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International Journal of Osteopathic Medicine (2012) 15, 22e27

www.elsevier.com/ijos

REVIEW

Anterior hip pain e Have you considered


femoroacetabular impingement?
J.K. Chakraverty a,*, N.J. Snelling b
a
b

Department of Radiology, University Hospital of Wales, Cardiff, UK


Department of Emergency Medicine, Royal United Hospital, Bath, UK

Received 28 May 2011; revised 21 September 2011; accepted 23 September 2011

KEYWORDS
Hip;
Impingement;
Femoroacetabular;
Osteopathy

Anterior hip pain is a frequent presentation in both primary care and


musculoskeletal practice. Common diagnoses of anterior hip pain include iliopsoas
tendinopathy and bursitis, snapping hip syndrome, osteoarthritis of the hip and
sacro-iliac joint dysfunction or spinal referred pain. More potentially serious conditions including inguinal hernias, avascular necrosis of the femoral head and psoas
abcess all need to be considered.
One cause of anterior hip pain is femoroacetabular impingement (FAI). Here
follows a short review of the typical clinical presentations, imaging features and
management options of FAI. The possible role of osteopathy in the management
of this condition will also be briefly discussed.
2011 Elsevier Ltd. All rights reserved.

Abstract

Introduction
Femoroacetabular impingement (FAI) is recognized
as an important cause of premature osteoarthritis
of the hip in the young population.1e5 There are
a number of clinical examination and imaging
findings established in the literature that can help
in the diagnosis of FAI. The natural course of the
disease is still largely unknown, but early diagnosis
and appropriate surgery has been shown to reduce
* Corresponding author. Tel.: 44 117 9247317.
E-mail
address:
jchakraverty@doctors.org.uk
Chakraverty).

(J.K.

symptoms and improve function at least in the


short term.6,7 Early surgical intervention is also
believed to reduce the risk of significant degenerative changes in later life. There are two types
of FAI (Fig. 1); cam and pincer, although mixed
types do exist.8 In the cam lesion (the femoral
component of FAI) there is a decrease in the
normal waist and asphericity at the femoral head neck junction. The pincer lesion (the acetabular
component of FAI) results from focal or generalized over-coverage of the acetabulum. These
variances are thought to predispose to early and
repetitive pathological contact between the
femoral head and the acetabular labral and

1746-0689/$ - see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijosm.2011.09.003

Anterior hip pain e Have you considered femoroacetabular impingement?

THE CAM LESION

THE PINCER
LESION

Asphericity at the
femoral head-neck

Figure 1

23

Focal or general
over-coverage of
the acetabulum

The 2 types of FAI e the cam and pincer lesion.

articular surfaces during movement of the hip


joint. It is proposed that labral and articular
surface damage that results from this repetitive
contact predisposes the individual to the early
development of osteoarthritis. Osteopaths may be
the first port of call for young patients who present
with hip pain that is associated with FAI.

reproduces pain when the extended hip is forced


into external rotation. Although described in
other hip disorders, in some cases the hip on
initiation of flexion may swing into external
rotation. This is termed the Drehmann sign.11

Imaging features
Clinical presentation
The clinical presentation is variable. The condition affects the young to middle-aged and has
a rather insidious presentation but may develop
more abruptly following trauma. FAI appears to
have a propensity to individuals who have sporty
and active lifestyles.9 Groin pain appears to be
the most common site of presentation, but as
with other disorders of the hip, pain may be
referred to the low back, buttock or knee.9
Typically, affected individuals are aware of
limited mobility of the hip before symptoms
begin.1 Restricted movements of the hip, particularly in flexion, internal rotation and adduction
and a positive Trendelenberg sign may all be elicited.10 Specific tests for FAI, with high degrees
of sensitivity and specificity have been
described.2 A positive Impingement Sign marks
the presence of anterior FAI; in this test, pain in
the groin is reproduced when the hip is forced
into internal rotation in 90 of flexion. A Posterior Impingement Sign on the other hand,

A number of radiographic parameters associated


with FAI have been described. Standard anteroposterior radiographs and cross table lateral
views of the proximal femur will uncover many of
the morphological factors associated with cam and
pincer FAI (Figs. 2 and 3). Quantitative radiographic analysis is frequently undertaken by radiologists to assess the degree of asphericity of the
femoral head-neck junction (Fig. 4) and coverage
of the acetabular cup. As expected, advanced
cases will show the typical signs of osteoarthritis
(loss of joint space, sub-chondral sclerosis, subchondral cysts and osteophyte formation). MRI
with injection of contrast into the joint (MR
arthrography) and its multi-planar capability
provides the gold standard of imaging in FAI and
demonstrates not only the morphological abnormalities that are present, but also subtleties
including labral degeneration and tears and
hyaline cartilage ulceration (Fig. 5). Precise detail
of these radiological features is beyond the scope
of this paper and the reader is encouraged to refer
to the excellent paper by Tannast et al.1

24

J.K. Chakraverty, N.J. Snelling

Figure 2 Pistol Grip Deformity (PGD). Schematic (left) and radiographic (right) representations of (a) normal hip and
(b) PGD. The PGD is associated with cam FAI. Note the decreased concavity and osseous bump at the head-neck
junction. This is believed to result from abnormal extension of horizontally oriented femoral epiphysis (arrows in (b)).

Management
Osteopathic
To our knowledge, there are no published trials in
the literature regarding the osteopathic treatment
of FAI.
The main difficulty with assessing clinical efficacy is that many patients will be treated with
anterior hip pain that have not had imaging, and it
is therefore difficult to establish the presence or
absence of morphological parameters associated
with FAI. It may well be that many patients with
anterior hip pain who do not improve might have
radiographic features of FAI, or conversely that
osteopaths are successfully treating many of these
patients despite radiographic changes. As with all
radiographic findings, it is always important to
take these within the context of the clinical
picture. Studies of the spines of normal individuals
have found MRI abnormalities in the asymptomatic
population, and it is quite likely that some of the
above described changes can also be found in
asymptomatic individuals. These changes should
be considered more as predisposing factors. This is
echoed by Palmer12 who comments in his paper
that Imaging abnormalities alone are not sufficient. Clinical symptoms and signs are essential to
the diagnosis of FAI.
The osteopath might approach the patient from
two viewpoints, the first being for symptom
control, and the second being for prevention of
recurrence. Symptom control would be much the
same as for any inflamed or irritated tissue, and
will not be discussed here.
Prevention of recurrence is likely to be the more
challenging of the two. Some of the difficulties
come down to achieving a diagnosis, of which

there are a number of potential diagnoses as


mentioned in the introduction. A common theme
amongst osteopaths, physiotherapists and chiropractors would be to attempt to identify the
tissues causing the pain, and to attempt to offload
these tissues by altering biomechanics through
passive mobilization, joint distraction and
stretching techniques, as well as active muscle
strengthening approaches. With the attendant
morphological parameters that are present in both
forms of FAI, it is of the authors opinion that
strong
flexing
mobilization
(articulatory)
manoeuvres to the hip joint may only serve to
exacerbate labral injury and are to be avoided.
Although bony impingement plays a major role
in the limited hip function in FAI, the influence of
soft tissues as well as adjacent mobility in other
joints is still poorly understood. In a study by
Kennedy et al13 attenuated hip abduction, frontal
and sagittal ranges of motion were observed during
gait analysis in individuals known to have FAI. The
authors conclude that there lies a significant soft
tissue component in FAI and that it may involve
other joints including the lumbo-sacral joint.
These conclusions provide an attractive rationale
for the osteopath when formulating treatment.
The detection of certain postural abnormalities
may be beneficial in a case of FAI. Janda has
described a typical pattern of muscular imbalance
of the pelvis which he termed the lower crossed
syndrome.14 He suggests that chronic shortening
of the hip flexors and erector spinae is accompanied by weakness of the gluteal and abdominal
wall musculature. The subsequent imbalance
results in an anterior tilt of the pelvis (anterior
rotation of the pelvis in the sagittal plane around
a coronal axis). In the normally aligned pelvis, the
acetabulum is orientated on the pelvis to face

Anterior hip pain e Have you considered femoroacetabular impingement?

25

Figure 3 Coxa Profunda (CP) & Protrusio Acetabuli (PA). Schematic (left) representations of (a) normal hip, (b) coxa
profunda and (c) protrusion acetabuli, and radiographs (right) of coxa profunda (d) and protrusio acetabuli (e). Both
coxa profunda and protrusio acetabuli are associated with pincer FAI and indicate the presence of over-coverage of
the femoral head by the acetabulum. Note in coxa profunda the acetabular floor is flush with the ilioischial line (IIL).
In protrusio acetabuli the acetabular floor crosses the IIL.

laterally, somewhat inferiorly and somewhat


anteriorly. It is reasonable to suppose then, that
excess anterior pelvic tilt leads to apparent
retroversion of the acetabulum, contributing to
abnormal load transmission across the hip. Anterior pelvic tilt therefore, along with the secondary
soft tissue changes that occur could be addressed
when planning treatment. Indeed, a chronically
shortened iliopsoas has already been shown to
contribute to anterior labral tear because of

compression of the iliopsoas tendon across the


anterior capsulolabral complex.15,16
Conversely, the iliopsoas may test long and
weak, and this is implicated in the femoral anterior glide syndrome, described by Sahrmann17 and
many others. This is postulated to occur because
of inadequate posterior glide of the femoral head
during hip flexion, resulting in excessive anterior
glide causing pressure of the femoral head on
anterior joint structures, including the capsule and

26

J.K. Chakraverty, N.J. Snelling


primarily involve working on muscle balance and if
necessary improving joint accessory motion. The
reader is referred to Sahrmanns text for more
detail.17 However, it is difficult to locate any
studies demonstrating the efficacy of these
approaches. It is not known how many cases of FAI
syndrome involve femoral anterior glide, and
whether attention to biomechanics would settle
a symptomatic FAI syndrome. It may well be that
there is a large overlap between symptomatic FAI
syndrome and femoral anterior glide syndrome.

Surgical
Figure 4 Alpha Angle. The alpha angle is a measure of
asphericity at the femoral head-neck junction. An angle
>55 is associated with cam FAI. It can be measured in
the axial oblique plane with conventional radiography,
CT or MRI. The angle is measured between a line drawn
from the centre of the femoral head through the central
axis of the femoral neck and a second line drawn from
the centre of the femoral head to the point anteriorly
where the distance from the centre of the head exceeds
the radius of the femoral head.

iliopsoas. Increased anterior glide of the femoral


head is proposed to result from weakness or
decreased utilization of the gluteal muscles during
hip extension and the iliopsoas muscles during hip
flexion. The iliopsoas fibres, as described previously, have attachment to the anterior capsule and
contraction may help to avoid the capsule from
being pinched. Treatment approaches postulated

Surgery in symptomatic cases of FAI is becoming


increasingly commonplace. There are a variety of
surgical approaches: open, combined arthroscopiclimited open and arthroscopic techniques are used.
Addressing a cam lesion may involve surgical dislocation of the hip and resection osteoplasty of the
aspherical portion of the femoral head (bumpectomy).18 For the pincer lesion, resection of the
acetabular rim or even a periacetabular osteotomy
may be undertaken to reorient a retroverted
acetabulum.18,19 The short term results with regard
to symptoms and function following surgery are
promising (level IV evidence, mean follow up of 3.2
years) - there is however, no long term outcome
data with regard to the defined end points of joint
preservation and prevention of osteoarthritis.7

Conclusion
The aim of this paper has been primarily to make
practitioners aware of the concept of FAI, with
a brief overview of possible approaches to
management. If a patient is not improving practitioners should consider referral for imaging as
there may be a surgical approach to management
which can not only provide symptomatic relief, but
may also reduce the risk of early development of
osteoarthritis. Further research is needed to
determine the best management options for
patients suffering with FAI.

References

Figure 5 MR arthrogram (proton density and fat


saturation sequence) of the hip showing a labral tear
(arrow).

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