FAI, and the importance of listening to the person in front of you

FAI: Femo-acetabular impingement. Describes “subtle deformities in hip shape that cause impingement between the femoral neck and anterior rim of the acetabulum during the normal range of hip functional movement” (Fernandez et.al, 2014). Increasingly common in young adults between the ages of 21-50. 

I recently had a client contact me for some training. I worked with her for a while last year, and after selling her house and dealing with some personal things, she took up swimming. This isn’t uncommon; people that are motivated to exercise on their own come and go, using me as a way to get new ideas and work on their perceived weaknesses for spurts of time. We had kept in touch, and her e-mail suggested she was having some hip issues in addition to wanting to build strength. When we met, it quickly became apparent the hip issues were posing a bigger problem than she had initially led on. Her right leg hurt to extend, kicking was bothering her during swimming, and walking aggravated it. She had done some physical therapy, and the therapist had speculated the pain was coming from issues in her back. He prescribed her some extension exercises based on the Mackenzie technique, one of which she liked, the other was causing her some discomfort. I checked her position ala PRI and watched her move. She had a difficult time dissociating her hip from her back during squatting type activities, moving into a butt wink every time she squatted and demonstrated a strong bias towards internal rotation on her right leg. I observed what provoked pain (from working together in the past, she knows that is never my goal. I support open communication with my clients and all of them know if something hurts to tell me. I will revise the program and file the information away for later). After watching primal hip flexion on the right side occur in a jerky, uncoordinated manner, it occurred to me I hadn’t checked for pinching during flexion, adduction, and internal rotation. (She mentioned the physical therapist did a full hip work-up on her, checking for several different things, so I just assumed all hip issues had been ruled out). I quickly placed her supine on the massage table to find a very positive pincer test on the right side. 

Femoral acetabular impingement seems to be one of the latest “buzz” terms in the fitness and rehabilitation industry. As noted above, the term actually refers to deformities in the hip shape. Not all individuals with these deformities display symptoms, and of the three types that exist, cam impingement is most commonly seen in young men while the pincer type is more common in middle aged women. Interestingly, hip shape abnormality appears to be higher in asymptomatic athletes than the general population (Fernandez, et.al). The trouble, of course, occurs when secondary joint damage occurs because of the abnormality, frequently leading to surgical intervention (Byrd, 2014). Now, what leads an asymptomatic abnormality to become symptomatic is for the professionals to debate, not a lowly personal trainer that just counts reps. However, I will speculate that the lack of movement diversity due to year round, one sport play and the fact that high school athletes spend the rest of the time sitting probably isn’t help anything in the hip region.

My client’s anterior impingement test of flexion, adduction, and internal rotation tested positive on the side she was having pain. A positive test indicates hip pathology, not necessarily FAI, though it can be indicative of that as well. She had been cleared for exercise by the physical therapist and by her husband, a pain doctor specializing in backs. I decided to see if I could improve the objective measures of the test by improving her motor control, increasing activation in her external hip rotators, and improving coordination during primal hip flexion. By the end of our first session, the pinching was greatly reduced; by the end of the third session, the pinching was gone. She sent me a text 4 days later, declaring, “those exercises are magic. I do them twice a day. Thank you.” (I gave her a tall kneeling to low kneeling movement, focusing on hingeing from the hips, not the back, using the glutes to move the thigh bone forward and a side lying hip activation movement, 4-6 repetitions. We discussed motor control, and I worked with her on moving her leg from a stable pelvis). So why did this work? I didn’t “change” the structure of her hip joint or suddenly “fix” her impingement. I simply focused on improving overall hip activation and taught her how to flex from her hip rather than her back. During follow up sessions, we moved into strengthening the glute area using more traditional moves like deadlifts with kettle bells and cables, squat patterns, and lunge patterns, paying attention to pelvis and low back position, as well as using supported lunge positions to continue emphasizing femur position in relation to the pelvis. She is pain free and back to the activities she enjoys. This is really similar to people with shoulder impingement issues that don’t understand how to use their scapulae to reach. I have had remarkable improvements in clients’ levels of discomfort in their shoulders, simply by teaching them alternative reaching strategies and strengthening the back of the shoulder girdle. Improving motor control and a proper conditioning program need to go hand in hand to keep people moving in a pain free way,

Yours in health and wellness, 
Jenn

Fernandez, M., Wall, P., O’Donnell, J., & Griffin, D., (2014). Hip pain in young adults. Australian Family Physician, 43(4), 205-209.
Byrd, J.W., (2014). Femoroacetabular impingement in athletes: current concepts. American Journal of Sports Medicine, 42(3), 737-751.