In an eariler article on Femoral Acetabular Impingement (FAI), we reviewed the pathomechanics of the hip, pathophysiology of FAI and the typical clinical presentation. The purpose of this installment is to examine treatment options, and most importantly, training strategies to prevent FAI with your client.
Despite the causes of FAI, one thing is certain: per the research, many causes may also be missed because the pathology appears to be absent in the frontal/coronal plane. Magnetic resonance imaging is being more readily used because it provides a quantifiable assessment of the deformity.
Treatment options Like most pathologies, conservative care is the most logic approach to be tried initially. With FAI, it is logical for physicians to advise activity modification, to avoid the extremes of range of motion and a trial of non-steroidal anti-inflammatory (NSAID) medication.
Physiotherapy is also recommended to improve passive range of motion, joint mobility and function of the hip. If conservative treatment is ineffective, Surgery is always an option, however, has shown mixed results of success.4
When it comes to intraarticular hip injuries in athletes, these can cause significant functional problems ultimately career ending. Arthroscopy enables direct observation of the joint and thus enhances diagnostic specificity. Arthroscopy of the hip has lagged behind that of the other joints, probably because of its technical challenges and previously perceived difficulties. However, the technique is becoming increasingly adopted and is now regarded as an accepted or ‘gold standard’ of care.1
The aim of surgery is to improve the clearance for hip movement and to alleviate the abutment of the proximal femur against the acetabular rim. Both open and arthroscopic techniques have been described. For either technique, it is important to address both the damage to the labrum and the underlying cause.
In the open procedure, the aim is to recreate the normal concave contour of the femoral neck by sequential osteotomies of small sleeves of bone from the femoral head-neck junction.
The arthoscopic technique involves using a burr to resect the injured structure and debris where both an anterolateral and anterior portals are used for a clear assessment of the hip.2 The surgical approach used is dependent on several factors such as degree of structural injury, age, and intended functional outcome.
Training is going to depend upon whether or not the client has had surgery, but more likely, had a history of the symptoms above that was greatly improved with physiotherapy. It is essential to have the client performing a comfortable cardiovascular program such as elliptical that will provide not only aerobic training but assist with lengthening tight Iliopsoas complex. Strength training should focus on weak phasic muscles; glute maximus, glute medius/minimus as seen in Figures 1 and 2.
|Figure 1. Reverse lunge with wood chop||Figure 2. D1 extension to flexion with cable|
Stretching should focus on tight hip flexors, quadriceps and ITB in a controlled manner with the patient having a home program as well to perform independently of the training. Core stabilization training should focus on weaker phasic external oblique, quadratus lumborum and multifidi.
Most importantly, when working with any client, if there is uncertainty whether an exercise will cause pain or damage ask a physiotherapist, their physician or do not perform the exercise.
The best prevention is education. Cam impingement is caused by deformity of the proximal femur or femoral head. Impingement occurs during flexion as an aspherical femoral head with increasing radius is rotated into the acetabulum, placing undue stress on the anterosuperior acetabular rim. Any deformity of the proximal femur resulting in femoral retroversion or decreased head- neck offset can result in cam impingement, including pure asphericity of the femoral head, decreased femoral head-neck ratio, retroversion of the femoral neck due to a malunited fracture, Legg-Calvé-Perthes disease, or slipped capital femoral epiphysis. Pincer impingement results from local or global overcoverage of the femoral head by the acetabulum. The forces are transmitted through the labrum and to the underlying cartilage along the acetabular rim, resulting in a narrow band of damage extending around the lip of the acetabulum.
Thus, the primary pathologic mechanism is labral injury with secondary cartilage damage.3 In addition to education, keeping the postural(tight) muscles such as the hip flexors, quadriceps and ITB flexible is ideal. Shortened quadriceps, hip flexors and ITB creates adduction/internal rotation(IR) syndrome as described by Sahrman.5 This places the femur in a closed pack position increasing compressive forces and loading to the anterior(front) structures of the hip. Stretching the hip flexors and quadriceps and strengthening the weaker hip extensors, hamstrings will biomechanically decrease the load to the front of the hip.
Femoral acetabular Impingement(FAI) is a new dysfunction that a personal trainer should have a basic understanding about. With understanding the anatomy and muscles around the hip complex and how it moves similar to the shoulder, the trainer can now appreciate that dysfunctions and possibly prevented.
Training approaches can make a difference and also do serious damage when the exercise professional does not have a clear “picture” of the movement dysfunction/pathology, muscles/joint involved and proper exercise prescription and periodization training based on science.
Working with this type of client can be initially challenging or a bit challenging, but embrace the challenge, and the rewards and patient appreciation will be plentiful.
1. Keogh, M & Batt, M 2008, ‘A Review of Femoroacetabular Impingement in Athletes’, Journal of Sports Medicine, Vol. 38, No. 10, pp. 863-878.
2. Crawford, R, Villar, R.N. 2005, ‘Current concepts in the management of femoroacetabular impingement’, The Journal of Bone & Joint Surgery, Vol. 87, No. 1, pp. 1459-1462.
3. Yuan, BS, Sierra, R & Trousdale, R 2008, ‘Femoral-Acetabular Impingement,’ Journal of Orthopedics, Vol.31, No. 9, pp. 890-892.
4. Hossain. M. et al. 2008, ‘Current management of femoro-acetabular impingement.’ Current Orthopaedics, Vol. 22, pp: 300-310.
5. Sahrman, S, 2011, ‘Movement Impairment Syndromes of the Extremities, Cervical and Thoracic Spines, Elsevier Mosby, St. Louis, p. 365.
About the Author
Chris Gellert, PT, MPT, CSCS, CPT Biography Chris is the President of Pinnacle Training & Consulting Systems, LLC. A consulting and education company that is committed to create and provide evidenced based educational material in the form of home study courses, dynamic live seminars, mini-books, DVD’s and other electronic media that educates personal trainers taking their knowledge and training to another level. Chris has extensive clinical experience having worked with primarily orthopedic patients, spinal injuries, post-surgical conditions, traumatic and sport specific injuries. As both an experienced physical therapist and certified personal trainer, a national fitness presenter at the following conferences;(Club Industry, ECA, IDEA, IHRSA, NSCA, TSI Summit), he continues to write for various publications and websites, consults and is presently pursuing Postgraduate studies in Physical Therapy & Clinical Reasoning in Australia completing at end of 2011.