Femoroacetabular Impingement and Acetabular Labral Tears – Part 2: Clinical Diagnosis, Physical Examination and Imaging

Abstract

The clinical diagnosis of femoral acetabular impingement (FAI) continues to evolve as the understanding of normal and pathological hips progresses. Femoral acetabular impingement is currently defined as a syndrome in which the diagnosis consists of the combination of a previously-obtained comprehensive clinical history, followed by a consistent and standardized physical examination with specific orthopedic maneuvers. Additionally, radiographic and tomographic examinations are used for the morphological evaluation of the hip, and to ascertain the existence of sequelae of childhood hip diseases and the presence of osteoarthritis. The understanding of the femoral and acetabular morphologies and versions associated with images of labral and osteochondral lesions obtained through magnetic resonance imaging (MRI) contributes to the confirmation of this syndrome in symptomatic patients, and helps in the exclusion of differential diagnoses such as iliopsoas tendon snaps, subspine impingement, ischiofemoral impingement, and other hip joint pathologies.

Keywords

diagnosis - hip - radiography - femoroacetabular impingement

Publication History

Received: 16 October 2019

Accepted: 05 December 2019

Article published online:
17 July 2020

• Referências

• 1 Martin H, Palmer I, Hatem M. Patient History and Exam. In: Callaghan A, Rosenberg A, Rubash H, Clohisy J, Della Valle C, Parvizi J. , editors. The Adult Hip: Arthroplasty and Its Alternative and Hip Preservation. 3rd ed. Lippincott Williams & Wilkins; 2014
• 2 Clohisy JC, Keeney JA, Schoenecker PL. Preliminary assessment and treatment guidelines for hip disorders in young adults. Clin Orthop Relat Res 2005; 441 (441) 168-179
• 3 Reiman MP, Mather III RC, Hash II TW, Cook CE. Examination of acetabular labral tear: a continued diagnostic challenge. Br J Sports Med 2014; 48 (04) 311-319
• 4 Reiman MP, Goode AP, Cook CE, Hölmich P, Thorborg K. Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis. Br J Sports Med 2015; 49 (12) 811
• 5 Saied AM, Redant C, El-Batouty M. et al. Accuracy of magnetic resonance studies in the detection of chondral and labral lesions in femoroacetabular impingement: systematic review and meta-analysis. BMC Musculoskelet Disord 2017; 18 (01) 18-83
• 6 Byrd J. Physical Examination. Operative Hip Arthroscopy. 2nd ed. New York: Springer US; 2005: 36-50
• 7 Byrd JW. Evaluation of the hip: history and physical examination. N Am J Sports Phys Ther 2007; 2 (04) 231-240
• 8 Guimarães RP, Alves DP, Silva GB. et al. Tradução e adaptação transcultural do instrumento de avaliação do quadril “Harris Hip Score.”. Acta Ortop Bras 2010; 18 (03) 142-147
• 9 Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988; 15 (12) 1833-1840
• 10 Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy 2000; 16 (06) 578-587
• 11 Cibere J, Thorne A, Bellamy N. et al. Reliability of the hip examination in osteoarthritis: effect of standardization. Arthritis Rheum 2008; 59 (03) 373-381
• 12 Ross JR, Nepple JJ, Philippon MJ, Kelly BT, Larson CM, Bedi A. Effect of changes in pelvic tilt on range of motion to impingement and radiographic parameters of acetabular morphologic characteristics. Am J Sports Med 2014; 42 (10) 2402-2409
• 13 Beighton P, Horan F. Orthopaedic aspects of the Ehlers-Danlos syndrome. J Bone Joint Surg Br 1969; 51 (03) 444-453
• 14 Lewis CL, Sahrmann SA, Moran DW. Effect of hip angle on anterior hip joint force during gait. Gait Posture 2010; 32 (04) 603-607
• 15 Lewis CL, Sahrmann SA. Effect of posture on hip angles and moments during gait. Man Ther 2015; 20 (01) 176-182
• 16 Legaye J, Duval-Beaupère G, Hecquet J, Marty C. Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J 1998; 7 (02) 99-103
• 17 Saltychev M, Pernaa K, Seppänen M, Mäkelä K, Laimi K. Pelvic incidence and hip disorders. Acta Orthop 2018; 89 (01) 66-70
• 18 Perry J. Gait Analysis Normal and Pathological Function. Thorofare, NJ: Slack Incorporated; 1992
• 19 Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am 1985; 67 (01) 39-47
• 20 Delgado ED, Schoenecker PL, Rich MM, Capelli AM. Treatment of severe torsional malalignment syndrome. J Pediatr Orthop 1996; 16 (04) 484-488
• 21 Kelly BT, Bedi A, Robertson CM, Dela Torre K, Giveans MR, Larson CM. Alterations in internal rotation and alpha angles are associated with arthroscopic cam decompression in the hip. Am J Sports Med 2012; 40 (05) 1107-1112
• 22 Kumar S, Sharma R, Gulati D, Dhammi IK, Aggarwal AN. Normal range of motion of hip and ankle in Indian population. Acta Orthop Traumatol Turc 2011; 45 (06) 421-424
• 23 Prather H, Harris-Hayes M, Hunt DM, Steger-May K, Mathew V, Clohisy JC. Reliability and agreement of hip range of motion and provocative physical examination tests in asymptomatic volunteers. PM R 2010; 2 (10) 888-895
• 24 Simoneau GG, Hoenig KJ, Lepley JE, Papanek PE. Influence of hip position and gender on active hip internal and external rotation. J Orthop Sports Phys Ther 1998; 28 (03) 158-164
• 25 Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR. ; PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Management of severe lower abdominal or inguinal pain in high-performance athletes. Am J Sports Med 2000; 28 (01) 2-8
• 26 Hammoud S, Bedi A, Magennis E, Meyers WC, Kelly BT. High incidence of athletic pubalgia symptoms in professional athletes with symptomatic femoroacetabular impingement. Arthroscopy 2012; 28 (10) 1388-1395
• 27 Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003; (417) 112-120
• 28 McCarthy J, Busconi B, Owens B. Assessment of the painful hip. Early Hip Disorders. New York, NY: Springer US; 2003: 3-6
• 29 Kapron AL, Aoki SK, Peters CL, Anderson AE. In-vivo hip arthrokinematics during supine clinical exams: Application to the study of femoroacetabular impingement. J Biomech 2015; 48 (11) 2879-2886
• 30 Martin RL, Palmer I, Martin HD. Ligamentum teres: a functional description and potential clinical relevance. Knee Surg Sports Traumatol Arthrosc 2012; 20 (06) 1209-1214
• 31 Philippon MJ, Zehms CT, Briggs KK, Manchester DJ, Kuppersmith DA. Hip Instability in the Athlete. Oper Tech Sports Med 2007; 15: 189-194
• 32 Cheatham SW, Enseki KR, Kolber MJ. The clinical presentation of individuals with femoral acetabular impingement and labral tears: A narrative review of the evidence. J Bodyw Mov Ther 2016; 20 (02) 346-355
• 33 Birnbaum K, Prescher A, Hessler S, Heller KD. The sensory innervation of the hip joint--an anatomical study. Surg Radiol Anat 1997; 19 (06) 371-375
• 34 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 (07) 1668-1674
• 35 Polesello GC, Nakao TS, de Queiroz MC. et al. Proposal for standardization of radiographic studies on the hip and pelvis. Rev Bras Ortop 2015; 46 (06) 634-642
• 36 Griffin DR, Dickenson EJ, O'Donnell J. et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med 2016; 50 (19) 1169-1176
• 37 Clohisy JC, Carlisle JC, Beaulé PE. et al. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am 2008; 90 (Suppl. 04) 47-66
• 38 Reis AC, Rabelo ND, Pereira RP. et al. Radiological examination of the hip - clinical indications, methods, and interpretation: a clinical commentary. Int J Sports Phys Ther 2014; 9 (02) 256-267
• 39 Nepple JJ, Martel JM, Kim YJ, Zaltz I, Clohisy JC. ; ANCHOR Study Group. Do plain radiographs correlate with CT for imaging of cam-type femoroacetabular impingement?. Clin Orthop Relat Res 2012; 470 (12) 3313-3320
• 40 Tannast M, Zheng G, Anderegg C. et al. Tilt and rotation correction of acetabular version on pelvic radiographs. Clin Orthop Relat Res 2005; 438 (438) 182-190
• 41 Siebenrock KA, Kalbermatten DF, Ganz R. Effect of pelvic tilt on acetabular retroversion: a study of pelves from cadavers. Clin Orthop Relat Res 2003; (407) 241-248
• 42 Monazzam S, Bomar JD, Agashe M, Hosalkar HS. Does femoral rotation influence anteroposterior alpha angle, lateral center-edge angle, and medial proximal femoral angle? A pilot study. Clin Orthop Relat Res 2013; 471 (05) 1639-1645
• 43 Büchler L, Schwab JM, Whitlock PW, Beck M, Tannast M. Intraoperative evaluation of acetabular morphology in hip arthroscopy comparing standard radiography versus fluoroscopy: a cadaver study. Arthroscopy 2016; 32 (06) 1030-1037
• 44 Ruelle M, Dubois JL. [The protrusive malformation and its arthrosic complication. I. Radiological and clinical symptoms. Etiopathogenesis]. Rev Rhum Mal Osteoartic 1962; 29: 476-489
• 45 Anderson LA, Kapron AL, Aoki SK, Peters CL. Coxa profunda: is the deep acetabulum overcovered?. Clin Orthop Relat Res 2012; 470 (12) 3375-3382
• 46 Nepple JJ, Lehmann CL, Ross JR, Schoenecker PL, Clohisy JC. Coxa profunda is not a useful radiographic parameter for diagnosing pincer-type femoroacetabular impingement. J Bone Joint Surg Am 2013; 95 (05) 417-423
• 47 Tannast M, Leunig M. ; Session Participants. Report of breakout session: Coxa profunda/protrusio management. Clin Orthop Relat Res 2012; 470 (12) 3459-3461
• 48 Wiberg G. The anatomy and roentgenographic appearance of a normal hip joint. Acta Chir Scand 1939; 83 (Suppl. 05) 7-38
• 49 Tönnis D, Heinecke A. Acetabular and femoral anteversion: relationship with osteoarthritis of the hip. J Bone Joint Surg Am 1999; 81 (12) 1747-1770
• 50 Reynolds D, Lucas J, Klaue K. Retroversion of the acetabulum. A cause of hip pain. J Bone Joint Surg Br 1999; 81 (02) 281-288
• 51 Kalberer F, Sierra RJ, Madan SS, Ganz R, Leunig M. Ischial spine projection into the pelvis : a new sign for acetabular retroversion. Clin Orthop Relat Res 2008; 466 (03) 677-683
• 52 Zaltz I, Kelly BT, Hetsroni I, Bedi A. The crossover sign overestimates acetabular retroversion. Clin Orthop Relat Res 2013; 471 (08) 2463-2470
• 53 Hetsroni I, Larson CM, Dela Torre K, Zbeda RM, Magennis E, Kelly BT. Anterior inferior iliac spine deformity as an extra-articular source for hip impingement: a series of 10 patients treated with arthroscopic decompression. Arthroscopy 2012; 28 (11) 1644-1653
• 54 Larson CM, Kelly BT, Stone RM. Making a case for anterior inferior iliac spine/subspine hip impingement: three representative case reports and proposed concept. Arthroscopy 2011; 27 (12) 1732-1737
• 55 Stulberg SD, Cordell LD, Harris WH, Ramsey PL, MacEwen GD. Unrecognized childhood hip disease: a major cause of idiopathic osteoarthritis of the hip. In: Mosby C. , editor. The Hip. Proceedings of the Third Open Scientific Meeting of the Hip Society. St Louis: 1975: 212-128
• 56 Goodman DA, Feighan JE, Smith AD, Latimer B, Buly RL, Cooperman DR. Subclinical slipped capital femoral epiphysis. Relationship to osteoarthrosis of the hip. J Bone Joint Surg Am 1997; 79 (10) 1489-1497
• 57 Nötzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br 2002; 84 (04) 556-560
• 58 Sutter R, Dietrich TJ, Zingg PO, Pfirrmann CW. How useful is the alpha angle for discriminating between symptomatic patients with cam-type femoroacetabular impingement and asymptomatic volunteers?. Radiology 2012; 264 (02) 514-521
• 59 Eijer H, Myers SR, Ganz R. Anterior femoroacetabular impingement after femoral neck fractures. J Orthop Trauma 2001; 15 (07) 475-481
• 60 Smith TO, Hilton G, Toms AP, Donell ST, Hing CB. The diagnostic accuracy of acetabular labral tears using magnetic resonance imaging and magnetic resonance arthrography: a meta-analysis. Eur Radiol 2011; 21 (04) 863-874
• 61 Reiman MP, Thorborg K, Goode AP, Cook CE, Weir A, Hölmich P. Diagnostic Accuracy of Imaging Modalities and Injection Techniques for the Diagnosis of Femoroacetabular Impingement/Labral Tear: A Systematic Review With Meta-analysis. Am J Sports Med. 2017;45(11):2665–2677