From PT to Patient – Femoroacetabular Impingement

Femoroacetabular Impingement (FAI) and Hip Labral tears — Part 1
If you’re in our West Loop clinic any time this fall, you’ll notice that these days I’ve switched from physical therapist to patient — crutches, leg brace and all.  In July, I had hip surgery to correct a femoroacetabular impingement (FAI) and a labral tear in my left hip.
My medical history looks something like this: “35-year-old female with 5 year history of worsening left hip pain. Was relieved via physical therapy and activity modification for several years. Now post-op labral repair, femoral osteochondroplasty, acetabular rim trim, and capsular plication.” GROSS. But what does all that mean? Here’s a brief rundown.

What is FAI?

In a normal hip, the femur (thigh bone) and acetabulum (part of the pelvic bone) fit together in a nice little ball and socket arrangement, like the picture on the left. The shallow cup of the hip socket is deepened by a fibrocartilaginous rim called the labrum —there’s one in the shoulder joint, too— which creates a seal and helps to hold the head of the femur in place.
In patients with femoroacetabular impingement, one or both of these bones are improperly shaped. Abnormality of the femur is called a CAM lesion, and of the socket is called a pincer lesion. The abnormal shape of the bones means the ball and socket doesn’t fit together right — I like to describe it as a square peg in a round hole, though that’s not entirely accurate — and as the bones bump up against one another, it leads to wear and tear on the cartilage surrounding the joint. In the long run, it can cause a labral tear as the labrum gets pinched between the rubbing bones, and in the longer run it can wear down the slippery articular cartilage that lines the joint, leading to arthritis.

What causes FAI? What does it feel like?

The exact cause of FAI is a bit unclear, but it seems bony abnormality could be hereditary (thanks, mom and dad for the lemon leg) or due to improper bone formation during childhood years (hip dysplasia, Legg-Calves Perthes, Slipped Capital epiphysis). Some people have FAI for most or all of their lives and really don’t feel a thing. In my case, a CAM lesion coupled with a personal history of vigorous physical activity — I played soccer and have been a runner all my life, have snowboarded for years and have a regular yoga practice — was the recipe for symptomatic FAI and a labral tear. Labral tears can also occur traumatically, from motor vehicle accidents or high velocity pivoting sports such as hockey, golf, soccer, and dancing.
Interestingly, according to this article in the Dallas Morning News last fall, 50 or so of the players on the Dallas Stars had X-rays, and roughly 70% of them had some sort of hip issue, which seems to point towards repetitive sports stress as another hip pathology culprit.
Symptoms off femoroacetabular impingement and labral tears vary, but common patient complaints include: · Pain or pinching in the groin area · The “C sign”, which is pain which extends around the side of your hip towards your butt, as if you were cupping your hip with your hand in a C shape · Pain often dull and aching, worse with prolonged sitting · Occasional sharp catching pain with activity · Symptoms worsen with hip flexion, adduction (bringing leg towards or across midline), and internal rotation (rolling the leg inwards).

You’ve been told you have FAI, now what?

Step one: conservative management. With early stages of hip pain, treatment usually focuses on activity modification to decrease further hip irritation, physical therapy to address muscular, joint, and soft tissue imbalances, and general self-management of symptoms, which can include improving your posture, becoming mindful of habits that could be damaging to joints, as well as icing, NSAIDS, etc.
How can physical therapy help?
In patients with femoroacetabular impingement, addressing posture, flexibility, mobility, strength and overall movement patterns in the whole body can help to ward off compensation and to help prevent further damage to the joints.
Imbalances in the body affect the hips in a really powerful way. For example, many people — including myself — develop a standing posture is where your pelvis tilts forwards (in the rehab and fitness world you’ll see us refer to this as “anterior pelvic tilt”). This posture may seem innocuous in the short run, but it leads to a host of problems like tight hip flexors, weak glutes, and inefficient abs. With FAI, this can cause an excessive forward shift of the femur, which increases the impingement at the front of the hips, ultimately causing more joint compression and damage.
Physical therapy can help you tune in to these shifts in the kinetic chain. When everything works the way it is supposed to work, it helps to take pressure off of your joints. In my case, I became significantly symptomatic about 5 years ago, and was able to ward off surgery and avoid any real worsening in my condition with regular PT and good self-compliance with my home regimen. In the last five years I’ve run multiple half marathons, elevated my yoga practice, waterskiied, dabbled in muay thai, crawled around on the ground with my dogs, and stayed extremely active at work. There have been many points in the last few years where I have been pain-free and felt better than ever.
Is surgery necessary?
Pain and symptoms of FAI and/or labral tears are certainly manageable and can be in some cases completely alleviated with conservative care. However, those underlying structural abnormalities and damage can’t be reversed. For some patients, surgical care is necessary. Hip arthroscopy can repair the torn labrum and remove the bony bits to help improve the movement of that ball and socket. That leads us to step two: time to go see the orthopedic surgeon. In Part 2 (posted next week), I’ll let you in to all the (not-so-juicy) details of my surgical journey.