Tag: femoroacetabular impingement

Performance Training: Adaptations for Femoroacetabular Impingement (FAI)

A few weeks back I briefly mentioned that I’ve been working with a lacrosse player with femoroacetabular impingement (FAI). I’ve written quite a bit about FAI in the past, and the posts seem to attract a lot of attention, probably because so many athletes (and especially hockey players) suffer from related symptoms and haven’t had much success in traditional rehabilitation approaches. If you’re new to FAI, I’d highly encourage you to quickly breeze through these previous posts, which discuss a bit about what FAI is, how prevalent it is among hockey player and general populations, and what can be done to train around it:

I’ve received several emails requesting to see the video that I posted at Hockey Strength and Conditioning of the lacrosse player with severe FAI, so I decided to throw it on youtube and wanted to share it with you today. Check it out below:

Training Around Femoroacetabular Impingement

This video is of a Division I lacrosse player I’ve worked with over the last several months at Endeavor. He has undergone 4 separate operations (2 on each side) to address his FAI and associated labral damage, and a bilateral athletic pubalgia (sports hernia) repair. He also has significant retroversion, bilaterally, meaning he has plenty of external rotation, but extremely limited internal rotation in both hips. When he first came in, he wasn’t able to jog (let alone sprint), shuffle, or do anything high impact or explosive. In fact, I would say he was generally cautious about movement in general. He’s now in his 6th month of training and can sprint, transition, and move explosively as well as ever. We were able to start moving him toward these types of exercises about 4-6 weeks into the training process. Each week, for the last month, he’s told me that he feels better than ever. I wanted to post this video to demonstrate how important it is to recognize each athlete’s individual limitations. Can you imagine if this athlete was told to squat to full depth, deadlift off the floor, do high box jumps, etc.?

I recognize this athlete’s case is a bit extreme, but the overwhelming majority of the hockey players we work with will be somewhere between this athlete and what is taught as normal. In other words, most players will have some sort of structural deviation that will need to be appreciated in your assessment of their movement quality and exercise technique. In this example, we spent a lot of time early on going through how he would need to move to to stay within his individual confines, but still accomplish what he needs to on the field. After grooving and improving these patterns for several weeks, he now does them without conscious thought, which is the ultimate goal if he’s to be successful.

A few things to look for in the video:

When he sets up in a quadruped position, his lumbar spine is already in a state of slight flexion secondary to hitting hip flexion end range. Attempting to drive further into hip flexion results in a SIGNIFICANT spinal compensation.
He can only squat to about 45-50 degrees of hip flexion beefore his lumbar spine begins to flex.
His hip only flexes about 45-50 degrees during the wall drill, which will have implications for how he runs.
He is still able to sprint, but he must maintain a more upright posture and de-emphasize his knee drive more than would typically be recommended.
He has almost no hip internal rotation on either side. The left appears to be slightly better, but this is because his pelvis is not neutral. When I measured this with a goniometer when he first started, he was under 20 degrees on each side.
Not having internal rotation will have significant implications for rotational movements, which are of paramount importance in most team-based sports (especially ones like lacrosse and hockey). Notice how, when he steps behind during the med ball exercise, he maintains a slight position of external rotation and how he opens up instead of rotating OVER the front leg like most athletes would. Both of these patterns were intentional, and ones that took time to groove.

Another important take home from this video is that this athlete is post surgical and STILL presents with significant range of motion limitations. This is certainly no challenge to the proficiency of the surgeon. In fact, this particular surgeon is regarded as one of the best in the world for this type of work. I’ve worked with several athletes that have had FAI-related surgeries from this surgeon, and some present with “normal” range of motion, and others still have restrictions. It’s likely a result of the complications of the individual case and the risk-reward associated with more invasive or destructive options.

Nonetheless, it’s important for the athlete to understand that getting surgery doesn’t mean you’re going to come out “normal”. It’s likely you will still have significant restrictions that you’ll need to accommodate in your movement lexicon. Also, it’s possible that the FAI is the RESULT of an underlying issue that will still need to be addressed. In other words, in these cases FAI can be thought of as a symptom that provokes other symptoms, none of which are likely to fully subside until the elephant in the room is poached. In some cases, this may mean attacking diaphragm position to restore a more optimal zone of apposition (something I’ll discuss more in the future); in other cases it may require using specific exercises to help restore a more neutral position and orientation of the pelvis; and in others it may simply require strategic soft-tissue work and help restore balance in stiffness across the hips and allow for balanced movement. In most cases, however, a combination of these techniques is warranted.

If you’re interested in more information about FAI, check out the webinar and recent interview I did at Sports Rehab Expert.

To your success,

Kevin Neeld

P.S. Don’t forget to sign up for Sports Rehab Expert’s 2012 Sports Rehab to Sports Performance Teleseminar! It’s 100% free and features some of the top minds in sports rehab and performance training.

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An Updated Look at Femoroacetabular Impingement (FAI)

Over the weekend I posted a video at HockeyStrengthandConditioning.com of a former (and hopefully future) division 1 lacrosse player that I’ve worked with over the last few months at Endeavor Sports Performance. What makes this player unique is that he’s undergone 4 hip surgeries (2 on each side) secondary to femoroacetabular impingement (FAI) and bilateral sports hernia surgery. The video alludes to the importance of recognizing individual limitations and teaching the athlete how to move within his or her own confines.

Working with this athlete also highlights the importance of understanding these so-called abnormalities. When he first came to Endeavor, light jogging wasn’t even an option. In other words, his range of motion was so poor, damage so significant, and overall comfort level with athletic movements so degraded that we really had to start slow. A few months later, he’s sprinting, cutting, and jumping explosively and without pain; he’ll be the first to tell you that he’s never felt better. My ability to effectively work with athletes like this stems directly from the amount of time I’ve spent studying the relevant research. I think this information is valuable for anyone that trains anyone, but if you work with hockey players, it’s absolutely essential. The amount of research in this area has exploded over the last decade; understanding the causes and implications of FAI will help you more effectively train players that present with these injuries (which is most) and help to prevent unnecessary complications.

Illustrating “normal” hip joint anatomy and FAI abnormalities

Below is a brief review of some of the current literature:

High prevalence of pelvic and hip magnetic resonance imaging findings in asymptomatic collegiate and professional hockey players

MRI findings from 21 professional and 18 NCAA D1 players; all were asymptomatic
14 (39%) dysfunction of adductor-rectus abdominis insertions
25 (64%) hip pathologic changes
30 (77%) have MRI finding of hip or groin pathologic abnormalities

The prevalence of cam-type femoroacetabular deformity in asymptomatic adults

Retrospective analysis of CT scans from 419 randomly selected patients from 2004-2009 that were taken for problems unrelated to the hip
Of the 215 male hips (108 patients) analyzed, a total of 30 hips (13.95%) were defined as pathological, 32 (14.88%) as borderline and 153 (71.16%) as normal.
Of the 540 female hips (272 patients) analyzed, 30 hips (5.56%) defined as pathological, 33 (6.11%) as borderline and 477 (88.33%) as normal.
This highlights the prevalence of these injuries in asymptomatic individuals, especially men. This means that, in the general population, roughly 1 in every 3-4 men that you train will have an underlying hip abnormality. The prevalence of these findings in hockey players is drastically higher (see above).

Prevalence of cam-type femoroacetabular impingement morphology in asymptomatic volunteers

200 asymptomatic individuals (111 females, 89 males; average age 29.4 years) had an MRI taken of their hips.
14% of the volunteers had at least one hip with CAM impingement
10.5% had CAM on either the right or the left side; 3.5% had CAM in both hips
22 of 28 individuals (79%) who had CAM were men; only 6 (21%) were women.
22 of 89 (24.7%) men had CAM impingement, compared with only 6 (5.4%) of 111 women.

Hip flexor muscle fatigue in patients with symptomatic femoroacetabular impingement

Comparison of hip flexor strength during submaximal isometric and repeated maximal dynamic contractions in those with and without FAI.
FAI participants exhibited significant hip flexor weakness compared to the controls
No changes were noted in fatigue indices between the two groups
Authors noted that those with FAI tend to have adductor and hip flexor weakness. It’s easy to look at these weaknesses and point to them as potential causes of FAI secondary to poor femoral head control. That said, it’s also worth noting that the bony overgrowth limits hip adduction and hip flexion and may cause weakness secondary to neurological inhibition, especially as bony end-range is approached.

Can we predict the natural course of femoroacetabular impingement?

Because FAI is so strongly associated with future osteoarthritis, these authors sought to determine whether age of total hip arthroplasty was related to certain radiographic findings and/or activities.
Given the complex and dynamic nature of these injuries, it’s not surprising that they weren’t able to find a relationship through their methods. That said, I think they hit the nail on the head with their conclusion: “Hence, considering the high prevalence of FAI-related radiographic findings, we conclude that not every radiographic abnormality requires treatment.”
This highlights the importance of not taking every positive radiographic finding and shipping the player off to the surgical table!

Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: a case series

Analyzed 37 hips (average age: 25 years) with BOTH a sports hernia and FAI. Patients were athletes competing at the pro (8), college (15) elite high school (5) and competitive club (9) levels.
Evaluation occurred at an average of 29 months post surgery (wide range of 12-78 months though)
Of 16 hips that had athletic pubalgia (sports hernia) surgery as the index procedure, 4 (25%) returned to sports without limitations, and 11 (69%) subsequently had hip arthroscopy at a mean of 20 months after pubalgia surgery.
Of 8 hips managed initially with hip arthroscopy alone, 4 (50%) returned to sports without limitations, and 3 (43%) had subsequent pubalgia surgery at a mean of 6 months after hip arthroscopy.
Thirteen hips had athletic pubalgia surgery and hip arthroscopy at one setting. Concurrent or eventual surgical treatment of both disorders led to improved postoperative outcomes scores (P < .05) and an unrestricted return to sporting activity in 89% of hips (24 of 27).
While it’s impossible to make any accurate inferences, I’d be interested to see how these numbers may differ if the athletes were in sport programs with medical professionals that truly understood the implications of the abnormalities and could teach the players how to move within their limits.

In my experience, most players do very well when they understand the limitations in their joint anatomy and are taught how to move within these confines. Because the primary suggested mechanism underlying athletic pubalgia involves a tug of war across the pubic symphysis between the adductors and abdominals AND because those with FAI tend to have very dense/fibrotic adductors, many players will benefit from some soft-tissue work in this region, especially in the area of the proximal adductor magnus attachment. Also, because posterior capsule density can push the femoral head forward in the joint and put excess stress on the anterior/superior labrum, this is another area worth having a manual therapist look at. The manual method itself is less important than the proficiency of the therapist. It can be tough to find someone that is comfortable working in that area, but it is well worth the trouble when you do!

To your success,

Kevin Neeld

P.S. If you’re interested in learning more about hockey hip injuries and associated assessments and corrective strategies, I highly encourage you to check out my presentation “Hockey Hip Assessments: An In-Depth Look at Structural Abnormalities and Common Hip Injuries”, which is now available at Hockey Strength and Conditioning

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This Week in Hockey Strength and Conditioning

This week I posted two new articles related to understanding, assessing for, and training around hip injuries or structural abnormalities that a significant proportion of the hockey population suffers from. My friend Dr. Jeff Cubos wrote a follow-up to Monday’s article for his site. All three have received a ton of great feedback so if you haven’t had a chance to read through them, check them out at the links below:

1) Training Around Femoroacetabular Impingement

2) Hockey Hip Assessment Questions

3) So Your Athlete Has FAI, Now What?

Jeff also added an awesome video series to Hockey Strength and Conditioning. His videos detail a progression to help reinforce single-leg stability and really ingrain requisite dynamic internal rotation control. As I recently mentioned, players that have poor single-leg stability tend to ride their inside edge during the gliding phase of skating. Even if they don’t exhibit this fault, they surely waste power and suffer from a compromised ability to give and withstand contact. This exercise would fit into a program as part of a dynamic warm-up, extra hip mobility/stability work, and/or core training. Check it out at the link below:

Click here to watch >> The Hip Airplane from Dr. Jeff Cubos

Sean Skahan also added a couple videos of sled/sprint contrast work he uses for a phase of the off-season program. Theoretically, contrast work should help maximize recruitment of movement-specific motor units and therefore provide a bigger engine for the secondary exercise that follows the “primer”. Sean’s videos demonstrate one way to apply this concept in a linear movement and lateral movement format, but he alludes to a couple other ways that he uses these during this phase of his program.

Click here to watch >> Sled and Sprint Contrast from Sean Skahan

If you have any questions about these articles or the videos, hop on the Hockey Strength and Conditioning forum and ask. That’s the quickest way to reach me and I know Sean, Darryl, Mike, Jeff Cubos and a couple other really bright guys are pretty active on them as well.

As always, if you aren’t a member yet, I encourage you to try out Hockey Strength and Conditioning for a week. It’ll only cost $1, and if it’s not the best buck you’ve ever spent, I’ll personally refund you!

To your continued success,

Kevin Neeld

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Training Around Femoroacetabular Impingement

As I mentioned on Friday, I gave a webinar last week called “Hockey Hip Assessments: An in-depth look at structural abnormalities and common hip injuries.” Over the last couple years, I’ve become known as a “hip guy”. In reality, I’m not sure how I could train high level hockey players without being a hip guy. Almost half of our players this off-season presented with a hip structure considered “abnormal”, and I think it’s fair to say that every single one of them is flirting with the overuse/under-recovery threshold of their adductor and hip flexor musculature. And these are all “healthy” players. Knowing how to spot individual structure differences and program/coach accordingly is of paramount importance in my setting.

One structural abnormality that is gaining momentum with regards to research attention is femoroacetabular impingement or FAI. I’ve trained several players that have FAI, a couple of which were unaware of their affliction. A 2007 study by Philippon et al. demonstrated that 100% of the 45 professional athletes (24 hockey players) that came to their office with FAI had labral tears. Unfortunately, there is a strong association between labral damage and subsequent osteoarthritis. Recognizing FAI early can help minimize labral damage and the rapidity of osteoarthritis onset, which has the potential to facilitate both short- and long-term performance improvements for the player.

FAI Basics
FAI results in a limitation of hip flexion to around 90 degrees and presents in one of three ways:

CAM impingement: A decrease in the offset between the femoral head and the femoral neck. Hip flexion is limited by the bony overgrowth butting up against the top of the acetabulum.
Pincer impingement: An overextension or growth of the acetabular hood. The femoral neck contacts the overgrowth at a lower degree of hip flexion.
Mixed impingement: A combination of the CAM and pincer structural deviations.

FAI Assessment
Because the common denominator in all forms of FAI is a limitation in hip flexion ROM, you can use a basic quadruped rock to get an idea of whether the athlete has a limitation or not.

Quadruped Rock

Just have the athlete set-up on all fours with their knees under their hips, hands under their shoulders, and spine in a neutral position. Have them push their hips toward their heels while attempting to maintain a neutral spine and note the position of hip flexion that causes a “tucking” of the hips and rounding of the lumbar spine. Ask the athlete where they feel the restriction. If they feel it more in the front/middle part of their hip (“groin” area), it’s more likely a bony limitation than a soft-tissue one. Athletes with FAI will tap out around 90 degrees of hip flexion and feel it primarily in the anteromedial border of their hip.

You can follow up this test by having the athlete lie on their back and take the “suspicious hip” into flexion, adduction, and internal rotation. A significant limitation and/or pain with this movement supports the thought that the athlete has some sort of FAI.

Training Approach
If I suspect an athlete has FAI, we’ll make some very basic adaptations to their training program. Underlying everything we do with these athletes is Mike Boyle’s profoundly simple idea of “if it hurts, don’t do it.” In these cases, I think the athlete’s success has as much to do with what they don’t do, as it does with what they do.

Teach the athlete to perform EVERY movement without flexing the hip past 90 degrees
This is by far the greatest service we can offer these athletes. Every time a player jams through their end range, they put excessive stress on their labrum, and likely cause compensatory problems at neighboring joints. Coaching hockey players with this problem to skate lower or squat deeper will invariably worsen their symptoms and expedite the degeneration process. Range of motion is very individual specific, and these athletes need to be taught how to move within their own structural limitations. This can lead us to making some simple exercise modifications like having the athlete performing 1/2 kneeling exercises with their back knee on a 12″ box to minimize hip flexion of the front leg, and program modifications such as not allowing the athlete to do any lifts off the floor (e.g. deadlifts, trap bar deadlifts, Olympic lifts, etc.).

Favor Single-Leg Exercises
This isn’t a huge change for us because we already place a premium on single-leg training, but it offers the additional advantage for players with FAI of providing more degrees of freedom should the athlete “accidentally” approach hip flexion end range. With bilateral exercises, end range hip flexion is coupled with lumbar flexion, which is an undesirable position for a heavily loaded exercise. In contrast, unilateral exercises allow the hip to tilt in the frontal plane AND usually necessitate lighter external loads, sparing the spine from unnecessary additional stresses associated with compensatory movement.

Augmented Emphasis on Medial Soft-Tissue Work, and Lateral Hip and Posterior Chain Strength/Control Work
Players with FAI tend to have very dense and stiff adductors. Paying extra attention to soft-tissue work to the high adductors, especially where the posterior adductor magnus merges with the medial hamstrings, can help bring some relief to the constant tension these players feel. In theory, the adductors may become overly dense because they adopt a role of tonic stabilizers, functioning to compress the hip joint in an effort to gain stability. Lateral hip work in the form of miniband walks and single-leg exercises can help improve the strength and function of the smaller, dynamic stabilizers of the hip and remove some of this burden from the adductors. Lastly, these players tend to present with an anterior pelvic tilt and poor posterior chain strength. Shifting a greater proportion of their lower body training toward a poster chain emphasis can help restore balance in passive and active strength across the hips.

This is just the tip of the iceberg when it comes to assessing for and training around common hip structural abnormalities. I went into a lot more detail into our assessment and training system in my presentation, which is now available at two of the best strength and conditioning and injury prevention sites out there. If you’re not already a member, I highly recommend you check out Strength and Conditioning Webinars and Sports Rehab Expert.

To your success,

Kevin Neeld

P.S. Both of these sites offer trials for $1. If you’re on the fence, shell out the two bucks and test drive them both to see which may be more appropriate for your needs! Strength and Conditioning Webinars, Sports Rehab Expert

References:

Philippon, M., et al. (2007). Femoroacetabular impingement in 45 professional athletes: associated pathologies and return to sport following arthroscopic decompression. Knee Surg Sports Traumatol Arthrosc. 1597, 908-914.

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