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Femoral Acetabular Impingement and Labral Tears

///Femoral Acetabular Impingement and Labral Tears
Femoral Acetabular Impingement and Labral Tears2019-08-26T14:06:24-05:00

Problem:

The mechanical abutment of the femoral head against the acetabulum is known as Femoral Acetabular Impingement (FAI). With this contact comes pain, loss of motion and disability. It can be either structural (cam or pincer lesion) or functional or sometimes a combination of the two.femoral-acetabular-2-web

Whether these x-rays show normal morphological changes based on autonomy and biomechanics or a structural pathology, researchers are not certain. Structural changes can be seen in asymptomatic patients. There are no controlled trials proving that these lead to early OA or the need for hip surgery.

Authors conducted a study of more than 2000 asymptomatic hips. They saw labral bone changes in 68% of patients and FAI bone changes in 67% of patients. They found that the prevalence of pathology with FAI was higher in asymptomatic athletes. With age, the pathology in asymptomatic hips increases.

Between 1999 and 2009, the number of surgeries increased 18 fold. There has been a 365% jump in surgery between 2004 and 2009 in individuals between the ages of 20 and 39, alone. Authors attribute this increase in surgeries, in part, to the fact that there has been an increase in the usage of MRIs in this population.

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Interventions:

femoral-acetabular-3-webPatients with anterior hip and groin pain from labral tears or FAI will start treatment with conservative methods. This could include activity modification, manual therapy (joint mobilization and manipulation, soft tissue mobilization and dry needling), education, self hip mobilizations and exercise (stretching, strengthening, balance and motor control) treatments.

In order to improve decision making for possible surgical referral, experts recommend a course of conservative care for approximately 8-12 weeks beforehand. A negative response to an injection predicts a negative outcome more than a positive response predicts a positive outcome following surgery, Ayeri et al. showed.

Evidence:

Currently, the evidence for the conservative treatment of FAI lesions is at the case series level of research for both conservative and the surgical treatments. No randomized controlled trials nor long term data exist on the surgical outcomes.

femoral-acetabular-4-web   femoral-acetabular-5-web   femoral-acetabular-6-web

For patients undergoing FAI surgery with greater chondral damage and those over the age of 40, Kemp et al. documented poor outcomes. Hunt et al. showed that a multimodal treatment program made up of manual therapy, education and exercise reduced the lower quarter impairments. It also improved function in both short and long term outcomes. 

Athletes and patients diagnosed with labral tears or FAI can return to sport following their treatment plan consisting of manual therapy, exercise, biomechanics evaluation modifications and education.

Refer:

Patients and athletes with groin pain, anterior hip pain, loss of hip range of motion and disability should consult the care of a Physical Therapist for conservative management. An acetabular labral tear may be diagnosed where there is pain mainly in the groin (sensitivity .96-1.0) and a subjective report of hip or groin pain with a clicking sound, locking and giving way (sensitivity 1.0, specificity .85).

References

  1. Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003(417):112–20.
  2. Collins JA, Ward JP, Youm T. Is prophylactic surgery for femoroacetabular impingement indicated? A systematic review. Am J Sports Med 2014;42:3009–15.
  3. Reiman, M. Femoracetabular Impingement Surgery: Are we moving too fast and too far beyond the evidence? Br J Sp Med. 2015. 0:1-6.
  4. Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy 2013;29:661–5.
  5. Frank, J. et al. Prevalence of FAI imaging findings in asymptomatic volunteers. A systematic review. Arthroscopy. 2015:1-6.
  6. Nardo, L. et al. FAI: Prevalent and Often Asymptomatic in Older Men: The Osteoporotic in Men Study. Clin Orthop Relat Res. 2015
  7. Hunt D, Prather H, Harris Hayes M, et al. Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders. Pm R 2012;4:479–87.
  8. Ayeni OR, Farrokhyar F, Crouch S, et al. Pre-operative intra-articular hip injection as a predictor of short-term outcome following arthroscopic management of femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc 2014;22:801–5.
  9. Kemp JL, Collins NJ, Makdissi M, et al. Hip arthroscopy for intra-articular pathology: a systematic review of outcomes with and without femoral osteoplasty. Br J Sports Med 2012;46:632–43.
  10. Keeney JA, Peelle MW, Jackson J, et al. Magnetic resonance arthrography versus arthroscopy in the evaluation of articular hip pathology. Clin Orthop Relat Res 58 2004;429:163–9.
  11. Burnett RS, Della Rocca GJ, Prather H, et al. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am 2006;88:1448–57.