The Management of Acetabular Labral Tears: A Contemporary Review

Abstract

Purpose of Review

To summarize contemporary evaluation and management of acetabular labral tears, particularly in the setting of femoroacetabular impingement syndrome (FAIS), including diagnosis, nonoperative care, surgical decision-making, and rehabilitation.

Recent Findings

The acetabular labrum is critical for maintaining hip stability, preserving the suction seal, and distributing load. Evaluation includes history, provocative examination, radiographs to assess CAM and Pincer morphology, and advanced imaging to confirm labral pathology and exclude alternative pain generators. Nonoperative treatment, including activity modification, targeted physical therapy, and selective intra-articular injections, is first-line. Appropriately selected patients often achieve significant pain relief and functional improvement with arthroscopic hip preservation surgery. Current surgical strategies prioritize labral preservation through repair when viable, reconstruction for irreparable tissue, correction of underlying osseous abnormalities, and meticulous capsular management.

Summary

Acetabular labral tears are a common source of hip pain frequently associated with FAIS. A structured diagnostic approach and stepwise management encompassing nonoperative and appropriately indicated surgical intervention optimize outcomes. Individualized, phase-based rehabilitation with objective testing and sport-specific criteria supports return to activity and sport, with typical return occurring around 6–8 months but varying widely by sport and athlete demands.

Introduction

Acetabular labral tears are increasingly recognized as a common source of hip pain and dysfunction across a wide range of patient populations. Initial descriptions of labral pathology appeared in the traumatic setting as early as 1959, with the first arthroscopically confirmed labral tear reported by Suzuki in 1986 [1, 2]. Subsequent observations linked labral tears to abnormal proximal femoral (CAM) or acetabular (Pincer) morphology, with the term femoroacetabular impingement syndrome (FAIS) coined by Ganz in 2003 [3]. These concepts established CAM and Pincer morphologies as bony abnormalities that can reproducibly induce labral shear and compressive injury during dynamic hip motion and as contributors to early joint degeneration [3, 4].

Epidemiologic studies have demonstrated that acetabular labral tears are highly prevalent in both symptomatic and asymptomatic individuals. Specifically, labral tears have been identified in 22% to 55% of painful hips and between 38% and 43% of asymptomatic hips [5–7]. Biomechanically, the labrum has been shown to play a critical role in shock absorption, maintenance of the hip suction seal, joint stability, and joint lubrication, with disrupted labral integrity resulting in increased cartilage contact stresses [5, 8–11]. Improved understanding of CAM and Pincer lesion development, including repetitive stress to the proximal femoral physis during maturation, has driven a shift toward labral preservation and bony correction in hip preservation strategies [12]. This evolution in understanding parallels a dramatic increase in hip arthroscopy utilization, with a reported 97% increase between 2015 and 2023 [13]. This rise in utilization is supported by studies demonstrating favorable long term outcomes and patient satisfaction following contemporary labral repair and capsular management [14–17]. In this review, we summarize the evaluation, nonoperative and operative treatment options, surgical indications, rehabilitation, and return-to-sport considerations for acetabular labral tears.

Anatomy of the Acetabular Labrum

The acetabular labrum is a fibrocartilaginous structure that forms a continuous ring around the acetabular rim, blending inferiorly with the transverse acetabular ligament (Fig. 1). It functions as a seal around the hip joint, maintaining a thin layer of pressurized fluid between the femoral head and acetabulum that distributes load and protects articular cartilage from compression and degeneration [18, 19]. Disruption of this complex compromises the hip’s suction seal, load distribution, and joint stability, leading to abnormal cartilage stresses.

Fig. 1.

Cadaveric dissection of the hip. (A) Femur articulating with the acetabulum, demonstrating the labro-acetabular complex and associated soft tissue structures forming a circumferential seal around the femoral head. (B) Pelvis with the femur disarticulated, illustrating the acetabulum with the acetabular labrum and transverse acetabular ligament surrounding the acetabular rim, the articular cartilage lining the acetabular surface within these structures and the central, acetabular (cotyloid) fossa

[5, 8, 20, 21]. The labrum is typically triangular in cross-section, wider and thinner anteriorly and thicker posteriorly, and on its articular surface blends with acetabular hyaline cartilage through a zone of calcified cartilage [18, 22–25]. Perfusion is limited to the outer third, rendering the inner portion largely avascular [26, 27]. Nerve endings and mechanoreceptors distributed throughout the labrum support its role in pain generation and proprioception, collectively explaining why labral disruption can produce pain, mechanical symptoms, and progressive chondral overload [28].

Anatomy of the Hip Capsule

The hip is surrounded by three primary reinforcing capsular ligaments: the iliofemoral, ischiofemoral, and pubofemoral ligaments [29]. The iliofemoral ligament, the strongest of the three, originates from the anterior inferior iliac spine and attaches to the intertrochanteric line as lateral and medial branches (Fig. 2A) [29, 30]. During hip arthroscopy, the capsule is incised to achieve adequate visualization and access to the joint. Interportal capsulotomy is the most commonly performed type and has been reported to violate up to 74.2% of the iliofemoral ligament width [31–34]. Failure to maintain or restore capsular integrity is a recognized cause of pain, dysfunction, and reoperation, accounting for up to 35% of revision hip arthroscopy cases [32]. Cadaveric studies have demonstrated that interportal capsulotomy reduces the force required to distract the hip, though side-to-side or suture anchor-based repair can restore strength to near-native levels [35]. Unrepaired capsulotomy has been associated with macro-instability events due to compromised resistance to anterior translation during hip extension and external rotation [36]. These findings underscore the critical importance of meticulous capsular management during hip arthroscopy to preserve native hip biomechanics and stability.

Fig. 2.

Cadaveric dissection of hip capsule structures. (A) The iliofemoral ligament, originating from the anterior inferior iliac spine (AIIS) and inserting along the intertrochanteric line as two distinct components: a lateral (superior) and a medial (inferior) branch. The pubofemoral ligament is also visible, extending from the pubic portion of the acetabular rim and blending with the inferior aspect of the capsule. (B) Extra-articular view of an interportal capsulotomy (dashed line) of the anterior capsule

Clinical Presentation of Labral Tears

The primary symptom of FAIS is motion or position-related hip or groin pain, which may be either traumatic or insidious in onset [37]. Pain may radiate to the lumbar spine, buttock, or thigh, and patients may also report clicking, catching, locking, stiffness, or weakness. Importantly, impingement-related pain may coexist with other pain generators, and clinicians must identify the primary source.

A focused physical examination should include palpation, range-of-motion assessment, strength testing, gait assessment, and provocative maneuvers [38]. Internal rotation is often limited by impingement, and the flexion adduction internal rotation (FADIR) maneuver is sensitive but not specific for FAIS [39]. Critically, provocative maneuvers must recreate the patient’s characteristic pain to assist in clinical assessment. Hip strength, gait, and single-leg control are frequently abnormal compared to the contralateral limb and should be assessed routinely, as abnormal hip patterns are frequently present in patients with FAIS [40].

Standard imaging includes anteroposterior pelvis radiographs (Fig. 3A-D), a lateral femoral neck view (Dunn or Frog-leg lateral) (Fig. 3E) to assess CAM morphology, and a false-profile view to evaluate anterior acetabular coverage (Fig. 3F) [37]. Key radiographic measures include the alpha angle, lateral center-edge angle (LCEA), Tönnis angle, and cross-over sign. MRI is the preferred advanced imaging modality for identifying labral pathology and excluding concomitant pathology (Fig. 4) [41, 42] while CT with 3D reconstruction is most useful for preoperative planning and quantifying version [43–46].

Fig. 3.

Radiographic measurements. On standing anteroposterior pelvis x-ray, the lateral center-edge angle (LCEA) is measured from a vertical reference line perpendicular to the inferior borders of the ischial tuberosities to the lateral edge of the sourcil from the center of the femoral head (A, B). LCEA values > 40º indicative of pincer-type femoroacetabular impingement syndrome (FAIS) (A) and values < 25º indicative of acetabular dysplasia (B). Tönnis angle (C) serves as an additional measure of acetabular coverage, measured as the angle between a horizontal reference line through the inferior borders of the ischial tuberosities and a line extending to the medial and lateral edges of the sourcil. Cross-over sign (D) represents acetabular retroversion or Pincer-type FAIS, whereby the anterior wall of the acetabulum (red line) crosses over the posterior wall (blue line) before reaching the inferior acetabular rim. Alpha angle is measured on the Dunn view (E), defined as the angle between the axis of the femoral neck through the center of the femoral head to the point where the head-neck junction loses sphericity. False-profile view (F) assesses anterior acetabular coverage; the anterior center-edge angle (ACEA) is measured as the angle between a vertical reference line through the center of the femoral head to the anterior edge of the sourcil

Fig. 4.

Magnetic resonance imaging of labral tear. T2 coronal view of a labral tear (red arrow), identifiable by a linear hyperintense signal separating the acetabular rim from the labrum (red bracket) signified by a disruption of the normal, low-signal structure of the labrum

Nonoperative Management of Femoroacetabular Impingement Syndrome and Labral Pathology

Nonoperative Treatment Strategies

The goal of conservative management for FAIS and labral pathology is to reduce pain, restore function, and achieve a level of activity that the patient perceives as satisfactory. For patients engaged in recreational or competitive sport, successful return to activity is an additional primary goal. An initial conservative trial of 6–12 weeks is recommended prior to considering surgical intervention, though persistent or worsening symptoms within this period should be considered treatment failure [47].

Conservative treatment includes activity modification, patient education, oral anti-inflammatory medications, intra-articular injections, and supervised physical therapy. Education regarding the dynamic nature of impingement allows patients to identify and modify positions and activities that exacerbate symptoms, such as deep hip flexion or high-impact loading [48]. Diagnostic intra-articular injections with local anesthetic, with or without corticosteroid, serve both diagnostic and short-term therapeutic purposes [37, 49]. Evidence for orthobiologics such as platelet-rich plasma and bone marrow aspirate concentrate remains limited and heterogeneous, and their routine use is not currently supported [50, 51].

Supervised physical therapy is the cornerstone of nonoperative management and mirrors many principles applied in postoperative rehabilitation. Therapy aims to improve hip stability, neuromuscular control, range of motion, strength, and movement patterns — the same functional deficits targeted following surgical intervention [52]. Although physical therapy can provide meaningful short-term benefit in a subset of patients, hip arthroscopy has been demonstrated to confer superior improvements in pain and function, with the UK FASHIoN randomized trial confirming that arthroscopic treatment exceeds clinically significant thresholds compared to supervised therapy alone [53]. Overall, most evidence supports an initial conservative trial, but suggests arthroscopy yields superior outcomes, is more cost-effective, and may reduce osteoarthritis risk [54–58].

Indications for Surgery

Hip arthroscopy with labral management is generally indicated for patients with symptomatic labral pathology confirmed by clinical examination and advanced imaging who have failed a trial of nonoperative treatment. Appropriate patient selection is critical, as several factors are associated with inferior outcomes and should inform surgical decision-making and preoperative counseling.

Radiographic and clinical signs of joint degeneration are the most consistently identified predictors of inferior outcomes following hip arthroscopy. A joint space less than 2 mm and Tönnis grade 2 osteoarthritis have been associated with significantly higher rates of conversion to total hip arthroplasty [59, 60]. Patient age greater than 40 years may also portend worse outcomes and higher arthroplasty conversion rates, though joint preservation status and intra-articular pathology remain more important determinants than chronologic age alone [61, 62].

Outside of joint degeneration, acetabular dysplasia represents an important morphologic contraindication to isolated arthroscopic management. Features reflecting significantly abnormal acetabular coverage including lateral center-edge angle less than 18°, anterior center-edge angle less than 20°, and elevated Tönnis angle are generally considered inadequately addressed by arthroscopy alone and may require periacetabular osteotomy [59, 60, 62–64]. In contrast, borderline hip dysplasia has demonstrated favorable and durable long-term outcomes with arthroscopic management in appropriately selected patients [65–67]. Additional factors associated with inferior outcomes include elevated body mass index (BMI), female sex, connective tissue hyperlaxity, and significant chondral damage [62, 68–74]. Careful consideration of these variables is essential for optimizing outcomes and setting realistic patient expectations.

Surgical Management

Surgical treatment of acetabular labral tears has evolved from primary excision toward labral preservation, driven by improved understanding of the labrum’s role in maintaining the hip fluid seal, joint stability, and preventing early osteoarthritis [75–78]. Contemporary management includes labral repair or reconstruction, femoral and/or acetabular osteoplasty, and meticulous capsular management, with the specific procedures performed directly influencing postoperative rehabilitation progression and return-to-sport timelines.

Debridement Versus Repair

Although early arthroscopic management relied primarily on labral debridement, comparative studies have consistently demonstrated superior outcomes with labral repair. Larson et al. reported good-to-excellent outcomes in 86.3% of repair patients versus 47.7% in the debridement group at 7 years, with superior pain and functional scores [79]. A prospective randomized controlled trial similarly demonstrated superior patient-reported outcomes following repair compared to debridement [80]. From a rehabilitation standpoint, debridement without concurrent soft tissue repair allows for more rapid early progression, with fewer range-of-motion restrictions and earlier return to impact activity. However, the inferior long-term outcomes associated with isolated debridement limit its application to carefully selected patients with stable tears, minimal chondral pathology, and Tönnis grade less than 2 [81].

Labral Repair and Reconstruction

When viable labral tissue is present, repair remains the gold standard, with mid- and long-term survivorship between 85 and 92% at 10 years and good-to-excellent outcomes in up to 92% of patients (Fig. 5) [80, 82–85]. In cases of irreparable tissue, insufficient labral volume, or calcified labrum, reconstruction is indicated and has demonstrated comparable clinical outcomes to repair despite less favorable baseline characteristics (Fig. 6) [86, 87]. Reconstruction, particularly circumferential reconstruction, may necessitate a more conservative early progression given the greater extent of tissue healing required. Return to sport following labral reconstruction occurs at a mean of 6.2 months, with an overall rate of 82.4% across athletic populations [88].

Fig. 5.

Labral repair with knotted suture anchor. Arthroscopic view of the acetabular labrum before (A) and after (B) repair. (A) A detached anterior labral tear at the chondrolabral junction. (B) Restoration of labral fixation to the acetabular rim following repair with a knotted suture anchor, with re-establishment of the labral contour. (C) Dynamic examination following femoral osteochondroplasty showing adequate restoration of the labral suction seal

Fig. 6.

Labral reconstruction with tibialis anterior allograft

Capsular Management

Routine capsular closure is strongly supported by current evidence, with systematic reviews demonstrating superior patient-reported outcomes, survivorship, and lower arthroplasty conversion rates compared with non-repair [89–92]. Complete closure confers additional benefit over incomplete repair, and capsular plication represents an important adjunct in patients with instability or borderline dysplasia [93]. Further, in appropriately selected patients, plication may be associated with meaningful improvements in patient-reported outcomes [94, 95]. Consistent with these findings, capsular closure has been widely adopted in contemporary practice, with surveys of high-volume hip arthroscopists reporting routine closure in nearly 90% of cases [96]. Although selective capsular release may be appropriate in patients with significant stiffness or inflammatory hip disorders, the preponderance of evidence supports routine capsular closure, and plication when indicated, as a key determinant of durable clinical outcomes following hip arthroscopy. The type and extent of capsular management, alongside labral procedure performed, are among the most important surgical determinants of postoperative rehabilitation progression and return-to-sport timeline.

Rehabilitation

Postoperative rehabilitation is essential to optimizing the return to both daily and high-level function, including sports participation, after hip arthroscopy. Numerous patient and surgical factors influence outcomes and should guide program development [97]. Rehabilitation is typically structured as a phase-based progression incorporating time and criteria-based milestones; however, substantial variability exists in the number of phases and progression criteria reported in the literature, with no universally accepted protocol [98–100].

Postoperative rehabilitation should be tailored to each individual patient, as factors associated with recovery are well documented and patient-specific characteristics should inform adjustments and expectation setting [101–105]. Bodendorfer et al. identified specific groups throughout the recovery period following hip arthroscopy, which were classified as early progressors, late regressors, and late progressors [97]. Demographic factors such as older age and male sex were predictive of being in the late regressor or late progressor groups. Other patient factors such as a history of back pain, a greater alpha angle, workers’ compensation, psychiatric history, preoperative chronic pain, and lower preoperative patient reported outcomes were also predictive of late group membership. Recognition of these variables is critical when tailoring rehabilitation and counseling patients on anticipated recovery.

As surgical techniques continue to evolve, it is essential that postoperative management remains consistent with these changes. Because capsular repair directly affects rehabilitation progression, early management must protect the repair to minimize stiffness, gait abnormalities, and delayed return to sport [106]. Precautions include avoiding excessive hip extension and external rotation, which increase anterior capsular stress, while promoting controlled mid-range motion to reduce guarding and pain. Rehabilitation must also reflect procedure-specific considerations. Extensive soft tissue procedures, such as large labral repairs or reconstructions, require greater postoperative protection than cases without significant soft tissue repair [99, 102, 103]. In general, labral fixation necessitates limiting hip flexion beyond 100° to reduce stress on the repair [3, 107–109], while acetabular microfracture requires strict non-weightbearing for 6–8 weeks to allow subchondral bone healing before progressive loading [99].

Early Phase

The current literature on phase based postoperative rehabilitation after hip arthroscopy organizes these guidelines into between 4 and 6 phases of rehabilitation. The initial early phases of postoperative rehabilitation are consistent among studies with the protection of healing tissues being emphasized. Most guidelines recommend a period of restricted weight bearing using an assistive device during this early postoperative phase, however, the time frames for this recommendation vary among studies ranging from less than 2 weeks up to 8 weeks. A consistent theme among studies in the early phases of postoperative rehabilitation is the emphasis on education of both the patient and caregiver related to range of motion precautions, avoidance of certain positions, appropriate use of an assistive device, and a general overview of rehabilitation phases and return to activity timelines to promote realistic expectations during recovery.

Intermediate Phase

During the intermediate phase of rehabilitation, restoring normal gait and strengthening the hip musculature are primary goals to prevent postoperative setbacks [108]. This phase typically spans 6 to 16 weeks postoperatively, depending on patient progression. There are generally no formal weight-bearing or range-of-motion restrictions, and patients should be advanced as tolerated under physical therapy supervision. Excessive fatigue, abnormal gait mechanics, or persistent joint irritability may indicate premature progression and should prompt reassessment and modification of the rehabilitation plan [102, 110]. To help build aerobic capacity during this phase the use of an upright stationary bike, gravity minimized treadmill, or elliptical trainer are recommended as each of these devices can help challenge the aerobic system, while maintaining low impact on the hip joint [25]. As rehabilitation advances, emphasis should shift toward multiplanar strengthening, functional training, and continued development of core stability, with gradual increases in activity intensity. Patients aiming to return to sport or high-demand occupations often require individualized, sport- or task-specific progression to meet higher functional demands [100, 103, 111].

Late Phase

The final phases of postoperative rehabilitation are where return to high intensity and sport activities are introduced. During this phase, structured physical therapy is usually discontinued; however, guided return to sport training consisting of sport specific and skill training, high velocity drills, and graded exposure competition and impact is recommended and should be overseen by a trained professional such as an athletic trainer, strength and conditioning specialist or coach. Adequate time should be allotted to ensure safe progression to high-level function.

Functional and Return to Sport Tests for Postoperative Rehabilitation

During postoperative rehabilitation after hip arthroscopy, rehabilitation clinicians should incorporate objective measures of physical and functional performance to quantify the recovery and guide rehabilitation progressions throughout the course of care [38, 112]. In the early and intermediate phases of postoperative rehabilitation physical performance measures of muscle strength should be performed at regular intervals using a quantitative device such as a handheld dynamometer, pull based strain gauge, or isokinetic system (Fig. 7). Objective measures of muscle force generating capacity and limb symmetry can be used to establish appropriate loading doses and guide advancement to later phases of rehabilitation.

Fig. 7.

Assessing different isometric hip movements using a dynamometer during postoperative rehabilitation. (A) A seated and stable position to test hip abduction and adduction while mitigating compensatory recruitment from other muscle groups. The prone (B) and supine (C) positions, respectively, are the optimal, stable positionings to assess for isolated hip extension, while the supine position allows for adequate assessment of hip flexion

Functional performance tests are also important assessments that should be made regularly throughout all phases of postoperative rehabilitation following hip arthroscopy. During the early stages of postoperative rehabilitation functional performance tests such as timed single leg balance, and repeated sit to stand tests can be used to assess aspects of balance, stability and lower extremity strength [113]. As patients progress to the intermediate stages of postoperative rehabilitation more challenging functional performance tests should be assessed. Some examples of more advanced functional tests include a single leg squat test, step down tests, and dynamic balance tests such as the STAR excursion or Y-balance tests (Fig. 8) [113]. These assessments provide information on single-leg strength, stability, power, and load transfer. During late phases, functional performance tests should progress to include power production, impact loading, and speed, including hop tests such as the hop-lunge and medial/lateral triple hop tests, and agility tests such as the modified agility T-test [113].

Fig. 8.

The crossover contralateral (A), anterior (B), and lateral (C) Y-tests are used to evaluate hip stability and neuromuscular control by completing dynamic movements in different planes. Overhead deep squats (D) and single-leg squats (E) are mainstay exercises to evaluate lower limb strength

Return to Sport

Return to sport (RTS) testing following hip arthroscopy should be sport-dependent and include a comprehensive battery of tests to demonstrate readiness for competition. One hip-specific option is the Vail Hip Sports Test, a criterion-based assessment adapted from a standardized test evaluating readiness to begin return-to-sport progression after knee injuries [114–117]. RTS testing should incorporate assessments that reflect the specific demands and environment of the athlete, with key criteria including pain-free reproduction of all sport-specific movements, which 85% of surgeons consider essential [118]. In a recent systematic review of return to sport criteria, it was shown that five criteria were most commonly utilized to determine safe return to sport, including (1) sports specific performance testing, (2) pain-free movement, (3) full range of motion, (4) symmetric hip strength, as well as (5) adequate performance-based measures [119]. However, no validated functional test currently exists to objectively assess RTS readiness, and most protocols rely on expert opinion rather than evidence-based criteria, underscoring the need for greater granularity in reporting return-to-sport protocols.

The mean timeframe for RTS is approximately 6–8 months postoperatively, with an overall reported average near 6 months [116, 120, 121]. However, timelines vary widely by sport and competitive level, ranging from 5.4 months for endurance athletes to 12.7 months for professional baseball athletes [120, 121]. Accelerated rehabilitation protocols have demonstrated average RTS time-frames of 9.4 months for high-demand athletes, 6.1 months for moderate-demand athletes, and 8.1 months for recreational athletes [122]. In terms of rates of return, approximately 85% of athletes return to sport, with many resuming their preinjury level or higher, and RTS rates reaching as high as 93.9% in elite cohorts [104, 120, 121, 123]. Several prognostic factors influence successful RTS. Revision surgery reduces return rates from 88% after primary procedures to 57%, whereas complete capsular closure improves RTS rates (90% versus 76%) and shortens time to return [121, 124]. Older age negatively predicts RTS, while lower preoperative BMI correlates with more successful return [121, 125]. Collectively, these data underscore the importance of individualized counseling and postoperative rehabilitation protocol that accounts for sport demands, surgical factors, and patient-specific characteristics when setting expectations for return to play.

Conclusion

Acetabular labral tears are a prevalent source of hip pain and mechanical symptoms, and outcomes are closely tied to the labrum’s role in maintaining the suction seal, distributing load, and protecting articular cartilage. An initial trial of conservative management is appropriate, but persistently symptomatic patients may benefit from arthroscopic hip preservation when selection is guided by joint preservation status and acetabular coverage. Contemporary operative principles emphasize labral preservation (repair when viable, reconstruction when irreparable), correction of underlying morphology, and meticulous capsular closure/plication to optimize stability and durable outcomes. Postoperative rehabilitation should be individualized and criterion-driven, using objective strength/functional testing and sport-specific return-to-sport assessment to guide safe return despite wide variability in timelines and rates.

Key References

• Allahabadi S, Chapman RS, Fenn TW, Brusalis CM, Kaplan DJ, Nho SJ. Hip Arthroscopic Surgery With Chondrolabral Refixation, Osteochondroplasty, and Routine Capsular Closure for Femoroacetabular Impingement Syndrome: Clinical Outcomes at a Minimum 10-Year Follow-up. Am J Sports Med. 2024;52:24–33. https://doi.org/10.1177/03635465231212663.

• ○ Provides long-term data supporting the durability of contemporary arthroscopic management of acetabular labral tears. Supports that labral repair, when performed in conjunction with correction of femoroacetabular impingement and capsular closure, yields sustained, clinically meaningful improvements in patient-reported outcomes with low reoperation rates.

• Chapman RS, Allahabadi S, Fenn TW, Larson JH, Beals CT, Kaplan DJ, et al. Outcome Scores and Survivorship of Patients Undergoing Primary Hip Arthroscopy With Borderline Hip Dysplasia: A Propensity-Matched Study With Minimum 10-Year Follow-up. Am J Sports Med. 2024;52:1744–52. 10.1177/03635465241247287.

• ○ Addresses a controversial population, patients with borderline hip dysplasia, within the context of arthroscopic management of acetabular labral tears. Demonstrates that, in appropriately select patients, arthroscopic treatment of acetabular labral pathology and concomitant femoroacetabular impingement can yield durable improvements in the long-term.

• Domb BG, Annin S, Monahan PF, Lee MS, Jimenez AE, Maldonado DR. Ten-Year Survivorship, Outcomes, and Sports Participation in Athletes After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome. Am J Sports Med. 2023;51:2383–95. 10.1177/03635465231180305.

• ○ Provides long-term comparative data on labral repair versus isolated debridement in the management of acetabular labral tears, specifically in an athletic population. It demonstrates that, while both techniques yield durable improvements at long-term follow-up, labral repair provides increased protection against conversion to total hip arthroplasty over isolated debridement. Supports sustained return to activity at long-term follow-up in an athletic population following hip arthroscopy.

• Economopoulos KJ, Chhabra A, Kweon C. Prospective Randomized Comparison of Capsular Management Techniques During Hip Arthroscopy. Am J Sports Med. 2020;48:395–402. 10.1177/0363546519894301.

• ○ Provides evidence in the form of a randomized control trial (i.e., high level of evidence) on capsular management, a critical adjunct in contemporary hip arthroscopy. Demonstrates that capsular closure after labral repair and femoral osteochondroplasty leads to superior patient-reported outcomes and reduced conversion arthroplasty rates compared with unrepaired capsulotomy techniques. These findings support the contemporary surgical paradigm emphasizing both labral preservation and restoration of capsular integrity to optimize long-term hip stability and functional outcomes.

• Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;112–20. 10.1097/01.blo.0000096804.78689.c2.

• ○ The seminal article by Ganz et al. is a cornerstone reference for understanding the pathomechanics underlying acetabular labral tears. It first established femoroacetabular impingement syndrome as a primary etiological factor driving labral pathology and subsequent hip osteoarthritis. Its foundational concepts underpin the rationale for contemporary surgical interventions aimed at correcting bony morphology to prevent labral damage and preserve the hip joint. This work remains indispensable for any comprehensive discussion of acetabular labral tear management.

• Kelly BT, Williams RJ, Philippon MJ. Hip arthroscopy: current indications, treatment options, and management issues. Am J Sports Med. 2003;31:1020–37. 10.1177/03635465030310060701.

• c This early comprehensive review by Kelly et al. is a foundational reference that defines the indications and surgical techniques for hip arthroscopy, including the management of acetabular labral tears. Provides critical insight into diagnosis and treatment options that have shaped subsequent practice. The article underscores the role of advanced imaging and minimally invasive techniques in improving outcomes for patients with intraarticular hip pathology. Remains relevant for understanding the evolution of arthroscopic management strategies and its expanding indications.

• Krych AJ, Thompson M, Knutson Z, Scoon J, Coleman SH. Arthroscopic labral repair versus selective labral debridement in female patients with femoroacetabular impingement: a prospective randomized study. Arthroscopy. 2013;29:46–53. 10.1016/j.arthro.2012.07.011.

• ○ Provides a prospective randomized evidence (i.e., high level of evidence) supporting labral repair over debridement in the arthroscopic management of acetabular labral tears. Demonstrates that, in female patients, labral repair yields significantly better functional outcomes and patient-reported hip function outcomes. This reinforces the contemporary emphasis on labral preservation and help guide surgical decision-making in select populations.

• McCarthy JC, Noble PC, Schuck MR, Wright J, Lee J. The Otto E. Aufranc Award: The role of labral lesions to development of early degenerative hip disease. Clin Orthop Relat Res. 2001;25–37. 10.1097/00003086-200112000-00004.

• ○ Among the first studies to systematically link acetabular labral lesions with early degenerative disease of the hip. Demonstrated that labral tears are commonly associated with chondral damage, supporting the concept that labral pathology contributes to a continuum leading to osteoarthritis.

• O’Connor M, Minkara AA, Westermann RW, Rosneck J, Lynch TS. Return to Play After Hip Arthroscopy: A Systematic Review and Meta-analysis. Am J Sports Med. 2018;46:2780–8. 10.1177/0363546518759731.

• ○ Demonstrates a high overall return to play rate of 85% with a mean return time of approximately 7.4 months following hip arthroscopy, highlighting the efficacy of arthroscopic management for acetabular labral tears in enabling athletes to resume high-level activity. Underscores significant variability and a lack of standardized, evidence-based rehabilitation protocols or functional tests.

• Philippon MJ, Briggs KK, Carlisle JC, Patterson DC. Joint space predicts THA after hip arthroscopy in patients 50 years and older. Clin Orthop Relat Res. 2013;471:2492–6. 10.1007/s11999-012-2779-4.

• ○ Identifies preoperative joint space narrowing as a strongest predictor of conversion to total hip arthroplasty (THA) after hip arthroscopy. These findings are critical for patient selection and counseling, providing an objective radiographic measure to guide expectations and identify those for whom joint-preserving arthroscopy may be less appropriate. This evidence underscores the importance of careful preoperative assessment in optimizing long-term outcomes after hip arthroscopy.

Author contributions

All authors contributed to the primary drafting of the manuscript, including the following sections: Abstract (J.C.B.), Introduction (J.C.B.), Anatomy of the Acetabular Labrum (C.A.S; J.C.), Anatomy of the Hip Capsule (C.A.S., J.C.), Clinical Presentation of Labral Tears (K.N.K; S.J.N), Nonoperative Management of Femoroacetabular Impingement Syndrome and Labral Pathology (K.N.K.), Indications for Surgery (J.C.B.; S.J.N.), Surgical Management (J.C.B.; S.J.N), Rehabilitation (T.L.M; P.M.), Conclusion (J.C.B.). All authors were responsible for final draft review.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Ethical Approval

N/A.

Competing interests

One or more authors have potential conflict of interests to disclose. Author K.N.K. is a consultant for AllaiHealth Inc. and is an associate editor for Arthroscopy: The Journal of Arthroscopic & Related Surgery. Author J.C. has received board or committee appointments from the American Orthopaedic Society for Sports Medicine, the Arthroscopy Association of North America, and the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; consulting fees from Arthrex, CONMED Linvatec, Ossur, RTI Surgical, Smith & Nephew, and Vericel; speaking fees from Smith & Nephew; hospitality payments from Breg, DePuy Synthes Sales, Joint Restoration Foundation, Medical Device Business Services, Pacira Pharmaceuticals, SI-Bone, and Vericel; and educational support from Midwest Associates. Author S.J.N. has received financial support from Stryker Orthopedics for intellectual property, as a consultant, and research support; intellectual property royalties from Ossur; publishing royalties from Springer; and are board members for the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America.