• Lionel Pannunzio PT / SCS

Femoro-acetabular Impingement in Soccer Players: Is your groin pain a problem of the hip joint ?


Introduction


FAI is a pathological hip condition characterized by abnormal contact between the acetabulum ( socket ) and femoral head / neck junction ( ball).


Femoroacetabular Impingement (FAI) is generally used to describe symptoms pertaining to the ball and socket joint of the hip.


This can occur within the normal physiological range of motion as a result of osseous abnormalities ( bone overgrowth ) described as either CAM or PINCER deformities.





There are 2 types of hip impingement; they may occur alone or together.


1. Pincer-Type Impingement:


This condition affects men and women equally; symptoms often begin early, appearing at any time between 15 to 50 years of age.


In pincer-type impingement, the hip socket (acetabulum), which is usually angled forward, may be angled toward the back.


The overgrown bone or incorrect angle of the socket causes the labrum (a rim of connective tissue around the edge of the hip socket) to be pinched.


Over time, this leads to inflammation and eventually could result in a labrum tear.



2. Cam-Type Impingement


Here the shape of the bone around the head of the femur the ball at the top of the bone in the thigh is misshapen with an overgrown bone formed at the top and front. The nickname “pistol grip” deformity is given to the appearance of the bony overgrowth on x-rays.


This also leads to pain or can cause the labrum to  become worn, frayed, or torn.


This condition affects men to women at a ratio of 3 to 1; symptoms often manifest during the teen years and 20s.


Most individuals with FAI experiencing discomfort with hip flexion ( bringing knee up towards the chest) , adduction, and internal rotation.



A recent study found that 87% of teens and adults with hip pain showed evidence of hip impingement on diagnostic images taken of their hip joints.


To have a diagnosis of FAI it is not a sentence to a life of pain. Many patients get better with a comprehensive rehabilitation program.


Surgery is an option when the conservative treatment has failed


That’s why it’s important to assess the person and their goals and not solely base the prognosis on x-rays or MRIs.



FAI diagnosis is obtained through a combination of  symptoms + clinical signs + diagnostic imaging





SYMPTOMS






Hip impingement may cause:


Stiffness or deep aching pain in the front or side of the hip or front of the upper thigh while resting.


Sharp, stabbing pain when standing up from a chair, squatting, rising from a squat, running, "cutting," jumping, twisting, pivoting, or making lateral motions.


Hip pain described in a specific location by making a "C" with the thumb and hand and placing it on the fold at the front and side of the hip, known as the "C-sign."


Pain that most often starts gradually, but can also remain after another injury resolves.

Pain that increases with prolonged sitting or forward leaning.


Feeling less flexible at the hips, including a decreased ability to turn your thigh inward on the painful side.



To the physical exam patient with FAI will show:


Reduced ROM


Positive Hip Impingement Tests.

Several test can help with the diagnosis of FAI , for example “log roll” test where the therapist gently roll your leg in and out, or bend your hip up and in while turning the lower leg out to the side (the "FADDIR" test) to assess your condition.


Diagnostic Imaging ( Xrays ):

Antero-posterior radiograph of the pelvis and a lateral femoral neck view of the symptomatic hip to identify pincer or cam morphologies, and identify other causes of hip pain.


If further diagnosis is needed, your doctor may order diagnostic tests to help identify any joint changes, including x-rays, magnetic resonance imaging (MRI), or diagnostic injections. Hip impingement can occur at the same time as low back, buttock, or pelvic pain, or from conditions such as bursitis or groin strain.


The final diagnosis of hip impingement may take some time, especially when other conditions are present




Treatment of Femoro-Acetabular Impingement - FAI



Exercise-based treatments are recommended for people with hip-related pain. Exercise-based treatment should be at least 3 months duration.


Physical Therapy Interventions:





1. Improve the strength of your hips and trunk.


Strengthening of the hips and trunk can reduce abnormal forces on the already injured joint and help with strategies to compensate.


People with FAI will benefit from a comprehensive program that addresses all the imbalances in the hip - pelvis - lumbar area that may be causing the impingement.

The position of the pelvis is crucial to avoid or decrease the amount of contact between the femur and acetabulum.


Therefore a combination of  core +  hip  strengthening along with postural exercises are necessary in people with FAI.


The goal here is to create stability at the lumbo-pelvis complex to allow a normal movement of the hip


2. Improving hip muscle flexibility and joint mobility

See video below


3. Joint mobilization may help ease pain from the hip joint

See video below


4. Improving tolerance of daily activities through activity modification


Analyzing your job and the recreational activities you do to maintaining postures that are healthier for your hip and. Often this involves limiting the amount of bending at the hip to avoid further hip damage.





Joint Mobility Videos ( read instructions carefully)






Two of the main issues with FAI are .


Stiffness or deep aching pain in the front or side of the hip or front of the upper thigh while resting.


Feeling less flexible at the hips, including a decreased ability to turn your thigh inward on the painful side.


To combat this sensation of tightness and lack of movement the hip must be challenged in end range.


But the problem is that if patients push to hard it may be exacerbate their pains.


Therefore, one of the best ways to move the hip gently is to use bands to assist in the mobilization of the hip joint.


Here in these videos I demonstrate a couple of different techniques, try and see which one works better for you.


Tips


Warm up with aerobic exercises ( elliptical / treadmill ) .


Don’t force the movement too much, just get to the end and push a tiny bit more


Work on repetitive movements more than pushing hard .

Keep core muscle active throughout the mobilization to avoid excessive strain in lumbar spine




Conclusion:

  • FAI is a problem of the hip joint or its components: the ball or socket of the hip

  • Treatment of FAI requires a general approach with core and all aspect of the hip included.

  • Research shows that FAI is a common finding among athletes and soccer players and its only when painful that the FAI becomes a problem.

  • Conservative treatment with Physical Therapy for 12 weeks is the first line of treatment of this condition. In Adults ( + 40 y/o) surgey need to be considered only when the Physical Therapy has failed because of the Poor to Fair results of the Surgery in the long run

Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located  in the beautiful City of Weston,  where he treats Soccer Player, Runners and Athletes of all ages

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Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy

“Keeping Athletes in the game”

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