Pain with Femeroacetabular Impingement

I’m an Emergency Doc. I had a young patient recently who came in during army basic training. He had some mild to moderate hip pain for a couple weeks. He came in that day because he stepped in a hole during a road march and had sudden increase in pain. He could bear weight, but preferred to use crutches due to severe pain when doing so. Pain was mostly along the lateral aspect of the hip during palpation and pain with basically any range of motion with active or passive ROM beyond a few degrees. My biggest concern was for a stress fracture. X-ray of hip showed femeroacetabular impingement cam type without acute fracture. I know still a chance for stress fracture, so he was directed to followup on base for further imaging. The question I have is regarding how you would frame this diagnosis (or similar one) for the patient?

​​​​​The reading I’ve done on the condition isn’t super deep, but looks like an increased chance of early degenerative changes with some experiencing painful/limited range of motion. Some require surgical intervention. I informed him of the above. I also let him know that his pain that day and from previous weeks may or may not be due to the condition, but that it was likely due to a soft tissue injury and should heal given some rest. He needed to know about the condition because it needs to be monitored and he is currently having pain likely due to other factors. But that day he is hearing he has anatomically abnormal hips and he is having severe pain in one of those hips. My concern is that despite my attempts to communicate that he should recover from this pain event this diagnosis found during a time with an injury could be a background for him to have bad expectations.

Knowing how the folks work at our nearby base, thanks to their many frequent inappropriate referrals with patients in a catastrophic mind set, I think he is going to be doomed to hear only worse things about his diagnosis. I don’t know how I could have done things much differently. Any suggestions for future similar encounters?

@Derek_Miles

If the symptoms are more lateral related FAI would not really be on my radar from a differential perspective. While CAM did show up on imaging there is a high base rate of that with a higher predisposition in males. The anecdotal sign that typically leads more towards some type of impingement diagnosis is the “C-sign” popularized by Byrd’s group. It is generally accepted that impingement type diagnoses are more related to anterior hip pain. The problem with diagnosis of what I will call “lateral hip symptoms” is that the special tests (FADIR and FABER) suck and don’t really tell you much. If he is a few weeks out and still using an assistive device step one is transitioning him to at least WBAT and working on weaning from those.

I typically try and frame this through incidental findings. When I have athletes (military recruit meets this criteria by my definition) come in with an “impingement” diagnosis I try and take the heat of of it by explaining just how common it is. Almost 80% of hockey players present with an alpha angle that would classify as CAM type impingement Prevalence of femoroacetabular impingement morphology in asymptomatic youth soccer players: magnetic resonance imaging study with clinical correlation - PMC. 95% of collegiate football players looked at in one cohort exhibited either cam or pincer Radiographic prevalence of femoroacetabular impingement in collegiate football players: AAOS Exhibit Selection - PubMed. I would have framed it through “this likely just means you’re an athlete. Athletes by definition are able to do things that normal people cannot so it should be no surprised there are differences in their bodies. This finding did not magically appear when you stepped in the hole and likely we would see the same on the other side. It is what makes you, you. Stepping in a hole and having lateral hip pain can be a normal experience. If you cut your hand 4 weeks ago you would still have a scab there but you would still use your hand. Just because you can’t see the scab in your hip does not mean it is not healing and it will not heal. But just like with your hand, you need to move it in order to get it healing right. This doesn’t need to be huge movements but we need to start somewhere and right now that somewhere is likely just trying to get you to bear some weight through that extremity.”

1 Like

Thanks. Much appreciate the insight!