M u s c u l o s k e l e t a l I m a g i n g • B e s t P r a c t i c e s / R ev i ew

Naraghi and White

MRI of Labral and Chondral Lesions of the Hip

Musculoskeletal Imaging
Best Practices/Review
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FOCUS ON:

MRI of Labral and Chondral Lesions

of the Hip
Ali Naraghi1 OBJECTIVE. Unenhanced MRI, indirect MR arthrography, and direct MR arthrography
Lawrence M. White have been used in the radiologic evaluation of patients with suspected labral tears and chondral
lesions of the hip. The purpose of this article is to examine the existing evidence for the use of
Naraghi A, White LM these techniques in patients with hip pain and suspected labral or chondral abnormalities.
CONCLUSION. Evidence from a review of the radiologic literature supports the use of
direct MR arthrography over unenhanced MRI and indirect MR arthrography for the detec-
tion of labral and cartilage abnormalities in the hip. Although high-resolution unenhanced
3-T MRI appears promising, limited information in the literature supports its use in the de-
tection and characterization of chondrolabral lesions.

Keywords: acetabular labrum, cartilage, hip, MR
arthrography, MRI, unenhanced MRI
DOI:10.2214/AJR.14.12581
Received January 16, 2014; accepted after revision
February 7, 2015.
1
Both authors: Joint Department of Medical Imaging,
University Health Network, Mount Sinai and Women’s
College Hospitals, University of Toronto, 585 University
Ave, 1- PMB 284, Toronto, ON M5G 2N2, Canada. Address
correspondence to L. M. White (lawrence.white@uhn.ca).
This article is available for credit.
AJR 2015; 205:479–490
0361–803X/15/2053–479
© American Roentgen Ray Society
Clinical Vignettes and Images
Patients with pathologic conditions affect-
ing the labrum and cartilage of the hip may
present with a variety of symptoms, includ-
ing hip pain typically localized to the groin,
limitation of range of motion, and clicking.
These symptoms may be aggravated by physi-
cal activity. Labral and chondral lesions may
be seen in patients with femoroacetabular im-
pingement (FAI), developmental dysplasia of
the hip, Legg-Calvé-Perthes disease, slipped
capital femoral epiphysis, iliopsoas impinge-
ment, repetitive or acute trauma, or osteo-
arthritis. Improvements in surgical tech-
niques have meant that chondral lesions and
labral tears are amenable to surgical interven-
tion. However, because labral tears and chon-
dral loss are among the many possible causes
of hip pain [1, 2], diagnosis is based on a com-
bination of clinical features and supportive
imaging findings. As such, imaging is often
undertaken to confirm the diagnosis and ex-
clude other causes of hip pain [3]. Clinical vi-
gnettes and images are presented in Figures
1–5. All findings described were surgically
proved at arthroscopy.
The Imaging Question
Despite advances in MRI hardware and ac-
quisition pulse sequences that result in high-
er-resolution MR images with improved sig-
nal-to-noise ratios, imaging of the articular
cartilage and the labrum in the hip remains
challenging. A diagnostic challenge in evalua-
tion of internal derangement of the hip is iden-
tifying an imaging technique that is reliable,
accurate, and convenient. MRI techniques, in-
cluding unenhanced MRI, direct MR arthrog-
raphy, and indirect MR arthrography, have
been used in the imaging evaluation of this
patient population [4–10]. The goal of this
review is to evaluate the most suitable tech-
nique for evaluation of patients with hip pain
that has a suspected labral or chondral cause.
Background and Importance
The hip labrum plays an important role in
hip function that includes hip stability, pro-
prioception, distribution of forces in the hip,
and joint lubrication [11, 12]. Although labral
tears can have a variety of causes, there has
been growing interest in the diagnosis and
treatment of chondrolabral lesions, partly
because of increasing interest in FAI. FAI,
which results in abnormal contact and abut-
ment between the femoral head and the ace-
tabular rim, has been proposed as a cause of
hip pain and a predisposing factor in the de-
velopment of osteoarthritis of the hip [13–16].
FAI is thought to be caused by morphologic
variations of the femoral head-neck junction,
the acetabulum, or both [13]. These variations
are characterized by anterolateral loss of the
offset at the femoral head-neck junction, re-
sulting in a cam type of deformity, or by ac-
etabular morphologic changes, such as retro-
version, focal or global overcoverage, or coxa
profunda or protrusio acetabulum, resulting in

AJR:205, September 2015 479

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TABLE 1: Studies Evaluating the Sensitivity and Specificity of MR Arthrography in the Detection of Hip Labral and Chondral Lesions

480
No. of No of Labrum Cartilage
Patients Patients Maximum
With With Field Slice In-Plane Pulse Sequence
No. of Reference Labral Chondral Strength FOV Thickness Resolution With Maximum Sensitivity Specificity Sensitivity Specificity
Authors Year Patientsa Standardb Tear Lesion (T) Coil 2
(cm ) (mm) (mm)c Resolution (%) (%) (%) (%)
Anderson et al. 2009 26 (27) Open (27) NA 9 NA NA NA NA NA NA NA NA 22.2 100
[35]
Aprato et al. [36] 2013 41 Open (21), 34 A 16, F 14 1.5 Torso phased 20–26 3–4 0.53 × 0.69 T1 91 86 A 69, F 46 A 88, F 81
arthroscopy (20) array, body
Blankenbaker et 2011 67 Arthroscopy (67) NA NA 3 Surface 18–24 1–4 0.56 × 0.80 T2 FS NA NA Conventional, Conventional,
al. [37] phased 70; IDEAL, 74 84; IDEAL, 77
array
Byrd and Jones 2004 40 Arthroscopy (40) 32 22 1.5 Torso NA NA NA NA 72 13 41 94
[38]
Chan et al. [39] 2005 30 Arthroscopy (17) 16 NA 1.5 NA 15 1.5 0.59 × 0.59 3D-FLASH 100 0 NA NA
Czerny et al. [40] 1996 56 (57) Surgery not 20 NA 1.0 (17), Surface 15 1.5 0.59 × 0.59 GRE 90 100 NA NA
otherwise 0.5 (40)
specified (22)
Czerny et al. [41] 1999 40 Open (40) 34 NA 0.5 (24), Surface 15 1.5 0.59 × 0.59 GRE 91 71 NA NA
1.0 (16)
Freedman et al. 2006 24 Arthroscopy (24) 23 NA 1.5 Torso phased 17–20 3–4 NA NA 96 0 25 NA
[43] array
James et al. [44] 2006 46 Arthroscopy (46) NA 38 1.5 Surface 15–17 3 NA NA NA NA 89 63–75
phased
array
Naraghi and White

Keeney et al. [45] 2004 101 (102) Arthroscopy (102) 93 A 46, F 21 1.5 Phased array NA NA NA NA 71 44 47 89
Knuesel et al. [46] 2004 47 (50) Open (21) NA A 20, F 6 1.5 Surface 15–16 1.7–4 0.29 × 0.29 DESS NA NA 58–81 69–100
Leunig et al. [47] 1997 23 Open, arthroscopy 17 NA 1.5 Surface 20 NA 0.39 × 0.59 T1, T2, FLASH 69 71 NA NA
(23)
Nishii et al. [49] 2005 18 (20) Arthroscopy (20) NA A 20, F 12 1.5 Surface 16 1.5 0.63 × 0.63 3D-fast spoiled GRE NA NA 49–67 76–89
Park et al. [50] 2013 45 (47) Arthroscopy (47) 46 NA 3 Torso, cardiac 17–20 1–3 0.60 × 0.60 3D intermediate- 74–78 89–92 NA NA
weighted FSE
Perdikakis et al. 2011 10 (14) Open, arthroscopy NA NA 1.5 Surface 16–19 3–4 0.31 × 0.31 T1 FS 100 50 63 33
[51] (14)
Petersilge et al. 1996 10 Open, arthroscopy 8 NA 1.5 Helmholtz 20–50 3–5 1.04 × 0.78 T1 FS 100 100 NA NA
[52] (10)
Pfirrman et al. [9] 2008 44 Open (44) NA 23 1.5 Surface 15–16 1.25–4 0.29 × 0.29 3D water excitation NA NA 22–74 57–95
DESS
Reurink et al. [53] 2012 93 (95) Arthroscopy (95) 91 NA 1.5 NA 15–36 3 NA NA 86 50–75 NA NA
Schmid et al. [6] 2003 40 (42) Open (42) NA 42 1.0 Surface 16 3–4 0.63 × 0.63 T1 FS and T1 FLASH NA NA A 48–84, F A 73–86, F
40–60 78–88
Studler et al. [7] 2008 57 Open, arthroscopy 44 NA 1.5 Body 15–17 3–4 0.29 × 0.29 3D Water excitation 98 54 NA NA
(57) DESS

AJR:205, September 2015

(Table 1 continues on next page)
 pincer impingement. A variety of morphologic imaging signs have been
MRI of Labral and Chondral Lesions of the Hip

A 25–100, F
Specificity
described for the relation between femur and acetabulum in patients with

Note—NA = not available, A = acetabular, F= femoral head, T1 = T1-weighted, T2 = T2-weighted, FS = fat-suppressed, IDEAL = iterative decomposition of water and fat with echo asymmetry and least-squares estimation,
46–91
(%)
NA

NA
NA

NA
FAI, and these are covered in other review articles [3, 17, 18].
Although controversies persist regarding the clinical significance
Cartilage

and treatment of patients with chondrolabral lesions and FAI [19], there
TABLE 1: Studies Evaluating the Sensitivity and Specificity of MR Arthrography in the Detection of Hip Labral and Chondral Lesions (continued)

Sensitivity has been an increase in incidence of surgical procedures to treat osse-

A 71–92, F
50–83
(%) ous, chondral, and labral abnormalities in such patients. Surgical tech-
NA

NA
NA

NA
niques include débridement or repair of labral tears, microfracture of
acetabular chondral lesions, resection of the acetabular rim, and femo-
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Sensitivity Specificity

ral osteochondroplasty [20]. These procedures were once performed at

50–100

100
(%)

NA
NA

open surgery but are more routinely performed arthroscopically or by

85
miniarthrotomy with or without arthroscopic assistance [21–23]. As
Labrum

a result, hip arthroscopy has become one of the most rapidly growing
85–89

90–95 areas in orthopedic surgery, and the annual number of hip arthroscop-
(%)
80

92

97
ic procedures was expected to exceed 70,000 in 2013, compared with
30,000 in 2008 [24]. This increase in the incidence of surgical inter-
0.29 × 0.29 3D water excitation

vention has led to an increase in demand for imaging of patients with

Pulse Sequence
With Maximum

suspected labral and chondral injuries.

Resolution
0.70 × 0.94 T1 and T2 FS

The goals of imaging when labral or chondral injury is suspected

0.55 × 0.73 T1 FS, T2 FS

are accurate identification of features that affect management by vi-

DESS

0.66 × 0.74 T1 FS

sualization of bony morphologic changes and detection and character-

NA

ization of chondral and labral lesions [17]. Features deemed necessary

for surgical decision making include acetabular version and coverage,
FOV Thickness Resolution
Maximum
In-Plane

(mm)c

morphologic changes in the femoral head-neck junction, presence and

NA

bReference standard is type of surgery (open vs arthroscopy). Numbers in parentheses are number of patients with surgical correlation.

location of labral tears, and the size and depth of chondral lesions, in-
cluding possible delaminating lesions of the acetabular chondral rim
cIn some cases a range of FOV and matrix were provided. It was not possible to calculate the in-plane resolution in these cases.

[25]. The presence of osteoarthritis should also be noted because this

1.25–4
Slice

(mm)

3–4
NA
4

can preclude surgical treatment of the chondral and labral lesions and
necessitate other surgical options, such as osteotomy or arthroplasty.
Torso phased 14–20
Surface, torso 18–24

14–18
15–17

MRI of the hip poses challenges that affect image quality and di-
(cm2)

17

agnostic accuracy. The articular cartilage of the hip is relatively thin

[26], the joint is obliquely oriented, and the articular surfaces are high-
ly curved and closely opposed. Use of conventional imaging planes re-
phased

phased
phased
Coil

Surface

Surface

1.5 and 3 Surface

sults in partial volume averaging due to the spheric shape of the hip
array

array

array
array

joint. This is most striking in relation to the anterosuperior and postero-

superior aspects of the joint on coronal and axial images. In addition,
Labral Chondral Strength

within traditional closed-bore MRI systems, the hip is located off iso-
Field

(T)
1.5

1.5

1.5
3

center of the magnetic field, which can hamper image quality owing to
GRE = gradient-recalled echo, DESS = dual-echo steady-state, FSE = fast spin-echo.

gradient nonlinearities and inhomogeneities of the main magnetic field.

Patients Patients

A 25, F 6
Lesion

There is also marked variability in the appearance of the acetabular la-

No of

With

NA

NA
NA
NA

brum even in volunteer subjects without symptoms [27, 28].

In addition to larger-FOV images, which are used to assess for ex-
No. of

traarticular causes of pain, it is necessary to obtain dedicated focused

With

Tear

144
26

59
24
5

images of the involved hip with a small (14–18 cm) imaging FOV.
Oblique axial images prescribed along the long axis of the femoral neck
are used to supplement conventional triplanar orthogonal acquisitions
Arthroscopy (144)
Arthroscopy (34)
Arthroscopy (30)
Arthroscopy (28)
Arthroscopy (5)
Reference
Standardb

and aid in evaluation of the femoral head-neck junction and acetabu-

lar overcoverage. These imaging planes may be supplemented by radial
images of the hip obtained at prescribed angular intervals perpendicu-
aValues in parentheses are number of hips.

lar to the surface of the hip joint with all resultant imaging planes in-
tersecting through the center of the joint. Radial imaging provides for
Year Patientsa

cross-sectional imaging depiction of the labrum and articular cartilage

No. of

144
34
30
28
8

of the hip joint, negating the effects of volume averaging. Radial ac-
quisitions also facilitate complete assessment of the femoral head-neck
2006

2006

Ziegert et al. [58] 2009

2014

2014

junction, including the anterosuperior quadrant, where the cam defor-

mity is often most pronounced [29].
Sutter et al. [55]

Toomayan et al.

High-resolution unenhanced MRI of the hip is easily performed

Sundberg et al.

Tian et al. [56]

Authors

with optimized state-of-the-art techniques. Improvements in surface

coil technology and the higher magnetic field strength associated with
[54]

[57]

3-T platforms deliver a higher signal-to-noise ratio, which can be used

to achieve high spatial resolution with a reasonable acquisition time.

AJR:205, September 2015 481


Imaging is best performed with a phased-
array surface coil or a multichannel cardiac
coil [30, 31]. Conventional MRI is an attrac-
tive option in comparison with MR arthrog-
raphy given the improved patient throughput
and the lack of gadolinium injection with its
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associated limitations, which include cost,
need for fluoroscopy or ultrasound, patient
discomfort, and risk of complications.
Direct MR arthrography, which entails in-
traarticular injection of a dilute gadolinium
mixture, has the advantages of distending
the joint, improving contrast-to-noise ratio,
and enabling acquisition of higher-resolution
images [32, 33]. In addition, intraarticular
administration of local anesthetic agents at
arthrography can be a useful adjunct in lo-
calization and confirmation of an intraar-
ticular source of hip pain [34]. Indirect MR
arthrography, achieved by IV injection of
gadolinium followed by exercise of the ex-
tremity of interest, has a similar effect with
regard to contrast resolution but does not
require intraarticular injection or imaging
guidance to facilitate intraarticular contrast
injection. One of the main limitations of in-
direct MR arthrography, however, is that it
does not produce substantial joint distention.
Synopsis and Synthesis of Evidence
We performed a literature review using
PubMed for English-language articles from
1990 to 2014. The search terms were MRI,
MR arthrography, indirect MR arthrogra-
phy, hip labrum, hip cartilage, and femoro-
acetabular impingement. A total of 678 ar-
ticles were identified. All available abstracts
were reviewed. Studies addressing the diag-
nostic accuracy of conventional MRI, direct
MR arthrography, and indirect MR arthrog-
raphy against a surgical reference standard
were selected. Studies of pediatric popula-
tions, postoperative hips, and cadavers were
excluded. The yield was 30 studies of the di-
agnostic utility of MRI of the hip labrum and
cartilage [4, 6, 7, 9, 10, 35–58]. Tables 1–4
show the pertinent features of these studies,
including magnetic field strength, coil used,
in-plane resolution, slice thickness, and the
sensitivities and specificities for detection of
labral and chondral abnormalities.
Assessment of Labral Tears
Ten studies were identified in which the
sensitivity and specificity of conventional
MRI for detection of labral tears were mea-
sured (Table 2). There was significant vari-
ation in the diagnostic performance of un-
482 AJR:205, September 2015
Naraghi and White
enhanced MRI for detection of hip labral
tears; both sensitivity and specificity ranged
from zero to 100%. Only three of these stud-
ies had a sensitivity greater than 90%, and
four studies showed specificity greater than
80%. Two of the studies with lower sensitivi-
ties were performed in the mid 1990s, when
the image quality and anatomic resolution
of MRI systems were more limited than in
later systems [40, 42]. Newer MRI systems,
with a combination of higher magnetic field
strength and, just as important, advances in
coil technology can deliver high spatial res-
olution while maintaining a high signal-to-
noise ratio and contrast resolution. Stud-
ies by Mintz et al. [4], Sutter et al. [55], and
Zlatkin et al. [10]—who used phased-array
coils, a small FOV (12–17 cm), and high in-
plane resolution—showed sensitivity of 77–
97% for the detection of labral tears at 1.5
T. Three studies evaluated detection of labral
tears at 3 T with variable results. In a small
cohort, Sundberg et al. [54] found sensitiv-
ity of 100% in a cohort of five patients. Tian
et al. [56] found sensitivity of 61–66% and
specificity of 74–77% in a larger population.
Interestingly, the in-plane resolution in both
these studies was inferior to that in the stud-
ies by Mintz et al., Zlatkin et al., and Sutter
et al., which were conducted with high-reso-
lution technique at 1.5 T. Using high-resolu-
tion imaging at 3 T, White et al. [59] found
sensitivity of 100% and specificity of 50%
for the detection of labral tears.
We found 19 studies evaluating the diag-
nostic accuracy of MR arthrography against
a surgical reference standard in the assess-
ment of labral tears (Table 1). The sensitiv-
ity for detection of labral tears ranged from
69% to 100% in these studies, most showing
sensitivities greater than 90%. The variabil-
ity in sensitivities of MR arthrography stud-
ies is less striking than that found in studies
of conventional MRI. The specificity for de-
tection of labral tears was far more variable
in those studies, ranging from zero to 100%,
most of the studies showing specificity less
than 80%. There does not appear to be a
clear relation between spatial resolution and
the diagnostic accuracy of MR arthrography.
This may be partly related to joint distention
with imbibition of contrast material into the
tear and to the improved signal-to-noise ratio
afforded by use of intraarticular gadolinium
and T1-weighted imaging.
We found only two studies [10, 48] of the
diagnostic accuracy of indirect MR arthrog-
raphy of the hip in the assessment of labral
tears (Table 3). The sensitivities of this tech-
nique were 82% and 100% and the specifici-
ties 100% and zero.
Six studies directly compared the diag-
nostic accuracy of MRI with that of MR ar-
thrography or indirect MR arthrography in
the same patient population (Table 4). Apart
from the study by Sundberg et al. [54], which
included only five patients with arthroscopic
correlation, all of the studies showed supe-
rior sensitivity of MR arthrography. Interest-
ingly, there was little difference in specific-
ity between the two imaging techniques in
the studies directly comparing conventional
MRI and MR arthrography.
Smith et al. [60] performed a meta-analy-
sis of the diagnostic accuracy of unenhanced
conventional MRI and MR arthrography for
the detection of labral tears. In a search of
multiple databases, they identified 19 studies
as of April 2010 that assessed the sensitivity
and specificity of MRI and MR arthrogra-
phy in the evaluation of hip labral tears. They
found pooled sensitivity of 66% and specific-
ity of 79% for conventional MRI and pooled
sensitivity and specificity of 87% and 64%
for MR arthrography. After analyzing ROC
curves, those investigators concluded that MR
arthrography is superior to conventional MRI
for detection of labral tears. Results of more
recent studies [36, 50, 51, 53, 55, 56] have
been in keeping with their findings. Smith
et al. did not specifically evaluate the influ-
ence of MRI pulse sequences, spatial resolu-
tion, or coils on diagnostic accuracy because
it would be difficult to establish a trend given
the marked variability in imaging techniques
in a relatively small number of studies.
Assessment of Chondral Lesions
Direct comparison between studies eval-
uating chondral abnormalities is difficult
because some authors report the accura-
cy of MRI in the detection of chondral le-
sions, whereas others assess the accuracy of
­grading chondral abnormalities of the hips
or evaluated specific types of chondral le-
sions. In general, sensitivity of MRI and MR
arthrography is limited in the evaluation of
cartilage abnormalities of the hip, but speci-
ficity is typically high.
Six studies examined the diagnostic per-
formance of conventional MRI in identifica-
tion of chondral lesions of the hip (Table 2).
Sensitivity of conventional MRI for chondral
lesions was 0–93%. Specificity ranged from
50% to 100%. In four of the studies, the ac-
curacies of MRI in the detection of femoral
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TABLE 2: Studies Evaluating the Sensitivity and Specificity of Conventional Unenhanced MRI in the Detection of Hip Labral and Chondral Lesions
No. of No of Labrum Cartilage
Patients Patients Maximum
With With Field Slice In-Plane Pulse Sequence
No. of Reference Labral Chondral Strength FOV Thickness Resolution With Maximum Sensitivity Specificity Sensitivity Specificity
Authors Year Patientsa Standardb Tear Lesion (T)c Coil (cm2) (mm) (mm)d Resolution (%) (%) (%) (%)
Byrd and 2004 40 Arthroscopy (40) 32 22 1.5 Torso NA NA NA NA 25 50 18 100
Jones [38]
Czerny et al. 1996 56 (57) Surgery not 20 NA 1.0 (17), Surface 15–37.5 1.5–4.0 0.59 × 0.59 GRE 30 100 NA NA
[40] otherwise 0.5 (40)
specified (22)
Edwards et al. 1995 23 Arthroscopy (23) 1 NA 1.5 NA NA NA NA NA 0 95 A 0–67, F A 95–100, F
[42] 25–75 94–95
Mintz et al. [4] 2005 92 Arthroscopy (92) 89 A 44, F 42 1.5 Surface 15–17 3–4 0.33 × Intermediate- 96–97 33 A 91–93, F A 75–85, F
0.44–0.59 weighted 86–93 72–88
Sundberg et al. 2006 8 Arthroscopy (5) 5 NA 3 Body 16–22 0.9–4.0 0.70 × 0.70 3D DESS 100 NA NA NA
[54] multichan-
nel phased
array
Sutter et al. 2014 28 Arthroscopy (28) 26 A 25, F 6 1.5 Surface 15–17 1.25–4 0.29 × 0.29 3D water 77–89 50 A 58–83, F A 50–100, F
[55] phased excitation DESS 50–83 59–100
array
Tian et al. [56] 2014 90 Arthroscopy (90) 59 NA 3 Surface 18 3 0.70 × 0.78 Intermediate- 61–66 74–77 NA NA
weighted FS,
T2 FS
Toomayan et al. 2006 14 Large Arthroscopy (21) 12 Large NA 1.5 Body, torso 30–38; NA 1.17 × 1.56, T1, T2 Large FOV, Large FOV, NA NA
[57] FOV, 7 FOV, 4 phased 14–20 0.55 × 0.73 8; small 100; small
small small array FOV, 25 FOV, 100
FOV FOV
MRI of Labral and Chondral Lesions of the Hip

White et al. 2014 42 Arthroscopy (42) 41 A 36, F 11 3 NA 13 2–4 0.41 × 0.58 Intermediate- 100 50 A 94, F 94 A 67, F 100
[59] weighted
Zlatkin et al. 2010 14 Arthroscopy (14) 13 11 1.5 Body phased 12 4 0.38 × 0.63 PD, PD FS, T2 FS 85 100 82 NA
[10] array, spinal
phased
array
Note—NA = not available, GRE = gradient-recalled echo, A = acetabular, F= femoral head, DESS = dual-echo steady-state, FS = fat-suppressed, FS = fat-suppressed, T2 = T2-weighted, T1 = T1-weighted, PD =
proton density–weighted.
aValues in parentheses are number of hips.
bReference standard is type of surgery (open vs arthroscopy). Numbers in parentheses are number of patients with surgical correlation.
cValues in parentheses are number of patients.
dIn some cases a range of FOV and matrix were provided. It was not possible to calculate the in-plane resolution in these cases.

AJR:205, September 2015 483

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484
TABLE 3: Studies Evaluating the Sensitivity and Specificity of Indirect MR Arthrography in Detection of Hip Labral and Chondral Lesions
No. of No of Labrum Cartilage
Patients Patients Maximum
With With Field Slice In-Plane Pulse Sequence
No. of Reference Labral Chondral Strength FOV Thickness Resolution With Maximum Sensitivity Specificity Sensitivity Specificity
Authors Year Patients Standardb Tear Lesion (T) Coil 2
(cm ) (mm) (mm)c Resolution (%) (%) (%) (%)
Nishii et al. [48] 1996 19 Arthroscopy (19) 11 NA 1.5 Surface 16 3 0.62 × 0.83 T1 82 100 NA NA
Zlatkin et al. 2009 14 Arthroscopy (14) 13 11 1.5 Body phased 12 3 0.47 × 0.63 T1 FS 100 0 82 NA
[10] array, spinal
phased
array
Note—NA = not available, T1 = T1-weighted, FS = fat-suppressed.
aReference standard is type of surgery (open vs arthroscopy). Numbers in parentheses are number of patients with surgical correlation.
bIn some cases a range of FOV and matrix were provided. It was not possible to calculate the in-plane resolution in these cases.

TABLE 4: Studies Directly Comparing Sensitivity and Specificity of Unenhanced MRI and MR Arthrographic Techniques in Detection of Hip Labral
and Chondral Lesions
No. of No of Pulse Labrum Cartilage
Patients Patients Maximum Sequence
With With Field Slice In-Plane With
MRI No. of Reference Labral Chondral Strength FOV Thickness Resolution Maximum Sensitivity Specificity Sensitivity Specificity
Author Year Type Patientsa Standardb Tear Lesion (T) Coil (cm2) (mm) (mm)c Resolution (%) (%) (%) (%)
Byrd et al. [38] 2004 MRI 40 Arthroscopy (40) 32 22 1.5 Torso NA NA NA NA 25 50 18 100
Byrd et al. [38] 2004 MRA 40 Arthroscopy (40) 32 22 1.5 Torso NA NA NA NA 72 13 41 94
Czerny et al. 1996 MRI 56 (57) Surgery not 20 NA 1.0 (17), Surface 15–37.5 1.5–4.0 0.59 × 0.59 GRE 30 100 NA NA
[40] otherwise 0.5 (40)
Naraghi and White

specified (22)
Czerny et al. 1996 MRA 56 (57) Surgery not 20 NA 1.0 (17), Surface 15 1.5 0.59 × 0.59 GRE 90 100 NA NA
[40] otherwise 0.5 (40)
specified (22)
Sundberg et al. 2006 MRI 8 Arthroscopy (5) 5 NA 3 Body 16–22 0.9–4.0 0.70 × 0.70 3D DESS 100 NA NA NA
[54] multichannel
phased array
Sundberg et al. 2006 MRA 8 Arthroscopy (5) 5 NA 1.5 Surface, 18–24 4 0.70 × 0.94 T1 FS, T2 FS 80 NA NA NA
[54] torso phased
array
Sutter et al. 2014 MRI 28 Arthroscopy (28) 26 A 25, F 6 1.5 Surface 15–17 1.25–4 0.29 × 0.29 3D water 77–89 50 A 58–83, F A 50–100,
[55] phased array excitation 50–83 F 59–100
DESS
Sutter et al. 2014 MRA 28 Arthroscopy (28) 26 A 25, F 6 1.5 Surface 15–17 1.25–4 0.29 × 0.29 3D Water 85–89 50–100 A 71–92, F A 25–100,
[55] phased array excitation 50–83 F 46–91
DESS
Tian et al. [56] 2014 MRI 90 Arthroscopy (90) 59 NA 3 Surface 18 3 0.70 × 0.78 Intermediate- 61–66 74–77 NA NA
weighted
FS, T2 FS
(Table 4 continues on next page)

AJR:205, September 2015

 MRI of Labral and Chondral Lesions of the Hip

head and of acetabular chondral lesions were reported separate-

Sensitivity Specificity Sensitivity Specificity

TABLE 4: Studies Directly Comparing Sensitivity and Specificity of Unenhanced MRI and MR Arthrographic Techniques in Detection of Hip Labral

Note—NA = not available, MRA = MR angiography, GRE = gradient-recalled echo, DESS = dual-echo steady-state, T1 = T1-weighted, FS = fat-suppressed, T2 = T2-weighted, A = acetabular, F= femoral head, PD =
ly. Of the conventional MRI studies, the study by Edwards et al.

NA
NA

NA

NA

NA
(%)
[42] dates from 1995 and yielded the lowest sensitivity. Only one
Cartilage

group of investigators [59] reported the accuracy of 3-T conven-

tional MRI in the detection of chondral lesions of the hip; they
NA
NA

NA
(%)

82

82
found sensitivity of 94% and specificity of 67% for the acetabu-
Downloaded from www.ajronline.org by 14.142.109.34 on 03/28/19 from IP address 14.142.109.34. Copyright ARRS. For personal use only; all rights reserved

lum and 100% for the femur.

small FOV small FOV

8 Large 100 Large
Twelve studies measured the accuracy of MR arthrography in
FOV, 25 FOV, 100

100

100
(%)

assessing chondral lesions of the hip (Table 1). There was a wide
85

0
Labrum

range in sensitivity (22–92%) and specificity (25–100%). The

two studies with the lowest sensitivities [9, 35] only evaluated the
90–95

accuracy of MR arthrography in the detection of delaminating

100
(%)

92

85
chondral lesions. Three studies [6, 36, 55] evaluated the perfor-
0.38 × 0.63 PD, PD FS, T2 mance of MR arthrography separately for femoral head and ac-
0.55 × 0.73 T1 FS, T2 FS
Resolution
Sequence

Maximum

etabular chondral lesions. These showed lower sensitivity of MR

Pulse

With

arthrography for the detection of femoral head chondral lesions.

1.17 × 1.56; T1, T2
0.66 × 0.74 T1 FS

0.47 × 0.63 T1 FS Only one study of indirect MR arthrography of chondral

FS

changes [10] showed sensitivity of 82% (Table 3). The speci-

FOV Thickness Resolution

0.55 × 0.73

ficity was not reported.

Maximum
In-Plane

(mm)c

Two studies evaluated the performance of conventional MRI

and MR arthrography in the same patient population for detec-
bReference standard is type of surgery (open vs arthroscopy). Numbers in parentheses are number of patients with surgical correlation. tion of chondral abnormalities (Table 4). Byrd and Jones [38]
found higher sensitivity and lower specificity of MR arthrogra-
Slice

(mm)

NA

NA
3

cIn some cases a range of FOV and matrix were provided. It was not possible to calculate the in-plane resolution in these cases.

phy. In the study by Sutter et al. [55], sensitivity for acetabular

chondral lesions was improved with the use of MR arthrography
30–38;
phased array 14–20

14–20
(cm2)

for both readers, but specificity was poorer with MR arthrogra-

17

12

12

phy for one reader. For femoral lesions, there was no difference
in sensitivity, but specificity was poorer with MR arthrography.
phased array

phased array
array, spinal

array, spinal
Torso phased

Body phased

Body phased

Smith et al. [61] performed a meta-analysis of the diagnos-

Body, torso
Coil

tic accuracy of MRI and MR arthrography in the assessment of

Surface

array

hip chondral lesions using a method similar to the one they used
in their meta-analysis of hip labral lesions. They identified 16
MRI studies of the diagnostic accuracy of MRI or MR arthrog-
Labral Chondral Strength
Field

(T)

1.5

1.5

1.5

1.5

raphy in the detection of chondral lesions of the hip. They cal-

3

culated pooled sensitivity and specificity of 59% and 94% for

Patients Patients

MRI and pooled sensitivity and specificity of 62% and 86% for
Tear Lesion
No. of No of

With

NA
NA

NA

11

11

MR arthrography in overall detection of chondral lesions. The

pooled sensitivity and specificity for conventional MRI for fem-
FOV, 4

oral head lesions were 63% and 95% versus 79% and 97% for
Large

small
With

FOV
59

24

13

13
12

acetabular lesions. They identified only one MR arthrography

study showing accuracy of detection of femoral head chondral
Arthroscopy (34)

Arthroscopy (30)
14 Large Arthroscopy (21)

Arthroscopy (14)

Arthroscopy (14)
and Chondral Lesions (continued)

lesions. The pooled sensitivity and specificity of MR arthrogra-

Reference
Standardb

phy for acetabular lesions were 76% and 92%. After analyzing
ROC curves, Smith et al. concluded that the diagnostic accura-
cy of MRI is superior to that of MR arthrography in the detec-
tion of chondral lesions.
Type Patientsa

aValues in parentheses are number of hips.

FOV, 7
No. of

small
FOV
34

30

14

14

Evidence-Based Guidelines
Current evidence supports the use of MR arthrography in the
2009 Indirect

2009 Indirect
MRA

MRA

MRA

MRA
MRI
MRI

evaluation of labral tears of the hip. This evidence comes from

pooled analysis of the available literature and from studies di-
proton density–weighted.

rectly comparing conventional MRI and MR arthrography in

Toomayan et al. 2006

Toomayan et al. 2006

2014
Year

the same patient population. Most studies related to unenhanced

MRI of the hip for evaluation of intraarticular abnormalities have
Tian et al. [56]

Zlatkin et al.

Zlatkin et al.

been conducted with MRI performed on a 1.5-T platform, and

Author

the imaging spatial resolution in some of the older studies does

[57]

[57]

[10]

[10]

not compare to the high-resolution imaging achievable later. Al-

though the current evidence favors the use of MR arthrography,

AJR:205, September 2015 485


we have found that optimized high-resolution
nonarthrographic 3-T MRI of the hip can be
highly accurate in detection of chondral and
labral abnormalities of the hip. Sundberg et
al. [54] and White et al. [59] found that 3-T
conventional MRI may be a suitable alter-
Downloaded from www.ajronline.org by 14.142.109.34 on 03/28/19 from IP address 14.142.109.34. Copyright ARRS. For personal use only; all rights reserved
native, but there are insufficient data about
whether high-resolution unenhanced MRI
performed at 3 T with modern multichannel
surface coil technology can replace MR ar-
thrography in the accurate diagnosis of labral
abnormalities of the hip. There does not ap-
pear to be a clear relation between in-plane
resolution and diagnostic accuracy for labral
tears, likely because of the influence of other
factors, such as signal-to-noise ratio and con-
trast resolution, related to the pulse sequences
used. Current findings in the literature sug-
gest that although imaging with a large FOV
encompassing the whole pelvis is beneficial
for detection of extraarticular causes of hip
pain, it has low accuracy in the evaluation of
the hip labrum.
With regard to evaluation of hip articular
cartilage, there appears to be less discrepan-
cy between conventional MRI and MR ar-
thrography. Sensitivity of both techniques is
limited, but specificity is relatively high, par-
ticularly for conventional MRI.
The foregoing guidelines are in accor-
dance with the American College of Radi-
ology appropriateness criteria, which give a
rating of 9 for the use of MR arthrography
in the evaluation of individuals with chronic
hip pain with suspected labral tear with or
without findings suggestive of FAI [62]. This
compares to a rating of 6 for unenhanced
MRI and a rating of 7 for CT arthrography.
However, it is noted within the criteria that
use of high-resolution 3-T MRI may obvi-
ate contrast administration in the future. As
such, if unenhanced MRI is undertaken, pro-
tocol optimization to yield high spatial res-
olution and high contrast resolution is crit-
ical. Protocol parameters similar to those
published by Mintz et al. [4] and Potter and
Schachar [31] entailing fast spin-echo proton
density–weighted or intermediate-weighted
pulse sequences, a small FOV (< 18 cm), and
small acquisition voxels are important fac-
tors in optimizing image resolution and over-
all image quality in MRI evaluation of the
hip. Such unenhanced imaging should ideal-
ly be performed at 3 T with local multichan-
nel surface coils.
Another factor that has to be taken into
consideration in the diagnostic evaluation of
patients with hip-related pain and possible
486 AJR:205, September 2015
Naraghi and White
FAI is identification of the source of the pa-
tient’s symptoms. Labral and even chondral
abnormalities may be seen in many individ-
uals who do not have symptoms. Therefore,
the presence of such intraarticular abnormal-
ities does not necessarily mean that these le-
sions are the cause of symptoms or that ar-
throscopic treatment would result in their
alleviation [63]. Periarticular causes of hip
pain can result in groin pain and produce
symptoms similar to those in individuals
with intraarticular abnormalities. Some or-
thopedic surgeons use the response to in-
traarticular injection of local anesthetic
agents, performed in conjunction with in-
traarticular injection of contrast medium at
MR arthrography, as part of their decision-
making algorithm [34, 38, 64]. In this situa-
tion, even if unenhanced MRI is performed,
the patient may still need an intraarticular
injection as part of the treatment algorithm.
Outstanding Issues That
Warrant Research
Few studies have directly compared high-
er-resolution unenhanced MRI directly with
MR arthrography. Only three studies have
evaluated the utility of 3-T MRI in the as-
sessment of labral or chondral abnormali-
ties of the hip, and the numbers of patients
in these studies is small. Studies on the ac-
curacy of unenhanced 3-T MRI in compari-
son with arthroscopy that have larger series
of patients and reproducible results are lack-
ing and would be needed to establish the ac-
curacy of this technique. Direct comparative
studies between high-resolution unenhanced
3-T MRI and MR arthrography in a larger
group of patients with arthroscopic correla-
tion would be ideal.
The accuracy of newer 3D fast spin-echo
pulse sequences has been assessed in the knee
and shoulder [65–74]. We found no such stud-
ies in the hip, and the usefulness of the newer
3D pulse sequences remains unproven.
The focus of this article has been on mor-
phologic imaging of the labrum and cartilage.
However, chondral pathologic features may
also be discerned by probing the biochemi-
cal environment using techniques such as
delayed gadolinium-enhanced MRI of carti-
lage, T2 mapping, and T1-ρ imaging. These
techniques are predominantly research tools,
but several articles [75–80] describe the fea-
sibility of using these techniques in the hip.
The details of such techniques are beyond the
scope of this article but have been covered in
other reviews [81, 82]. Their place in the im-
aging assessment of articular cartilage in the
hip requires further validation.
The prognostic utility of MRI in the evalu-
ation of patients with labral and chondral le-
sions is not well established and would be an
important factor to determine as we continue
to image more patients with these lesions.
Summary
Recommendations for Best Practices
MR arthrography is the current standard
technique of advanced imaging for the eval-
uation of patients with suspected labral tears
and chondral lesions. Limited data suggest
that high-resolution unenhanced MRI, par-
ticularly performed at 3 T, may be as accu-
rate as MR arthrography in the detection of
labral and chondral tears. Large-FOV unen-
hanced MRI is far inferior to both MR ar-
thrography and high-resolution unenhanced
MRI in the detection of labral and chondral
abnormalities of the hip.
Recommendations for Future Research
Data regarding the use of high-resolution
unenhanced 3-T MRI of the hip are limited.
Larger-scale studies comparing 3-T MRI and
MR arthrography would be a major require-
ment for validating the use of unenhanced
3-T MRI. Additional studies on the validity
and reliability of biochemical imaging tech-
niques for articular cartilage would also be
required to determine whether they could be
applied in routine clinical practice.
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(Figures start on next page)
 Fig. 1—24-year-old man with 1-year history of
MRI of Labral and Chondral Lesions of the Hip
mechanical hip pain.
A, Sagittal T1-weighted fat-suppressed 3-T MR
arthrogram (TR/TE, 630/8.6) shows extension of
gadolinium (arrowhead) into labrum. Finding is
consistent with labral tear.
B, Axial oblique T1-weighted fat-suppressed 3-T
MR arthrogram (TR/TE, 630/8.6) shows labral tear
(arrowhead) involving base of labrum and extending
into substance of labrum.
Downloaded from www.ajronline.org by 14.142.109.34 on 03/28/19 from IP address 14.142.109.34. Copyright ARRS. For personal use only; all rights reserved

A B

Fig. 2—32-year-old male soccer player with acute

twisting injury of hip.
A, Axial oblique T1-weighted fat-suppressed 1.5-T
MR arthrogram (TR/TE, 620/12) shows full-thickness
chondral defect of femoral head (arrowhead) and tear
of anterosuperior labrum (arrow).
B, Coronal T2-weighted fat-suppressed MR
arthrogram (TR/TE, 4350/82) shows delaminating
nature of chondral lesion (arrowhead).

A B

Fig. 3—22-year-old male varsity athlete with chronic

anterior hip pain.
A and B, Coronal unenhanced 3-T intermediate-
weighted fat-suppressed (TR/TE, 4460/28) (A) and
proton density–weighted radial (TR/TE, 1990/21)
(B) images of left hip show tear of superior labrum
(arrow) that extends into anterosuperior labrum
(not shown). Full-thickness chondral defect (small
arrowhead) is present at chondrolabral junction.
Small subarticular cyst (large arrowhead, A) is
evident on coronal image.
A B

AJR:205, September 2015 489

 Naraghi and White

Fig. 4—28-year-old woman with intermittent groin

pain and occasional feeling of clicking in hip.
A, Coronal unenhanced 3-T intermediate-weighted
(TR/TE, 4430/26) MR image shows somewhat
hypertrophic labrum with tear cleft and detachment
through base of labrum (arrow). Focal chondral
fissures (arrowheads) are present in superior aspect
of acetabular cartilage.
Downloaded from www.ajronline.org by 14.142.109.34 on 03/28/19 from IP address 14.142.109.34. Copyright ARRS. For personal use only; all rights reserved

B, Sagittal proton density–weighted fat-suppressed

MR image (TR/TE, 1980/22) shows area of
delamination (arrow) involving acetabular cartilage
and chondral fissuring (arrowhead).

A B

Fig. 5—19-year-old woman with ill-defined hip pain

exacerbated by exercise with feeling of catching and
instability in hip.
A and B, Sagittal unenhanced 3-T fat-suppressed
proton density–weighted (TR/TE, 2000/24) (A) and
coronal intermediate-weighted fat-suppressed
(TR/TE, 4450/27) (B) images show anterosuperior-
superior labral tear (arrow). Delaminating chondral
lesion (arrowhead, A) is present in anterosuperior
aspect. Partial tear of ligamentum teres (arrowhead,
B) also is present.
A B

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490 AJR:205, September 2015

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