Femoroacetabular Impingement


132 Femoroacetabular Impingement


Marc J. Philippon MD, Ioanna K. Bolia MD, and Karen K. Briggs MPH


The Steadman Philippon Research Institute, Vail, CO, USA


Clinical scenario



  • A 25‐year‐old male hockey goalie complains about right hip pain.
  • The pain is intermittent, is aggravated with activity, and peaks when he obtains the butterfly stance during hockey. Prolonged sitting also reproduces his hip pain.
  • He has tried conservative management (physical therapy, oral analgesics, activity modification) with no resolution of symptoms.

Introduction


Femoroacetabular impingement (FAI) is a common source of hip pain in patients who participate in sports.1 FAI results from an abnormal biomechanical relationship between the proximal femur and the acetabulum which leads to bony impingement and is associated with soft tissue injury and chondral damage.2,3 Certain sport activities, including hockey, predispose the hip joint to the development of FAI due to overuse injury.4 Such sports include repetitive hip flexion and rotational movements which generate conflict between the femur and the acetabulum.5


Cam and pincer impingement are the two main types of FAI. Pincer impingement refers to the acetabular component and it is less understood than the cam FAI, which refers to the femoral component.6 Studies have shown the association between the cam lesion and labral or chondral damage in the hip.2,3,6 Untreated FAI has been associated with hip labral tears and early osteoarthritis, and therefore early diagnosis and prompt therapy are necessary to avoid this complication in young, active individuals.3,7,8 Hip arthroscopy is an expanding procedure which treats FAI and the associated lesions with minimal intervention.9 Hip arthroscopy has been reported to result in superior general health‐related quality of life (HRQoL) in the Short Form 12 (SF‐12) physical health component compared to open FAI surgery, although the hip‐specific outcomes were not different based on a recent study.10


Top three questions



  1. In young adults with hip pain, which physical examination maneuvers are most accurate in the diagnosis of FAI, compared to others?
  2. In patients with cartilage defects of the hip, do some treatment options, compared to others, result in better outcomes?
  3. In young patients who have undergone treatment for FAI, what are the timelines for return to sport?

Question 1: In young adults with hip pain, which physical examination maneuvers are most accurate in the diagnosis of FAI, compared to others?


Rationale


The young hockey player had a positive anterior impingement sign and he had an increased flexion, abduction, and external rotation (FABER) distance test on the painful hip. Before prescribing advanced imaging, exam results should provide a strong suspicion of FAI.


Clinical comment


A thorough physical exam is critical in order to determine the source of the patient’s symptoms. Physical exam findings should guide the clinician in the ordering of further diagnostic investigations.


Available literature and quality of the evidence



  • Level of evidence I or II: 3 systematic reviews.
  • Most other studies are descriptive or have limited analysis of the accuracy of the physical exam tests.

Findings


Several studies have investigated the physical exam for diagnosis of hip pain.11–16 One systematic review on physical examination test for FAI found that the accuracy of exam tests are limited due to the heterogenicity of studies.11 They found that the FABER test had sensitivity of greater than 0.8 and the anterior impingement test had specificity and positive predictive value (PPV) of 1.0.11 Another systematic review with meta‐analysis found the sensitivity of flexion–adduction–internal rotation, which can be compared with the anterior impingement test, equal to 0.99 and a PPV of 0.90.12 This study also concluded that the current research did not support exam tests for diagnosis.12


The other systematic review looked at diagnosis in the skeletally immature patient.13 Of the six articles included on hip arthroscopy, five reported the physical exam. All five reported using the impingement test for diagnosis. The study made no conclusions on the best physical exam test.13 The FABER test has been modified to the FABER distance test. One study showed that the FABER distance test was associated with higher alpha angle, which is a common radiographic measurement associated with FAI.14


The use of ultrasound has become more popular for diagnosis; however, the literature is limited on its diagnostic capability for FAI.15 In addition, new three‐dimensional models may assist with accurate diagnosis and preoperative planning.16 While the anterior impingement test is very examiner specific, it has been shown to have good diagnostic characteristics. The FABER distance can provide a measurement to compare both hips with greater interobserver reliability. When used in combination, these tests (anterior impingement and FABER distance test) can be helpful in identifying patients who are at high risk for chondrolabral dysfunction due to FAI and may need addition imaging.


Resolution of clinical scenario

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May 14, 2023 | Posted by in Uncategorized | Comments Off on Femoroacetabular Impingement

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