Many people contact me with problems of a confusion in their hip or low back diagnosis. They have confusion because they have had low back pain coupled with hip pain and after a long time trying to determine what was the cause of their pain, their doctors came back with a diagnosis of Femoroacetabular Impingement (FAI) or more simply a hip impingement. They were then told that they have a condition where the ball and the socket of the hip were rubbing against each other in a non-anatomically correct way and that this was causing friction in the hip joint. This friction can also cause a sensation of low back pain.
Usually people who contact my office will have a diagnosis of their hip impingement broken down into one of three types.
They have a:
- A cam impingement. This is boney formations or spurs at the base of the ball or femoral head. If the bone spur is large enough it can prevent full range of motion in the hip and prevent the ball from rotating within the socket. The abnormal movement between the ball and socket can also cause an accelerated breakdown of the hip cartilage.
- A pincer impingement. Here instead of bone spurs at the base of the femoral head, the bones spurs form at the edge of the socket or acetabulum. This can also cause friction in the socket, accelerated cartilage damage, loss of range of motion and tearing or impingement of the hip labrum.
- Both. A situation of combined cam and pincer impingement.
In Femoroacetabular Impingement Syndrome bone spurs can develop around the femoral head (the ball) and/or along the acetabulum (the socket). The bone spurs prevent the normal range of motion and contact between the ball and socket. This is a degenerative disorder and over the course of time Femoroacetabular Impingement Syndrome can cause degenerative wear and tear of the hip labrum and cartilage resulting in hip osteoarthritis.
Connecting low back pain and femoroacetabular impingement syndrome
A January 2022 paper (1) examined the prevalence of low back pain and related disability in patients with femoroacetabular impingement syndrome. In this paper the researchers wrote: “Low back pain has been associated with worse hip function for persons with femoroacetabular impingement syndrome.” The researchers then hypothesized that study participants with low back pain would be older, have higher body mass index (BMI), and report worse groin pain, longer symptom duration, and worse hip function. We hypothesized that worse low back pain-related disability and low back pain severity would be related to worse hip function.” Their findings: “Clinically significant low back pain is highly prevalent in persons with femoroacetabular impingement syndrome and is associated with worse hip function. Worse femoroacetabular impingement syndrome-related disability, but not femoroacetabular impingement syndrome severity, was strongly associated with worse hip function.
Conservative care non-surgical treatment
Most people that come into our office have been to other doctors and they, for the most part, tell us about the treatments and recommendations they have received up until this point.
- Reduce or limit activities that worsen hip pain.
- Over the counter or prescription strength Nonsteroidal anti-inflammatory medications.
- Physical therapy and exercise programs.
A November 2021 paper (2) wrote about the more or less ineffectiveness of physical therapy: “Prescribed physiotherapy, consisting of hip strengthening, hip joint manual therapy techniques, functional activity-specific retraining and education showed a small to medium effect size compared with a combination of passive modalities, stretching and advice (very low to low quality of evidence; interpretation of evidence: very uncertain, but may slightly improve outcomes). Prescribed physiotherapy was, however, inferior to hip arthroscopy (small effect size; moderate quality of evidence; interpretation of evidence: hip arthroscopy probably increases outcome slightly).”
A March 2022 study (3) suggested which people may be at risk for a failed arthroscopic procedure for Femoroacetabular Impingement Syndrome. Using a unique scoring system to reliably predict clinically meaningful improvement after hip arthroscopy for Femoroacetabular Impingement Syndrome, the researchers wrote: “Despite consistent improvements after hip arthroscopy, meaningful improvements are negatively influenced by greater Body Mass Index (BMI), back pain, chronic symptom duration, preoperative mental health, and use of hip corticosteroid injections.”
From April 2020, from the The American journal of sports medicine.(4)
“While the indications for primary hip arthroscopic surgery in treating femoroacetabular abnormalities continue to be defined, the indications and outcomes for revision hip arthroscopic surgery remain ambiguous. However, revision hip arthroscopic surgery is performed in 5% to 14% of patients after their index procedure. While patient-reported outcomes generally improve after revision procedures, the extent of their improvement is not well defined. . . ” The researchers also note that after revision hip arthroscopic surgery, studies have suggested the rates of conversion to total hip replacement ranged up to 14.3%, and the rates of further arthroscopic revision ranged also ranged to 14% of patients.
The use of PRP during Femoroacetabular Impingement surgery
A January 2021 paper (5) examined the application of biologics (injections made from cells) during arthroscopic FAI surgery. In reviewing past research the study authors wrote: “An randomized control trial examined the effects of intra-articular injection of PRP during hip arthroscopy with indication of Femoroacetabular Impingement. (A group of patients) treated with PRP intraoperatively reported lower pain scores 48 hours post-operatively and demonstrated fewer joint effusions at six-month follow-up. The study supported the use of intraoperative PRP intra-articular injections to reduce inflammation following hip arthroscopy but concluded more research should be conducted to determine long-term benefits. Similarly, another randomized control trial demonstrated decreased inflammation and ecchymosis (skin discoloration) following hip arthroscopy with intra-articular PRP injections. Despite immediate post-operative benefits, the study concluded that PRP injections did not produce significant improvements in outcomes at 1-year follow-up when comparing 20 patients who received PRP to 15 control patients without PRP intra-articular injections.
1 Brown‐Taylor L, Bordner H, Glaws K, Vasileff WK, Walrod B, Di Stasi S. Prevalence of low back pain and related disability in patients with femoroacetabular impingement syndrome. PM&R. 2021 Feb 14.
2 Ishøi L, Nielsen MF, Krommes K, Husted RS, Hölmich P, Pedersen LL, Thorborg K. Femoroacetabular impingement syndrome and labral injuries: grading the evidence on diagnosis and non-operative treatment—a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF). British Journal of Sports Medicine. 2021 Nov 1;55(22):1301-10.
3 Kunze KN, Polce EM, Clapp IM, Alter T, Nho SJ. Association Between Preoperative Patient Factors and Clinically Meaningful Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Machine Learning Analysis. The American journal of sports medicine.:3635465211067546.
4 O’Connor M, Steinl GK, Padaki AS, Duchman KR, Westermann RW, Lynch TS. Outcomes of revision hip arthroscopic surgery: A systematic review and meta-analysis. The American Journal of Sports Medicine. 2020 Apr;48(5):1254-62.
5 Sullivan SW, Aladesuru OM, Ranawat AS, Nwachukwu BU. The use of biologics to improve patient-reported outcomes in hip preservation. Journal of Hip Preservation Surgery. 2021 Jan;8(1):3-13.
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