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Femoroacetabular Impingement & its Relevance to Chiropractors

Presented by: Dr. Brett S Jarosz – BAppSc(CompMed), MCl inChiro, ICSSD, PGradDipSportsChiro, CertPT, FICC

Will commence LIVE from Melbourne, Australia at 7pm AEDT

Dr. Matthew Bulman BHsc, MChiro

World Health Webinars (Australia) Chiropractic Program

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World Health Webinars (Australia) Host

Editor of the Chiropractic and Osteopathic College of

Australasia NEWS

Owner of The Runner’s Clinic, Sydney

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Dr Brett Jarosz

• Practicing Sports Chiropractor (SCA, FICS)

• Lecturer at RMIT University

• Reviewer for Journal of Chiropractic Medicine

Chiropractor

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Femoroacetabular Impingement and its relevance to chiropractors

Brett S. Jarosz BAppSc(CompMed), MClinChiro, ICSSD, PGradDipSportsChiro, CertPT, FICC

Course Objectives

1. Describe and discuss the morphological abnormalities and pathomechanics of FAI

2. Describe and discuss the clinical presentation, physical examination and radiographic features of FAI

3. Describe and discuss treatment options for FAI

4. Discuss the role chiropractors have in the management of FAI

Introduction

• Femoroacetabular impingement (FAI) has been increasingly recognized over the past five to six years as a major cause of pain and premature degenerative changes in the hips of young adults.1-10

• Recent investigation has indicated that FAI might be the underlying etiology in most DJD cases that were previously identified as “idiopathic”.11

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Introduction

• FAI is a condition resulting from morphologic abnormalities of the acetabular rim and proximal femur.

• The pathomechanics of FAI leads to abnormal contact between the acetabular rim and femoral head-neck junction, creating chondral lesions, labral pathology and secondary degenerative joint disease (DJD).11,12

Reprinted with permission from the American Journal of Roentgenology

Cam-type Impingement

• FAI can manifest through two different mechanisms – Cam-type or pincer-type - although a combination of both is often seen in clinical practice.13

• Cam-type FAI is found in two-thirds to three-quarters of cases.3

• The Cam-type impingement is due to proximal femur abnormalities, characterized by an absent or decreased offset between the femoral head and neck2 – also named pistol-grip or tilt deformity

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Cam-type Impingement Cam-type Impingement

• This femoral abnormality encroaches on the labrum and acetabulum when the hip is flexed, particularly with combined internal rotation and/or adduction.3

• It often causes labral detachment and outside-in damage to the anterosuperior acetabular articular cartilage as the abnormal femoral head-neck junction forces itself under the acetabular rim.2,14

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• Over time, the repetitive anterosuperior contact causes continual damage to the labrum, articular cartilage, and subchondral bone, eventually leading to DJD.3

• The Cam-type impingement is known to be associated with femoral neck fractures, slipped capital femoral epiphysis, Legg-Calve-Perthes’ disease, or in any hip in which the femoral neck is too large.5,7,11,12


Pincer-type Impingement

• Pincer-type impingement accounts for approximately one-quarter of cases of FAI.3

• Pincer-type FAI results from focal or generalised acetabular abnormalities including:2,3,11 – an acetabulum that is too deep

• coxa profunda or protrusion

– an acetabular rim that is curving downward

– retroversion

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Pincer-type Impingement

• The acetabular over-coverage causes the labrum to be compressed between the acetabular rim and the femoral neck during hip flexion and internal rotation.3,14

• The pincer-type impingement leads to degeneration and eventual ossification of the labrum, worsening the problem of acetabular over-coverage.14

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Pincer-type Impingement Relevance Clinically?

• The abnormal loading through the femoral head-neck junction and the acetabular rim predispose patients to functional restrictions, articular cartilage and labral damage, and subsequent DJD.15

• Therefore, it is crucial that a timely diagnosis of FAI can be made in order to improve management of this condition, and provide an opportunity for joint preservation.15

Relevance Clinically?

• Many patients with symptomatic FAI experience delays in diagnosis, incorrect diagnosis, and ineffective treatment recommendations.15

– It has been reported the mean time from symptom onset to definitive FAI diagnosis is 3.1 years.15

– Additionally, patients are evaluated by an average 4.2 healthcare providers prior to diagnosis.15

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Relevance Clinically?

• Recently, it has been illustrated that the loss of hip motion from FAI may result in compensatory injury patterns and conditions including osteitis pubis, sports hernia, low back pain, SIJ pain, adductor strain, rectus femoris strain, and posterior hip (medical) subluxation26 – FAI is often misdiagnosed and mismanaged as

groin strain, early osteoarthritis or a low back disorder.14,19

Relevance to Chiropractors

• Chiropractors are often the primary contact for patients presenting with lumbopelvic-hip pain that may be associated with FAI.

• As such, the chiropractic profession is an important position to appropriately assess and diagnose these patients early, and offer evidence-based clinical recommendations in order to improve the management of FAI. – Therefore, it is essential that chiropractic practitioners

are familiar with the assessment, diagnosis and management of this condition.

Diagnosis of FAI

• The diagnosis of FAI should be made through synthesis of the patient history, physical examination, and radiographic findings.

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Clinical Presentation

• Typically, FAI presents as insidious onset groin pain in physically active adults aged 20 to 50 years (average age: 33-35 years).3,15 – Males account for two-thirds of cases.15,16

– The Cam-type impingement is most common in men between the ages of 20-30; whereas the pincer-type is more common in middle-aged women9

– Patients are often involved in athletic activities, with participation in sports reported in 70% of cases in a prospective study, with 30% of patients being elite athletes.17

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• Athletic activities that involve extreme ranges of motion, typically cause an increase in intensity or duration of symptoms.3,7,10,15,18,19

– Especially:

• repetitive hip hyperflexion

• hyperextension

• internal and external rotation

• e.g. Australian rules football, ballet, martial arts, soccer, netball, gymnastics, rowing


• Initially, FAI symptoms are often insidious and may include intermittent groin pain, lateral trochanteric pain, or both.11,14,15,19 – Pain may be referred to the low back, gluteal region or

knee (as with other hip disorders).6

• As the acetabular labrum and articular cartilage degenerate, symptoms gradually worsen and are exacerbated by continued athletic activity, prolonged sitting, and prolonged walking.7,14 – Due to the gradual onset, and intermittent symptoms,

patients often wait several months or years before seeking advice from a health care provider3


• Patients may report a dull ache or a sharp pain in the anterior groin; episodes of catching, locking or giving way (these findings are pathognomonic for labral pathology)12 with pain for a few minutes to a few hours; or a feeling of discomfort or apprehension especially with prolonged sitting, particularly when the seat is low.3,7 – These symptoms most commonly occur with

movements that involve some degree of hip flexion or de-flexion3 • i.e. standing after prolonged sitting

Examination

• Without a focused physical examination and the appropriate diagnostic tests, FAI is often misdiagnosed and mismanaged

Examination

• The gait pattern of a patient with FAI may reveal a positive Trendelenburg sign6,7,19 – hip abductor weakness during the stance phase of gait

• Passive range of motion of the hip is restricted, and often painful, in hip flexion and internal rotation in flexion, as a result of the morphologic abnormalities. – This is unlike the global restriction of motion found in

advanced cases of DJD. 7,12,14

• Internal rotation with the hip in 90 of flexion is markedly limited in comparison to the other side.19

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Examination

• Almost 90% of hips reproduce pain symptoms with the anterior impingement test

– Possibly the most important clinical finding indicative of FAI.19

– It has been demonstrated that in patients with a positive impingement test, there is a significant association with labral pathology.20

Anterior Hip Impingement Test

• The anterior hip impingement test is performed with the patient in a supine position

• The hip is internally rotated and adducted, as it is passively flexed to 90.12,14

• A reproduction of the patients symptoms is considered a positive sign.12,14

• The anterior impingement test results in contact between the junction of the femoral head-neck and acetabular rim which cause pain where there is a labral or chondral lesion.14 – The Log roll test, FABERE test and other provocative maneuvers

may also be positive, but are nonspecific for FAI.21

Anterior Hip Impingement Test Radiological Examination

• Radiographic examination for FAI includes an anteroposterior (AP) pelvic view, and a lateral hip view on both sides. – It is beneficial to use 10-15 of hip internal rotation on

the AP pelvic view to compensate for femoral anteversion, providing optimal visualization of a Cam lesion.13

– Additional radiographs include an axial cross-table lateral view, frog-leg lateral view, and a false-profile view.7,12

• All lateral views should be obtained bilaterally for the purpose of comparison.3

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AP Pelvic Radiographs

• The AP pelvic radiograph provides visualization of the contour of the lateral femoral head-neck junction

• Should be routinely evaluated for the:3,7 – Cam lesion

• pistol-grip or tilt deformity

– Acetabular protrusion

– Acetabular retroversion

– Pincer lesion • excessive arching of the

acetabular roof

Lateral Hip Radiographs

• The lateral hip view will allow visualization of:13

– Subchondral sclerosis

– Early subchondral cyst formation within the anterior acetabular rim

– Joint space narrowing

– Acetabular over-coverage of the femoral head.

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Alpha Angle

• FAI can be further quantified on the lateral hip view, through measurement of the alpha angle. – A line is drawn along the axis

of the femoral neck, and a second line drawn from the centre of the femoral head through the femoral head-neck junction.7,12

• It has been concluded that an alpha angle of greater than or equal to 55 is an indicator of FAI.4

Radiological Examination

• Advanced cases of FAI will demonstrate the typical signs of DJD

– loss of joint space

– subchondral sclerosis

– subchondral cysts

– osteophyte formation

• The presence of advanced degenerative changes precludes a diagnosis of FAI.19

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MRI-arthrography

• MRI-arthrography (injection of contrast into the joint) is considered the most specific and sensitive imaging study in the diagnostic work-up for patients with FAI.23

MRI-arthrography

• A triad of anomalies has been described in the MRI of patients with FAI:12

– Abnormal femoral head-neck morphology

– Anterosuperior acetabular cartilage

– Anterosuperior labral pathology

MRI-arthrography

• The two main secondary lesions of anterosuperior chondropathy and labral pathology may be suspected on MRI, however they can only be confirmed on MRI-arthrography.3

Diagnosis

• The diagnosis of FAI should be made through synthesis of the patient history, physical examination, and radiographic findings.

• The diagnosis should not rely on radiographic findings alone.

– It should be noted that plain film radiographs are often reported as normal

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Diagnosis

• The radiographic signs of the Cam and pincer morphological abnormality are often overlooked because they are not looked for routinely.

• An inability to recognize the morphological abnormalities, or a lack of access to imaging, does not surpass an indicative patient history and physical examination findings, which includes a positive impingement test.19

Diagnosis

• The abnormal loading through the femoral head-neck junction and the acetabular rim predispose patients to functional restrictions, articular cartilage and labral damage, and subsequent DJD.15

• Therefore, it is crucial that a timely diagnosis of FAI can be made in order to improve management of this condition, and provide an opportunity for joint preservation.15

Management Options

• Based upon the current evidence, surgical intervention has been demonstrated to be the most successful treatment approach for FAI in the absence of advanced degenerative changes to the hip.8

• Whilst surgical procedures demonstrate good to excellent clinical outcomes (if performed prior to secondary degenerative changes), there is a lack of evidence to support or refute the use of conservative treatment interventions.25

Management Options

• In cases of FAI where exacerbating activities can be modified or removed, conservative management may provide improvement in function and symptoms.25,27

• However, it must be emphasised that conservative management will not eliminate the underlying morphological abnormalities.27

Conservative Management

• There has been minimal documentation regarding the conservative management of FAI, despite a number of publications suggesting an initial trial of conservative therapy is warranted.6,7,18,25-27

• The literature suggests that subjective and objective improvements in hip function can be achieved through conservative treatment. – However, there are no published randomized

controlled trials addressing manual therapy, exercise therapy or any other conservative therapy intervention in patients presenting with FAI.

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• Conservative management of FAI is a difficult clinical challenge as various therapeutic methods may be effective for relieving acute pain in the short-term, but some treatment approaches may, in fact, exacerbate the condition.7

• The goal of any conservative treatment approach is to decrease the mechanical contact (impingement) between the femoral head-neck junction and the acetabular rim.27

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• It has been stated that the following approaches 6,7,10,19,26,27 should be utilized as part of the initial trial of conservative treatment: – NSAIDs – Relative rest – Activity modification or avoidance – Hip range of motion therapy – Treatment to improve hip flexor tightness – Stretching to improve hip external rotation and abduction – Core and hip muscle strengthening

• Conversely, it has been suggested that stretching or other techniques to improve passive hip range of motion (e.g. manipulation/mobilization) may exacerbate the symptoms.7,12,19,28

Multi-modal Chiropractic Management Approach

• This author has demonstrated the use of a multi-modal chiropractic approach can improve the function and symptoms of patients with FAI.


• The multi-modal treatment and management approach utilised by this author addresses the entire kinetic chain

• Cervical and Thoracic spine

• Lumbopelvic-hip complex

• Knee

• Ankle

• Foot

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• Pre-manipulative myofascial release (MFR) and active release soft tissue techniques (ART) applied to the psoas, iliacus and TFL musculature.

• The soft tissue release techniques were followed by long-axis traction HVLA MAT to the involved hip, utilizing a chiropractic drop-piece table. – The hip manipulation was performed with the patient

in supine and side-lying positions, and modified with flexion, extension, external rotation and/or abduction where dynamic (range of motion) palpation was determined restricted and pain-free.


• Caution should be applied with manipulation/mobilisation of the hip joint, as attempts to passively improve hip range of motion may exacerbate FAI symptoms.

• Hence the author uses hip manipulation/mobilisation techniques involving long-axis traction

– These have shown to be beneficial in hip DJD


• Post-manipulative post-isometric relaxation (PIR) and proprioceptive neuromuscular facilitation contract-relax-antagonist-contract (PNF-CRAC) stretching protocols were employed to promote hip abduction, external rotation and extension.

• Any general motion restriction of spinal, sacro-iliac and lower extremity articulations noted during dynamic (inter-segmental motion) palpation were treated with HVLA manipulation; joint mobilization and/or MAT.

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• Corrective exercise therapy focusing on core and hip muscle strengthening

• Active isolated stretching (AIS) techniques to encourage hip extension, abduction and external rotation were prescribed

• Instruction to modify or remove (where possible) activities predisposing to FAI was provided. – Any technique(s) which exacerbated the patients’

symptoms were modified or removed throughout the course of patient management.

Corrective Exercise Program Conservative Management

• According to the literature, conservative therapy of FAI can achieve good results so long as patients can modify activities of daily living to adapt to their abnormal hip morphology.27,37

• However, many patients are unable to remove or modify their activities, and also have ambitions to return to their previous asymptomatic endeavors.

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• Given the mechanical nature of FAI, conservative treatment will not eliminate the underlying morphological abnormalities, and attempts to return to previous athletic activities (or activities of daily living which involve recurrent or prolonged hip flexion or de-flexion) will simply aggravate the condition and cause symptoms to recur.7,19


• An initial period of conservative treatment is certainly recommended, but chiropractors should not dismiss the fact that many athletically inclined patients may require surgical intervention

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• More importantly, it has been declared that a delay in surgical correction of symptomatic FAI may lead to disease progression to the point where joint preservation is no longer indicated.8

• Therefore, early surgical intervention is recommended to avert the pathological progression from impingement to end-stage DJD.27

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Role of the Chiropractor

• In cases of FAI that require orthopaedic intervention, chiropractors serve an important role in the early diagnosis, prehabilitation and post-surgical rehabilitation.

Prehabilitation

• Prehabilitation is the practice of improving the functional capacity of an individual to withstand a stressful event (e.g. surgery).38

• According to the literature, prehabilitation is effective in:39,40 – Enhancing postoperative functional ability

– Decreasing the risk of postoperative complications and hospital stay

– Reducing the need for extensive inpatient rehabilitation.

Prehabilitation

• Swank et al41 demonstrated that 4-8 weeks of prehabilitation was effective for increasing leg strength and the ability to perform functional tasks in individuals with severe OA prior to total knee arthroplasty.

• Furthermore, Topp et al42 indicated that prehabilitation was effective at improving functional ability, decreasing pain, and increasing muscle strength after total knee arthroplasty surgery.

Prehabilitation

• FAI patients demonstrate:15,43 – Specific muscle weaknesses in:

• Hip adduction • Hip flexion • Hip external rotation • Hip abduction

– Restrictions in: • Hip flexion ROM • Hip internal rotation (in flexion) ROM

• Therefore, FAI prehabilitation should be directed toward improving hip range of motion and increasing hip muscle strength.

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Surgical Treatment

• The aim of surgical treatment for FAI is to improve the femoroacetabular clearance and eliminate the mechanical obstruction at the limits of the desired hip range of motion.13,18,28

• The technical goals of joint preservation surgery (prior to advanced DJD) are to correct the joint pathomechanics, and to treat the associated acetabular articular cartilage and labral pathology.18

Surgical Treatment

• In cases of advanced DJD, prosthetic replacement surgery (total hip replacement, arthroplasty) is the orthopaedic treatment of choice18, and is beyond the scope of this presentation

• Both open surgical techniques and arthroscopic treatment have been described in the operative management of FAI.

Surgical Treatment

• Factors associated with a good outcome include minimal radiographic DJD, limited cartilage damage at surgery, young age and labral repair (rather than debridement).29

• The three main causes of treatment failure were marked DJD, extensive chondropathy, and age older than 35 years at the time of surgery.32

• These findings underscore the importance of early diagnosis and timely treatment for symptomatic hips.15

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Pre- and Post-surgery

Post-surgical Rehabilitation

• Post-surgical rehabilitation occurs at different rates depending on the specific procedure performed, patient age, pre-injury health status and rehabilitation compliance.

• The patients pre-surgical health status and post-surgical goals/physical demands will direct the rehabilitation program and its progressions.44

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Discussion

• Given the mechanical nature of FAI, it makes sense that a multi-modal and multi-disciplinary biomechanical approach to management that includes manipulation, mobilization, soft tissue and stretching techniques, corrective exercise therapy, prehabilitation, surgery, and rehabilitation programs go hand in hand.

• The effectiveness of manual therapy and exercise programs in hip DJD has been demonstrated within the literature.45,46

Discussion

• Furthermore, chiropractic management of the full lower limb kinetic chain involving manipulation, mobilization, lengthening and stretching exercises has been shown to increase hip range of motion, improve physical function, and reduce pain in hip DJD.36

• It could be conjectured that the utilization of multi-modal chiropractic management that involves full kinetic chain manual therapy, plus corrective exercise intervention could delay or prevent pathological progression from FAI to end-stage DJD.

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Discussion

• However, the efficacy of conservative management remains a concern because it does not address the underlying morphological abnormalities and disease progression is common.18

Discussion

• In cases of FAI where patients are unable to remove or modify their activities (as occurs with semi-elite and elite athletes), or when patients fail to respond to conservative management, referral for MRI-arthrography is warranted.

• The presence of articular cartilage or labral pathology necessitates referral and evaluation by an orthopaedic surgeon who specialises in hip joint preservation procedures.7

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Discussion

• For FAI that requires co-management, chiropractors serve an important role in the diagnosis, prehabilitation (multi-modal treatment approaches utilised prior to surgical intervention) and post-surgical rehabilitation.

Conclusion

• FAI has been increasingly recognized over the past five to six years as a major cause of pain and premature degenerative changes in the hips of young adults.

• Early diagnosis is crucial in order to improve the management of this condition and avert the pathological progression from impingement to end-stage DJD.

• FAI typically presents as insidious onset groin pain in physically active adults aged 20 to 50 years, often in association with sporting activities.

• On examination, internal rotation in flexion is markedly limited in comparison to the other side.

• A positive impingement test is possibly the most important clinical finding indicative of FAI.

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Conclusion

• The plain film radiographic signs of the Cam and pincer morphological abnormality are often overlooked because they are not looked for routinely.

• When detected, these radiographic signs provide the diagnosis of FAI, provided they are consistent with the clinical findings.

• MRI-arthrography to evaluate acetabular chondropathy and labral pathology is considered the gold standard.

• The diagnosis is based on the synthesis of the clinical pain presentation, a positive impingement sign, and imaging studies demonstrating morphological abnormalities associated with FAI.

Conclusion

• Chiropractors are in an important position to appropriately assess and diagnose patients with FAI, and offer evidence-based clinical recommendations in order to improve the management of this disorder.

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Conclusion

• For further information regarding clinical presentation and multi-modal chiropractic management of FAI, please refer to the authors articles: – Jarosz BS. Femoroacetabular impingement and its

relevance to chiropractors. Part I: a commentary. Chiropr J Aust. 2012; 42(4):126-36.

– Jarosz BS. Femoroacetabular impingement and its relevance to chiropractors. Part II: a case series. Chiropr J Aust. 2012; 42(3):91-7.

References

1. Ito K, Minka MA, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br. 2001 Mar.;83(2):171–6.

2. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br. 2005 Jul.;87(7):1012–8.

3. Lequesne M, Bellaïche L. Anterior femoroacetabular impingement: An update. Joint Bone Spine. 2012. doi:10.1016/j.jbspin.2011.10.012

4. Nötzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br. 2002 May;84(4):556–60.

5. Leunig M, Casillas MM, Hamlet M, Hersche O, Nötzli H, Slongo T, et al. Slipped capital femoral epiphysis: early mechanical damage to the acetabular cartilage by a prominent femoral metaphysis. Acta Orthop Scand. 2000 Aug.;71(4):370–5.

6. Chakraverty JK, Snelling NJ. Anterior hip pain - Have you considered femoroacetabular impingement? International Journal of Osteopathic Medicine. 2011. doi:10.1016/j.ijosm.2011.09.003.

7. Emary P. Femoroacetabular impingement syndrome: a narrative review for the chiropractor. J Can Chiropr Assoc. 2010 Sep.;54(3):164–76.

8. Leunig M, Beaulé PE, Ganz R. The concept of femoroacetabular impingement: current status and future perspectives. Clin Orthop Relat Res. 2009 Mar.;467(3):616–22.

9. Ganz R, Leunig M, Leunig-Ganz K, Harris WH. The Etiology of Osteoarthritis of the Hip. Clin Orthop Relat Res. 2008 Jan. 10;466(2):264–72.

10. Hart ES, Metkar US, Rebello GN, Grottkau BE. Femoroacetabular impingement in adolescents and young adults. Orthop Nurs. 2009 Apr.;28(3):117–24.

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References

11. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res; 2003;(417):112-20.

12. Kaplan KM, Shah MR, Youm T. Femoroacetabular impingement--diagnosis and treatment. Bull NYU Hosp Jt Dis. 2010;68(2):70–5.

13. Banerjee P, Mclean CR. Femoroacetabular impingement: a review of diagnosis and management. Curr Rev Musculoskelet Med. 2011 Mar. 16;4(1):23–32.

14. Huang R, Parvizi J. Femoroacetabular Impingement: Saving the Joint. YSART. 2011 Jun. 1;22(2):52–5. 15. Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H. Clinical Presentation of Patients with

Symptomatic Anterior Hip Impingement. Clin Orthop Relat Res. 2009 Jan. 7;467(3):638–44. 16. Allen D, Beaulé PE, Ramadan O, Doucette S. Prevalence of associated deformities and hip pain in patients with cam-

type femoroacetabular impingement. J Bone Joint Surg Br. 2009 May;91(5):589–94. 17. Nogier A, Bonin N, May O, Gedouin J-E, Bellaiche L, Boyer T, et al. Descriptive epidemiology of mechanical hip

pathology in adults under 50 years of age. Prospective series of 292 cases: Clinical and radiological aspects and physiopathological review. Orthopaedics & Traumatology: Surgery & Research. 2010 Dec.;96(8 Suppl):S53–8.

18. Zebala LP, Schoenecker PL, Clohisy JC. Anterior femoroacetabular impingement: a diverse disease with evolving treatment options. Iowa Orthop J. 2007;27:71–81.

19. Dooley PJ. Femoroacetabular impingement syndrome: Nonarthritic hip pain in young adults. Can Fam Physician. 2008 Jan.;54(1):42–7.

20. Burnett RSJ, Rocca Della GJ, Prather H, Curry M, Maloney WJ, Clohisy JC. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am. 2006 Jul.;88(7):1448–57.

References

21. Jaberi FM, Parvizi J. Hip Pain in Young Adults. The Journal of Arthroplasty. 2007 Oct.;22(7):37–42.e1. 22. Leunig M, Beck M, Kalhor M, Kim Y-J, Werlen S, Ganz R. Fibrocystic changes at anterosuperior

femoral neck: prevalence in hips with femoroacetabular impingement. Radiology. 2005 Jul.;236(1):237–46.

23. James SLJ, Ali K, Malara F, Young D, O'Donnell J, Connell DA. MRI findings of femoroacetabular impingement. AJR Am J Roentgenol. 2006 Dec.;187(6):1412–9.

24. Palmer WE. Femoroacetabular impingement: caution is warranted in making imaging-based assumptions and diagnoses. Radiology. 2010 Oct.;257(1):4–7.

25. Wright AA, Hegedus EJ. Augmented home exercise program for a 37-year-old female with a clinical presentation of femoroacetabular impingement. Manual Therapy. 2011 Nov. 10;:1–6.

26. Voos JE, Mauro CS, Kelly BT. Femoroacetabular Impingement in the Athlete: Compensatory Injury Patterns. YOTOR. 2010 Dec. 1;20(4):231–6.

27. Emara K, Samir W, Motasem EH, Ghafar KAE. Conservative treatment for mild femoroacetabular impingement. J Orthop Surg (Hong Kong). 2011 Apr.;19(1):41–5.

28. Hossain M, Andrew JG. Current management of femoro-acetabular impingement. Current Orthopaedics. 2008 Aug.;22(4):300–10.

29. Pollard TCB. A perspective on femoroacetabular impingement. Skeletal Radiol. 2011 Mar. 15;40(7):815–8.

30. Papalia R, Del Buono A, Franceschi F, Marinozzi A, Maffulli N, Denaro V. Femoroacetabular impingement syndrome management: arthroscopy or open surgery? International Orthopaedics (SICOT). 2011 Dec. 22; DOI 10.1007/s00264-011-1443-z

References

31. Gedouin J-E, May O, Bonin N, Nogier A, Boyer T, Sadri H, et al. Assessment of arthroscopic management of femoroacetabular impingement. A prospective multicenter study. Orthopaedics & Traumatology: Surgery & Research. 2010 Dec.;96(8):S59–S67.

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