There is rise in hip pain in the general population but especially the athletic population. One of the biggest causes of hip pain is Femoral Acetabular Impingement (FAI). There are two main anatomical causes of FAI Cam impingement and Pincer impingement.
Patients who have impingement syndrome are likely to have one of the two above conditions that predisposed them to a hip labral injury.
Sports or activities that were thought to increase or predispose athletes to hip injuries were sports where there is increased hip flexion. However we are now seeing these same injuries in sports where there is increased hip extension and hip circumduction. It is now thought that if there is repetitive movement at the hip joint it can cause stress and injury to the labrum.
Presentation of hip impingement is commonly being seen in younger and younger populations. Agricola 2014, Cordelia 2014, Li 2015, DeSilva 2016 all describe anterior hip pain in athletes as young as 10-12 years old. These athletes complain of hip pain that increases commonly with hip flexion and often describe the pain as a pinching, catching discomfort. Some present with tightness along the hip flexor or upper quadriceps. Research supports (Reiman 2014,Tijssen 2016, Agricola 2014) two basic test Impingement test: hip flexion to 90 degrees and internal rotation, and FADIR: hip flexion internal rotation and adduction. If the athlete has anterior hip pain or pinching it is a positive test. Combining these two test with FABERE test; along with restricted internal rotation and hip flexion has shown increased sensitivity and specificity for hip impingement.
Research has started looking at why Cam and Pincer impingements occur. Cam impingement is being seen in a younger population, and causation is thought to be an over use stress reaction. It is occurring at or near the femoral physis in 12-14 year old females and 13-15 year old males (Agricola 2014, Cordelia 2014). One of the indicators of Cam deformity beginning in the younger population, in the above studies, is decreased internal rotation. This phenomenon has a higher incidence in males but is also now being seen intraoperatively in females 88% of the time. (Nepple 2014, Duncan 2014)
Pincer impingement has been described as a bony acetabular retroversion or over coverage of the femoral head by radiologist. Currently (Ross 2014, 2015, Cibulka 2014, Musielak 2016) has shown acetabular orientation and position changes with anterior and posterior pelvic tilt. Sacroiliac dysfunction changes the innominate position and is creating a functional acetabular over coverage of the femoral head impinging upon the hip.
Treatment of impingement syndrome is being focused on functional restoration of the pelvis in order to normalize the pelvic position/rotation. Once normal functional Sacroiliac movement has been restored the next step is stabilizing the new pelvic neutral position. Ilium position and the ability to maintain control of it while standing, running, squatting etc… mechanically will take pressure off the potential abutment of the femur on the acetabulum.
Hopefully, this information will help practitioners to take a closer look at hip complaints in our patients especially the younger athletes. Understanding the possible causes and biomechanics of this type of injury should help practitioners design a rehabilitation program. If the program is built around stabilization of the pelvis and ilium, then the hip strengthening exercises will be more effective.
FAI is growing very quickly in the younger population we need to identify these injuries earlier before they progress.
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