Hip Joint Pain (Femoroacetabular Impingement)
The hip can often be a trouble maker, and these types of conditions often make it into our office. They can act as low back pain or knee pain, and the hip joint is vital in our daily lives, from walking to running to going upstairs, and is an instrumental joint in rotational sports. If you have hip pain, more than likely, you might be experiencing femoroacetabular impingement or FAI. This is a long, daunting name for a condition that can be handled conservatively more times than not. In the sections below, we detail what the condition is, what we do for an assessment and our treatment options. If you would like to read more about this from an outside source, please click the link below.
What classifies Femoroacetabular Impingement?
Femoroacetabular impingement (FAI) results from an abnormal articulation between the femoral head and the pelvis or the acetabular rim. It is classified as bony or morphological changes in either the femoral head and/or the acetabular rim from either repetitive injury or degeneration of the soft tissue in the area such as the labrum and articular cartilage. This bony growth we refer to as wolf’s law, which states bone grows in response to stress due to adaption and protection. This is an excellent protective measure the body uses to protect hard tissue but can cause biomechanical restriction we want to avoid. We typically see this with males age 20-50 with painful motions of the hip being flexion, adduction, and internal rotation. This can be withstanding, walking uphill, sitting, or jumping, but also, we see this at the end of the swinging motions or the deceleration phase of both golf and tennis players. Other activities that may provoke this include getting out of a car or swimming breast-stroke. People who walk with a toe out or retroverted hips are predispositioned to this condition because they lack internal rotation of the femur and repetitively run into the joint motion barrier until pain occurs. The pain typically is dull and achy unless aggravated it could present as sharp, and these patients tend to have hip flexor tightness with reported catching or locking in the hip associated with a snapping sound with the hip in a neutral position (not extended in the case of a psoas tendon snapping noise) in internal or external rotation.
Often we notice imaging may or may not reflect the severity of the case and symptoms. Through clinical observation, larger tears in the labrum do not necessarily mean more pain, and smaller tears could be very painful. In an MRI study of hockey players, 54% found labra tears that did not alter their ability to compete at a high level. This is why it is vital to get a thorough conservative assessment and trial of care because if we see good therapeutical outcomes, surgery is not warranted. Hip surgery should be avoided if possible because of the depth and complexity of the procedure, so you should visit your local chiropractor or physical therapist for a first opinion before expensive imaging and invasive procedures. To gain a better understanding of FAI, we will go into detail of the two most common types of FAI: cam and pincer. Both may be present simultaneously, and this combined impingement is by far the most common at 72% of impingement cases.
Cam impingement is the bony growth of the femoral head and neck that decreases hip joint clearance and causes shearing motions to occur. We see this is most common with congenital conditions or secondary to conditions of a young age such as slipped capital femoral epiphysis or Legg-Calve-Perthes. This is typically seen in young males between 20 and 30 years of age after the damage has had time to cause a bony reaction and is present in 10% of impingement cases.
These impingements are seen more frequently than cam impingements at 18%. Pincer impingement we see from excessive acetabular rim cartilage pinching against a normal femur. This is seen more often in females and the third decade of life.
How we assess and treat Femoroacetabular Impingement?
We always start our exam ruling out worse pathology through history questions, orthopedic tests, and neurological tests. These, along with a movement assessment and functional tests, also give us a better idea of the entire case. Often we will find problems in multiple areas, and our job is to find the primary cause of dysfunction and pain. These types of patients might talk about knee or low back pain in the past or currently. This can seem like a domino effect, but for someone with primarily FAI, we can work on the hip, and other reactionary pain can subside.
Another common problem with FAI is tight bands in the muscles around the hip, thigh, and low back called trigger points. Trigger points are our body’s way of protecting an area with poor function. In other words, they are a good thing in a poor functioning system. So through muscle work, chiropractic manipulation, and corrective exercise, we can not only relieve these tight bands but can help you move better to keep the symptoms from recurring. Examples of soft tissue we will often work on in these cases are groin muscles such as adductors and pectineus, along with those tight hip flexors we discussed before, such as the psoas.
Adjustments are also crucial to this area to help gap the hip joint and allow space in movements that would have been painful prior. Adjustments to this area, particularly anterior to posterior sheer, long axis distraction, and circumduction, often do not have a large popping sensation, depending on the adjustment, but are highly effective. If someone cannot tolerate an adjustment, we choose to help this area's mobility through various mobilization techniques.
Our Three-Step Approach
As described above in our treatments, we will be using a triage of techniques to help you get out of pain, stay out of pain, and return to your activity
1) Get out of pain
2) Build resiliency
3) Return to sport/activity
These steps are similar in many conditions because we have to put out the fire, keep the fire out, and build a strong foundation for day-to-day life, so it does not come back. Since this can be more structural, it would do you a disservice to not talk about how important consistency of care is. People with possible structural hip pain, if not carefully monitored, will have a high likelihood of recurrence. This is why we have the 3 steps.
This first step is to help you break the cycle of nagging pain. This includes soft tissue work like Active Release Technique and Graston, adjustments, and lifestyle modifications or movement medicine if pain returns or to keep the pain away.
The second step is to build tissue tolerance after we break this cycle of pain. This will be continued treatment typically alongside exercises promoting motion in limited ranges of movement addressed in the assessment.
The final step will help you get back onto the golf course or whatever sport you do, or help you live life with fewer limits from your hip pain. This could include sports/life specific exercise targeting the longevity of your hip and/or a Titleist Performance Institute assessment to improve your golf game. Either way, we want to see you living your best life and are here to be an advocate for your health.
Frequently Asked Questions (FAQ)
Will my hip pain cause degeneration?
It depends on the individual case. With proper care and resolving painful movements, we can be pretty optimistic that it will not. In the following study, 82% of FAI cases did not develop degeneration, so the correlation is low between the two. In our office, we monitor functional and pain baselines that provide us with a more accurate understanding of your hip pain. https://pubmed.ncbi.nlm.nih.gov/21511921/
What should I do before exercise to prevent this pain?
The short answer is gradual movement preparation. Static stretches, although we recommend you do stretch and there are health benefits to holding a stretch, do not reduce your likelihood of injury. So the answer is we have to move all the joints utilized in the activity. This could be active leg swings, lunge with reaching overhead and across the body, or anything to blood flow around the joints and muscles of the body. https://bjsm.bmj.com/content/48/11/871.long
Should I continue the activity that caused the pain in the first place?
The answer a lot of health care professionals want to give patients is to stop the activity that caused the pain. This comes down to a couple of follow-up questions, is that activity safe in general and does that activity bring you closer to your goals? We want to be the first ones to tell you, “yes.” Yes to continuing running or playing golf or picking up your grandchildren. We just may need to modify the activity if your mechanics need improvement but eventually, we want you to get back to what you love doing as safely as possible. It is important to get a full evaluation before continuing the activity and to listen to what your body is telling you. We focus heavily on injury resistance measures with our patients to help them get better and stay better. If you are dealing with any hip problem, we encourage you to call our office and schedule a new patient exam. Our doctors will provide you with the best conservative treatment options for your condition and goals