ULTIMATE GUIDE TO HIP IMPINGEMENT: PART 1

Updated: Sep 11, 2020

Hip impingement is a fairly common problem, but that doesn’t mean it’s normal. Pinching, catching, popping, snapping… all words that may come to mind if you struggle with impingement. Part I of this blog takes a deep dive into what hip impingement is and what can be done to help manage it.

WHAT IS HIP IMPINGEMENT?

Femoroacetabular impingement (FAI), otherwise known as hip impingement, occurs when the femur (thigh bone) makes excessive contact with the acetabulum (pelvis) and results in pinching of the anterior structures of the hip [1]. There are a few different causes of FAI:

Structural FAI

Some people are naturally born with a hip joint structure that makes them more prone to developing symptoms. There are 3 types of structural problems:

  1. Cam impingement- extra bone growth on the femoral heal

  2. Pincher impingement- extra bone growth on the acetabulum

  3. Combination of cam and pincer

In all of these scenarios, the extra growth causes the bones to excessively come in contact with one another during movement, which can result in pinching of soft tissues and discomfort.


Functional FAI

Functional FAI is the result of muscle imbalances and altered movement patterns. When the hip moves, the joint must stay centered. So, the ball must stay in the middle of the socket throughout the entire range of motion. Otherwise, we get excessive stress on one part of the joint. In the case of hip impingement, the head of the femur tends to shift forward, putting more stress on the front part of the joint [2].


Having good muscle strength and stability is what helps maintain proper alignment and prevents impingement. There is evidence that those with hip impingement have greater hip muscle weakness and altered movement patterns compared to other asymptomatic individuals [3].

There are also other diagnoses that can coincide with FAI, such as labral tears, tendinitis, or early onset osteoarthritis. Early treatment and prevention is key to lowering your chances of developing any of these secondary problems.


ANATOMY OF THE HIP JOINT

The hip is a ball and socket joint, made up of the head of the femur (ball) and the acetabulum on the pelvis (socket). There are numerous ligaments and muscles that help to stabilize and support the joint during movement. In the case of FAI, we tend to see muscle activation change as a protective strategy to avoid pain and discomfort. Here’s a few key muscles that play a role in hip impingement:

Tensor Fascia Latae (TFL)- This muscle on the front, lateral part of your hip and helps with

lifting, or flexing, the hip. Remember how I mentioned the hip joint must stay well-centered during movement? When overactive, this muscle is responsible for causing excessive forward glide of the femoral head and impingement [2].

Iliopsoas (hip flexor)- This one always gets a bad rap. “It’s so tight.” “I feel like I need to stretch all the time.” Sound familiar? Well, “tight” is not usually not the problem. WEAK is the problem. The hip flexor is responsible for flexing, or lifting, the leg. However, when it is weak or under trained, the TFL overpowers it. The result? more forward glide, and more pinching. Strengthening the hip flexor will help keep the joint more centered and you will be shocked at how fast that “tight” feeling subsides without needing to stretch.

Hip rotators- These are a group of small muscles on the back side of the joint that rotate the hip, as well as provide stability during movement. We tend to see altered strength, mobility and movement patterns in the hip rotators in patients with FAI.


SYMPTOMS OF HIP IMPINGEMENT

  • Pain in the front of the hip that may also radiate to the outer hip (also called the “C-sign” because the pattern of pain is in a C-shape)

  • Pinching, catching or popping in the hip that occurs with movement

  • Worse with hip flexion (i.e. lifting the leg, sitting, up & down stairs, squatting)

  • Limited mobility, most commonly with internal rotation and flexion

  • Hip muscle weakness

STRUCTURE DOES NOT DICTATE FUNCTION

FAI is common in the general population, but not everyone has symptoms. Before you run out and get an MRI, know this: Research continues to show that a large majority of people with hip pathologies present on MRI scans are often completely symptom free.

Most recently, a study was published in the Journal of Clinical Radiology looking at the prevalence of labral tears in asymptomatic dancers and rugby players. Each participant in the study was completely free of symptoms at the time of the MRI. It was found that labral tears were present in 87% of hips, and cartilage loss was present in 54% of hips [5]. You can see that structure does not always dictate function, and often MRI’s to diagnose FAI are not necessary.

So why do only some people develop symptoms? It depends a lot on your activities. FAI is more problematic in activities that involve extreme ranges of motion, like dance or soccer. In dance, for instance, the hip is flexed repetatively, which is a motion that naturally causes the bones to come closer together. Combine that with altered movement mechanics, weakness or structural changes, and you end up with a much higher likelihood of developing symptoms.


TREATMENT FOR HIP IMPINGEMENT


Physical Therapy

To be honest, the research is still mixed on the best course of treatment. In my experience, conservative care (AKA Physical Therapy) should always be your first step. Physical therapy has positive outcomes when it comes to pain and symptom relief for FAI. Treatments may include hands on therapy, strengthening, mobility work and of course, lots of patient education [5]. In my own opinion, it is extremely important that you seek out a Physical Therapist who is experienced at treating FAI. Not all PT’s are created equal, and it can make or break your success in rehab.