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The frustrating hip: hip impingement syndrome By Megan Fryer


For people, especially athletes, who experience hip pain there is a huge level of frustration with persistent pain in their groin, frustration with limitations of physical activities and immense worry that a hip replacement is inevitable. Athletes may struggle with the inability to perform at their best, fear losing their competitive edge and concerns about their future in sports.


Recent research found that the prevalence of hip pain in athletes from hip impingement was 3.7% and pain from musculoskeletal injuries of the hip complex was 13.9% (Safran et al., 2022). The incidence of hip impingement is less common in the general population 0.44% (Röling et al., 2016) however, of those suffering with a troublesome hip, 30% were found to have a hip impingement condition.


What can be done for troublesome hip?

Physiotherapy is a good option for the treatment of hip conditions and the condition of hip impingements. A course of physiotherapy, planned specifically for your symptoms, forms an integral part of conservative management for hip impingement (Fortier et al. 2022).

Firstly, an understanding of the hip and condition of hip impingement is useful:


What is hip impingement?

Hip impingement, otherwise known as femoral acetabular impingement syndrome (FAIS), occurs when there is pinching between the femoral head (ball of the hip) and acetabulum (cup of the hip) due to irregularity in bone formation of either the femoral head or the acetabulum (Witstein et al, 2024).


Anatomy:

The hip is a ball and socket joint.

  • The socket is formed by the acetabulum, which is part of the pelvis.

  • The ball is the femoral head, which is the top of the femur.


Articular cartilage covers the ball and socket of the hip. It helps to reduce friction allowing for a smoother movement when the bones glide over one another.


The acetabulum has an additional ring of fibrocartilage, called the labrum, which helps provide stability to the hip joint.


Hip impingement or FAIS occurs because either the femoral head or acetabulum have additional bone growth or bony spurs (Witstein et al, 2024). This causes abnormal movement in joint resulting in irregular forces and contact across the joint. Over time this can cause damage to the articular cartilage, labrum, and surrounding soft tissue (Fortier et al. 2022).

 

Types of hip impingement?

There are three different types of hip impingement, or FAIS. These are the cam impingement, pincer impingement, and a combination of cam and pincer impingements (Fortier et al. 2022).


 Cam:

  • A cam impingement refers to an abnormal shape or excess bony growth of the femoral head.

  • The femoral head is no longer spherical and cannot rotate smoothly in hip socket.

  • This causes an increase in the forces on the articular cartilage of the acetabulum and labrum.

  • It is most common in young male athletes, especially in high impact sports such as soccer or basketball.


Pincer:

  • A pincer impingement refers to excess bone formation of the acetabulum.

  • This excess bone growth leads to overlap of the acetabulum over the femoral head.

  • This results in abnormal articulation and a direct impingement of the labrum.

  • It is more common in physically active, middle-aged women.


Combination of cam and pincer:

  • This involves excess bone formation on the rim of the acetabulum as well as the femoral head.

  • This in turn causes frequent damage to both the acetabular rim cartilage as well as the labrum.

  • This mixed impingement will often have a worse prognosis than those who have just one type of impingement.

Symptoms of hip impingement:

  • The primary symptom of hip impingement, or FAIS, is movement or position related pain in the hip or groin.

  • Pain reported in the thigh, back or buttock.

  • Hip stiffness.

  • Restricted hip range of movement.

  • Clicking or catching.

  • Locking or giving way.

  • Decreased ability to perform activities of daily living and sport.

 

Symptoms are commonly aggravated by acceleration sports, squatting, climbing stairs, and prolonged sitting (Pandya, 2024).

 

Conservative treatment:

Physiotherapy treatment is usually recommended as the first line of treatment for mild-moderate hip impingement. Physiotherapy provides symptomatic relief, and your physiotherapist will work with you to improve overall function so that the perpetual strain on your painful hip is reduced and thereby promote an environment that recovery can proceed. A course of physiotherapy, planned specifically for your symptoms, forms an integral part of conservative management for hip impingement (Fortier et al. 2022).


Physiotherapy treatment plan:

  • Improving the neuromuscular function of the hip. This includes:

o   Hip specific lower limb strengthening and functional movement strengthening.

o   Improving core stability.

o   Postural balance exercises.

  • Holistic involvement of the body:

o   Analysis of the function and subsequent influence of both lower limbs, pelvic floor muscles, and lower back muscles on the troubled hip (Pandya, 2024).

o   Advice on lifestyle changes; maintain a healthy weight, stay active with low- impact exercises, practice good posture to reduce strain on the hip.

Hoit et al. (2020) conducted a meta-analysis on physiotherapy outcomes in patients with hip impingement and found that patient specific physiotherapy and exercise programmes were important for successful outcomes. Exercise programmes including core stability were also shown to be more effective compared to programmes that did not.


However, depending on the type and severity, for some types of hip impingement the outcomes for postoperative intervention remain significantly better.

 

Surgical management:

The aim of surgery for hip impingement is to restore normal function of the hip joint by correcting the cause of the impingement as well as repair any damage caused by the impingement (Witstein et al, 2024).


Surgical management most often involves a hip arthroscopy which can include:


  • An acetabuloplasty – removal of excess bony growth on acetabulum.

  • A femoroplasty - removal of excess bony growth on femoral head.

  • A labral repair.


Arthroscopic repair of hip impingement and associated labral injury, has proven to be successful in young adults, with outcomes being more inconsistent in older populations (Fortier et al. 2022).


Even after surgery it can take time to show a functional improvement and physiotherapy and rehabilitation is needed to correct the altered biomechanics (Pandya, 2024).


References:

BOSTON CHILDREN’S HOSPITAL. 2020. Hip Impingement. Available at: https://www.childrenshospital.org/conditions/hip-impingement. Accessed 13 May 2024

FORTIER LM, POPOVSKY D, DURCI MM, NORWOOD H, SHERMAN WF, KAYE AD. 2022. An Updated Review of Femoroacetabular Impingement Syndrome. Orthopedic Reviews,14(3)

HOIT G, WHELAN DB, DWYER T, AIRAWAT P, CHAHAL J. 2020. Physiotherapy as an Initial Treatment Option for Femoroacetabular Impingement: A systematic Review of the Literature and Meta-analysis of 5 Randomized Controlled Trials. Am J Sports Med., 48(8):2024-2050.

RÖLING, M. A., MATHIJSSEN, N. M. C. & BLOEM, R. M. 2016. Incidence of symptomatic femoroacetabular impingement in the general population: a prospective registration study. Journal of Hip Preservation Surgery, 3, 203-207.

SAFRAN, M. R., FOARD, S. J., ROBELL, K. & PULLEN, W. M. 2022. Incidence of Symptomatic Femoroacetabular Impingement: A 4-Year Study at a National Collegiate Athletic Association Division I Institution. Orthopaedic Journal of Sports Medicine, 10, 23259671221084979.

TEACH ME ANATOMY. 2022. Bony surfaces of the hip joint, head of femur, and acetabulum. Available at: https://teachmeanatomy.info/wp-content/uploads/Bony-Surfaces-of-the-Hip-Joint-Head-of-Femur-and-Acetabulum..jpg. Accessed on 13 May 2024.

WITSEIN JR, MULCAHEY MK, BYRD JWT. 2024 Femoroacetabular Impingement. OrthoInfo AAOS.  Accessed 13 May 2024, https://orthoinfo.aaos.org/en/diseases--conditions/femoroacetabular-impingement/.

 

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