Hip impingement, or femoroacetabular impingement, is associated with an abnormal ball-and-socket joint shape. It is common among active sportspeople and even more prevalent among elite athletes. But what does hip impingement mean, and how should it be managed?
What is hip impingement?
Femoroacetabular Impingement of the hip occurs when an abnormal shape of the ball and socket joint causes restricted movement and pain. Commonly, bone spurs form around the hip joint. These bony spurs mean that the ball of the hip (top part of the femur) gets pinched in the socket portion (acetabulum) when you move the hip in specific directions. This pinching causes pain and restricted movements.
Symptoms of hip impingement
People often complain of pain during physical activity, especially in sports that involve sudden changes of direction. The location of the pain can vary, but it is usually at the front of the hip or groin. In addition, pain can sometimes be felt in the buttocks and lower back. Additionally, a weak feeling and restricted hip movement are common.
If we suspect hip impingement, we recommend a plain X-ray to show the hip’s shape. MRI is also helpful in revealing potential cartilage damage. However, we need to be careful, as some people with no pain have changes of hip impingement on imaging. Fifty per cent of elite athletes have hip impingement changes on X-ray, but most do not have pain. Therefore, performing a thorough clinical assessment before ordering tests is essential.
Does Impingement of the Hip Lead to Early Arthritis?
Hip impingement is a risk factor for early arthritis. Progression to early arthritis is more common if you have a type of bony spur called a CAM, located between the head and neck of the femur. We also believe that the more prominent the CAM, the more likely you are to develop early arthritis. However, not everyone who has a CAM develops arthritis. Other factors that contribute to the development of arthritis, such as genetics and co-occurring diseases like diabetes and obesity, are also important.
The bottom line is that a bony spur or CAM does not necessarily lead to arthritis. Therefore, surgical removal of the bump should only be performed to alleviate pain, not to prevent arthritis. We don’t know whether surgery to remove the bony spur prevents the progression of arthritis.
So, How Do We Manage Hip Impingement?
You should always give conservative management and physical therapy a go first. Then, pain relief and return to sport can occur without the need to remove the bony spur or fix a labral tear.
The therapy goals are to improve the range of motion and strength of the lower back and hip while reducing pain. Exercise should be the primary form of treatment for femoroacetabular Impingement. Exercises could include:
- Hip stretching and mobility exercises
- Hip strengthening, including the glutes, hip flexors, and adductors
- Balance exercises
- Abdominal strengthening exercises
Often, pilates and yoga can help you achieve these therapy goals.
Another effective therapy is neuromuscular training. This type of training involves performing exercises correctly to ensure that your lower back, hips, and legs are properly aligned during the activity. We think it reduces stress on your hip joint.
How effective is physical therapy for hip impingement?
Until recently, we had little data to support conservative treatment for hip impingement.
However, a recently published study is more favourable for rehab. In a study of young athletes with FAI, 75% chose rehab compared to surgery. Out of the exercise group, most got better, and only a tiny minority (14%) struggled with pain and needed injections into the hip joint. After the injeciton, only half of the 14% had surgery.
Overall, about 80% of the original cohort of patients did not need surgery. All three groups (rehab, injection, and surgery) responded similarly.
How Long Should You Give Conservative Management of Hip Impingement?
You should notice an improvement in pain, strength, and range of motion after about eight weeks. It would be helpful if you aimed to return to sport within 3-6 months and be prepared to continue with independent rehabilitation for at least six months. If you don’t experience relief with therapy, consider consulting your doctor about alternative treatments.
Hip Impingement cortisone injection
Sometimes, a cortisone injection into the hip joint reduces pain and allows you to continue with therapy. Also, a cortisone injection can be used to clarify the diagnosis. However, we should always perform injections with ultrasound for accuracy.
Hip arthroscopy may be needed in other cases to remove the bony spurs and repair the labrum. We know that keyhole surgery improves symptoms such as pain. However, not all patients who undergo hip arthroscopy experience improvement, and some (approximately 5%) worsen. Additionally, do not expect to return to completely normal function immediately after surgery. While surgery provides pain relief, it is likely that you won’t be able to return to all your activities. Also, we think that men with hip impingement tend to do better than women.
Also, the success of an ultrasound-guided hip injection often determines the success of hip arthroscopy. In a recent study, improvements in pain after an ultrasound-guided hip joint injection were found to predict the success of hip arthroscopy. So, if an injeciton works, surgery is more likely to be successful.
PRP Injection for hip labral tear: Does it work?
PRP, or platelet-rich plasma, is obtained from a patient’s blood. We spin the blood in a centrifuge to separate the heavier red blood cells and white blood cells from the plasma. This plasma contains a high concentration of platelets, which contain growth factors that promote wound healing. Injecting a high concentration of platelets into a hip joint can reduce inflammation and pain. While we have evidence that PRP injections improve hip arthritis, the effectiveness of PRP injections for labral tears remains unclear. Nevertheless, PRP injections are an option for hip labral tears instead of cortisone injections.
Can hip arthroscopy get you back to the same level of sport?
While hip arthroscopy can improve symptoms, only 50% of athletes return to their sport, and only 14% return to their previous level of play before surgery. Therefore, surgery should only be considered for severe symptoms and not to return to the same level of competition.
Ultimately, some doctors believe that hip arthroscopy should be considered a joint-preserving surgery. They think that removing the CAM lesion prevents further damage to the hip joint, thereby halting the progression of arthritis. However, the evidence for hip preservation is controversial. A recent study comparing hip arthroscopy to physiotherapy in patients with hip impingement found that the surgical group experienced worsening joint metabolism at 12 months. Overall, at this current time, keyhole surgery should not be done to prevent arthritis. However, keyhole surgery does improve symptoms. Finally, some people might benefit from surgery earlier, especially young males with a labral tear who sustain their injury after a pivot or twist during sport.
Bottom Line regarding Hip Impingement
Hip impingement can cause pain and restriction, limiting your ability to participate in activities and sports. We also know that hip impingement is a risk factor for arthritis; however, only a small percentage of patients with bony spurs develop arthritis. Optimal management is subject to much debate, but treatment should always be conservative initially. If pain continues, a cortisone injeciton may help. Keyhole surgery should be a final option and only done for symptoms and not to prevent arthritis.
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