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Diagnosis and
Management of
Femoroacetabular
Impingement

An Evidence-Based Approach

Olufemi R. Ayeni
Jón Karlsson
Marc J. Philippon
Marc R. Safran
Editors

123
Diagnosis and Management of
Femoroacetabular Impingement
Olufemi R. Ayeni • Jón Karlsson
Marc J. Philippon • Marc R. Safran
Editors

Diagnosis and
Management of
Femoroacetabular
Impingement
An Evidence-Based Approach
Editors
Olufemi R. Ayeni Marc J. Philippon
Division of Orthopaedic Surgery Orthopaedic Surgeon
McMaster University Steadman Clinic and Steadman
Hamilton, Ontario Philippon Research Institute
Canada Vail, Colorado
USA
Jón Karlsson
Departement of Orthopaedics Marc R. Safran
Sahlgrenska University Hospital Dept. of Orthopaedic Surgery
Sahlgrenska Academy Stanford University
Gothenburg University Redwood City, California
Gothenburg USA
Sweden

ISBN 978-3-319-31998-8 ISBN 978-3-319-32000-7 (eBook)

DOI 10.1007/978-3-319-32000-7

Library of Congress Control Number: 2016947959

© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG Switzerland
Preface

Using Evidence to Power Surgical Decision-Making:

It Is the Right Time!

Evidence-based orthopedics (EBO) is part of a broader movement known as

evidence-based medicine, a term first coined at McMaster University in 1990
for applicants to the internal medicine residency training program. Clinicians
at McMaster described EBM as “an attitude of enlightened skepticism”
toward the application of diagnostic, therapeutic, and prognostic technolo-
gies. While orthopedic surgeons were generally slow to adopt this new
approach, the last 5 years have experienced an increasing popularity of the
language and practice of EBO.
Evidence-based orthopedics does not accept the traditional “eminence-
based” paradigm as being sufficiently adequate to address clinical problems,
especially when considering the large quantity of valuable information avail-
able to surgeons to help them in their problem-solving process. Today, lesser
emphasis is placed on the surgeon’s own professional authority. The new
EBO approach posits that surgeons’ experiences, beliefs, and observations
alone are not enough to make satisfactory decisions with respect to patient
care. Evidence-based orthopedics promotes the need to evaluate the evidence
available in the surgical literature from published research and integrate it
into clinical practice. Practicing EBO requires, in turn, a clear delineation of
relevant surgical questions, a thorough search of the literature relating to the
questions, a critical appraisal of available evidence, its applicability to the
surgical situation, and a balanced application of the conclusions to the prob-
lem at hand. The balanced application of the evidence (i.e., the surgical
decision-making) is the central point of practicing evidence-based orthope-
dics and involves, according to EBO principles, integration of our surgical
expertise and judgment with patients’ values (or preferences) with the best
available research evidence.
The paradigm of EBO is particularly important in the uptake of surgical
procedures in the cycle of innovation. Orthopedics is a breeding ground for
innovation often led by surgical pioneers and early adopters. The challenge,
however, to broad adoption of novel techniques in surgery is sufficient evi-
dence of patient safety and compelling data for treatment efficacy. A recent
systematic review evaluating sources and quality of literature available for
hip arthroscopy indicated that although there has been a fivefold increase in

v
vi Preface

publications related to hip arthroscopic procedures from 2005 to 2010, lower-

quality research studies (Level IV and Level V studies) accounted for more
than half of the available literature with no randomized control studies identi-
fied [1].
How do surgeons evaluate novel techniques purported to improve out-
comes in femoroacetabular impingement in a time when good evidence
always trumps surgeon “eminence”? Practicing EBO is not easy. Surgeons
must know how to frame a clinical question to facilitate use of the literature
in its resolution. Typically, a question should include the population, the
intervention, and relevant outcome measures. Evidence-based practitioners
must know how to search the literature efficiently to obtain the best available
evidence bearing on their question, evaluate the strength of the methods of
the studies they find, extract the clinical message, apply it back to the patient,
and store it for retrieval when faced with similar patients in the future.
Because becoming a regular EBM practitioner comes at the cost of time,
effort, and other priorities, surgeons can also seek information from sources
that explicitly use EBM approaches to select and present evidence. Given the
paucity of clinical trials, surgeons aiming to understand the evidence must
resort to time-consuming searches of the medical literature to collate current
best observational studies.
Ayeni, Karlsson, Philippon, and Safran in this evidence-based approach to
femoroacetabular impingement provide a highly efficient solution to the sur-
gical community. Using the tenets of EBO, they bring together a wonderfully
talented group of authors and researchers to collate the world’s knowledge on
this rapidly changing specialty area in orthopedic surgery. To the busy sur-
geon, this text is one critical must-have resource. While modern approaches
to EBO are sometimes perceived as a blinkered adherence to only random-
ized trials, it more accurately involves informed and effective use of all types
of evidence to inform patient care. The approaches and evidence in this text,
despite a lack of randomized trial evidence, still represent the state of the art
in the field. What we learn most from this important work is an ever-present
need for a shift from traditional opinion-based textbooks to ones which
involve question formulation, validity assessment of available studies, and
appropriate application of research evidence to individual patients.

Mohit Bhandari, MD, PhD, FRCSC

Evidence-Based Orthopaedics
McMaster University
Hamilton, ON, Canada

Reference
1. Ayeni OR, Chan K, Al-Asiri J, et al. Sources and quality of literature addressing femo-
roacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):415–9.
Contents

1 Historical Background of the Treatment

of Femoroacetabular Impingement . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Edwin R. Cadet
2 Differential Diagnosis of Hip Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Filippo Randelli, Fabrizio Pace, Daniela Maglione,
Paolo Capitani, Marco Sampietro, and Sara Favilla
3 Clinical Diagnosis of FAI: An Evidence-Based Approach
to History and Physical Examination of the Hip . . . . . . . . . . . . . . 27
Aparna Viswanath and Vikas Khanduja
4 Evidence for the Utility of Imaging of FAI . . . . . . . . . . . . . . . . . . . 39
Danny Arora and Daniel Burke Whelan
5 Pathophysiology of Femoroacetabular Impingement (FAI) . . . . . 51
Gavin C.A. Wood, Hamad Alshahrani, and Michel Taylor
6 Evidence-Based Approach to the Nonoperative
Management of FAI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Nolan S. Horner, Austin E. MacDonald, Michael Catapano,
Darren de SA, Olufemi R. Ayeni, and Ryan Williams
7 Physiology of the Developing Hip and Pathogenesis
of Femoroacetabular Impingement . . . . . . . . . . . . . . . . . . . . . . . . . 79
Páll Sigurgeir Jónasson, Olufemi R. Ayeni, Jón Karlsson,
Mikael Sansone, and Adad Baranto
8 Surgical Management of CAM-Type FAI:
A Technique Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Darren de SA, Matti Seppänen, Austin E. MacDonald,
and Olufemi R. Ayeni
9 Arthroscopic Management of Pincer-Type Impingement . . . . . . 103
James B. Cowan, Christopher M. Larson, and Asheesh Bedi
10 Open Management of CAM Deformities in FAI . . . . . . . . . . . . . 115
Colleen A. Weeks and Douglas D.R. Naudie
11 Open Surgical Management of Pincer Lesions in FAI . . . . . . . . 127
Etienne L. Belzile

vii
viii Contents

12 Treatment of Labral Tears in FAI Surgery . . . . . . . . . . . . . . . . . . 153

Marc J. Philippon and Karen K. Briggs
13 Reconstructive Techniques in FAI Surgery . . . . . . . . . . . . . . . . . 163
Marc J. Philippon and Karen K. Briggs
14 The Evidence for the Treatment of Cartilage
Injuries in FAI Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Mats Brittberg and Marc Tey
15 Management of Extra-articular Hip Conditions
in Patients with Concurrent FAI . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Nolan S. Horner, Uffe Jorgensen, Darren de SA,
and Olufemi R. Ayeni
16 The Evidence for Rehabilitation After Femoroacetabular
Impingement (FAI) Surgery: A Guide to Postsurgical
Rehabilitation and Supporting Evidence . . . . . . . . . . . . . . . . . . . 201
Darryl Yardley
17 Complications of FAI Surgery: A Highlight of Common
Complications in Published Literature . . . . . . . . . . . . . . . . . . . . . 229
Cécile Batailler, Elliot Sappey-Marinier, and Nicolas Bonin
18 Revision FAI Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
James T. Beckmann and Marc R. Safran
19 Future Directions of FAI Surgery: Diagnosis and Treatment . . . 255
Michael J. Salata and W. Kelton Vasileff
20 Future Directions in Training FAI Surgeons . . . . . . . . . . . . . . . . 269
Justin W. Arner, Raymond Pahk, Vonda Wright,
Craig Mauro, and Volker Musahl
 Historical Background of the
Treatment of Femoroacetabular 1
Impingement

Edwin R. Cadet

Contents 1.1 Historical Background

1.1 Historical Background 1
Early degenerative hip disease has often been
References 3
noted in patients with abnormal acetabular mor-
phology usually secondary to developmental
dysplasia of the hip (DDH), and it has been
hypothesized to be the consequence of abnormal
edge loading on the anterosuperior acetabular
cartilage from an eccentrically centered femoral
head. However, the role femur morphology
played in the development of degenerative hip
disease was not as defined. In 1936, Smith-
Petersen classically described a concept of
impingement in which hip pain was theorized to
be caused the femoral neck impinged against
anterior acetabular margin [1]. Surgical correc-
tion, by way of impingement correction, was suc-
cessful in his small case series. Decades later,
Murray et al. described a tilt deformity of the
proximal femur and its association with the
development of osteoarthritis of the hip [2]. In
1986, Harris described his theory on how
derangements in femoral anatomy development
caused primary or “idiopathic osteoarthrosis of
the hip” in the non-dysplastic hip [3]. Harris
wrote that based on his numerous radiographic
observations, the convex, “pistol grip” femoral
deformity at the femoral head-neck junction fol-
lowing the sequelae of a recognized or unde-
E.R. Cadet, MD
tected slipped capital femoral epiphysis (SCFE),
Raleigh Orthopaedic Clinic, 3001 Edwards Mill Road,
Raleigh, NC 27608, USA Legg-Calve-Perthes disease, or the congenital
e-mail: [email protected] epiphyseal dysplasia was a common pathway for
© Springer International Publishing Switzerland 2017 1
O.R. Ayeni et al. (eds.), Diagnosis and Management of Femoroacetabular Impingement,
DOI 10.1007/978-3-319-32000-7_1
2 E.R. Cadet

development of the so-called “idiopathic” degen- non-dysplastic hip [11]. The authors suggested
erative hip disease. Although Harris reported of that the mechanism of articular cartilage and
the association of abnormal femoral head-neck labral damage and degradation in these hips was
deformity and osteoarthritis, he did not elaborate that of aberrant hip motion rather than isolated,
on the underlying mechanisms that such defor- abnormal eccentric axial loading of the anterosu-
mity can result in the development of primary perior acetabulum that was hypothesized to occur
degenerative hip disease. in hip dysplasia. The authors arrived at their
In this early report, Harris also implied that hypothesis based on the observations seen of
the acetabular labrum may play an important role labral injury and cartilage wear patterns in over
in the development of primary osteoarthritis. 600 surgical dislocations performed for patients
Harris described what he termed the “intra- with hip pain without dysplasia. The authors pro-
acetabular” labrum. He viewed the labrum as an posed three mechanisms of femoroacetabular
extra-articular structure, and any presence of impingement: (1) CAM impingement, (2) pincer
labrum within the intra-articular space should be impingement, or (3) a combination of both. CAM
considered abnormal and represented an “inter- impingement resulted from decreased clearance
nal derangement” of the hip, analogous to a torn of the acetabulum from a convex, femoral head-
glenoid labrum in the shoulder or meniscus in the neck junction, particularly during flexion. The
knee [3, 4]. Such observations were early sugges- “abutment,” as the authors described it, between
tions that acetabular labral pathology could play the diminished femoral head-neck offset and ace-
a part in the development of primary degenera- tabulum is thought to cause shear injury to the
tive hip disease. adjacent cartilage and labro-chondral junction,
Subsequently to the assertions made by Harris, thus leaving the bulk of the labrum undisturbed.
McCarthy et al. reported that chondral injury was Pincer impingement was described to originate
noted in 73 % of 436 consecutive hip arthrosco- from the acetabular side, where general (coxa
pies where labral fraying or tears were present, profunda) or regional acetabular retroversion
thus suggesting the role of labral pathology in the may cause direct, crushing injury to the labrum
development of degenerative hip disease in a with a normal femoral head-neck surface. The
patient population. These findings were further continuous labral injury could cause intra-labral
supported in the authors’ cadaveric examination substance degeneration or labral ossification.
of 52 acetabula in the same report [5, 6]. Moreover, the premature impact on the femoral
Subsequently, basic science studies further dem- head-neck junction could cause chondral injury
onstrated that the labrum was found to be a criti- to the posteroinferior acetabulum secondary to
cal structure in hip joint preservation by abnormal shear stresses from the excessive pre-
maintaining a “fluid seal” that prevents the efflux mature levering, which the authors termed the
of synovial fluid from the central compartment, “contrecoup” lesion. Finally, there can be a com-
thus maintaining hydrostatic pressure to lower bination of both, which we now know occurs
contact stresses between the femoral and acetab- most commonly in clinical practice. The authors
ular cartilage surfaces [7–9]. found that pincer impingement was more com-
The interplay between the femoroacetabular monly seen in middle-aged women, and CAM
anatomy, labral and chondral injury, and the impingement was more often observed in young,
development of degenerative hip disease in the athletic male populations.
non-dysplastic hip was best narrated in the work Moreover, the authors outlined the principles
done by Ganz et al. and Lavigne et al. [11, 12]. In for successful surgical management of femoroac-
2003, Ganz and colleagues outlined the biome- etabular impingement: (1) establishing a safe and
chanical rationale on how the disease they coined reproducible approach to the hip joint that would
“femoroacetabular impingement” can cause respect and protect the femoral head vascularity
labral and articular cartilage degradation in the and viability, (2) improving femoral head clear-
1 Historical Background of the Treatment of Femoroacetabular Impingement 3

ance by reestablishing normal femoral neck and

acetabular anatomy via femoral and/or acetabular 3. Harris WH. Etiology of osteoarthritis of
osteoplasty, and (3) addressing labral and chondral the hip. Clin Orthop Relat Res. 1986;
injury with repair or debridement. To accomplish 213:20–33.
these principles, Ganz et al. in a previous report 4. Ferguson SJ, et al. The acetabular
described an anterior surgical hip dislocation tech- labrum seal: a poroelastic finite element
nique via a posterior approach by using a “tro- model. Clin Biomech (Bristol, Avon).
chanteric flip” osteotomy that would preserve the 2000;15(6):463–8.
medial femoral circumflex arteries [13]. 5. Ganz R, et al. Femoroacetabular
Over the last decade, the surgical management impingement: a cause for osteoarthritis
of femoroacetabular impingement has evolved of the hip. Clin Orthop Relat Res. 2003;
from open surgical dislocations to more minimally 417:112–20.
invasive techniques such as mini-open exposures
and arthroscopic techniques. The importance of
labral preservation and restoration has also been
stressed as critical factor for successful manage- References
ment of femoroacetabular impingement [10, 14–
18]. Although open surgical dislocation has 1. Smith-Petersen MN. Treatment of malum coxaeseni-
lis, old slipped upper capital femoral epiphysis, intra-
yielded good to excellent results [19], the advent pelvic protrusion of the acetabulum, and coxae plana
of advanced arthroscopic instruments designed to by means of acetabuloplasty. J Bone Joint Surg Am.
accommodate the complex anatomy of the hip has 1936;18:869–80.
contributed to equal, and in some cases surpassed, 2. Murray RO. The aetiology of primary osteoarthritis of
the hip. Br J Radiol. 1965;38(455):810–2.
clinical outcomes historically reported with open 3. Harris WH. Etiology of osteoarthritis of the hip. Clin
techniques [20–22] with less morbidity, thus Orthop Relat Res. 1986;213:20–33.
increasingly becoming the “gold standard” for the 4. Harris WH, Bourne RB, Oh I. Intra-articular acetabu-
management of femoroacetabular impingement. lar labrum: a possible etiological factor in certain
cases of osteoarthritis of the hip. J Bone Joint Surg
With this historical description laying the founda- Am. 1979;61(4):510–4.
tion of diagnosis and treatment, the next chapters 5. McCarthy JC, Noble PC, Schuck MR, Wright J, Lee
will introduce contemporary approaches to J. The Otto E. Aufranc Award: the role of labral
addressing FAI. Evidence-based approaches for lesions to development of early degenerative hip dis-
ease. Clin Orthop Relat Res. 2001;393:25–37.
the comprehensive management for FAI and asso- 6. McCarthy JC, Noble PC, Schuck MR, Wright J, Lee
ciated disorders will be focused upon highlighting J. The watershed labral lesion: its relationship to early
the best strategies, opportunities, and challenges arthritis of the hip. J Arthroplasty. 2001;16(8 Suppl
of current practice. 1):81–7.
7. Ferguson SJ, Bryant JT, Ganz R, Ito K. The influence
of the acetabular labrum on hip joint cartilage consoli-
dation: a poroelastic finite element model. J Biomech.
2000;33(8):953–60.
Key Evidence Related Sources
8. Ferguson SJ, Bryant JT, Ganz R, Ito K. The acetabular
1. Smith-Petersen MN. Treatment of labrum seal: a poroelastic finite element model. Clin
malum coxaesenilis, old slipped upper Biomech (Bristol, Avon). 2000;15(6):463–8.
capital femoral epiphysis, intrapelvic 9. Ferguson SJ, Bryant JT, Ganz R, Ito K. An in vitro
investigation of the acetabular labral seal in hip joint
protrusion of the acetabulum, and coxae mechanics. J Biomech. 2003;36(2):171–8.
plana by means of acetabuloplasty. 10. Cadet ER, Chan AK, Vorys GC, Gardner T, Yin B.
J Bone Joint Surg Am. 1936;18:869–80. Investigation of the preservation of the fluid seal
2. Murray RO. The aetiology of primary effect in the repaired, partially resected, and recon-
structed acetabular labrum in a cadaveric hip model.
osteoarthritis of the hip. Br J Radiol. Am J Sports Med. 2012;40(10):2218–23.
1965;38(455):810–2. 11. Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H,
Siebenrock KA. Femoroacetabular impingement: a
4 E.R. Cadet

cause for osteoarthritis of the hip. Clin Orthop Relat of femoroacetabular impingement in professional
Res. 2003;417:112–20. hockey players. Am J Sports Med. 2010;38(1):
12. Lavigne M, Parvizi J, Beck M, Siebenrock KA, Ganz 99–104.
R, Leunig M. Anterior femoroacetabular impinge- 18. Sierra RJ, Trousdale RT. Labral reconstruction using
ment: part I. Techniques of joint preserving surgery. the ligamentum teres capitis: report of a new tech-
Clin Orthop Relat Res. 2004;418:61–6. nique. Clin Orthop Relat Res. 2009;467(3):753–9.
13. Ganz R, Gill TJ, Gautier E, Ganz K, Krügel N, 19. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D,
Berlemann U. Surgical dislocation of the adult hip a Ganz R. Anterior femoroacetabular impingement:
technique with full access to the femoral head and part II. Midterm results of surgical treatment. Clin
acetabulum without the risk of avascular necrosis. Orthop Relat Res. 2004;418:67–73.
J Bone Joint Surg Br. 2001;83(8):1119–24. 20. Bedi A, Chen N, Robertson W, Kelly BT. The manage-
14. Larson CM, Giveans MR. Arthroscopic debridement ment of labral tears and femoroacetabular impingement
versus refixation of the acetabular labrum associated of the hip in the young, active patient. Arthroscopy.
with femoroacetabular impingement. Arthroscopy. 2008;24(10):1135–45.
2009;25(4):369–76. 21. Philippon MJ, Briggs KK, Yen YM, Kuppersmith
15. Philippon MJ, Briggs KK, Hay CJ, Kuppersmith DA, DA. Outcomes following hip arthroscopy for femoro-
Dewing CB, Huang MJ. Arthroscopic labral recon- acetabular impingement with associated chondro-
struction in the hip using iliotibial band autograft: labral dysfunction: minimum two-year follow-up.
technique and early outcomes. Arthroscopy. 2010; J Bone Joint Surg Br. 2009;91(1):16–23.
26(6):750–6. 22. Philippon MJ, Stubbs AJ, Schenker ML, Maxwell
16. Murphy KP, Ross AE, Javernick MA, Lehman RA Jr. RB, Ganz R, Leunig M. Arthroscopic management of
Repair of the adult acetabular labrum. Arthroscopy. femoroacetabular impingement: osteoplasty tech-
2006;22(5):567.e1–3. nique and literature review. Am J Sports Med. 2007;
17. Philippon MJ, Weiss DR, Kuppersmith DA, Briggs 35(9):1571–80.
KK, Hay CJ. Arthroscopic labral repair and treatment
 Differential Diagnosis of Hip Pain
2
Filippo Randelli, Fabrizio Pace, Daniela Maglione,
Paolo Capitani, Marco Sampietro, and Sara Favilla

Contents 2.1 Introduction

2.1 Introduction 5
Since the introduction of femoroacetabular
2.2 Intra-articular Pathologies 6
2.2.1 Ligamentum Teres Tears 6
impingement (FAI) [1–3] and new diagnostic
2.2.2 Pigmented Villonodular Synovitis 6 tools, such as intra-articular injections and more
advanced magnetic resonance imaging (MRI)
2.3 Extra-articular Pathologies 7
2.3.1 Bone Marrow Edema Syndromes 7 [4–6], a number of previously unexplained causes
2.3.2 Osteonecrosis 8 of hip pain have been revealed.
2.3.3 Greater Trochanteric Pain Syndrome/ Nevertheless a comprehensive diagnosis of
Trochanteric Bursitis 8
hip pain is not always easy to obtain for a vari-
2.3.4 Snapping Hip Syndrome 9
2.3.5 Ischiofemoral Impingement 10 ety of reasons. First, radiographic signs of FAI
are found in a high percentage of the asymptom-
2.4 Hip Mimickers 11
2.4.1 Osteitis Pubis 11 atic population [7, 8]. Consequently, radio-
2.4.2 Sports Hernia 12 graphic signs of FAI alone should not be
2.4.3 Piriformis Muscle Syndrome 13 considered as the only cause of pain around the
2.4.4 Meralgia Paresthetica 14 hip. Second, a variety of possible associated
2.4.5 Obturator Neuropathy 15
2.4.6 Osteoid Osteoma 16 pathologies may be found in patients with hip
2.4.7 Cruralgia/Leg Pain 16 pain. Sometimes these associated pathologies
2.4.8 Buttock Claudication 17 represent the real cause of hip pain, and FAI is
References 19 secondary or not related to the hip pain. That is
why a careful history, a thorough clinical evalu-
ation, and knowledge of the other possible clini-
cal entities should be considered. This chapter
A description of other conditions that may present like or will provide an overview of the more frequent
with FAI
and/or insidious causes of hip pain (Table 2.1)
F. Randelli (*) • F. Pace • D. Maglione • P. Capitani that may be confused or associated with FAI.
M. Sampietro • S. Favilla Pathologies have been divided in the classi-
Hip Department and Trauma, I.R.C.C.S. Policlinico
cal three major groups: intra-articular patholo-
San Donato, Piazza Malan 1, San Donato Milanese,
Milan 20097, Italy gies, extra-articular pathologies and hip
e-mail: [email protected] mimickers.

© Springer International Publishing Switzerland 2017 5

O.R. Ayeni et al. (eds.), Diagnosis and Management of Femoroacetabular Impingement,
DOI 10.1007/978-3-319-32000-7_2
6 F. Randelli et al.

Table 2.1 Differential diagnosis of hip pain

Intra-articular Extra-articular Hip mimickers
Femoroacetabular impingement Greater trochanteric pain syndrome Adductor-rectus abdominis tears
Isolated labral tears External snapping hip Osteitis pubis
Loose bodies Internal snapping hip Sports hernia
Chondral damage Bursitis Obturator neuropathy
Ligamentum teres tears Osteoid osteoma Piriformis syndrome
Capsular laxity Bone marrow edema syndrome Meralgia paresthetica (Roth)
Developmental dysplasia of the hip Avascular necrosis of the femoral head Spine-derived cruralgia
Slipped capital femoral epiphysis Stress fractures SI joint disease
Post Perthes disease Bone and soft-tissue neoplasms Buttock claudication
Septic arthritis Ischiofemoral impingement
Inflammatory arthritis and synovitis

2.2 Intra-articular Pathologies then passively internally and externally rotated to

available end range of motion; the test is positive
Different intra-articular pathologies may be asso- when there is reproduction of pain either upon
ciated or mistaken for FAI. The most important internal or external rotation [14].
are ligamentum teres tears and inflammatory Imaging rarely identifies ligamentum teres
synovitis as synovial chondromatosis and pig- injuries and a preoperative diagnosis varies from
mented villonodular synovitis (PVNS). 1 to 5 % [15]. MRI and MRA (magnetic reso-
nance arthrography) appear to be accurate
diagnostic tools [16, 17], while arthroscopy
2.2.1 Ligamentum Teres Tears remains the gold standard in identifying these
lesions.
2.2.1.1 Introduction
Lesions of the ligamentum teres have been 2.2.1.3 Treatment
increasingly recognized as a source of pain. Byrd In case of failure of conservative treatment such
reported them as the third most common diagno- as physiotherapy, arthroscopic debridement [18]
sis in athletes undergoing hip arthroscopy [9]. A is indicated in patients with pain caused by
complete lesion is usually associated with trau- partial-thickness lesions, while reconstruction
matic dislocation but may be also seen in high- with autografts [19], allografts, or synthetic
impact athletes [10, 11]. grafts may be indicated in patients with full-
thickness lesions that cause instability or in
2.2.1.2 Diagnosis which debridement was not effective in reducing
Clinical diagnosis can be difficult. Symptoms are symptoms [11].
nonspecific during clinical evaluation, character-
ized by a reduced or painful range of motion, a
painful straight leg raise test, and locking of the 2.2.2 Pigmented Villonodular
joint [12]. O’Donnell et al. [13] have proposed a Synovitis
diagnostic test for ligamentum teres tears with a
sensitivity and specificity of 90 % and 85 %, 2.2.2.1 Introduction
respectively. The clinician passively flexes the Pigmented villonodular synovitis (PVNS) is a
hip fully and then extends 30°, leaving the hip at rare proliferative disorder of the synovium.
about 70° flexion (knee is flexed 90°); the hip is Eventhough PVNS is a benign disease, it may be
then abducted fully and then adducted 30°, typi- aggressive in certain cases. PVNS may also occur
cally leaving it at about 30° abduction; the leg is in a localized or more diffused form.
2 Differential Diagnosis of Hip Pain 7

2.2.2.2 Diagnosis The main differential diagnosis is avascular

Patients typically present with mild to severe necrosis of the femoral head (AVN), and it is still
pain and impaired joint function. Recurrent hem- controversial, whether BMES represents a dis-
arthrosis is typical. The concurrent presence of tinct self-limiting disease or merely reflects a
FAI can mistakenly lead to a diagnosis of a sec- subtype of AVN [25].
ondary synovial reaction instead of Etiology remains unclear in most patients, but
PVNS. Diagnosis is suspected through MRI and appears to be multifactorial and related to
confirmed by histology. increased intraosseous pressure with increased
bone turnover, a diminished perfusion, and sub-
2.2.2.3 Treatment sequent hypoxia producing pain [27].
Treatment is often surgical, either via open or
arthroscopic synovectomy, or, in more severe 2.3.1.2 Diagnosis
cases, a total hip arthroplasty (THA) is indicated TOH mainly affects male patients who are 30–50
once significant degenerative changes are pres- years old and women in the third trimester of
ent. Treatment with radiation and intra-articular pregnancy, without history of trauma. The main
injections of radioisotope are indicated in incom- symptoms are severe hip pain with weight bear-
plete synovectomy or recurrences. Treatment of ing and functional disability. Radiographs may
hip PVNS presents a high rate of failure. Hip show diffuse osteoporosis in the hip after several
arthroscopy has been shown to be effective but weeks from the onset of hip pain. In addition,
with a recurrence rate of 12 % and a conversion MRI shows bone marrow edema in the femoral
rate to THA ranging from 8 to 46 %. A high rate head, sometimes involving the femoral neck.
(31 %) of aseptic loosening in THA after PVNS MRI is also useful in differentiating between
has been also reported. An open transtrochanteric BME, FAI, and greater trochanteric pain syn-
approach has been recently suggested with some drome (GTPS) that may present as localized
success [20–24]. bone marrow edema but with different edema
patterns [28].
A bone scan may differentiate BME from
2.3 Extra-articular Pathologies AVN at its initial stage where a “cold in hot”
image is seen. A “cold” zone of decreased tracer
These disorders affect structures surrounding the uptake (the necrotic zone) is surrounded by a
joint or the bone itself. It is not rare to find them half-moon-shaped area of increased uptake (cres-
in association with FAI. cent) [29].
Regional migratory osteoporosis presents a
similar clinical course but is characterized by a
2.3.1 Bone Marrow Edema polyarticular involvement.
Syndromes RSD, also called algodystrophy, complex
regional pain syndrome (CRPS), or Sudeck’s
2.3.1.1 Introduction dystrophy, is characterized by a history of trauma
The term bone marrow edema syndrome (BMES) and presents three phases: acute, dystrophy, and
refers to several different clinical conditions. atrophy. Symptoms are dull and burning pain
They are usually self-limiting (may take up to 24 with a rapid onset and subsequently skin atrophy,
months) and they are best seen on MRI [25]. sensorimotor alteration, and joint contractures.
Different clinical entities have been reported, Osteoporosis is early visible radiographically
such as transient osteoporosis of the hip (TOH), [29].
transient marrow edema, regional migratory
osteoporosis (RMO), and reflex sympathetic dys- 2.3.1.3 Treatment
trophy (RSD) also known as complex regional The recommended treatment is often nonsurgi-
pain syndrome (CRPS) [25, 26]. cal, with protected weight bearing and analge-
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