Working Diagnosis:
Femoroacetabular impingement

Treatment:
Twelve week follow up reveals no improvement with steroid
injection/PT. Patient referred to Hospital for Special Surgery for second surgical opinion. However, the patient decided to have surgery done in Albany, NY. Exploratory arthroscopic surgery planned for
diagnosis/treatment of FAI and labral pathology.

Outcome:
Surgery planned.
At time of publication the patient remains unable to participate in any physical activity secondary to pain.

Author's Comments:
Femoroacetabular impingement is an anatomic cause of hip pain which may lead to early arthritis, articular cartilage damage and labral tear. It has only recently been recognized as a relatively common cause of hip pain, with a prevalence of 10-15%. Symptoms include chronic pain and decreased range of motion. The structural abnormality disrupts the soft tissue structures during normal ROM, specifically flexion and internal rotation cause impingement of the labrum and cartilage. Diagnostic imaging includes Xray, CT, MRI and MRA.

It is classified into two forms (but is mixed in 86%): pincer and cam
impingement. Pincer impingement is an acetabular etiology, with acetabular retroversion (relative posterior opening of acetabulum) and/or coxa profunda (overcoverage of femur by acetabulum). Cam impingement is a femoral etiology, seen with sub-clinical SCFE, mal-union of femoral neck fx, and decreased femoral anteversion. Conservative treatment does not alter bony abnormalities causing impingement. Treatment typically involves surgical resection of the cause of impingement, using open or laproscopic techniques. No treatment may result in labral and/or cartilage tears and early arthritis. Risks of surgery include avascular necrosis, femoral neck fracture, and adhesions.

Editor's Comments:
Evaluation of the hip is complex but enlightening when anatomy and exam techniques are mastered. The interested reader would do well with the following review article:
Martin HB, Shears SA, Palmer IJ. Evaluation of the Hip. Sports Med Arthrosc Rev 2010;18:63.

Femoracetabular impingement (FAI) is associated with labral pathology and hip impingement. However, prior DDH, Perthes' disease, SCFE, and trauma can also lead to labral tears and/or hip impingement. While the full extent of FAI long-term morbidity is unknown, many sports medicine specialist believe that early treatment (usually arthroscopic) will change the natural history of hip arthritis. We will still have to wait for long-term data to be certain patients are truly helped but short term results of surgical treatment for FAI is promising in the hands of experienced orthopedists.

This case makes a good point of continued attempts at quality and well-directed physical therapy is warranted while contemplating the need for surgery. Also, ensuring the pain is related to an intra-articular process with hip injection is notable. However, the editor would remark that true femoral retroversion of Cam impingement would not be associated with full or symmetric ROM (especially IR and ER of the hip) if the process was unilateral.

References:
Jude CM and Modarresi S. Radiologic Evaluation of the Painful Hip in Adults.� Uptodate.com, accessed January 13, 2010.
Philippon M, Schenker M, Briggs K and Kuppersmith D. Femoroacetabular Impingement in 45 Professional Athletes: Associated Pathologies and Return to Sport Following Arthroscopic Decompression.� Knee Surg Sports
Traumatol Arthrosc. 2007; 15: 908-914. Tannast M, Siebenrock KA, and
Anderson SE. Femoroacetabular Impingement: Radiographic Diagnosis- What the Radiologist Should Know.� AJR. 2007; 188: 1540-1552.

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