What is hip impingement syndrome?
Hip impingement syndrome – also called femoroacetabuar impingement (FAI) – is a pain syndrome of the hip, frequently diagnosed in dancers. FAI is primarily a functional problem, although it can lead to structural lesions inside the hip – such as labrum or cartilage lesions – over time. FAI arises from impaired joint kinetics, based upon pelvic dysfunction and impaired muscle function (muscle dysfunction) of the hip, thigh and trunk musculature. Often, its underlying causes are not identified properly, whereby the therapeutic approach does not target the appropriate goal. Bone abnormalities on the femoral neck or the acetabulum are often considered the cause of FAI. However, it is important to understand that such anatomical variations are often found in dancers’ hips and that they do not necessarily have to cause problems, unless they are really severe. Muscle dysfunction and decompensated muscle dysbalance are the cause of altered joint kinetics of the hip, which can lead to an impingement. Anatomical variations such as boney “bumps” on the femoral neck may be important contributing factors, although they are often not the true underlying cause of the impingement.
How can it occur?
When the hip is flexed, adducted and internally rotated, the space between the acetabulum (hip socket) and the femoral neck will automatically narrow. Anything that causes further narrowing has the tendency to impinge the labrum (a ridge of cartilage, lining the rim of the hip joint socket) and joint capsule, as well as causing an inflammation or damage of these soft tissues.
FAI is based upon impaired joint kinetics, caused by pelvic dysfunction and muscle dysfunction of the hip musculature. Muscle overuse often occurs when the body fails to compensate for existing muscle dysbalance. Muscle dysbalances are very common and naturally occur as the body adapts to specific training demands over time. As long as compensation is effective – or, in other words, as long as the dysbalance is well managed by the body – this need not cause any problems. However, with high training loads, insufficient rest or after a minor injury, the body may struggle to compensate, leading to muscle dysfunction in the various muscle groups involved in the compensation. This is why symptoms may simultaneously occur in different parts of the body in an overuse situation. Muscle dysfunction can appear as muscle tightness (contraction) or weakness (inhibition). In either case, the muscles affected will not work at their normal power and they will be unable to fulfill their physiological functions properly.
Dancers with limited turnout of the hip are especially at risk of developing a hip impingement. They often try to increase their turnout by rotating the pelvis forward on the affected side as a laxation of the anterior hip capsule permits increased external rotation of the hip. This malalignment leads to a number of problems and demands extraordinary muscular compensation. If this compensation fails, muscle dysfunction will subsequently arise. The psoas muscle is probably the most important muscle affected. Psoas dysfunction leads to tightness of the rectus femoris muscle (a part of the quadriceps) and deactivation of the piriformis (one of the smaller pelvic muscles inserting on the sacrum). This causes pelvic torsion and functional leg length discrepancy, as well as high pressure inside the hip joint.
What are the typical symptoms of hip impingement syndrome?
The typical symptoms of hip impingement syndrome are pain and stiffness. The pain associated with it is typically felt in the groin or front of the hip. If muscle dysfunction of the external thigh muscles is present, you may also feel pain on the side of the hip. Buttock pain is usually caused by an si-joint block, which is often associated with a hip impingement syndrome. Pain will occur particularly after intense training and may remain for an extended period of time. It usually improves with a reduction in activity. Stiffness occurs especially after rest, although it will improve when you become active again. You will probably find that your pain will vary and that you have good days and bad days, sometimes depending on how active you have been, but sometimes for no clear reason.
How can hip impingement syndrome be diagnosed?
Your doctor will examine your hip and review your symptoms as well as your current training activities. Correct diagnosis of this issue demands a thorough functional clinical examination, including specific tests to identify joint and muscle dysfunction. Finding out the exact causes of hip impingement syndrome is often challenging and your doctor may ask a specialist in manual medicine for his opinion.
X-rays may be ordered to find out about bony bumps or spurs (osteophytes) due to degenerative changes or anatomical abnormality. They can also reveal an ongoing osteoarthritis of the hip. However, X-rays are not a good indicator of how much pain or disability you have. Some people have significant pain from minor joint deformation while others only feel little pain from severe damage. Your doctor may also suggest having an MRI scan of your hip, which will show the soft tissues – especially the cartilage and the labrum – and changes inside the bone (e.g. stress reactions) that cannot be seen on standard X-rays.
This MRI scan shows a hip with a deformation of the femoral head (marked “bony bump”) and a degenerated acetabular labrum. Functional problems as described in the text cannot be identified in an MRI scan. They demand a specific clinical examination of the pelvis.
What are the treatment options?
If you have severe or constant hip pain, you should take a break from your ballet training immediately. Ignoring the pain can have serious consequences, as the situation will become increasingly complicated the longer you train with pain.
The RICE concept (rest, ice, compression and elevation) is an easy guideline that can be used to initially treat acute as well as overuse injuries.Please read my “First Aid” post to obtain some background information that you will need to adapt this concept successfully and learn about the use of painkillers.
Correction of present hip and pelvis dysfunction stands at the beginning of treating hip impingement. However, in order to handle this overuse issue successfully, its underlying causes – namely muscle dysfunction and muscle dysbalance – have to be addressed specifically in the rehabilitation process. Muscle dysfunction can appear as muscle tightness (contraction) or weakness (inhibition) and the muscles affected have to be treated accordingly. Some muscles will have to be stretched whereas others will rather have to be strengthened. A well-suited training program including corrective exercises as well as a general strengthening and endurance routine is the most effective way to deal with most overuse situations.
Manual medicine and especially deep myofascial release treatment is recommended to address present joint and myofascial dysfunction. Restriction of the fascia plays a key role in hip impingement syndrome and can be addressed effectively with manual medicine. Ensure that you follow your specific training routine after the rehabilitation is finished. Myofascial rollers (Blackroll, Triggerpoint Roll, etc.) as well as Lacrosse balls and resistance bands are easy to use in the studio and will help you remain balanced in the long run.
Surgery may be recommended if you have severe pain or mobility problems and non-operative treatment has failed to improve the situation or if a severe labrum or cartilage lesion has been diagnosed. There are different surgical methods to address femoroacetabuar impingement. Your doctor and orthopedic surgeon should help you choose the best option for you, taking into account the condition of your hip and your general health. Arthroscopic surgery seems to have surgical outcomes equal to or even better than other methods, with a lower rate of major complications when performed by experienced surgeons.
Do you have a hip problem and want to have it sorted out? These are the next steps:
- See a doctor
Dancers seek help from various different kinds of therapists, many of whom may employ treatments that are outside of mainstream medicine. Before considering the use of such alternative medicine, you should see a doctor for an evaluation and diagnosis.
Finding a doctor who is familiar with the specific medical issues faced by dancers is often challenging and you may need to see several different specialists in order to get a full picture of your diagnosis. A good place to start is to ask your friends and fellow dancers for the names of their favorite doctors.
- Find a specialist in manual medicine
Doctors who specialize in manual medicine practice a whole-body approach. They will try to identify and specifically treat the underlying causes of your problem, rather than just the localized symptoms. This approach is important in addressing all aspects of the often very complex overuse problems that dancers experience. A specialist in manual medicine will perform a functional examination on every part of your body and will treat you according to these thorough findings.
To find a physician who specializes in this field, search for “Manual Medicine”, “Osteopathic Manipulative Medicine” or “Osteopathic Physician” on the internet.
- Start working on your problem
There is a lot that you can do to work on your problem after a proper diagnosis has been set. Ultimately, it often comes down to addressing the same fundamental issues. Here are some useful exercises that I recommend to my patients:
Please refer to your doctor to confirm that the exercises you choose to do are suited to your individual problem, and obtain supervision from a professional trainer to ensure that you are performing them correctly.
- Talk to your ballet master or dance teacher
Technical issues and faulty dance technique are important predisposing factors of overuse and injury in dancers. Amending dance techniques often plays a crucial role in the treatment and prevention of overuse and injury and you should not hesitate to address any issues, if necessary.