Page 6 - SMU Spring 2020

TEAM PHYSICIAN’S CORNER
Hip Impingement and FAI correction of both cam and pincer lesions
have been reported to be superior using
Athletes with impingement will commonly 5,6
present with groin pain (anterior) during an open surgical dislocation approach.
cutting, pivoting movements, hip flexion Regardless of approach, good outcomes
activities, and also sedentary activities and reliable return to sport can be achieved
1,7
like sitting. Historically, these injuries when conservative measures fall short.
were commonly misdiagnosed as hip Extensive high level research including
flexor strains or adductor tears. FAI can two prospective multi-center randomized
be the result of an aspherical anterolateral controlled trials have demonstrated the
head-neck junction that causes a pistol- improvements for arthroscopy are much
grip or cam type deformity, or it can greater than best conservative care for
8,9
be the result of over-coverage of the patients with FAI. Patients and athletes
acetabulum (commonly referred to as with borderline dysplasia can present in
“pincer impingement”). Extra-articular different ways depending on if instability
impingement may also coexist such as or impingement seems to be the driving
sub-spinous (anterior inferior iliac spine) pathologic issue. There are signs of
impingement. Treatment should begin impingement with limited internal rotation
with a rehabilitation program focused in flexion, normal to low hip range of
A recent systematic review of 1,296 on core strength, lumbar mobility, and motion, impingement positive, results of
arthroscopic treatment can be favorable.
patients revealed a return to sport rate hip abductor strengthening. Non-steroidal
Extra-articular impingement can arise
of 85 percent at a mean of 7.4 months anti-inflammatory medications can also from a large sub-spine deformity. These
after surgical intervention. Isolated be used, and occasionally intra-articular
arthroscopic procedures should be injections. pelvic deformities are thought to arise
from old rectus avulsions that heal with
avoided in athletes with dysplasia. Surgical management of FAI has grown
In cases of borderline dysplasia substantively over the past two decades. a bony protuberance below the level of
2,3
the acetabular sourcil. These deformities
(LCEA 20-25) a thoughtful approach Arthroscopic and open techniques can be
to conservative care, rehabilitation, and used to treat FAI with similar outcomes, should be addressed concurrently during
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arthroscopic FAI correction. (Figure 5)
surgical intervention must be employed. however, radiographic outcomes including
Dysplasia
There is a significant incidence of hip
dysplasia in sports that require high range
of hip motion such as dance (ballet), 10-12
hockey (butterfly-style hockey goalies in
particular), 13-15 wrestling, and gymnastics.
17
16
Acetabular dysplasia is often combined
with femoral head-neck offset deformity
with high hip motion; a complex pattern
of instability and impingement. 12,13 Higher
Figure 1: Preoperative AP pelvis of an 18-year-old wrestler Figure 2: AP pelvis status post bilateral staged hip
with borderline hip dysplasia (LCEA 22 right and 20 left) arthroscopies (4 weeks apart). Note the cam correction activity levels and more severe deformity
and cam-type FAI. Femoral anteversion was 8 degrees at the lateral head-neck junction. are associated with onset of symptoms at a
on both sides.
younger age. Athletes with dysplasia and
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instability will more commonly present with
lateral as well anterior hip/groin pain, and
pain with standing, running, and activities
that involve hip extension. The first line
treatment for an athlete with symptomatic
hip dysplasia is a core and hip abductor
focused physical therapy/rehabilitation
program, non-steroidal anti-inflammatory
medications, and activity modification.
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Figure 3: The 45-degree Dunn lateral of the left hip. Figure 4: The 45-degree Dunn lateral of the right hip.
Note interval osteochondroplasty and restoration of Note interval osteochondroplasty and restoration of Individuals with more active lifestyles are
femoral head-neck offset. femoral head-neck offset. more likely to choose surgical management
despite these conservative treatments.

 4 SPORTS MEDICINE UPDATE | Spring 2020, Issue 2