What is hip impingement?

Femoroacetabular Impingement (FAI) is a condition whereby the bone at the front of the ball part of the hip joint (the femoral head) rubs against the edge of the socket (the acetabulum) when the hip is flexed up (i.e. when the knee is brought up towards the chest).

There are generally two types of FAI:

Cam – this is where the femoral head is not entirely round, and the edge of the head is therefore prominent.

Pincer – this is where the edge of the hip socket catches on the femoral head/neck.

A lot of the time, these two forms exist together.

Normal hip shape (ball and socket).

Cam-type FAI caused by bony ‘bump’ at front of femoral head/neck.

Pincer-type FAI caused by deep socket or spikes of bone (osteophytes) at front of socket.

What causes FAI?

It is not yet clear whether FAI is something that is congenital (people are born with it) or acquired (after birth) due to other factors, such as significant athletic activity before children’s bones have become mature. Symptoms may be worsened by contact sports. It is likely that FAI is most probably caused by a combination of genetic and environmental factors.

What are the symptoms of FAI?

FAI may be without symptoms for a long time. After a while, it may cause pain and stiffness in the hip joint that is often felt in the front of the groin or at the top of the thigh. The condition can stop people fully bending their hips, and the pain may be particularly bad when the knee is brought up towards the chest and the hip is flexed, especially if the thigh is rolled inwards at the same time (flexion + internal rotation of the hip). Pain may worsen after prolonged sitting, running or jumping.

How is FAI investigated?

FAI can often be seen clearly on simple X-rays, especially if there is a cam-shaped femoral head/neck present. Additional investigations, such as a CT scan and high-resolution 3T MRI scan, may also be performed. CT scanning may be useful to identify contributing factors, such as an altered position of the ball and socket joint. It also allows motion analysis to be carried out to confirm whether FAI is occurring. MRI scans can also show up other pathologies within the hip joint, such as whether there is a tear of the acetabular labrum (labral tear) or degenerative changes within the joint (thinning of the lining of the ball or the socket).

What happens if FAI is left alone?

If FAI is left untreated then it may potentially get worse with time, and the pinching of the edge of the hip may cause acetabular labral tears (tears of the rim of cartilage around the hip socket), and it is possible that with time one may subsequently begin to develop increasing arthritis in the hip joint.

What are the treatments?

If the symptoms from FAI are mild, then conservative treatments may well suffice. These can include:-

• Painkillers and anti-inflammatories.
• Physiotherapy.
• Restriction of aggravating activities (rest).

There is evidence that physiotherapy can provide good lasting outcomes. However, surgical intervention may provide better and longer-lasting outcomes.

For cases where the severity of the symptoms justifies intervention, then surgical treatment options include:-

• Intra-articular injection of the hip joint with cortisone/steroid (in theatre under X-ray control or using ultrasound guidance in the clinic or radiology department)
• Hip arthroscopy. With this technique, it is possible to shave down the excess bone at the front of the femoral head/neck and to trim or repair any labral tears that might have developed. Cartilage damage in the joint can also be treated at the same time.

Each patient will receive an individualised treatment plan tailored to their symptoms and their personal situation.

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What is Trochanteric Bursitis?

The greater trochanter is the prominent piece of bone situated at the upper outer aspect of the femur, as is palpable in most people just to the outer side of where a trouser pocket starts. It is the area of bone where a large mass of muscles (the hip abductors) attach to the femur.

A bursa is a sack of fluid, which acts a lubricator. Bursae are found in many sites around the body; typically between areas of bone or tendon and the skin. The function of a bursa is to minimise potential rubbing and friction between two tissues.

The trochanteric bursa is found just lateral (outside) of the hip joint, beneath the skin, the fat and the facia lata, just superficial to the muscle layers of the gluteus medius and the vastus lateralis, where they attach to the bone.

When a bursa becomes inflamed, the area becomes tender and painful. The region may become hot, red and swollen. However, with certain deep bursae (such as the trochanteric bursa), these signs may not be apparent. When a bursa becomes inflamed, the condition is referred to as ‘bursitis’.

Sometimes inflammation of the muscle tendons can mimic symptoms. Some people may have multiple problems, and this is called ‘trochanteric syndrome’.

What causes it?

Trochanteric bursitis may come on after trauma, repetitive micro-trauma (overuse), in the presence of osteoarthritis, or even after a hip replacement. Tendon problems may also occur due to problems with how you walk or run (gait). Many times, no specific cause can ever be clearly identified.

What are the symptoms?

Trochanteric bursitis normally causes a sharp or burning pain over the lateral (outside) side of the hip. The pain may radiate down the lateral side of the thigh towards the knee. The pain is usually made worse by walking or trying to run. The most pathognomic (typical) symptoms and signs are tenderness over the lateral side of the hip, plus pain when trying to lie on that side in bed. This pain often interferes with patients’ sleep

How is it investigated?

Diagnosis is often clear from simple history taking plus clinical examination. However, in cases where the diagnosis may not be entirely clear, or where more definite confirmation is desired, then the investigation of choice is an ultrasound or high-resolution 3T MRI scan of the hip. An MRI scan will also be able to check for other hip pathology, such as a labral tear or early hip arthritis. X-rays should also be performed to exclude the potential presence of osteoarthritis of the hip.

What is the treatment?

Sometimes, no actual treatment may be needed. The first step in the treatment of trochanteric bursitis is to try rest and to use anti-inflammatories. Some patients’ symptoms may be helped by physiotherapy. In cases where the symptoms are severe enough to justify intervention, then the first line of treatment is to have a local anaesthetic plus cortisone injection into the bursa. The cortisone is a very powerful anti-inflammatory and normally works very well, although it may sometimes be necessary to repeat the injection more than once. The injection can sometimes be given directly in the outpatient clinic; however ultrasound-guided injection in the X-ray department is the gold-standard. Ultrasound has the advantage of being able to target other areas, such as inflammation of the tendons.

Other treatment options may include shockwave therapy.

In that very small proportion of patients where all other treatment options fail and where the symptoms remain severe, surgical excision of the bursa is very occasionally necessary. This is an open operation, performed normally under a general anaesthetic. The operation lasts only 20 or 30 minutes, but the dissection does go quite deep. Therefore, there can be significant post-operative discomfort, and patients normally need to stay in hospital overnight post-operatively. The wound normally takes only a week or so to heal, but the deeper tissues may take up to 6 weeks to settle, during which time some patients may require a walking stick initially to help them walk, followed by a course of physiotherapy treatments to help them regain their strength and motion.

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What is Hip Arthritis?

Arthritis of the hip is a painful condition, where the cartilage in the hip joint wears away, leaving bone rubbing on bone within the joint. The symptoms are normally an aching or burning pain within the joint, with stiffness. The pain is often felt in the groin or down the front of the thigh (referred pain). Arthritis of the hip can even sometimes cause pain to be felt in the region of the knee.

Sometimes there may also be cartilage tears or loose pieces of cartilage or bone within the joint, and these may cause sudden sharp pains, locking (when the hip becomes fixed) or giving way of the hip.

In severe arthritis, the leg can become slightly shortened, with the hip joint becoming severely stiff. Walking becomes painful and daily activities such as reaching down to put on socks or getting into a car can become increasingly difficult.

Normal Hip X-ray. Note the preserved gap between the femoral head (ball) and the acetabulum (socket).

Hip X-ray showing advanced arthritis. Note that the gap between the head and acetabulum has disappeared, and the bone is collapsing and eroding away.

When you come to clinic

When you come to clinic your appointment with your consultant will involve your surgeon asking you about the symptoms you experience in your hip. The surgeon will then examine your hip.  X-rays, and if required, an MRI scan of your hip will be requested. The assessment of your symptoms and examination findings are correlated with the X-ray and MRI findings. A specific treatment plan is discussed with you. This is because many people with radiological features of osteoarthritis do not necessarily have significant clinical symptoms.

Non surgical treatment of early hip arthritis include:

• Doing nothing!
• Education and lifestyle aids
• Walking aids
• Glucosamine and/or chondroitin sulphate tablets
• Simple painkillers
• Anti-inflammatories
• Physiotherapy

Moderate exercise may improve pain and muscle function, and may slow down disease progression. Other benefits include improvement in body weight, cardiovascular fitness and mood.

It is important to appreciate that the rate of progression of arthritis can vary significantly between different people. Sometimes, a patient may never require surgery. When the various non-operative measures have failed to control the symptoms of hip arthritis, surgical treatment becomes an option for those patients with significant enough symptoms.

Potential surgical treatments for hip arthritis include:-

• Injection of cortisone/steroid into the hip joint (in theatre under X-ray control)
• Hip arthroscopy (keyhole surgery)
• Hip replacement
• Hip resurfacing
• Custom made hip replacements

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What is the acetabular labrum?

The acetabulum is the socket of the hip joint, within the bones of the pelvis. The acetabular socket is lined with a layer of smooth articular cartilage, which is extremely low friction and which also provides some degree of shock absorbency. The peripheral rim of the acetabulum is surrounded by a lip of fibrocartilage (elastic cartilage, like the cartilage of the outer ear), called the acetabular labrum. This labrum deepens the socket and also helps to provide a suction effect, aiding in the lubrication of the joint.

The acetabular labrum is a rim of elastic cartilage around the edge of the socket of the hip, and, just like the knee cartilages, can tear causing symptoms in the joint.

Why and how do labral tears occur?

The acetabular labrum can tear through sudden major trauma to the hip joint, or through repeated minor trauma (such as high impact sports). Alternatively, the labrum can suffer ‘wear and tear’ as part of a slow onset of degeneration within the hip, either with or without evidence of more general arthritis in the joint. A labral tear can also occur with an abnormally shaped femoral head, which causes femoroacetabular impingement.

What are the symptoms?

Tears of the acetabular labrum often cause:-

• Activity-related sharp groin or anterior thigh pain
  pain that may be worse with internal rotation and/or flexion of the hip. This pain may be sharp, with catching sensations.
• Deep clicking within the hip joint (normally felt deep within the groin).
• Feeling of giving way within the hip.

How is it investigated?

Traditional investigations such as X-rays, CT-scans, Ultrasound or even basic MRI are notoriously bad at diagnosing acetabular labral tears. The best way to confirm the presence of a clinically suspected tear is to have a high-resolution 3-Tesla MRI scan.  An MR-arthrogram, which is an MRI scan combined with injecting the hip joint with a special dye, may sometimes be required – this has a diagnostic accuracy of about 90%.

MR-arthrogram showing a labral tear (the white blob, highlighted by the yellow arrow).

What is the treatment?

Labral tears may be treated with physiotherapy. Evidence suggests that this can often provide good long-term benefits. However, hip arthroscopy (keyhole surgery of the hip) may provide better longer-term benefits for acetabular labral tears. It is a technique that enables labral tears to either be trimmed or repaired, as appropriate, depending on how ragged or severe the tear might be.

Intra-operative view of a labral tear (white flap coming from the top right of the image) seen at the time of hip arthroscopy.

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