Femero Acetabular Impingement Syndrome

Hip groin pain in the young adult may be caused by Femero Acetabular Impingement Syndrome arising from abnormal contact between the femero head and the acetabulum at the end of hip motion. This is caused by a structural abnormality at the femoral head/neck junction or the acetabulum. FAIS generally refers to TOO MUCH coverage of the ball by the socket.

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HISTORY

But in the physical examination, it becomes apparent that there is distinctly reduced range of motion of the hip, with a hard end-feel . They may then remark that they have indeed a stiffness in the groin, even pain.

Of course, as this patient ages, later in life s/he will present not just with stiffness in the hip but with frank pain in the groin, perhaps as the initial complaint, as the general public begins to realise that chiropractors are not only spine specialist, but of any and all joints.

All except the joints between the ossicles in the inner ear! Those are the only joints I have no idea how to treat!

What chiropractors have learnt about joints of the spine, can be applied to any joint in the body.

PHYSICAL EXAMINATION

IF YOU DON'T LOOK FOR IT, YOU PROBABLY WON'T FIND IT, RIGHT?

In Femero Acetabular Impingement Syndrome there may (less commonly) be decreased external rotation . Shortly we will see that they are really two different conditions that, for convenience, we wrap into one.

It took me more than twenty years in practice to grasp the reason why there may be decreased internal or external rotation in the neutral position, but not in the flexed hip. Or vice versa. All typical of FAIS.

HIP PAIN QUESTIONAIRE

Two basic mechanisms of impingement

1. CAM - FEMORAL HEAD deformation (abnormality at the level of the anterior head/neck junction.)
2. PINCER - ACETABULUM deformation (abnormality which increases the covering of the femoral head.)

Either way, there is increased contact between the acetabular rim and the femoral head/neck junction.)

They produce subtle differences which may be elicited by the orthopaedic tests listed later on this page.

FEMERO ACETABULAR IMPINGEMENT SYNDROME Pincer ...

The nett result in both syndromes is groin/ hip stiffnes, later there is progressive pain and degeneration of the labrum if the condition is not appropriately treated. Cartilaginous lesions form either along the postero-inferior or the superior aspect of the acetabulum, limiting full range of movement of the hip.

The end result is the same, if it is not correctly managed: osteoarthris (OA) of the hip (called Cox arthritis).

These new understandings help us to grasp why sometimes hip OA is in the superior part of the acetabulum, and sometimes in the postero-inferior aspect.

Repetitive shock, particular in sport, between the CAM deformity on the femoral neck and the anterior wall of the acetabulum eventually may even result in an avulsion (a fracture) of the antero-superior acetabular labrum with very sharp stabs of groin pain.

FROM THE COAL FACE

Can this early recognition prevent the inexorable deformity and pain that is likely to occur? Only time will tell.

Coalface 2: Pincer

Interestingly, the radiologist called it a normal study.

Who is likely to get it?

Typically, CAM and Pincer present in quite different ways:

1. CAM: Limitation of the hip ROM particularly in flexion and INTERNAL rotation.
2. PINCER: Limitation of the hip ROM particularly in flexion and EXTERNAL rotation.

• 86% patients with Femero Acetabular Impingement Syndrome have a combination of both CAM and Pincer. Both internal and external rotation, flexion and adduction are gradually and progressively more limited.

What is odd is that sometimes the condition begins with pain in the groin, but no stiffness, currently with a 34-year old woman. X-rays have confirmed a Pincer deformity but she has a full and free normal range of motion. Presumptious perhaps, but one expects the stiffness to develop later... and the hip arthritis if the appropriate chiropractic management is not applied.

Of course the syndrome then continues into old age producing the same signs and symptoms of hip/ groin pain so frequently associated with the degenerative changes of osteo-arthritis of the hip. Improperly managed this is what inexorably happens:

Can Chiropractic prevent this inexorable progress from early stiffness to the severely arthritic hip? I believe so, if FAIS is correctly recognised and diagnosed. And the appropriate treatment is effectively applied.

What causes FAIS?

Has granny had a hip replacement?

Some experts believe that overly robust athletic activity before skeletal maturity increases the risk of Femero Acetabular Impingement Syndrome, but no one truly knows. Significant contact sports (eg. football) are associated with FAIS impingement.

How is Femero Acetabular Impingement Syndrome diagnosed?

Orthopedic examination of hip groin pain.

• Decreased ROM (flexion and rotation, and later adduction) with hard end-feel. (soft end-feel would point to a lesion in the capsule or muscle)
• Positive Impingement sign - Two basic types:

1. Anterior Femero Acetabular Impingement Syndrome

The FAdIR test : If the hip/ groin pain is reproduced in Flexion, Adduction with forced internal rotation of the leg at 90° of flexion.

The FAdER test : If the hip/ groin pain is reproduced in Flexion, Adduction with forced external rotation of the leg, with the hip in 90 degrees of flexion.

The Drehmann sign : If the patient passively externally rotates the leg whilst the hip is flexed causing groin hip pain.

2. Posterior FAIS if there is hip/ groin pain in forced external rotation with the leg in full extension.

X-ray

Specific attention is directed to the head-neck region. Fullness or a prominence of this region laterally on the AP view is indicative of anterolateral disease.

Often an MRI of the hip is used to confirm a labral tear or damage to the joint surface. The MRI is most helpful in eliminating certain other causes of non FAI hip pain including avascular necrosis (dead bone) and tumors.

Congenital hip dysplasia and Developmental Dysplasia of the hip (DDH)

DDH generally refers to TOO LITTLE coverage of the ball by the socket, whereas FAI generally refers to TOO MUCH coverage of the ball by the socket.

Because of the decreased coverage, hip dysplasia results in increased range of motion. It needs to be differentiated from "hypermobility" - general loose ligaments resulting in increased range of motion in the hip, but without the developmental changes associated with DDH.

Too little cover ... this woman has pain in both groins, with no limitation of movement. We've caught it in time - there are no degenerative changes yet.

Both DDH and FAI are associated with labral/cartilage tears and hip arthritis.

FAI and DDH may coexist in the same hip.

HYPERMOBILE HIP DYSPLASIA CAM FAIS

One added factor in her case was a chronic magnesium deficiency that causes chronic arthritis called Chondrocalcinosis. Spinach has the highest levels of magnesium... HYPERMOBILE HIP DYSPLASIA CAM FAIS

FRESH SPINACH RECIPES ...

Can back pain be a sign of FAIS ?

Fundamentally, abnormal biomechanics at one joint can and does affect other joints, primarily local, but also remote.

Common activities associated with FAIS

Horseback Riding

Football (American)

Soccer

Rugby

Ballet/Dance/Acrobatics

Lacrosse

Martial Arts

Deep squatting activities such as power lifting

And of course many other sports will be painful if you have FAIS, like golf, cause you can't go thru with the swing without adducting the hip. Pain!

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Treatment

1. Adjustment and management of the sacro-iliac joints. The Thompson drop protocol will usually be best. Lumbar roll techniques will often exacerbate the pain in the groin, and should only be used with discrimination and care, to avoid adduction of the hip which will cause groin hip impingement.
2. The Derefield protocol helps decide whether to adjust the sacrum or the ilium.
3. Mobilisation and adjustment of the hip joint.
4. Stretching of the hip joint, and associated muscles, avoiding those hip movements that cause pain in the hip groin area.
5. Deep soft tissue techniques of muscles with active trigger points. The Adductor Magnus muscle, the Ilio-psoas muscle as well as the fine hip rotator muscles are often involved in hip groin pain. This treatment may be extremely painful, and should either by lightly done, or only two or three deep strokes.
6. Cross friction of the capsule in the groin, not neglecting the approximation of the Femoral Nerve and the Femoral Artery.
7. Some chiropractors may choose to use needling, acupuncture and electrical modalities.
8. Active rehabilitation of the muscles of the pelvis and thigh.
9. Managed return to sport for the patient with hip groin pain is advisable, recognizing that competitive sports such as basketball and football may no longer be advisable if the congenital structural abnormalities in the acetabulum are significant.

10. If you have hip groin pain it is possible that you may have to accept that only sports such as cycling and swimming are advisable. Your chiropractor will advise you. The alternative is early hip degeneration and consequent premature hip replacement.

11. Weight control and a healthy diet is important.

12. Supplements such as glucosamine phosphate may help.

Surgery may be recommended in extreme cases.Cortico steroid injections are used by skilled orthopaedic surgeons and may have benefit, however there is risk of tendon rupture.

Femero Acetabular Impingement Syndrome case file