005;87:1459-1462.
- Groh GM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2:105-117.
- Murphy, N. J., Eyles, J. P., & Hunter, D. J. (2016). Hip Osteoarthritis: Etiopathogenesis and Implications for Management. Advances in Therapy, 33(11), 1921–1946. http://doi.org/10.1007/s12325-016-0409-3
- Banerjee P, McLean CR. Femoroacetabular impingement: a review of diagnosis and management. Curr Rev Musculoskeletal Med. 2011;4:23-32.
- Pun, S., Kumar, D., and Lane, N. Femoroacetabular Impingement. Arthritis Rheumatol.2015;67(1):17–27.
- Cuccurullo SJ, ed. Physical Medicine and Rehabilitation Board Review. 2nd ed. New York, NY: Demos Medical Publishing; 2010.
- Kivlan BR, Martin RL, Sekiya JK. Response to diagnostic injection in patients with femoroacetabular impingement, labral tears, chondral lesions, and extra-articular pathology. Arthroscopy. 2011:27:619-627.
- Beatty T. Osteitis pubis in athletes. Curr Sports Med Rep. 2012;11:96-98.
- Troelsen A, Mechlenburg I, Gelineck J, Bolvig L, Jacobsen S, Soballe K. What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics? Acta Orthop. 2009;80:314-318.
- McAlindon, T., Bannuru, R., Sullivan, M., Arden, N., Berenbaum, F., Bierma-Zeinstra, S., Hawker, G., Henrotin, Y., Hunter, D., Kawaguchi, H, Kwob, K., Lohmander, S., Rannou, F., Roos, E., and Underwood, M. OARSI guidelines for the non-surgical management of knee Osteoarthritis. Osteoarthritis and Cartilage.2014;22.
- De Luigi AJ. Complementary and alternative medicine in osteoarthritis. PM R. 2012;4(5 Suppl):S122-133.
- Gordon AH, Karam CS, De Luigi AJ. Intra-articular injection of platelet rich plasma (PRP) relieves pain induced by hip labral tear. Poster presented at: Second Annual Symposium on Regenerative Rehabilitation; November 12-13, 2012; Pittsburgh, PA.
- Nguyen RT, Borg-Stein J, McInnis K. Applications of platelet-rich-plasma in musculoskeletal and sports medicine: an evidence-based approach. PM R. 2011;3:226-250.
- Sanchez M, Guadilla J, Fiz N, Andia I. Ultrasound-guided platelet-rich plasma injections for the treatment of osteoarthritis of the hip. Rheumatology. 2012;51:144-150.
- Mardones, R. and Larrain, C. Cartilage restoration technique of the hip. Journal of Hip Preservation Surgery.2015 1(3):30–36.
- Wilson JJ, Furukawa M. Evaluation of the patient with hip pain. Am Fam Physician. 2014;89(1):27-34.
- Clohisy JC, Carlisle JC, Beaulé PE, et al. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am. 2008;90 Suppl 4(Suppl 4):47-66. doi:10.2106/JBJS.H.00756
- Kivlan BR, Martin RL. Functional performance testing of the hip in athletes: a systematic review for reliability and validity. Int J Sports Phys Ther. 2012;7(4):402-412.
- Harris EC, Coggon D. HIP osteoarthritis and work. Best Pract Res Clin Rheumatol. 2015;29(3):462-482. doi:10.1016/j.berh.2015.04.015
- Reiman MP, Mather RC 3rd, Cook CE. Physical examination tests for hip dysfunction and injury. Br J Sports Med. 2015;49(6):357-361. doi:10.1136/bjsports-2012-091929
- Battaglia PJ, D’Angelo K, Kettner NW. Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging. J Chiropr Med. 2016;15(4):281-293. doi:10.1016/j.jcm.2016.08.004
- Schram B, Orr R, Pope R, Canetti E, Knapik J. Risk factors for development of lower limb osteoarthritis in physically demanding occupations: A narrative umbrella review. J Occup Health. 2020;62(1):e12103. doi:10.1002/1348-9585.12103
- O’Rourke RJ, El Bitar Y. Femoroacetabular Impingement. [Updated 2021 Jun 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547699/
- Oliveria SA, Felson DT, Reed JI, Cirillo PA, Walker AM. Incidence of symptomatic hand, hip, and knee osteoarthritis among patients in a health maintenance organization. Arthritis Rheum. 1995;38(8):1134-1141. doi:10.1002/art.1780380817
- Neumann G, Mendicuti AD, Zou KH, et al. Prevalence of labral tears and cartilage loss in patients with mechanical symptoms of the hip: evaluation using MR arthrography. Osteoarthritis Cartilage. 2007;15(8):909-917. doi:10.1016/j.joca.2007.02.002
- Lee AJ, Armour P, Thind D, Coates MH, Kang AC. The prevalence of acetabular labral tears and associated pathology in a young asymptomatic population. Bone Joint J. 2015;97-B(5):623-627. doi:10.1302/0301-620X.97B5.35166
- Thier S, Gerisch D, Weiss C, Fickert S, Brunner A. Prevalence of Cam and Pincer Deformities in the X-Rays of Asymptomatic Individuals. Biomed Res Int. 2017;2017:8562329. doi:10.1155/2017/8562329
- Navani A, Li G, Chrystal J. Platelet Rich Plasma in Musculoskeletal Pathology: A Necessary Rescue or a Lost Cause?. Pain Physician. 2017;20(3):E345-E356.
Original Version of the Topic
Arthur J. De Luigi, DO, Andrew H. Gordon, MD, PhD. Hip and pelvic arthropathies and labral tears. 9/20/2013.
Previous Revision(s) of the Topic
William Micheo, MD, Brenda Castillo, MD, Belmarie Rodriguez, MD, and Coral Candelario, MD. Hip and pelvic arthropathies and labral tears. 2/13/2018.
Lawrence Chang, DO, MPH
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Shirin Ardeshirzadeh, MD
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Breanna Benjamin, DO
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