Hip Impingement

Hip impingement, or technically known as femoroacetabular impingement, involves a change in the shape of the surface of the hip joint. Over time, the impingement can lead to pain, stiffness, and damage to the tissue and/or bone. Conditions that can potentially cause hip impingement can develop over time or be a lifelong condition that is present at birth.

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There are two types of hip impingement that may occur alone or together.

Pincer-Type Impingements

The hip socket typically angles forward but with a Pincer-Type Impingement, it will be angled toward the back. Pincer-type impingements will pinch the labrum, which is the rim and area of connective tissue that helps to deepen the hip socket. This pinching can occur especially when bringing the leg toward your chest. During this motion of hip flexion, the femur bone's neck can impinge or bump on the rim of the socket. Over time this extra pressure can lead to irritation of the labrum that can cause inflammation. Over time if this condition isn't treated, the cartilage which lines the hip joint may become worn or frayed. This type of impingement affects both men and women equally.

Cam-Type Impingements

The shape of the bone around the head of the femur (the ball at the top of the thigh bone) is misshaped and not round. This type of impingement can impact the femoral head’s ability to move within the hip socket smoothly. As the misshapen bone makes contact with the cartilage that lines the hip socket, it can lead to the hip socket becoming frayed, worn, or even torn. This deformity can be due to a variation of the typical shape of the head of the femur that may be present at birth or can develop over time. Cam-type impingements typically affect men more often than women.

Hip impingement usually affects people who are younger than 50, especially those who lead an active lifestyle. If left untreated, hip impingement can potentially lead to osteoarthritis in many patients.

Causes of Hip Impingement

Activities that require repetitive movement in the legs beyond their normal range of motion may lead to or cause hip impingement. Athletes from several sports including football, soccer, baseball, tennis, lacrosse, hockey, golfers, and dancers could suffer from hip impingement.

In other less active patient populations, daily movements and dynamic weight bearing can cause impingement type symptoms if weakness exists in the hip muscles.

Flat feet can also affect the alignment of the body when a person is standing, walking, or running. As a result, they can increase the likelihood of pain in the hip due to repeated impingement.

Other Risk Factors and Medical Conditions

  • Repetitive Movements
  • Sports-Related Overuse
  • Daily Movements and Dynamic Weight Bearing
  • Weak Muscles

Symptoms of Hip Impingement

Hip impingement may cause patients to experience difficulty or limitations while performing activities in their daily life and could worsen during demanding physical activities. Pain that typically begins or starts out gradually and worsens over time. A dull and aching pain in front of the hip joint that may become sharp or stabbing when squatting, sitting, or standing.

Pain when performing certain athletic activites like running, twisting, jumping, or pivoting. Stiff feeling when moving, lifting, or turning your leg. Loss of motion in leg. Pain while sitting or learning forward for long periods of time. The inability to flex the hip beyond a right angle due to pain or a "catching" sensation. Difficulty with certain leg movements accompanied by additional complaints of lower back pain.

  • Difficulty when Performing Daily Activities
  • Limited Movement
  • Gradual Pain That Increases Over Time
  • Sharp Pain when Squatting, Sitting, or Standing
  • Pain When Performing Athletic Movements
  • Inability to Flex Hip Beyond a Right Angle
  • Muscle Weaknesses for Hip Muscle Groups

Diagnosis of Hip Impingement

A physician may order tests and perform a comprehensive evaluation to identify any potential changes in the labrum or joint. The physician may also seek to perform an X-Ray or MRI for confirmation on their findings or get additional clarification on the damage. A diagnosis of hip impingement can take time as there are several other contributing factors which could cause hip impingement or hip-related pain including lower back pain, pelvic pain, and buttock pain.

However, licensed physical therapists are well trained to identify the symptoms and identify individual factors that can lead to hip impingement during a comprehensive physical therapy evaluation. During your initial evaluation, your physical therapist will interview you to learn more about your symptoms. They also will ask how your symptoms affect your daily life. They will discuss your goals for physical therapy and work with you on how best to achieve them.

Your physical therapist will perform an exam, which may include watching you walk and noting any abnormalities, observing movements that are difficult for you to do such as squatting and bending. Evaluating the range of motion and painful motions of your hip and back. Assessing the strength of hips, legs, and core. Patients with hip impingement oftentimes exhibit muscle weakness for several hip muscle groups including the hip abductors, flexors, and external rotators.

Your physical therpaist will also observe your coordination and balance for each lower extremity and test the flexibility of each hip and other joints in your legs.

Treatment of Hip Impingement with Physical Therapy

Physical therapy has been proven to be a very effective and beneficial when managing people with symptoms of hip impingement. Physical therapists may help you avoid the need for surgery or delay your condition from getting worse. Conservative care aims to ease pain and discomfort, addressing individual limitations and activities that are difficult.

Your physical therapist may use some or all of the following approaches to help you achieve your goals which include modifying your daily, job-related, and/or sports activities. Teaching you safe motions that will help minimize stress on the hip. Joint mobilization that will help to loosen up the hip in specific directions that will also help to normalize your movement.

Improving the strength of your lower extremities and trunk which will help to provide better support and stabilization for your hip. Stretching the hip which can reduce abnormal forces that contribute to pain with motion. Stretching other body regions also may decrease stress at the hip as well as help to provide better body mechanics with squatting and other activities that you are having difficulty with.

Improving lower extremity balance and coordination which will help to control your hip motion during functional movements. Your physical therapist at Results Physiotherapy might also work to identify other contributing factors such as show wear recommendations or use of orthotics.

Functional training activities that are specific to the activities that you are currently having a difficult time performing to include exercises and stretches for daily activities, work-related functions, and a return to sports.

Your licensed physical therapist will also work to develop a specific home exercise program based on your needs and goals for you to do on your own. By doing this, you will get back to feeling better, faster!

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Prevention Tips for Hip Impingement

Despite a significant increase in research to learn more about this condition, there is a great deal that is unknown. For example, many active young people whose X-rays show abnormal hips do not have pain, despite active lives and playing sports. As mentioned above, the best way to prevent the symptoms associated with hip impingement include proper shoe wear, maintaining good hip strength, and proper mechanics during functional and sports/leisure activities.

Avoiding aggravating activities such as deep squats, lunges, leg press, high knees, plyometric jumps, cycling with the seat height too low, and any other activities that require excessive hip flexion with loading will also help to minimize symptoms.

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References and Additional Research Reading

  1. N.C. Casartelli, N.A. Maffiuletti, J.F. Item-Glatthorn, S. Staehli, M. Bizzini, F.M. Impellizzeri, M. Leunig, Hip muscle weakness in patients with symptomatic femoroacetabular impingement, Osteoarthritis and Cartilage, Volume 19, Issue 7, 2011, Pages 816-821, ISSN 1063-4584.
  2. R. Ganz, J. Parvizi, M. Beck, M. Leunig, H. Nötzli, K.A. Siebenrock, Femoroacetabular impingement: a cause for osteoarthritis of the hip, Clin Orthop Relat Res, 417 (2003), pp. 112-120.
  3. Pun, Stephanie et al. “Femoroacetabular impingement.” Arthritis & rheumatology (Hoboken, N.J.) vol. 67,1 (2015): 17-27. doi:10.1002/art.38887
  4. Freke M, Kemp JL, Svege I, et al. Physical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidenceBritish Journal of Sports Medicine 2016;50:1180.
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