Recently, a recurrent male patient of mine, now middle-aged, presented to our office with hip pain on a daily basis that interferes with his getting in and out of the car, sitting for longer periods, and getting up from his seat.
In the past, I examined him for spinal problems and had to learn discovertebral degeneration, a lesion that became known with the wide-spread use of MRI and is known by the name of Dr. M.T. Modic, which indicates segmental instability of the spine. His tall stature and the postural abnormality of his spine due to Scheuermann's disease served as the basis of his spinal problems.
On physical examination, in addition to his Scheuermann dorsolumbar scoliosis and asymmetrically limited range of lumbar motion, painful restriction of the hip on flexion and internal rotation was observed.
X-ray, MRI scan was performed, which, in addition to the incipient degeneration of the acetabular joint, showed femoral head deformity, called “CAM” morphology at the head and neck border.
Well.... now my recurrent patient taught me Hip Impingement Syndrome (femoro-acetabular impingement FAI).
Shoulder impingement syndrome has been known for a long time, but similar impingement of the hip is less well known. The shoulder and the hip are both axial joints. In the case of the shoulder dynamic large movements, flexible stabilization, the role of the rotator cuff muscles are emphasised, on the other hand the hip joint is for static load bearing, and thus the joint itself and its components, the femoral head and the acetabular socket, play the main role.
In a healthy hip, the surface of the spherical femoral head and the corresponding joint socket are covered by a thin layer of hyaline cartilage, allowing the femoral head to move relatively freely within the joint. The head of the femur is fixed by a fibrocartilage ring (labrum) around the edge of the socket. With certain movements (typically flexion and internal rotation) the bad shaped femoral head contacts the anterior socket, which can lead to labrum tears and subsequent damage to joint cartilage, leading eventually to hip osteoarthritis.
If a young or middle-aged individual presents with hip pain that is not attributable to a developmental abnormality, or is a person who either plays a lot of sports or (on the contrary) has a sedentary lifestyle, the possibility of hip (femoroacetabular) impingement syndrome arises.
Hip impingement syndrome is often caused by bone deformities. These include congenital hip joint abnormalities, developmental deformities, or acquired juvenile hip diseases (Perthes disease, epiphyseolysis). Certain sport activities, such as football, tennis, running , water polo, gymnastics, which require movements of the hip joint beyond the normal range of motion, can lead to hip impingement even without deformities.
Based on bad bone morphology of the hip, three main types of impingement are distinguished, known as "cam", "pincer" and mixed . In the cam type, the femoral head is not perfectly round, a small bump at the femoral head-neck junction collides with the rim of the socket, when the joint moves. In the pincer type, there is extra bone on the acetabulum, so that the femoral neck collides with the overhanging rim of the socket, when it is flexed. There is a third type, a mixture of these.
Hip impingement syndrome based on bone deformity may be treated surgically. If there is no significant wear and tear in the joint, correctional surgery involves removing the bad bone, stitching (suture) of the torn labrum and treating any damage of the cartilage. The aim of the surgery is to correct the abnormal joint shape and to eliminate impingement during movement. Several months of rehabilitation are required after surgery. Even if the surgery is successful, it may not resolve all the pain and restrictions the patient feels, and may well be associated with complications.
However, the hip is not only made up of bones, but also of soft tissues, tendons, ligaments and the hip muscles that move and stabilise the joint. The bones are important, but not the only determinants of hip health and mobility. Muscle tissue, flexibility, extensibility and mobility are equally important factors. If the muscle is too tight or weak, full of knots, hip impingement syndrome can occur without bone deformity. The tightness of the thigh extensor (quadriceps) and thigh adductors (adductors), and the weakness of the glutei and the hamstrings often result in hip impingement.
The treatment of hip impingement syndrome is therefore primarily non surgical, but conservative physiotherapy and excercises. A good excercise programme can treat the pain and the limitation of movement associated with hip impingement and can often resolve it.
The restoration of healthy hip function is based on 3 pillars: muscle tissue regeneration, muscle stretching and muscle reactivation/reeducation (TSR programme).
1. Tissue regeneration means revitalization of the overloaded and overused muscles which sometimes results in prompt pain relief and mobility. The correct massage is far from general and superficial, but should be deep, targeted and pinpoint.
2. Stretching of the muscles. Overtired, overused muscles become tight, shortened and easily lead to hip impingement syndrome. Stretching the hip muscles restores their flexibility and extensibility. All of the hip muscles (quadriceps, hamstrings, adductors, gluteus, iliopsoas) should first be streched, then focusing on the impingement causing, tightest ones. The hip flexor muscle is particularly prone to tightness and shortening.
3. Unused, atrophied, weak muscles need to be reactivated and reeducated. A sedentary lifestyle, one-sided movement, faulty motor control leads to muscle amnesia, muscle memory loss. Amnesia of the gluteal muscles is very common.
In addition to the tissue quality, flexibility and mobility of the hip muscles, physiotherapy also involves posture correction. Anterior pelvic tilt (e.g. when squatting or flexing the hip joint) mainly leads to tightness and shortening of the hip flexor muscle (iliopsoas)
Lifestyle changes are also necessary! Sitting all day - in the office, in front of the computer, in the car - is terrible for your hip joint. Lifestyle changes are required, above all regular exercise. Motion is Lotion! Best position is next position! The best posture is to stand instead of sitting, walk instead of standing.... and avoid one-sidedness. Avoidance of certain physical activities can also be recommended to prevent wear and tear. Introduction of regular physiotherapy, periodic physical therapy, pills for pain relief and sometimes joint injections might also be needed.