Diagnostic Approach and Treatment for Labral Tears and Femoroacetabular Impingement (FAI) Syndrome

Diagnostic Differentiation

The British Journal of Sports Medicine recommends that diagnosis and treatment should integrate clinical examination, imaging findings, and patient symptoms, as neither labral tears nor FAI syndrome should be diagnosed based on imaging alone 1, 2
A negative flexion adduction internal rotation (FADIR) test helps rule out both conditions, while a positive test may indicate either condition but has limited diagnostic specificity 3
Initial diagnostic imaging should include anteroposterior (AP) pelvis and lateral femoral head-neck radiographs 4
For labral tears, MR arthrography is superior to CT arthrography and non-contrast MRI, according to the Journal of the American College of Radiology 5
Advanced imaging (MRI/MRA or CT) should be used when three-dimensional morphological assessment is needed or to evaluate intra-articular structures like the labrum, cartilage, and ligamentum teres 1, 2
Incidental intra-articular findings are common in asymptomatic individuals 4

Hip-related pain may be categorized into three main conditions: FAI syndrome, acetabular dysplasia and/or hip instability, and other conditions causing hip-related pain (including isolated labral tears) 4, 3, 1, 6
The British Journal of Sports Medicine suggests that prescribed physiotherapy consisting of education should be part of the initial treatment 1
Intra-articular injections can be both diagnostic and therapeutic, according to the Journal of the American College of Radiology 5

Diagnosis should never be based on imaging alone, but should combine clinical signs, symptoms, and imaging findings, as recommended by the British Journal of Sports Medicine 1, 2, 4
Beware of incidental findings, as labral, chondral, and ligamentum teres pathology are common on imaging in asymptomatic people 6
Consider coexisting conditions, as many hip-related pain conditions, especially labral and chondral conditions, coexist with FAI syndrome 4
Exclude other causes, including non-musculoskeletal and serious hip pathological conditions and competing musculoskeletal conditions, as recommended by the British Journal of Sports Medicine 6

A negative FADIR test helps rule out hip disease in young and middle-aged active adults with hip-related pain, according to the International Hip-related Pain Research Network consensus, which strongly recommends this approach with a median score of 9/9 7, 8, 9, 10, 11
Negative tests are most valuable for excluding hip pathology rather than confirming it, as stated by the International Hip-related Pain Research Network consensus 7, 8, 9, 10, 11

The FADIR test demonstrates high sensitivity but low specificity, making it ideal for ruling out disease when negative but poor for confirming disease when positive, although the exact sensitivity and specificity values are not provided in the cited references 7

When both FABER and FADIR tests are negative, consider alternative diagnoses such as lumbar spine pathology, sacroiliac joint dysfunction, or other competing musculoskeletal conditions, and exclude serious pathology including tumors, infections, stress fractures, and slipped capital femoral epiphysis (SCFE), as recommended by the British Journal of Sports Medicine 8, 11
If hip-related pain persists despite negative tests, imaging should still be combined with clinical signs and symptoms rather than relying on clinical tests alone, as suggested by the International Hip-related Pain Research Network consensus 7, 9, 12

The International Hip-related Pain Research Network consensus emphasizes that imaging findings must always be combined with patient symptoms and clinical signs, never used in isolation, to avoid misdiagnosis 7, 9, 12
Do not use negative tests to completely exclude hip pathology in isolation, but rather consider the entire clinical picture, including history, symptom pattern, and imaging findings, as recommended by the International Hip-related Pain Research Network consensus 7, 9, 12

The FABER test is used to assess for hip-related pain in young and middle-aged active adults, particularly screening for FAI syndrome, acetabular dysplasia, hip instability, and labral pathology, with its greatest clinical utility being to rule out hip disease when negative rather than to confirm it when positive, as recommended by the British Journal of Sports Medicine 13
Imaging findings must always be combined with patient symptoms and clinical signs—incidental labral tears and other findings are common in asymptomatic individuals, according to the British Journal of Sports Medicine 13