femoral acetabular impingement(fai) by chris gellert, pt, mmusc & sportsphysio, mpt, cscs, ams

8/10/2019 Femoral Acetabular Impingement(FAI) by Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS

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FAI: The New ImpingementTraining options to help yourclient

By Chris Gellert, PT, usc ! "portsphysio, PT, C"C", A"

Intro#uction

Hip pain has been typically perceived in older adults, however, can bepresent in young adults or even athletes. A new dysfunction of the hiphas been talked about recently in the medical eld and in varioushealth & tness journals. This is femoral acetabularimpingement!A"#. $hat is !A"% !emoral acetabular impingement isnot necessarily a disease but rather a pathomechanical process inwhich abnormal contact stresses can cause potential joint damagearound the hipeunig, 'eaule, & (einhold )**+#. This article willreview the background on !A", clinical presentation & pathology, thetypes of !A" andthe medical and physical therapy treatment approach. rovide the

latest evidenced based research about how !A" can lead to labralpathologies, while reviewing conservative vs. surgical interventions.-ective programming will be discussed using periodi/ation trainingprinciples guiding the personal trainer to utili/e the most eectivetraining strategies and e0ercises.

Clinical presentation ! Pathology1omeone who is suering from !A" is fre2uently aggravated byathletic activities and movements that re2uire e0cessive hip 3e0ion,or prolonged walking, pivoting on the aected side, prolonged sittingor driving. 4ommon symptoms include5 locali/ed deep ache pain

typically in the groin and in the front of the hip. 6ccasionally pain canalso be referred to the outside of hip, buttock and thigh area.7echanical symptoms from the hip such as painful locking or givingway are common presenting feature if a labral tear ispresentHossain. 7. et al. )**8#.!emoroacetabular impingement!A"# is a pathologic process caused by abnormality of the shape ofthe acetabulum, the femoral head, or both, predisposing to thedevelopment of osteoarthritis and labral degeneration.

$ow FAI #e%elops an# contri&uting ris' (actorsThere are many theories on the cause of how an individual

develops !A". 6ne proposed theory is that during development, theremay be structural abnormalities of the hip such as hip dysplasia.$hich is where the femur becomes dislocated. hysicalstressestrauma# such as a femoral neck fracture is seen commonly inactive middle aged adults, specically males in such sports as hockey,tennis and soccer.9ones et al. )*::#. ;enetics has been e0amined anddiscussed as potential factoreunig, 'eaule, & (einhold )**+#. 6nethings is certain. The research indicates that !A" occurs when there is


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an abnormality of the femoral head with respect to the congruency tothe acetabulum.

!A" causes hip pain and develops over time. (epeated ande0cessive hip 3e0ion and internal rotation places ma0imal contactbetween the anterosuperior femoral head


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Figure 1. Anterior hip complex Figure 2. Posterior HipComplex

Comparison o( two types o( FAI: Pincer an# Cam Impingement"mpingement at the hip can occur with e0tremes of movement, lack ofmovementmobility# or as a result of a combination of both. Thecontributing factors previously described provide a deeperunderstanding of !A" and the two types of !A" "mpingement.

There are two dierent types of impingementD pincer and camimpingement.incer impingement occurs from a bony prominence ofthe front of the acetabulum placing e0cessive pressure from thelabrum against the neck of the femur. Thus impacting one?s range ofmotion leading to pain.incer lesions are more common seen in

middle


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the ball of the hip joint from the thigh bone#. Trauma such as femoralneck fractures and chondral lesions especially in the acetabulum canplay a role'anjaree & 7clean )*::#.

Figure *+ Cam an# Pincer Impingement

e#ical an# Physical Therapy Treatment Approach4onservative management is initially recommended for mostindividuals with modication of activities, avoiding e0cessive hipmovement and taking nonathlete, this will continually stress internal structures suchas the capsules, supporting ligaments and connective tissue. Thisrepetitive stress activates the pain bers within the joint anddependent on the pain threshold of the patient, physical conditioning,body type, muscle balances, pain can be acute or insidious in nature.

-0cessive hip 3e0ion with e0ternal rotation or e0cessive hip 3e0ionwith internal rotation of the hip places e0cessive compression andtorsional forces on the hip, particular the labrum. This is seen indancers and other sports. astly, muscle imbalancestightness#particularly in the hip 3e0ors, adductors, piriformis, 2uadriceps and"T', all contribute to compressive loading of the hip joint,predisposing it further to mechanical stress. 6nce pain as mentioned


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previously aects daily activities, ability to play sport, a person hastwo choices. 4onservative treatment begins with physical therapy. Thechoice is based on the patient and physician, however, the literaturehas show that conservative management can be very eective.

"f surgery is re2uired, the most common procedure is hip arthoscopy.Here, the surgical process begins visuali/ing the hip while the patientis positioned supine with traction applied, and F standard portalsproviding the surgeon with a deeper view of the underlyingabnormalities. The underlying hip joint is debrided and involvesreshaping the head of the femur. After being bone has been reshapedto recreate the normal concave relationship at the junction of thearticular surface, this eliminates the cam or pincer lesion.

Postoperative Rehabilitation for Arthoscopy(eshaping of the femoral head>neck junction necessitates some

precautions. The patient is allowed to bear full weight, but crutchesare used to during the rst B weeks. !ull bony remodeling takes Fmonths, during which time some precautions are necessary to avoidhigh


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shaped manner e0posing the femoral head. Titanium anchors areplaced from the labrum into the acetabulum. Gon


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client to two plane a0is e0ercisesie. diagonal reverse lunge, diagonalforward lunge challenging the nervous system, dynamic musclerecruitment for stability while targeting the weaker sagittal stabili/ersneeded in every day movement. rogressed further to compounde0ercises such as mini s2uat with mid row, reverse lunge with

overhead medicine ball chop, forward lunge with trunk rotation withmedicine ball as e0amples.

There are several e0ercises that shoul# &e a%oi#e#based onscience. The deep s2uat at end range places e0cessive compressingloading to the hip joint, nerve endings and connective tissue# placingpotential risk for pain. -0ercises that involved e0cessive hip 3e0ionwith internal rotation or hip 3e0ion with e0ternal rotation both placestress on the joint capsule, nerve endings and hip joint. lyometrics,particularly bo0 jumps, bo0 jumps with outward land


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perform independently of the training. 4ore stabili/ation trainingshould focus on weaker phasic e0ternal obli2ue, 2uadratus lumborumand multidi. -0ercises such as bridging with ball, standing trunkrotation with cable or medicine ball progressed to partial lunge withtrunk rotation with medicine ball is ideal. "ntegrating more

challenging e0ercises such as wood chop with reverse lunge is idealas seen in gure B. 4ross training with yoga and pilates can not onlyimprove 3e0ibility and breathing but core strength in multi directionsand progressed as appropriate. 1wimming also can serve tocompliment training due to the buoyancy principle and how rela0ing itcan feel.

7ost importantly, when working with any client, if there is uncertaintywhether an e0ercise will cause pain or damage ask a physiotherapist,their physician or do not perform the e0ercise.

Case "tu#y3#ancerA )8 year old woman who worked as an engineer came to my oice@) years ago with a referral with the diagnosis0# of !emoralAcetabular "mpingement. After evaluating her, reviewing her history& medical history, she told me that her P hip pain was ongoing3uctuating in discomfort to pain for the last months without traumaor recent injuries. 6ne interesting bit of information was that she wasa dancer for isney $orld for :C years. 1he complained of focal deepache pain along the front of the hip, lateral to the greater trochanterand pain that went into the groin region. !rom a patient proleperspective, she was an engineer, who sat 2uite a bit but was

otherwise active, e0ercising fre2uently with cardio and weights )manual therapy addressing the shortened myofascial in her"T', glute medius, lumbo


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followed with myofascial release to the piriformis and surroundingtissue. 'ecause of her e0ercise e0perience, core strengtheningcommenced with single leg bridging progressed to bridging with ball,single leg bridge with ball and bridging with ball with hamstringcurls. Then challenging her to 11 on ground to having her on Q roll

then catching a ball. 1trengthening her glutes by using therabandstanding initially was performed and progressed to diagonal reverselunges holding a medicine ball. Then progressed to forward lungeswith medicine ball twists.

After weeks of physical therapy, she made signicant improvementsfrom when she was rst evaluated. Accomplishing O+*J of ourmutual goals, had mild ache & pain in her hip compared to themoderate to severe pain initially. !unctionally she was able to performmost functional activities and even start to perform some dancing inshort bouts that was improving each week.

"ummaryHip pain can be e0perienced by older adults, younger or even athletesrendering debilitating eects. 'ecause !A" is a pathomechanicalprocess due to abnormal stresses aecting the hip joint,understanding the dynamic anatomy and muscles around the hipcomple0 and their synergistic role can provide greater insight intounderstanding !A". -ective programming using periodi/ationtraining principles is fundamental. Training approaches can make adierence or can do serious damage when the e0ercise professionaldoes not have a clear LpictureM of the movement pathology,

muscles>joint involved and proper e0ercise prescription andperiodi/ation training re2uired. $orking with this type of client canbe initially challenging but embrace the challenge, and the rewardsand patient appreciation will be plentiful.


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a review of diagnosis and 7anagement? Current Reviews inMusculoskeletal Medicine,vol. B, no. :, pp. ))


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0#4.

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femoral acetabular impingement(fai) by chris gellert, pt, mmusc & sportsphysio, mpt, cscs, ams

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