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Femero Acetabular Impingement SyndromeHip 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. HISTORYTypically we find FAIS (remember? Femero Acetabular Impingement Syndrome) in the sporty younger person. Often they will have consulted me for another condition, perhaps a neck or ankle injury.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 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. Chiropractor Bernard Preston writes light-hearted short stories that will amuse and entertain you. For an exerpt from Frog in my Throat, click here.
PHYSICAL EXAMINATIONTypically in Femero Acetabular Impingement Syndrome there is reduced range of motion in flexion and internal rotation with a hard end feel. For me it still comes as a surprise to find mark stiffness in the younger person. For years I have associated hard end-feels in the hip with the elderly, and never even bothered looking for it in the younger patient.IF YOU DON'T LOOK FOR IT, YOU 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 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. Two basic mechanisms of impingement
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 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 hip pain. Who is likely to get it? FAIS and hip groin pain affects particularly the young and active person from 20 to 40 years old. It is due to repetitive shock between the anterior acetabulum and the femoral neck. Patients present with groin hip pain. Typically, CAM and Pincer present in quite different ways:
86% patients with Femero Acetabular Impingement Syndrome have a combination of both CAM and Pincer. Both internal and external rotation are limited. 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.
What causes FAIS?No one knows if Femero Acetabular Impingement Syndrome is a condition that begins at birth (congenital) or develops during periods of growth (acquired). It's likely a combination of ones genetics and environment.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.
X-rayX-ray films are used to determine the shape of the ball and socket as well as assess the amount of joint space in the hip. Diminished joint space is generally associated with a greater chance of arthritis.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 or developmental dysplasia of the hip is a different diagnosis than Femero Acetabular Impingement Syndrome.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. Both DDH and FAI are associated with labral/cartilage tears and hip arthritis. FAI and DDH may coexist in the same hip. Can back pain be a sign of FAI?Yes. While the cause is not well understood, patients with Femero Acetabular Impingement Syndrome often complain of low back pain. This pain is often localized to the sacroiliac joint (SIJ), the buttock, or greater trochanter (side of hip). FAIS pain typically does not go beyond the level of the knee.Fundamentally, abnormal biomechanics at one joint can and does affect other joints, primarily local, but also remote. Common activities associated with FAISIce HockeyHorseback RidingYogaFootball (American)SoccerRugbyBallet/Dance/AcrobaticsGolfTennisBaseballLacrosseField HockeyBike Riding/CyclingMartial ArtsDeep squatting activities such as power liftingRowing Sports (Kayaking, Sculling/Rowing)Car riding (deep seated position)TreatmentHip groin pain can usually be successfully managed by the chiropractor. Treatment will include some of the following: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.
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