Sports Injuries

In the first part of the 2-part article on femoro-acetabular impingement (FAI), chiropractor, Dr. Alexander Jimenez discussed FAI and how it can lead to insidious onset abdominal pain and damage the hip joint labrum, leading to early arthritic changes. Given that conservative management generally fails in young athletes and needs operation, part two describes the post-operative rehabilitation period required to take an athlete back to full competition.

The post-operative rehabilitation period is highly dependent on the magnitude of pathology and the subsequent procedure; weight-bearing development is consequently variably reported in the literature.

If the labrum is surgically repaired, then protected weight bearing is encouraged to allow the repair site in order to be protected during the early healing phase. Also, avoiding extremes of flexion (beyond 60°) and also internal/external rotation for the initial 4 to 6 weeks is important to safeguard the repaired labrum. Any positions that possibly create an impingement and boost inflammation ought to be prevented. These include:

• Deep squatting
• Prolonged sitting
• Low couch sitting
• Lifting off the ground
• Pivoting on a fixed foot

These positions are more safely tolerated following the six week post-operative period. But on account of the selection of hip flexion limitations imposed in the initial six months, usual activities of daily living are rather restricted, making yield to work and daily chores challenging if not impossible from the first few weeks following surgery. Therefore, the post- surgical patient does have to make substantial lifestyle changes and they need assistance in the first six weeks following surgery.

Special precautions in certain types of FAI processes. Reshaping of the femoral head- neck junction can weaken the rectal neck so particular care must be taken in this post- operative period. Fracture of the femoral neck is an unlikely but potentially serious complication after a reshaping process. The athlete may be allowed to bear full weight, but crutches are needed to avoid twisting movements during the initial four weeks after surgery. High impact pursuits and high torsion moves should be prevented in the first 3 months, as bone grafting requires around three weeks to attain full structural integrity.

Furthermore, if microfracture of this femoral head is also done for femoral head cartilage defects, then the athlete ought to be restricted to partial weight- bearing for two weeks so as to optimize the premature maturation of the fibrocartilaginous healing response.

Key points

1. Weight bearing status is dependent on the kind of reshaping procedure, whether the labrum was repaired, and also what the surgeon favors

2. Steer clear of hip flexion beyond 60° in the first 4-6 Weeks

3. Avoid extremes of rotation

Post-Surgical Rehab

Rehabilitation protocols provided in the literature have a tendency to be quite generic in their own advice and at best explain broad transitional phases during the rehab process. They usually describe the transition in weight bearing status, the development of gait through walking into jogging, and give general guidelines as to how to and when to progress activity based on a time dependant strategy.

They then progress describing transitions into twisting and affect actions -- usually explained as beginning at 3 weeks following surgery -- and generally the guidance is that the speed with which the athlete progresses is variable and might need yet another 1 to 3 months to get full return based on the game. Trainers are usually advised that return to sports after surgical correction of FAI can require 4 to 6 weeks. However it's critical that progression through rehabilitation phases is driven more by subjective and objective measures during the transition phases. This allows the athlete and therapist to track load (type and quantity) and ascertain whether the joint arrangements are able to withstand changes in load securely.

Wahoff et al (2014) have provided some standards which may be utilized to guide the transition from one point to the next(1). They describe their rationale and supply a complete description of all of the cited tests in their printed clinical comment. Essentially, the exit criteria they offer in each phase are as follows;

So as to advance through the six clarified stages, the athlete may undergo extensive physiotherapy, focusing on hip range of movement exercises, manual therapy and trigger point releases, active stretching, potentially deloaded activities like hydrotherapy or Alta G walking/ running and strong hip rotator and gluteal strengthening exercises. Much of this will be 'controlled' and led by the wishes of the surgeon as they will provide the framework on if and what happens concerning loading.

But more direct physiotherapy Interventions have been devised to direct the physiotherapist through the rehabilitation protocol. The Takla-O’Donnell Protocol (TOP) is a validated physiotherapy intervention program which may be utilized to induce the arthroscopically handled FAI patient (Bennel et al)(2).) This protocol is shown in box 2.

Hip Muscle Control

The focus of the rest of this article Will be to summarize some common yet powerful hip strengthening exercises which may be used to progress the hip muscle control throughout the rehabilitation phases.

Regaining hip muscle power, particularly in the heavy hip external rotator group, is imperative from the FAI recovering athlete. Good muscle endurance and strength in those muscle groups will ensure adequate hip joint compression happens with motion to reduce any shearing effect between the head of femur and acetabulum(3). The muscle groups needing focus are (see figure 5):

1. Posterior fibres Gluteus Medius (PGMed)
2. Gluteus minimus
3. Superior and Inferior Gemellus
4. Internal and External Obturator
5. Quadratus Femoris
6. Piriformis

There's plenty of exercises that can be utilized to fortify the hip joint musculature. The chosen ones below are a sample of some effective exercises that can be used throughout the rehabilitation phases. However, the key requirements of the contained exercises include:

1. Performed in neutral stylish places to no more than 60 degrees hip flexion. This range of movement protects the hip joint from any possibly damaging impingement.

2. Minimal rotation of the hip, letting them be used in most stages of the rehabilitation process.

3. Performed isometrically or utilizing little oscillating concentric/eccentric contractions -- to contract and hold to maintain the hip joint compacted and stable. This represents how these muscles work in individual function.

Summary

In many ways. hip joint labral tears, capsule sprains, cartilage and muscle accidents and bony architectural issues like FAI can all lead to debilitating hip pain. FAI is a real concern for the athlete as the existence of a bone abnormality may lead to a painful hip impingement, damage to the acetabular labrum and premature onset degeneration. FAI's don't respond to conservative management. If the athlete suffers debilitating pain that affects competition then the options are either to cease competition all together or have the FAI surgically corrected. Once corrected by the surgeon, regaining complete motion and muscle strength and ultimate game related functional skills will require some time. Hip rotator muscle strengthening must shape the foundation of all handling post-surgical FAI issues.

References
1. International Journal of Sports Physical Therapy. 9(6); pp 813-826
2. Arthroscopy. 2006;22(12):1304-1311
3. Int J Sports Phys Ther. 2012;7(1):20-30.

In the first part of this 2-part article, chiropractor, Dr. Alexander Jimenez looks at the surgery and rehab Alternatives for Femoro - Acetabular Impingement (FAI), a increasingly common musculoskeletal disorder that can affect young to middle aged athletes. In part two, Dr. Jimenez will describe in detail the postoperative rehabilitation interval required to have an athlete back to full competition

Introduction

A potential cause of hip arthritis and degeneration was originally indicated by Stulberg et al (1975), even when they identified the 'pistol grip deformity' from the x-ray signs of abnormal head of femur (HOF) clearance from the acetabulum in patients with hip arthritis(1). This resulted in the idea that mechanical impingement could possibly be among those underlying causes of hip degeneration and hip joint pain.

Over the next few decades, with Improvements in radiology and hip joint surgery, and more complex clinical assessment skills, it was recognized that a number of atypical hip joint morphologies often existed that may contribute to hip joint pain in athletes.

In the late 1990's, Mayer et al (1999)(two) Were the first to use the word 'Femoro- acetabular impingement' or 'FAI' to explain the morphology of the hip as being a causative factor in hip joint arthritis, and the notion of FAI was further initiated by Reinhold Ganz(3) and colleagues during the early 2000s.

An FAI is a real complication for an athlete, especially for young male athletes, because it cannot only cause hip joint pain and labral and cartilage damage, but it can also contribute to other athletic injuries like osteitis pubis and cerebral hernias due to the detrimental effect that too little hip joint rotation plays on thoracic strain injuries(4). The purpose of this rehabilitation Masterclass would be to explain the appropriate anatomy and biomechanics of the hip joint, explain the pathogenesis of both FAI and offer management ideas and also an in depth overview of the rehabilitation of the hip joint post-FAI operation.

1. The head is slightly more than half a sphere.

2. The femoral neck is cylindrical, narrowest in the midpoint and widest laterally, and attaches the head to the shaft.

3. The acetabulum is cup shaped.

4. The labrum is triangular in cross section using its base attached to the acetabular rim.

Usually a space is maintained between the Femoral head neck junction and the acetabular rim, and this provides unhindered hip motion. The normal head cancel is 9 mm(6 feet).

Symptoms

Lead to impingement kind symptoms. A deviation from the standard alignment of the hip can cause a mechanical blockage between the acetabular rim and/ or head-neck of femur. This deviation away from the ordinary may be due to inherent geometry flaws from the patient's hip joint complicated.

• Pistol grip deformity of the femoral neck.

• Reduced femoral neck offset in anterolateral aspect of head neck junction.

• Reduced femoral anteversion.
• Loss of spherecity from the femoral head.

• Excessive coverage of acetabulum

• Retroversion of acetabulum (causes over-coverage and restricts flexion of the femoral neck).

FAI As Injury

Although some examples of hip joint Impingement are caused by inherent hip joint abnormalities, FAI as an injury is an anatomical mal-alignment between the head and neck of femur and the acetabulum. This causes compression of the labrum and articular cartilage through hip flexion demonstrating as anterior hip pain and development to premature osteoarthritis of the hip. It is a state that seems to influence younger active men and women, particularly men. For instance, in a radiological analysis of 155 young active individuals 18-50 decades old with complaints of hip pain, it had been discovered that a staggering 87 percent of subjects had evidence of an FAI(7).

The natural development of an FAI to Since the labrum frays along the thoracic borders, this progresses into a more consequential tear of the labrum. The articular cartilage then delaminates away from the articular margin adjacent to the labral lesion. This subsequently contributes to unnatural shear forces throughout the joint, which over a long expression, induces more international labral and articular degeneration.

Furthermore, more recent research Suggests a strong link between FAI and other athletic groin pain syndromes, in particular athletic pubalgia. Economopoulos et al (2014) found that in 43 patients who underwent operation for athletic pubalgia, 86% of these had evidence of a FAI in a minumum of one hip, together with Cam lesions being the most prevalent (see below for Cam lesion)(9). This highlights the possible interaction between forces acting across the pelvis and hip joint. Hammoud et al (2014) supply an in-depth discussion on the way the FAI can potentially lead mechanical reimbursement routines, which can subsequently result in a plethora of sports injuries like osteitis pubis, sacroiliac joint problems, posterior hip impingement and proximal hamstring syndrome simply to name a few(10).

In the context of FAI, two primary Manifestations of FAI are described. These are 'Cam' and 'Pincer' lesions (see figure 2).

Cam Lesions

The Cam lesion is attributed to an Asymmetric or non-spherical section of the femoral head or neck abutting from an acetabular rim. This abutment is the most evident in flexion and internal rotation where a shear force happens along the anterolateral edge of the acetabulum. This deformity reduces the mind neck counter, raises the femoral head radius of curvature and results in relative retroversion of the femoral head.

The smooth motion between the Femoral head and acetabulum is missing, which causes an outside-in abrasion of the acetabular cartilage with avulsion in the labrum and subchondral bone (delamination). This may result in separation of the cartilage in the antero superior part of the labrum(11). Labral injuries are more likely to affect the anterior region possibly due to its inadequate blood supply.

Cam lesions are typical in young Active guys with a ratio of around 25 percent in asymptomatic hips(13), and around 78 percent in thoracic hips(14). It's more prevalent in males than in women at a ratio of 3:1(15). It is possible that a major factor in the development of a Cam lesion is a slipped capital femoral epiphysis where posterior displacement of this capitis leaves a prominence of the anterior neck, leading to severely limited internal rotation of the hip(16). Furthermore pistol grip deformities may result in more subtle forms of aspherical mind of femurs, and these have been correlated with early onset osteoarthritis in adults.

Pincer Lesions

Pincer lesions produce repeated contact between a normal femoral head neck and an over coated acetabular rim. This causes multiple cleavage planes in the labrum and subsequent labral degeneration, intrasubstance ganglion formation, ossification of the acetabular rim, and ultimately a portion of the acetabulum further compounding the pincer lesion.

Unlike in cam lesions, the chondral Harm associated with pincer lesions is much more circumferential in the anterior and supero-lateral acetabular rim, where force transmission is larger and as a 'contre- coup' lesion in the posterior capsular- labral junction as the 'levering' from the femoral head along the fulcrum generated by the anterior pincer lesion whilst the hip is bending(17,18).

Retroversion of the pelvis can also cause the acetabular rim to roll backward. It's to be noted that spinal deformities like scoliosis or kyphosis can cause pelvic rotation and practical retroversion of the acetabulum that might work as a pincer lesion. There can also be an extra bit of bone along the lateral rim of the acetabulum known as an 'os acetabulum'(19). Pincer lesions are more frequent in busy females(20).

Mixed Lesions

Rarely do cam and pincer lesions happen in isolation. Most type of FAI happens from mixed cam and pincer pathology at the But, Cobb et Al. (2010) argued against that after Analyzing the morphology of 60 acetabula Using CT scans(21). They reported that Acetabula with cam hips were shallower Than ordinary hips, which subsequently were Hence, they Concluded, that camera and pincer lesions Were different patho-anatomic entities With camera hips being shallow while the Pincer hips are deeper than normal hips.

Signs & Symptoms of FAI

FAI in the athlete may pose as insidious onset groin pain worsened by hip flexion and hip flexion with internal rotation type movements. It is more common in male athletes on account of the male inclination towards Cam impingements. Sports with a higher incidence of FAI are sports which involve a great deal of forced flexion with inner rotation including treading water polo, breaststroke kicking, football sports like football and AFL, rugby, field hockey, combat sports like wrestling and Brazilian Jujitsu and ice hockey.

The athlete themselves might aid the identification by providing information regarding childhood diseases that could result in abnormal head throat junctions. Conditions for example Perthes disease (3-12 year olds) or slipped capital femoral epiphysis (SCFE) (12-14 year olds) may alert the sports medicine practitioner an underlying FAI could be present.

The typical collection of symptoms and signs are;

1. Insidious onset of symptoms at active young and middle aged adults.

2. Groin pain associated with action and no prior history of trauma.

3. Inability to perform tasks such as high hip flexion or extend sitting.

4. May hurt moving from squat or sit to standing.

5. Sharp stabbing pain with motions like aggressive turning or pivoting.

6. Painful clicking, locking or instability out of a labral tear leading to undiagnosed FAI.

7. Reduced range of motion especially flexion, adduction and internal rotation. Often athletes notice that they are less elastic as their team-mates.

Objective Signs

Due to underlying hip muscle weakness associated with the hip joint pathology, the patient could often show poor proximal pelvic control during single position tests along with a Trendelenburg sign may be present. Passive selection of motion is going to be limited compared with the non-affected side, especially hip flexion (usually significantly less than 110°) along with hip internal rotation (less than 15°). A range of tests have been proposed that may aid the sports medicine practitioner in clinically identifying an FAI in an athlete.

Impingement Tests

FADDIR sign (22) -- This evaluation involves passive hip joint flexion, adduction and internal rotation (Flexion-ADDuction- Internal Rotation). Pain is felt deeply in the anterior hip/groin region and that the assessor may sense a mechanical block to motion.

Posterior inferior impingement test(23) -- With the hip in hyper expansion, passively by hanging the leg above the end of the mattress, the affected hip is passively externally rotated. The test is positive if it arouses similar pain as complained by the individual.

FABER test (24) -- Together with the hip in flexion, abduction and external rotation (Flexion- ABDuction, External Rotation), abutment of the labrum and cartilage also can happen. The test is positive if it elicits similar pain as complained of by the patient, or when the space between the knee along with the exam table differs between the symptomatic and contra lateral hip.

Radiographs

Anterior/Posterior (AP) viewpoints will also define the acetabular version like the cross- over sign. This may also be seen reminiscent of a notable anterior acetabular wall (pincer impingement). AP viewpoints will reveal acetabular retroversion, acetabular depth, os acetabulum and/or herniation pit at the neck of femur or impingement cysts can be present.

Standard Lateral View

This can be completed in 10-15° internal hip rotation to compensate for femoral anteversion. This is best to view the Cam impingement lesion and reactive fibro cystic changes of the anterior head-neck junction. Other radiological measurements which can be made include head-neck offset(25), alpha angles(26), and anterior counter ratio(27).)

Magnetic Resonance Imaging (MRI) & Arthopgraphy (MRA)

MRI is helpful if hip labral pathology is suspected in conjunction with FAI, and might show articular cartilage thinning. It is more likely indicative of a subchondral stress reaction in the anterior acetabulum because of failure of the subjacent thoracic surface. Therefore, anterior acetabular subchondral edema is indicative of important articular pathology(28).

MRA is much more sensitive for seeing intra-articular pathology such as labral lesions. This can also be helpful, as the gadolinium injection related to the MRA also has local anaesthetic which can be used as a diagnostic cube to get intra-articular joint pathology.

Computerized Tomography (CT)

CT 3D reconstructions are useful to assess the shape of the femoral head neck junction and this is deemed useful for surgical resection. A new CT opinion has been invented by Pritchard and O’Donnell to show FAI lesions(29). CT scanning at the position of discomfort (POD perspective) enables symptomatic Cam deformity to be accurately mapped in a 3-dimensional reconstruction. This procedure helps in identification of the problem by visualization and following preparation for surgical resection.

Surgery

Because of the mechanical nature of FAI, conservative direction along with physiotherapy usually fails as ultimately, the impingement of bone on bone will turn out to be restrictive to the athlete. Frequently conservative applications are only effective as behaving as identifiers of both FAI and then to prevent additional mechanical symptoms by preventing the offending movements. Gym based movements such as squats past 60° hip flexion, Bulgarian squats and leg press are avoided, or modified to be done in external rotation. But, finally if pain persists then operation is the only method to handle those issues.

Before the development of more advanced hip joint surgery techniques, athletes using 'FAI' could have lived and performed within the confines of their symptoms. They simply would have avoided movements that generated hip joint pain and when this proved too hard to prevent, they simply would have stopped to compete. In this present day, improvements in not only diagnosis but also both open and arthroscopic hip joint operation has enabled simple management of those conditions. Therefore surgery is often recommended for your young athlete using FAI. The goal of surgery is to remove the mechanical block of the proximal femur against the acetabulum and additionally to tackle any related labral pathology and articular damage. Open and closed arthroscopic techniques are described.

Prior to 2001, direct access into the hip joint was very difficult due to the risk of avascular necrosis, therefore most fashionable joint impingements were handled with labral debridement and/or labral reattachment. Back in 2001, Ganz et al described a surgical technique that included surgical dislocation using a 'trochanteric reverse osteotomy' that preserved the blood flow to the frontal brain(30). This prevented the critical negative effect of avascular necrosis of the femoral head associated with hip joint dislocation procedures. This technique led to greater diagnosis of FAI as a genuine hip joint pathology and correcting this was possible.

Open Surgery

This entails dislocation of the hip anteriorly using a trochanteric flap osteotomy. This allows a full view of their head neck junction. One other osseous impingement visualised can then be excised to restore the normal contour of the femoral neck fascia. Retroversion of the acetabulum may be managed with resection of the anterior acetabular rim. Any labral tear should be treated with excision or fix.

Continuing groin pain after an open process can be brought about by insufficient recovery of the femoral or acetabular morphology, advanced joint degeneration, joint space narrowing, ongoing cartilage damage, or scar adhesions between the hip joint capsule and rectal neck resection, also between the labrum and hip joint capsule(31). Whether this scarring is thick then they may interfere with movement involving the femur and acetabulum. These can impinge during flexion and internal rotation movements.

Arthroscopic Repair

Arthroscopic intervention is now becoming increasingly popular.

1. Central compartment -- the structures medial to the labrum.

2. Peripheral compartment the structures outside the labrum but within the hip capsule.

A traction device is utilized to separate the femur in the acetabulum to visualise the central compartment. Traction isn't needed for peripheral compartment procedures. The joint is full of saline and also two to three portals are utilized (anterior, anterolateral or posterolateral).

The procedures achieved by hip arthroscopy presently include;

Philippon et al (2007) discovered that at 93 percent of athletes returned to competitive sport following arthroscopically handled FAI(33). The small number who didn't had complex OA changes at the time of surgery.

Conclusion

FAI is an increasingly more common musculoskeletal disorder affecting the young to middle aged athlete that can lead to insidious onset groin pain and harm that the hip joint labrum and lead to premature OA changes. It's common in sports that need hip flexion and hip rotation positions as part of their art implementation. Cam and pincer lesions are the two forms of FAI lesions and these can unite to form double lesions. Conservative management generally fails in the young athlete to fully manage their pain, so surgery, either open or arthroscopic is usually the recommended treatment.

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