Femoral Acetabular Impingement Sydrome Case Study

FAIs Case study

 

Triad of symptoms (Warrick agrreemenet)

• Symptoms / Hip and Groin Pain
• Imaging / +ive (Morphology) Soft tissue / labral
• Signs – Impingement tests – see below
• Physical impairments – poor performance functional tests. Reduced ROM Reduced MP

 

Clinical Presentation

• Female runner
• 34 year old 
• Gradual Onset of groin pain over 2 years
• Anterior thigh / into buttock
• High irritability 
• Gradually getting worse
• ℅ Clicking
• Low back Pain

 

Aggravating activities

• Painful on change of direction, stairs. 
• Limping
• Unable to sit for >20 mins
• Flexion based activities
• In and out of a seat / chair or car
• Yoga poses

 

Easing

• NSAIDs and paracetamol (not helping much)
• Rest (reluctant)

 

Medical History 

• Nil to note
• FH – Nil
• PMH – Nil

 

Physiotherapy and Medical Management

?Onward Referral for diagnosis if required 

• MRI of the hip

• Analgesia

• Rest and offload (activity management) based on functional capacity.
• Address muscular low back pain
• Expectations management and goal setting

• Address Muscular imbalances – long Iliopsoas muscle – likely weak (resisted hip flexion)
• Pain on Thomas test – 
• Pain management – STM, TPr
• Postural education – not to hyperextend hips (women)
• Trunk (abdominal and gluteal) strengthening/Endurance

• Education – avoiding prolonged sitting, cycling, rowing, excessive hip adduction and flexion.
• Load Management 
• Rehabilitation – balance / proprioception, sporting technique and movement quality

 

Rehabilitation

• Phased return package
• Sensitive / irritable don’t poke the bear. Avoid positions that are irritable for the time being. 
• Squat difficulty

 i Get them squatting in a pain free way. 

ii Hip ABd / ER / Use a gym ball. 

iii Add load via Trap bar. Minimal pain squatting. 

• Specific exercise plan based on function. Recreate positions based on function. 
• Maintain comprehensive strength through a gym based programme. Quads, Hams, Lx spine. Stay strong. Offload from painful positions. 
• Pseudo giving way – body’s protective mechanism – perhaps not tolerable through range. Slowly move to an uncomfortable position as it starts to feel better. Use pain tolerance as a guide. If you can stay strong through movement – good sign. 
• Depth
• Sets and Reps
• Speed is a component of a force. Move quickly at a higher velocity creates higher force. Mass x Acceleration. 
• Timeline – back to sport within 6 weeks of initial clinic. 

 

Exercises

 

• 4 Point Kneeling – Hip Extension 

– Watch points good pelvic alignment, neutral lumbar spine, scapulae stability. +/_ resistance bands through Hip Extension

• Glute bridge – Turn out foot position, mindful not to push through into hip extension, Use of theraband into abduction +/- step +/- Single Leg
• Single leg control, Single leg with KB +/- TRX, +/- Bosu
• Double leg squat, Hip abduction, Foot in turnout, +/- theraband into abduction +/- weighted squat i.e Goblet +/- Bosu

• Bulgarian Split squat for eccentric Psoas, stretch and front leg glute / hip control +/- weighted squat i.e Goblet +/- Bosu

 

Watch out for Red Flags

• Adolescent (perthes, slipped capital femoral epiphysis) Low Threshold for referral / additional imaging. 
• Middle Aged 40 – 60 (possible underlying) OA 
• >6/12 history of chronic groin pain (likely hip pain source)
• Female runners – stress fracture femoral neck (Compression, Displaced, Tension)
• Previous history of Ca 
• Night pain
• Trauma – post traumatic OA
• Perthes/Childhood hip disease – increased likelihood to develop OA 
• Family history 
• Early OA/ THR

 

Screening test

FlexionAdd and IR (Impingement test) Not be negative

FABER

Both good at ruling out

 

Hip related Groin Pain (Non Red Flag)

• FAIS
• Labrum
• Chondral (AM stiffness)

 

OA

• Early AM stiffness for a few mins (CAM, OA) 

More than 10mins consider RA, AS, Inflammatory conditions – better with NSAIDs

• Groin Pain, Anterior Thigh, lateral hip, buttock pain, lumbar spine pain. 
• Ache, decreased ROM through IR<15degrees – effects SIJ and Lumbar spine mechanics.

 

FAI

• AGG – Sitting 
• Hip Flexion – long periods 20-30mins
• No response to NSAIDs
• High Irritability
• Increased flare ups (labral pathologies)
• Intensity of groin pain (high)
• Spectrum of FAI – Labral, Bone marrow oedema, chondral oedema. 

 

Acute Labral 

• Clicking, catching
• High level of pain
• Sharp as well as an underlying dullness
• Night pain
• Easy to flare up – long rehab

 

• Early OA 30-55
• hip impingement
• labrum
• hip dysplasia 
• EOR pain Abd/ IR
• Post natal – hormonal changes, loss of dynamic stability
• Simple XR to diagnose between OA and dysplasia

 

Morphology

• Pincer – Extra bone on the Acetabulum is deeper, over coverage 
• Cam – Convex shape of Head Neck Jnct 60% / Extra bone on the femur / common in athletic loading / youth / Femoral growth plate is open. Twisting turning, Axial loading (Football / American f’ball) 
• Combined – Mixed deeper acetabulum / +extra bone on the Femur
• Clicking, locking, catching, giving way and pain on twisting may suggest a presence of labral or chondral pathology.