On September 13, 2011, in Controversies, Hip, Overuse Syndromes, by Craig Liebenson
Femoral-Acetabular Impingement (FAI) is an increasingly popular diagnosis for patients with stubborn hip problems. Hip replacement surgery has been a great advance, but recently the hope for it being a panacea has been dashed. Now, surgeons are diagnosing FAI in many aging athletes & weekend warriors. What is it? How do we diagnose it. And, how can we treat it?
WHAT IS IT?
FAI is a wear & tear injury from repetitive strain.
HOW CAN WE DIAGNOSE IT?
There are no specific diagnostic tests for it, however groin pain is one signature of it’s presentation. According to the revolutionary hip surgeon from Colorado Dr Philippon “A positive impingement test was defined as groin pain with 90 degrees of hip flexion and maximal internal rotation.”.
He also states that the Faber Test can be positive – limited & painful abduction & external rotation.
X-rays may show bony reaction on the femoral head or neck, and on the acetabular rim.
MRI can reveal fraying or tears of the cartilage and labrum.
FAI has to be distinguished from Hip Dysplasia (HD), and a Labral Tear (LT).
HD is present if the hip socket -acetabulum – is too shallow for the ball – femoral head. It is a congenital condition. This can be associated with tearing of the labral and articular cartilages. There should be laxity & instability.
A LT can be visualized on an MRI and can occur with AFI or HD. Like FAI, pain with hip flexion, internal rotation and adduction are hallmarks. The MRI finding of a LT does not mean there is a clinical problem since is it is present in many asymptomatic individuals.
Since tears can be asymptomatic and dysplasia occurs with instability when we have restricted or painful motion FAI is a reasonable working diagnosis.
HOW CAN WE TREAT IT?
Surgery is not the first choice, but last resort. Conservative care should always be considered
option 1.
Activating the posterior chain in order to “check” uncontrolled or excessive hip flexion is a key.
Integrated core activity with lower quarter control is a “no brainer”.
Frontal plane stability
Visualization training for movement education of the hip
Regarding acetabulo-femoral amnesia this is inspired by Eric Franklin’s movement education work. Most people have no idea where their hip is. When they learn it’s actual location it becomes much easier to train the hip hinge and activate the posterior chain. This is an example of the neuro-matrix whereby an new neural signature is created via motor control training.
WHAT IS THE ROLE OF MUSCLE IMBALANCE?
It is unlikely that FAI caused by muscle imbalance, however muscular compensations such as gluteal inhibition are typically present. Pr Janda put our attention on the gluteus maximus (posterior chain), gluteus medius (lateral chain) & abdominal wall (anterior chain) with his revolutionary work from the 1960′s. Today, our terms have changed – posterior chain, frontal plane stability, and functional core control, but it the same faulty movement patterns which Pr Janda the Father of Rehabilitation Medicine spoke about.
HOW CAN REHAB BE PROGRESSED TO RETURN TO SPORT & SELF-CARE?
First, identify quad dominance. Check where the patient “feels” squats, lunges, balance reaches, etc.. Most patients only feel their anterior thighs. This is our trigger to commence a posterior chain facilitation program. There are “many roads to Rome”. Find what works best. I am not about methods, but principles. If you know the goal you will find the means.
A few ideas though would include – 2 & 1 LDLs; functional reaches; 2 & 1 leg box squats; reverse lunge steps; Rear foot elevated split squats; monster walks, and bridges.
Second, ensure integrated core-lower quarter control. Planks; Supine foam roll marching with med ball chest press; 2/1 Hamstring bridges & curls with the gym ball; Kolar dying bug vs the wall; and Nordic or Russian eccentric hamstring lowers.
Third, determine if lateral hip stability is present check single leg balance for pelvic unleveling. Then, look at single leg squats to see if pelvic unleveling leads to medial knee collapse occurs. Third, check side lying hip abduction to determine if there is gluteus medius insufficiency or asymetric strength. Training can include clam shells; lateral band walks; kettlebell carries, posterior-lateral balance reaches (5:00 or 7:00).
If these 3 fundamental components can be mastered, then to maximize functional stability plyometric control must be ensured. This is essential for athletes as a functional test of improved stability resulting from the initial rehab. If the stretch-shortening cycle is sluggish overload will occur at the “weakest link” – achilles, anterior knee, or hip. Start with 2 legs jump squats; scissor lunges; and 360 degree jump squats. Progress to lateral hops, diagonal X-Hops; and single leg hop and holds.
For functional training once plyometric stability is ensured begin to build power by utilizing triple extension exercises such as Waterbury’s High Pull.
The key is to train for power by finding the athlete’s 10 RM then train only as many reps as can be performed at top speed without breaking form. The 1st set might by 6-7 reps. When performed as part of circuit of perhaps 3 exercises with each successive set the reps performed will drop before speed or form decays. 5 sets are ideal and if the initial RM was chosen wisely a Russian Reverse Pyramid of training will have occurred naturally. For instance, Set 1 – 6 reps; Set 2 – 5 reps; Set 3 – 4 reps; Set 4 – 3 reps; Set 5 – 2 reps. Grand Total of reps might be 15-20 reps. To increase power start by finding the 7-8 RM, so Set 1 at top speed is likely to be only 5 reps. Individualize this to the patient’s capabilities and demands.
Sources from craigliebenson.com
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