Femoral Acetabular Impingement

Normal Anatomy Acetabulofemoral joint synovial joint Articulation between the acetabulum and femoral head Fibrocartilage called the labrum rings around the acetabulum Deepens acetabulum improving stability Hip is a very stable joint During hip flexion the femoral rolls superiorly and the femoral neck moves closer to the acetabulum

Pathology Osseous abnormality that can lead to labral or acetabular cartilage damage Femur coming into contact with the acetabulum

Mechanism of Injury Insidious Traumatic Osseous morphology abnormality Abnormal bone growth following fracture

Classification Cam Impingement Pincer Impingement Combined Impingement Most common isolated FAI Typically seen in young adult men 20 – 30 Loss of normal anterolateral femoral head-neck contour Non spherical portion of the femoral head produces a shear force at the chondrolabral junction as it enters the acetabulum during hip flexion Repetitive shearing results in chondrolabral separation, acetabular chondral delamination from subchondral bone and labral detachment Pincer Impingement Typically seen in women 30 – 40 Acetabular over coverage Causes compression of the labrum against the femoral neck in hip flexion and internal rotation Leads to labral degeneration Combined Impingement Most common form of FAI Components of both cam and pincer morphology

Associated Pathology Osteoarthritis Labral Tear

Subjective Examination Inguinal pain “C-Sign” – cup their hand around the anterior hip region May refer to greater trochanter or buttocks Insidious onset of symptoms Anterior pinching sensation in flexion, adduction, internal rotation May report sharp pain with clicking and giving way Worse with flexion, adduction and internal rotation activities Worse with rotation and pivoting athletic positions Pain with prolonged sitting, standing and walking

Objective Examination Restricted flexion and/or internal rotation Grinding or popping sensation in the hip on testing

Special Tests Flexion Adduction Internal Rotation Test (FADIR) Flexion Internal Rotation Test Thomas Test Flexion Abduction External Rotation Test (FABER)

Further Investigation X-ray CT MRI

Management Conservative management usually attempted first for 8-10 weeks Should symptoms not change surgery is required to correct anatomical/bony abnormalities

Conservative Reduce pain and inflammation NSAID’s Ice Massage Rest from aggravating activities for positions Restore Normal Range of Movement Lumbar spine, Hip Joint mobilisation Joint manipulation Stretches N.B stretches should not replicate clients symptoms

Conservative Reduce pain and inflammation NSAID’s Ice Massage Rest from aggravating activities for positions Restore Normal Range of Movement Lumbar spine, Hip (Posterior capsule) Joint mobilisation Joint manipulation Stretches N.B stretches should not replicate clients symptoms

Conservative Restore Normal Muscle Activation Hip Flexors Hip Extensors and Abductors Deep Hip Rotators Restore Dynamic Stability Proprioceptive Training Sport Specific Training

Plan B Surgery Different types of surgery depending on arthroscopic findings and surgeon preference Acetabular rim resection Labral debridement Labral repair Femoroplasty

References Anderson, C. N., G. M. Riley, G. E. Gold and M. R. Safran (2013). "Hip- femoral acetabular impingement." Clin Sports Med 32(3): 409-425. Cheatham, S. W., K. R. Enseki and M. J. Kolber (2016). "The clinical presentation of individuals with femoral acetabular impingement and labral tears: A narrative review of the evidence." J Bodyw Mov Ther 20(2): 346-355. Hendry, D., E. England, K. Kenter and R. D. Wissman (2013). "Femoral acetabular impingement." Semin Roentgenol 48(2): 158-166. Reiman, M. P., R. C. Mather and C. E. Cook (2015). "Physical examination tests for hip dysfunction and injury." British Journal of Sports Medicine 49(6): 357-361. Tijssen, M., R. E. van Cingel, E. de Visser, P. Holmich and M. W. Nijhuis-van der Sanden (2016). "Hip joint pathology: relationship between patient history, physical tests, and arthroscopy findings in clinical practice." Scand J Med Sci Sports.