Hip Injuries

Hip Injuries in
Athletes
Donna G. Blankenbaker, MD*, Arthur A. De Smet, MD
KEYWORDS
Hip Injury Labrum Cartilage Tendon Muscle
Apophyseal injury
Hip pain is a common complaint in the active the acetabulum is essentially an upside-down
athletic population with a variety of possible horseshoe, which is covered by hyaline cartilage.
causes. The differential diagnosis of hip pain is The femoral head is entirely covered with hyaline
extensive, and affected athletes may have acute cartilage except for the region of the fovea capitis.
or chronic symptoms of widely ranging intensity, The fovea is a depression along the central surface
location, and duration. Clinical findings are highly of the femoral head. The ligamentum teres femoris
variable, and the numerous regional anatomic arises from this depression and courses inferiorly
structures make the clinical evaluation difficult. within the joint to attach medially to the transverse
The demand for improved diagnosis of hip condi- ligament and to several surrounding structures.
tions has led to several advanced imaging tech- The ligamentum teres is a conduit for a small
niques, including magnetic resonance (MR) branch of the obturator artery, but that branch is
imaging, MR arthrography, computed tomo- often occluded in adults. The primary blood supply
graphic (CT) arthrography, and sonography. MR for the femoral head passes retrograde up the
imaging is considered the imaging technique of femoral neck; this blood supply can be disrupted
choice for examining injured athletes after initial by displaced femoral neck fractures and hip
radiography. Sonography plays a role in the evalu- dislocations.
ation of other maladies around the hip. This article
discusses the normal anatomy of the hip joint and
Labrum
surrounding structures of the hip, including abnor-
malities of the hip, both commonly and less The labrum is a fibrocartilaginous structure lining
commonly encountered in the active athletic the horseshoe-shaped acetabulum. The labrum
population. is thought to have several important functions,
including the containment of the femoral head
NORMAL ANATOMY during acetabular formation and stabilization of
the hip by deepening the acetabulum.1,2 The
The hip is the prototypical ball-and-socket joint labrum is generally triangular in cross section3,4
that allows a wide range of motion in all directions. as it arises from the rim of the acetabulum,
The osseous components consist of the femoral although it can have a variable shape at MR
head and the acetabulum. The acetabulum is obli- imaging.5 These labral shapes include triangular
que to all planes, with mild anteversion and lateral (most common), round, flat, or absent.5 The
opening in the normal hip. The socket of the labrum is thinner anteriorly and thicker posteri-
acetabulum is deficient centrally, where the coty- orly.3,4,6 The acetabular labrum overlies the hyaline
loid fossa is filled with fibrofatty tissue and is lined cartilage around the perimeter of the acetab-
with synovium. The depression of the cotyloid ulum.3,7 The acetabular labrum blends with the
fossa is continuous with the inferiorly positioned transverse ligament at the margins of the acetab-
radiologic.theclinics.com
acetabular notch. Thus, the articular surface of ular notch, except for a small area where the
Musculoskeletal Division, Department of Radiology, University of Wisconsin School of Medicine and Public
Health, 600 Highland Avenue, Madison, WI 53792-3252, USA
* Corresponding author.
E-mail address: dblankenbaker@uwhealth.org
Radiol Clin N Am 48 (2010) 1155–1178

doi:10.1016/j.rcl.2010.07.003
0033-8389/10/$ e see front matter Ó 2010 Elsevier Inc. All rights reserved.
1156 Blankenbaker & De Smet
ligament and labrum join. The appearance of Trochanteric Anatomy

a “cleft” or “sulcus” can often be seen between
The greater trochanter serves as the main attach-
the labrum and transverse ligament where they
ment site for the strong abductor tendons. Four
join.8 The labrum is innervated by nerves that
facets of the greater trochanter each have
play a role in proprioception and pain production.9
a specific tendinous attachment and specific
The vascular supply to the labrum is limited,
nearby bursa.18 The anterior facet is located on
without significant penetration of vessels from
the anterolateral surface of the trochanter, has an
the underlying acetabular bone into the labral
oval appearance, and shares a medial border
substance, thus leaving the majority of the labrum
with the intertrochanteric line. The lateral facet
avascular with limited potential for an injured
has an inverted triangular shape and the caudal
labrum to heal.10,11 The labrum is not designed
portion representing the palpable part at physical
to withstand significant weight-bearing forces;
examination. The superoposterior facet forms the
when subjected to such forces it eventually degen-
most cranial and posterior part of the trochanter,
erates and tears.
and has an oblique transverse orientation. The
Capsule posterior facet is the most posterior aspect of
the trochanter.
The capsule of the hip joint extends just above the The trochanteric bursa is located immediately
acetabular rim proximally and down to the intertro- posterior to the cortex of the posterior facet of
chanteric ridge distally; the anterior extent of the the greater trochanter, the distal lateral part of
capsule is more distal than the posterior extent. the gluteus medius tendon (lateral facet), and the
The capsule attaches to the acetabulum above proximal part of the vastus lateralis insertion.
the base of the labrum in most people, creating The subgluteus medius bursa is located deep to
a normal perilabral recess between the labrum the lateral part of the gluteus medius tendon and
and the capsule.3,12 Most of the femoral neck covers the superior part of the lateral facet. The
lies within the joint capsule. A series of ligaments subgluteus minimus bursa is located beneath the
helps to reinforce the capsule, including the iliofe- gluteus minimus tendon, medial and superior to
moral, ischiofemoral, and pubofemoral ligaments; its insertion in the area of the anterior facet.
these are described as thickenings of the joint The gluteus medius attachment has been
capsule. Along the middle of the femoral neck, divided into 3 parts.18 The tendon attaches onto
there is a band of thickening of the capsule, called the superoposterior facet (main tendon), the lateral
the zona orbicularis. facet from posterior to anterior (lateral portion of
the tendon), and the anterior portion of the tendon
Iliopsoas to the gluteus minimus tendon. The gluteus mini-
mus attachment consists of 2 parts.18 The main
The iliopsoas musculotendinous unit consists of 3
tendon of the gluteus minimus inserts onto the
muscles: the psoas major, the psoas minor, and
anterior facet of the trochanter on its lateral and
the iliacus. The major action of the psoas and ilia-
inferior aspect. The second part of the tendon
cus muscles is to flex the thigh on the pelvis, as
inserts in the ventral and superior capsule of the
well as function as a lateral flexor of the lower
hip joint.
vertebral column.13 The fibers of the iliacus and
Avulsion injuries in the pelvis primarily occur
psoas muscles converge to form the iliopsoas
at 6 sites. The anterior-superior iliac spine is
tendon. Anatomic dissections have shown that
the site of origin of the sartorius tendon and
with the hip in a neutral position, the iliopsoas
the tensor muscle of the fascia lata. The anterior
tendon at the brim of the pelvis lies in a groove
inferior iliac spine is the site of origin of the
between the anterior inferior iliac spine laterally
straight head of the rectus femoris tendon. The
and the iliopectineal eminence medially. The
rectus femoris is composed of 2 tendons: one,
muscular portions of the iliacus and psoas that
the anterior or straight head, from the anterior
surround the tendon cover the anterior inferior iliac
inferior iliac spine; the other, the posterior or
spine and the iliopectineal eminence.14,15 The
short head, from a groove above the brim of
tendon proper remains within the groove even at
the acetabulum.19 The ischial tuberosity is the
its far lateral and medial points of excursion. The
site of origin of the hamstring tendons. The iliac
iliopsoas tendon is closely related to the anterior
crest is the site of attachment of the abdominal
aspect of the hip joint. The musculotendinous
musculature and the pubic symphysis, and the
unit is separated from the adjacent bony struc-
inferior pubic ramus is the site of origin of
tures by the iliopsoas bursa. A direct communica-
the adductors of the hip, which includes the
tion exists between the joint capsule and the
adductor longus, adductor brevis, and gracilis
iliopsoas bursa in 15% of adult individuals.16,17
Hip Injuries in Athletes 1157
muscles, and is also the site of distal attach- the patient with hip pain depends on the referring
ment of the rectus abdominis. physician and clinical question to be answered.
When the referral comes from primary care physi-
IMAGING TECHNIQUES cians, the authors advocate starting with a global
Radiography assessment to include the entire pelvis and dedi-
cated small-field-of-view imaging of the symptom-
The imaging workup of hip pain should still almost atic hip. Often the authors have found pathology
always begin with radiographs. According to remote from the hip as the cause of the patient’s
American College of Radiology (ACR) criteria, radi- pain. Therefore, their imaging protocol consists
ography of a hip should always include an antero- of coronal T1-weighted, coronal T2-weighted fat-
posterior view of the pelvis centered at the level of suppressed or short-tau inversion recovery (STIR),
the hips. Including the other hip in the image axial T1-weighted and axial T2-weighted fat-sup-
provides valuable information regarding symmetry pressed sequences from just above the iliac crests
or asymmetry of findings. Imaging the entire pelvis to below the lesser trochanters with a field of view
allows one to evaluate for causes of “hip pain” that of 48 cm 48 cm, at least a 256 224 matrix with
are outside the hip joint proper. This view should 5-mm slice thickness. Additional small-field-of-
be accompanied by at least one other view of view images are obtained through the symptom-
the hip, such as the frog-lateral, cross-table lateral, atic hip to assess for labral tears, cartilage lesions,
and false profile views. or tendinous pathology. The authors obtain
coronal T2-weighted fat-suppressed and sagittal
Computed Tomography proton density fat-suppressed sequences with
CT scanning is indispensable in the setting of a field of view of 24 cm through the symptomatic
trauma. The cortical detail is unparalleled, and hip.
small intra-articular fragments are readily Alternatively, when the referring physician
apparent. Outside of the setting of major trauma, specializes in musculoskeletal disease and has
though, CT is seldom used in the evaluation of a specific question with regard to the hip (ie, labral
hip pain. CT arthrography of the hip, although tear, stress fracture), dedicated small-field-of-view
seldom performed, has been shown to accurately imaging of the symptomatic hip can be employed.
define articular cartilage defects in patients with A comprehensive hip examination would include
hip dysplasia.20 The efficacy of CT arthrography coronal T1-weighted, coronal T2-weighted fat-
in diagnosing labral tears has not been published. suppressed/STIR, axial T1-weighted, axial
T2-weighted fat-suppressed, sagittal proton
density fat-suppressed, and axial oblique (parallel
MR Imaging
to the femoral neck) proton density fat-
Hip MR imaging protocols vary from institution to suppressed sequences through the hip with a field
institution, depending on the patient population, of view from 22 cm 22 cm to 24 cm 24 cm, at
the physician’s experience, clinical question to least a 320 192 matrix, and 3- to 4-mm slice
be answered, and the MR imaging equipment. thickness. Some investigators advocate radial
There are 2 different types of MR imaging proto- imaging.21
cols that often are employed depending on the
clinical concern for internal derangement (ie, labral
MR Arthrography
tear, cartilage lesion) or nonspecific hip pain
(stress fracture, bursitis, muscle or soft tissue MR arthrography is an ideal technique for evalu-
injury). ating the internal structures of the hip joint. Indica-
When the differential for a patient’s hip pain tions for MR arthrography include assessment of
remains broad, MR imaging is the best imaging the acetabular labrum for tears or degeneration,
technique after initial radiographs. Indications for detection of cartilage defects, evaluation of the
routine MR imaging include fracture (stress/insuffi- intrinsic ligaments and hip capsule, evaluation for
ciency), muscle/tendon injuries, osteonecrosis, intra-articular loose bodies, and assessment of
pubalgia, and the individual with nonspecific hip the morphologic changes of femoroacetabular
pain. MR imaging provides excellent soft tissue impingement. Numerous structural alterations
contrast, and edema often points the way to path- within the joint are visible with joint distention
ologic processes on fluid sensitive sequences. MR created by the intra-articular administration of
imaging is very effective at evaluating the regional contrast. Several anatomic variants and potentially
muscles and tendons as well as the bone marrow. asymptomatic lesions have been described.4,6,8,22
Whether an MR imaging or MR arthrogram As arthroscopy of the hip continues to emerge,
should be the study of choice in the evaluation of knowledge about the clinical significance of these
structural alterations grows. MR arthrography of pain with intra-articular anesthetic confirms that
remains the preferred technique for imaging of the source of pain is from within the joint.22,28e30
the acetabular labrum. Pain relief following injection at MR arthrography
The sensitivity and accuracy of MR arthrogra- is important to orthopedic surgeons in considering
phy for detection of labral tears and detachments hip arthroscopy. If no pain relief is achieved, the
is 90% and 91%, respectively, versus 30% and treating physician must consider that the hip pain
36% for conventional MR imaging.6,7,23 However, may be referred from another site (ie, sacroiliac
Mintz and colleagues24 found a high accuracy for joint, lumbar spine) and therefore the patient is
labral tear detection using optimized noncontrast not a candidate for hip arthroscopy.
MR imaging. MR arthrography has been shown A surface phased-array coil should be used to
to have a sensitivity of 79% and specificity of obtain an adequate signal-to-noise ratio. Imaging
77% in the detection of cartilage lesions.25 parameters include a field of view of 16 to 18 cm,
Most investigators prefer MR arthrography over at least a 256e320 224e256 matrix, and 3.0 to
conventional MR imaging in the assessment of 4.0 mm slice thickness. T1-weighted fast spin
cartilage lesions, although the study by Mintz echo with fat suppression images are obtained in
and colleagues24 reported a higher accuracy at least 3 imaging planes. The authors obtain these
with conventional MR imaging. In their study, images in the standard sagittal and coronal
the accuracy for detection of cartilage lesions imaging planes, with an axial T1 sequence without
of the femoral head was 82% to 87% and fat suppression (to assess bone marrow and fatty
acetabular cartilage lesion detection was 84% changes within muscle) and an oblique axial T1-
to 88%; however, they graded the cartilage into weighted fat-suppressed sequence parallel to
disease positive (grades 2, 3, and 4) and disease the femoral neck. These images allow better eval-
negative (grades 0 and 1), and did not directly uation of the anterosuperior portion of the labrum,
compare the exact grade of cartilage lesion where most tears occur. Alternatively, some inves-
detection. tigators have described using radial imaging for
The technique of MR arthrography has been well identifying these tears of the labrum.21 However,
described.6,23 A needle is passed into the hip joint, a recent study by Yoon and colleagues31 evalu-
usually under fluoroscopic guidance using an ating the radial sequences with MR arthrography
anterior approach. Once the joint is entered, iodin- did not find any additional morphologic changes
ated contrast is injected confirming intra-articular in patients with femoroacetabular impingement.
location. Subsequently, a dilute gadolinium solu- Finally, a coronal T2-weighted fat-suppressed or
tion is injected. There are numerous recipes for STIR sequence is included to detect edema, fluid
the contrast solution. The authors’ choice is to collections, and surrounding soft tissue pathology.
combine 5 mL saline, 5 mL iodinated contrast A prior study has shown that the axial oblique
(300 mg/mL, Amersham Health Inc, Princeton, imaging plane has the highest individual detection
NJ, USA), 5 mL 0.5% ropivacaine HCl (5 mg/mL, rate of labral tears32 with a greater than 95%
Novation, Irving, TX, USA), 5 mL 1% preservative detection rate of labral tears achieved with 3
free lidocaine (10 mg/mL, Hospira Inc, Lake imaging sequences (axial oblique T1-weighted
Forest, IL, USA), and 0.1 mL (0.2 mmol/L) gadoli- fat-suppressed, sagittal T1-weighted fat-sup-
nium dimeglumine solution (Magnevist; Berlex pressed, and coronal T2-weighted fat-sup-
Laboratories, Wayne, NJ, USA). Recently, several pressed). Leg traction has been suggested to
experimental studies have suggested that some improve visualization of the femoral head and
local anesthetics may damage articular cartilage, acetabular cartilage surfaces33; however, no
and that 0.5% bupivacaine is toxic to both bovine studies have been performed to determine if this
articular chondrocyte cultures and bovine articular technique improves the accuracy in detecting
osteochondral tissue.26,27 Although this is a small cartilage lesions.
risk as only a small amount of diluted anesthetic Finally, does it matter whether the patients are
is injected, most of these patients are young and scanned on the 1.5-T or 3-T magnet? The authors
any chondrolysis would be tragic. The authors prefer 3-T scans for dedicated hip imaging and
therefore have changed their long-acting anes- MR arthrography if available. For MR arthrogra-
thetic to ropivacaine. This mixture is injected until phy, it is recommended the gadolinium concen-
the joint is distended (approximately 12e15 mL), tration be more dilute at 3-T imaging34 to
stopping if the patient feels an uncomfortable full- optimize contrast. A concentration of 1 to 1.23
ness or a higher pressure impedes injection. Inclu- mmol Gd/L has been suggested to optimize the
sion of anesthetic in the solution is not mandatory, signal-to-noise ratio of T1-weighted sequences.
but provides additional diagnostic information as Moreover, the addition of iodinated contrast
studies have shown supporting evidence that relief lowers the signal intensity more at 3 T than 1.5 T,
and therefore the concentration of iodinated radiography and may be missed, especially in
contrast at 3 T should be limited to the least the osteoporotic patient. In the traumatic setting
amount possible. following identification of fractures on radio-
graphs, CT is used for fracture assessment and
Sonography extent as well as for surgical planning.
As with most joints, the role of sonography in the
hip is probably best limited to evaluation of Stress Fracture
a specific question or two. For instance, ultraso-
nography is a fine technique for evaluating Fatigue-type stress fractures result from repetitive
pathology of individual tendons, but should not stress on normal bone, resulting in a region of
be routinely used to survey the entire joint. Espe- accelerated bone remodeling.37 At the micro-
cially in small children, sonography is ideal for scopic level, repetitive overloading leads to
defining joint effusions and guiding subsequent increased osteoclastic activity that exceeds the
aspiration.35 Sonography can also pinpoint sus- rate of osteoblastic new bone formation; this
pected bursitis and can demonstrate snapping results in bone weakening, microtrabecular frac-
tendons. It is ideal for performing imaging-guided tures (stress injury), and eventually may lead to
injections. The labrum can be visualized at the a cortical break (stress fracture).38 These injuries
anterior attachment onto the acetabulum with often occur along the medial aspect of the femoral
sonography36; however, MR arthrography remains neck, where compressive forces are pronounced,
the primary imaging technique of choice for evalu- but can also develop along the outer aspect,
ation of the acetabular labrum. where tensile forces predominate.39e41
The diagnosis of stress injuries can be made
based on the clinical history and characteristic
HIP PATHOLOGY
radiographic findings of focal periosteal reaction,
Osseous Injuries
cortical disruption, and trabecular sclerosis.41 The
MR imaging can be used to diagnose fractures subtle, ill-defined area of the affected cortex,
and contusions, and helps to exclude other the “gray cortex sign,” may also be seen during
uncommon osseous pathology in the athletic pop- the early stages of stress fractures. However, these
ulation, for example, osteonecrosis and transient fractures are frequently occult on initial radio-
osteoporosis. Most traumatic fractures of the hip graphs, and MR imaging is the best imaging
are diagnosed by radiographs, but the diagnosis method for diagnosing stress fractures (Fig. 1).
of nondisplaced fractures may be difficult at On MR imaging, a focal or diffuse, ill-defined
Fig. 1. A 36-year-old woman with left hip pain. She has been recently training for a marathon. (A) Coronal T2-
weighted fat-suppressed MR image demonstrates periosteal edema (arrow), endosteal edema, and increased
signal within the medial femoral neck cortex representing a stress fracture. (B) Axial T2-weighted fat-suppressed
MR image shows a small low-signal intensity line within the endosteal edema (arrow).
hypointense area on T1-weighted images that has without concomitant injuries (Fig. 2).44 The diag-
increased signal on fluid-sensitive sequences is nosis of a traumatic hip injury is obvious in
characteristic of stress injury (microtrabecular frac- severe cases of dislocation; however, more
ture).42,43 The identification of periosteal edema, subtle traumatic subluxation of the hip can occur
endosteal edema, and high signal within the cortex, with seemingly minimal trauma. The radiologic
even without a fracture line, should suggest the workup after a presumed traumatic hip injury
diagnosis of a stress fracture, as the slice thickness begins with radiographs. In many cases, this
may have missed a small fracture line. In addition, provides a definitive diagnosis. CT imaging is
an accurate diagnosis of a stress fracture of the commonly performed to evaluate associated
hip is important, as many athletes would otherwise known acetabular fractures, or to look for a subtle
be reluctant to reduce their activity so as to protect nondisplaced fracture of the proximal femur or
the hip from a more extensive fracture. acetabulum. MR imaging is typically not per-
formed acutely, but to assess for the sequelae
Traumatic Hip Subluxation or Dislocation
of traumatic malalignment such as chondral
The spectrum of traumatic hip malalignment injuries, labral tears, capsular injuries, and
ranges from subluxation to dislocation with or injuries to the surrounding supporting soft tissue
Fig. 2. A 17-year-old football player following acute injury. Coronal (A) T2-weighted fat-suppressed, axial
T2-weighted fat-suppressed (B, C) MR images through the right hip demonstrate anterior and inferior dislo-
cation of the femoral head (arrow). A large hemarthrosis fills the acetabulum (notched arrow). There has
been tearing of the adductor muscles and ligamentum teres.
structures. Injury patterns depend on the age of Labrum and Labral Tears
the patient and the competency of the
MR appearance of the asymptomatic labrum
surrounding supporting soft tissue structures. In
There is a wide spectrum of appearances of the
the athlete, a forward fall on the knee with
acetabular labrum in asymptomatic individuals.5,50
a flexed hip or a blow from behind while down
The shape of the labrum is triangular on conven-
on all 4 limbs can cause a wide range of associ-
tional MR images in the majority of asymptomatic
ated injuries.44 Traumatic dislocation in the
patients.1,5,50 The posterior labrum is more
athlete is accompanied by a variety of intra-
commonly triangular in shape than the anterior
articular pathologies, the most common being
labrum.50 The labrum has a tendency to become
labral, chondral, and intra-articular loose frag-
rounded and irregular with age.1,5 A previous study
ments and disruption of the ligamentum teres.45
by Abe and colleagues50 showed a triangular lab-
One of the complications following hip disloca-
ral shape in 96% of patients 10 to 19 years old, but
tion is osteonecrosis of the femoral head, which
in only 62% of patients older than 50 years. These
must not be overlooked. MR imaging is useful
investigators proposed that the loss of the normal
in the detection of osteonecrosis. However, MR
triangular-shaped labrum may be caused by
imaging is not an accurate predictor of osteonec-
degenerative changes. Abe and colleagues also
rosis in the acute setting following trauma.46 A
found that an irregularly shaped labrum was only
repeat MR imaging scan can be performed at 6
seen in patients older than 40 years, and an absent
weeks to exclude traumatic osteonecrosis.44 If
labrum only in patients 50 years or older.50 This
patients have no evidence of osteonecrosis at 6
irregularity of the labrum, thought to represent
to 12 weeks, they may return safely to sports
degeneration, may be difficult to distinguish from
activity.
small tears.50 Other studies have documented an
absent labrum on one or more MR images in
Apophyseal Avulsion Injuries
10% to 14% of asymptomatic patients.1,5 There-
Avulsion injuries of the pelvis occur most often in fore, when the labrum is absent or irregular in
the adolescent athlete, usually resulting in a middle-aged or elderly patient it may represent
displacement of an unfused apophysis at the site degeneration, but a tear should be considered,
of the tendon attachment due to the inherent especially in symptomatic patients.
weakness at this site.19,47 The ischial tuberosity The acetabular labrum consists mainly of fibro-
is the most common location for apophyseal injury cartilage tissue, accounting for the single most
in the pelvis.19,48 Apophyseal avulsion injuries are common appearance on MR of low signal intensity
usually detected on radiographs, but may require on T1- and T2-weighted images. Several studies
CT, MR imaging, or sonography to identify subtle have demonstrated a homogeneous low signal
lesions or to better define the extent of the injury. intensity labrum in 44% to 56% of asymptomatic
Avulsion injuries may be caused by sudden individuals.1,5,23
forceful (often eccentric) contraction of the muscu- About half of asymptomatic individuals have
lotendinous unit during running, jumping, or kick- intermediate or high signal intensity within the
ing a ball.39 In addition, repetitive microtrauma labrum.1 A common location for intralabral inter-
from intensive training can cause biomechanical mediate signal intensity is at the junction between
failure at the physeal plate.39 the labrum and acetabulum.7 Additional increased
An anteroposterior radiograph of the pelvis intralabral signal is most commonly seen within the
should be the first imaging study for patients sus- superior labrum.1 This intralabral signal may be
pected of having these injuries, because the diag- linear, globular, or curvilinear, and can involve
nosis of avulsion injury may be documented the capsular or articular surfaces of the labrum,
without further imaging. Apophyseal avulsions, or both.1,5 Therefore, this appearance may mimic
however, may be radiographically occult if the a labral tear on conventional MR imaging images.
apophysis is not ossified, so further imaging may Degeneration within the fibrocartilage can produce
be needed for confirmation. Although MR imaging high signal intensity, and may explain some of the
can reveal these injuries, sonography is advanta- labral heterogeneity seen on MR imaging.
geous because of its faster examination time and However, a study in elderly cadavers7 found
decreased cost.49 MR and CT imaging improves a poor correlation between intralabral signal
detection of the subtle avulsion injury: CT depicts abnormalities and histologic evidence of degener-
the amount of displacement and retraction of the ation. The investigators described this increased
apophysis, while MR imaging better defines the intralabral signal as the presence of small intrala-
extent of adjacent soft tissue injuries and retrac- bral fibrovascular bundles.7 Another cause for
tion of tendons (Fig. 3).48 this increased intralabral signal of the acetabular
Fig. 3. A 14-year-old boy with right-sided hip pain following hockey injury. Axial T2-weighted fat-suppressed (A)
and coronal short-tau inversion recovery (B) MR images show an acute avulsion injury of the sartorius from the
anterior-superior iliac spine (large arrow). There is underlying hematoma (small arrow). Additional partial avul-
sion of the origin of the gluteus minimus muscle is also present (notched arrow).
labrum on T1-weighted images could be the magic give a similar presentation. The physical examina-
angle effect.1 tion is variable, although pain is often provoked
with flexion and internal rotation of the hip.12,51e53
Clinical findings of labral tears
If an active patient has a catching or clicking Labral tears
sensation in the hip after a twisting or slipping Tears of the acetabular labrum have been increas-
injury, a labral tear should be suspected. Labral ingly recognized as a cause of mechanical hip
tears may also occur in the absence of specific pain. Labral tears have been reported in patients
recognizable trauma.10 More commonly the with hip dysplasia, Legg-Calve-Perthes disease,
symptom presentation is subtle, characterized by osteoarthritis, instability, trauma, and femoroace-
dull activity-induced or positional pain that fails tabular impingement, but may occur in young
to improve over time. Often patients describe patients with normal radiographs or no previous
a “deep” discomfort within the anterior groin or injury to the hip.1,6,53e56 A high percentage of
occasionally laterally, just proximal to the greater patients with intra-articular hip pain from synovitis,
trochanter.10 Although a clicking mechanical loose bodies, and cartilage defects also have
symptom suggests an acetabular-labral tear, other acetabular-labral tears.6,54 Individuals with even
entities such as snapping iliopsoas tendon may mild degrees of hip dysplasia are at increased
Fig. 4. A 25-year-old woman with hip pain. Clinical concern was stress fracture. Coronal T2-weighted fat-sup-
pressed (A) and sagittal proton density (B) conventional MR images demonstrate a tear of the anterosuperior
labrum confirmed at arthroscopy (arrows).
risk for labral tears because decentering of the

femoral head generates high loads at the acetab-
ular rim. Certain types of athletic activities, such
as gymnastics and dance, may self-select for
athletes with greater arcs of hip motion.57 In these
individuals, increased forces on the labrum can
result in biomechanical overload and injury.39
Athletes are particularly vulnerable to labral
tears because their hip joints are exposed to
extremes of motion (Fig. 4). It is theorized that
the forces exerted on the labrum, either periodi-
cally or repetitively, are responsible for the injury
patterns as seen at arthroscopy.10 Certain sports
such as golf, hockey, or soccer involve frequent
external rotation of the hip. It is these repetitive
motion sports that may produce an insidious onset
of a labral tear. Hyperextension combined with
femoral external rotation is the injury pattern
most commonly associated with an acute presen-
tation of anterior acetabular-labral pathology,
which may result from mild subluxation and sheer
injury of the femoral head on the anterior acetab- Fig. 5. A 28-year-old male runner with hip pain.
ulum.10 Posterior labral lesions typically occur in Coronal T1-weighted fat-suppressed MR arthrogram
an athlete as a result of axial loading of the hip in image shows a partial-thickness tear of the superior
a flexed position.10 Tears of the acetabular labrum labrum (arrow). Notice the acetabular and femoral
may result in disabling mechanical symptoms, head cartilage loss (curved arrow) and osteophytes
which limit daily activities as well as participation at the head-neck junction.
in athletics.
Labral tears have been diagnosed by conven-
tional arthrography, CT arthrography, conven-
tional MR, and MR arthrography.7,50,58e61 When
labral tears are identified either clinically or radio-
logically, these tears are now often treated with
hip arthroscopy. Early diagnosis and treatment of
tears is important because it not only provides
pain relief but may prevent the early onset of
osteoarthritis.11,53,59
Labral abnormalities include partial tears or lab-
ral detachments, with detachments more common
than tears (Figs. 5e7).12,23,30 The terms labral
“tears” and “detachments” are often used inter-
changeably. Labral tears can be classified accord-
ing to location, etiology, and morphologic features.
The location of tears can be divided into quadrants:
anterior, anterior-superior, posterior-superior, or
posterior. Tears can also be described by the
extent of the tear using a clock face.62 Tears occur
anteriorly in most reported series.2,11,30,51,54,58
Tears of the posterior-superior labrum have been
described in younger patients.59 Isolated posterior
labral tears are also most frequently seen after
a posterior hip dislocation or in patients with hip
dysplasia (Fig. 8).11
Labral tears can also be classified with respect Fig. 6. A 51-year-old man with hip pain. Sagittal T1-
to etiology. Tears can be degenerative, dysplastic, weighted fat-suppressed MR arthrogram images
traumatic, or idiopathic. Degenerative tears can be demonstrate a full-thickness tear of the superior
seen with long-standing inflammatory arthropathies, labrum (arrow).
Fig. 7. A 40-year-old woman with hip pain. Coronal (A) and sagittal (B) T1-weighted fat-suppressed MR arthro-
gram images show a complex type tear with a vertical and horizontal component (arrows).
osteoarthritis, or related to old trauma. Tears associ- Labral tears as seen at arthroscopy have been
ated with hip dysplasia occur most frequently anteri- morphologically classified by Lage and colleagues2
orly but also can occur posteriorly or be diffuse. The into radial flap, radial fibrillated, longitudinal periph-
anterior labrum in patients with acetabular dysplasia eral, and unstable tears. It is difficult for MR arthrog-
is commonly hypertrophied and torn. Labral tears raphy to subtype tears into these types. A recent
secondary to trauma are typically isolated to one study comparing the Lage classification2 for hip
particular region. Patients who have a labral tear after labral tears did not correlate well with the Czerny
trauma without dislocation typically have anterior MR arthrography classification23 or an MR arthrog-
tears. These tears occur in the same region as those raphy modification of the Lage classification
seen in athletes or secondary to mild hip dysplasia.11 system.62 Most hip arthroscopists resect or repair
Idiopathic tears are those that do not fall into any of the labrum based on other features, and morpho-
the above categories. logic type usually does not affect surgery.
Fig. 8. A 21-year-old woman with history of prior hip dislocation. Coronal T2-weighted (A) fat-suppressed and
coronal T1-weighted (B) fat-suppressed MR arthrogram images show a large intra-articular bony fragment
(arrow) off the medial femoral head representing sequelae of prior dislocation injury. (B) A posterosuperior labral
tear is present (notched arrow). In the setting of prior posterior dislocation, the posterosuperior labrum should
be closely scrutinized for labral lesions.
Therefore, a more useful classification system for soft tissues.39,65 Common associated findings
labral tears includes the descriptive terms: frayed seen in individuals with labral lesions are subchon-
(irregularity of the free edge of the labral substance dral bone marrow edema, subchondral cystic
seen with degeneration), partial-thickness tear, full- change, and cartilage lesions. Within the adjacent
thickness tear, and complex tear. soft tissues, paralabral cysts can also be found.
Paralabral cysts have been described in
MR arthrography of labral tears
patients with developmental dysplasia of the hip,
In the assessment of the labrum at MR arthrogra-
osteoarthritis, and both acute and remote hip
phy, 4 items should be addressed: (1) what is the
trauma.66 The cysts are associated with either
morphology, such as triangular, thickened, or dis-
degeneration or tears of the labrum.55,65,67 When
torted/irregular (representing a tear)?; (2) does
a labral tear is present, there is an increase in
contrast extend into the labrum (indicating
intra-articular pressure secondary to the loss of
a tear)?; (3) does contrast extend between the
congruency between the femoral head and the
labrum and acetabulum indicating labral detach-
acetabulum.55 It is this elevated pressure that
ment?; and (4) is there increased signal intensity
forces synovial fluid through the labral tear, result-
within the labrum indicating mucoid degeneration
ing in a paralabral cyst.58
but not a tear?
Paralabral cysts are of low to intermediate signal
Acetabular-labral tears are recognized on MR
intensity on T1-weighted images and high signal
arthrography by the presence of contrast material
intensity on T2-weighted images (Fig. 9). The
extending into the labrum (see Fig. 5).4,23,63
differential diagnosis of a homogeneous fluid
Detachments are identified by the presence of
signal intensity mass adjacent to the acetabulum
contrast material interposed at the acetabular-
would include a ganglion unrelated to a labral
labral junction with or without labral displacement
tear, an atypical synovial cyst, neural tumor,65
(see Fig. 6).4,23,64 The signal intensity within a tear
and iliopsoas bursitis. Determining the location of
does not have to be equal to that of gadolinium or
the fluid collection in relation to the iliopsoas
fluid to confirm the diagnosis of labral tear.32 It is
tendon has been useful in differentiating between
important to assess the acetabular labrum on all
iliopsoas bursitis and a paralabral cyst. In the
imaging planes, as a tear may be detected on
authors’ experience, a paralabral cyst frequently
only one image; however, tears are typically seen
is located lateral to the iliopsoas tendon, whereas
on more than one imaging plane and on more
iliopsoas bursal fluid collections are located
than one image.32
medial to the iliopsoas tendon.65 Another useful
Secondary findings sign in determining the cause of the paralabral
Labral lesions may be associated with several cyst is to look for a communication of the cyst
abnormalities in the adjacent cartilage, bone, and with a torn acetabular labrum. At MR arthrography,
Fig. 9. A 56-year-old active man with hip pain. (A) Coronal T2-weighted fat-suppressed MR and coronal (B) T1-
weighted fat-suppressed MR arthrogram images of the hip show a paralabral cyst anterior to the acetabular
labrum (arrow). A complex tear is seen involving the anterosuperior labrum (notched arrow). Note the subchon-
dral cyst within the superior acetabulum.
high signal intensity contrast filling the paralabral detachment may exist at the anterior-superior
cystic structure on T1-weighted fat-suppressed acetabulum.12,22 Byrd22 described a partial sepa-
images adjacent to an abnormal labrum confirms ration of the labrum from the margin of the superior
the diagnosis. Occasionally a paralabral cyst can bony acetabulum as a normal variation in patients
have an unusual low signal appearance on T2- with acetabular dysplasia.
weighted images, which may be due to gelati- Two recent studies have evaluated the presence
nous/mucinous material, debris, or proteinaceous of sublabral sulci at MR imaging and arthroscopy.
products. Recognizing a paralabral cyst is helpful In the study by Saddik and colleagues,69 30 sulci
because this observation may confirm an uncer- were identified at hip arthroscopy in 25% (27) of
tain diagnosis of a labral tear (Fig. 10). Care should 121 patients. Of the 30 sulci found at arthroscopy,
be taken to recognize a normal variant, the obtu- 12 were located anterosuperiorly, 14 posteroinfer-
rator externus bursa. There is a potential commu- iorly, 2 anteroinferiorly, and 2 posterosuperiorly,
nication between the hip joint and obturator bursa, indicating that sulci may be seen within any quad-
seen in approximately 5.5% of MR arthrograms, rant. In the arthroscopy study by Studler and
which could be misinterpreted as a paralabral colleagues,71 10 (18%) of 57 patients had subla-
cyst.68 bral sulci in the anteroinferior part of the acetab-
ulum. Contrast material interposed at the labral
Pitfalls base within the anterosuperior portion of the
One pitfall of MR imaging of the labrum is the labrum always indicated a labral tear.71
normal posterior inferior acetabular sublabral It is the authors’ experience that there can be
sulcus or groove.8,69 The posterior inferior location a normal sublabral sulcus at the anterior-superior
of the sublabral sulcus is helpful, differentiating it acetabulum at the labral acetabular junction. The
from most labral injuries that occur at the anterior differentiating characteristics of a sulcus from
or anterior-superior acetabulum.2,11,30,70 Dinauer a tear are that: (1) contrast should not completely
and colleagues8 defined the presence of a poster- extend through the labrum, (2) smooth borders
oinferior sulcus when labral separation from the are seen with a sulcus, whereas irregular borders
articular cartilage was clearly observed on at least are seen with tears, and (3) sulci are generally
2 MR images in the absence of surgical pathology shallow, whereas tears extend deeper within the
in the same region of the acetabulum; this is labrum (Fig. 11).72 The authors do not know
a commonly seen finding and should not be misin- exactly how deep a sulcus can extend into the
terpreted as a tear. labrum. However, as in the study by Dinauer and
The presence of a sublabral sulcus other than in colleagues,8 whenever the authors have noted
the posteroinferior acetabulum has been raised contrast extending greater than 50% across the
as a potential pitfall in the diagnosis of labral anterior-superior labral base at MR arthrography,
tears,4,6 although this topic remains controversial. this finding has surgically correlated with labral
Several investigators have suggested that a normal injury.73 Lastly, if there is a high clinical suspicion
sublabral sulcus mimicking a traumatic labral for labral tear and the patient gets pain relief with
Fig. 10. A 28-year-old male soccer player with chronic hip pain. (A, B) Two sequential axial oblique T1-weighted
fat-suppressed and axial (C) T1-weighted MR arthrogram images demonstrate a small posterior-superior parala-
bral cyst (arrow in A). A neck from this cyst can be seen to extend to the labrum (arrow in B). Axial T1 image help
to confirm the posterior labral tear (arrow in C). Whenever a cyst is identified around the hip, close inspection of
the labrum to evaluate for associated labral tear should be made.
Fig. 11. A 17-year-old male athlete with hip pain. He had symptomatic relief of his hip pain following anesthetic
injection. Two sequential sagittal (A, B) and axial oblique (C) T1-weighted MR arthrogram images of the left hip
show high signal at the labral cartilage interface. Initial sagittal image (A) could be interpreted as a sulcus;
however, this is slightly irregular and deep (arrow). The next image (B) demonstrates irregularity, distortion,
and abnormal morphology of the anterior labrum with subtle high signal within the labral substance indicating
a tear (arrow). The high signal also extends greater than 50% across the labral base (arrow in C).
intra-articular injection of anesthetic, and MR ar- the likelihood of an extracapsular leak.74 Inad-
thrography imaging findings are equivocal for lab- vertent injection of air into the joint could lead
ral tear, it may be helpful to point out this pain relief to a false-positive diagnosis of intra-articular
and indicate that this is suspicious for a labral tear loose bodies, and depending on the location
rather than a normal sulcus. may cause difficulty in assessing for labral
Diagnostic difficulties can also result from pathology.
extra-articular injection or leak of contrast mate-
rial through the capsular puncture site, which Surgical treatment
may simulate a tear within the capsule. However, The management of hip abnormalities has evolved
injecting less than 15 mL into the joint decreases significantly in the past few years with the
advancement of arthroscopic techniques, and ligament (Fig. 12). Treatment consists of limited
arthroscopy has been shown to be of benefit in debridement of the entrapping fibers.83
the treatment of labral tears.53,75 Surgical treat-
ment for labral tears includes either resection or Capsule and Extrinsic Ligaments
repair of a tear.11,30,52,53,76,77 Recently a new tech-
nique has been described using the ligamentum With MR imaging, injuries to the extrinsic liga-
teres for labral reconstruction.78 ments may be diagnosed using the criteria
commonly used for ligaments elsewhere in the
body. The most common injury following traumatic
Ligamentum Teres dislocation of the femoral head is injury to the ilio-
femoral ligament of the hip joint capsule, easily
Injury of the ligamentum teres has been increas- diagnosed at MR imaging.84 The capsule may
ingly recognized at hip arthroscopy and consid- also be injured following dislocation or during
ered as a source of hip pain in athletes.79 With sports-related activities. The identification of
advances in imaging techniques in assessing contrast across the capsule (not at the site of
intra-articular structures of the hip, ligamentum puncture during arthrography) indicates a capsular
teres pathology should be evaluated on all hip injury (Fig. 13).
MR imaging and should be part of the search
pattern. Injury of the ligamentum teres is known
Osteochondral Lesions, Chondral Defects,
to occur with dislocation of the joint, but disruption
and Intra-Articular Loose Bodies
in the absence of a dislocation has also been
described.79,80 The ligamentum teres generally is Osteochondral lesions are caused by impaction
not thought to contribute to hip joint stability, injuries that result in laceration of the articular
although this remains uncertain.81,82 Tear of the cartilage and microfracture of the underlying sub-
ligamentum teres can be a source of persistent chondral trabeculae.85 Within the hip joint, osteo-
hip pain following injury, with the disrupted fibers chondral injuries have been reported most
catching within the hip joint.79 At arthroscopy, lig- commonly following hip dislocation.86 The location
amentum teres pathology has been classified as of osteochondral impaction injury depends on the
complete ligamentum teres rupture, partial tear, direction of dislocation. Following anterior disloca-
and degeneration.82 At MR arthrography, the diag- tion, the site of impaction is typically located along
nosis of a complete rupture of the ligament is the posterolateral aspect of the femoral head,
made when no intact ligament can be identified whereas following posterior dislocation the ante-
or only wavy incomplete fibers are visualized. A rior margin of the femoral head is mostly involved.
partial tear may be more difficult to diagnose, Patients who have chronic, persistent hip pain
with irregularity of the fibers or thickening of the following injury, with negative or equivocal
Fig. 12. A 16-year-old runner with hip pain. Coronal (A) T2-weighted fat-suppressed and axial oblique (B) T1-
weighted fat-suppressed MR arthrogram images demonstrate a thickened and slightly irregular ligamentum
teres (arrows).
33% of patients at arthroscopy had alterations of

the articular surface of the femoral head associ-
ated with a labral tear. A more recent study by
McCarthy and colleagues11 showed a highly
significant association between the presence of
labral lesions and degeneration of the articular
cartilage. Labral and articular lesions are
commonly located in the same zone of the acetab-
ulum.11 In the study by McCarthy and
colleagues,70 they observed a preponderance of
chondral lesions involving the anterior labral carti-
lage junction in their arthrographic and cadaveric
series. It is thought that certain repetitive rotational
maneuvers preferentially subject the anterior
portion of the cartilage near the labral junction to
recurrent microtrauma and eventual mechanical
attrition. Arthroscopic and anatomic observations
support the concept that labral tears and chondral
lesions frequently are part of a continuum of
degenerative joint disease.70 As in other joints,
the long-term consequences of chondral lesions
Fig. 13. A 22-year-old football player with hip pain. are a major concern. Symptomatic improvement
Axial oblique T1-weighted MR arthrogram image has been shown from arthroscopic debridement
shows contrast extravasation through the posterior of unstable cartilage flaps, although future
capsule (arrow) indicating a posterior capsular tear. advances in cartilage resurfacing procedures
may promote long-term overall health of the hip
joint.52
radiographic findings, may benefit from evaluation The detection of a discrete chondral or osteo-
with MR imaging or MR arthrography. When chon- chondral defect should prompt a thorough search
dral injury is suspected, MR arthrography is for a displaced intra-articular body (Fig. 16). Os-
preferred.87 teochondral lesions of the femoral head have
been described in athletes, and have an MR
Cartilage assessment imaging appearance similar to osteochondral
Normal hyaline cartilage has intermediate to bright lesions in other locations such as the knee and
signal on MR imaging images, although typically ankle.90,91 Intra-articular loose bodies manifest
less intense than gadolinium solution.88 The artic- as a low signal intensity filling defect within the
ular cartilage should be closely scrutinized on all fluid-filled joint (Fig. 17). Ossific bodies may be
imaging planes. The gadolinium solution outlines isointense to fat containing bone marrow. Progres-
the articular margins, defining any cartilage sive joint space narrowing after traumatic hip
surface irregularities and filling partial- or full- subluxation or dislocation, occurring in the months
thickness defects (Figs. 14 and 15).89 With a carti- immediately following trauma, may indicate post-
lage flap tear, there is undercutting of the chondral traumatic chondrolysis.92
surface with fluid/gadolinium visualized. MR ar- Newer MR imaging techniques in cartilage
thrography has been shown to have a sensitivity imaging with dGEMRIC and T2 mapping may
of 50% to 79%, specificity of 77% to 84%, and provide more detailed information regarding early
accuracy 69% to 78% in detection of cartilage changes within articular cartilage, and may guide
lesions overall.25 Most investigators prefer MR ar- surgical intervention.20,93,94 Additional cartilage
thrography over conventional MR images, sequences performed during MR arthrography
although the study by Mintz and colleagues24 re- may provide increased lesion conspicuity
ported a similar accuracy for detection of cartilage (Fig. 18).95,96
lesions on conventional nonarthrographic MR
images. However, as noted previously, this study
Plicae
did not compare the exact grades of cartilage
lesions at MR imaging with those seen at Synovial plicae are normal anatomic structures
arthroscopy. that sometimes become symptomatic (Fig. 19).
Chondral lesions are often noted in association Symptomatic plicae are a well-known cause of
with labral tears. In the study by Fitzgerald,30 knee pain.97,98 Hip plicae have been described in
Fig. 14. A 40-year-old woman with hip pain (same patient as Fig. 7). (A) Axial oblique and sagittal (B) T1-
weighted fat-suppressed MR arthrogram images demonstrate articular cartilage lesions within the femoral
head and 2 focal lesions within the acetabulum (arrows). If subchondral cysts or bone marrow edema are present,
one should closely evaluate the overlying articular cartilage for lesions.
Fig. 15. A 52-year-old active woman with hip pain. Coronal (A) and sagittal (B) T1-weighted fat-suppressed MR
arthrogram images of the left hip demonstrate gadolinium signal intensity filling a cartilage defect within the
acetabulum and femoral head (arrows).
Fig. 16. A 16-year-old girl with recurrent catching,

locking, and mechanical symptoms. Coronal T2-
weighted fat-suppressed MR image at arthrography Fig. 18. A 25-year-old man with hip pain. Sagittal Iter-
shows an osteochondral lesion within the superior ative Decomposition of water and fat with Echo
acetabulum (arrow). There is no surrounding bone Asymmetry and Least-squares estimation Spoiled
marrow edema. Osteochondritis dissecans has been Gradient Echo (IDEAL-SPGR) image shows a cartilage
described in the hip, classically within the femoral lesion (arrow). This cartilage sequence may increase
head. the conspicuity of cartilage lesions and help to detect
shallow defects.
cadavers99 and in patients undergoing diagnostic

hip arthroscopy.100 Symptomatic hip plicae are
now becoming recognized and treated at hip
arthroscopy.100 The normal pectinofoveal fold
should be recognized at MR imaging, has been
shown to have various appearances and attach-
ment sites, and should not be misinterpreted as
a thickened hip plicae.101
Femoroacetabular Impingement
Another cause of hip pain is femoroacetabular
impingement (FAI). There is some overlap of this
entity with labral tears because some tears seen
at MR arthrography may be caused by FAI. FAI
can result from anatomic abnormalities of the
proximal femur and/or acetabulum. FAI occurs
with hip flexion, adduction, and internal rotation
(described as the “anterior impingement position”)
in individuals who have subtle predisposing
Fig. 17. A 27-year-old man with hip pain. Coronal T2-
anatomic features.25,102e104 These anatomic
weighted fat-suppressed MR arthrographic image
demonstrates a low signal intensity structure within features result in decreased clearance between
the hip joint compatible with a loose body (arrow). the anterior acetabular rim and the anterior femur
Note the diffuse cartilage loss of the femoral head at the head-neck junction. This impingement can
and acetabulum, abnormal morphology of the lead to labral tears, cartilage lesions, and eventu-
labrum, and osteophytes. ally premature osteoarthritis.
Fig. 19. A 52-year-old man with hip pain. (A) Coronal T1-weighted MR arthrogram image demonstrates a mildly
thickened plicae (arrow) within the medial hip joint space just medial to the normal pectinofoveal fold (notched
arrow). (B) Arthroscopic image depicts the irregular, thickened plicae (arrows) adjacent to the pectinofoveal fold
(curved arrow); this was excised at arthroscopy.
The anatomic abnormalities that lead to FAI and physical examination. The morphologic abnormal-
can be divided into 2 main types of impingement: ities help confirm the diagnosis and may be identi-
cam and pincer. The most common situation is fiable on radiographs, but some cases are
a mixed cam and pincer pathology, occurring apparent only on CT or MR imaging.
along the anterior femoral neck and the anterior-
superior acetabular rim.56 Cam impingement is Anteroposterior pelvis and frog-leg lateral
due to an abnormal morphology of the anterior radiographs
femoral head-neck junction, and is typically seen In cam FAI there may be an osseous prominence
in younger individuals.102,105,106 The prominence in the anterosuperior region of the femoral head-
of the femoral head-neck junction can be seen neck junction (femoral bump), or the femoral
as an overall decreased offset at the femoral neck may have a pistol-grip deformity.109
head-neck junction. This decreased offset has Pincer-type FAI can be visualized as acetabular
been termed the “pistol-grip deformity,” which retroversion, coxa profunda, protrusio acetabuli,
describes a flattened head-neck junction seen on and acetabular rim ossification.110 One radio-
standard anteroposterior radiographs of the graphic sign of acetabular retroversion that has
hip.107 Pincer impingement is caused by an abnor- been described is the crossover sign.111 In
mally retroverted acetabulum contacting a normal a positive crossover sign, the anterior acetabular
femur during hip flexion, and is more common in rim is projected laterally relative to the same
older women. Retroversion, a cause of pincer point of the posterior rim in the superolateral
impingement, may be seen as a result of trauma, aspect of the acetabulum. Another sign seen in
as part of a complex acetabular dysplasia, or in pincer-type FAI is when the acetabular fossa or
isolation, and is thought to play a role in early- the femoral head lies medial to the ilioischial
onset degenerative joint disease. This condition line, indicating increased acetabular socket
can result from decreased acetabular anteversion depth, as seen with protrusion acetabuli.111,112
or coxa profunda. Acquired causes can be acetab- A lucency within the anterosuperior femoral
ular protrusion, or postsurgical prominent antero- neck may be associated with femoroacetabular
superior acetabulum. Another cause can be coxa impingement.110 These lucencies are known to
vara.108 Both types of FAI are common in athletes represent synovial herniation pits within the sub-
presenting with hip pain, loss of range of motion, capital femoral neck. The lucencies are often
and disability.56 seen in athletes, and have been thought to repre-
sent an abnormal interaction between the iliop-
Imaging FAI soas tendon and the joint capsule, which
The diagnosis of femoroacetabular impingement is produces increased pressure on the anterior
based on the patient’s distinct clinical history and portion of the proximal femur.
MR imaging with patients without clinical symptoms.102 The

MR imaging is ideal for evaluation of the anatomic larger the neck radius in the superior and anterior
changes of FAI (Fig. 20). On MR images an aspects of the neck, the more likely there is to be
abnormal morphology of the anterior femoral impingement, although no absolute measure-
head-neck junction is clearly seen in the cam ments are defined.102
type of FAI. The abnormal head-neck morphology
Treatment of FAI
can be seen on conventional MR images, but MR
Arthroscopic treatment of FAI allows athletes to
arthrography is preferred because it also provides
return to sports competition.56 The treatment of
better evaluation of the labrum and cartilage.
symptomatic cam-type FAI unresponsive to
Radial imaging may be helpful is assessing FAI
conservative measures is surgical, and consists
morphology.113 An alpha angle greater than 55
of excision osteoplasty of the nonspherical portion
has been shown to be closely associated with
of the femoral head and neck.105,106,115 This
symptomatic cam-type femoroacetabular
procedure improves the head-neck offset and
impingement.103,106 The alpha angle is used as
increases bony clearance during hip motion. The
an objective representation of the prominence of
procedure is often combined with resection of
the anterior femoral head-neck junction. The
the soft tissue anterior to the hip joint that may
greater the alpha angle, the greater the likelihood
also be involved in impingement. For pincer
for impingement of the anterior/anterosuperior
impingement, periacetabular osteotomy or exci-
femoral head-neck against the acetabulum.
sion of the bony prominence at the anterior
However, the alpha angle measurement is fraught
acetabular rim is performed to reduce anterior
with inconsistencies. A recent study by Lohan and
over-coverage.105 Articular cartilage smoothing
colleagues114 found that the alpha angle per-
and/or debridement near the acetabular rim are
formed poorly and was statistically of no value in
also done. A torn or degenerated labrum may
suggesting the presence or absence of cam FAI.
need to be excised and/or repaired. If there has
There is often MR imaging evidence for corre-
been development of an extra-articular bony
sponding impaction damage at the superior
prominence along the femoral head-neck region,
portion of the superolateral femoral head-neck
excision osteoplasty may also be performed to
junction. One can also often see acetabular-
increase the femoral neck offset and create
labral damage resulting from this structure being
a better waist at the head-neck junction.105,106
impinged between the acetabulum and the adja-
cent femoral head-neck region.
The Snapping Hip
Patients with clinical symptoms of FAI have
been found to have increased ratios of femoral Another cause of hip pain, usually in young individ-
neck size relative to the femoral head as compared uals, is the snapping hip syndrome, a symptom
Fig. 20. A 27-year-old man with persistent hip pain. (A) Coronal and axial oblique (B) T1-weighted MR arthro-
gram images of the right hip demonstrate loss of the concavity at the femoral head-neck junction and an osseous
“bump” (arrows) compatible with cam FAI. Note the anterosuperior labral tear (notched arrow).
complex characterized by pain and an audible or

perceived snapping of the hip during movement
of the hip. Symptoms are reproduced during
specific movements of the hip but most frequently
when the hip moves from a position of flexion-
abduction-external rotation (frog-leg position) to
the neutral position.116 Snapping hip has various
causes, which have been categorized as external,
internal, and intra-articular. Diagnosing the exact
cause clinically is sometimes difficult.
The external type of snapping hip is the most
common, and occurs as a result of catching of
either the posterior iliotibial band (ITB) or the ante-
rior aspect of the gluteus maximus muscle as it
moves over the greater trochanter during flexion
and extension of the hip joint.17,116e118 An external
snapping hip is typically a clinical diagnosis, so
imaging is seldom needed.
Intra-articular causes of a snapping hip include Fig. 21. An 18-year-old female athlete with snapping
labral tears, loose bodies, synovial osteochondroma- hip. Transverse sonogram image of the iliopsoas
tosis, synovial folds, and fracture fragments. Hip MR tendon at the level of the acetabular brim during
arthrography is commonly used to assess for these injection of the iliopsoas bursa/tendon sheath show
intra-articular conditions, and they often require the needle entering from a lateral to medial approach
surgery for relief of symptoms.17,116,117,119e121 (large arrow). The needle tip should be placed adja-
An internal snapping hip is most often related to cent to or just beneath the iliopsoas tendon (thin
arrow) at the level of the acetabular brim (notched
the iliopsoas tendon, and has been suggested as
arrow) Care should be taken not to inject too caudal,
a more common cause of snapping hip than the
as the hip joint may be inadvertently injected.
extrinsic type.116 There are 3 proposed mecha-
nisms to explain the snapping: contact between
the iliopsoas tendon and the iliopectineal sense that inflammation of one will often result
eminence, or at the lesser trochanter (“friction in inflammation of the other due to their close
syndrome”),15,72 and catching between the iliop- proximity.120
soas tendon and its muscle.122 An accurate diagnosis of the cause of painful
snapping hip is essential for deciding on the
Snapping iliopsoas tendon (internal appropriate treatment. The cause for an individ-
snapping hip) ual’s hip pain may not be identified until after iliop-
The normal iliopsoas tendon glides smoothly over soas bursa injection confirms pain relief.
the pelvic brim during hip rotation.15 Sonography Treatment options for the painful snapping iliop-
has demonstrated a snapping or abnormal jerky soas tendon include nonoperative management
movement of the iliopsoas tendon in the snapping (rest, analgesics, and physical therapy), injection
hip.123 Sonography has emerged as the preferred of corticosteroids and anesthetic agents into the
technique for examining the iliopsoas tendon iliopsoas bursa (Fig. 21), and surgery.15,121,124e126
because it allows both static and dynamic evalua-
tion of the soft tissues around the hip SUMMARY
joint.116,119,123 Sonography also provides an accu-
rate method for injection into the iliopsoas bursa. There are many causes for hip pain in the athlete.
However, because sonography may not allow Having an understanding of the spectrum of
accurate evaluation of intra-articular pathologic abnormalities around the hip will help with the
conditions, some combination of radiography, decision for the appropriate imaging method in
hip arthrography, CT, or MR imaging is still recom- the evaluation of these disorders. MR imaging
mended if an intra-articular cause for hip pain is and sonography will aid not only in preoperative
suspected.123 planning but in the appropriate selection of
Although iliopsoas tendinopathy and bursitis patients to undergo hip arthroscopy, which tends
can be seen,120 sonographic signs of tendinop- to lead to better postoperative results. Although
athy are not a common feature of a snapping radiographs are the first step in the workup for
iliopsoas tendon.72,116 When it does occur, iliop- the painful hip, MR imaging is considered the
soas bursitis and tendinitis are interrelated in the next imaging test of choice for the evaluation of
most common hip abnormalities in athletes, 16. Chandler SB. The iliopsoas bursa in man. Anat Rec
including labral injuries, ligament injuries, osteo- 1934;58:235e40.
chondral injuries, fractures, bursitis, and musculo- 17. Schaberg JE, Harper MC, Allen WC. The snapping
tendinous injuries. hip syndrome. Am J Sports Med 1984;12(5):361e5.
18. Pfirrmann CW, Chung CB, Theumann NH, et al.
Greater trochanter of the hip: attachment of the
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Hip Injuries in

Radiol Clin N Am 48 (2010) 1155–1178

ligament and labrum join. The appearance of Trochanteric Anatomy

risk for labral tears because decentering of the

33% of patients at arthroscopy had alterations of

Fig. 16. A 16-year-old girl with recurrent catching,

cadavers99 and in patients undergoing diagnostic

MR imaging with patients without clinical symptoms.102 The

complex characterized by pain and an audible or

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