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REHABILITATION HIP IMPINGEMENT

also shifts towards the acetabular rim, proving that the labrum provides both structural resistances to lateral movement of the femoral head and joint congruity (9,10). It is important to note that labrum tears are uncommon (11). Therefore, it is also important to consider differential diagnosis in athletes with groin pain. There are many papers that very effectively describe groin pain in athletes (8,12,13) and offer a number of alternatives that must be considered before surgery (Table 1). Blood vessels penetrate the labrum from the outermost layer of the capsule to a depth of only 0.5 mm, leaving most of the labrum avascular, and hence any healing is minimal (14). Vascularity is seen as an influential factor in labral tears. The most vascularised area, which is also the most common site of pathology, is a zone encompassing the anterior, posterior and inferior parts of the labrum (15). This is also the area that encounters the highest mechanical stresses. Free nerve endings have also been identified in labral tissue (16).

HISTORY Over the past 10 years, as our understanding of intra-articular hip pathology has increased, patients are referred more frequently for investigation specifically of the hip joint. Most of these patients have seen a number of practitioners over a prolonged period. The average time to diagnosis is 8 months (17), with the vast majority having had previous surgery, ranging from inguinal hernia repair to lumbar disc surgery. The increasing frequency is supported in a recent paper by Bradshaw et al., who looked at 218 consecutive patients with groin pain and found that 50.4% had hip-based pathology following further investigations (18). The pistol grip deformity has,

over the years, been correlated with idiopathic osteoarthritis. Subclinically, slipped capital femoral epiphysis has been suggested as a possible cause of this deformity and thus of secondary OA. Other authors have disputed this, suggesting instead that the deformity is secondary remodelling of the proximal femur as a result of idiopathic OA itself (19). The predisposing factors leading to the development of hip pain are unclear, although the pattern of chondral

www.sportEX.net damage is well documented.

PATHOLOGY To put this into perspective, a cadaveric study (mean age 78 years) showed 96% of the 55 hips studied had labral lesions, of which 74% were located in the anterosuperior quadrant (20). These occur commonly on the articular non-vascular edge of the tissue. This was further confirmed by Blankenbaker and Tuite, who found that 94% of the 61 subjects had labral damage in the anterior quadrant, of which 40% extended to more than one quadrant (21). Kelly et al. reviewed 300

arthroscopies and found that 90% had labral tears (22). They broadly classified five causes of labral tears: n Trauma n FAI n Capsular laxity/hip hypermobilty n Dysplasia n Degeneration. Labral lesions tend not to occur

in isolation: 55% of labral injuries have associated articular cartilage lesions of either the acetabulum or the femoral head (23). Tannast et al. performed a computer simulation, showing that the damage caused to the labrum and acetabulum was caused at the zone of the FAI, causing early OA and labral changes (24). Clinically, impinging joints, labrum degeneration and cartilage

Figure 1: The Faber test

delamination occur in the anterior superior region of the acetabulum (25). Similar patterns of pathology were reported in elite handball players (26). There are both cam and pincer impingements. Beck et al. reported that 80% of patients with FAI have a combination of both pincer and cam lesions (25). Pincer-type lesions are more common in women due to the excessive femoral head coverage (27). Pincer lesions are thought to be more common in Asia due to the nature of work and cultural differences in the west (28). James et al. concluded that any

evidence of fibrocystic changes at the anterosuperior femoral neck with or

TABLE 1: HIP PAIN DIFFERENTIAL DIAGNOSIS EXTRA-ARTICULAR Infection

Iliopsoas bursitis Avulsion injuries

Rectus femoris tendonitis

Stress fracture of the lesser trochanter Adductor strains

Gluteus medius strain

External rotators tendonitis Myositis ossificans Gracilis strain

Hamstring strains

Iliopsoas tendon strain Greater trochantic bursitis Ischial bursitis

Sacroiliac joint strain Hip pointer

Obturator neuropathy Inguinal/femoral hernia (35)

11

online Video

With thanks to Youtube user jschuber

INTRA-ARTICULAR Acetabular labral tears Capsular sprain Chondral injuries

Developmental dysplastic hip Femoral neck stress fracture Inflammatory arthritis Instability

Legg–Calve–Perthes disease Loose bodies Osteoarthritis Osteonecrosis

Post-traumatic arthritis Ruptured ligamentum teres

Slipped capital femoral epiphysis Transient synovitis

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