Femoroacetabular Impingement of the Hip - Part 3
Once all the test results are available, a course of action is determined. This may be conservative care (nonoperative) with anti-inflammatories and Physical Therapy or it may be surgery. Generally patients undergo a trial of conservative care before doing any surgery but in some cases, surgery is recommended right away.
Physical Therapy at Actify Physiotherapy can be very helpful for FAI. The goals of conservative management are to relieve pain, improve function by correcting muscle strength imbalances and alignment, and prevent future issues with the hip.
During your first few appointments at Actify Physiotherapy your Physical Therapist will focus on relieving your pain and inflammation simply to settle the hip down. They may use modalities such as ice, heat, ultrasound, or electrical current. In addition, your Physical Therapist may massage your hip or leg to improve circulation and help decrease your pain. Another crucial step to settling your pain down is activity modification. Your therapist will discuss this with you. It is nearly impossible to give the hip a complete rest but avoiding activities such as pivoting on the involved leg when there is a labral tear or irritation, and avoiding long periods of sitting can give the hip a chance to calm down. All sports should also be avoided in these initial stages as should prolonged walking. Sometimes it is necessary to reduce your normal activity in some respect for up to six months in order to let the tissues around the hip joint heal. Your Physical Therapist will closely guide you regarding activity modification and will give suggestions for maintaining physical fitness while dealing with this injury.
Based on your individual assessment findings your therapist will design a program of stretches and strengthening exercises specifically for you to help improve the biomechanical function of the hip, the range of motion of the hip, and alter any muscle imbalances that may be present.
Tight muscles around the hip can contribute to pinching between the femoral head and acetabulum in certain positions.
Your Physical Therapist will give you stretches for both the front and back parts of your hip which includes, in particular, the hip flexors and the external rotators and abductor muscles (deep gluteals) of the hip. They may also ask you to do groin or knee stretches depending on their assessment findings. A program of flexibility for the joint and stretching exercises won’t change any bony abnormalities present but can help lengthen the muscles, correct muscle imbalances, and reduce bony contact and subsequent impingement in the hip. If completing your exercises is difficult, your therapist may suggest you initially go into a hydrotherapy pool where the warmth and hydrostatic properties of the water can assist your discomfort. As soon as you are able, however, your Physical Therapist will encourage you to start completing your exercises on land to more closely simulate regular activities of daily living.
Strengthening exercises will focus on correcting any muscle imbalances that have developed as a result of your injury. It is most common that the gluteal muscles, which are the major supporters of the hip as well as rotators, abductors and extensors of the hip, are weak in comparison to other muscles around the hip. This can contribute to the impingement at the hip. Exercises for the gluteals as well as other areas such as the groin, anterior hip, and core area may be prescribed based on your individual assessment findings. Exercise bands, weights or weight machines may be used to add extra resistance and help to build up strength and endurance.
Your therapist will discuss your lower limb alignment, overall posture, and any abnormal movement patterns you may have developed. Sometimes even small changes in your posturing particularly as you walk, such as changing your foot or knee position, can make a significant difference in the pain you feel and how quickly your hip improves. In some cases orthotics to improve arch alignment or a heel lift to correct a leg length discrepancy can make a difference.
When both legs have nearly equal strength, it is possible to gradually resume a full and normal level of all activities (so long as there is no pain during any of those movements or activities). For the young or active adult, this includes activities of daily living as well as recreational and competitive sports participation. Older adults experiencing labral tears associated with the impingement problem may expect to be able to resume normal daily functions but may still find it necessary to limit prolonged sitting or standing positions. Your Physical Therapist will closely guide your activity levels during your return to activity in order to ensure you don’t overdo any aspect and to ensure that you avoid re-injuring the hip.
You Physical Therapist at Actify Physiotherapy will liaise with your doctor regarding your progress with rehabilitation. While undergoing Physical Therapy treatment some patients may also benefit from intra-articular injection from a doctor. This injection combines a numbing agent with an anti-inflammatory (steroid) medication in order to calm the hip down and allow you to strengthen and stretch the hip.
If conservative care does not relieve your problem, surgery may be required. It should be noted, however, that anyone needing surgery will also benefit from Physical Therapy prior to the surgical procedure in order to address any muscle imbalances and abnormal movement patterns that may have contributed to the FAI.
Surgery is advised when there is persistent pain despite a good effort at conservative care and when there are obvious structural abnormalities of the hip. Early diagnosis and surgical correction may be able to restore normal hip motion. Delaying surgery is possible for some patients but the long-term effects of putting surgery off have not been determined. Once it has been decided that surgery is the way to go, the surgeon has three choices: 1) full open incision and correction of the problem, 2) arthroscopic surgery, and 3) osteotomy (cutting the bone to reshape the socket.)
With the fully open surgical procedure, the head of the femur is dislocated from the socket to make the changes and corrections and reshape it. With arthroscopic surgery, hip dislocation is not required. Osteotomy is done for pincer-type impingement. Whenever possible, the surgeon tries to save the hip. When there is extensive damage to the cartilage, hip resurfacing or total joint replacement may be needed. There are many factors to consider when making the decision whether or not to do a hip replacement.
These factors include the patient's age, findings on imaging studies, type and severity of deformity, as well as the presence of arthritic changes.
If there is a labral tear, surgery is usually done arthroscopically, whenever possible, to repair the damage. The surgeon trims the acetabular rim and then reattaches the torn labrum. This procedure is called labral refixation. Each layer of tissue is sewn back together and reattached as closely as possible to its original position (called the footprint) along the acetabular rim. When repair is not possible, then debridement (shaving or removing) the torn tissue or pieces of tissue may be necessary.
Correction of the problem can result in improved function and pain relief. The hope is that early treatment can prevent arthritic changes but long-term studies have not been done to prove this idea. After surgery, patients will be restricted to a partial weight-bearing status. The exact weight bearing recommendations will depend on the amount of bone removed and whether or not the labrum was torn and repaired.
On the next posting of this sequence we will be discussing the post-surgical rehabilitation, but if you have any questions feel free to contact us.
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