Femoroacetabular Impingement and Labral Injuries









Introduction



John C. Clohisy, MD

Epidemiology


Age





  • Average age 35 yrs (range, 16 to 91)



Sex





  • 57% male



  • 43% female



Sport





  • Any sport with repetitive hip flexion, bending and squatting (soccer, hockey, football, baseball, basketball, etc.)



  • One recent study indicated:




    • 59% participated in regular sporting activities.



    • 59% classified participation intensity as high.



    • 28% reported intensity as moderate.



    • Average UCLA was 7.1 ± 2.8, consistent with patients participating in activities like fast walking, golfing, and bowling.



    • 29% participated in impact activities like jogging, tennis and ballet on regular basis.




Position





  • Athletic activities/positions with repetitive hip flexion are at highest risk.



Pathophysiology


Intrinsic Factors





  • Hip pathomorphology—Acetabular overcoverage ( Figure 26-1 )




    FIGURE 26-1


    Acetabular overcoverage—deep socket, preoperative view.



  • Hip pathomorphology—Femoral head-neck offset deformities ( Figure 26-2 )




    FIGURE 26-2


    Femoral head-neck offset deformity, preoperative frogleg view.



  • Soft tissue laxity with excessive hip motion



Extrinsic Factors





  • Repetitive hip flexion activities including occupational and athletic activities



  • Athletics: hockey, soccer, basketball, football, and others that involve repetitive hip flexion activities



Traumatic Factors





  • Forced hip flexion can result in acute labrochondral injury



  • Forced hip flexion with combined adduction and internal rotation can result in subluxation or hip dislocation.



  • Patients with femoroacetabular impingement (FAI) anatomy may be more susceptible to subluxation/dislocation episodes due to levering from anterior impingement.



Classic Pathological Findings





  • Structural abnormalities of the acetabulum and proximal femur consistent with femoroacetabular impingement (FAI; see Figure 26-2 )



  • Acetabular labral abnormalities including detachment, degeneration, and ossification



  • Chondral abnormalities specifically of the acetabular rim including delamination, articular cartilage flap formation and full thickness defect ( Figure 26-3 ).




    FIGURE 26-3


    Chondral abnormality, labral disruption.



  • The most common intraarticular abnormality includes injury to the acetabular labrochondral complex.



Clinical Presentation


History





  • Groin pain



  • Activity-related symptoms



  • Activity limitation owing to hip symptoms



  • Locking, catching of the hip



  • Groin pain with prolonged sitting or hip flexion activities



  • History of recurrent groin pulls, compensatory symptoms (low back pain, SI joint pain, trochanteric bursitis, adductor strain)



Physical Examination


Abnormal Findings





  • Limited hip flexion



  • Limited internal rotation in flexion



  • Positive impingement test (sensitive but not specific for FAI).



  • Positive flexion, abduction, external rotation (FABER) test



Pertinent Normal Findings





  • Normal external rotation/motion



  • Normal gait



  • Athletes may have normal muscle strength and function



Imaging





  • Plain radiographs including the anteroposterior (AP) pelvis, frog lateral, and 45° Dunn view



  • Parameters consistent with acetabular overcoverage



  • Femoral head-neck offset abnormalities are present.



  • Magnetic resonance imaging (MRI) and magnetic resonance arthrography can demonstrate labrochondral disease, structural anatomy, and secondary articular cartilage changes.



  • CT scan with three-dimensional images provides detailed information regarding deformity characteristics.



Differential Diagnosis





  • Hip dysplasia



  • Secondary hip osteoarthritis



  • Lumbar spine dysfunction



  • Sacral Iliac joint dysfunction



  • Athletic hernia



  • Muscle imbalance syndromes



  • Stress fractures



  • Adductor strain



  • Symphysis pubalgia



  • Comprehensive history, physical exam, and imaging evaluation of the patient distinguish the above conditions from a symptomatic femoroacetabular impingement. Compensatory disorders are common and many of the above diagnoses can occur simultaneously with femoroacetabular impingement.



Treatment


Nonoperative Management





  • Activity modification and patient education



  • Nonsteroidal antiinflammatory medicines



  • Physical therapy with muscle strengthening and balancing



  • Intraarticular corticosteroid injection



Guidelines for Choosing Among Nonoperative Treatments





  • A panel of nonsurgical treatment options to block the pain cycle and optimize function about the hip is preferred.



  • Corticosteroid injections are mostly used in patients greater than 40 years of age with early osteoarthritis.



Surgical Indications





  • Patients less than 50 years of age



  • Symptomatic hip impingement disease



  • Failure of nonsurgical treatment methods



  • Defined hip impingement deformity



  • Imaging studies demonstrate lack of moderate to advanced osteoarthritis of the hip.



  • Body mass index (BMI) less than 35



  • Positive response to intraarticular injection (with pain relief)



Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment





  • Age



  • Physical health



  • Deformity characteristics



  • Articular cartilage integrity



Aspects of Clinical Decision Making When Surgery Is Indicated





  • Open versus closed surgical correction



  • Treatment of the acetabular labrum (partial resection or repair)



  • Correction of the impingement deformity (acetabuloplasty, femoral plasty or both) ( Figures 26-4 , 26-5 )




    FIGURE 26-4


    Deep socket, postoperative view.



    FIGURE 26-5


    Head-neck offset postoperative frogleg view.



  • Treatment of acetabular articular cartilage disease including chondromalacia, delamination, articular cartilage flap and full thickness defects.



Evidence


  • Beaule P: Prevalence of associated deformities and hip pain in patients with cam-type femoracetabular impingement. J Bone Joint Surg 2009; 91-B: pp. 589-594.
  • One hundred and thirteen patients, 82 male and 31 females aged 55 or less, with symptomatic cam-type impingement of at least one hip were evaluated for this study. Bilateral cam deformity was seen in 77.8% of the population, whereas only 26% had pain in both hips. Hips with alpha angles greater than 60° had an odds ratio 2.59 for being painful. Pincer deformity was seen in 42% of the cases. (Level IV evidence)
  • Byrd J: Arthroscopic femoroplasty in the management of cam-type femoroacetabular impingement. Clin Orthop Relat Res 2008; 467: pp. 739-746.
  • Prospective assessment of 200 patients (207 hips) undergoing arthroscopic treatment for cam-type impingement. Patient cohort consisted of 138 men and 62 women with mean age 33 years. One hundred and sixty-three hips underwent femoroplasty, whereas 44 hips received a concomitant procedure to correct for pincer impingement. The Harris hip score improved an average of 20 points at a minimum of 1 year, whereas 0.5% went on to total hip arthroplasty. (Level IV evidence)
  • Clohisy JC, Knaus ER, Hunt DM, et. al.: Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res 2009; 2467: pp. 638-644.
  • This prospective study of 51 patients with a diagnosis of FAI evaluated clinical history, physical exam, previous treatments performed, and patient outcome scores. Patients indicated a relatively high level of activity, yet had restrictions of function and overall health. (Level II evidence)
  • Ellis T: Efficacy of surgery for femoroacetabular impingement. Am J Sports Med 2010; 38: pp. 2337-2345.
  • Systematic review of 970 cases included 1 level II, 2 level III, and 20 level IV studies. Patients improved in all studies based on outcome scores. Patients with intraoperative Outerbride classification of III or IV or preoperative radiographic Tonnis grade greater than 1 showed less improvement. Longer follow-up will be needed to determine if onset or progression of osteoarthritis is delayed. (Level III evidence)
  • Philippon MJ, Briggs KK, Yen Y-M, et. al.: Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up. J Bone Joint Surg (Br) 2009; 91: pp. 16-23.
  • One hundred and twelve patients underwent arthroscopy for femoroacetabular impingement with a mean age of 40.6 years. Twenty-three patients were treated with osteoplasty for cam impingement only, 3 had acetabular rim trimming for pincer type impingement, and 86 underwent both procedures for mixed type impingement. At a mean follow-up of 2.3 years, the mean modified Harris hip score improved from 58 to 84, and median satisfaction score of 9. Ten patients underwent total hip arthroplasty at mean of 16 months. Predictors of better outcome were preoperative Harris hip score, joint space narrowing, and labral repair versus labral debridement. (Level II evidence)
  • Siebenrock KA, Ferner F, Noble PC, et. al.: The cam-type deformity of the proximal femur arises in childhood in response to vigorous sporting activity. Clin Orthop Relat Res 2011; 469: pp. 3229-3240.
  • This retrospective review compared 72 hips in 37 male basketball players and 76 asymptomatic hips of 38 nonathletic volunteers. Findings suggest high- intensity sports activities performed in adolescence are likely to increase the risk of cam-type impingements. (Level II evidence)

  • Multiple-Choice Questions




    • QUESTION 1.

      What is the most common pain location of symptomatic hip impingement?



      • A.

        Groin


      • B.

        Lateral


      • C.

        Buttock


      • D.

        Thigh



    • QUESTION 2.

      What is the most common location of intraarticular damage in patients with femoroacetabular impingement?



      • A.

        Acetabular labrum


      • B.

        Acetabular labrochondral complex


      • C.

        Acetabular articular cartilage


      • D.

        Femoral head articular cartilage



    • QUESTION 3.

      Nonsurgical management of hip impingement should focus on the following combination of modalities:



      • A.

        Hip range of motion and activity modification


      • B.

        Hip strengthening and hip range of motion


      • C.

        Hip strengthening, muscle balancing, and activity modification


      • D.

        Nonsteroidal antiinflammatory medicines, hip strengthening and balancing, and range of motion.



    • QUESTION 4.

      What is the most common physical examination finding in patients with symptomatic hip impingement?



      • A.

        Reduced hip flexion and external rotation


      • B.

        Reduced hip abduction and external rotation


      • C.

        Reduced hip flexion and internal rotation


      • D.

        Limited extension and external rotation



    • QUESTION 5.

      Which of the following disease characteristics is a relative contraindication for hip preservation FAI surgery?



      • A.

        Severe deformity


      • B.

        History of injury to the joint


      • C.

        Symptoms of catching and locking


      • D.

        Moderate (50%) joint space narrowing




    Answer Key (identify where in text the answer can be found)







    Nonoperative Rehabilitation of Hip Stiffness and Hip Impingement (Cam/Pincer Lesions)



    Erik P. Meira, PT, SCS, CSCS
    Mark B. Wagner, MD



    Guiding Principles of Nonoperative Rehabilitation





    • Avoid exacerbating the anterior hip pain associated with femoroacetabular impingement (FAI).



    • Range of motion may be limited by bony deformity—DO NOT FORCE MOTION.



    • Focus on increasing strength and coordination within pain-free range of motion.



    • Specific attention should be made to controlling dynamic knee valgus.



    • Activation of hip abductors should be reinforced during each phase of rehab.



    • Modify lifestyle to accommodate FAI as able.




    Phase I (weeks 0 to 2)


    Protection





    • Weight bearing as tolerated.



    • Limit motion to pain-free range.



    • Minimize activation of the iliopsoas.



    Timeline 26-1

    Nonoperative Rehabilitation of Femoroacetabular Impingement














    PHASE I (weeks 0 to 2) PHASE II (weeks 2 to 4) PHASE III (weeks 4 to 8) PHASE IV (weeks 8+)



    • WBAT



    • PT Modalities



    • Mobilizations as needed for pain control



    • Gentle iliopsoas and lumbar extensor stretching



    • Exercise bike with elevated seat



    • Total body strengthening/total leg strength (TBS/TLS) activities as recommended & tolerated



    • Single leg stance as tolerated



    • OKC Rhythmic stabilization exercises



    • Prone heel squeezes



    • Isometric adductor squeeze



    • Clamshells (OKC)



    • Bridging (CKC)




    • FWB



    • PT Modalities as needed



    • ROM-limited to pain-free motion



    • Mobilizations as needed



    • Elliptical trainer



    • TBS/TLS activities as recommended & tolerated



    • Hip band ambulation



    • Core stability



    • Continue OKC/CKC exercises



    • Standing hip abduction/adduction/extension (OKC)



    • Bridging with marching (CKC)



    • Leg press in pain-free range (CKC)



    • Single leg lunge on wall with physioball (CKC)



    • Romanian Deadlift (RDL) with focus on lumbopelvic coordination (CKC)



    • Submaximal jumps on shuttle (Plyo)



    • Double leg bounces on mini-trampoline (Plyo)




    • PT Modalities as needed



    • ROM-limited to pain-free motion



    • Mobilizations as needed



    • Elliptical trainer



    • TBS/TLS activities as recommended & tolerated



    • Hip band ambulation



    • Core stability



    • Side planks



    • Single leg stance on unstable surface with perturbations



    • Continue OKC/CKC/Plyo exercises



    • Lunges in multiple planes with focus on knee control (CKC)



    • Squats/deadlifts in pain-free range (CKC)



    • Single leg squats in Smith machine with focus on knee position (CKC)



    • Resisted sit to stand with kettle bell or dumbbell (CKC)



    • Double leg jumps on stable surface (Plyo)



    • Single leg bounces on mini-trampoline (Plyo)




    • ROM-limited to pain-free motion



    • Mobilizations as needed



    • Progression to running as tolerated



    • TBS/TLS activities as recommended & tolerated



    • Hip band ambulation



    • Core stability



    • Continue OKC/CKC/Plyo exercises



    • Power lifts as indicated for specific sports



    • Double and single leg jumps on stable and unstable surfaces



    • Sport-specific exercises progressed

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    Apr 5, 2019 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Femoroacetabular Impingement and Labral Injuries

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