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Femoracetabular Impingement(FAI) by Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS

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FAI: The “New Impingement”Training options to help your client By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS Introduction Hip pain has been typically perceived in older adults, however, can be present in young adults or even athletes. A new dysfunction of the hip has been talked about recently in the medical field and in various health & fitness journals. This is femoral acetabular impingement(FAI). What is FAI? Femoral acetabular impingement is not necessarily a disease but rather
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  FAI: The “New Impingement”Training options to help your clientBy Chris Gellert, PT, usc ! portsphysio, PT, C C , A Intro#uction Hip pain has been typically perceived in older adults, however, can be present in young adults or even athletes. A new dysfunction of the hip has been talked about recently in the medical eld and in various health & tness journals. This is femoral acetabular impingement!A #. $hat is !A % !emoral acetabular impingement is not necessarily a disease but rather a pathomechanical process in which abnormal contact stresses can cause potential joint damage around the hipeunig, 'eaule, & (einhold )**+#. This article will review the background on !A , clinical presentation & pathology, the types of !A and the medical and physical therapy treatment approach. rovide the latest evidenced based research about how !A can lead to labral pathologies, while reviewing conservative vs. surgical interventions. -ective programming will be discussed using periodi/ation training principles guiding the personal trainer to utili/e the most eective training strategies and e0ercises. The learning o$%ecti&es o' this C() article are to: 1. earn what !emoral Acetabular mpingement!A # is e0amining common symptoms, reviewing the pathology, how it develops and potential contributing risk factors.). 'e able to dierentiate and understand the two types of !A 2 cam and pincer impingement.3. 4nderstand how the progression of !A can lead to labral pathologies while e0amining what the latest evidenced based researchstates.5. earn the latest rehabilitation and treatment approaches for !A while reviewing some operative techni6ues used for patients who do not respond to conservative treatment.7. 'e able to design individuali/ed periodi/ed training programs that holistic address the client that are practical and integrative in nature. 8onsisting of aerobic, anaerobic, stretching, yoga, pilates and swimming to assist the client achieve optimal tness. Clinical presentation ! Pathology  9omeone who is suering from !A is fre6uently aggravated by athletic activities and movements that re6uire e0cessive hip :e0ion,  or prolonged walking, pivoting on the aected side, prolonged sitting or driving. 8ommon symptoms include; locali/ed deep ache pain typically in the groin and in the front of the hip. <ccasionally pain can also be referred to the outside of hip, buttock and thigh area. =echanical symptoms from the hip such as painful locking or giving way are common presenting feature if a labral tear is presentHossain. =. et al. )**>#. !emoroacetabular impingement !A # is a pathologic process caused by abnormality of the shape of the acetabulum, the femoral head, or both, predisposing to the development of osteoarthritis and labral degeneration. *ow FAI #e&elops an# contri$uting ris+ 'actors There are many theories on the cause of how an individual develops !A . <ne proposed theory is that during development, there may be structural abnormalities of the hip such as hip dysplasia. $hich is where the femur becomes dislocated. hysical stressestrauma# such as a femoral neck fracture is seen commonly in active middle aged adults, specically males in such sports as hockey, tennis and soccer.?ones et al. )*11#. @enetics has been e0amined anddiscussed as potential factoreunig, 'eaule, & (einhold )**+#. <ne things is certain. The research indicates that !A occurs when there isan abnormality of the femoral head with respect to the congruency to the acetabulum.!A causes hip pain and develops over time. (epeated and e0cessive hip :e0ion and internal rotation places ma0imal contact between the anterosuperior femoral headneck junction and the acetabular labrum, especially when there is not enough clearance to avoid friction. This repetitive movement and compressive load createsa torsion aect on the internal structures inside the hip socket. A person with !A that progresses will develop a movement pattern that is abnormal, asymmetrical and accommodative. These are important things to consider why a person develops femoral acetabular impingement.-mara, B, et al. )*11# 8ommon contributing factors include; previous trauma to femurChip, muscle imbalances, structural abnormalities of the femoral head, depravation of o0ygenCnutrients to the femoral head and repetitive stressorsCloadsie. dancing# There is also substantial evidence supporting the hypothesis that osteoarthritis of the hip is a major etiologic factor in !A 8lohisy, ? et al. )*1*#. atients with e0cessive range of movement of the hip can suer from impingement can potentially predisposing them to !A due to the biomechanical stressors. e&iew o' hip pathomechanics The hip joint is a ball and socket joint enabling a wide range of movement designed to function by providing weight bearing for  locomotion and movement.  Anatomically, the iliopsoas, glute medius, glute minimus, glute ma0imus all provide anterolateral stability as seen in gure 1 & ). However, if muscle imbalances develop this can lead to dysfunction at the hip. !or e0ample, it is common to observe inclientsD tightpostural# hip :e0ors, 6uadriceps and weakerphasic# glute medius, glute minimus and hamstrings. This alters load transfer throughout the kinematic chain in placing e0cessive load to the joint altering the movement pattern of the individual. n the sagittal plane, during hip :e0ionE1)* degrees#, the femoral head translates down as the glute ma0imus creates a downward pull. Furing hip e0tensionE)* degrees# iliopsoas is eccentrically lengthened. n the frontal plane, during hip abductionE5* degrees#, glute medius contacts pulling the femur up which then translates down. Furing hip adductionE)7 degrees#, the femur glides down and out as the tensor fascia latae, ischiofemoral ligament and glute medius is eccentrically  lengthened. Figure 1. Anterior hip complex Figure 2. Posterior Hip Complex Comparison o' two types o' FAI: Pincer an# Cam Impingement mpingement at the hip can occur with e0tremes of movement, lack of movementmobility# or as a result of a combination of both. The contributing factors previously described provide a deeper understanding of !A and the two types of !A mpingement. There are two dierent types of impingement2 pincer and cam impingement.   incer impingement occurs from a bony prominence of the front of the acetabulum placing e0cessive pressure from the labrum against the neck of the femur. Thus impacting oneDs range of motion leading to pain. incer lesions are more common seen in middleaged active women. <ccurring through repeated contact between the normal femoral neck junction and the acetabular rim.  This repeated contact results in labral degeneration, iossication of the acetabular rim and deepening of the acetabular rim'anjeree & =clean )*11#. The causes of pincer impingement include; developmental changes, structural changes such as a retroverted acetabulum, trauma and post traumatic deformity of the acetabulum'anjaree & =clean )*11#. n contrast, cam impingement, is more common in active men. The cam is attributed to a nonspherical portion of the femoral head placing e0cessive pressure against the acetbular rim. This is most noticeable with active hip :e0ion and e0ternal rotation. n which the position of the femoral head is too large to pass in the acetabulum, and when the hip is :e0ed, this stresses the rim of the labrumaude, !. et al. )**G#   This is seen in gure 3. The causes of cam impingement include2 developmentalnon spheric femoral head, perthes disease, which involves inade6uate blood supply and slipped capital femoral epiphysis, which is a separation of the ball of the hip joint from the thigh bone#. Trauma such as femoral neck fractures and chondral lesions especially in the acetabulum can play a role'anjaree & =clean )*11#.   Figure -. Cam an# Pincer Impingement e#ical an# Physical Therapy Treatment Approach 8onservative management is initially recommended for most individuals with modication of activities, avoiding e0cessive hip movement and taking nonsteroidal antiin:ammatory9AF 9# whichmay provide some relief.   The role of physical therapy is to improve passive range of motion, soft tissue   joint mobility, lateral and posterior strengthening of weak musculature, improve core stability and education of cross trainingyoga, swimming#. However, if symptoms continue and do not improve, then the patient may be a candidate for surgery.
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