Home Blog Hip Pain in Athletes: The Origin of Femoroacetabular Impingement?

Hip Pain in Athletes: The Origin of Femoroacetabular Impingement?

Written on August 22, 2011 at 6:39 am, by Eric Cressey

Over the weekend, I attended my third Postural Restoration Institute seminar, Impingement and Instability.  I’ve written previously about how this school of thought has profoundly impacted the way that we handle many of our athletes – and this past weekend was certainly no exception.  This weekend was also my first chance to meet and learn directly from Ron Hruska, the man initially responsible for bringing many of these great ideas to light.

While I am admittedly still processing all the awesome information from the weekend, I wanted to write today about one big “Ah-Ha” moment for me over the weekend.  At some point on Day 2, Ron said something to the effect of (paraphrased):

“A superior acetabulum isn’t much different than an acromion on a scapula.”

My jaw practically hit the floor.  I joked with the seminar organizer that I needed to go into the restroom to yell at myself for a few minutes for not thinking of this sooner.  Let me explain…

Over the past few years, there has been a huge rise in hip injuries in athletes (I’d even written about it HERE in response to a New York Times article about number of hip injuries in baseball).  Sports hernias, labral tears, and femoroacetabular impingement (FAI) are commonplace findings on the health histories that I see every day on first-time evaluations. In terms of FAI, you can have bony overgrowth of the femoral head (cam), acetabulum (pincer), or both (mixed), as the graphic from Lavigne et al. below demonstrates:

 

Many folks say that we’re getting better diagnostically and that’s why the prevalence has increased in recent years.  Let’s be real, though, folks: if we’d had hip pain and dysfunction on this level for decades, don’t you think anecdotal evidence would have at least tipped us off?  I find it hard that generations of athletes would have just rubbed some dirt on a painful hip, cowboyed up, and put up with it.

Consider those over the age of 60, though.  Sher et al. reported that a whopping 54% of asymptomatic shoulders in this population have rotator cuff tears; that doesn’t even include those who actually have pain!  Why does this happen?  They impinge over and over again on the undersurfaced of the acromion process secondary to poor thoracic positioning, scapular stabilization, breathing patterns, and rotator cuff function.  The end result is reactive changes on the acromion process that lay down more and more bone as the years go on.  And, an anteriorly tilted scapula kicks that impingement up a notch.  The “early” cuff irritation likely comes in those with Type 3 (beak-shaped) acromions, whereas the Type 1 (flat) and Type 2 (hook) acromions need time to lay down more and more bone for their anterior tilt to bring them to threshold.

Conversely, consider femoroacetabular impingement of the hip.  You can get bony overgrowth of the acetabulum, femoral head, or both.  It’s widely debated whether those with FAI are born with it, or whether it becomes part of normal development in some kids.  Well, I guess it would depend on whether you consider playing one sport to excess year-round “normal.”

You know what?  I’d estimate that over 90% of the femoroacetabular impingement cases I’ve seen have come in hockey, soccer, and baseball players.  What do these sports have in common?  They all live in anterior pelvic tilt – with hockey being the absolute worst.  Is it any surprise that the incidence of FAI and associated hip issues has increased dramatically since the AAU generation rolled in and kids played the same sport all 12 months of the year?

Conversely, I’ve never seen a case of FAI in a field hockey player.  Additionally, when I just asked my wife (who rowed competitively in college) if she ever saw any hip issues in her teammates in years of rowing, she joked that there weren’t any until they added distance running to their training. Field hockey players and rowers live in flexion (probably one reason why they have far more disc issues).  And, taking it a step further, I’ve never seen an athlete with FAI whose symptoms didn’t improve by getting into a bit more posterior pelvic tilt.

Finally, a 2009 study by Allen et al. demonstrated that in 78% of cases of cam impingement symptoms in one hip, the cam-type femoroacetabular impingement was bilateral (they also found pincer-type FAI on the opposite side in 42% of cases).  If this was just some “chance” occurrence, I find it hard to believe that it would occur bilaterally in such a high percentage of cases.  Excessive anterior pelvic tilt (sagittal plane) would be, in my eyes, what seems to bring it about the most quickly, and problems in the frontal and transverse planes are likely to blame for why one side presents with symptoms before the other.

People have tried to blame the increased incidence of hip injuries on resistance training.  My personal opinion is that you can’t blame resistance training for the incidence, but rather the rate at which these issues reach threshold.  Quality resistance training could certainly provide the variety necessary to prevent these reactive changes from occurring at a young age, or by creating a more ideal pelvic alignment to avoid a FAI hip from reaching threshold.

Conversely, a “clean-squat-bench” program is a recipe for living in anterior tilt – and squatting someone with a FAI is like overhead pressing someone with a full-thickness cuff tear; things get ugly quickly.

Honestly, this probably isn’t revolutionary for folks out there – particularly in the medical field – who have watched the prevalence of femoroacetabular impingement rise exponentially in recent years, but Ron made a great point to reaffirm a thought I’d been having for years and strengthened the argument.  And, more important than the simple “Ah-Ha” that comes with this perspective is the realization that an entire generation of young athletes have been so mismanaged that we’ve actually created a new classification of developmental problems and pathologies: femoroacetabular impingement, labral tears, and sports hernias.

Thanks, Ron, for getting me thinking!

For more information on appropriately managing kids during these critical development time periods, check out the International Youth Conditioning Association’s High School Strength and Conditioning Certification, which I helped to write.


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  • Great Post Eric,

    As an athletic trainer at the collegiate level, I have seen a high incidence of mismanaged incoming freshmen for years now. Every young man that walks through my door (mostly men’s soccer and baseball players, but certainly not limited to these sports) has some form of innominate rotation, SI joint dysfunction, sacral nutation, and/or a myofacial web nightmare resembling something like a neglected tackle box full of tangled fishing line.
    Let me first say that I 100% agree with this assessment as to the possible reasons for these hip pathologies, especially in our young athletes. In addition to poor management in training as a cause, there is also a terrible lack of proper soft tissue management and manual therapy with or without the occurrence of soft tissue injury. I have experienced that in a good majority of pelvic dysfunction cases, I can aid the resolution of these problems with regular manual therapy sessions, myofacial release, muscle energy techniques, and functional movement circuits. In fact, to address this issue, I now have my teams purchase a foam roller for every new athlete, which is then incorporated into their pre-practice warm-up, and goes back to the dorm rooms with the athletes for them to use throughout the day. While it is not as effective as my hands, just having some mechanical load on the tissue has done wonders for reducing the incidence of chronic injuries and recurring pelvic anomalies. Ideally, I would like to be able to treat every athlete individually and address all of their soft-tissue needs specifically whether they are symptomatic or not. However, the reality of the situation is that I am only one clinician, to service as many as 50 athletes in a day.
    While the number of Athletic Trainers at the secondary level has steadily risen, there is still a glaring lack of manual therapies being performed at said level. Especially in regard to the number of young athletes who participate in 1 sport year round, and who seek outside training in addition to work-outs with their school. I believe that if parents spent as much or even some money on a good manual therapist in addition to a private strength and conditioning coach, they would see not only a rise in performance but a stark decrease in the number and severity of injuries, especially those of the soft-tissue variety.
    Prevention is one of the hallmarks of Athletic Training, and as such, I believe manual therapies are JUST AS important in prevention of injuries as they are in the treatment and rehabilitation of athletic injuries.

    -Mike Stella, MTA, ATC

  • MNickerson

    Awesome post! Seemed like such an obvious comparison once you brought it to light

  • Shawn Fears

    Great stuff and awesome certification I did it this summer.

  • Nicholas St John Rheault

    Great info EC…. You’re not only a nerd, but a coach, a student, an inspiration to all of us who strive to be best. Thanks for all your support.

  • VRosenberg

    I am a parent of a past High School Hockey Goalie who had bilateral hip surgery in 2006 – 07. He lives with discomfort at 25 years old. According to his physician, if young athletes could have their hips checked through a test or X-Ray prior to putting hours and hours of time in anterior rotation, it may show congenital abnormalities and direct them to a sport that is more hip friendly. That said, hockey was my sons passion and he would do it all over again.
    Thank you for acknowledging this syndrome and educating those who train young athletes.
    I enjoy your articles and appreciate how you promote injury prevention as well as proper strength training techniques.

  • I understand what you’re talking about but what are the symptoms so I can recognize a pattern?

    Thanks,
    Andy

  • Well said, Eric. However I think we’re missing one possible mechanism in all this. Rotational athletes who strain obliques or other muscle unilaterally in the “core” area can present with acute unilateral FAI simply because the pelvis drops on the strained side. Rotational athletes aside, know someone who strained lateral musculature (not even playing sports), week later – pain with any hip flexion on that side. Funny thing it went away with heavy squatting. I take this to mean the core musculature tightened and lifted up the pelvis during the front squat. To further support this thought process the lighter warm up sets were painful but once it got heavy – zero pain sensation. I again take this to mean the core tightened enough to lift up the pelvis on that side and give space during femoral acetabular approximation whereas in the lighter sets it did not.

    All the best,
    Sam

  • Benjamin

    Well then what do you recommend besides the old and effective clean-squat-bench for someone who has lots of anterior tilt or FAI?
    How do you fix the former and how do you train around the latter?

  • As someone with FAI (mixed on L and Cam on R) who already has a labral tear and delamination, I can tell you from personal experience that had I had better movement coaching as an athlete in the weight room and on the field (o-lineman) could have saved me years of grief.
    I’ve been able to minimize the effect of my FAI by doing an absurd amount of hip mobility work and GOOD squatting. Perhaps surgery may be a foregone conclusion this far down the road, but had I discovered what is helping me now 15 years ago, I may have avoided this whole mess from the beginning. As many of the scholarly journals on FAI note, for years this type hip pain was often chalked up to “groin pulls” (as in my case) or hip flexor tightness (also something I was told to deal with by stretching in an awful anterior pelvic tilted lunge).

    Glad to hear that you’re addressing this issue aggressively. Any thoughts on what those of us who are already dealing with the effects of decades of FAI can do?

    Thanks,

  • Carter Fisk

    Well having had FAI in both hips and surgery for both, I would have to agree. I still have anterior tilt/lordosis issues and have had them for as long as I can remember.

  • Enjoying the article and comments-
    For these issues I have also repeatedly found squatting and deadlifting with progressively more weight to be helpful. Another mechanism that may be at work here is the active remodeling of the joint and it’s neuro-circulatory environment.

  • Sébastien

    Hi Eric, that’s very interesting stuff you’re bringing there.
    I’ve got a bilateral hip surgery last November, and I’m still in pain at 27 years 9 months post op. From all the readings I’ve seen until now, surgery was the only solution and gave good results. I’ll give a try on working on correcting a potential anterior tilt.

  • Good timing with the post.

    I tore my right hip labrum back in September of 2010 and have had a hell of a time getting it diagnosed. I’m finally booked in for surgery at the end of October but looking for any non-surgical route.

    You mentioned correcting an anterior tilted pelvis may help prevent those from tearing their labrum, but just wondering what you might advice a client with an existing tear?

  • Mike M

    Eric, great information. I’ve been having pain in my left hip while squatting to depth. I was a hockey player for many years and I have a rather severe case of anterior pelvic tilt. I also happen to have left rotator cuff pain (not sure if this is related). Can pelvic tilt be solved through stretching and/or mobility exercises? If so, what can I do? Thanks!

  • VRosenberg

    Andy,
    The sysmptoms my son experienced was back and hip discomfort. He could not sit in a chair for more than five minutes without feeling some discomfort in his lower back and anterior hip area.
    It started with nagging lower back discomfort and progressed to the point of no relief.
    Before we realized how badly his hips were and before surgery he foam rolled regularly, and went to a massage therapist once a week which gave him very temporary relief.

  • VRosenberg

    Andy,
    The symptoms my son experienced were low back discomfort and anterior hip discomfort. It began as a nagging ach.
    Before we were able to find the exact problem, he foam rolled regularly and had a massage once a week which gave him minimal releif.
    It had reached a point of being uncomfortable to sit in a chair for any length of time.

  • Thanks VRosenberg

  • Hi Eric,

    I have played field hockey in Australia for nearly 12 years now (8 years at an elite level) and have already had an arthroscope on my right hip (I’m 22 now) which determined I had both a Cam and Pincer impingement with a significant labral tear (the left was showing signs). I remember reading at the time that the average diagnosis for FAI was 2 years (I was diagnosed with the typical groin, hip flexor strains, glute issues etc). I think it’s probably down to around 3 months now given it’s ‘popularity’. Being a ex. & sp. Science student (I am going down the S & C pathway) I spent a lot of time researching this condition. I have been fortunate enough to be in some very good hands with regards to rehabilitation and as such I have minimal pain. I still lacking greatly in R hip internal rotation, which I believe is a combination of ext rotation tightness and capsular mobility.
    I recently read (I think it was on Charlie Weingroff’s blog) something that Shirley Sahrmann said at a seminar regarding FAI and the degree to which genetics play a role vs resistance training and other modalities. I personally believe the resting tone of the adductors plays a crucial role in the positioning of the femoral head as you move into hip flexion. When combined with a tight psoas and iliacus (typical in field hockey players) the head (I think) is drawn superiorly, anteriorly and medially into a impinged position. As such I have focused a lot on only hip strength and stabiltiy but also on releasing the tone of the adductors. Like I said so far it all appears to be going reasonably well with no major issues in 12 months.

    Alex

  • Andy,

    Here’s a great site that could really answer a lot of your questions: http://www.hipfai.com.

  • Sam,

    That’s basically what I was getting at with this statement:

    “…and problems in the frontal and transverse planes are likely to blame for why one side presents with symptoms before the other.”

    You just said it in more words! 🙂

    Thanks,

    EC

  • Ben,

    Training around FAI is an individual thing. Some folks can deadlift and single-leg just fine. Others may have done more considerable damage to the labrum and would need modifications.

    As for fixing anterior pelvic tilt, spending a lot of time on improving stiffness of the glutes and external obliques is where it’s at. More importantly, though, you have to actually educate an athlete on where “neutral” pelvis is and teach him to find it more often during the day. They literally have to relearn how to slightly reposition their center of gravity…no easy task.

  • Mark,

    See my reply to Ben above, but I’d also add that it would really help to get some aggressive soft tissue work in there. I really like Graston on the adductors and hip external rotators; those seem to be “money” areas for guys with FAI in almost every instance.

  • Stephane,

    Would depend on the nature of the tear and my assessment of the individual. No surprise that it’s the right hip…do you have a low right shoulder, left rib flair, and adducted right hip in your static posture? Very common.

  • Mike M,

    First, if squatting hurts, stop squatting!

    Yes, you can work on anterior pelvic tilt with proper training, but it takes time and persistence! See my post to Ben earlier in this thread.

    Check out our Assess and Correct product and follow the glute progressions: http://www.assessandcorrect.com.

  • Alex,

    Agree 100% on the adductor comment; spot on!

    Glad you’re doing well.

    Best,

    EC

  • Good stuff EC. I know PRI has their own approach for a solution, but given your significant experience in shoulders, I would love to see what you find when you look at the hips the same way (which is sounds like you are now= awesome).

    You stated, “I really like Graston on the adductors and hip external rotators; those seem to be “money” areas for guys with FAI in almost every instance.”

    Do you see these “same” muscles in the shoulder area too as money exercises?

    As you stated, the anatomy of the hip and shoulder are very very similar and we tend to see the same patterns too. Ditto for hands/feet, wrists/ankles, knees/elbows, etc…all down and up the chain.

    We know the right shoulder is related to the left hip (serape effect) and I am sure you see significant correlation in function between them also.

    The key questions are

    1) applying the info about the shoulder to the hip should equate to better and faster results

    2) working on the opposite shoulder should work to fix hip issues—I’ve lost count of how many times this has worked for me on chronic issues.

    The body is all connected!

    Rock on
    Mike T Nelson PhD(c)

  • Paul Mazzaferro

    Great Post Eric!! I had FAI with both CAM and Pincer. I also had to have both reoperated to release the psoas tendon which was starting to blunt the labrum. Dr. referred to this as “triple impingement”. Post surgery it improved my APT immediately and the cable-like pulling i had in my groin into my ab was gone. However, it is weak and takes time. Also i have to say i was a catcher for many years and first had it in my early 20’s which they ended up operating on my back…(pain is diffuse and showed up in my back and calf)…Back surgery did not work but i spent next few years core training and pain resolved, but hip stiffness did not. Fast forward 17 years and BAMM….same pain again…..this time 11 docs…finally pubalagia surgery and then the FAI…So i thank you for bringing this into the light because i went to more practitioners than i care to mention and nobody had a clue…So hats off for giving this thing recognition because the longer it takes to DX the more imbalances are created and the harder it is to resolve post-op.

  • Diana

    very interesting! Whats more interesting is I have bilateral FAI and was a field hockey player for years!

  • Tom

    Eric:

    I came across your post here and wanted to tell you something I learned after I had arthroscopic surgery for the hip labral tear and then later my surgeion went back in for the FAI.

    After doing my own research and carrying the injury for 10+ years from interval training and doing fartlek runs around a track to decrease my run time for military fitness tests, I found out one huge factor not only in myself as a former high level athlete and soldier, but very common with guys.

    1. While we were still growing as kids, we most likely played some type of contact sport, but our bones weren’t fully developed and we develop the FAI

    2. That the FAI most likely happens in sprinting type athletes or during types of sprinting training, which is very common with soccer players, baseball, football, etc….

    So, from what I gathered and you might already know this, the combination of 1 and 2 above, as well as not properly warming up, maintaining our flexibility and ROM over the years, the good ol’ FAI that we carry for years since active sports as kids and body still developing, is the most likely cause of the labral tears that many athletes, pro or amateur are getting these days.

    Note: Research shows if a guy has a hip labral tear, more than 90+ percent chance he has FAI….my doctor didn’t have to do two surgeries, but sure in the hell got his monies worth.

    Something your athletes should look into that is not common place is getting Platlet Rich Plasma (PRP) along with Prolotherapy for any type of labral tear or tendonosis/itis or tendon tear.

    Had I learned about it or had the money, I would have tried the PRP and Prolotherapy first, before getting surgery. Never the same after dealing with labral tears or having part of the labrum removed. Your just waiting on the inevitable of osteo arthritis later down the road.

    Check out http://www.prolotherapy.org and check out Dr. Hauser in Chicago….all over the net and real good info on this…..not covered by insurance companies, but I had it done on my 80 percent grade tear of my patellar tendon and it helped over 50-60 percent with one PRP treatment.

    Just thought this was good info to pass on to you since you deal with baseball players who are constantly having labral or tendon problems.

  • Ian Willows

    Dear Eric,

    I am an S&C coach in the UK. I have just taken on a client whom has recently had an MRI and been diagnosed with an FAI. This is more specifically the acetabulum ‘pincer’ impingement. There are no other complications e.g. labral tear.

    I read your post a while ago on FAI and used this as a reference. I have worked with this person in the past with success from what must have been the same problem.

    In short, my thoughts on this are to 1) implement SMR (& manual therapy using a sports massage therapist) mainly around the quads/hips and 2) strengthen with focus on glutes, ext OBL and hamstrings.

    I know it is hard to offer any specifics, as having done this job for 11 years I know it is difficult without seeing the individual yourself, however, any general recommendations on areas for SMR/manual therapy and strength work would be greatly appreciated?

    FYI – This person is a 5km runner and does a lot of driving!!!???

    I have been a follower of your posts for a number of years now and am excited at the thought of a reply.

    Your sincerely,

    Ian Willows

  • Mark Brunnen

    Eric,

    I am a 28yo from the UK and I have played field hockey 3-4 times a week since the age of 8. Over the last year and a half I have developed a deep pain in my left hip that has recently been diagnosed as an antero-lateral CAM deformity, together with slight pincer impingement.

    I’m particularly conscious of the pain when I ‘slap’ pass the hockey ball as per the demonstration at 1.07mins of the following video: http://youtu.be/kK_QoCmTPE4

    To my mind, this hockey pass closely replicates the impingement test that the doctor completed on me to help diagnose my problem – i.e. knee right up into the chest and apply a twist rotation through the joint. I believe that this repeated movement whilst playing field hockey over the years has significantly worsened my symptoms from a point where I was unaware of the deformity, to my current position of requiring surgery to correct it.

    Whilst I know little about the biomechanics and medical science behind FAI, I don’t believe you should exclude field hockey from your hit list of ‘at risk’ sports.

  • Eric,

    I went and saw you a few months ago, and have since had bilateral FAI surgery. I want to get back into powerlifting. Do you have any advice?

    Thanks,
    Eduardo

  • Eduardo,

    If you’re going to get back to squatting, make it that absolute last thing that you do! Wait as long as you possibly can and give those repairs time to settle. Stick with deadlifting and single-leg work in the meantime.

  • Thank you Eric. I will continue to use sumo for the deadlifts as you indicated. I also believe a wider stance with lots of external rotation would benefit me on the squats.

    I hope to make it out there some time in the future.

  • joe

    thanks!

  • John Ball

    Hi Eric, thanks for the article. I found this a little later from when you originally wrote it, better late than never. Ha. Anyway not waste your time, my question….is there a way to test the forementioned joints to see what type of impingement they might have (eg. CAM, PINCER, MIXED) without any type of MRI? Thanks.


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