Femoroacetabular Impingement | Prolotherapy
In this article, Ross Hauser, MD discusses the surgical and non-surgical options for Femoroacetabular Impingement. Non-surgical options discussed below include Prolotherapy.
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Femoroacetabular Impingement (FAI) or sometimes diagnosed simply as Hip Impingement is a condition where abnormal contact and rubbing of the ball and socket portion of the hip bones creates joint damaging friction. This “bone-on-bone” situation subsequently develops into degenerative osteoarthritis in addition to causing injuries to the labral area.
“Pincer-type” and “Cam-type” femoroacetabular impingement
Femoroacetabular Impingement may include acetabulum (socket) deformity, the femoral head may have a non-spherical head, or the orientation of the acetabulum to the femur bone (the angle where they meet) may be off.
In pincer femoroacetabular impingement, when the hip is in full flexion (as in pulling your knee to the chest), the femoral head-neck junction hits the anterosuperior aspect (the front of the acetabulum). This problem is commonly caused by the socket being “too deep,” and the ball will pinch structures like the labrum between the acetabulum and the femur neck, this problem is also diagnosed as coxa profunda or protrusion acetabuli (where the ball of the hip protrudes into the pelvic area).
In cam femoroacetabular impingement, there is abnormal contact between the head and socket of the hip because of a loss of roundness of the femoral head. Cam comes from the Dutch word meaning “cog.” This loss of roundness causes an abnormal contact between the head and the socket of the hip. In cam FAI, the impingement typically occurs when the hip is flexed, but also internally rotated. As already mentioned, patients often have “mixed” FAI, meaning they have a combination of both.
Both types of FAI can cause premature osteoarthritis of the hip because both types progress to hip labral and cartilage damage. Hip instability caused by FAI is not limited to the hip area. Doctors at the University of California at San Francisco found that patients with Femoroacetabular impingement (FAI) caused instability in not only the hip but the ankle as well by causing an altering in the gait. The patients favored their bad hip at the expense of the ankle. The ankle instability relayed instability back to the hip.(1)
When Hip Impingement goes beyond the hip and causes pain throughout the low back
Doctors from Cambridge University Hospitals say that extra-articular hip impingement syndromes encompass a group of conditions that have previously been an unrecognized source of pain. Extra-articular hip impingement syndromes means problems caused from outside of the hip joint itself as opposed to intra-articular hip impingement syndromes which come from within the hip itself. Where it was once thought that hip impingement was caused by bone abnormalities limited to the ball and socket portion of the hip joint, doctors, including the Cambridge report cited below are finding that hip impingement can be caused by the pelvic bones as well.
The Cambridge doctors categorized these syndromes as:
- Ischiofemoral impingement: quadratus femoris muscle becomes compressed between the lesser trochanter portion of the thigh bone and the ischial tuberosity (the sit bones of the lower pelvis). We cover this problem in our article: Ischial tuberosity pain and ischiofemoral impingement: Here we describe Ischial tuberosity pain and ischiofemoral impingement. Focus will be on two types of problems. Impingement caused by instability and non or malunion of the fragment of the Ischial tuberosity caused by apophyseal (growth plate) avulsion fractures in young athletes.
- Subspine impingement: anatomical problems of the anterior inferior iliac spine (the wing of the upper iliac/pelvic bones) and the distal anterior femoral neck (the neck of the thigh bone) causing soft tissue entrapment of muscle and tendon.
- Iliopsoas impingement: friction between the iliopsoas muscle and the hip labrum, resulting in hip labrum breakdown. We cover issues in this article of the iliopsoas or psoas muscle as a cause of difficult to treat groin pain. Also see our article on surgery for hip labral tear.
- Deep gluteal syndrome: pain occurs in the buttock due to the entrapment of the sciatic nerve in the deep gluteal space. In our articles we cover a lot of information on the buttock pain and the pelvic, lower spine connection. See also the connection with Hamstring injuries.
- Pectineofoveal impingement: pain occurs when the medial synovial fold impinges against overlying soft tissue, primarily the zona orbicularis (the hip hip annular ligament).
The researchers concluded with a message to doctors that extra-articular hip impingement syndromes should be taken into consideration and should form a part of the differential diagnoses alongside intra-articular pathology including femoro-acetabular impingement particularly in the younger patient with a non-arthritic hip.(2)
Diagnosing Femoroacetabular Impingement means NO MRI?
As described above, Subspine impingement involves problems of the anterior inferior iliac spine and the neck of the thigh bone. In looking at patients with Anterior Inferior Iliac Spine problems, doctors at the Walter Reed National Military Medical Center suggest that a high percentage of patients with Anterior Inferior Iliac Spine problems associated with subspinous impingement are, in fact, asymptomatic. That the current radiographic classification system should not be used exclusively for clinical decision making.(3)
But doctors keep looking at the Anterior Inferior Iliac Spine Anterior because as doctors report in the British Medical Journal, the “inconsistent bony morphology and the pull of the rectus femoris muscle putting it at risk for an avulsion fracture.”(4)
This is not the only research to question the route of treatment recommended by MRI
If you have a scan or MRI of your hip, doctors are saying it may as well be worthless. That is a powerful statement, here is some powerful research:
- In a study in the Journal of orthopaedic science suggests:
“Radiographic signs of FAI were not associated with the degree of hip pain or a positive positive anterior impingement sign (the doctor’s attempt to recreate your hip pain in an examination), which suggests that radiographic findings may not be important in the clinical diagnosis of FAI.”(5)
- In a study in the journal Clinical orthopaedics and related research Japanese doctors followed up with their findings that because FAI is seen on MRI in many symptom-free patients, doctors should question the need for femoroacetabular impingement surgery to correct a problem that does not seem to plague the patient.(6)
Doctors are noting that one of the main causes of Femoroacetabular impingement is hip arthroscopic surgery.
New research on Femoroacetabular impingement surgery is concerning. Doctors are noting that one of the main causes of Femoroacetabular impingement is hip arthroscopic surgery.
In an editorial, James H. Lubowitz, M.D. (Editor-in-Chief) wrote in the medical journal Arthroscopy:
Hip femoroacetabular impingement is overwhelmingly the primary cause of revision surgery after hip arthroscopy. FAI imaging is confusing and requires additional research. Therefore, hip arthroscopic surgeons must become experts at clinical evaluation and examination.(7)
Clearly a connection to the MRI research mentioned earlier.
- Further, researchers say that patients with protrusion acetabuli (displacement between the ball and socket, seen in advancing osteoarthritis and more common in middle-aged women) are at increased risk for failure after Femoroacetabular Impingement Surgery.(8)
In an editorial, Dr. JW THomas Byrd writing in Arthroscopy : the journal of arthroscopic & related surgery, suggests:
When performing arthroscopic surgical management of symptomatic cases of hip femoroacetabular impingement, it is important to consider how much cam lesion resection (removal of labral, cartilage and/or bone) is required, if any. Generally, failure to adequately address a cam lesion could result in progressive damage to the articular cartilage. Thus, while it is important to consider exactly how much arthroscopic intervention is necessary to achieve successful results, the potential consequences of neglecting a cam lesion are at least as worrisome as the risks of indicated cam lesion treatment.(9)
In June 2017, researchers in Denmark, as part of the Danish Hip Arthroscopy Registry study and publishing in the medical journal of the International Society of Orthopaedic Surgery and Traumatology questioned how cartilage degeneration is treated in patients undergoing Femoroacetabular Impingement surgery.
Listen to these results:
- The majority of patients with femoroacetabular impingement undergoing hip arthroscopy have significant cartilage changes at the time of surgery primarily at the acetabulum and to a lesser degree at the femoral head.
- During femoroacetabular impingement surgery the majority of patients have cartilage debridement performed but rarely cartilage repair.
- The presence of severe cartilage injury at the time of arthroscopic femoroacetabular impingement surgery results in reduced subjective outcome and hip function.(10)
In March of 2018, New York University’s Bulletin of the Hospital for Joint Diseases published Beyond the Scope Open Treatment of Femoroacetabular Impingement.
In this paper researchers suggested:
- Several recent reports of revision hip arthroscopy for treatment of residual FAI have exposed potential shortcomings of arthroscopic treatment of FAI, specifically limitations with hip arthroscopy’s ability to address large or complex cam and pincer deformities.
- While hip arthroscopy can certainly be useful for treatment of FAI in some patients, we have yet to identify which patients truly benefit from this minimally invasive approach and those who are better served by open surgical techniques.(11)
Femoroacetabular Impingement and Hip Instability
In the medical journal Osteoarthritis and Cartilage doctors found:
“The optimal therapy for femoroacetabular impingement is unclear.”
In trying to prove out the surgical option the doctors noted in their research of 18 studies comparing management strategies – No study compared surgical and non-surgical treatment.
When surgical approaches were compared there was evidence of superior symptom outcomes with arthroscopy compared to open surgery and with labral preservation. (The key word here is tissue preservation).
No conclusion regarding the relative efficacy of one surgical approach over the other can be made or even if the surgery caused or prevented osteoarthritis.(12)
The orthopedic surgery suggestion uses the premise that the primary cause of hip impingement is due to the bones of the hip joint coming too close together and pinching various tissues like labrum and cartilage tissue as explained above.
The question however can be asked, what is causing the bones to come too close together? In the physical examination, doctors should look for damaged connective tissue in the hip capsule or at the three ligaments of the hip and examine the hip labrum to see if stretched or torn tissue is causing the hip joint to become unstable.
Does femoroacetabular impingement cause hip instability or does hip instability cause femoroacetabular impingement?
Doctors at the University of Rochester suggest that: High rates of FAI morphologic characteristics are present in patients with hip instability. They share similar characteristics and may predispose the hip to instability through anatomic conflict caused by pincer or cam lesions (or both) levering the femoral head posteriorly.(13)
Hip tendinopathy and Greater trochanteric pain syndrome.
As we have mentioned many times in our hip pain related articles, the hip is a big joint, at Caring Medical and Rehabilitation Services we believe to help patients achieve their treatment goals, they need to have their entire hip treated with our comprehensive Prolotherapy program for hip pain.
Recently in our article on greater trochanter pain syndrome, an example of concentrating on specific hip problems instead of treating the whole hip joint can be found in medical research studies trying to find out why some hip procedures did not work as well as they should have.
The example we cited is a new paper from doctors in Italy who looked to see what caused greater trochanter pain syndrome in patients with suspected femoroacetabular impingement syndrome. After magnetic resonance arthrography of the hip and an evaluation of 189 patients, in the end it was hard to say because there were so many problems with the patient’s hips that they far outnumberd femoroacetabular impingement syndrome problems.
Femoroacetabular Impingement Instability Non-Surgical Treatment
Many patients ask us if a congenital (genetic) hip problem requires surgical correction. The answer is – sometimes. Sometimes pelvic osteotomy, femoral osteotomy, or joint replacement surgeries are needed. If someone has avascular necrosis of the hip, sometimes surgery is needed.
When Prolotherapy is considered a good option
For the patient who wants to first explore a more conservative approach, we recommend Prolotherapy inside the joint, as well as around the structures of the joint causing some or all of the pain.
If the patient has some reasonable range of motion remaining, ie 50% or greater normal range of motion, then Prolotherapy works at helping with the pain and exercises like cycling and swimming will slowly allow the patient to regain some of the lost range of motion.
Some patients have conditions that predispose them to less range of motion. A person may present with 50% of normal motion in his right hip with regard to external rotation compared to his left hip, but not have any pain in the right hip. He may be able to run and continue sports with no problem, as the range of motion deficiency does not necessarily hinder sports performance or feel painful.
In another example, a patient has FAI and his main symptom is groin pain. The patient is a cyclist and is experiencing pain with cycling. In seeing this particular patient, we would try and determine if he truly has FAI on physical examination, looking for a positive impingement sign and then determine the cause of it. If the cause is some tremendous structural problem with the hip like a dysmorphic problem or orientation problem of the femur, then surgical correction may be needed. However the most common cause of FAI and other premature osteoarthritic conditions is simply some type of soft tissue injury such as a ligament injury, so thus Prolotherapy is the best treatment! Injury to the iliofemoral or ischiofemoral ligaments, as well as a torn hip labrum, can cause hip joint instability. Given enough time this can cause premature osteoarthritis and eventually FAI.
Sometimes the patient will only achieve pain relief, which, of course, the patient is excited about. However, some sports like martial arts require not only improved pain levels, but also improved range of motion. So sometimes, even though the patient is a good Prolotherapy candidate for decreasing pain levels, the patient may still need arthroscopy or some other surgical procedure to help with range of motion. It is surprising, however, the high number of patients we have seen over the years who do not really get much improved range of motion with surgical procedures! For those who are inquiring about a surgical procedure for premature osteoarthritis of the hip, have a frank discussion not just with your Prolotherapy doctor, but also with your orthopedic surgeon. If you end up choosing surgery, you can always get Prolotherapy after the surgical procedure. Better yet, if Prolotherapy does not fully meet your expectations, you can always then choose surgery. Our philosophy is always to go the least invasive, most potentially successful route first.
Sports hernia and femoroacetabular impingement in athletes
David N. Woznica, MD discusses sports hernia and femoroacetabular impingement in athletes.
The idea that sports related chronic groin pain represents a major diagnostic and therapeutic challenge in sports medicine has been discussed at length in the medical research. Ohio State University researchers writing in the medical journal Frontiers in Surgery. write the “complexity of the anatomy and biomechanics of the groin makes these injuries more difficult to identify and manage. Patients may find themselves evaluated by multiple physicians and receive numerous diagnostic studies over a period of months.(14)
Italian researchers reporting in the World journal of clinical cases say Femoroacetabular impingement has been reported in as few as 12% to as high as 94% of patients with sports hernias, athletic pubalgia or adductor-related groin pain.
Cam-type impingement is proposed to lead to increased symphyseal motion (resulting in cartilage deterioration) with overload on the surrounding extra-articular structures and muscle, which can result in the development of sports hernia and athletic pubalgia. In simpler terms, hip/pelvic instability.
In this paper the researchers are suggesting that for patients with FAI and sports hernia, the surgical management of both problems is more effective than sports pubalgia surgery or hip arthroscopy alone (89% vs 33% of cases).
As sports hernias and FAI are typically treated by general and orthopedic surgeons, respectively, a multidisciplinary approach for diagnosis and treatment is recommended for optimal treatment of patients with these injuries.(15)
This idea that to successfully treat sports hernia you would need to surgically repair numerous areas is not new. In 2011 doctors at the Minnesota Orthopedic Sports Medicine Institute wrote: When surgery only addressed either the athletic pubalgia or intra-articular hip pathology in this patient population, outcomes were suboptimal. Surgical management of both disorders concurrently or in a staged manner led to improved postoperative outcomes scoring and an unrestricted return to sporting activity in 89% of hips.(16)
For some athletes this is good news, for others multi-stage surgeries present time off challenges. Here are the results of that study:
- 37 hips (mean patient age, 25 years) were diagnosed with both symptomatic athletic pubalgia and symptomatic intra-articular hip joint pathology.
- There were 8 professional athletes, 15 collegiate athletes, 5 elite high school athletes, and 9 competitive club athletes.
- Outcomes included an evaluation regarding return to sports and various scoring systems to determine successful treatment.
- Thirty-one hips underwent thirty-five athletic pubalgia surgeries.
- Hip arthroscopy was performed in 32 hips (30 cases of femoroacetabular impingement treatment, 1 traumatic labral tear, and 1 borderline dysplasia).
- Of 16 hips that had athletic pubalgia surgery as the index procedure, 4 (25%) returned to sports without limitations, and 11 (69%) subsequently had hip arthroscopy at a mean of 20 months after pubalgia surgery.
- Of 8 hips managed initially with hip arthroscopy alone, 4 (50%) returned to sports without limitations, and 3 (43%) had subsequent pubalgia surgery at a mean of 6 months after hip arthroscopy.
- Thirteen hips had athletic pubalgia surgery and hip arthroscopy at one setting. Concurrent or eventual surgical treatment of both disorders led to improved postoperative outcomes scores sporting activity in 89% of hips (24 of 27).
For the patient concerned about surgery for femoroacetabular impingement who desires a conservative approach, Comprehensive Prolotherapy with the additions of Platelet Rich Plasma and Stem Cell Therapy for the hip may be warranted.
Prolotherapy inside the joint, as well as around the structures of the joint causing some or all of the pain is what we typically do. Prolotherapy, along with other proliferants, addresses all the pain-producing structures. It typically works well with FAI, along with the other conditions causing premature hip osteoarthritis. We use this along with an exercise program that we prescribe geared at stimulating joint health.
Danielle Steilen-Matias, PA-C | Katherine Worsnick, PA-C | Ross Hauser, MD | David Woznica, MD
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