New Research in FAI and Concomitant Pathologies

Femoroacetabular impingement morphology is a polarizing recent development in hip/pelvic literature. While its impact on symptomatic anterior hip/groin pain can be seen in many cases1, there is also literature supporting these morphological changes in asymptomatic patient populations.2 Due to this ongoing discussion over appropriate management of FAI, we may underappreciate how these anatomical variants impact the incidence of additional pathology. Below is a quick overview of a few studies that observed the incidence of FAI and concomitant pathologies.

ACL Risk3

VandenBerg and colleagues attempted to determine the risk of an ACL injury in those with FAI. Here’s what they found:

  • Individuals with an ACL tear experienced significant decrease in hip internal rotation (IR) compared to the control group
  • Every 10-degree increase in hip IR, reduced likelihood of ACL injury by a factor of 0.42
  • FAI (validated with a radiological evaluation) increased risk for ACL injury

Greater Trochanteric Pain Syndrome (GTPS)4

Greater trochanteric pain syndrome (gluteal tendinopathy, trochanteric bursitis, and capsular pathology) is a common cause of hip pain. With the prevalence of FAI in the symptomatic and asymptomatic population, Pozzi and colleagues looked at the interaction between the two conditions.

After comparing hip magnetic resonance arthrography (MRA) findings in those with and without FAI morphology, individuals with ‘normal’ morphology showed a higher incidence of greater trochanteric pain syndrome (p= 0.023). In patients under 40 years old, the association between normal morphology and GTPS increased compared to those over 40.

Athletic Pubalgia5,6

Athletic pubalgia is another common source of anterior hip/groin pain. It is often a competing diagnosis when a clinician evaluates a patient reporting hip pain. However, the clinician needs to know how frequently these conditions present concomitantly. Here are two different studies that looked at FAI and athletic pubalgia:

Naal et al. found evidence of groin herniation in 34 hips with FAI (41%):

  • 27 inguinal (6 female, 21 male)
  • 10 femoral (9 female, 1 male)
  • 3 combined inguinal and femoral

Tendinopathy of the proximal adductor insertion was also detected in 19 cases (23%; 11 female, 8 male). There were no significant differences for any of the radiographic or clinical parameters between patients with or without tendinopathy.

A different study from Economopoulos et al. found a higher rate of concomitance:

  • Radiographic evidence of FAI in at least one hip in 37 of 43 athletic publagia patients (86%)
  • Cam lesions identified in 83.7% of subjects
  • Pincer lesions present in 28% of hips

Appropriate Management

When evaluating a patient for hip/groin pain it’s important to understand the presence of FAI. Using the studies above we can take an evidence-based approach into evaluation and strive for the best possible outcome.

  1. Röling MA, Mathijssen NMC, Bloem RM. Incidence of symptomatic femoroacetabular impingement in the general population: a prospective registration study:. J Hip Preserv Surg. 2016;3(3):203-207. doi:10.1093/jhps/hnw009.
  2. Tresch F, Dietrich TJ, Pfirrmann CWA, Sutter R. Hip MRI: Prevalence of articular cartilage defects and labral tears in asymptomatic volunteers. A comparison with a matched population of patients with femoroacetabular impingement. J Magn Reson Imaging. December 2016:1-12. doi:10.1002/jmri.25565.
  3. VandenBerg C, Crawford EA, Sibilsky Enselman E, Robbins CB, Wojtys EM, Bedi A. Restricted Hip Rotation Is Correlated With an Increased Risk for Anterior Cruciate Ligament Injury. Arthroscopy. November 2016. doi:10.1016/j.arthro.2016.08.014.
  4. Pozzi G, Lanza E, Parra CG, Merli I, Sconfienza LM, Zerbi A. Incidence of greater trochanteric pain syndrome in patients suspected for femoroacetabular impingement evaluated using magnetic resonance arthrography of the hip. Radiol Med. December 2016. doi:10.1007/s11547-016-0716-4.
  5. Naal FD, Dalla Riva F, Wuerz TH, Dubs B, Leunig M. Sonographic Prevalence of Groin Hernias and Adductor Tendinopathy in Patients With Femoroacetabular Impingement. American Journal of Sports Medicine. 2015;43(9):2146-2151. doi:10.1177/0363546515591259.
  6. Economopoulos KJ. Radiographic Evidence of Femoroacetabular Impingement in Athletes With Athletic Pubalgia. Sports Health: A Multidisciplinary Approach. 2014;6(2):171-177. doi:10.1177/1941738113510857.