A review of femoroacetabular impingement and hip arthroscopy in the athlete.

C L I N I C A L F E AT U R E S

A Review of Femoroacetabular Impingement and Hip Arthroscopy in the Athlete

The Physician and Sportsmedicine Downloaded from informahealthcare.com by Nyu Medical Center on 05/19/15 For personal use only.

DOI: 10.3810/psm.2014.02.2050

Michael J. Tranovich, DO 1 Matthew J. Salzler, MD 2 Keelan R. Enseki, MS, PT, OCS, SCS, ATC, CSCS 3 Vonda J. Wright, MD, MS 4 Research Fellow, Department of Orthopaedic Surgery; 2Orthopaedic Sports Medicine Fellow, Department of Orthopaedic Surgery; 3Physical Therapist and Director, Orthopaedic Physical Therapy Residency, Department of Physical Therapy, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences; 4Assistant Professor and Director, Performance and Research Initiative for Masters Athletes, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 1

Correspondence:Vonda J. Wright, MD, MS, Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water St, Pittsburgh, PA 15203. Tel: 412-432-3651 Fax: 412-432-3690 E-mail: [email protected]

Abstract: Femoroacetabular impingement (FAI) is increasingly recognized as a pathological condition of the hip in athletes. Although it is not always symptomatic, the bone structure l eading to FAI and its associated pathology can result in significant pain and performance decline in athletes. Recognition of athletes with symptomatic FAI is of the utmost importance, as prompt treatment is necessary in order to maintain desired sports activity levels and preserve joint function. This review explores the recent evidence on the evaluation, recognition, and treatment of femoroacetabular impingement, and discusses conservative management, postoperative rehabilitation, and treatment in the pediatric and master athlete populations. Keywords: femoroacetabular impingement; FAI; hip arthroscopy; rehabilitation

Introduction

Femoroacetabular impingement (FAI) is a common hip condition that affects young, active persons and can cause significant disability and sports performance deficits. It entails the abnormal contact of the femur with the acetabular rim due to bony abnormalities or functional extremes of the hip’s range of motion (ROM). The condition was first described by Smith-Petersen1 in 1936 as a cause of pain and potential osteoarthritis of the hip, but interest in this cause was renewed after a more recent publication in 2003 by Ganz and colleagues.2 The 2 main types of bony impingement in FAI are cam impingement and pincer impingement. Cam impingement stems from an osseous abnormality, or bony bump, at the femoral head–neck junction; it is an abnormality of the femur. Pincer impingement is an abnormality of the bony acetabulum, leading to over-coverage of the femoral head. Individuals may demonstrate cam impingement, pincer impingement, or both, the latter of which is termed combined/mixed impingement. These forms of impingement often lead to labral tears or labral detachment from the underlying acetabulum and cartilage. The repeated microtrauma caused by abnormal joint contacts in patients with FAI also leads to chondral delamination or detachment. In combination, these tissue pathologies can cause pain and debilitation. Femoroacetabular impingement is caused by repetitive hip motion at an individual’s anatomic limit. Professional dancers and highly flexible athletes, such as gymnasts and soccer and hockey players, who often push the extremes of their hip ROM, especially with pivoting and internal rotation, are at risk of becoming symptomatic at a young age. Athletes who require less hip ROM, such as runners, may exhibit the acquired or congenital bony abnormalities associated with FAI, but they may never become symptomatic or may become symptomatic only at a later age.3 Recognition and proper referral of symptomatic athletes is important, as untreated FAI can lead to pain and sports performance decline, and it increases the risk of early osteoarthritis. D eveloping

© The Physician and Sportsmedicine, Volume 42, Issue 1, February 2014, ISSN – 0091-3847 75 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.

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a basic understanding of the pathology associated with FAI, its diagnosis, conservative treatment, surgical treatment, postoperative rehabilitation, and outcomes will aid clinicians in maximizing an affected athlete’s treatment outcome and minimize time to return-to-play.


Anatomy

The hip joint is composed of the acetabulum, femoral head, and multiple soft tissue structures that add stability to the joint, including the acetabular labrum and capsular ligaments.4 The acetabular labrum is a horseshoe-shaped fibrous tissue structure and is thought to provide a “suction seal” around the femoral head, increase the depth of the acetabulum, and provide increased stability to the joint (Figure 1). In order to understand the pathological processes of FAI, one must possess a general understanding of the normal and pathological bony anatomy of the hip, which can be recognized on plain radiographs.

Neck-Shaft Angle

The femoral neck connects the femoral head to the shaft of the femur. When viewed on an anteroposterior (AP) radiograph, this connection should form an angle of approximately 120° to 135°. Neck-shaft angles , 120° are termed coxa vara, and those . 135° are termed coxa valga. A neck-shaft angle

of either extreme can cause abnormal contact between the femoral head and acetabulum which, in turn, may lead to hip pain.5

Center Edge Angle

A common way to measure the coverage of the femoral head by the acetabulum is the lateral center edge angle (LCEA).6 This measurement is composed of the angle created by a plumb line dropped to the center of the femoral head and a line drawn from the center of the femoral head to the edge of the acetabulum on an AP radiograph (Figure 2). A normal LCEA is between 25° and 45°. Patients with an LCEA , 25° are considered to have a dysplastic hip and those . 40° or 45° may have pincer impingement (Figure 3). In addition to measuring the lateral coverage of the femoral head by the acetabulum, the anterior coverage of the femoral head can be assessed in a similar fashion using the anterior center edge angle measured on a false-profile radiographic view. Patients with dysplastic hips are susceptible to joint damage caused by subluxation or dislocation of the femoral head, whereas patients with pincer impingement may experience acetabular labral tears, decreased ROM, and subsequent pain. Figure 2. Anteroposterior radiograph demonstrating the lateral center edge angle in a patient with pincer impingement.

Figure 1. Normal hip anatomy with the femoral head removed from the acetabulum.

Drawn by Randy McKenzie. Abbreviations: AAC, acetabular articular cartilage; F, fovea; FHAC, femoral head articular cartilage; L, acetabular labrum; LT, ligamentum teres (cut); TL, transverse ligament of the acetabulum.

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Abbreviation: LCEA, lateral center edge angle.

© The Physician and Sportsmedicine, Volume 42, Issue 1, February 2014, ISSN – 0091-3847 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.

Review of Femoroacetabular Impingement in Athletes Figure 3. Representation of cam and pincer impingement, as well as the compressed acetabular labrum as a result.

impingement (Figure 3). Cam lesions typically present in the anterosuperior portion of the femoral head–neck junction, although they may occur elsewhere. Cam impingement often results in articular cartilage delamination and labral tears in patients, which may progress to osteoarthritis when left untreated.


Crossover Sign and Acetabular Version

Drawn by Randy McKenzie.

Alpha Angle

The alpha angle measurement assists in gauging the sphericity of the femoral head and femoral head–neck offset.7 Using a cross-table lateral, modified Dunn, or AP radiograph, a sphere is drawn around the contour of the femoral head. Then, from the center of the femoral head, 2 lines are drawn; 1 line runs through the center of the femoral neck and 1 line connects to the point where the contour of the femoral head exits the sphere. The resultant alpha angle is normal when it is , 50° or 55° (Figure 4). Individuals with alpha angles . 55° may be considered to have an oval-shaped femoral head or cam

The acetabulum is anteverted approximately 15° to 20° with respect to the pelvis. A retroverted acetabulum or excessively anteverted acetabulum can lead to abnormal contact points with the femoral head and result in pincer impingement. A simple way to assess possible superior or cranial retroversion of the acetabulum is to examine an AP radiograph of the pelvis for “crossover” of the lines of the anterior and posterior walls of the acetabulum8 (Figure 5). The line of the posterior wall of the acetabulum is generally continuous with the ischium, and the line of the anterior wall is continuous with the superior pubic rami. In addition, full retroversion of the acetabulum can be confirmed on an AP radiograph of the pelvis by determining whether the line of the posterior wall of the acetabulum lies medial or lateral to the femoral head’s center point of rotation. A posterior wall that lies medial to this point signifies acetabular retroversion. The ischial spine sign, when the ischial spine can be seen projecting into the pelvis (medial to the iliopectineal line) on an AP radiograph is another finding suggestive of acetabular retroversion.9 Figure 5. Anteroposterior radiograph demonstrating a positive crossover sign indicative of acetabular cranial retroversion. In an individual without acetabular cranial retroversion, the white dotted line would remain completely medial to the black dotted line. The white dotted line indicates the border of the anterior wall of acetabulum; the black dotted line represents the border of the posterior wall of acetabulum.

Figure 4. (A) Anteroposterior radiograph demonstrating an abnormal alpha angle in a patient with superior cam impingement. (B) Cross-table lateral radiograph demonstrating an abnormal alpha angle in a patient with anterosuperior cam impingement.

Abbreviation: α, alpha angle. © The Physician and Sportsmedicine, Volume 42, Issue 1, February 2014, ISSN – 0091-3847 77 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.

Tranovich et al


Evaluation

An athlete with FAI often presents with an insidious onset of hip pain, which may include pinching in the groin, painful or nonpainful popping, or locking and catching. Affected athletes often report exacerbating activities such as getting into a car, walking up stairs, sitting for prolonged periods, and sportspecific internal rotation maneuvers such as a hockey goalie doing a butterfly.10–12 Determination of chronicity of symptoms is beneficial, as acute traumatic injuries often are attributed to fracture, acute labral tears, or focal chondral injuries, whereas a more gradual onset may be attributed to chronic labral tears and cartilage delamination as a result of worsening bony impingement. It is important to localize all symptoms, because intraarticular hip pain most often presents in the groin and occasionally is associated with pain in the lateral thigh or buttock. When asked where the hip hurts, athletes may cup their hip just above the greater trochanter with a hand in the shape of a “C,” with the fingers placed in the groin and the thumb pointed posteriorly. This has been termed the C sign.13 In addition to the athletes’ signs, symptoms, and h istory, common physical examination maneuvers used by hip specialists can aid clinicians in developing a differential diagnosis and suspicion of FAI.14

Gait

Although gait is neither sensitive nor specific for intraarticular hip pathology, it can be used to guide the examiner toward a diagnosis. An antalgic gait, where the athlete spends less time in the weight-bearing phase, suggests the athlete is experiencing significant pain; weight-bearing activity loads the femoroacetabular joint, which suggests an intra-articular pathology as the etiology of pain when it is avoided. A Trendelenburg gait is seen with weak hip abductors. Hip abductors in the stance phase of gait elevate the contralateral hemipelvis, and weak hip abductors can cause the contralateral hip to drop during its swing phase. Both gait patterns suggest the need for further evaluation of an athlete’s hip.

band friction syndrome. Patient pain over the superior greater trochanter near the gluteus medius/minimus insertions suggests gluteus medius/minimus tendinopathy or tears, whereas tenderness to palpation of the iliopsoas tendon in the groin suggests hip flexor tendinopathy.

Trendelenburg Sign

The Trendelenburg sign assesses dysfunction of the gluteus medius, which stabilizes the pelvis when the contralateral leg is lifted from the ground. Therefore, athletes with a weak gluteus medius muscle, gluteus medius tendinopathy, or gluteus medius tears will have a positive Trendelenburg test. The test is performed with the athlete standing and lifting a foot off of the floor by flexing at the hip and knee. If the pelvis sags or does not remain level on that side, the test is positive for weakness of the contralateral gluteus medius (Figure 6).

Flexion-Adduction-Internal Rotation (FADDIR) Test

The FADDIR test, or anterior impingement test, is one of the most preferred tests in the physical examination of suspected femoroacetabular impingement. Several studies reported a high sensitivity and high positive predictive value of the Figure 6. (A) Patient with a negative Trendelenburg sign. The pelvis remains level when the leg is lifted from the floor. (B) Patient with a positive Trendelenburg sign indicative of a weak gluteus medius muscle on the left. Note the pelvic sag on the side of the lifted leg.

Range of Motion

Flexion, extension, abduction, adduction, internal rotation, and external rotation of the hip are all important motions in athletic performance and should be evaluated. A decrease in motion, especially in hip internal rotation, should raise the suspicion of FAI as a possible diagnosis.

Palpation

Pain with palpation over the posterior greater trochanter raises suspicion for trochanteric bursitis or iliotibial (IT) 78


Review of Femoroacetabular Impingement in Athletes

FADDIR test for FAI, with the vast majority of FAI patients experiencing a positive test.2,11,12,15 To perform the test, position the athlete supine and passively move the athlete into full hip flexion, adduction, and internal rotation. A positive test is signified by a reproducible groin pain that is often very uncomfortable for the athlete (Figure 7).

Figure 8. Patient placed in the figure-4 position in performance of the FABER test. Pain elicited when in this position should be localized and described by the patient.


Flexion-Abduction-External Rotation (FABER) Test

The FABER test is used to elicit pain in the sacroiliac joint, posterior hip, or pain originating from the lumbar spine. With the athlete supine, rotate the hip into flexion, abduction, and external rotation by placing the ankle just proximal to the contralateral knee so that the patient is in the figure-4 position (Figure 8). The ROM and pain compared to the contralateral hip should be recorded. The FABER test may be positive anteriorly, laterally, or posteriorly depending on the pain’s origin.

Thomas Test

The Thomas test is used to evaluate the flexibility of the iliopsoas muscles. The athlete is seated with the buttocks on the very edge of an examination table so that the legs are hanging from the end of the table. The athlete is asked to lie back and flex the unaffected leg to the chest (Figure 9). If the contralateral, affected leg rises from the table, this is a positive Thomas test and signifies tight iliopsoas musculature. Figure 7. Patient passively placed in full hip flexion, adduction, and internal rotation for the anterior impingement or FADDIR test. Reproducible pain in the groin area is a positive FADDIR test.

Abbreviation: FABER, flexion-abduction-external rotation.

Athletes with deep groin pain and a positive Thomas test may have a soft tissue impingement known as iliopsoas impingement, which can lead to labral tears and intra-articular hip pain.

Ober Test

The Ober test is used to assist in the diagnosis of a tight IT band or tensor fascia lata. With the athlete in a lateral position, place the affected leg on top and flex the unaffected hip and knee to 90°. The top knee is flexed to 90°, during which the affected hip is abducted and ranged to full extension with the pelvis stabilized. The hip is then adducted toward the table. The inability to adduct the hip past neutral is a positive test (Figure 10). When performing this test, some examiners advocate placing the top knee in extension to further isolate Figure 9. Evaluation of the flexibility of the right hip flexor musculature using the Thomas test. In a positive Thomas test, the right leg would remain level with the table or demonstrate an even higher flexion contracture.

Abbreviation: FADDIR, flexion-adduction-internal rotation. © The Physician and Sportsmedicine, Volume 42, Issue 1, February 2014, ISSN – 0091-3847 79 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.

Tranovich et al

the IT band. A tight IT band may contribute to external snapping hip, trochanteric bursitis, and resultant pain.

FAI, as the quality, consistency of technique, and reporting methods of studies examining the diagnostic accuracy of these tests are relatively poor.16 Specifically, athletes with a history of symptoms consistent with FAI and a clinical exam suggestive of FAI should be referred to an orthopedic hip preservation specialist for further workup before a definitive diagnosis is established. An examiner must also use caution in order to not confuse FAI with abdominal or genitourinary conditions. One such condition that is often mistaken for or significantly overlaps with FAI is athletic pubalgia/sports hernia.17 Sports hernia is a collection of diagnoses related to weakening of the abdominal wall/fascia that encompass another common cause of groin pain distinct from FAI. It presents with symptoms, such as groin pain radiating to the testicles, that is exacerbated by maneuvers that increase intra-abdominal pressure, which is similar to an inguinal hernia. In patients with a suspected sports hernia, a standard inguinal hernia examination should be performed. Following this, the examiner should have the athlete perform a sit-up. Halfway through the sit-up, the examiner should add additional resistance to the athlete, which will further increase intra-abdominal pressure and reproduce symptoms in a patient with a sports hernia.18

Straight Leg Raise

Imaging


Figure 10. Evaluation of the left iliotibial band with the Ober test. The top hip is extended, then adducted toward the floor. In a positive Ober test, the top hip cannot be adducted past neutral.

The straight leg raise helps differentiate lumbar from hip pathology. With the athlete supine, the examiner raises the athlete’s leg from the table and flexes the hip with the knee extended. The foot is dorsiflexed at 45° of hip flexion. Pain located solely in the buttocks and down the leg is more likely indicative of a lumbar etiology of pain.

Resisted Straight Leg Raise

In contrast with the straight leg raise, a positive resisted straight leg raise may suggest hip pathology. With the athlete supine, flex the affected leg from the hip while keeping the knee extended. At 45° of hip flexion, apply a force to the thigh resisting flexion at the hip. Eliciting groin pain may signify an iliopsoas tendon placing excessive strain on the hip capsule and labrum. A recent systematic review examined studies that reported the accuracy and validity of the physical examination tests used in the evaluation of suspected FAI. The FADDIR and FABER tests had a sensitivity of 0.9 to 1.0, and the FADDIR test, FABER test, resisted straight leg raise, and Thomas test had a specificity of 0.9 to 1.0.16 These clinical examination maneuvers have utility in the evaluation of hip pathology, but they should not be used exclusively to rule in or rule out 80

Hip radiographs are essential for a complete evaluation of an athlete’s bony anatomy. Typical radiographs include an AP pelvis, AP of the affected hip, false-profile, and cross-table lateral or modified Dunn view of the affected hip(s). A magnetic resonance arthrogram (MRA) or highresolution (3-tesla [T]) magnetic resonance imaging (MRI) scan may be ordered if the physician’s review of the history, clinical examination, and radiographs suggests a diagnosis of FAI. Although noncontrast 1.5-T MRI scans are useful in the diagnosis and preoperative planning of many joint pathologies, MRAs and 3-T MRI scans are the preferred diagnostic methods because the 1.5-T MRI scan generally does not adequately evaluate the acetabular labrum when performed at most imaging centers.19–21 In addition to evaluating the integrity of the acetabular labrum in association with FAI, MRI scanning enables the evaluation of the alpha angle on radially reformatted coronal or axial oblique sequences, the beta angle (the angle between the femoral head–neck junction and acetabular rim), acetabular coverage, acetabular depth, the presence of paralabral cysts, the presence of FAI-associated herniation pits at the femoral head–neck junction, and the presence of os acetabuli.22–24 Magnetic resonance arthrography can also




assist in the evaluation of femoral and acetabular chondral lesions, though most studies report suboptimal sensitivity in predicting these lesions.25,26 As a result, more accurate chondral MRI methods such as high-definition MRI and delayed gadolinium-enhanced MRI of cartilage are currently under evaluation. In addition to the gadolinium contrast injected in the joint before an MRA, many hip specialists will ask the radiologist to inject a steroid or local anesthetic for diagnostic and/or therapeutic purposes. The athlete is instructed by the physician to remember the duration and percent relief of the hip pain as a result of the injection. For diagnostic injections, we utilize 6 cc of 2% lidocaine, 6 cc of 0.25% bupivacaine, and 80 mg of triamcinolone; positive relief of pain for 3 to 4 hours following the intra-articular injection helps confirm that the pain is intra-articular in nature.25,27

Treatment of FAI in the Athlete Conservative/In-Season Management

Some individuals with symptomatic FAI can return to a normal level of functioning with conservative management. In general, athletes with suspected FAI should partake in a rehabilitation regimen before surgical options are considered.28,29 During the acute phase, athletes attempting nonoperative management should avoid all aggravating activities, utilize cold modalities 3 to 5 times per day, and take nonsteroidal anti-inflammatory drugs as appropriate to reduce pain and inflammation. Other possible modalities include electrical stimulation and ultrasound. During this phase, utilization of joint distraction and low-grade mobilization, as well as passive range of motion (PROM), can be utilized with the goal of pain relief and gradual restoration of normal joint mobility. As acute inflammation decreases, the athlete should begin a stretching and strengthening program $ 5 days per week as tolerated. Stretching tight hip musculature, including the piriformis, iliopsoas, quadriceps, and the IT band, is important during this stage. The athlete should begin stationary cycling with minimal resistance with the seat placed high enough to avoid any painful hip flexion. The resistance can progress as tolerated. Muscular strengthening in all planes should be performed with a particular focus on the gluteus medius, external rotators, and core musculature. Lack of control in the frontal and transverse planes has been implicated as a factor related to increased pain in the presence of FAI.30 Functional balance exercises begin with 1-leg activities and progress to sport-specific exercises. Weight training progresses as tolerated with closed-chain activities at high repetitions and light

weight. Athletes may return to full activity when they have regained their full functional ROM; have no pain or tenderness, good muscular strength, and appropriate neuromuscular control; show the ability to attenuate rapid loading of the hip joint; and have a satisfactory clinical examination.

Operative Management

For athletes with unresolved pain or continued performance decline, arthroscopic surgical treatment options for FAI should be considered. Arthroscopic hip surgery is an outpatient procedure and generally involves 2 or 3 small incisions, measuring approximately 1 cm each. Surgical treatment varies based on the individual pathology present. Patients with labral tears may undergo repair, reconstruction, or debridement. In order to prevent further impingement and worsening labral tears and chondral damage, an osteoplasty is performed on patients with pincer or cam impingement, which entails shaving away the excess bone (Figure 11). If the iliopsoas is suspected to have contributed to a labral tear, an arthroscopic tenotomy can prevent pain and future labral tears in patients. Articular cartilage damage often presents as a result of impingement, and can be treated with chondroplasty and microfracture or cartilage repair. The above procedures may be performed individually or in combination, depending on the patient’s clinical and surgical findings. Although hip arthroscopy has increased in popularity during the past decade, open hip dislocation and mini-open procedures are still an effective treatment option for FAI. Open hip dislocation, which may allow visualization and Figure 11. Arthroscopic view of a patient with an acetabular articular cartilage delamination flap as a result of long-standing cam impingement. This patient underwent subsequent chondroplasty and microfracture of the chondral defect, labral repair, and osteoplasty of the causative cam lesion.



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treatment of areas not accessible arthroscopically, involves performing a greater trochanteric osteotomy with subsequent dislocation of the femoral head from the acetabulum. This approach facilitates excellent visualization of the a cetabulum, femoral head, and head–neck junction in addition to preserving the blood supply to the femoral head.31 Mini-open treatment of FAI involves an anterior approach to the hip without dislocation, which facilitates dynamic examination of the head–neck junction and its abutment with the acetabulum. Proponents of this approach report approximately 60% to 70% of the acetabulum can be visualized with simple manual traction.32 A systematic review by Matsuda and colleagues33 reported that all 3 approaches for FAI improve pain/function and are relatively safe, though the arthroscopic approach has a lower complication rate when performed by experienced surgeons. Studies have also reported a similar return-to-sport schedule following arthroscopic, mini-open, and surgical hip dislocation.32,34 As with any surgical procedure, risks, and benefits must be weighed among arthroscopic, open dislocation, and mini-open approaches before reaching a treatment decision.

Rehabilitation Following Hip Arthroscopy

As FAI becomes a more widely recognized entity in the athletic population, postoperative rehabilitation protocols utilized for these individuals are evolving. 28,35–37 Most protocols are procedure-specific and based on the healing time of the involved tissues and the clinicians’ experience. Although these factors are crucial to proper progression of healing, clinicians should also consider the achievement of clinical milestones when considering the rate of progression for athletes.

Immediate Postoperative Rehabilitation The initial goals of rehabilitation following hip arthroscopy to address FAI are similar to those of other surgical procedures. Inflammation and pain control are achieved through medication as prescribed by the surgeon and cryotherapy. Gentle ROM is initiated immediately through use of the stationary bike. Excessive joint motion may be controlled through use of a postoperative brace, and a night immobilizer system can be used to control excessive external rotation at the surgeon’s discretion.36,38 Gentle exercises utilizing muscles that cross the hip joint and collateral muscles are initiated immediately. Gentle, mid-range PROM should also be performed. The patient is typically placed on crutches with partial-weight bearing status for 10 days to 4 weeks depending on the nature of the procedure. 82

Acute Postoperative Rehabilitation The next phase of patient rehabilitation emphasizes regaining lower extremity strength and flexibility in addition to avoiding excessive inflammation. Non–weight-bearing exercises are progressed with a focus on the hip abductors, hip e xternal rotators, hip extensors, and quadriceps muscle groups. Exercises to promote lumbopelvic stabilization in patients should also be utilized. A cautious approach to hip flexion strengthening should be taken, as overaggressive utilization of these muscles early in the rehabilitation process may result in tendinitis.38 As the patient progresses toward full weight bearing (typically by 4 weeks after surgery), strengthening activities should be initiated. These should be performed with relatively little discomfort and in the appropriate form. Range of motion is typically progressed as tolerated by the patient. The exception to this would be individuals undergoing additional procedures to correct capsular laxity. In these athletes, ROM may be limited to protect vulnerable capsular tissue; the most common example is a limitation of overpressure into external rotation or extension to protect the anterior capsule. After full available PROM is achieved, gentle stretching may be tolerated within pain-free limits. By the end of this rehabilitation phase, the patient should be ambulating with a symmetrical gait pattern and minimal pain, as well as performing basic activities of daily living. The time range for patients to achieve these goals may vary from 4 to 6 weeks.

Functional Rehabilitation Following adequate achievement of strength, ROM, and flexibility, improving patient endurance and progressing functional activities should be emphasized. Use of the stationary bike for endurance can be continued and the elliptical machine may be used when the patient achieves weight bearing and pain-free ambulation. Balance activities should be initiated, starting with stabilization of position on 2 legs to single leg stance on variable surface conditions. Functional strength activities should be initiated with an emphasis on using multiple muscle groups during a single activity. Appropriate neuromuscular control during exercises should be emphasized. The potential for pain with insufficient dynamic control of the hip in the frontal and transverse plane has been described.30 Constant monitoring and reevaluation of the athlete’s symptoms should be employed, as the increase of activity intensity and frequency during this time period may leave the athlete vulnerable to relapsing inflammation. By the end of this phase, the athlete should be able to perform all rehabilitation activities without pain, report no difficulties with activities of daily living, demonstrate appropriate




n euromuscular control in all-planes motion with functionally oriented tasks, and demonstrate sufficient general cardiovascular endurance. The time to achieve these goals may range from 8 to 20 weeks and is highly variable, depending on surgery type and patient-specific characteristics. Once these goals are achieved, the athlete should be ready to start a progression back into sport-specific activities. It should be noted that postoperative rehabilitation protocols are evolving, much like their corresponding surgical procedures. Current postoperative hip arthroscopy protocols are based on expert opinion and the known healing properties of the surgically affected tissues. Continued research and scrutiny of the rehabilitation process is necessary to support or advance these guidelines.

Return-to-Play Considerations

The return-to-play phase and associated criteria following hip arthroscopy is vaguely described in the literature. Future criteria may be more fully developed using similar methodology to that employed for patients undergoing anterior cruciate ligament reconstruction.39 Edelstein et al35 described the concerns for athletes undergoing hip arthroscopy as they return to the competitive state. To date, only one sport-specific protocol (hockey goaltenders) is described in the literature.40 Return-to-play progression criteria should include tasks to determine if the individuals’ current physical capabilities can sustain the stresses created by specific sports. Appropriate control in all planes of motion should be demonstrated with activities such as step-down maneuvers to more explosive single-leg hop and hold tests in multiple directions. The athlete’s ability to attenuate torsional forces at the hip joint should be assessed (cutting and pivoting maneuvers). Tests should provide as much objective information as possible. Ideally, future efforts will produce multistaged return-to-play criteria allowing safe and efficient transition between the progressively more challenging stages of running, cutting and pivoting, practice, and competition. These data can offer a means of communication between physicians, physical therapists, athletic trainers, and the surgeon when attempting to determine the appropriate time for returning an athlete to sporting activities. Our preferred return-to-play criteria following hip arthroscopy are described in Table 1.

Outcomes of Surgical Treatment

Athletes treated surgically for FAI generally report favorable results and successful return to sports activity. In a mixed group of high school, college, and professional athletes, Nho

Table 1. Return-to-Play Criteria Following Hip Arthroscopy 1. Tolerate all exercises for strengthening, agility, running, sprinting, and plyometric exercises at 100% effort with no reports of instability, joint pain, or inflammation 2. All tests of involved hip must be within 90% of uninvolved before returning to practice with restrictions 3. Physician clearance 4. Pass return-to-play test: • Warm-up 10–20 minutes on a stationary bike, elliptical, or treadmill followed by stretching • Practice each of the following tasks at 25%, 50%, 75%, and 100% maximal effort followed by performance of 2 trials of each task 1. 10 rep max single leg squat 2. Triple broad jump, landing last jump on 1 foot 3. Single leg zig-zag jump (diagonal cross over) 4. Single leg forward jump 5. Single leg lateral jump 6. Single leg medial jump 7. Single leg rotating jump 8. Single leg vertical jump 9. Single leg triple jump 10. Timed 10-meter single leg hop 11. 10-yard lower extremity functional test (recommended goal, males 18–22 seconds; females 20–24 seconds) • Sprint/back-pedal • Shuffle • Carioca • Sprint 12. 10-yard–pro-agility drill

and colleagues41 reported a return-to-play rate of 79% at 1 year and 73% at 2 years. Similarly, in another series of collegiate and professional athletes who underwent arthroscopic treatment for FAI, a return to preinjury activity was reported in 85% of collegiate athletes and 95% of professional athletes.42 A study examining a cohort of recreational athletes also reported favorable return to low-impact sports activities following arthroscopic treatment of cam or mixed-type FAI.43 In a recent systematic review of 9 studies with a total of 418 athletes treated surgically for FAI, the overall return-to-play rate was 92% and the rate of return to preinjury activity level was 88%.44 Although these data are encouraging, evaluation of long-term sports performance and longevity following hip arthroscopy is relatively lacking in the literature.

Complications

Complications can present as a result of arthroscopic hip surgery. Hip arthroscopy portals often lie in close proximity to the lateral femoral cutaneous nerve, which provides sensation to the lateral thigh. When this nerve becomes irritated, a resultant numbness or paresthesia may occur on the lateral thigh that most often resolves with time. Another possible neurologic complication is transient neurapraxia in the groin



Tranovich et al

due to the traction applied to the hip joint during arthroscopy, causing pudendal nerve irritation. This neurapraxia often resolves over time, though it should be reported to the treating surgeon at follow-up. As with any lower extremity surgery, deep vein thromboses are a possibility, even in patients with no known risk factors. Any calf discomfort or calf fullness should be immediately reported to the treating physician. Stiffness about the hip joint may result, especially in individuals who fail to adhere to the strict postoperative rehabilitation protocol. Insufficient surgical bony resection is thought to be one of the most common factors contributing to failed hip arthroscopy, with unresolved impingement and continued pain. Iatrogenic labral and chondral injury may result from hip arthroscopy, which can lead to continued pain. Heterotopic ossification is also possible as a result of hip arthroscopy. Extremely uncommon, but more severe complications have been reported, including sciatic neurapraxia and foot drop, labia hematoma, vaginal tearing, fluid extravasation into the abdomen, septic arthritis, avascular necrosis, hip dislocation, and fracture of the acetabulum or femoral neck.45–51 A recent systematic review of 6962 hip arthroscopies by Kowalczuk and colleagues49 reported a complication rate of 4.0% with a major complication rate of 0.3%. Another recent systematic review of complications associated with 6134 hip arthroscopies found a major complication rate of 0.58% and a minor complication rate of 7.5%, with the most common complications being iatrogenic labral and chondral injuries during portal placement. Reoperation was reported in 6.3% of cases with a conversion to total hip arthroplasty rate of 2.9%.51

with labral tears, chondral delamination, decreased motion, and resultant pain due to impingement. Several studies have supported the notion that patients with more severe arthritis at initial presentation have worse outcomes following arthroscopic hip surgery.54–58 A 2011study demonstrated that male sex, increasing alpha angle, and increasing age were positive predictors of more severe intra-articular degeneration, and patients with these attributes are therefore more likely to experience fewer positive outcomes from hip arthroscopy.57 In a study of hip arthroscopy patients aged $ 50 years, improved outcomes were found in patients with . 2 mm of joint space on preoperative radiographs, whereas patients with # 2 mm of joint space experienced continued pain and often underwent total hip arthroplasty.58 Based on the data presented in these studies, an athlete aged . 40 years may benefit from hip arthroscopy for FAI in the absence of moderate to severe osteoarthritic changes (joint space narrowing, subchondral sclerosis, osteophytes) at initial presentation.

Special Considerations in the Pediatric Athlete

Conclusion

Femoroacetabular impingement is a diagnosis recognized in pediatric and adolescent populations as well as in adult populations. Arthroscopic management of symptomatic FAI in adolescents has been reported with good outcomes in the short-term and at 2- to 5-year follow-up.52,53 Although the long-term benefits are only theoretical, it is thought that decreasing or eliminating impingement may decrease the risk of adult conditions associated with FAI, including labral tears, cartilage delamination, and early osteoarthritis.

Special Considerations in Master Athletes

Selected athletes aged . 40 years may benefit from arthroscopic treatment of FAI. However, it is important to distinguish between athletes who have pain from moderate to severe osteoarthritis and those master athletes presenting 84

Other Conditions Amenable to Hip Arthroscopy

In addition to treatment of FAI, hip arthroscopy can be used to treat a large variety of pathologies including, but not limited to, osteochondral defects, loose bodies, iliopsoas impingement/internal snapping hip syndrome, trochanteric bursitis/external snapping hip syndrome, synovial chondromatosis, ligamentum teres tears, septic hips, anterior inferior iliac spine impingement/subspine impingement, and hip instability59–72 (Table 2).

Femoroacetabular impingement is a clinical diagnosis of hip pain caused by repeatedly stressing the limits of the ROM for a given athlete’s hip. Certain anatomic abnormalities such as cam, pincer, or combined lesions increase the risk of FAI by decreasing the safe functional ROM, whereas certain athletes who require extreme flexibility of the hip are susceptible even with lesser bony constraints to motion. These repetitive motions of FAI can lead to multiple intra-articular pathologies including synovitis, chondral flaps and delamination, and labral tears. The initial treatment of these is typically conservative management, including relative rest, stretching, and hip, core, and pelvic girdle strengthening. If conservative measures fail, arthroscopic repair or debridement of soft tissue damage and the resection of bony abnormalities can lead to decreased pain, increased ROM, and a safe return-to-play with proper postoperative rehabilitation.




Table 2. Other Conditions Amenable to Hip Arthroscopy Condition

Symptoms and Findings

Treatment

Osteochondral defects

Deep groin pain; worsens with weight bearing/activity

Loose bodies Iliopsoas impingement/internal snapping hip

Pain, irritation, popping, clicking Deep groin pain, medial snapping with hip flexion/ extension, + Thomas test

Trochanteric bursitis/external snapping hip

Tenderness to palpation over greater trochanter, + Ober test

Synovial chondromatosis

Pain, irritation, popping, clicking

Ligamentum teres tears

Groin pain; often associated with other conditions and their symptoms Hip held in flexion, abduction, external rotation; significant pain with any hip motion Groin pain, decreased hip flexion and internal rotation Hip subluxations or dislocations; increased ROM; laxity of other joints, connective tissue disorder

Arthroscopic debridement, microfracture, repair with fibrin adhesive, or autologous chondrocyte implantation59–61 Removal of loose bodies Stretching, strengthening, ROM, injection Iliopsoas tenotomy and treatment of associated pathology (labral tears, synovitis, etc)62,63 Stretching/foam rolling; steroid/local anesthetic injection Fractional lengthening of iliotibial band and debridement of bursa64,65 Removal of loose bodies, irrigation, synovial debridement66 Debridement or reconstruction and treatment of associated pathologies67,68 Irrigation and debridement; oral/IV antibiotics69

Septic hip AIIS impingement/subspine impingement Hip instability

AIIS/subspine osteoplasty and correction of associated intra-articular pathology70,71 Capsular plication; correction of associated intra-articular pathology72

Abbreviations: AIIS, anterior inferior iliac spine; ROM, range of motion.

Acknowledgment

We would like to thank Randy McKenzie at McKenzie Illustrations for creating the medical illustrations in Figures 1 and 3.

Conflict of Interest Statement

Michael J. Tranovich, DO, Matthew J. Salzler, MD, Keelan R. Enseki, MS, PT, OCS, SCS, ATC, CSCS, and Vonda J. Wright, MD, MS, have no conflicts of interest to declare.

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Hip arthroscopy for femoroacetabular impingement: a health economic analysis.

Preoperative physical examination and imaging of femoroacetabular impingement prior to hip arthroscopy-a systematic review.

Fifty Most Cited Articles for Femoroacetabular Impingement and Hip Arthroscopy.

Management of incarcerating pincer-type femoroacetabular impingement with hip arthroscopy.

Hip arthroscopy for challenging deformities: global pincer femoroacetabular impingement.

Hip muscle strength recovery after hip arthroscopy in a series of patients with symptomatic femoroacetabular impingement.

Surgery for treating hip impingement (femoroacetabular impingement).

Femoroacetabular impingement and osteoarthritis of the hip.

Hip arthroscopy for femoroacetabular impingement: the changing nature and severity of associated complications over time.

Hip chondropathy at arthroscopy: prevalence and relationship to labral pathology, femoroacetabular impingement and patient-reported outcomes.

Danish Hip Arthroscopy Registry (DHAR): the outcome of patients with femoroacetabular impingement (FAI).

Proposed Referential Index to Resect Femoroacetabular Cam-Type Impingement During Arthroscopy Using a Cadaveric Hip Model.

A less-invasive technique for capsular management during hip arthroscopy for femoroacetabular impingement.

Closed intramedullary derotational osteotomy and hip arthroscopy for cam femoroacetabular impingement from femoral retroversion.

Measuring hip muscle strength in patients with femoroacetabular impingement and other hip pathologies: A systematic review.

Effect of warmed irrigation solution on core body temperature during hip arthroscopy for femoroacetabular impingement.

Hip arthroscopy with labral repair for femoroacetabular impingement: short-term outcomes.

The demographic characteristics of high-level and recreational athletes undergoing hip arthroscopy for femoroacetabular impingement: a sports-specific analysis.

The direct environmental impact of hip arthroscopy for femoroacetabular impingement: a surgical waste audit of five cases.

Radiological variables associated with progression of femoroacetabular impingement of the hip: a systematic review.

Variability and Comprehensiveness of North American Online Available Physical Therapy Protocols Following Hip Arthroscopy for Femoroacetabular Impingement and Labral Repair.

Hip pain in young adults: diagnosing femoroacetabular impingement.

Hip Joint Stresses Due to Cam-Type Femoroacetabular Impingement: A Systematic Review of Finite Element Simulations.

Pelvic posture and kinematics in femoroacetabular impingement: a systematic review.