Pinchy hip or groin pain is a relatively common issue. Running, squatting, getting down on the floor to play with your kids, can all trigger groin pain. Say you’re a recreational athlete – maybe a runner, Crossfitter, weightlifter, basketball, softball, or soccer player. Or maybe you’re a mom/dad/grandparent of young kids, a gardener, or love doing DIY projects around your house – the onset of groin pain can really curtail or stop you from doing those things you love. It can even get to the point where it hurts just to rise from sitting, get in and out of your car, or go up and down stairs. It’s an injury I see fairly frequently in my practice, and many of my patients do get better with therapy. But what if it doesn’t? Or what if your doctor performs imaging and recommends surgery?

Recently, diagnosis and surgery for a particular source of groin pain called femoroacetabular impingement (FAI) have increased significantly – surgeries have increased 400% over the past decade! In order to understand the reason for the increase, a panel of experts convened and published guidelines in the British Journal of Sports Medicine (BJSM). In this blog, I want to discuss hip/groin injuries, the BJSM guidelines, and how FAI, in particular, can be treated.

Hip anatomy and impingement

The hip and shoulder have a couple of similarities; They are both ball and socket joints, and they both have a labrum (a ring of cartilage around the socket that deepens the joint). However, that is where the similarities end. The shoulder is a shallow ball and socket with relatively weak ligaments. This allows for great motion, which in turn asks much of the muscles to provide stability. On the other hand, the hip has a deep ball and socket which allows significantly less movement. Its ligaments are strong and it is very stable. With this, it is very rare to hear of hip dislocations but is more common in the shoulder. We also hear of shoulders and hips having impingements with the idea that there is a painful catch between the ball and the socket and other structures such as the labrum. There are also other sources of groin pain such as the hip flexor tendon, the femoral nerve, and hernia. The guidelines by BJSM seek to help to increase diagnostic accuracy to help ensure the best treatment. The guidelines require three features to be present for an FAI diagnosis: symptoms, clinical signs and imaging findings.

Symptoms

The main feature of FAI is pain in the groin that is related to motion or position. Pain might also be felt in the back, buttocks, abdominals, or thigh. There may also be clicking, catching, locking, stiffness, restricted range of motion or giving way. The pain is typically severe and limiting. Injection of an anesthetic into the hip joint under imaging guidance can be useful in helping to determine if the above symptoms are likely from an FAI or not.

Clinical Signs

One of the concerns of the BJSM panel was that there is high variability in how different clinicians apply and interpret tests. However, they felt that several things should be considered in a good examination:

• Hip range of motion – will typically be limited
• FABER (Flexion, ABduction, External Rotation) test will likely be positive (This still does not mean the problem will be FAI).
• Tenderness in surrounding musculature
• Gait. Walking, or running depending on level of patient.
• Hip muscle strength – weakness often found
• Single leg control – e.g. single leg squat.

The video below runs through several of these:

Imaging Findings

No doctor or therapist has X-Ray vision! For FAI to be considered a true diagnosis, you need imaging. This is different from the latest guidelines on patellofemoral knee pain (anterior knee pain) which only require symptoms and clinical signs for diagnosis. The imaging findings of the hip will help us to see if there two major anatomical variants:

• Cam lesion – This is where there is either a flattening or convexity of the head of the femur (The ball). This means the ball is not as circular as it should be, is more cam-like, which will potentially cause impingement and pressure.
• Pincer lesion – This is where there is an overgrowth of the acetabulum (The socket) which again leads to opportunity for impingement.

Illustration of the normal hip, cam lesion, pincer lesion and mixed lesion.

Illustration showing how the lesions will increase the chance of impingement during hip motion.

The initial imaging should be X-Ray, which essentially shows bone and space and will also show any other findings such as a fracture. To visualize the hip in 3-dimensions and to see the soft tissue (tendon, muscle, labrum, or ligament problems), advanced imaging such as MRI, MRI arthrogram, or CT scan should be used if planning on surgery. So, the first time you see the doctor for this issue you will likely only have X-Ray and would then go onto advanced imaging if conservative measures have failed.

Three positive components = FAI

When these three components are all positive, the expert panel concludes that a patient likely has FAI. This is important, as we know there are a significant number of people, even sporting, have no pain but have “pathology” on hip imaging. For example, 81% of asymptomatic (no pain, catching, etc) professional hockey players have some form of pathology on hip imaging. So, could the “pathology” actually be a physical adaptation to the sport? We don’t have an answer yet, but the above should give caution to jumping to surgery based off of imaging findings when perhaps the other two components are not so clear. A recent study in 2016 found that 92% of FAI surgical decisions were based on imaging, but only 56% were based on the three components. Only 44% had described previous failed conservative treatment or worse still only 18% described failed physiotherapy as a reason for surgery! Hopefully, with these guidelines being published in the past year we will see a shift in the approach of healthcare professionals to this issue and therefore a change in these statistics.

How best to treat FAI?

So what are the treatment options? At this point there is not clear evidence for what treatment is best for each specific patient, i.e. are there some who should skip straight to surgery. The panel makes a recommendation for physiotherapy-led rehabilitation and they agree surgery is an option. Let’s quickly consider each option and what they involve:

Rehabilitation

The rehabilitation needs to help control the position of the pelvis (the socket) relative to the ball. As you can see in the video below, if I have a significant anterior pelvic tilt, there is an increased chance of impingement. This chance would be increased if there is already some form of bony lesion of a tear already reducing space. So we need to assess when this might occur in the tasks that they find painful. For example, a runner who has excessive amounts of pelvic tilt may need to work on correcting this using various strengthening and cueing strategies. Another example would be someone lifting weights and using excessive hip flexion as they have a restriction elsewhere (e.g. ankles). We would work to correct this by correcting form, as well as strength deficits (wherever found in the trunk and lower extremity), and improve mobility where it was lacking.

Manual therapy can also be useful in FAI using a technique called mobilization with movement (MWM). To do this, I use a belt that provides a force along the length of the femur. We previously thought that we were decompressing the joint, but now we know this is only happening to a small degree. We do not really know the mechanism, but when it works (which this technique seems to do regularly) it is having an effect on the nervous system and pain. This allows the muscles around the hip to work better helping the patient regain function and have ongoing pain relief.

Surgery

Surgery can be either arthroscopic (keyhole) or open, and typically involves removal of the excess bone and fixation of other findings (e.g. labrum tear). Arthroscopic hip surgery has been shown longer term to give a better quality of life versus open surgery. Surgery for FAI has certainly been shown to be effective for return to sport (RTS) at 87%, and 82% RTS at the same level. Another study showed 94% of runners returned to running at an average of 8.5 months after surgery. It also showed good outcomes at 2 years for both pain and function. There is a ~10% conversion rate to hip replacement, but some of these people probably should not have had the surgery in the first place (perhaps even had not met the three components in the guidelines?!). However, a recent paper published from research in the military found no significant difference between a surgical and non-surgical group at two years and ⅓ had not returned to active duty.

So, even if there are some less promising findings that have been published, if you had it and two years out are feeling great, you would probably recommend it! However, there have not been any papers comparing the surgery with a sham (fake surgery), so we don’t really know what the outcome would be if surgery had not been undertaken. It may be a while till we get this sort of study as only 25% of surgeons are willing to participate in a well-designed study comparing surgery and conservative care. Getting this type of study is important as we have recently seen how the common knee scope for a degenerative joint is now strongly advised against in new guidelines as it performs no better than conservative care at mid (6-month) and long terms (2-year) when compared with rehabilitation. Knowing that there is a high number of people with “pathology” and no problems, it is arguable that some of these surgical patients got better due to enforced rest after surgery more than the surgery itself. This may be particularly true if we consider that cam and pincer lesions could just be physical adaptations to activity and sport.

What if I was the patient!

It is not my place to tell you what to do, or to try and tell the surgeon what to do! All I can do is provide education and then practice the best physical therapy I can, based off of the best research evidence. However, if I had groin pain and it was diagnosed as FAI, based on the above information, I would want to try a good course of conservative care. This may initially involve relative rest and appropriate analgesia and anti-inflammatories. If the pain persists more than a week, then I would seek out physical therapy to progressively increase activity, load the muscles, and improve my control of movement.  If the pain is still not settling, I might accept an injection into the joint as it might significantly reduce my pain and is to some degree diagnostic. If the injection provides relief, I would again try the physical therapy as described above – i.e. load the muscles/joint and improve control. If running was something that provoked my pain, I would review my technique (video analysis is great for this) and would make gait changes (e.g. cadence, stance width, correction of pelvic drop). If I felt I had exhausted these options, (this might be a year-long process), I would consider surgery and I would try and find the best surgeon possible to do it!

If I can be of any further help please let me know. I have treated hip surgeries from several local doctors and also from Dr. Byrd in Nashville who is one of the pioneers of arthroscopic hip surgery. You can contact me by email or by phone. You are also welcome to sign up for our e-mail list to stay up to date on the latest research as we get it!

References

• Gupta A, Redmond JM, Stake CE, Dunne KF, Domb BG. Does Primary Hip Arthroscopy Result in Improved Clinical Outcomes?: 2-Year Clinical Follow-up on a Mixed Group of 738 Consecutive Primary Hip Arthroscopies Performed at a High-Volume Referral Center. Am J Sports Med. 2016;44(1):74-82.
• Ross JR, Bedi A, Clohisy JC, Gagnier JJ, Larson CM. Surgeon Willingness to Participate in Randomized Controlled Trials for the Treatment of Femoroacetabular Impingement. Arthroscopy. 2016;32(1):20-4.e23.
• Nwachukwu BU, Rebolledo BJ, Mccormick F, Rosas S, Harris JD, Kelly BT. Arthroscopic Versus Open Treatment of Femoroacetabular Impingement: A Systematic Review of Medium- to Long-Term Outcomes. Am J Sports Med. 2016;44(4):1062-8.
• Levy DM, Kuhns BD, Frank RM, et al. High Rate of Return to Running for Athletes After Hip Arthroscopy for the Treatment of Femoroacetabular Impingement and Capsular Plication. Am J Sports Med. 2016;
• Mansell NS, Rhon DI, Meyer J, Slevin JM, Marchant BG. Arthroscopic Surgery or Physical Therapy for Patients With Femoroacetabular Impingement Syndrome: A Randomized Controlled Trial With 2-Year Follow-up. http://journals.sagepub.com/eprint/XzicCn4qThfrDUtFtDCe/full. Accessed Ahead of Print The American Journal of Sports Medicine February 22, 2018.