FAI: The Hip Pinch That Won’t Quit.
FAI, or femoroacetabular impingement, is a syndrome of symptoms that affects many individuals, especially youth athletes that participate in sports such as soccer, ice hockey, baseball, and other high intensity sports. FAI was classically described as a structural deformity because of variations in how the top of the femur connects to the pelvis. The connection is called the femoroacetabular joint (hence the name femoroacetabular impingement). The structural variation that has been used to describe this condition has to do with the top part of the femur; called the neck of the femur, and the cup that the head of the femur sits within; called the acetabulum. The variants are called cam, pincer and mixed. The cam deformity results from a bony overgrowth of the neck of the femur. The neck of the femur then becomes too large to move through the normal range of motion without abutting against the acetabulum. In the pincer type, the cup itself is too large, which leads to the same contact but in the opposite way. The most common form is the mixed type, in which both the acetabulum and neck of the femur have become overgrown.
The reason I say this is how the condition is classically described is because we now know that many individuals have these same structural abnormalities, but no symptoms or limitations(Kapron et al. 2015; Frank et al. 2015). There are also many other variables that have been associated with FAI and symptoms, such as: hip muscle weakness (Casartelli et al. 2011), altered motor patterning in the hip (Diamond et al. 2017), inflammation in the hip (Elias-Jones et al. 2015), and smaller muscles in the hip (even when compared to the side not showing any symptoms) (Malloy et al. 2019)and mental health scores(Jacobs et al. 2017).
Want to know why I know so much about FAI? Besides being a clinician and treating this condition regularly, I HAVE FAI. This likely developed as a result of playing repetitive motion sports such as baseball and soccer during my early years of skeletal development. As a result I have limited Range of motion in my hip, especially in flexing, and rotating my hip inwards. This all came to a head in the summer of 2019 when I, off the couch, played in an ultimate frisbee tournament with my school's intramural team. We were a team of chiropractic students relying on fitness from our undergrad glory years, when there was ample time to train and practice. Compared to other teams, we had very few substitutes and matters were only made worse by the fact that over the course of the weekend we sustained many injuries. These injuries likely resulted from excessive muscle fatigue from playing multiple back to back games with too few subs, and too little preparation. Every player was a mess by the end of the weekend, I wasn’t event the worst off. I limped off the field that day, but that night I had a deep burning pain in the front of my hip that would simply not go away. It was so bad I had to take Ibuprofen, a practice I am not terribly fond of and hadn't had to do since running 100 mile weeks in college. The Ibuprofen helped me sleep, but didn’t help me out long term.
After about a month of not getting my hip looked at, I was assigned a clinical partner and clinician as a part of the trimester 7 student clinic. My clinic partner and clinician assessed my hip, and since the discomfort and range of motion was still present, we decided to get an MRI. Not only did I have FAI, I also had a tear in my hip labrum which is a common complication from FAI in athletes. The labrum is a piece of connective tissue that surrounds the acetabulum to increase the coverage and surface area of the hip joint. This provides a negative pressure and suctioning effect and is another one of the reasons the hip joint is such a stable joint, and unlikely to dislocate.
When you have a labrum tear you have two options; surgery, or conservative management. I did many hours of research and even wrote school papers on the topic. I learned about many of the complexities of the condition as well as when to treat conservatively, and when to get surgery. The surgical correction of a labrum tear is a fairly invasive procedure, and has a very long recovery time. I decided to get to work with rehabbing and strengthening my hip in order to try and avoid the surgery and its long recovery time.
I learned and began utilizing rehab and strengthening exercises from instructors all around the world. Stretching from California, to New Zealand, and even Prague Czech republic. The exercises changed over time as I became stronger. Slowly but surely, my hip pain began to diminish. My range of motion and mobility have increased dramatically, and I have almost no limitations in activity or daily life. Since being diagnosed with hip impingement and a labral tear, I have deadlifted over 300lbs, bouldered V8, and sport climbed 5.12d grades. I’ve run tonnes of miles and rarely get pain in my hip now.
Being a chiropractor that specializes in sports injuries and rehabilitation, I now have the opportunity to share and use my experiences to help young athletes take the right direction when dealing with FAI. With all of the things that I have learned both in school as well as with my own experiences, we can explore the different options regarding both surgical intervention and rehabilitation programs.
References:
Malloy, P., A. V. Stone, K. N. Kunze, and W. H. Neal. 2019. “Patients With Unilateral Femoroacetabular Impingement Syndrome Have Asymmetrical Hip Muscle Cross-Sectional Area and Compensatory Muscle Changes ….” : The Journal of …. https://www.sciencedirect.com/science/article/pii/S074980631831137X.
