Femoroacetabular Impingement inPediatric Patients

Evan D. Sheppard, MD,* Connor R. Read, MD,† Brad W. Wills, MD,* A. Reed Estes, MD*

*Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL†Department of Orthopaedic Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN

Practice Gaps

1. To appropriately diagnose and care for patients with femoroacetabular

impingement (FAI), clinicians should be able to identify the signs and

symptoms of FAI, understand the pathoanatomy behind this condition,

be able to order the appropriate radiologic evaluation, and provide

appropriate management.

2. Clinicians should be aware of when to refer patients to a specialist for

further care.

Objectives After completing this article, readers should be able to:

1. Understand the epidemiology and causative factors associated with

femoroacetabular impingement (FAI).

2. Identify the major anatomical factors that contribute to FAI.

3. Recognize clinical signs and symptoms of FAI.

4. Become proficient with basic physical examination of a patient with

FAI.

5. Recognize classic radiographic findings of FAI.

6. Appropriately manage first-time presentation of FAI.

7. Have a general understanding of surgical options.

8. Know when to refer patients with FAI to a specialist for further care.

Abstract

Subacute, nontraumatic hip pain is often a diagnostic challenge.

Femoroacetabular impingement (FAI) is a common cause of atraumatic

hip pain that is poorly understood. FAI is a result of abnormalmorphologic

changes in either the femoral head or the acetabulum. FAI is more

prevalent in people who perform activities requiring repetitive hip flexion,

but it remains common in the general population. Evaluation begins with

physical examination maneuvers to rule out additional hip pathology and

AUTHOR DISCLOSURE Drs Sheppard, Read,Wills, and Estes have disclosed no financialrelationships relevant to this article. Thiscommentary does not contain a discussion ofan unapproved/investigative use of acommercial product/device.

ABBREVIATIONS

AP anteroposterior

FAI femoroacetabular impingement

LCP Legg-Calve-Perthes disease

MRI magnetic resonance imaging

SCFE slipped capital femoral epiphysis

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provocation tests to reproduce hip pain. Diagnosis is often made by

radiography or magnetic resonance imaging. Initial treatment is generally

more conservative, featuring activity modification and physical therapy,

whereas more aggressive treatment requires operative management.

INTRODUCTION

Patients with subacute, nontraumatic hip pain can represent

a diagnostic challenge for the general pediatrician. The

classic differential diagnosis includes Legg-Calve-Perthes

disease (LCP), subacute slipped capital femoral epiphysis

(SCFE), snapping hip syndrome, and iliotibial band ten-

donitis, among other entities. In the past 20 years, an en-

tity known as femoroacetabular impingement (FAI) has

become widely recognized as a common hip condition.

FAI is a condition that results in morphologic changes to

the head of the femur or rim of the acetabulum, generating

pain and limiting range of motion. It is estimated that FAI is

prevalent in more than 30% of the population. (1) Although

less common in the pediatric population, certain pediatric

conditions (ie, LCP, SCFE) predispose patients to the devel-

opment of FAI. It has also been linked to the potential for

idiopathic osteoarthritis in adulthood. (2) Since its recogni-

tion, there have been a growing number of diagnostic

studies, radiographicmeasurements, and treatment options

available. Appropriate referral to a specialist is important,

but without adequate understanding of the pathoanatomy,

physical examination findings, and radiographic evaluation

results, primary care pediatricians risk either overreferring

or underreferring children with this condition.

PATHOPHYSIOLOGY

FAI occurs as a result of abnormal morphologic changes

in either the acetabulum or the head of the femur. These

changes are classified into 3 categories: CAM lesions, pincer

lesions, or mixed lesions. CAM deformities are changes in

the femoral head and neck that cause the femoral head to

lose its normally spherical shape (Fig 1A) and become

shaped more like a rod or camshaft (Fig 1B). This causes

the femoral head to contact the acetabulum during normal

activities, particularly during flexion (Fig 1C). CAM lesions

can be caused by a proximal physeal arrest (growth arrest at

proximal femur growth plate), native femoral retroversion

(rotation of the proximal femur), or a combination of the

two. Relative femoral retroversion can lead to reduced

internal rotation of the hip. CAM deformities can lead to

anterosuperior labral injury. (3)

Pincer lesions relate to the prominence of the acetabular

rim (Fig 1D). The result is that the acetabulum excessively

covers the femoral head, mechanically blocking range of

motion (Fig 1E). Essentially, it is an overreaching of the

acetabular rim over the femoral head. Pincer lesions com-

monly place the labrum and, to a lesser degree, the cartilage

at risk. In addition, pincer lesions increase the risk for

contrecoup injury, an injury whereby the acetabulum acts

as a fulcrum for the femur, producing posteroinferior sub-

luxation, which may lead to damage of the posteroinferior

and posteromedial chondral surfaces. (2) Pincer lesions are

generally less common than CAM deformities.

FAI may also present as a mixed CAM-pincer lesion, also

called a combination lesion. This type of lesion has features

of both CAM deformity and pincer lesions. Patients with a

history of proximal femur pathology, such as SCFE injuries,

femoral neck fractures, and LCP, have been observed to have

CAM lesions. (4) At a mean of 6.1 years of follow-up after

fixation, approximately one-third of patients with SCFE

injuries had positive impingement signs on physical exam-

ination, and 70% had evidence of FAI radiographically. (5)

There was no correlation between the severity of the slip and

FAI development. (5) LCP remains a risk factor for FAI

development but is less common compared with SCFE.

Collectively, these conditions predispose patients to hip

impingement secondary to alterations in morphology of

the femoral head and neck. Both SCFE and LCP provide

explanations for FAI in the skeletally immature, however,

Figure 1. A. Normal hip anatomy. B. CAM deformity. C. Engagement ofthe CAM lesion. D. Pincer acetabular lesion. E. Pincer lesion impingingon the femoral neck.

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other mechanisms have been proposed for FAI occurring in

adolescents without a history of SCFE or LCP. FAI has been

observed in adolescents who are athletes or participate in

activities demanding repetitive hip flexion. One study fol-

lowed skeletal maturation over 2 years in adolescent male

soccer players (n ¼ 63; mean age, 14 years). The authors

found significant radiographic changes that correlated with

the development of FAI. (6)

EPIDEMIOLOGY

FAI is a unique and often overlooked cause of hip pathology.

Recently defined in the past 20 years, numerous studies

have sought to fully describe this condition. Three studies

have shown FAI to be more prevalent in males and that

males were also more likely to have a more severe deformity

compared with females. (7)(8)(9) In addition, FAI has a

higher prevalence in young athletes. (8) CAM deformities

have been found to be more common than pincer lesions.

(7)(8) Multiple studies have shown that patients with more

severe deformities are more likely to have an increased

symptom burden, increased risk of hip dislocation, greater

need for bilateral treatment, and higher prevalence of

chondral pathology. (5)(6)(7)(9)(10)(11)(12)(13)

The prevalence of FAI in athletes has been shown to be

greater than that in the general population. The risk is

particularly higher in sports requiring repetitive hip flexion

(ie, football, basketball, soccer). One meta-analysis found

that high-level male athletes (ie, collegiate and professional)

were 1.9 to 8 times more likely to develop FAI than were

their male nonathlete counterparts. (13)(14) A review of the

literature found that 95% of collegiate football players have

at least 1 radiographic sign of FAI. (5) The prevalence of FAI

in high-level basketball players was found to be as high as

89%. (13)

In general, FAI most commonly is found as a CAM

deformity or a mixed CAM-pincer deformity and is more

commonly seen in the pediatric and young adult population

compared with middle-aged and older adults. It is more

likely to affect males and individuals who are more fre-

quently involved in activities involving repeated hip flexion.

Injuries or developmental conditions resulting in trauma

(eg, femoral neck fracture, SCFE) may also lead to the

development of FAI.

TYPICAL PRESENTATION

FAI typically presents as deep anterior groin pain or antero-

lateral hip pain. Several authors describe the C sign dem-

onstrated by young patients during the description of hip

pain, where the cupping of the hand above the greater

trochanter makes a C (Fig 2). (3)(14) Less commonly,

patients describe lower lumbar back pain or posterior pelvic

pain. Pain may also radiate to the anterior thigh and distally

to the knee. The C sign has not been associated with groin

injury or hernia pain. FAI pain is strongly associated with

activities requiring repetitive hip flexion or rotation (eg,

soccer, football, track) but may also be insidious in onset

depending on the etiology. Similarly, pain may be present

during times of prolonged hip flexion, such as lengthy car

rides. Patients may experience popping, locking, or catching

during physical activity.

PHYSICAL EXAMINATION

The physical examination for FAI is highly focused on

ruling out other hip pathology, as there may be multiple

causes of pain around the hip region. As always, it is

important to compare with the contralateral extremity.

Initial assessment of gait may show signs of possible

muscular imbalance. After gait assessment, it is important

to palpate the thigh for tenderness, which may be attributed

to a muscular origin of pain, or tenderness over the greater

trochanter secondary to trochanteric bursitis. Next, hip

range of motion is tested, and attention should be directed

at whichmotions elicit pain. Internal rotation in a flexed hip

may be limited with the presence of a CAM deformity. (15)

Strength testing follows range of motion to better assess

possible muscle imbalances. It is prudent to also evaluate

the spine and knee as possible sources of pain.

Figure 2. C sign commonly demonstrated coinciding with hip pain infemoroacetabular impingement.

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There are several commonly used provocative tests for

the hip; however, the best for FAI is the impingement test

(Fig 3). (16) During this examination maneuver, the hip is

flexed to 90° and then is adducted and internally rotated.

This will commonly evoke pain in a patient with FAI. Hip

extension with external rotation may also be used to check

for posterior impingement. Painwith either of thesemaneu-

vers would indicate the need for further evaluation with

imaging.

The Stinchfield test (Fig 4) is another examination that

can further narrow down the diagnosis of hip pain. The

patient actively flexes the leg to 30° to 45° while lying supine,

and the examiner resists further flexion while applying

pressure to the thigh just proximal to the knee. This is

believed to load the anterosuperior labrum, reproducing

groin pain. This test may also be positive, however, with hip

flexor pathology.

Much of the physical examination is aimed at determin-

ing whether the pain is coming from an intra-articular

source (as in FAI) or an extra-articular source. If the physical

examination does not narrow down the source of pain, in a

patient with a presentation otherwise consistent with FAI,

an image-guided (ultrasonographic or fluoroscopic) intra-

articular hip injection may be used to isolate the pain to an

intra-articular cause. (17)(18)–(19) If the patient’s symptoms

are relieved by the injection, an intra-articular pathology is

identified and further evaluation can commence to identify

the pathology.

IMAGING

The initial imaging ordered for a patient with concern for

FAI, or any other hip pathology, includes an anteroposterior

(AP) pelvis and a frog-leg lateral of the hips. It is always

important to compare imaging of both hips, although

patients may present with bilateral disease. Figure 5 shows

a normal, skeletally mature hip. When reviewing hip radio-

graphs it is important to understand the normal anatomy. A

good AP pelvis has the coccyx centered over the pubic

symphysis and approximately 2 cm above it. Line A repre-

sents the acetabular roof, and line B represents the anterior

wall of the acetabulum. Structure E is the radiographic

teardrop, which is not a true anatomical landmark; however,

if it is abnormal it can represent pathology of the acetabu-

lum. Note the congruity and sphericity of the femoral heads.

F represents normal joint space, and a decrease in this

distance signifies cartilage loss.

CAM-type lesions will demonstrate a pistol grip defor-

mity, where the proximal femur has a decreased offset and

aspherical femoral head (Fig 6A). (20) Alpha angle is used to

measure a CAM lesion. It is measured off the frog-leg lateral

view by drawing a line between the center of the femoral

head and the center of the femoral neck (Fig 6B). (21)

Figure 3. Physical examination technique for impingement. A. The hip isflexed to 90o. B. The hip is then internally rotated. C. The hip is thenadducted while flexed and internally rotated.

Figure 4. Stinchfield test. The patient actively flexes the leg to 30° to 45°while lying supine, and the examiner resists further flexion whileapplying pressure to the thigh just proximal to the knee.

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Another line is drawn from the femoral head center to the

area on the femoral neck where sphericity is lost. This point

can be found by placing a circle around the femoral head and

identifying themost proximal portion that lies outside of the

circle. The angle between these 2 lines is then calculated. A

normal value is less than 42°. (22)

Pincer deformity will demonstrate excessive overhang of

the acetabulum (Fig 7), or acetabular protrusion, and ret-

roversion of the acetabulum that will result in impinge-

ment. Typically, pincer deformity is identified from the AP

pelvis from excessive coverage of the acetabulum, typically

the anterosuperior acetabulum, or from identification of

a crossover sign. The crossover sign is an indication of

acetabular retroversion and is noted when radiographic

lines of the anterior and posterior walls converge and cross

before meeting at the most lateral portion of the acetabu-

lum. (23) Other signs of acetabular retroversion include a

prominent ischial spine where any portion of the ischial

spine is found inside the pelvic brim on AP radiographs.

(24)

Most surgeons use magnetic resonance imaging (MRI)

with an arthrogram or computed tomographic scan for

surgical planning to further evaluate the extent of the

deformity and other associated hip pathology. The surgeon

will review the coronal, sagittal, and axial views of the hip

looking for chondral damage and labral pathology. If the

primary care physician feels confident in the diagnosis

and the patient is requesting surgical management, it

is prudent to obtain an MRI to expedite the patient’s

management.

TREATMENT

Nonoperative ManagementAs with most musculoskeletal complaints, nonoperative man-

agement is often first-line treatment in mild FAI. Although

there are few high-quality studies on nonoperative manage-

ment for this condition, those that exist argue favorably for

this treatment route. In Emara et al’s cohort of 37 adult

patients with FAI and a mild deformity treated nonsurgically

with activity modification, 89% of patients had significant

improvement at 2-year follow-up. (25) The first part of the

protocol called for avoidance of excessive physical activity and

the use of anti-inflammatory medications for 2 to 4 weeks

during the acute inflammatory phase (when pain was acute

and limiting). The next step involved physical therapy in the

form of stretching exercises for 2 to 3 weeks, 20 to 30minutes

daily, that focused on improving hip flexibility, mainly by

Figure 5. A normal, skeletally mature hip showing the acetabular roof(A), anterior wall of the acetabulum (B), greater trochanter (C), lessertrochanter (D), radiographic teardrop (E), normal joint space (F),posterior wall of the acetabulum (G), epiphysis in a young patient andepiphyseal scar in the skeletally mature (H), coccyx (I), pubicsymphysis (J), anterosuperior iliac spine (K), and anteroinferior iliacspine (L).

Figure 6. A. Anteroposterior radiograph of the hip. B. Frog-legradiograph of the hip with demonstration of alpha angle measurement.

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external rotation and abduction in extension and flexion. The

final step involved educating patients on safe range of motion

to avoid impingement and teaching patients how to adapt

their restrictions to their activities of daily living. They were

taught to avoid positions between maximum internal and

external rotation and to avoid full flexion. They were restricted

also from running and cycling long term.

Intra-articular injections serve as another nonoperative

modality in treating FAI in conjunction with or after phys-

ical therapy and activity modification. The added benefit of

an intra-articular injection is the diagnostic as well as

therapeutic value. (26) A systematic review by Khan et al

(26) found that hyaluronic acid injections achieved up to 1

year of symptom relief. This review showed less success

with corticosteroid injections.

Unfortunately, the nonoperative data were gathered from

young-adult and adult populations, so the role of nonoper-

ative management in pediatric FAI is not well delineated.

More research needs to be conducted in this field.

Operative ManagementPatients who have failed nonoperative therapies, have more

severe bone deformity, or have chondrolabral pathology

(labral tear or osteochondral lesion) on MRI often necessi-

tate referral to an orthopedist for surgical consideration. (27)

Operative management of patients with symptomatic FAI

aims to address the pathology of the chondrolabral surfaces

and underlying bone deformity. The type of surgery heavily

depends on the severity of the deformity and MRI findings.

Historically, surgical dislocation was used to manage FAI.

(28) This method safely exposed the proximal femur and

acetabulum without compromising the blood supply to the

neck. Early studies reported moderate success (68%–82%).

(29) Complications rates were approximately 9%. (30) Open

treatment allows for good visualization of the femoral neck

and acetabulum and allows the surgeon to address lesions

of both easily. Periacetabular osteotomies are indicated in

patients with severe acetabular retroversion. In small case

reports, good to excellent results in 90% of patients at a

minimum of 2 years of follow-up were noted. (31)

As early as the 1970s, hip arthroscopy was used to treat

labral pathology in the hip. As FAI became better under-

stood and recognized, arthroscopy was used to attempt to

treat this pathology. Hip arthroscopy is becoming the treat-

ment of choice in the pediatric population. (27)(32) Arthro-

scopic management of CAM deformities begins with a

fluoroscopic examination to identify areas of dynamic

impingement. An arthroscope is then introduced into the

joint and the pathology assessed. If a CAM lesion is present,

a burr and a shaver are used to resect the lesion. The

arthroscopic burr is used for acetabular rim resection as

well. If there is labral pathology, suture anchors are used to

repair the labrum if amenable. Cartilage lesions can be

assessed and treated with microfracture if found to be full

thickness. (27)(32) Microfracture entails taking a small

pointed instrument and creating holes in the subchondral

bone with the hope that the ensuing bleeding brings stem

cells to the surface and to create a scar of fibrocartilage to

replace the damaged hyaline cartilage. Once finished, the

hip is put through another dynamic intraoperative exami-

nation under fluoroscopy. Currently there is no established

postoperative rehabilitation protocol and, thus, the decision

depends on an individual surgeon’s preference.

Results of arthroscopic treatment of FAI are encourag-

ing. There have been several studies demonstrating early

success of these procedures, measured by improvement in

the modified Harris Hip Score and Hip Outcomes Score.

(27)(32) In a small study of 34 patients younger than 18

years, 78% returned fully to sports and saw an improvement

from 77 to 94 (of 100) in themodifiedHarris Hip Score. (33)

The complication rate reported in a large cohort of patients

younger than 18 years was 1.8%. (33) Transient pudendal

nerve palsy, suture abscess, and intra-articular instrument

breakage were the most common complications, and no

growth disturbances were observed.

Operative versus Nonoperative TreatmentThere are few data comparing surgical and nonsurgical

treatment in the pediatric population. A recent systematic

review assessed 29 papers looking at outcomes after surgical

and nonsurgical treatment of FAI. These studies were mostly

level IV evidence. They encompassed both American and

European populations, and the average age was 34 years. They

found that in symptomatic patients, those treated surgically

had better functional score outcomes. (34)

Figure 7. A. Pincer lesion represents acetabular overhang. B. Crossoversign represents acetabular retroversion.

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WHEN TO REFER TO A SPECIALIST

As with any subacute complaint, it is important to know

which patients require referral to a subspecialist for oper-

ative consideration and which patients warrant conservative

measures first. Evaluation of these patients is important to

obtain an accurate diagnosis. Appropriate physical exami-

nation findings, such as limited hip internal rotation with

the hip flexed or pain with anterior and posterior impinge-

ment testing, should alert the clinician to consider FAI as a

possible diagnosis. Radiographs should then be obtained,

and if results are concerning for FAI, an MRI can be

ordered. Once the diagnosis is made, physical therapy,

activity modification, and hip injections should be tried.

If these conservative measures fail, surgical intervention

will likely be warranted and referral to a sports medicine or

pediatric orthopedist must be considered.

References for this article are at http://pedsinreview.aappubli-

cations.org/content/40/3/129.

Summary• Based on level of evidence IIa, femoroacetabular impingement(FAI) is a common enough cause of hip pathology and should beincluded in the differential diagnosis in patients with subacute,nontraumatic hip pain. (1)(2)(3)(4)(5)(6)(7)(8)

• Based on level of evidence IV, a good history and physicalexamination are beneficial in identifying higher-risk patients,elucidating features consistent with FAI pain, and assessinglimited range of motion or positive impingement findings onphysical examination. A good history and physical examinationwill also help rule out other causes of hip pathology, such asiliopsoas tendonitis, slipped capital femoral epiphysis, orLegg-Calve-Perthes disease. (2)(13)(15)(16)(17)

To view teaching slides that accompany this article,

visit http://pedsinreview.aappublications.org/

content/40/3/129.supplemental.

• Based on level of evidence IIa, initial imaging should becompleted with radiography, which may reveal 1 or acombination of lesions specific to FAI: CAM lesion, pincer lesion,or mixed. (17)(18)(19)(20)(21)

• Based on level of evidence IIa, conservative management maybe offered first and should consist of activity restrictions andanti-inflammatory medications. Intra-articular injections may beuseful. (24)(25)

• Based on level of evidence V, referral to a specialist should occurwhen the patient with FAI fails conservative management. (26)(27)(28)(29)(30)(31)(32)(33)(35)(36)(37)

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1. A 14-year-old boy is seen in the clinic for a sports preparticipation physical. He is in good healthand plays for his school soccer team. He reports pain around his right hip but denies any historyof trauma. From the following signs and symptoms, which additional one should lead theclinician to consider a diagnosis of femoroacetabular impingement (FAI) in this patient?

A. Hyperflexibility of the hip joint.B. Numbness in the anterior thigh.C. Popping or catching during activity.D. Pain associated with repetitive hip extension activities.E. Weakness in the quadriceps muscle.

2. In the patient described in the vignette in question 1, physical examination is performedincluding gait assessment, hip range of motion, strength testing, and assessment of thespine and knee. A diagnosis of FAI is suspected. Which of the following provocativemaneuvers is the best to confirm the diagnosis of FAI in this patient?

A. Flexion, abduction, external rotation (FABER) test.B. Impingement test.C. Log roll test.D. Stinchfield test.E. Straight-leg raise test.

3. The patient in question 1 complained of pain while the examiner performed theimpingement provocation test. Which of the following imaging studies is the mostappropriate initial diagnostic test that should be obtained to confirm the diagnosis of FAI?

A. Bone scan.B. Hip computed tomography.C. Magnetic resonance imaging of the hips.D. Radiographs in anteroposterior pelvis and frog-leg lateral of both hips.E. Ultrasonography of the affected hip.

4. A 14-year-old soccer player was brought to the sports medicine clinic for evaluation of hip pain.The findings from the history and physical examination, including the provocative maneuvers,were consistentwith FAI. A hip radiographwas obtained and is shown in the photographbelow.The radiologist has drawn some lines over the radiograph.Which of the following represents thebest interpretation of what the red dashed line represents in the radiograph of this patient?

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A. Crossover sign (acetabular retroversion).B. Pincer lesion (acetabular overhang).C. Pistol grip deformity.D. Prominent ischial spine.E. Slipped capital femoral epiphysis.

5. The patient described in the vignette in question 4 is diagnosed as having FAI. He wasstarted on a nonoperative management protocol that included activity modification, anti-inflammatory medications, physical therapy, and intra-articular injections of hyaluronicacid. The patient was seen in follow-up for 1 year. Today he reports recurrence of hissymptoms over the past few months after a period of partial relief. Which of the followingsurgical techniques is most likely to be considered at this point by the treating orthopedicsurgeon in this patient?

A. D-rotation osteotomy of the hip.B. Hip arthroscopy.C. Internal fixation of the hip.D. Periacetabular osteotomy.E. Surgical dislocation.

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DOI: 10.1542/pir.2017-01372019;40;129Pediatrics in Review 

Evan D. Sheppard, Connor R. Read, Brad W. Wills and A. Reed EstesFemoroacetabular Impingement in Pediatric Patients

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DOI: 10.1542/pir.2017-01372019;40;129Pediatrics in Review 

Evan D. Sheppard, Connor R. Read, Brad W. Wills and A. Reed EstesFemoroacetabular Impingement in Pediatric Patients

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