Hello,
I have been diagnosed with a femoral labral tear by a MR Arthrogram. Got the news from a phone call so I haven’t talked with the doctor in person yet.
Seems like I have 3 options
- Steroid Shot – Seems like this is for people who aren’t interested in solving the problem
- PT – May make living with it easier but it also doesn’t seem like it will solve the problem
- Surgery
(I completely understand that you may be hesitant to give generalizations without knowing the specifics of my situation but I’m going to ask anyway)
How often does surgery solve the problem?
What does recovery time look like for this kind of surgery?
Assuming no bone pathology that makes me more likely to have labral problems, is this section of labrum now more likely to have problems in the future?
What questions should I ask the doctor when I go in to go over my images and discuss treatment?
One last question, is it possible that I caused this by over exaggerating ‘knees out’ when squatting?
Thanks,
Peter
So there is a lot to unpack here. The first of which would be to ask what you perceive to be the problem? I’m going to assume that the original complaint was anterior hip pain. If that was the case, relating this directly to an imaging finding is likely not the best way of going about it. There is a high rate of imaging findings related to the hip labrum in the asymptomatic population and sometimes, searching for a surgical solution is putting the cart before the horse.
There is no good evidence for corticosteroid injections (there is some low level evidence but they typically use the Harris Hip Score which is okay for activities of daily living, but has a ceiling effect for people who want to train.
The problem with PT is that it is difficult to determine who and what is a good PT. My question here would be, if PT alleviates your symptoms would you still consider yourself having a “problem?”
Now, to directly answer your questions:
- Depending on the study you read, and where you are aiming for what you consider a “good” outcome depends on the answer to this question. If it is to return to sport, a systematic review from last year had the return to sport level at 74%, but it did not disclose at what level the individual returned to sport.Femoroacetabular impingement surgery allows 74% of athletes to return to the same competitive level of sports participation but their level of performance remains unreported: a systematic review with meta-analysis - PubMed 1. This is variable depending on the surgeon’s criteria and procedure. Normal return to sport is accepted as approximately 9 months at this point. If they do a labral repair, you may be non weight bearing for up to 6 weeks with restrictions on how much your can internally rotate, extend, and adduct your hip.
- No
- I would ask him if he were in your exact position would he undergo the procedure? I would also ask him what the expectations are for you to return to sport and ask in terms of percentages. Make him give you a number and let that influence your decision. If he says 66% are you okay with that?
- I would say there are likely multiple things that may be exaggerating your symptoms right now. The knees out cue is likely lower on that list.
Thanks for your response.
The first of which would be to ask what you perceive to be the problem?
Yes anterior hip pain is the primary problem. I have experienced significant ROM decreases for internal and external hip rotation with pain, popping and clicking at the edges of those ROMs. Training causes a gradual build of pain and loss of ROM until finally I had to stop all lower body training.
Looking around some more I am finding people saying that I should get a “Diagnostic intra-articular hip injections”. What is that and what is it hoping to diagnose?
When I decided to go see a doctor about it my goal was to get back to squatting and deadlifting but now reflecting on it just taking a walk with my wife is painful. I’d like to have that back.
Hey Peter,
This is a good place to start the discussion. If anterior hip pain is the problem, the ultimate goal would be developing a plan with which to decrease that pain. Whether that plan would involve surgery is ultimately up to you but I would also explore what modifiable variables are within your control to address the issue. Many of those variables can be addressed through a good rehabilitation program that focuses on gradually increasing what you are able to tolerate and increasing protective variables. Specific to anterior hip pain, things like decreased internal rotation (which you expressed) and lower strength tend to be linked to experiencing symptoms. Both of those variables are influenceable without utilization of surgery. This gets back to the ultimate question of “where do we start.” If you are experiencing pain even with walking then our first goal is just getting you to where you can walk farther without symptoms. Small gains add up over time. If you are currently able to walk 10 minutes with your wife and you can increase to 15 minutes, that seems like a short increase, but it is 50%. Reintroducing barbell movements will come with time, but sometimes different movements are more advantageous earlier on. Related specifically to anterior hip pain, abductor and adductor strength are correlated with symptoms so even introducing something like a lateral lunge (to tolerance) can start working towards increasing capacity. Even this can be approached from two angles with looking at the weight moved and range of motion obtained. In the same way we advocate for the introduction of a pin squat if someone is experiencing anterior knee pain to work through a tolerable range of motion, the approach can be taken for a lateral lunge.
The problem with looking around for advice is there is just so damn much of it. I tend to try and stick to the original sources from where the statistics are produced. These two studies are likely at least worth a look regarding the diagnostic injection.
Correlation Between Hip Arthroscopy Outcomes and Preoperative Anesthetic Hip Joint Injections, MR Arthrogram Imaging Findings, and Patient Demographic Characteristics - PubMed
Intra-articular Diagnostic Injection Exhibits Poor Predictive Value for Outcome After Hip Arthroscopy - PubMed
I’m going to assume from your two prior messages that you are a least a middle aged individual. This would also give me caution with not attempting conservative measures before advocating for surgery as outcomes do not seem to be as good for individuals over 40.
Hip Arthroscopy in Patients Age 40 or Older: A Systematic Review - PubMed
I do not make that last point to doom and gloom. There are absolutely means with which to address your symptoms and start making your hip feel better. Surgery is certainly among those means, I would not advocate it as a first line option before attempting conservative measures. I would make it clear that your imaging findings may contribute but it is certainly not the cause of your symptoms. There are many variables that can be addressed through much more conservative means to start getting you back to where you want to be.
Derek
Thanks Derek. You have given me a lot to think about.