Functional Management of Femoroacetabular Impingement

As the imaging and surgical techniques have improved over the last several years for the hip, the rise of procedures and treatments for femoroacetabular impingement (FAI) and hip labral tears has exploded in popularity. A 2013 study in the Journal of Arthroplasty showed a 600% rise in hip arthroscopy procedures from 2006 to 2010[1]. While the value of these procedures is significant and often necessary, the value of manual therapy and Functional Dry Needling with a carefully monitored exercise program should not be underestimated in this population. In the world of direct access, clinicians will commonly see athletes and healthy individuals presenting with anterior hip and groin pain.

FAI is often broadly defined as an abnormality of the proximal femur and/or acetabular rim. This abnormal wearing can result from a femoral side impingement (CAM impingement), an acetabular rim impingement (pincer impingement), or a combination of both. This can prove to be problematic, as this can often be associated with pain, cartilage and labral abnormalities[2].

Clinically, we will often see pain in the anterior hip and groin, pain with cutting, twisting and turning, sharp pain deep in the hip, limited hip internal rotation, as well as pain with squatting or forceful hip extension. Pain is often present with passive hip flexion, log roll, hip scour and FABER/FADIR testing. These patients will also present with signs of trochanteric bursitis, as well as low back pain. Use of Craigs test to determine hip anteversion/retroversion can be helpful as well.

Dry needling for the anterior hip and adductor musculature is extremely valuable for these patients and is often introduced on the first visit for pain relief. Functionally, rectus femoris, TFL, distal psoas insertion, as well as adductor longus/magnus often present with significant myofascial dysfunction. Overuse and myofascial dysfunction of the rectus femoris, TFL, and distal psoas insertion, based on anatomical attachments, can often hold the femur in a relative anterior glide position which will increase the mechanical abutment of the femoroacetabular joint with hip flexion movements. With gait, we will often see diminished pelvic rotation and diminished hip extension which can encourage greater use of the hip flexor group. Exercise will emphasize mobility of the anterior hip and adductors, as well as core stability work with a particular emphasis on thoracolumbar junction stabilization during these exercises.  This can help promote better co-contraction of the deep core musculature and hip flexor group.  Without sufficient core stability, the anterior hip muscles will often become overused during functional activities[3].

Finally, for the athlete population, it is important to monitor squatting progression and volume in the gym, and emphasize the importance of posterior chain training.  This includes but is not limited to bridging and deadlift progressions.  Hip structure may help determine the best foot position during these movements to prevent further aggravation of the ‘impinged’ area.

While many of these cases can result in surgical intervention, the role of the physical therapist is an important one and can allow vast improvement in return to function.  Physical therapy should play a critical role in the management of this population before considering surgical intervention.

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[1]Trends in hip arthroscopy in the United States. J Arthroplasty. 2013 Sep;28(8 Suppl):140-3

[2] Femoroacetabular Impingement: a review of diagnosis and management. Curr Rev Musculoskelet Med. 2012 August 1; 5(4): 315.

[3] Dynamic Neuromuscular Stabilization & Sports Rehabilitation. Int J Sports Phys Ther. 2013 Feb; 8(1): 6273.