What is femoroacetabular impingement?
In a nutshell: too much friction in the hip joint. Femoroacetabular impingement (FAI), a.k.a. hip-impingement syndrome, typically occurs when the femoral head – the ball of the hip joint and the highest point of the thighbone, or femur – rubs abnormally against what’s known as the acetabulum, or hip socket. (They’re all connected a la “Dem Bones.”) As a result, damage may occur to the labrum, the surrounding rubbery cartilage (fibrocartilage) that essentially serves as a gasket, providing cushion to the joint.
Femoroacetabular impingement is a mouthful. How is it pronounced?
Fem-er-oh as-i-tab-yuh-lar (impingement), which, incidentally, only became part of medical vernacular in 1999. But let’s stick with FAI; it’s easier to say.
What are the symptoms of FAI?
There may be no symptoms, especially in the early stages. But if the condition progresses and inflammation builds, FAI sufferers may feel a consistent dull ache in the groin area, sometimes extending to the thigh, buttocks and lower back. Some people may experience a catching or popping sensation. Stiffness and discomfort may occur after running or sitting for prolonged periods. There may also be a decreased range of motion in the hip joint, and even some limping. At its worst, going up and down stairs may seem as challenging as mountain climbing.
What causes FAI?
FAI is typically the result of excessive bone growth – bone spurs, or “osteophytes” in physician parlance – that can develop in the head or neck of the femur bone or in the (acetabulum) hip socket.
Are there different types of impingement?
Hip impingement comes in different flavors. Bone growth around the head and/or neck of the femur is known as “cam” impingement, and around the acetabular socket it’s known as “pincer” impingement.
Interestingly, “cam” impingement is often seen in younger athletic males, while “pincer” is more common in middle-aged women, according to studies. If you’re interested in learning more about gender differences, check out this study published in the American Journal of Sports Medicine.
There is also another type of impingement, “psoas impingement” (or internal snapping hip). With psoas impingement, the iliopsoas (hip flexor) tendon, located outside the hip joint, becomes inflamed and tightens, causing it to snap across the acetabulum or femoral head. In some cases the tendon compresses the labrum, causing a tear.
Can you have both “cam” and “pincer” impingement?
Regrettably, yes. You can have both cam and pincer impingement at the same time – in fact, it’s fairly common. Research work published on the American Academy of Orthopaedic Surgeons website, which also explores gender differences, noted that the two characteristics coexist in 60 to 80 percent of FAI cases.
Is it common to have impingement in both hips?
A significant number of “lucky” FAI sufferers have to deal with impingement in both hip joints, though not all will need surgery to correct the problem. Some hip surgeons put the number at 1 in 6, or around 17 percent, and others as high as nearly 40 percent.
Is hip dysplasia the same thing as FAI?
Nope, though the two disorders are sometimes confused, probably because hip dysplasia can also cause hip labral tears, and because the two share some of the same painful symptoms.
In hip dysplasia – sometimes referred to as “developmental dysplasia of the hip” (DDH) – the hip joint may be the wrong shape, or the hip socket incorrectly positioned. Essentially, you’re born with it. Treatment usually means a surgical re-alignment of the hip joint. Additional information can be found at the International Hip Dysplasia Institute.
Are you born with FAI?
No one knows for sure, really. Some experts in the field believe there may be a congenital predisposition to FAI; others maintain that the condition develops over time, the result of certain physical activity or trauma. A study published by the National Institutes of Health looked at the genetic influences in siblings.
How exactly do the bone spurs that cause FAI to develop?
These bony abnormalities (a.k.a osteopaths) that form on the femur (causing cam impingement) and/or the socket (pincer) develop over time.
Interestingly, bone spurs are a natural defense mechanism for your body. When there is too much pressure, stress or injury in the hip joint – this can be the result of vigorous physical activities, like running, dancing, cycling or skating – the body tries to repair itself by building extra bone. (In other words: being too helpful for its own good!)
The Mayo Clinic provides a detailed explanation here.
Can the bone spurs that cause FAI grow back?
Unfortunately, yes, though some experts maintain that the more aggressive a surgeon is in shaving down the affected bone, the lesser the likelihood the bone spurs will return.
Can you re-tear the hip labrum?
If the labrum is repaired without removing enough of the offending bony impingement, then, yes, there is a likelihood that the labrum will tear again. There’s also a possibility that a traumatic injury can cause another labral tear.
Is it possible to have a hip labral tear and never know about it?
Yes. Many torn labrums – which can occur from a variety of causes, including FAI, as well as degeneration from osteoarthritis – may be asymptomatic and require no treatment. (You may never know you even have one unless you get an MRI!) An extensive study on professional hockey players found this to be the case. Fifteen of the 21 players who received an MRI (or around 71 percent) were found to have hip labrum tears. But only 20 percent had any symptoms within two years and about 7 percent missed games within four years because of hip-related pain.
Furthermore, 74.1 percent of torn labrums have no known direct cause, according to another study. And the study’s authors seem to suggest that “labral abnormalities are a natural part of aging.”
In case you’re wondering: The reported age range for hip pain and a labral tears is 8 to 75 years.
How is FAI diagnosed?
Simple answer: It’s not easy. FAI can often be confused with other diagnoses, like tendonitis, bursitis, groin pull, even endometriosis. It takes, on average, 21 months and visits to at least three health professionals before a diagnosis is finally made, according to one study. Here’s a link. Another study put the timeframe for an accurate diagnosis at 32 months, and said that average amount of money spent during that process was $2,456.97.
Doctors can make an initial diagnosis from a patient’s medical history and by conducting a physical exam testing out range of motion. They may, for instance, bend a patient’s leg up and internally rotate the hip so the knee is pressed toward the opposite leg. This position can reproduce the painful symptoms of FAI.
To know for sure, however, doctors may order up X-rays; a magnetic resonance imaging, or MRI; or CT/CAT (Computer Tomography) scans. Sometimes an MRA (magnetic resonance angiography) will be needed – that’s when dye is injected into the affected area before the MRI in order to provide greater detail of the joint surface.
A detailed study on diagnosis can be found here.
Once a diagnosis is made, how is FAI treated?
There are nonsurgical and surgical treatments for FAI, both of which are intended to assuage the pain and improve mobility in the hip joint.
The nonsurgical, or conservative/conventional, route includes everything from modifying your physical activity – your doctor may first suggest scaling back – to physical therapy to strengthen “core” muscles like your glutes and abdomen, to cortisone or platelet-rich plasma (PRP) injections. Therapeutic exercises, in particular, may improve the overall mechanics of the hip, which can lead to improved function and decreased pain.
On your own, you may find relief through a combination of icing of the affected area (A bag of frozen green peas often works great), some rest and nonsteroidal anti-inflammatory drugs, or NSAIDs (ibuprofen, naproxen). Stretching, massages and acupuncture may help, too.
In more severe cases, surgery may be necessary, though this should only be considered as a last resort. This can be accomplished through open and arthroscopic surgery.
What is PRP therapy, and is it a good option for alleviating hip-joint pain?
PRP, or platelet-rich plasma, therapy is a nonsurgical procedure for pain management that has gotten a lot of attention of late. Quite simply: A patient’s own blood is used to rebuild a damaged cartilage or tendon. Blood is drawn and placed in a centrifuge for about15 to 20 minutes in order to separate out the platelets, then injected into the affected area with the guidance of an ultrasound machine.
Although PRP injection therapy has shown much promise, including among FAI sufferers, it is not yet approved by the Food and Drug Administration, and therefore, not covered by most insurance plans. (The F.D.A. has approved PRP in other applications within the field of orthopedic surgery; PRP injections are still considered off-label use.)
The Emory Healthcare website offers a detailed explanation about PRP therapy.
Will FAI eventually go away on its own?
It’s unlikely FAI will go away on its own. In fact, left untreated, there’s a chance, some experts say, that FAI may eventually develop into osteoarthritis of the hip, a degenerative, often debilitating joint disease. In extreme cases, hip resurfacing or a total hip replacement may be in order. (An explanation of resurfacing and THR can be found here. FAI treatment is often considered part of hip preservation treatment.
Will having corrective surgery reduce the likelihood of a hip replacement down the road?
It’s difficult to say who will end up needing an arthroplasty, a.k.a. total hip replacement (THR).
The success of hip-impingement surgery seems to depend in large part on a patient’s age: the younger the better, typically. But older patients – that is, those 50 and older – will do well, too, studies show, if their joint cartilage is otherwise healthy. The Tönnis grading system is often used to assess cartilage health, with “0” described as showing no signs of osteoarthritis and “1” mild, “2” moderate, and “3” severe. Additional information can be found here. Joint space is another predictor – the narrower the space, the more problematic.
How do you know when it’s time to seek medical help?
Many sports-related injuries will eventually heal themselves. Ask any avid runner! But you may need to seek outside help if these situations occur: the pain hasn’t gone away after a couple of weeks’ resting, icing and compression; the pain interferes with everyday life like walking, using the stairs or getting into and out of cars; the pain prevents you from having a good night’s sleep; and the pain continually returns after your usual physical activities. You can read more about it here, and listen to some advice.
Remember: The longer painful symptoms are allowed to go untreated, the more damage may occur.
What is arthroscopic hip surgery?
Arthroscopic hip surgery is a minimally invasive procedure increasingly used to repair a torn labrum, the rim of cartilage that surrounds and seals the hip joint, and correct hip impingement.
In a hip scope, as they’re commonly called, a surgeon uses a thin telescopic camera, called an arthroscope, to view inside the hip joint, along with rod-like instruments to repair and clean the damaged area. All these instruments are inserted into the joint through small, surgical incisions, or portals, which usually means less pain and a speedier recovery than open surgery.
Further detailed information can be found here.
Who are the best candidates for arthroscopic hip surgery?
Active and otherwise healthy individuals that do not have significant cartilage damage, or arthritis, are often considered the best candidates for this procedure. Hip surgeons will typically review your X-rays and MRI’s before deciding on whether to take you on as a patient.
Here is a study about why a scope might fail.
How do I find a good surgeon?
Finding the right surgeon can be an arduous task – just Google “hip scope doctors” and you’ll find more than 2.2 million results to wade through – but it’s oh so important to get it right.
Arthroscopic hip surgery is, after all, a highly specialized skill, and not all orthopedic surgeons are truly qualified to perform this procedure. (The really good ones often have done hundreds.) The same holds true for open surgery.
Many of the good hip-scope surgeons were trained by Marc J. Philippon, a managing partner of the Steadman Clinic in Vail, Colo. He specializes in sports medicine and is a pioneer in hip-joint preservation techniques using arthroscopic surgery. Dr. Philippon is also best known for treating professional and elite athletes, and his list of patients includes the baseball players Luis Castillo and Alex Rodriguez; the football players Kurt Warner, Jay Fiedler and Priest Holmes, the golfer Greg Norman, the hockey player Mario Lemieux and the Olympic figure skater Tara Lipinski. Among the many surgeons trained by Dr. Philippon are Struan Coleman and Bryan T. Kelly, both of whom practice at the Hospital for Special Surgery, ranked No. 1 in orthopedics by U.S. News & World Report; Dr. Kelly’s patients have included Lady Gaga and Alex Rodriguez.
To find the right surgeon you’ll likely need to do some research: talk to people who have had the surgery; check out online chat rooms, forums and even Facebook pages devoted to hip impingement discussion; and ask your local orthopedist.
But keep in mind: Some of these specialists may not take your health insurance. And even if they do, they may not agree to take you on as a patient, either, especially if it is determined that you have too much cartilage damage.
What exactly happens during a hip scope?
If you’re a little on the squeamish type, you may want to hurry through this answer.
A hip arthroscopy often starts with your affected leg placed in traction so that the femoral head and socket are separated enough for the surgeon to insert the instruments and perform the procedure. In other words: Your hip will be temporarily dislocated. Not to worry: You’ll probably be knocked out. Patients may be placed under general anesthesia or receive intravenous sedation via medication like Propofol (a drug that induces a deep twilight sleep), coupled with spinal or epidural anesthesia.
The surgeon will make two or three small incisions (about a quarter to a half-inch long) in the joint area that will serve as portals into which the tube-like instruments and arthroscope camera are inserted. The surgeon will use images from the camera displayed on a nearby screen to guide the surgical instruments.
Hip-scope activities will vary by patient, but typically the treatment involves repairing the torn labrum, shaving down the bony growths and removing inflamed tissue.
Labral tears are generally repaired with suture anchors (labral refixation) or by removing a small portion of the labrum (debridement).
The whole procedure typically takes from 45 to 90 minutes. In most cases, patients are released on the same day – it’s not uncommon to report to the hospital at 6 a.m., have the surgery a couple of hours later, then get discharged by 3 p.m. (The time in between is spent in the recovery room, where you’re likely to be fed a light meal before being instructed on how to use the crutches.)
A graphic video of the procedure by Dr. J. W. Thomas Byrd of Nashville can be found here.
What happens if the labrum is so severely damaged that it cannot be repaired?
Those with shredded or destroyed labrums may be candidates for what is being called a new generation of treatment for labral tears: labral reconstruction. Surgeons that perform this procedure will typically use a portion of the iliotibial band (the tissue on the side of the leg extending from the hip to the knee) to reconstruct a new labrum; in some cases, cadaver tissue is utilized. This study shows a generally positive outcome for graft recipients.
What happens in open surgery?
If you’re really squeamish, you may want to skip this entirely.
Surgical hip dislocation, as the open surgery is known, is far more invasive than a hip scope, though it may be better suited for some patients with more severe hip issues. In this surgical procedure, an incision is made to the side of the leg, and a section of the thighbone, known as the greater trochanter, is cut, with muscle intact, in order to dislocate the hip joint and provide full access to the area. The surgeon will use a burr, chisel or rasp to trim away excess bone growth and make repairs to the labrum.
This procedure is usually performed under general anesthesia and takes about two or three hours to complete. Patients may need to spend at least a night in the hospital.
If you’re really curious about this surgery, the American Hip Institute provides a graphic video on its website. A tamer version can be found here.
What is “mini-open” surgery?
Another way to treat hip impingement is through mini-open surgery. This technique combines both open and arthroscopic procedures. The surgeon will insert an arthroscope into the hip joint area as well as make an incisiion (a capsulotomy) to help instrument navigation. Though it is more invasive than a hip scope, which means recovery time might be longer, one advantage of using a mini-open technique, doctors say, is that it reduces the traction necessary for assessing the hip joint, compared with a scope. Comparative studies show that this procedure has a high rate of success.
Does a hip scope produce better results than open surgery?
Not necessarily. Studies have shown that both approaches produce similar outcomes, though patients receiving a hip scope had fewer complications and a faster recovery. The Hospital for Special Surgery published one study in the American Journal of Sports Medicine. You can read about it here. Another study appears in the Journal of Arthroscopic and Related Surgery.
How should I prepare for a hip scope?
The short answer: stay healthy, build up your physical strength and don’t smoke.
On surgery day, wear comfortable, loose-fitting clothes for your hospital visit. (An easy-to-slip-on tennis dress works well for women, as do flat shoes with good traction for both genders.) Most important, make sure you’ve rented a good ice machine – this will numb the pain and speed up recovery – or at the very least secure an adequate ice supply ahead of time.
Of course, each surgeon and medical center will have its own preoperative requirements that you will need to follow. In addition, some FAI patients may be instructed to undergoing physical therapy a few months before the scheduled surgery in order to shore up the core muscles. Here’s how the Hospital for Special Surgery helps prepare patients.
Are both hips ever done at the same time?
Typically no. Some surgeons may make an exception, especially in cases involving young adults and children, since they heal so fast.
Are there any complications associated with a hip scope?
While the procedure is generally considered safe and complications are said to be rare, some problems may arise with both the surgery and anesthesia. There is a risk of injury, for instance, to the surrounding nerves or vessels, or to the joint. The traction needed for the procedure can in some cases, stretch the nerves and cause temporary numbness, and some patients have reported knee pain afterwards. There is also the risk of infection, along with the development of blood clots.
Some patients may also have a bad reaction to the anesthesia. Nausea is one side effect. And when spinal anesthesia, or a spinal tap, is administered, there is the possibility of leaking spinal fluid, which can cause severe headaches. (To fix that problem, a procedure known as an epidural “blood patch” may be necessary.) To prevent nausea, some anesthesiologists may place an anti-nausea patch behind an ear.
This study published in the Bone and Joint Journal details some of the complications, most of which it describes as “transient.”
What are my options for anesthesia during a hip scope?
There are two options available: general anesthesia, which causes complete unconsciousness, and regional anesthesia, which numbs the body from the waist down and blocks pain, that is combined with deep sedation.
Spinals and epidurals involve the injections of numbing medications near the spinal cord; this is usually done after a patient is sedated intravenously with a drug like Propofol, which causes a deep twilight sleep.
Doctors often prefer regional over general anesthesia because it typically has fewer side effects and risks.
What equipment or medication is needed after a hip scope?
The main goal in the days following surgery is to manage pain, prevent injury and stimulate mobility so the hip joint doesn’t become stiff.
Scope patients, therefore, are likely to be sent home with a cache of medical equipment, or else have it waiting for them, from a preorder, when they return home. (They’ll have to be rented or purchased separately.)
Among the items you typically will need: crutches or a walker, to help you move around and reduce pressure/weight bearing on the affected leg; a hip brace, for stability; an ice machine (i.e., Game Ready), to reduce inflammation and lessen the need for pain medication; and a CPM (Continuous Passive Motion) machine, to move the hip joint and prevent stiffness and scarring from forming. Not all doctors will require a hip brace, and some doctors may suggest using a low-resistance stationary bike instead of the CPM machine.
As far as medication is concerned, you’ll likely be given a prescription for a narcotic painkiller like Tylenol-Codeine (acetaminophen and codeine), Norco (acetaminophen and hydrocodone) or Percocet (oxycodone and acetaminophen) as well as anti-inflammatories like Mobic (meloxicam) or Naproxen. Antibiotics may also be prescribed.
How do I walk with crutches?
Walking with the ubiquitous “under arm” alloy crutches – you’re usually on it for a week or two – is a required skill, though pretty easy to master. Here are the basic instructions for walking: While your feet are flat grip the crutches firmly. Move both crutches a few inches in front of you, then follow with the operated (or bad) leg and then the unoperated (good) leg. Both legs should be even. (The mantra: crutches, bad leg, good leg, crutches, bad leg good leg, and so on …)
Going up the stairs you’ll bring the unoperated leg up first, then the crutches, then the operated leg. (Good leg, crutches, bad leg, and so on …) Going down the stairs is similar to walking: Bring down both crutches onto the first step, then the operated leg followed by the unoperated leg. (Crutches, bad leg, good leg …)
Here’s a video that might help. Or you can find good written directions on the Hospital for Special Surgery website.
Will I need physical therapy?
Most doctors will prescribe postoperative physical therapy, and it usually begins after the stitches are removed (and Steri-Strips put in its place) – typically a week to 10 days following surgery. Each doctor or medical center has its own protocol of PT exercises. At the Hospital for Special Surgery, for example, it is broken into four phases that span 16 weeks. The main goal after Phase I is to have 75 percent range of motion, according to the protocol.
Core strengthening is an important part of the recovery process. It will improve your body’s alignment and make you less prone to injury after you resume your normal activities. The core includes the gluteus maximus, a.k.a butt or glutes; the abdominal muscles; hip flexors and abductors; and the illotibial band on the outside of the leg. A few examples of core exercises can be found on the Core Exercises page.
How are patient outcomes measured?
Doctors, of course, can see for themselves through examinations. But many also like to collect additional data and may use questionnaires, like the Modified Harris Hip Score (MHHS), the Nonarthritic Hip Score (NAHS) and the Hip Outcome Score (HOS).
Here are PDFs to take a look at for the MHHS; the NAHS; and the HOS.
When will I be able to return to my normal activities and sports after surgery?
That’s the one question everyone seems to ask – and to which there isn’t one universal answer. Each person heals differently – depending in part on age and the severity of the impingement. Most doctors say you can begin impact activities like running after three months and contact sports after four months. For some people, it can take a full year, or longer, to feel “normal” again; some never do. Hip scopes are not everyone’s panacea.
But the good news, according to studies, is that many hip arthroscopy patients return to sports and other physical activities at the pre-injury level. One study that tracked high-level athletes in a variety of sports found that 78 percent of surgery patients got back in the game after about nine months, on average, and 91 percent of them were able to compete at the pre-injury level (or maybe better). You can read more about this study here.
How soon after surgery can I drive?
It all depends on how well you are recovering and so long as you are no longer taking narcotic painkillers – for some it could be a week, and others after a month. Of course, it will likely be sooner for those with their left hips scoped than their right, provided they have automatic transmission.
When can I return to work?
If you work from home in a sedentary type of job, almost right away. Otherwise, one to three weeks after surgery is considered common. If your job involves physical labor, though, it might be longer. In all cases, your doctor is the boss here – follow his or her suggestions.
When can I have sex again?
You’ll need to ask your doctor – and spouse or partner – that question. But usually you’ll get the go-ahead if you’re stitches are out and you have returned to doing most other normal activities.
Do you have a question?
If there’s a question you’d like to ask, or something you’d like information on, send your request here.