The Millennial and Middle-Aged Hip

Summary of CASEM Presentation by Dr. Burghardt on

The Millenial and Middle Aged Hip 

Two consensus papers regarding Femoral Acetabular Impingement Syndrome (FAI) were discussed:

Warwick agreement of FAI syndrome 2016

7 questions answered:

  1. What is FAI syndrome?: it is a motion related clinical disorder of the hip with a triad of symptoms, clinical signs, and imaging findings. It represents a symptomatic premature contact between the proximal femur and acetabulum
  2. How should FAI be diagnosed: FAI is diagnosed by symptoms and exam and diagnostic imaging
    • The primary symptom of FAI syndrome is motion-related or position-related pain in the hip or groin. Pain may also be felt in the back, buttock or thigh. In addition to pain, patients may also describe clicking, catching, locking, stiffness, restricted range of motion or giving way.
    • FADIR test (hip flexion, adduction, and internal rotation) is sensitive but not specific
    • Xray with AP and lateral views should be obtained, MRI/MRIA/CT is useful for further assessment and pre-surgical planning
  3. What is the appropriate treatment of FAI syndrome
    • Can be treated by conservative care, rehabilitation, or surgery.
    • Intra-articular injections: symptom relief with injections is positive predictor of surgical outcome
      • Ultrasound guided is better tolerated than Xray guided injections
      • Injections of saline are effective too
  4. What is the prognosis of FAI syndrome
    • If treated , symptoms frequently improve and patients return to full activity. Without treatment, it will probably worsen over time. Long term outlook is unknown but it is likely that certain types of hip morphology/shapes (specifically CAM morphology) is associated with osteoarthritis. It is unclear if treatment prevents osteoarthritis.
  5. How should someone with an asymptomatic hip with cam or pincer morphology be managed
    • This answer is unclear at this time
  6. What outcome measures should be used to assess treatment
    • Standardized outcome scores like iHOT, HAGOS, or HOS scores should be used
  7. What future research needs to be conducted?
    • Much more research still needs to be done!
Consensus recommendations on the classification, definition and diagnostic criteria of hip-related pain in young and middle-aged active adults from the International Hip-related Pain Research Network, Zurich 2018

6 Recommendations:

  1. FADIR test (hip flexion, adduction, and internal rotation) is a rule out test: if this test is negative (pain-free), it means it is very unlikely that intra-articular hip disease is present.
  2. Diagnostic imaging have limited utility alone as many asymptomatic people also show abnormalities in hip morphology/shape (increased alpha angle and central edge angle)
  3. Xrays of AP pelvis and lateral femoral head-neck radiographs are recommended. Cross sectional imaging is recommended if further morphological assessment or intra-articular structure assessment is needed
  4. Hip related pain can be categorized into:
    • FAI syndrome
    • Acetabular dysplasia and/or hip instability
    • Other conditions causing hip related pain including soft tissue (labrum, cartilage, ligamentum teres) without a specific bony morphology
  5. More research is still needed to standardize bony morphology
  6. More research is needed to assess the relationship between bony morphology and hip conditions, and movement related factors relative to each hip-related pain condition

Review of treatment options and outcomes for FAI/labral tear

  • Lifestyle modifications: avoiding deep flexion and impact loading
  • Physiotherapy: previous research showed studies are quite variable and have a significant risk of bias, but PT for over 3 months may improve function and strength. No consensus on type/duration/intensity/modality of PT.
  • Hip arthroscopy (from an expert opinion): this is a very specialized surgery, and accurate position is key. Outcomes are mixed but lots of variability.
    • A study done in 2018 (UK FASHIoN study) showed hip scope led to better quality of life than therapy, but had a higher risk of adverse events.
    • It is believed that FAI can predispose individuals to osteoarthritis – however there is no clear evidence that fixing FAI prevents osteoarthritis.
    • Unfortunately many individuals do not return to pre-injury levels of function

Patient selection criteria for hip arthroscopy:

  • Very unlikely to be offered if over age 50. For people under 50, it is surgeon dependent.
  • Positive response to injection suggests more likely to benefit from arthroscopy
  • Patient ideally should not have arthritis, at most mild diffuse osteoarthritis. Ideally isolated symptomatic labral tear
  • Narrow posterior hip joint space may be a contraindication (this criterion is not widely used in Canada though)

By Dr. Jim Niu
MD, CCFP (SEM), Dip. Sport Med.
Sport and Exercise Medicine Physician
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