Clinical Diagnosis of Femoroacetabular Impingement

Abstract
Jeffrey J. Nepple, MD Heidi Prather, DO Robert T. Trousdale, MD John C. Clohisy, MD Paul E. Beaul, MD, FRCSC Sin Glyn-Jones, MD, MBBS, DPhil, FRCS (Orth) Young-Jo Kim, MD, PhD

The diagnosis of femoroacetabular impingement (FAI) syndrome is made based on a combination of clinical symptoms, physical examination ndings, and imaging studies. A detailed assessment of each of these components is important to differentiate FAI from other intra- and extra-articular hip disorders. Clinical and physical examination ndings must be viewed collectively because no single pathognomonic nding exists for FAI. Nevertheless, common components of the history and physical examination do suggest a diagnosis of FAI.

History
Patients with symptomatic femoroacetabular impingement (FAI) present with a variety of clinical symptoms.1,2 Obtaining a detailed and thorough history is an important component of the diagnostic evaluation. Any history of trauma; childhood hip disease, including developmental dysplasia of the hip, slipped capital femoral epiphysis, and LeggCalv-Perthes disease; or previous surgery should be noted. Risk factors for the following disorders also should be noted: osteonecrosis (alcohol and steroid use), osteopenia or osteoporosis (vitamin D deficiency, delayed menarche, or menstrual dysfunction in adolescents and young adults), and stress fracture (overuse). Although the FAI patient population is diverse, most patients are young and active and may participate in recreational or occupational activities requiring repetitive hip flexion. It is important to obtain detailed information on the patients participation in sports activities and the associated hip positions during these activities. Often, symptoms are

From the Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO (Dr. Nepple, Dr. Prather, and Dr. Clohisy), the Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN (Dr. Trousdale), The Ottawa Hospital, Ottawa, ON, Canada (Dr. Beaul), the Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK (Dr. GlynJones), and the Department of Orthopaedic Surgery, Boston Childrens Hospital, Harvard Medical School, Boston, MA (Dr. Kim). J Am Acad Orthop Surg 2013; 21(suppl 1):S16-S19 http://dx.doi.org/10.5435/ JAAOS-21-07-S16 Copyright 2013 by the American Academy of Orthopaedic Surgeons.

insidious in onset with activities that require joint loading, rotation, or hip flexion.3 Symptoms can include stiffness, pain, clicking, popping, or catching. Any associated painful snapping or popping should be noted, including its location, association with pain, and reproducibility. Typically, pain is activity related but over time can occur even with activities of daily living or at rest. Pain often is reproduced in positions of hip flexion, such as prolonged sitting in a car or rising from a chair. Some patients may compensate by altering their posture to avoid hip flexion >90. The distribution of pain related to intra-articular hip disorders, including FAI, is variable but generally includes groin pain. In one study, 83% of patients with symptomatic FAI reported groin pain.1 Commonly, pain distributions also may include the lateral hip and posterior pelvis and may even extend to the lumbar spine, anterior and posterior thigh, and knee. Intra-articular hip pain commonly is localized by the patient using the C sign, that is, the patient cups the hand above the greater trochanter when describing

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deep interior hip pain.4 Pain intensity can range from mild to severe, and patients have reported moderate to severe impairments in function.1,5

Physical Examination
In general, physical examination maneuvers are sensitive to pathology in FAI but are not specific. Therefore, examination of the hip initially is focused on determining whether an intra-articular source of pain is present. Compensatory extra-articular disorders may coexist, however. It is important to assess the gait pattern and association of pain with weight bearing. Gait patterns such as the Trendelenburg gait or lateral lurch, described as lumbar side-bending over the side of the muscle weakness, may indicate muscle weakness in the hip abductors. A single-leg stance or single-leg squat assessment can be helpful in assessing pain provocation with single-leg weight bearing and muscle strength at the hip as evidenced by the ability of the patient to maintain balance without a drop in the pelvic girdle on the opposite side (ie, Trendelenburg sign). Additionally, noting the patients sitting posture on the examination table may be useful because patients with symptomatic FAI may sit with a slouched posture. Passive hip range of motion (ROM) in multiple planes provides a

measurement of the limits of ROM, as well as information regarding the provocation of pain with motion. Comparisons with the contralateral extremity are useful, but FAI deformities often are bilateral.6 Measurements of ROM in hip flexion can be performed with the patient in the supine or seated position, whereas measurements in hip extension can be performed with the patient in the supine or prone position. The end point for hip flexion is assessed most accurately with the examiner placing one hand on the pelvis to determine the point at which compensatory pelvic motion begins to occur. Wyss et al7 showed a strong association between the amount of internal rotation in 90 flexion and the presence and extent of cam deformity in symptomatic and asymptomatic hips. Internal rotation in the control group averaged 28 (range, 10 to 40), compared with an average of 4 (range, 10 to 20) in the symptomatic FAI group. The overlap between these groups may result from the underlying prevalence of asymptomatic FAI deformities in the general population. Restriction of internal rotation (<20) in 90 of flexion generally is thought to be indicative of an increased risk of FAI. In an asymptomatic cohort of patients, Hack et al8 found that only 25% with internal rotation <20 had a cam-type deformity. Estimation of the degree of femoral version can be done in the

prone position by noting the angle of the leg relative to vertical in the position of maximal trochanteric prominence.9 Assessments of femoral version based on physical examination are thought to have limited reliability and validity, however.10 In patients with excessive motion of the hip, examination of the knee and elbow joints is useful to determine the degree of hyperextension. Typically, the dynamic assessment of motion and any associated pain is performed through the hip flexionextension arc in adductioninternal rotation, as well as in abductionexternal rotation.9 Hip abductor strength can be tested in the sidelying position. Resisted leg abduction with the knee flexed may isolate the strength of the gluteus medius by removing contributions from the iliotibial band.9 Various provocative hip tests commonly are used in an attempt to provoke pain in a distribution similar to or in addition to the presenting complaint.9 The most commonly used tests include the impingement test;11 flexion, abduction, and external rotation (FABER) or Patrick test; posterior impingement test; resisted hip flexion (ie, Stinchfield) test; and log roll test. The impingement test or the flexion, adduction, and internal rotation test is performed in 90 of hip flexion and reproduces pain with adduction and internal rotation of the

Dr. Prather or an immediate family member serves as a board member, owner, officer, or committee member of the North American Spine Society. Dr. Trousdale or an immediate family member has received royalties from and serves as a paid consultant to DePuy, Wright Medical Technology, and MAKO Surgical. Dr. Clohisy or an immediate family member serves as a paid consultant to Biomet and Pivot Medical and has received research or institutional support from Wright Medical Technology and Zimmer. Dr. Beaul or an immediate family member has received royalties from and has stock or stock options held in Wright Medical Technology; is a member of a speakers bureau or has made paid presentations on behalf of Smith & Nephew and MEDACTA; serves as a paid consultant to Corin USA, Smith & Nephew, and MEDACTA; and has received research or institutional support from Corin USA and DePuy. Dr. Glyn-Jones or an immediate family member has received royalties from, serves as a paid consultant to, and has received research or institutional support from Zimmer and is a member of a speakers bureau or has made paid presentations on behalf of Zimmer Surgical Innovations. Dr. Kim or an immediate family member serves as a paid consultant to Arthrex and serves as an unpaid consultant to, has received research or institutional support from, and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-researchrelated funding (such as paid travel) from Siemens Healthcare. Neither Dr. Nepple nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

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Clinical Diagnosis of Femoroacetabular Impingement

leg. The posterior impingement test reproduces pain with hip extension and external rotation. Martin et al9 demonstrated moderate levels of interobserver reliability of the impingement and FABER tests among a group of experienced examiners. The sensitivities of the impingement and FABER tests to intra-articular hip pathology were 78% and 60%, respectively, with specificities of 10% and 18%, respectively.12 None of these examination tools in isolation is specific to intra-articular hip pain. The history of activities that provoke and relieve symptoms in combination with any cluster of positive findings on physical examination can guide the examiner toward the diagnosis of an intraarticular hip disorder, however. Physical examination of the patient with hip pain should include assessment of the regions adjacent to the hip, as well, to exclude disorders that may present with similar symptoms and to identify coexisting disorders. Patients with intra-articular hip pain can develop adaptive patterns of movement that may cause overload or shearing, creating symptoms in extra-articular regions. Important adjacent regions to examine include the lumbar spine and pelvic girdle. Standard lower extremity neurologic examination of muscle stretch reflexes, sensation, and strength should be performed, and lumbar spine ROM should be assessed. Pain associated with lumbar spine motion is important in including or excluding the lumbar spine as a contributor to symptoms. In patients with pain in the lower extremity, the passive straight-leg raise and slump tests can help include or exclude neurogenic sources of pain. The passive straight-leg test is performed with the patient seated, and the leg is elevated passively by the examiner. The slump test also is performed with the patient seated. The examiner directs the patient to round the lumbar spine, slouch forward in a flexed position,

and tuck the chin in flexion while the examiner passively raises the leg. Either test is considered positive if it reproduces symptoms in the leg distal to the gluteal fold.13 A positive test directs the examiner to assess for sources of pain in addition to a hip disorder.

Diagnostic Image-guided Intra-articular Hip Injection

A diagnostic image-guided intraarticular hip anesthetic injection can be a useful adjunct to help confirm that the patients pain is related to an intra-articular hip disorder. Intraarticular hip injections have been shown to relieve pain associated with provocative hip physical examination tests.14 Byrd and Jones15 reported 90% accuracy of a positive response to injection, which correlated with findings on hip arthroscopy in a population of young adults with prearthritic hip disease. Pateder and Hungerford16 found hip injections to be 100% sensitive and 81% specific for differentiating hip pathology from lumbar spine pathology. Kivlan et al17 noted approximately 90% pain relief following injection in patients with FAI. The method by which intraarticular hip injections are performed and the type of injection used vary. Although untested, this variability may affect diagnostic accuracy. Typically, the intra-articular hip injections are performed with fluoroscopic or ultrasonographic guidance in an outpatient setting. The fluoroscopic approach involves exposing the patient to a small amount of radiation and requires contrast to aid in visualization but allows for the visualization of an arthrogram. Ultrasonographic guidance avoids exposing the patient to radiation and does not involve contrast.18-20 However, with ultrasonography, confirmation of intra-articular placement is limited

to visualization of the needle tip and not the entire joint capsule. Furthermore, the accuracy of the needle placement depends on the quality of the equipment, the experience of the examiner in using ultrasonography, and patient size.21 Anecdotally, hip specialists have noted inconsistencies in patient response to injection when anesthetic is mixed with contrast as part of magnetic resonance arthrography. The volume of injectate may have implications for pain response. Although it has not been studied, diagnostic injection as a stand-alone procedure may provide the best opportunity for accurate feedback from the patient. Typically, 4 to 6 mL of anesthetic is injected to avoid the pain from capsular extension related to a large-volume joint injection. On the day of the injection, documenting the distribution and location of pain before and after injection can reduce error related to patient recall at a later date. Repeating provocative hip tests after a diagnostic injection can be useful in determining the effect of the injection on painful provocative maneuvers.

Summary
The clinical diagnosis of FAI syndrome often is one of exclusion because these hip deformities are common and can be present in asymptomatic hips. Therefore, careful clinical and radiographic correlation is necessary (see Diagnostic Imaging of Femoroacetabular Impingement, p S2022). FAI syndrome is a dynamic phenomenon in which a structurally predisposed hip may become symptomatic with minimal activity but a structurally normal hip may become symptomatic only with extreme activity. Therefore, in the clinical setting, it is challenging to provide firm criteria to make the diagnosis of FAI syndrome. In the clinical trial setting, specific criteria for entry are necessary. Sug-

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4. Byrd JWT: Physical examination, in Byrd JWT, ed: Operative Hip Arthroscopy, ed 2. New York, NY, Springer, 2005, pp 36-50. Hunt D, Prather H, Harris Hayes M, Clohisy JC: Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders. PM R 2012;4(7):479-487. Allen D, Beaul PE, Ramadan O, Doucette S: Prevalence of associated deformities and hip pain in patients with cam-type femoroacetabular impingement. J Bone Joint Surg Br 2009; 91(5):589-594. Wyss TF, Clark JM, Weishaupt D, Ntzli HP: Correlation between internal rotation and bony anatomy in the hip. Clin Orthop Relat Res 2007;460:152158. Hack K, Di Primio G, Rakhra K, Beaul PE: Prevalence of cam-type femoroacetabular impingement morphology in asymptomatic volunteers. J Bone Joint Surg Am 2010;92(14):2436-2444. Martin HD, Kelly BT, Leunig M, et al: The pattern and technique in the clinical evaluation of the adult hip: The common physical examination tests of hip specialists. Arthroscopy 2010;26(2):161172. Souza RB, Powers CM: Concurrent criterion-related validity and reliability of a clinical test to measure femoral anteversion. J Orthop Sports Phys Ther 2009;39(8):586-592. Klaue K, Durnin CW, Ganz R: The acetabular rim syndrome: A clinical presentation of dysplasia of the hip. J Bone Joint Surg Br 1991;73(3):423429. Martin RL, Irrgang JJ, Sekiya JK: The diagnostic accuracy of a clinical examination in determining intraarticular hip pain for potential hip arthroscopy candidates. Arthroscopy 2008;24(9):1013-1018. 18. 13. Magee DJ: Lumbar spine, in Orthopedic Physical Assessment, ed 2. Philadelphia, PA, WB Saunders, 1992, pp 515-614. Maslowski E, Sullivan W, Forster Harwood J, et al: The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology. PM R 2010;2(3):174-181. Byrd JW, Jones KS: Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients. Am J Sports Med 2004;32(7):1668-1674. Pateder DB, Hungerford MW: Use of fluoroscopically guided intra-articular hip injection in differentiating the pain source in concomitant hip and lumbar spine arthritis. Am J Orthop (Belle Mead NJ) 2007;36(11):591-593. Kivlan BR, Martin RL, Sekiya JK: Response to diagnostic injection in patients with femoroacetabular impingement, labral tears, chondral lesions, and extra-articular pathology. Arthroscopy 2011;27(5):619-627. Chen CP, Lew HL, Tsai WC, Hung YT, Hsu CC: Ultrasound-guided injection techniques for the low back and hip joint. Am J Phys Med Rehabil 2011; 90(10):860-867. Choudur HN, Ellins ML: Ultrasoundguided gadolinium joint injections for magnetic resonance arthrography. J Clin Ultrasound 2011;39(1):6-11. Rowbotham EL, Grainger AJ: Ultrasound-guided intervention around the hip joint. AJR Am J Roentgenol 2011;197(1):W122-127. Kantarci F, Ozbayrak M, Gulsen F, Gencturk M, Botanlioglu H, Mihmanli I: Ultrasound-guided injection for MR arthrography of the hip: Comparison of two different techniques. Skeletal Radiol 2013;42(1):37-42. Nepple JJ, Prather H, Trousdale RT, et al: Diagnostic imaging of femoroacetabular impingement. J Am Acad Orthop Surg 2013;21(suppl 1):S20-S26.

Table 1 Potential Criteria for the Diagnosis of Femoroacetabular Impingement in a Clinical Trial Persistent hip pain for >3 mo No clinical evidence of inammatory arthritis Hip internal rotation 20 in 90 of hip exion Lateral center-edge angle >20 (ie, absence of dysplasia) Alpha angle >60 on any plain radiographic view or radial MRI/CT reformat and/or lateral center-edge angle >40 and/or presence of cranial acetabular retroversion conrmed on MRI/CT Intra-articular pathology conrmed with diagnostic injection or evidence on MRI of labral-chondral, chondral, or labral damage

14.

5.

15.

6.

16.

7.

17.

8.

9.

gested inclusion criteria are outlined in Table 1.

19.

References
1. Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H: Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res 2009;467(3):638-644. Ganz R, Parvizi J, Beck M, Leunig M, Ntzli H, Siebenrock KA: Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003;(417):112-120. Tibor LM, Sekiya JK: Differential diagnosis of pain around the hip joint. Arthroscopy 2008;24(12):1407-1421.

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11.

21.

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12.

3.

22.

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