Femoroacetabular impingement (FAI) is a common problem in the athletic population that can significantly affect sports performance. FAI is defined based on a triad of motion-related symptomatic hip pain, clinical signs of hip impingement, and imaging findings of abnormal hip pathomorphology. This triad of symptoms is important, as the presence of imaging abnormalities in asymptomatic individuals may be as high as 68%, with athletes being three times more likely to have these imaging abnormalities.
The pathoanatomy of FAI is often multifactorial and includes both osseous (bony) and soft tissue abnormalities. Osseous pathomorphology may include cam, pincer, or mixed deformities. In cam impingement, an abnormal femoral head is wedged against the acetabulum in motions such as forced or excessive flexion. On the other hand, pincer femoral impingement is the result of an irregular projection of the acetabular rims that contacts the head of the femur. Chondrolabral pathology commonly occurs in the anterosuperior region with cam deformities and in the posteroinferior region with pincer deformities.
FAI is most commonly diagnosed in athletes participating in sports that require (1) repeated changes of direction and cutting causing hip rotational loads across the hip joint (e.g., soccer), (2) high hip flexion, adduction, and internal rotation motions (e.g., hockey) and (3) supraphysiological hip ranges of motion (e.g., dance).
Athletes with impingement usually have pain in the groin area, although it can be elsewhere. Sharp stabbing pain my occur with turning, twisting, and squatting, or specific sporting activities, but sometimes, it is just a dull ache. Catching, clicking, or popping, may indicate a labral tear associated with the impingement.
Literature supports a trial of non-operative management for the initial treatment of FAI. This includes a functional assessment of the athlete, addressing specific limitations in flexibility, strength, proprioception, and conditioning. If symptoms persist, surgery may be indicated. Hip surgery aims to treat the intra-articular pathologies resultant from FAI, i.e., labral tears and articular cartilage lesions. While the torn labrum is usually debrided or repaired, chondroplasty and/or microfracture are often used to treat the damaged hip joint cartilage. For the purpose of this protocol, we will be dealing with FAI treated surgically.
Below is a guideline of the multiple steps involved in navigating successful hip arthroscopy rehabilitation with the goals of each outlined below:
Pre-Op Phase: Injury recovery and readiness for surgery
Phase 1: Post-Op recovery
Phase 2: Control and capacity
Phase 3: Strength and accumulation
Phase 4: Sport preparation
Phase 5: Return to play and maintain performance
Pre- Surgery Stage:
The purpose of the stage is to get individuals ready both physically and mentally for surgery. Your physio will take you through a rehabilitation program to help build up lower limb and core strength along with working on neuromuscular control
This stage also allows us to pick up on any compensatory strategies or weakness that may have contributed to your injury or that might help in navigating a successful rehab. If you are part of a team environment working with a strength and conditioning coach or other coaches, they might be involved in helping to work on other aspect of your training to help keep you sport fit.
Post-Op Recovery - Phase 1:
The primary goals immediately following acetabular labral debridement or repair are to minimize pain and inflammation, protect the surgically repaired tissue, and initiate early motion exercises. Aqua therapy is strongly recommended in the literature in this phase. Aqua therapy allows for improvements in gait by allowing appropriate loads to the joint while minimizing unnecessary stresses to the healing tissue. Once the stitches have been removed and the wound given clearance, pool therapy can begin. Breaststroke is contraindicated.
Literature additionally strongly recommends cycling on a stationary bike, from day-one post-op. Twenty minutes twice a day is adequate, with no resistance until 4 weeks post-op.
Range of motion precautions may vary in this stage, depending on the surgical procedure. Typically, these include limiting flexion beyond 100 degrees for 21 days to avoid undue compression of the anterior labrum. No extension is permitted past 0 degrees for 21 days to protect capsular closure via the iliofemoral ligament. Additionally, no external rotation past 0 degrees, and abduction past 45 degrees for the first 21 days post-op. If range of motion does not improve, it is recommended to perform vigorous stretching at end of range after the 10-week mark.
Control and Capacity – Phase 2:
This phase is about continued protection of the repaired tissue, restoration of full pain-free hip ROM, and improving muscular endurance of the hip, pelvis and both lower extremities. Literature has highlighted the importance of addressing any weakness in gluteus medius during this phase. The stage will typically involve gym work to help build back up muscle strength and coordination, along with identify and address compensatory strategies.
It is important during this phase to restore full hip extension. Hip extension is particularly important to ensure adequate stride length and maintain the hip in a relatively neutral position.
Strength Accumulation - Phase 3:
This phase of the rehabilitation process introduces running, impact and change of direction. This is done in a graduated method in a control, safe environment to ensure successful progression.
The emphasis of this phase is to ensure good awareness and control of the limb. This coupled with continued strengthening helps to form the strong foundation blocks to introduce sports specific movement and training in the next phase. Additionally, this phase focuses on restoring full hip strength – isometric and isotonic.
Sport Preparation Phase – Phase 4:
Athletes are now building into running, hopping, and changing directions in both a controlled and unpredictable environment. This phase is highly tailored to both the individual sport and position to help ensure all physical and mental goals are achieved.
Rotational jumps are included in this phase to challenge the unique rotational forces experienced by the hip.
Return to Play and Maintain Performance – Phase 5:
Athletes are now well into running, hopping and changing directions in both a controlled unpredictable environment. This phase is about incorporating sport specific movement back into rehab and integrating the athlete back into a sport/team environment.
Once you have been given the all clear from the medical team to return to sport it is important to keep fit and maintain your strength.
On average literature reports that 87% of participants return to sport following a hip arthroscopy, while return to sport at the same level of sport as before the occurrence of symptoms as 82%. The average RTS timeline following surgery is 7 months. However, the recommended return may underestimate the return-to-play rate for a middle-aged patient with a pincer impingement, for example, in comparison with a competitive young athlete with cam impingement. Obviously, we then need to consider differences in sport, and how these affect return to sport. A recent systematic review showed that flexibility athletes (dance) had the highest rate of return to sport, followed by endurance athletes. The lowest rate of return to sport was observed in contact sports. They also highlighted that contact sports took the longest to return to.
For more information on the Foundation Clinic Lisfranc Protocol email [email protected], or phone 07 579 5601.
