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
Multiple-Choice Questions
- QUESTION 1.
What is the most common pain location of symptomatic hip impingement?
- A.
Groin
- B.
Lateral
- C.
Buttock
- D.
Thigh
- A.
- 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
- A.
- 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.
- A.
- 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
- A.
- 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
- A.
Answer Key (identify where in text the answer can be found)
- QUESTION 1.
Correct answer: A (see Pathophysiology: Clinical presentation )
- QUESTION 2.
Correct answer: B (see Pathological Findings )
- QUESTION 3.
Correct answer: C (see Nonoperative Management )
- QUESTION 4.
Correct answer: C (see Physical Exam Findings)
- QUESTION 5.
Correct answer: D (see Surgical Indications )
Nonoperative Rehabilitation of Hip Stiffness and Hip Impingement (Cam/Pincer Lesions)
- Erik P. Meira, PT, SCS, CSCS
- Mark B. Wagner, MD
- •
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.
| PHASE I (weeks 0 to 2) | PHASE II (weeks 2 to 4) | PHASE III (weeks 4 to 8) | PHASE IV (weeks 8+) |
|---|---|---|---|
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