Diagnosing a Hip Labral Tear

Diagnosing labral tears in the hip involves:

• Evaluating the hip joint to check for labral problems
• Conducting specific hip labral tear tests to determine if the labrum may be torn or degenerated
• Identifying or ruling out other hip conditions contributing to the patient’s symptoms

A labral tear commonly occurs as a result of another hip condition and the accurate diagnosis and treatment of both the conditions are necessary for overall improvement. For example, hip impingement causes hip labral tear, and both conditions need to be treated.

Physical Evaluation

The initial evaluation involves collecting the medical history and performing a physical examination to evaluate the hip joint.

• Patient history: Specific questions are asked about:
  • Nature of the symptoms, including when they started and what movements cause pain
  • Location of the pain
  • Information on any past injuries and surgeries

A detailed history also helps rule out other sources of the pain, which may be referred to the hip joint.

• Physical examination: In a physical exam, the doctor evaluates:
  • The hip joint’s strength and range of motion
  • Symptoms such as swelling and redness near the hip
  • A pelvic floor and rectal examination may sometimes be necessary depending on the patient’s history and other physical examination findings.

Next, specific hip impingement tests and hip labral tear tests are performed, including an assessment of surrounding joints such as the sacroiliac (SI) joint, lower back, knees, ankles, and feet.

Hip Labral Tear Tests

Specific clinical tests are used to check for labral tears and understand the potential location of the tear (tears in front vs tears at the back).

Three common hip labral tear tests performed in a clinic or doctor’s office include:

Hip labral tear test 1: Twist test¹O’Connor FG, Wilder RP, Nirschl R, eds. Running Medicine. Second edition. Healthy Learning; 2014.

• Initial position: The patient stands in front of the examiner, keeping the feet shoulder-width apart, and holding the examiner’s hands for support.
• Initiate hip joint movement: The patient bends the knee on the affected side to 30° and without moving the hip, moves the bent knee side to side like a windshield wiper.
• Positive response: Pain in the hip joint and/or asymmetric movements while moving the knee (more movement to one side vs the other) may indicate a labral injury and/or hip joint problem.

Hip labral tear test 2: Hip impingement test ²Su 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

• Initial position: The patient lies on their back with the head supported and both arms rested to the side.
• Induce external rotation: The examiner bends the patient’s hip and knee on the affected side to a 90° angle and moves the knee away from the patient’s midline while bringing the patient’s leg and foot toward the body’s midline. This maneuver is called external rotation of the hip. 
  The examiner then returns the patient’s leg to the initial position.
• Induce internal rotation: The examiner bends the patient’s hip and knee on the affected side to a 90° angle and moves the knee toward the patient’s midline while bringing the patient’s leg and foot away from the body’s midline. This maneuver is called internal rotation of the hip and this step is also called an IROP test (internal rotation over pressure).³Berthelot 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;90(1):105465. doi:10.1016/j.jbspin.2022.105465
• Positive response: Pain in the hip joint during internal and/or external rotation may indicate a labral injury and/or hip impingement.

Hip labral tear test 3: FABER test

• Initial position: The patient lies down with both legs straight and relaxed.
• Figure-4 motion: The doctor places the affected leg in a “figure-4” position, by bending the knee to 90° and placing the ankle on top of the opposite knee (which remains straight).
• Downward push: The doctor then applies a gentle downward force against the knee of the bent leg, pushing it toward the examination table.
• Positive response: Groin pain on the side of the bent leg may indicate a problem in the labrum and/or hip joint.

While a positive labral tear test suggests a labral injury, it does not conclusively diagnose a hip labral tear, and additional diagnostic testing is needed for an accurate diagnosis.

Diagnostic Tests for Hip Labral Tears

Diagnostic tests to confirm a labral tear injury include radiographic imaging, ultrasound imaging, injections, and—occasionally—arthroscopic surgery.

• X-ray. Front-and-back view and side-view x-rays are useful in identifying or ruling out bony conditions contributing to the labral tear, such as hip impingement, fractures, and degenerative changes.
  X-rays do not reveal soft tissue tissues, such as the labrum, but sometimes, chronic labral tears that have calcified (calcium deposits in the labrum) are seen on an x-ray.¹O’Connor FG, Wilder RP, Nirschl R, eds. Running Medicine. Second edition. Healthy Learning; 2014.
• Magnetic resonance arthrography (MRA). An MRA scan is similar to an MRI. It uses an injected contrast fluid, which provides doctors with a better image for diagnosing labral tears and related problems, such as damage to hip cartilage or hip osteoarthritis.
  MRA is more accurate and reliable than standard MRI for diagnosing hip labral tears.⁴Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2(2):105-117. doi:10.1007/s12178-009-9052-9
• Diagnostic hip injections. If a diagnosis remains unclear after an MRA, the doctor may suggest injecting a numbing medicine (such as lidocaine) into the hip joint. This type of injection is called a diagnostic intraarticular injection. 
  Ultrasound or fluoroscopy is used to guide the needle to the precise location of the suspected tear. 
  If pain relief is achieved, then the labrum is likely to be the source of pain.
• Arthroscopic hip surgery. This minimally invasive surgical procedure allows the doctor to see and treat the suspected labral tear by making 2 or 3 small incisions, about 5 mm each, near the hip joint. 
  A pencil-sized tool called an arthroscope, equipped with a tiny camera, is inserted through the incision and guided near the hip joint using ultrasound or fluoroscopy. The camera displays the view around the joint on a computer screen for the doctor to confirm a labral tear and/or other problems affecting the joint.
  If a labral tear is identified, surgical treatment for the tear is performed during the same procedure.
  Arthroscopic surgery typically involves general anesthesia and is reserved for cases where a labral tear is strongly suspected.

MRA and arthroscopic surgery are the most reliable tests for diagnosing hip labral tears, with arthroscopic surgery considered the gold standard diagnostic procedure for this condition.⁴Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2(2):105-117. doi:10.1007/s12178-009-9052-9