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Chiropractic Journal of Australia : CJA September 2012
Chiropractic Journal of Australia Volume 42 Number 3 September 2012 91 INTRODUCTION Femoroacetabular impingement (FAI) has been increasingly recognized over the past fve to six years as a major cause of pain and premature degenerative changes in the hips of young adults.1-10 Ganz et al11 summarised the pathomechanics of FAI, in which morphologic abnormalities of the acetabular rim and proximal femur (i.e. femoral head-neck junction) lead to anterosuperior soft tissue damage and continued bony contact (Figure 1). During end-range hip motion, abnormal contact between the acetabular rim and femoral head-neck can occur, creating developmental lesions within the labrum and/or adjacent cartilage.12 With repetitive loading, these lesions progress and lead to the development of degenerative joint disease (DJD).12 FAI can manifest through two different mechanisms – Cam-type or pincer-type (Figure 1) - although a combination of both is often seen in clinical practice.13 Cam-type FAI is found in two-thirds to three-quarters of cases.3 The Cam- type impingement is due to proximal femur abnormalities, characterised by an absent or decreased offset between the femoral head and neck (also named pistol-grip or tilt deformity).2 This femoral abnormality encroaches on the labrum and acetabulum when the hip is fexed, particularly Femoroacetabular Impingement and its Relevance to Chiropractors. Part I: A Commentary BRETT S. JAROSZ ABSTRACT: Femoroacetabular impingement (FAI) is a condition resulting from morphologic abnormalities of the acetabular rim and proximal femur. FAI can manifest through two different mechanisms – Cam-type or pincer-type – although a combination of both is often seen in clinical practice. The Cam-type impingement is characterized by an absent or decreased offset between the femoral head and neck. Pincer-type impinge- ment results from focal or generalised acetabular abnormalities. Either mechanism leads to abnormal contact between the acetabular rim and femoral head-neck junction, creating chondral lesions and labral pathology. FAI has been increasingly recognized as a major cause of pain and premature degenerative changes in the hips of young adults. FAI typically presents as insidious onset groin pain in physically active adults aged 20 to 50 years, often in association with sporting activities. Early diagnosis is crucial in order to improve the management of this condition and avert the pathological progression from impingement to end-stage DJD. Therefore, it is important that the chiropractic profession increases their awareness of FAI, as chiropractors are often the primary contact for patients presenting with this disorder. INDEX TERMS: (MESH): ATHLETIC INJURIES; CHIROPRACTIC; HIP INJURIES; OSTEOARTHRITIS, HIP. (OTHER): FEMOROA- CETABULAR IMPINGEMENT. Chiropr J Aust 2012;42: 91-7. Brett S. Jarosz, BAppSc(CompMed), MClinChiro, ICSSD, CertPT Sessional Lecturer, RMIT University, Discipline of Chiropractic, Bundoora, Victoria; Chiropractor, Private Practice of Chiropractic, Gisborne, Victoria. Received: 15 March 2012 Accepted: 24 May 2012 Confict of Interest Notifcation: There were no funding sources for this study and no conficts of interest have been identifed. with combined internal rotation and/or adduction.3 It often causes labral detachment and outside-in damage to the anterosuperior acetabular articular cartilage as the abnormal femoral head-neck junction forces itself under the acetabular rim.2,14 Over time, the repetitive anterosuperior contact causes continual damage to the labrum, articular cartilage, and subchondral bone, eventually leading to DJD.3 The Cam- type impingement is known to be associated with femoral neck fractures, slipped capital femoral epiphysis, Legg- Calve-Perthes’ disease, or in any hip in which the femoral neck is too large.5,7,11,12 Pincer-type impingement accounts for approximately one-quarter of cases of FAI.3 Pincer-type FAI results from focal or generalised acetabular abnormalities including: an acetabulum that is too deep (coxa profunda or protrusion); an acetabular rim that is curving downward; or retroversion.2,3,11 The acetabular over-coverage causes the labrum to be compressed between the acetabular rim and the femoral neck during hip fexion and internal rotation.3,14 The pincer-type impingement leads to degeneration and eventual ossifcation of the labrum, worsening the problem of acetabular over-coverage.14 The abnormal loading through the femoral head-neck junction and the acetabular rim predispose patients to functional restrictions, articular cartilage and labral damage, and subsequent DJD.15 Therefore, it is crucial that a timely diagnosis of FAI can be made in order to improve management of this condition, and provide an opportunity for joint preservation.15 Chiropractors are often the primary contact for patients presenting with lumbopelvic-hip pain that may be associated with FAI. Therefore, it is essential that chiropractic practitioners are familiar with the assessment, diagnosis and management of this condition. The purpose of this paper is to describe the clinical presentation, physical examination fndings, radiographic features, and treatment
CJA June 2012
CJA December 2012