There have been many journal pages dedicated to Femoroacetabular impingement (FAI) over the past year. I attended 2 conferences in 2014 where FAI was discussed – FSEM (Ire) Annual Scientific Conference in association with WFATT which took place at DCU, Dublin and the FSEM/BASEM UK Annual Conference in Edinburgh.
In Dublin, Geoff Verrall discussed how we often diagnose conditions that we expect to find. Listening to some of the varying delegate discussions at coffee and lunch breaks, I also think we often take away what we want to hear, from a presentation.
Is it possible to go to a presentation with a truly open mind? Probably not but then why would we. We all have our own opinions based on our clinical background, patients we have seen, how they have responded to our treatments and journal papers we have read. A more appropriate question is, are we prepared to change our opinions based on what we have just heard at the presentation?
The following is my own current take on FAI:
What we know:
- FAI is usually caused by a cam deformity but can also be caused by pincer deformities, deep acetabulum, retro-version, retro-torsion, extra-articular causes
- SUFE is a cause of cam deformities
- There are a large number of asymptomatic athletes with cam and pincer deformities
- Elite athletes have a higher prevalence of cam and pincer deformities than recreational athletes
- Hip pathology is a frequent cause of groin pain
- Uss guided intra-articular hip injections can be used to determine if the pain is coming from the joint
- Hip joint stress can be caused by intrinsic factors and extrinsic factors
- Intrinsic factors – hip morphology, strength, ROM, gait biomechanics
- Extrinsic factors – type of activity, amount of activity, body mass
- Once a patient with a cam or pincer deformity develops hip/groin pain, the cause may not be due to the cam or pincer deformity
- Symptomatic elite and recreational athletes with FAI have been successfully rehabilitated without the need for surgery
- Like other sports medicine conditions there is not one rehab programme that fits all
- Arthroscopic surgery can successfully relieve pain and improve function in patients with FAI
- Some surgeons advocate early surgery whereas others advise rehab initially and only surgery once rehab has failed.
What we don’t yet know:
- We can screen for morphological changes but what do we do about these in an asymptomatic individual
- What are all the causes of cam and pincer deformities
- How to predict which patients may go on to develop chondral defects
- Which patients can be managed conservatively and which require early surgery
- What is the best way to modify the intrinsic factors
- What is the best way to modify the extrinsic factors
- Wow long rehab needs to continue for
- When can rehab be considered as failed
- What is the best post-operative rehab
- When is it safe to return to play
So, how do we manage a 25yr old footballer with medial groin pain, +ve impingement signs and a CAM deformity on xray, once we decide the cause of the pain is FAI?
- Can we rehab him or does he require surgery?
- We can’t adjust his hip morphology without surgery but can we make adjustments to his extrinsic factors and intrinsic factors to relieve the impingement?
- How do we reliably measure strength? How do we best improve strength deficits without aggravating his symptoms? Does this change help?
- Do we need to improve his ROM? How best do we do this? Is the improvement maintained? Does this help?
- Is his gait contributing to the hip pain? How do we best modify it? Does the adjustment help?
- How best do we modify his type and amount of activity in the short-term to help? Does this need to continue long-term or if we make adjustments as above, are long-term modifications to activity unnecessary?
- Once he is asymptomatic, how do we monitor him?
- How much time have we got to do all of the above? Is he playing low level sport and time is not a limiting factor? Is he on £300,000 per week and every match missed is crucial?
- How do we decide when rehab has failed?
- When do we seek a surgical opinion? Do we involve a surgeon at the beginning as part of the team or do we only involve a surgeon when we decide rehab has failed?
- Which surgeon do we seek an opinion from?
By my reading of current literature, there is some evidence on how to clinically assess for FAI and rule out other conditions1. There is also evidence on how to reliably measure strength around the hip2. There are several papers on how best to strengthen individual muscle groups about the hip and groin but these may not be relevant to our patient3,4,5. If some of the exercises exacerbate the impingement pain then we need to adjust them. I can’t find any other high quality research to address the other issues mentioned above but am open to correction.
So how would I manage our 25yr old footballer?
- Assess the player’s intrinsic and extrinsic factors
- Take into consideration the level of sport
- Determine the player’s short-term and long-term goals
- Determine the time frame for rehab
- Involve appropriate team – physio/podiatrist/surgeon/S&C coach/ sports psychologist/players coach/players agent
- Implement a rehab programme
- Continually reassess goals
- Adjust programme according to the player’s response
- Where possible continue to monitor on return to play
- Where possible, monitor performance rather than just return to play.
As FAI is a very topical condition, with a significant amount of ongoing research, I have little doubt that our understanding and management of this condition will change over the next few years. It is up to us as sports medicine doctors and physios to keep up to date with this research and change our practices when the evidence dictates.
- Clinical examination and physical assessment of hip-joint related pain in athletes. Reiman MP, Thorborg K. Int J Sports Phys Ther 2014.Nov:9(6):737-55
- Hip and Knee strength assessments using a hand held dynamometer with external belt fixation are inter-tester reliable. Thorborg K, Bandholm T, Holmich P. Knee Surg Sports Traumatol Arthrosc. 2013 Mar: 21(3):550-5
- Emg activity of hip adduction exercises for soccer players: implications for exercises in prevention and treatment of groin injuries. Serner A, Jakobsen MD, Andersen LL, Holmich P, Sundstrup E, Thorborg K. Br J Sports Med. 2014. Jul:48(14):1108-14
- A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises. Reiman MP, Bolgla LA, Loudon JK. Physiother Theory Pract 2012 May:28(4):257-68
- Rehabilitation exercise progression for the gluteus medius muscle with consideration for iliopsoas tendinitis: an in vivo electomyography study. Phillipon MJ, Decker MJ, Giphart JE, Torry MR, Wahoff MS, LaPrade RF. Am J Sports Med. 2011 Aug:39(8):1777-85
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