Femoroacetabular impingement, FAI, tight hip, impingement, Cam, Pinser, hip pain, groin pain, deep buttock pain, pain in motion, impaired range of motion, arthrosis, ache
Femoroacetabular impingement (FAI) is, as the name suggests, associated with a narrowed hip joint in which the proximal femur is in premature contact with the acetabulum. This causes increased loading on the structures of the hip and may lead to degenerative changes and osteoarthritis in the long term.
The pain experienced in femoroacetabular impingement typically presents as deep pain in the groin, especially during movements that involve increased hip flexion. Activities like deep squatting, sprinting, twisting motions and extreme rotations exacerbate the pain; however, discomfort can also occur during common daily tasks and even at rest. There is often a restriction of movement in the hip and tension in the surrounding muscles.
This condition can affect individuals of all ages, but initial symptoms often begin at a relatively young age. Structural changes in the hip are observed, but symptomatic femoroacetabular impingement is often associated with functional factors as well.
Timely diagnosis and treatment are crucial for managing symptoms and preventing long-term complications.
Etiology
FAI is associated with three different morphologies of the hip joint: cam, pincer, and a combination of both. These morphologies are thought to be quite common (about 30% of the population), including individuals who do not exhibit hip problems. The altered shape of the hip joint narrows the joint, causing increased stress on the internal structures of the hip.
Cam morphology describes the flattening or convexity of the femoral neck. This morphology is more common among young, athletic men.
Pincer morphology, on the other hand, describes the overcoverage of the femoral head due to changes in the acetabulum. In this case, the acetabular rim extends beyond the normal range over the round head of the femur. Pincer morphology is more prevalent in women.
The combined form of cam and pincer morphology occurs when both cam and pincer-related morphologies are present in the hip. Estimates suggest that up to 85% of all FAI patients possess this type of mixed morphology.
Forms of FAI: Pincer, Cam, and their combination
Structural changes in the hip can, over time, lead to damage of the articular cartilage and the labrum (the cartilage ring that deepens the acetabulum), as the edge of the acetabulum and the femoral head repeatedly collide with each other.
However, it is important to remember that radiological changes associated with FAI can also be found in asymptomatic individuals; thus, a morphological abnormality alone might not be sufficient to cause symptoms. Often, in addition to the impingement, functional and behavioral factors are also observed in individuals with symptomatic FAI. Such factors may include:
Weakness of the deep hip flexors or core can lead to increased loading, instability and pain in the hip.
Intense training and sports that involve repetitive hip flexion, rotation and squatting (e.g., soccer, hockey or gymnastics) can increase the load on the hip joint and exacerbate symptoms.
Biomechanical challenges and alignment issues in the lower limbs increase stress on the hip and can worsen pain.
A hypermobile joint structure decreases joint stability and increases wear.
Being overweight increases the load on the hips and exacerbates both pain and mechanical dysfunction.
Previous injuries to the hip can alter the anatomy and function of the joint.
Osteoarthritis and other degenerative changes in the hip often worsen pain and symptoms related to FAI.
Insufficient rehabilitation following an injury or surgery can lead to so-called muscle imbalances and increased hip dysfunction.
A sedentary lifestyle can lead to stiffness and weakening of the hip, which may contribute to the worsening of symptoms.
Symptoms
The primary symptom of FAI is deep pain in the groin that may radiate down the front of the thigh toward the knee. Pain can also be felt deep in the buttocks, lower back or on the outer parts of the hip. Additionally, the affected hip often feels stiff, and there may be clicking or other joint sounds, as well as a sensation of locking or catching.
The pain is generally associated with activities like sprinting, squatting, climbing stairs or prolonged sitting. In cases where FAI has progressed significantly, there are often signs of wear and tear.
The main symptoms reported in association with FAI are:
Moderate to severe pain in the hip or groin during certain movements or positions.
Pain in the thigh, back or buttocks.
Stiffness and restricted range of motion in the hip.
Joint sounds and a sensation of locking.
Decreased ability to perform daily activities or engage in sports.
Diagnosing femoroacetabular impingement can sometimes be challenging, as similar symptoms occur in other pathologies related to the hip or surrounding tissues. In 2016, specific criteria were established for the diagnosis in the Warwick Agreement. According to these criteria, it is likely to be a pain condition associated with FAI when the following three criteria are met:
Symptoms: Pain in the hip or groin area that worsens with movements that cause hip impingement. Additionally, there may be stiffness, joint sounds and limited motion in the hip.
Clinical Findings: Certain clinical examination results support the diagnosis of FAI. These may include impingement tests that provoke pain, restrictions in joint movement or changes related to hip strength.
Imaging Findings: Diagnostic imaging studies, such as X-rays or MRI, that show changes associated with FAI. These changes may include alterations related to cam or pincer morphology, labral tears or other structural changes in the hip joint.
Treatment
The primary treatment for femoroacetabular impingement (FAI) is conservative. This approach combines pharmacological and non-pharmacological pain management methods with physical therapy. The goal of exercise is to improve the biomechanical properties of the lower limbs and reduce the increased load on the hip.
The objectives of treatment are to alleviate pain and enhance functional ability and work capacity. This is often achieved through a precise, progressive and individualized exercise program. Additionally, exercises that improve or maintain mobility, combined with manual therapy, seem to alleviate symptoms associated with FAI.
Pharmacological treatment typically involves a combination of pain relievers and anti-inflammatory medications. In some cases, corticosteroid injections into the joint may also provide benefits.
Surgical procedures should be considered only if conservative treatment does not yield the desired results or if the patient experiences severe pain that significantly impairs functionality. The goal of surgery is to remove or reshape the bony structures causing the impingement and to address any potential damage to the labrum and articular cartilage.
Surgery can be performed either arthroscopically or through open surgery. The recovery time for open surgery is usually longer than that for arthroscopy, but the outcomes of open surgery are often better. After surgery, it is crucial to undergo rehabilitation through physical therapy to restore strength, range of motion and control. Poorly executed rehabilitation can diminish the benefits of the surgery.
Physiotherapy
Physiotherapy always begins with a thorough assessment of the underlying factors, which allows for the development of an individualized and effective rehabilitation program. No two rehabilitation programs are identical, even though they often share similar components and goals.
The primary objectives of physiotherapy are to reduce the pain caused by femoroacetabular impingement (FAI) and improve functional ability. Initial rehabilitation focuses on pain relief, usually achieved through various passive interventions, such as soft tissue techniques, joint mobilization or manipulation, acupuncture or other pain management methods.
In FAI, it's important to identify which movements and activities exacerbate or prolong symptoms, so necessary adjustments can be made. These include positions and movements that require increased hip flexion, adduction, or internal rotation. Modifying one's load is part of treatment and physiotherapy. Understanding the nature of the condition, underlying factors, and potential duration of pain improves the prognosis for treatment.
As pain subsides, rehabilitation progresses to strengthening tissues and improving control and kinematics of the core, pelvis and the entire lower limb. In the rehabilitation of FAI, it is especially important to strengthen the deep stabilizing muscles of the hip and the core. Training these muscles enhances stability of the hip, improves lower limb kinematics and reduces unnecessary loading on the hip. Progressive training aims to improve the load tolerance and functionality of the affected structures, so they do not become painful as easily in the future. Any movement restrictions are addressed through a combination of manual therapy and mobility exercises.
When creating a rehabilitation plan, it's crucial to consider the individual’s needs and preferences. The content of physiotherapy may vary significantly depending on the person's background, symptom profile, and goals. Thus, the physiotherapy program is tailored to the individual and is not always the same.
Below are some physiotherapy interventions and their primary goals in the rehabilitation of femoroacetabular impingement:
Progressive training and load modification aim to:
Manage overall loading and reduce pain.
Decrease compression and tension on irritated tissues.
Strengthen the deep stabilizing muscles of the hip and improve dynamic stability.
Enhance the load tolerance of muscle and tendon structures.
Alleviate pain and improve functional capacity.
Manual therapy aims to:
Alleviate pain and activate descending pain pathways.
Reduce muscle tension.
Improve muscle and joint performance.
Decrease cortisol release in the tissues.
Increase or improve circulation in the treated tissues.
Enhance mobility.
Reduce the disruptive nature of pain.
Read more about the effectiveness of manual therapy and the applied treatment methods here.
Guidance and counseling aim to:
Provide sufficient information about the nature of the condition, underlying factors and prognosis so that pain does not cause excessive worry or fear. Knowledge of the healing process and treatment prognosis enhances motivation for self-directed rehabilitation and improves self-efficacy. At the same time, factors that can positively or negatively affect the treatment prognosis and timeline are addressed, allowing for adjustments as needed. This reduces the patient's uncertainty and potential anxiety, making it easier to live with pain.
Self-Care
Rest and load modification: Allow your hip and surrounding tissues adequate time to heal by avoiding activities that aggravate pain. This includes prolonged sitting, intense training or vigorous stretching.
Try cold therapy: Cold treatment can help relieve pain and possible inflammation. You can use ice, cold packs or cold gels.
Pain medication: Ibuprofen and paracetamol can alleviate pain and inflammation. Always follow the recommended dosage and consult a healthcare professional if you are uncertain.
Heat therapy: Heat can help relax muscles and reduce pain.
Stretching: Try gentle pumping stretches to improve circulation in the tissues surrounding the hip. However, avoid intense or prolonged stretches, as these often exacerbate pain. Refrain from stretching positions that further compress the hip.
Strengthening exercises: Strengthening exercises develop muscles and increase hip stability. Start gradually and increase the load over time. A rapidly progressing exercise program often only worsens pain.
Modify postural and movement habits: Avoid movements and positions that exacerbate pain. These include prolonged sitting, standing with the hip joint open, climbing stairs or long periods of standing.
Weight management: If you are overweight, losing weight can reduce stress on the hip and help alleviate pain. The fundamental pillars of weight loss are reducing energy intake and increasing physical activity, with the former being significantly more important.
Sleeping position: Avoid sleeping positions that put the affected hip in a compressed or stretched state during the night. Consider placing a thick pillow between your knees while sleeping on the side of the unaffected hip.
If your pain persists despite self-care measures or disrupts your daily activities, consult a physiotherapist. They can create a rehabilitation plan tailored to your needs and implement the necessary interventions to help you quickly overcome pain.
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