Femoro Acetabular Impingement Syndrome PINCER

Keywords; femoro acetabular impingement syndrome pincer.



The stiff hip in the young adult is something of an anathema; it has all the signs on the physical examination of full blown arthritis, but the radiographs deny any such thing.

Usually there is no pain initially; just stiffness. But later, for one reason or another stabs begin in the groin with certain movements.

Eventually an xray is taken showing a large spur forming on the lateral edge of the socket. We used to think it was early arthritis, but researchers eventually realised this was not so; it was the first sign of FAIS.

FAIS is a condition of the socket and neck of the femur, almost certainly with a strong hereditary link, which causes too much coverage of the ball. The net result is initially a stiff, non painful hip in the young adult, mimicking arthritis, but with no degenerative change seen on Xray.

Flexing the hip fully becomes difficult and painful in the groin; initially in the young adult, but progressively continuing on of course through life.

It comes in three forms;

  • Pincer; an abnormality of the socket (called the acetabulum) in which a spur arches out from the rim of the socket.
  • Cam; an abnormality of the neck of the femur in which a prominent ridge of bone reduces the range of motion of the hip joint. 
  • Mixed; both Pincer and Cam defects simulaneously.


In the following two x-rays you can see a moderately severe case of pincer, in a 58 year old woman.


Femoro Acetabular Impingement Syndrome PINCER

Early hip arthritis is a frequent consequence of femoro acetabular impingement syndrome pincer.

Most diseases come in mild and severe forms. You can have dangerously high, life threatening blood pressure of 220 over 120, and mildly raised hypertension of 145 over 95. Both are high blood pressure but there's a world of difference between the two, of course.

So too with Femoro Acetabular Impingement Syndrome Pincer. In the above mild case there is minimal hip arthritis. Tthe medical report states: There are no bony abnormalities in the pelvis In reality there is clear evidence of a pincer deformity bilaterally, as well as early sclerotic change in the left sacroiliac joint anatomy.

In moderate and severe cases of untreated pincer, the hip usually becomes prematurely arthritic leading to a total hip replacement.



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PRESENTATION of

Femoro Acetabular Impingement Syndrome PINCER

Pain in the groin and front of the thigh begins insidiously. At first walking is not limited. In a severe case pain and disability begins in the teen years, but more usually in the forties and fifties. Hiking soon becomes impossible.

It is often associated with pain in the low back, because the lumbar spine, pelvis, and upper leg share some very large muscles, and the upper anterior thigh is innervated from the upper lumbar spine.

This sometimes makes for a chicken-and-egg situation. Did the pain begin in the back and radiate to the thigh. Or, is it a dodgy hip, and the radiation is actually from the hip to the back?

CLINICAL FINDINGS of

Femoro Acetabular Impingement Syndrome PINCER

Flexion, adduction and internal and/or more usually external rotation of the hip is restricted. Diagnosed early, it's just stiff. No pain. Left to brew for a few years, and these movements become painful in and around the groin.

Almost invariably some of the muscles in the groin become very painful. That could be the Iliopsoas muscle, the Pectineus, the Adductor magnus, the Sartorius... for you the patient what you will find is very tender muscles in the groin, and sometimes the buttock.


DIFFERENTIAL DIAGNOSIS of

Femoro Acetabular Impingement Syndrome PINCER

Your chiropractor will be looking out for nerve conditions that may refer to the upper thigh. Well known are Meralgia Paresthetica and Maignes Syndrome... the femoral nerve stretch test may be positive, and then there may well be numbness, changes in reflexes and very occasionally weakness of the quadriceps muscles.

Then of course an Inguinal hernia causes pain in the groin, and the area has many lymph nodes which may become infected, and very occasionally cancerous.

All in all, pain in the groin must be taken seriously. Usually, but not always, it's a chiropractic condition, but a thorough examination is indicated.




FROM THE CHIROPRACTIC COALFACE

Abnormalities often come in twos and threes. Mrs S, the 58-year old woman whose pelvis you saw above consulted me six weeks ago. She has had a life time of low back pain. She's been to physios, another chiropractor, orthopaedic- and neuro-surgeons. A difficult back.

Five years ago she started getting significant pain in the right (and lesser extent left) groin and upper thigh. Nothing helped, and the condition gradually worsened so that she was having considerable difficulty walking.

These are her back X-rays. You can see the scoliosis, and a severely degenerated lumbar joint at L3-L4:



My initial impression was a severely pinched nerve in the low back. At L3/L4 the pain would radiate to the front of the leg. Plus the Femoral nerve stretch test was positive. This has in many ways the appearance of a lumbar stenosis, a chronic narrowing of the spinal canal.



"Remember the patient can have more than one disease..."

Dr G. Till, DC.



However, ranges of motion of the hips were also limited and painful in the groins.

Conclusion: She has two independent conditions both of which can and do cause pain in the front of the upper leg.

  1. A severe neurological condition radiating from the midlumbar spine.
  2. A mild orthopaedic condition in the hip joints: femoro acetabular impingement syndrome pincer.


So, what is the treatment of femoro acetabular impingement syndrome pincer?

By addressing both the hip condition, and the lumbar stenosis, this good lady says that after only six weeks she almost no pain in her legs and groins. She can walk normally, though she has yet to test the distance.

Her low back aches, but isn't painful any more.

I've made it plain: exercises for the hip and back daily, for life; heavy lifting is absolutely forbidden. She knows full well: the neurosurgeon told her, I've confirmed it, she sits on the verge of major spinal decompression surgery which is a nasty business. Playing silly buggers is not for her.

Her biggest gripe is that she can't lift the grandchildren. No, she can't, but they can sit on her lap, and she can hug them every day, and tell them stories about Hans Brinker, and how he saved Holland with his thumb!



IMMOBILISATION ARTHRITIS and

Femoro Acetabular Impingement Syndrome PINCER


There is now heaps of scientific evidence that joints not-in-normal-motion rapidly become arthritic. This is because the hyaline cartilage is starved of  nutrients, and waste products build up, caused by the joint fixations.

Chiropractic's approach is to get the joints moving again, rehab exercises done on a daily basis to keep them moving, and sound nutritional support. In particular, a chicken bones broth and fish soup ... which are rich in gelatine powder and the latter Omega-3 oil. For the vegetarian, and of course everybody, freshly ground flax seeds are also rich in Omega-3.


DEVELOPMENTAL HIP DYSPLASIA

In contrast, DDH has "too-little-cover" of the ball. The result is the same but different. Both DDH and FAIS give pain in the groin, both are pre-arthritic but DDH has a hip joint where the range of motion is greatly increased. They make wonderful dancers and gymnasts... which makes it very difficult for your chiropractor: s/he will be telling you that if you dance, duck and dive you are surely going to end up with an early total hip replacement. It's not an issue with FAIS pincer - with those stiff hips you simply obviously wouldn't choose a career in ballet.


MIXED FAIS DDH syndrome

Very occasionally FAIS and DDH may co-exist in the same hip producing confusing symptoms and pain, and a clinical challenge to all concerned. Stiffness of FAIS? Or the hypmobility of DDH? Or hip arthritis?


Hip and thigh pain

These hip conditions are what we call syndromes; a complex mixture of signs and symptoms. There's nothing easy about the diagnosis of acute hip and thigh pain. Fortunately acute conditions of recent onset usually respond quickly to treatment; allowed to become chronic they become nuggety and stubborn.


Disability

The stiffness of an arthritic hip in the older person is something to be borne; difficulty with cutting toenails and even putting on socks and shoes is to be expected.

But in a young person the stiffness and disability of FAIS Pincer is a misery; recently, whilst clambering around in the pokey ceiling, making the connections for my solar generator, I realised that it would have been quite impossible with a stiff hip.

Read all about it at a day in the life of solar geek Bernard Preston.


USEFUL LINKS

Femoro Acetabular Impingement Syndrome PINCER



› FAIS Pincer



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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost painfree. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65 year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.



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