Review Question - QID 215519

The patient's clinical exam of anterior hip impingement and groin pain with squatting is consistent with a labral tear in the setting of femoroacetabular impingement (FAI). Figure C demonstrates a right hip x-ray with an alpha angle of 70 degrees indicative of CAM-type FAI, and an MRI of an anterosuperior labral tear.

Femoroacetablar impingement (FAI) is a syndrome characterized by abnormal acetabular and/or femoral neck morphology. There are two sub-types of FAI: pincer-type, in which there is acetabular over-coverage, and CAM-type, which is characterized by an abnormal femoral head-neck junction. These subtypes can exist in isolation, or concurrently. Individuals with FAI who frequently place the hip into a position of flexion, adduction, and internal rotation (FADIR) are at a high risk of sustaining a labral tear. Hockey goalies, gymnasts, and dancers are at particular risk of suffering labral tears given the repetitive impingement-generating motions classically associated with these sports.

Lynch et al. performed a best-practice analysis across 15 high-volume hip arthroscopists to determine the ideal management of FAI. They used a Delphi process to determine consensus among a variety of perioperative considerations, and their final recommendations had 100% support from all queried surgeons. They postulated that all patients with symptomatic FAI should undergo a minimum of 3 months of conservative management to include rest, NSAIDs, activity modification, and physical therapy.

Nepple et al. performed a critical evaluation of the available literature regarding the treatment of symptomatic FAI. They put forth a number of recommendations regarding the optimal management of symptomatic FAI. Although the authors acknowledge the limited quality of outcomes data available for nonoperative management, they did recommend an initial trial of activity modification, NSAIDs, and physical therapy for all patients.

Menge et al. performed a review of the literature surrounding the treatment of FAI. In it, they reported a positive-predictive value of 95.7% for FAI for the flexion-adduction-internal rotation (FADIR) impingement test in patients with hip pain. They state that the first line of treatment for patients with hip and/or groin pain from symptomatic FAI is physical therapy, activity modification, and NSAIDs.

Figure A demonstrates sacroiliitis, with SI joint sclerosis seen on the AP radiograph, and increased T2 fluid intense signal in the same area on MRI. Figure B demonstrates a compression-sided femoral neck stress fracture, with a linear lucency on the inferior aspect of the femoral neck seen on the AP radiograph, and an increased T2 fluid intense signal in the same area on MRI. Figure C demonstrates a right hip x-ray with an alpha angle of 70 degrees indicative of CAM-type FAI, and an MRI of an anterosuperior labral tear. Figure D demonstrates a displaced femoral neck fracture. Figure E demonstrates osteitis pubis, with increased peri-symphyseal sclerosis and osteolysis seen on the AP radiograph, and increased T2 fluid intense signal seen in the same area on MRI.

Incorrect Answers:
Answer 1: Figure A demonstrates sacroiliitis which would cause the patient to have pain with prolonged standing and for the pain to be located primarily in the low back. Furthermore, the examination would reveal pain with FABER of the hip (flexion, ABduction, external rotation) unlike FAI that is exacerbated with FADDIR of the hip.
Answer 2: Figure B is a compression-sided femoral neck stress fracture, which is treated with non-weightbearing if the fracture spans less than 50% of the femoral neck, or percutaneous screw fixation if the fracture spans more than 50% of the femoral neck.
Answer 4: Figure D is a displaced femoral neck fracture, which is treated with ORIF in younger patients and arthroplasty in older patients.
Answer 5: Figure E is osteitis pubis, which is treated with NSAIDs, rest, and activity modification. Impingement testing is typically not provocative in these patients, and the pain is located more centrally and exacerbated with direct palpation of the pubic symphysis and with resisted hip adduction/abduction.