Hip labral tear

The acetabular labrum is a fibrocartilaginous ring surrounding the rim of the acetabulum, the socket of the pelvis in which the femoral head articulates. A hip labral tear refers to a tear, detachment, rupture or degeneration of this tissue.

In runners, it can cause groin or hip pain, but its mere presence on imaging does not necessarily mean that it is responsible for the symptoms: labral tears are frequently seen in people with few or no symptoms.

Labral tears are frequently associated with femoroacetabular impingement (FAI/FAIS), a cam or pincer hip morphology, hip dysplasia, repetitive sports overload, trauma or a twisting movement, or associated cartilage lesions. Moreover, the diagnosis of femoroacetabular impingement syndrome is not based solely on the presence of a bony morphology or a labral tear: it requires agreement between symptoms, clinical signs and imaging.

The labrum is a fibrocartilaginous ring attached to the rim of the acetabulum, the socket of the pelvis that receives the femoral head. It plays several essential roles in hip mechanics.

Deepening the acetabulum

It increases the functional depth of the acetabular socket and thus contributes to hip stability.

“Seal” effect

The labrum helps maintain a suction effect around the femoral head, a function that also contributes to joint stability.

Load distribution

It helps distribute pressure between the femoral head and the acetabulum.

Cartilage protection

It helps protect the articular cartilage and maintain the mechanical properties of the synovial fluid. A labral tear can therefore alter joint mechanics, but its clinical significance depends heavily on the context: bony morphology, state of the cartilage, and associated symptoms and clinical signs.

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The different types of labral tears

A tear may be peripheral, longitudinal, radial, complex, or detached from the acetabular rim, with or without associated cartilage damage. It may also occur in isolation, or be associated with cam impingement, pincer impingement, dysplasia or early osteoarthritis. This distinction matters: a labral tear associated with dysplasia is not treated in the same way as a tear related to cam impingement.

Labral tears mainly affect runners, pivoting sports athletes (football, tennis, dance), people practising sports involving deep flexion, and young active adults (20–45 years). Many tears are present without pain but become symptomatic during mechanical overload. In runners, they are a common cause of persistent groin pain, unexplained discomfort on returning to sport, and chronic hip pain.

Mechanisms of labral injury

The labrum can be subjected to significant stress during movements combining hip flexion, adduction, internal rotation, external rotation and axial loading. Repeated movements at end range can cause repetitive stress on the acetabular rim. In athletes, labral tears are particularly common when the hip has a morphology that predisposes to femoroacetabular impingement.

Femoroacetabular impingement (FAI)

Femoroacetabular impingement, or FAI, is a common cause of labral tears in athletes. There are two main morphologies, which can also occur together (mixed form).

Cam morphology: there is a bony prominence at the femoral head–neck junction. During hip flexion and rotation, this prominence can impinge on the acetabular rim.

Pincer morphology: the acetabular rim covers more of the femoral head. Certain positions can then compress the labrum against the femoral neck.

Why are runners affected?

Running involves thousands of cycles of flexion-extension, loading, pelvic rotation and single-leg stabilisation: the hip must control the movement of the pelvis with every foot strike. Certain situations can increase the stresses: a sudden increase in training volume, trail running, significant elevation changes, speed sessions, a long stride, hill work, muscle fatigue or a major change in running technique.

However, there is no evidence that running alone is responsible for a labral tear: hip morphology, medical history, sporting demands and individual factors all interact.

The most typical presentation is groin pain: the patient often describes a deep, anterior pain located in the groin. They may show the painful area by cupping the front of the hip with their hand — a sign sometimes called the C-sign.

Positions combining marked flexion and rotation can provoke symptoms: deep squatting, crouching, getting in and out of a car, climbing certain stairs, prolonged sitting. During a run, pain may appear at the start of the session, after several kilometres, during accelerations, on hills or after the session. Some patients also experience clicking, snapping, a catching sensation or a feeling of locking — although these symptoms are not specific to the labrum.

In runners, the pain can be difficult to locate: it may be felt in the groin, at the front of the hip, in the buttock area, on the side of the hip, or sometimes in the thigh. Clearly lateral pain should prompt a search for gluteal tendinopathy or trochanteric bursopathy; posterior pain should prompt a search for other diagnoses.

A labral tear can also cause discomfort in flexion, pain during rotation, reduced performance or limitation of certain ranges of motion. However, a genuinely marked limitation of mobility should prompt a search for more widespread joint involvement.

Clinical examination

The examination starts with an overall assessment of the lower limb: walking, running if possible, hip mobility, muscle strength, pelvic control, single-leg stability, and mobility of the lumbar spine, knee, sacroiliac joint and peritrochanteric structures.

Hip mobility is assessed in all planes (flexion, extension, abduction, adduction, internal rotation, external rotation). Limited internal rotation, particularly in flexion, may be found in femoroacetabular impingement syndrome — but no single limitation is enough on its own to make the diagnosis.

Several provocation tests can be used. The FADIR test (flexion, adduction, internal rotation) is frequently positive in femoroacetabular impingement syndrome; its high sensitivity mainly means that a negative test can be useful to rule out certain conditions, but a positive test is not specific to a labral tear. The FABER test (flexion, abduction, external rotation) explores different structures of the hip and looks for provoked pain. The log roll test (passive rotation of the lower limb) can reproduce intra-articular pain or reveal laxity. The resisted flexion test can reproduce some anterior hip pain. However, no single test can diagnose a labral tear on its own.

When should surgery be considered?

Surgery may be discussed when symptoms are persistent, functional impairment is significant, properly conducted rehabilitation has not brought sufficient improvement, the intra-articular diagnosis is well established, a correctable structural lesion has been identified, and the patient has a morphology suitable for joint-preserving surgery.

The decision must be individualised: age, the state of the cartilage, dysplasia, osteoarthritis and the severity of symptoms influence the prognosis. The 2025 consensus notably considers age, pain severity, dysplasia and degenerative changes to be important prognostic factors for the surgical outcome.

Hip arthroscopy

The procedure may involve several steps. When the labrum is repairable, the current aim is, as far as possible, to preserve and repair it; when the tissue is irreparable or insufficient, reconstruction may be considered in certain situations. Osteoplasty can correct the bony prominence responsible for cam impingement, and targeted bone resection can correct an acetabular rim responsible for pincer impingement. The joint capsule must also be taken into account in order to preserve or restore hip stability.

Modern surgery therefore aims to treat the mechanical cause associated with the labral tear, and not simply to remove the labrum.

Rehabilitation after surgery

Recovery depends on the type of tear, the type of repair, any cam/pincer correction or reconstruction, the state of the cartilage and the sporting level. There is no single protocol applicable to all hip arthroscopies: weight-bearing and permitted ranges of motion depend on the surgical procedure performed.

Post-operative rehabilitation is generally organised in several phases: an early phase aimed at controlling pain and inflammation, protecting the repaired tissues and gradually recovering the permitted mobility; a muscle recovery phase (gluteus medius activation, strengthening of the gluteus maximus, rotators, quadriceps and hamstrings, core work, single-leg work) aimed at functional symmetry; an advanced strengthening phase gradually introducing loaded squats, split squats, lunges, deadlifts, step-ups, step-downs, single-leg work and multidirectional exercises; then a power phase (jumps, bounding, plyometrics, accelerations, changes of pace), conditional on prior recovery of strength and motor control. The running-specific phase then follows a progression comparable to that of conservative treatment (brisk walking, walk-run intervals, continuous running, increasing distance, accelerations, hills, specific work, return to usual volume), with speed and hills only reintroduced once good tolerance of easy running has been regained.

Return to sport after surgery

The return should not be determined by the calendar alone. Criteria include mobility, pain, strength, stability, neuromuscular control, endurance, power, agility and sport-specific tasks: modern rehabilitation programmes after hip arthroscopy increasingly use a criteria-based rather than strictly time-based progression.

Published data generally report high rates of return to sport after surgery for femoroacetabular impingement, but returning to the same level depends in particular on the state of the cartilage, the type of sport and the initial level: one systematic review reported approximately 87% return to sport and 82% to the same level, with considerable heterogeneity between studies.

Prognosis

The prognosis depends heavily on the overall condition of the hip. Favourable factors include younger age, moderate pain, preserved cartilage, the absence of significant osteoarthritis or dysplasia, an accurate diagnosis, well-conducted rehabilitation and correction of a mechanical abnormality when indicated. Unfavourable factors include osteoarthritis, significant cartilage damage, dysplasia, severe and long-standing pain, older age and significant degenerative changes. An isolated labral tear in a young runner with preserved cartilage therefore does not have the same prognosis as a labral tear associated with hip osteoarthritis.

Timeframes vary widely. A gradual return to running generally takes place several months after surgery, and for athletes, a full return to sport is often around 6 to 8 months, with considerable variation depending on the type of procedure, the labral repair, the bony correction performed, the sporting level, the recovery of strength and the functional criteria achieved.

It is therefore best to avoid giving the patient a fixed return date: the timeline guides rehabilitation, the criteria determine progression.

There is no programme that can prevent all labral tears, but certain strategies can be helpful.

Load progression should avoid sudden increases in mileage, intensity, elevation gain or speed work. Muscle strengthening (glutes, quadriceps, hamstrings, trunk muscles) should be maintained regularly, as should single-leg control: the runner must be able to stabilise their pelvis properly during stance.

Range-of-motion management means avoiding unnecessary repetition of forced end-range movements when they are painful. Finally, varying the stresses by alternating running, cycling, strengthening, mobility and recovery helps limit repetitive overload of the hip.