Hip Labral Tear? Causes of Pain After Hip Arthroscopy
POSTED ON 12/1/2016 IN Research BY Christopher Centeno
The animated GIF above may drive you a bit nutty if you watch it long enough, but it's crucial nonetheless. Arthroscopic hip surgery to treat a labral tear is frequently billed as a minimally invasive procedure, but from the damage we've seen created by the tools used to perform the surgery, I don't know if that's true. This is another one, in our ever-expanding collection of MRIs, that shows tissue damage caused by the surgery, which led to pain after hip arthroscopy. So let's explore today why a patient would still be in pain despite this procedure. It's also helpful to educate you through the lens of a patient's experience and what I found this week on an examination.
Hip Arthroscopy Rates Have Exploded in the Past Decade
In the last decade, hip arthroscopy rates have exploded, making it the fastest growing type of orthopedic surgery. On the surface, this seems like a good thing as before arthroscopy most hip conditions couldn't be operated on without more invasive open hip surgery or replacement. However, when we dig beneath the surface, we discover there are many problems with hip arthroscopy, including not only poor results but also the fact that many are just simply unnecessary.
A hip arthroscopy involves making an incision through the skin and into the body and inserting a scope into the hip joint to visualize the structures. Once the scope is inserted, portals, or access tunnels, are then created through the body and into the joint, so the surgeon can insert the surgical tools needed to complete the procedure. Through these portals, the surgeon performs the repair as he or she visualizes it through the scope. Tears in the labrum and hip impingement are the two most common conditions treated using hip arthroscopy.
The hip is a ball-and-socket joint, and the lip around the socket where the ball of the femur inserts is called the labrum. The labrum can experience tears or degeneration. A hip impingement can occur when any of the bones of the joint somehow become misshapen or even when the patient is born with an oddly shaped hip. In addition to the lack of high-level research showing the effectiveness of hip arthroscopy, there are a number of reasons why hip arthroscopy may be unnecessary or even cause further complications, including the following:
The Portal Syndrome
In the last section, I mentioned the portals, those tunnels created through the patient's skin, tissues, and muscles during hip arthroscopy to insert surgical tools and instruments to access the joint. These portals in and of themselves can cause chronic pain and other problems, and I've seen this in enough patients that I created a term for it: “portal syndrome.”
The idea is that those portals used for arthroscopy equipment should heal up quickly; however, sometimes this isn't the case, and instead a gaping tunnel through the tissue remains. Understandably, portal syndrome, this unhealed tissue, can be the source of chronic and ongoing pain. Add this to the poor results for some patients and constant pain in the hip joint itself following arthroscopy, and it's easy to see why patients should be cautious about making this surgical decision.
What Other Things Can Cause Hip Pain if Not the Hip?
I've mentioned the idea of “MRI hysteria” before. This happens when doctors find an abnormality on a patient's MRI and assume it is the cause of the patient's pain. To the patient, this makes sense. The patient's hip hurts, and the MRI shows a tear in the labrum—problem solved, let's operate. But it's just not that simple. In fact, there is a great deal of scientific evidence that there is no association between hip pain and labral tears that show up on an MRI.
Consider this for a minute. Research shows that patients can have labral tears and have NO pain, and it also indicates that patients who have hip pain have no more labral tears than those with no pain. So if labral tears are not associated with hip pain, how is operating on the labrum going to address the patient's hip pain? And if it isn't the tear in the labrum seen on MRI causing the hip pain, what else could it be?
We see many patients after hip arthroscopies still complaining of pain. The reason is that the pain was never coming from their hip joint but from somewhere else. Click on this link to view my “Common Causes of Chronic Hip Pain” infographic. Let's review a few of these:
My Patient's Pain after Hip Arthroscopy Story
This patient is an ex-figure skater who noted sharp hip pain after a sudden movement a few years back. She had an MRI showing a labral tear and then was told she needed hip arthroscopy to help the damage. The recovery was awful, taking 6–7 months in PT to feel halfway normal. After the surgery, she had more pain than before, so she sought out our care.
The first interesting thing I found on this patient's exam is that she also has severe SI joint instability on the same side as her labral tear. This is likely from many falls on her backside as a figure skater. This diagnosis was completely missed as the operating surgeon never considered or looked at her low back. So right off the bat, most of her hip pain could very well be originating from that SI joint problem.
However, what's on her MRI is fascinating, so much so that I've created an animated GIF of the issue above. I used this form of media because the area of interest shows up on about 10 different slices, making it impractical to show on static images. Realize that the picture above is a cross section looking down at the hip, which appears as the circular structure. The yellow arrow points to the problem. The white stuff is MRI contrast injected into the joint. What does the animated GIF show?
Note the normal dark-appearing muscle in cross section just to the right of the yellow arrow and above the circular hip bone. Also note that the arrow points to an area of white in that dark muscle. What is this? It's MRI contrast that has leaked from the joint into the tears in the muscle. In fact, parts of this white area mirror pathways that the surgical tools took to enter the hip. These injuries to her psoas muscle have never healed, as it's been years since her surgical procedure. Also, the entire undersurface of the psoas muscle is damaged as a result of the hip arthroscopy. This is similar to the portal syndrome I have outlined above. Given that the psoas is a key stabilizer of the hip and spine and is involved in flexing your hip or needs to relax for you to straighten up, it's not surprising she now has more severe chronic hip pain. I'll treat this issue this week using a same-day stem cell injection by precisley injecting these into her hip as well as this damaged muscle.
The upshot? There's nothing "minimally invasive" about hip arthroscopy surgery. The tools and devices used to get into the joint can cause severe and permanent injury to the ligaments, muscles, and fascia around the joint. We've seen it many times in many patients. So do yourself a favor: avoid hip arthroscopy where possible and stick with precise injections instead! We don't leave gaping holes in our patients when we inject them...
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