Femoroacetabular impingement

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What is femoroacetabular impingement?

Femoroacetabular impingement (FAI) is a condition that results from an abnormal shape and consequently an abnormal contact between the two bones that form the hip joint – the thigh bone (femur), and the pelvis.

This change in bone shape can be found in either or both of these two bones. If it occurs on the top of the thigh bone (femoral head) it’s called a CAM lesion. If it happens on the hip socket/ pelvis (acetabulum) we call it a Pincer lesion. It is less common to happen on both sides of the hip joint, however some people can have a CAM lesion together with a Pincer lesion. This is known as a combined lesion and creates significantly more restriction to normal movement.

What are the signs & symptoms of FAI?

The main symptoms of FAI are pain and movement restriction within the hip. The pain is caused by impingement and subsequent inflammation of soft tissues such as the joint capsule and labrum (a rim of fibrocartilage that surrounds the hip socket increasing its size) that can get ‘squeezed’ and ‘pinched’ between these abnormally shaped bones.

The pain is usually a deep ache sensation around your hip that tends to be worse in the mornings or after repetitive hip movements, such as squatting, cycling or sitting with legs crossed for long periods of time.

What are the common causes of FAI?

Femoral acetabular impingement is a common condition in young athletes. About 15% of the population have, unawarely, a slightly different shaped hip which makes them more likely to suffer from symptoms caused by FAI. This is especially the case if they engage in sports or activities involving repetitive hip movements with big ranges of motion such as cycling, rugby, football or yoga.

Usually symptoms will start being noticeable between the end of the second and third decade of life. FAI can also be a consequence of a more widespread process of osteoarthritis in which case the symptoms usually start a bit later in life.

How is FAI diagnosed?

During your initial consultation your therapist or doctor will ask you a range of different questions related to your hip pain to try and determine the cause of the pain. The diagnosis of FAI is a result of a combination of a physical assessment and specific orthopedic tests. In the physical assessment a marked reduction in hip mobility is likely to be found, especially rotating the hip inwards and crossing the leg over to the other side is often limited by pain.

In some cases further testing may be required. This may include an Xray of the hip joint and/or a MRI to assess the morphology (shape) of the hip joint.

What are the treatment options for FAI?

The treatment options for FAI are varied and usually follow a pathway starting with more conservative measures and progressing to more invasive treatments as and if needed.

Usually, people will try a first course of conservative treatment which can include exercise and physical therapy. The goal of conservative treatment is to change how you load your hip joint and let other muscles or joints take more load so that the load on the hip joint decreases and the symptoms start settling. This usually lasts from 8 to 12 weeks and has the added benefit of improving your function and muscle strength so that even if a more invasive treatment is necessary, your recovery rate will be quicker as your hip muscles will be stronger from the training carried out during the conservative treatment.

In some cases more invasive treatments such as a joint injection and surgery may be needed. The aim of the injection is to decrease pain and inflammation on the soft tissues around the hip joint. This allows the symptoms to settle, however the effect of the injection can start wearing off after 4 to 6 weeks.

When symptoms don’t improve or keep worsening despite conservative treatment, then a surgical intervention might be the most appropriate approach (for example if the increase in bone size is such that there is too much pressure on the soft tissues). The goal of surgical intervention is to reshape the hip bones back to a more ‘normal’ shape that allows more space in the joint for the soft tissues and also permitting a wider range of movement of the hip joint.

How long does FAI last?

Femoral acetabular impingement usually starts as a gradual insidious onset following increased physical activity levels or increased length of time loading the hip joint.

The amount of time FAI lasts can vary from a couple months to approximately 6-8 months to get back to full activities following conservative treatment or surgery. The length of time and amount of treatments needed depends on a few different factors, including:

  • The length of time between the beginning of your symptoms to the start of an appropriate course of treatment.
  • Age.
  • Previous physical activity levels.
  • Associated conditions such as osteoarthritis, rheumatoid arthritis and diabetes, can have an effect on recovery time.

Can FAI be prevented?

Femoral acetabular impingement symptoms can be minimised by optimising the way in which your hip moves so that the load and impact is taken up by the hip muscles rather than loading the hip joint itself. This can be achieved through an exercise programme that addresses the muscle strength around your hip, thigh and core muscles, as well as improving your balance and coordination.

If you are already experiencing pain then avoid repetitive hip movement, especially deep flexion. This should help the symptoms to settle down. Cycling, running, deep squats, twisting in a squat position, such as in rugby, or spending too much time in deep flexion such as in some yoga poses, are all things known to aggravate hip symptoms.

What are the best exercises for FAI?

Glutes strengthening exercises such as bridging, single leg bridging, side leg raises, squats and lunges, will help by training your body to absorb more load through the hip muscles rather than the hip joint itself, thereby supporting the joint better.

  • Lie on your back with your knees bent.
  • Raise your forefoot and push your heel to the ground to relax the muscles in the back of your thighs.
  • Squeeze your buttocks together and lift them off the ground to make a straight line with your body.
  • Slowly lower your body and repeat.

Core stability exercises such as plank, side plank, single leg raises, side lunges, lunges with trunk rotation. These stability exercises are very important as you cannot possibly have a stable hip if the centre of your body is not stable in the first place.

Pilates is a great option as it usually involves a combination of these exercises, however you should let your Pilates instructor know that you are having hip pain so that you don’t do too many exercises that might flare up your hip pain the next day. For example mountain climbers are to be avoided on an initial phase as the repetitive hip flexion motion is likely to temporarily aggravate the FAI symptoms.

  • Lie on your stomach, propped up on your forearms and feet tucked in.
  • Lift up your body, creating a straight line with your body.
  • Hold the position for as long as you can.

Balance and coordination exercises such as single leg knee bending, step down, and balance board exercises are essential to improve the general coordination and control of your body and especially important is the coordination of the motion of your hip in relation to your pelvis – the angle of your pelvis will determine which part of the hip socket is more loaded during weight bearing activities.

  • Stand up straight on top of a book or small step with the foot of the affected side facing forward.
  • Put your hands on your hips and lower your body by bending at the right hip and knee, keeping your back straight and your right knee cap aligned with the second toe so that the knee doesn’t turn inwards.
  • Just before your foot touches the ground, raise yourself back to the standing position and repeat.

Do I need to go to the GP or visit my local hospital?

FAI is usually diagnosed by a physical therapist such as a physiotherapist or osteopath or hip specialist which means you will have already gone through a thorough examination and special testing.

If you start to experience a sudden worsening in symptoms, or if you develop constant night pain or a catching/clunking or painful clicking in your hip, then it would be advisable to check these symptoms with your GP, physiotherapist or osteopath.

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What is the difference between an Osteopath and Chiropractor?

The primary objective for both Osteopaths and Chiropractors is, most frequently, to relieve aches and pain. However, osteopaths also treat a broader range of functional problems, such as disorders of the respiratory or digestive systems. Both Osteopaths and Chiropractors treat Free Osteopathy Discovery Sessionmore than just bones joints and soft tissues. By working with the nervous system and blood supply they are able to influence all of the bodies systems, making them capable of alleviating the symptoms of a number of diagnosed medical conditions, such as; asthma, stress, digestive disorders, period pain, migraine and many more.

In many cases, patient experiences with osteopaths and Chiropractors will be very similar; however, there are some differences. When diagnosing patients, osteopaths and Chiropractors both use visual inspection (observation) and palpation (touch). Chiropractors frequently rely on more diagnostic procedures, such as X-rays, MRI scans, blood tests, and urine tests. Osteopaths tend to place more emphasis on the physical examination and will generally refer patients on for more diagnostic procedures if required.

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