femoracetabular impingement(fai) by chris gellert, pt, mmusc & sportsphysio, mpt, cscs, ams

8/10/2019 Femoracetabular Impingement(FAI) by Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS

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FAI: The “New Impingement”Training options to help your client

By Chris Gellert, PT, usc ! "portsphysio, PT, C"C", A"

Intro#uction

Hip pain has been typically perceived in older adults, however, can bepresent in young adults or even athletes. A new dysfunction of the hiphas been talked about recently in the medical eld and in varioushealth & tness journals. This is femoral acetabularimpingement!A"#. $hat is !A"% !emoral acetabular impingement isnot necessarily a disease but rather a pathomechanical process inwhich abnormal contact stresses can cause potential joint damagearound the hipeunig, 'eaule, & (einhold )**+#. This article willreview the background on !A", clinical presentation & pathology, thetypes of !A" andthe medical and physical therapy treatment approach. rovide the

latest evidenced based research about how !A" can lead to labralpathologies, while reviewing conservative vs. surgical interventions.-ective programming will be discussed using periodi/ation trainingprinciples guiding the personal trainer to utili/e the most eectivetraining strategies and e0ercises.

The learning o$%ecti&es o' this C() article are to:1. earn what !emoral Acetabular "mpingement!A"# is e0aminingcommon symptoms, reviewing the pathology, how it develops andpotential contributing risk factors.

). 'e able to dierentiate and understand the two types of !A"2 camand pincer impingement.

3. 4nderstand how the progression of !A" can lead to labralpathologies while e0amining what the latest evidenced based researchstates.

5. earn the latest rehabilitation and treatment approaches for !A"while reviewing some operative techni6ues used for patients who donot respond to conservative treatment.

7. 'e able to design individuali/ed periodi/ed training programs thatholistic address the client that are practical and integrative in nature.8onsisting of aerobic, anaerobic, stretching, yoga, pilates andswimming to assist the client achieve optimal tness.

Clinical presentation ! Pathology 9omeone who is suering from !A" is fre6uently aggravated byathletic activities and movements that re6uire e0cessive hip :e0ion,



or prolonged walking, pivoting on the aected side, prolonged sittingor driving. 8ommon symptoms include; locali/ed deep ache paintypically in the groin and in the front of the hip. <ccasionally pain canalso be referred to the outside of hip, buttock and thigh area.=echanical symptoms from the hip such as painful locking or giving

way are common presenting feature if a labral tear ispresentHossain. =. et al. )**>#. !emoroacetabular impingement!A"# is a pathologic process caused by abnormality of the shape ofthe acetabulum, the femoral head, or both, predisposing to thedevelopment of osteoarthritis and labral degeneration.

*ow FAI #e&elops an# contri$uting ris+ 'actorsThere are many theories on the cause of how an individual

develops !A". <ne proposed theory is that during development, theremay be structural abnormalities of the hip such as hip dysplasia.$hich is where the femur becomes dislocated. hysical

stressestrauma# such as a femoral neck fracture is seen commonly inactive middle aged adults, specically males in such sports as hockey,tennis and soccer.?ones et al. )*11#. @enetics has been e0amined anddiscussed as potential factoreunig, 'eaule, & (einhold )**+#. <nethings is certain. The research indicates that !A" occurs when there isan abnormality of the femoral head with respect to the congruency tothe acetabulum.

!A" causes hip pain and develops over time. (epeated ande0cessive hip :e0ion and internal rotation places ma0imal contactbetween the anterosuperior femoral headneck junction and theacetabular labrum, especially when there is not enough clearance to

avoid friction. This repetitive movement and compressive load createsa torsion aect on the internal structures inside the hip socket. Aperson with !A" that progresses will develop a movement pattern thatis abnormal, asymmetrical and accommodative. These are importantthings to consider why a person develops femoral acetabularimpingement.-mara, B, et al. )*11#

8ommon contributing factors include; previous trauma tofemurChip, muscle imbalances, structural abnormalities of the femoralhead, depravation of o0ygenCnutrients to the femoral head andrepetitive stressorsCloadsie. dancing# There is also substantialevidence supporting the hypothesis that osteoarthritis of the hip is a

major etiologic factor in !A"8lohisy, ? et al. )*1*#. atients withe0cessive range of movement of the hip can suer from impingementcan potentially predisposing them to !A" due to the biomechanicalstressors.

e&iew o' hip pathomechanicsThe hip joint is a ball and socket joint enabling a wide range ofmovement designed to function by providing weight bearing for



locomotion and movement. Anatomically, the iliopsoas, glute medius,glute minimus, glute ma0imus all provide anterolateral stability asseen in gure 1 & ). However, if muscle imbalances develop this canlead to dysfunction at the hip. !or e0ample, it is common to observe inclientsD tightpostural# hip :e0ors, 6uadriceps and weakerphasic#

glute medius, glute minimus and hamstrings. This alters load transferthroughout the kinematic chain in placing e0cessive load to the jointaltering the movement pattern of the individual.

"n the sagittal plane, during hip :e0ionE1)* degrees#, the femoralhead translates down as the glute ma0imus creates a downward pull.Furing hip e0tensionE)* degrees# iliopsoas is eccentricallylengthened. "n the frontal plane, during hip abductionE5* degrees#,glute medius contacts pulling the femur up which then translatesdown. Furing hip adductionE)7 degrees#, the femur glides downand out as the tensor fascia latae, ischiofemoral ligament and glute

medius is eccentrically lengthened.

Figure 1. Anterior hip complex Figure 2. Posterior HipComplex

Comparison o' two types o' FAI: Pincer an# Cam Impingement"mpingement at the hip can occur with e0tremes of movement, lack of movementmobility# or as a result of a combination of both. Thecontributing factors previously described provide a deeperunderstanding of !A" and the two types of !A" "mpingement.

There are two dierent types of impingement2 pincer and camimpingement. incer impingement occurs from a bony prominence ofthe front of the acetabulum placing e0cessive pressure from thelabrum against the neck of the femur. Thus impacting oneDs range ofmotion leading to pain. incer lesions are more common seen inmiddleaged active women. <ccurring through repeated contactbetween the normal femoral neck junction and the acetabular rim.



This repeated contact results in labral degeneration, iossication ofthe acetabular rim and deepening of the acetabular rim'anjeree &=clean )*11#. The causes of pincer impingement include; developmental changes, structural changes such as a retrovertedacetabulum, trauma and post traumatic deformity of the

acetabulum'anjaree & =clean )*11#.

"n contrast, cam impingement, is more common in active men. Thecam is attributed to a nonspherical portion of the femoral headplacing e0cessive pressure against the acetbular rim. This is mostnoticeable with active hip :e0ion and e0ternal rotation. "n which theposition of the femoral head is too large to pass in the acetabulum,and when the hip is :e0ed, this stresses the rim of the labrumaude,!. et al. )**G# This is seen in gure 3.The causes of cam impingement include2 developmentalnon sphericfemoral head, perthes disease, which involves inade6uate blood

supply and slipped capital femoral epiphysis, which is a separation ofthe ball of the hip joint from the thigh bone#. Trauma such as femoralneck fractures and chondral lesions especially in the acetabulum canplay a role'anjaree & =clean )*11#.

Figure -. Cam an# Pincer Impingement

e#ical an# Physical Therapy Treatment Approach8onservative management is initially recommended for mostindividuals with modication of activities, avoiding e0cessive hip

movement and taking nonsteroidal antiin:ammatory9AF"9# whichmay provide some relief. The role of physical therapy is to improvepassive range of motion, soft tissue joint mobility, lateral and

posterior strengthening of weak musculature, improve core stabilityand education of cross trainingyoga, swimming#. However, ifsymptoms continue and do not improve, then the patient may be acandidate for surgery.



(&i#ence# Base# esearch!A" can predispose a hip not only for osteoarthritis, but also lead todegenerative labral tears due to the repetitive compression and sheerforces placed on the hip. Fespite the time of impingement, overuse bythe patientCathlete, this will continually stress internal structures such

as the capsules, supporting ligaments and connective tissue. Thisrepetitive stress activates the pain bers within the joint anddependent on the pain threshold of the patient, physical conditioning,body type, muscle balances, pain can be acute or insidious in nature.

-0cessive hip :e0ion with e0ternal rotation or e0cessive hip :e0ionwith internal rotation of the hip places e0cessive compression andtorsional forces on the hip, particular the labrum. This is seen indancers and other sports. astly, muscle imbalancestightness#particularly in the hip :e0ors, adductors, piriformis, 6uadriceps and"T', all contribute to compressive loading of the hip joint,

predisposing it further to mechanical stress. <nce pain as mentionedpreviously aects daily activities, ability to play sport, a person hastwo choices. 8onservative treatment begins with physical therapy. Thechoice is based on the patient and physician, however, the literaturehas show that conservative management can be very eective.

"f surgery is re6uired, the most common procedure is hip arthoscopy. Here, the surgical process begins visuali/ing the hip while the patientis positioned supine with traction applied, and 3 standard portalsproviding the surgeon with a deeper view of the underlyingabnormalities. The underlying hip joint is debrided and involves

reshaping the head of the femur. After being bone has been reshapedto recreate the normal concave relationship at the junction of thearticular surface, this eliminates the cam or pincer lesion.

Postoperative Rehabilitation for Arthoscopy (eshaping of the femoral headCneck junction necessitates someprecautions. The patient is allowed to bear full weight, but crutchesare used to during the rst 5 weeks. !ull bony remodeling takes 3months, during which time some precautions are necessary to avoidhighimpact or torsional forces. Furing this time, gentle range ofmotion is emphasi/ed to stimulate the healing process. At 3 months,

specic precautions are lifted and functional progression is allowed.The speed with which the athlete advances is variable and mayre6uire another 1 to 3 months for full return. Thus, patientDs andathletes are generally advised that return to sports after surgicalcorrection of !A" at E 5 to I months'yrd & ?ones )*11#.

Another surgical option is the open procedure which again is intendedis to correct deformities with either an osteoplastysurgical repair



using bone from another part of the body# or involves trimming of theacetabular rim. The torn labrum can be resected or re0ated. Anydelaminated cartilage is debrided to a stable edge. The opentechni6ue is performed using a trochanteric :ip osteotomy or alimited anterior approach combined with arthroscopy to address the

labral and chondral injuries.

The labral fxation procedure involves cutting through the fascia thatinterconnects the glute medius. "n athletic patients, a release is madein the front of the gluteus ma0imus while being performed pro0imallyclose to the iliac crest. An osteotomybone removal# is performed nearthe greater trochanter along to vastus lateralis. (etraction of thesubcutaneous tissue is made and a 17 mm incision is made from thetip of the trochanter to the pro0imal vastus lateralis. A thin oscillatingsaw is used to remove the front portion of the lateral aspect of theupper portion of the greater trochanter. Then a retractor is used to

e0pose the hip joint further. The hip capsules is e0posed and cut in a Jshaped manner e0posing the femoral head. Titanium anchors areplaced from the labrum into the acetabulum. onabsorbable suturesare used while knots are tied on the outer capsular surface with thesuture being placed through the base of the labrum. The acetabulumis irrigated to remove debris. The capsule is closed with singlestitches can be used while the trochanter is anatomically reduced and0ed with two or three 3.7 or 5.7mm cortical screws aimed towardthe lesser trochanter. Thereafter, the various softtissue layers areclosed -spinosa et al. )**G#

The research shows that patients who underwent labral resection vs.labral 0ation had signicantly poorer clinical outcomes at a )yrfollowup. (esults indicate that the patients at ) years with labralresection reported )>K e0cellent results, 5>K good, )*K moderateand 5K poor. $hile those who underwent labral re0ation reported>*K e0cellent, 15K good, IK moderate, and *K poor @, L et al)*1*#.

Programming-0ercise prescription with a client with !A" is individuali/ed. Theemphasis should be on the 6uality of e0ercises not 6uantity. To avoid

MirritatingN the client, but most importantly, to achieve clientDs goalsand optimal tness outcomes. $orking with a client who has !A"should begin by rst understanding what type the client has.4nderstanding the pathology, surgical procedure and communicatingwith the physical therapist and rehabilitation team is fundamental.!or optimal outcomes with a client who underwent !A" surgery,consult the clientDs physical therapist with any 6uestions.



<ne of the most important variables to consider when designing atraining program is the results of the tnessCmovement assessment,age of the client, lifestyle, priorCpresent e0ercise habits and medicalhistory. These variables are important to consider when designing theprogram. 'ecause a personal trainer must consider how all of these

aect anatomical, biomechanical, physiological and neurophysiogicaldemands on the body. @eneral programming approach should focus onlengthening the tight musculature via stretching, yoga, pilates, selfstretching followed with stabili/ing the weaker phasicmusculatureglutes, hamstring and core#combined with a6ua therapy,and cardio vascular training to holistically train the client.

The individuali/ed e0ercise program should be based on the principlespreviously reviewed. "nitially, teaching single plane e0ercises, such ashori/ontal leg press progressed to inverted leg pressavoiding endrange#, leg curls and hip e0tension as e0amples. This will create a

foundation & base for more advanced e0ercises. Then progressing theclient to two plane a0is e0ercisesie. diagonal reverse lunge, diagonalforward lunge challenging the nervous system, dynamic musclerecruitment for stability while targeting the weaker sagittal stabili/ersneeded in every day movement. rogressed further to compounde0ercises such as mini s6uat with mid row, reverse lunge withoverhead medicine ball chop, forward lunge with trunk rotation withmedicine ball as e0amples.

There are several e0ercises that shoul# $e a&oi#e# based onscience. The deep s6uat at end range places e0cessive compressing

loading to the hip joint, nerve endings and connective tissue# placingpotential risk for pain. -0ercises that involved e0cessive hip :e0ionwith internal rotation or hip :e0ion with e0ternal rotation both placestress on the joint capsule, nerve endings and hip joint. lyometrics,particularly bo0 jumps, bo0 jumps with outward landrun, createse0cessive loading, compressive forces that could irritate the client. Any e0ercise that the client has pain with should also be avoided.

Training strategies"t is essential to have the client perform a comfortable cardiovascularprogram using machines such as the elliptical. $hich will provide

physiological benets to the 8L system but also assist with increasingcirculation. 9trength training should focus on weaker phasic musclessuch as; glute ma0imus, glute mediusCminimus andhamstringsO6uadriceps. The choice of e0ercise and type of e6uipmentdepends on several factors; the clientDs e0perience with e0ercise,time, body type, goals and whether or not the client had or underwentsurgery.



Figure /. e&erse lunge Figure 0. 12 (3tension to

with woo# chop 4e3ion with ca$le

9tretching should focus on tight hip :e0ors, 6uadriceps and "T' in acontrolled manner with the patient having a home program as well toperform independently of the training. 8ore stabili/ation trainingshould focus on weaker phasic e0ternal obli6ue, 6uadratus lumborumand multidi. -0ercises such as bridging with ball, standing trunkrotation with cable or medicine ball progressed to partial lunge withtrunk rotation with medicine ball is ideal. "ntegrating morechallenging e0ercises such as wood chop with reverse lunge is idealas seen in gure 5. 8ross training with yoga and pilates can not onlyimprove :e0ibility and breathing but core strength in multi directionsand progressed as appropriate. 9wimming also can serve to

compliment training due to the buoyancy principle and how rela0ing itcan feel.

=ost importantly, when working with any client, if there is uncertaintywhether an e0ercise will cause pain or damage ask a physiotherapist,their physician or do not perform the e0ercise.

Case "tu#y5#ancer A )> year old woman who worked as an engineer came to my oiceE) years ago with a referral with the diagnosisF0# of !emoral Acetabular "mpingement. After evaluating her, reviewing her history

& medical history, she told me that her P hip pain was ongoing:uctuating in discomfort to pain for the last I months without traumaor recent injuries. <ne interesting bit of information was that she wasa dancer for Fisney $orld for 17 years. 9he complained of focal deepache pain along the front of the hip, lateral to the greater trochanterand pain that went into the groin region. !rom a patient proleperspective, she was an engineer, who sat 6uite a bit but wasotherwise active, e0ercising fre6uently with cardio and weights )30



week and performed other outdoor activities. Her pain wasaggravated with jumping and twisting, prolonged sitting andmovement that internally rotated her hip with trunk rotation. 9he hadrelief with heat, water therapy and yoga that was short lived.<therwise her health was unremarkable.

9he complained of locali/ed deep ache pain typically in the groin andin the front of the hip.$as limited in hip :e0ion, adduction and e0ternal rotation, hadincreased muscle tightness in hip :e0ors, adductors, pirformis and6uadriceps. After throughouly evaluating her and mutual goal setting,the focus of my treatment was on restoring her hip mobility. 4singsoft tissueCmanual therapy addressing the shortened myofascial in her"T', glute medius, lumbopelvic girdle accompanied with having herstretch at home. " integrated using recumbent bike to assist withimproving blood :ow and enhance mobility. As her mobility improved,

joint mobili/ations were used to improve the ability of the femoralhead to glide down with both hip :e0ion and abduction. This wasfollowed with myofascial release to the piriformis and surroundingtissue. 'ecause of her e0ercise e0perience, core strengtheningcommenced with single leg bridging progressed to bridging with ball,single leg bridge with ball and bridging with ball with hamstringcurls. Then challenging her to 99 on ground to having her on Q rollthen catching a ball. 9trengthening her glutes by using therabandstanding initially was performed and progressed to diagonal reverselunges holding a medicine ball. Then progressed to forward lungeswith medicine ball twists.

After I weeks of physical therapy, she made signicant improvementsfrom when she was rst evaluated. Accomplishing O+*K of ourmutual goals, had mild ache & pain in her hip compared to themoderate to severe pain initially. !unctionally she was able to performmost functional activities and even start to perform some dancing inshort bouts that was improving each week.

"ummaryHip pain can be e0perienced by older adults, younger or even athletesrendering debilitating eects. 'ecause !A" is a pathomechanical

process due to abnormal stresses aecting the hip joint,understanding the dynamic anatomy and muscles around the hipcomple0 and their synergistic role can provide greater insight intounderstanding !A". -ective programming using periodi/ationtraining principles is fundamental. Training approaches can make adierence or can do serious damage when the e0ercise professionaldoes not have a clear MpictureN of the movement pathology,musclesCjoint involved and proper e0ercise prescription and



periodi/ation training re6uired. $orking with this type of client canbe initially challenging but embrace the challenge, and the rewardsand patient appreciation will be plentiful.

(F((NC("

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femoracetabular impingement(fai) by chris gellert, pt, mmusc & sportsphysio, mpt, cscs, ams

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