Femero Acetabular Impingement Syndrome

(Keywords: Femero acetabular impingement syndrome (FAIS), CAM defect, Pincer defect, chiropractic, Developmental hip dysplasia (DDH), hip arthritis)

FAIS arises from TOO MUCH cover of the ball by the acetabulum. It is, in my opinion, a pre-arthritic hip condition which, if not properly managed, progresses inevitably to a prosthesis, often bilaterally. Because it is only a fairly recently understood condition, there are no long term studies available to confidently make a prognosis.

Fig 2. Femero Acetabular Impingement Syndrome

This 55 year old man has had stiffness in both hips for many years. Three years ago pain began in the groins. Now he can barely get his socks on. He can't walk 9 holes on the golf course - he has to use the wagon.

Within three weeks of Chiropractic care, the range of motion has dramatically increased, he can get his socks on, though there is no decrease in the pain yet. He has twice walked 9 holes without painkillers. Still, it's not easy yet.

In Fig 1 (R hip) a CAM deformity is clearly seen. In Fig 2, closer inspection shows that he has in fact mixed CAM-Pincer deformity in the right hip. In fact in both. Moderate degenerative change is seen. An orthopaedic surgeon expects a bilateral hip replacement within two years.

We'll see ...

Oh, Glucosamine Chondroitin sulphate for 12 months helped not an iota ... Glucosamine Chondroitin.

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Conversely, DEVELOPMENTAL HIP DYSPLASIA (DDH)

Notice the steeply sloping roof of the acetabulum, yet the ball is not markedly unroofed. A mild case of DDH so no degenerative change at this stage.

DDH too has a prediliction for hip arthritis, but for different reasons. The shallow socket means a smaller area of ball-socket contact to support the full weight of the body, thus greater pressure directly on the cartilage: increased wear and tear.

DEVELOPMENTAL HIP DYSPLASIA ...

DEVELOPMENTAL HIP DYSPLASIA Ortolani Galeazzi tests improve the possibility of early diagnosis.

What is well understood is that any process that reduces the movement in a joint leads inexorably to Immobilisation Arthritis. Joint cartilage is perfused by the inarticular fluids, bringing oxygen and nutrients, and removing waste products of metabolism. Reduction of this perfusion is now well known to be noxious for joint cartilage.

Paradoxically, an increased range of motion also leads to hip arthritis.
HIP ARTHRITIS ...

IMMOBILISATION ARTHRITIS ...

TWO MECHANISMS OF Femero Acetabular Impingement Syndrome

Clinically, the presentation is one of a "stiff, non-painful, non-arthritic" hip in the early stages, the patient usually not realising that something is amiss. They regard it as normal, and do not report it. It is only discovered by the astute Chiropractic physician who is being thorough in his/her examination.

"If you don't look for it, you probably won't find it."

- Bernard Preston D.C.

Repetitive shock in sport between the femoral neck and the anterior wall of the acetabulum eventually result in these degenerative changes and may even result in an avulsion of the antero-superior acetabular labrum with very sharp stabs of groin hip pain.

Femoral head deformation (aka CAM)







Fig.3







Fig.4
In CAM there is an abnormality at the level of the anterior femoral head, or the head-neck junction, resulting in increased femoral neck/head - acetabular rim contact. Cartilaginous lesions form along either the postero-inferior or superior aspects of the acetabulum, causing stiffness and limiting the range of motion. A hard end-feel is characteristic.

There is limitation of flexion, often adduction, and characteristically limited INTERNAL ROTATION, with a hard end-feel (in the young person, continuing of course into degenerative old-age arthritis, indistinguishable from conventional Cox arthritis, if not recognised and appropriately treated).

In Figure 1 there is no sign of CAM. The patient has absolutely no limitaton of internal rotation, but Faber is extremely limited. But there are strong signs of ...





Acetabulum deformation (aka PINCER)






In Pincer-Femero Acetabular Impingement Syndrome - the acetabulum gives increased coverage of the femoral head - femoral neck juntion, limiting the full range of motion of the hip. In particular, EXTERNAL ROTATION of the flexed hip is characteristic, again with a hard end-feel.


FEMERO ACETABULAR IMPINGEMENT SYNDROME PINCER ...



GENETIC INFLUENCES

In a sibling study of 64 patients treated for primary impingement deformities and osteoarthritis, a British group reporting in J Bone Joint Surg Br found a 2.8 times greater risk if a sibling had a CAM deformity, and 2.0 times for a Pincer deformity. J Bone Joint Surgery Br 2010 Feb;92(2)



Faber sign FAbER




In the Pincer form of Femero Acetabular Impingement Syndrome, the Faber sign is strongly positive:

F - Flexion

Ab - Abduction

ER - External Rotation

1. Place the foot of the stiff hip on the opposite knee.

2. The examiner places one hand on the opposite ASIS and the other hand on the knee of the affected leg.

3. Pressing down on the knee of the affected leg immediately produces restriction, a hard end feel, and pain in the groin. The patient tends to roll the whole pelvis to reduce the pain in the groin as the examiner does the Faber test.

   (Pain in the SI-joint may also occur if there is a concomitent Sacro-Iliac syndrome)

4. If the condition is bilateral, doing a double Fabere test immediately reveals that the patient cannot open (abduct) the thighs in the normal way.



A FAIS-Pincer sufferer would find it quite impossible to sit in the lotus position. In the early stages it's not painful, they simply cannot do it. Stiffness. In contrast the patient with Developmental Hip Dysplasia is hypermobile, and would find the lotus routine. In fact she can do it spectacularly with ease. She can probably put her feet behind her ears too!











Mixed femoral AND acetabular deformation

Always with the characterisitic sign: BONE ON BONE, HARD END-FEEL. It's quite unexpected in the young person, and the arthritis associated with hard end-feel that we would expect to find simply isn't seen on the x-ray.

Hence the paradox: A hard end-feel characteristic of arthritis, but no arthritis! Not yet. Unmanaged with good chiropractic, it will as surely as night turns to day, form a typical Cox arthritis in the future.

FROM A DIFFERENT PERSPECTIVE

Positive Impingement sign - ANTERIOR FAIS

FAdIR

With the patient lying supine, the examiner flexes the hip to 90*, adducts and then internally rotates. Restriction with a hard end feel, and pain in the groin is indicative of Femero Acetabular Impingement Syndrome - CAM.

FAdER

Now the examiner externally rotates the flexed and adducted hip. Pain in the groin and limitation of external rotation is indicative of Femero Acetabular Impingement Syndrome - PINCER.

Drehmann sign

Drehmann sign is positive with pain in the groin with Flexion and External rotation. Obviously this is very similar to FAdER restriction, and indicative of Pincer.

Positive Impingement sign - POSTERIOR FAIS

ExER

Pain in the groin with a hard end feel is POSTERIOR Femero Acetabular Impingement Syndrome..

FROM THE CHIROPRACTIC COALFACE

On further investigation, in was immediately apparent that flexion, adduction and internal rotation of the left hip was also severely limited with an abrupt hard end-feel. X-rays revealed NO degenerative changes in the hip.

What I find interesting is that he belongs to a group of perhaps 1-2% in whom it almost impossible to get an audible release in the neck.

Clinically, with the protocol that I have developed for the hip, range of motion has improved dramatically (within a month), but the improvement in his neck has been much slower. After a year of treatment (2/w x 4w, 1/w x 3w, now 1/6w (15 in all) he has absolutely no restriction in the hip, and the neck has little pain, but the ROM is still restricted.

Postulated: The early diagnosis of Femero Acetabular Impingement Syndrome and appropriate treatment of the hip has resulted in a dramatic improvement in the hip, but the late diagnosis of the neck points to a far poorer prognosis. Understanding the mechanisms involved in Immobilisation Arthritis helps to explain the underlying disease process. More about IMMOBILISATION ARTHRITIS... Is there a connection between the stiffness in the neck and the hip? Is it coincidence perhaps. Certainly he has no psoriasis.

"THE LIFE SO SHORT, THE CRAFT SO LONG TO LEARN."

- HIPPOCRATES

Case File: Femero Acetabular Impingement Syndrome

Case File: Developmental Hip Dysplasia

MIXED FAIS DDH SYNDROME

From the literature

• Femoroacetabular impingement (FAI) is considered a cause of labrochondral disease and secondary osteoarthritis.

• Pain occurred predominantly in the groin (83%).

• The mean time from symptom onset to definitive diagnosis was 3.1 years.

• Patients were evaluated by an average 4.2 healthcare providers prior to diagnosis and inaccurate diagnoses were common.

• Thirteen percent had unsuccessful surgery at another anatomic site.

PAIN IN UPPER LEG

CHIROPRACTIC and Hip Arthritis

Firstly in the early diagnosis of abnormal hip movement, though it's certainly only the observant and conscientious clinician will will discover these conditions in the patient who consults him for neck pain.

Early diagnosis of Femero Acetabular Impingement Syndrome means getting the patient onto early range of motion exercises long before he or she even knows they have a problem. Prevention. Everyone gives it lip service, few take it seriously.

Secondly, chiropractors are routinely treating babies with Colic Chiropractic, and the examination should include the hips, listening for the characteristic 'thunk' of the subluxating hip. If not discovered early, and the pediatrician can miss it on a bad day, or in a mild case, they will never have a normal socket.

Thirdly, by advising their patients early that their hips simply won't go all fifteen rounds, to accept that marathon running, break dancing, ballet and gymnastics are not for them, is crucial.

And fourthly, I am personally getting great results in the treatment of early and moderate hip arthritis. Sometimes frustratingly not, but on average great progress with incrased ROM and less pain.

Chiropractic first!

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