Hip tear surgery didn’t work? The concept that hip labrum tears cause pain is relatively new in medicine. Despite that, the number of arthroscopic hip surgeries to treat hip labrum tears and impingement have exploded this past 5 years. However, have we as physicians become way too zealous? A patient I evaluated in clinic yesterday is an example of what we see more and more-an MRI of the hip that showed a labral tear which was assumed to be the cause of her pain. However, for my patient, the surgeon clearly operated on a phantom.
Regrettably, we as doctors are to blame for what I call “MRI hysteria”. This is when an MRI of some body part that hurts shows some abnormality and the patient believes that this is “smoking gun” evidence of the cause of their pain. This is despite scientific evidence that it’s very unlikely that the abnormality is causing their pain. One example is a knee meniscus tear in a middle aged person with new onset knee pain. It’s very unlikely that the meniscus tear is causing the patient’s knee pain, but despite the fact that science backs that up, there are still many thousands of patients operated every month for a meniscus tear. While some doctors have begun to get the memo on meniscus tears, the surgical community operating on hip labrum tears seems to be operating on these MRI findings with wild abandon.
The labrum is the fibrous lip around the hip socket where the leg bone (femur) attaches. It’s an important stabilizer of the hip, but just like the meniscus spacer in the knee, tears here are common in patients without hip pain. In fact, one recent study showed no association between hip labral tears as seen on MRI and hip pain. Think about that for a second. We have research that shows that patients without hip pain have labral tears and patients with hip pain have no more tears in that structure than patients who have no pain. Huh? Why then are operating on hip labral tears that are seen on MRI based a cursory physical exam and a short discussion with the patient? What if the hip labrum tear isn’t causing the hip pain, isn’t that unnecessary surgery? The patient I saw yesterday is a great example of what I call operating on a phantom.
This middle aged woman used to be a big runner and loved high level exercise. A few years back she began to notice pain and aching in her thigh. She then ultimately ended up with pain in the back and side of the hip as well. As this became more disabling and she had to get rid of more and more exercise, she ultimately saw an orthopedic surgeon who ordered an MRI arthrogram of her hip. That image showed a labral tear, but regrettably little else about her symptoms was convincing for primary hip pain (which is usually in the deep groin). Given that the MRI image also showed a an “Impingement Syndrome”, surgery to “repair” the labral tear and reconstruct the labrum, was performed. However, the pain never changed one bit. Yesterday when I first saw her, I was the first physician to consider the obvious. What if we injected her hip with a numbing agent? If the surgery failed and the hip was the problem, this should take away most of her pain. Given that the numbing shot didn’t change her pain, her hip joint isn’t causing the hip pain. Hence she had a surgery with all of the risks of same and this never changed the pain because the wrong area was treated. So what was causing the hip pain? A comprehensive exam revealed it is likely her low back and SI joint.
The upshot? While operating on problems that aren’t causing pain might seem like a rarity, we see patients in this same situation every week. Hip pain, knee pain, shoulder pain all being caused by areas not in the joint, all with MRIs showing issues in the joint, all operated without any relief. Why is this happening? Cursory exams, 40 patients a day, and a firm belief that the MRI findings are all you need. So if you have pain in the hip, knee, or shoulder don’t buy the quick explanation and promise quick fix without much analysis of what’s really going on, don’t let a surgeon operate based on your MRI.