The following post is one I composed for MedBridge Education regarding a course given by Carrie Hall, PT, MHS on Femoral-Acetabular Impingement (FAI).  FAI is definitely becoming more mainstream diagnosis so I do recommend educating yourself on the condition.  Words have meaning and if I was told I had Femoral-Acetabular Impingement (longer word than spondylolisthesis!), it would be very threatening terminology that could lead to fear avoidance and catastrophizing behaviors.  As mentioned in the latter part of the post, there is a large amount of information given in her presentation and I focused on one aspect, “overcoverage” for patient education.   If you decide to try out MedBridge, use this link or the affiliate logo on right side of page.  Hope you enjoy.

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In the last few years, Femoral Acetabular Impingement (FAI) seems to have risen in the ranks as the top diagnosis of non-arthritic hip pain. This is mainly due to the increased awareness and understanding of the condition by healthcare practitioners, but also in part due to higher prevalence in active adults as numerous exercise routines are being introduced to the mainstream public.

Recently, I had a patient arrive to my clinic under Direct Access for main complaint of right groin pain. She was a 38-year-old female who started exercising 3 months ago with the intent to lose weight and become healthier. She started running up to 3 miles on her own and sought care from a personal trainer. Her exercise routine with the trainer included upper and lower body workouts, with a particularly large number of squats and lunges. The patient developed her symptoms shortly after beginning her exercise routine, with worsening intensity and frequency. She was very excited with her body changes as of late, but was afraid that she would not be able to continue to be physically active due to her symptoms.

A detailed subjective history, demographic analysis, and confirmation through objective findings provided a clinical diagnosis of FAI. Considering the patient was not aware of this condition, she was very interested in additional information. She wanted to understand the condition, but more importantly, she wanted to know what she could do about it. As with most physical therapy treatments, patient education is a large aspect of my patient care. This particular case was no different, especially with lack of a medical diagnosis and radiographic imaging.

Carrie Hall, PT, MHS provides a very detailed lecture entitled, “Pre-Arthritic Hip Disease (PAHD): Medical Classification and Movement System Approach Toward Prevention and Management” through MedBridge’s online coursework. Armed with this education and evidence-based knowledge under my belt, I was confident enough to inform the patient of her condition, but most importantly, I was able to explain the multiple influences that can be addressed describing her limitations that lead directly into treatment.

Ms. Hall contributes an extensive amount of knowledge on FAI assessment and intervention in this lecture, but for brevity purposes in this piece, I am going to highlight the verbiage I learned that assisted in patient education. Patient education can be as simple as a patho-anatomical approach, but I mainly use it to describe the positive benefits of physical therapy intervention on improving function while decreasing disability, and in most instances, avoiding surgical intervention. I try to narrow down an element that the patient can latch onto, which will lead to greater understanding of the condition and hopefully maximal outcomes in the end. In this particular case, Ms. Hall’s use of the term overcoverage connected with me the most.

Overcoverage, also described as excessive coverage, is the linear contact between femoral head-neck junction and acetabular rim. It is the reason for “impingement”. I used this verbiage as the highlight reel to describe why certain activities elicit a threat while others do not. This helped me translate knowledge to the patient regarding the multiple influences of the femur, innominate, and functional activities that can cause mechanical impingement.

The 3D impact of the femoral head and acetabulum from early contact and increased shear by change in physical activity led to her symptomology. Specifically, repetitive activities such as running and increased loading movement of squatting and lunging aggravated underlying etiology. Through the use of the element overcoverage, it allowed me to use the following comprehensive visual of anatomical influences that arose from various activities to improve her condition.

"Coverage" of FAI

 

Even though I did not have plain film or advanced imaging to denote the structural influences on her condition, the patient was able to comprehend the element of overcoverage as described by Ms. Hall to grasp the patient education component of physical therapy intervention. As a result, she was better able to understand the symptomology, dampen fears, and create self-efficacy. She knew she would need to work on multiple limitations – as found in my examination – to increase the buffer zone of activity tolerance, as well as modify a few movements to minimize stress.

I highly recommend you virtually attend Ms. Hall’s presentation through MedBridge to find what you can glean for immediate use in the clinic. For me, overcoverage seemed to hit the spot. It not only benefited me personally, but it was also the primary element of patient education for this particular individual with FAI.

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6 comments

  1. I like the word “overcoverage” too, it’s non threatening, yet descriptive. I still think that it is our job to give a realistic prognosis in stating that these are in fact bony changes that we’re dealing with (cam, pincer and mixed) that no amount of exercise is likely to change. However in light of this, driving home the point to the patient that this does NOT mean they cannot be active but rather needs the skill of a PT to put together a correct program for their current functional status is where it’s at. This gives then hope that they can manage their pain, and it rightfully puts us in the position of exercise program developer rather than some weekend certified trainer who is just using exercises that “give the good burn” rather than meet the biomechanical need of the patient. Patients obviously don’t like to hear that anything bony is the problem because they automatically think “oh my gosh I am either stuck with this or I have to have surgery.” They would rather know in general that something is correctable. In light of diagnoses like FAI or spinal stenosis where there are radiographic changes that are involved with their etiology, I think driving home the point that their pain is MANAGEABLE gives them a lot more hope. Great post Harrison, nice to get back on here and read your stuff after a hiatus of having my first baby. I even got inspired and started my own blog.. Check it out. Have a good one

    1. Steve,
      Thanks for reading and the comments. Glad I was able to inspire you! I checked out your site and great content! Keep up the good work.

      I am about to have my first baby in a few weeks…so I’m sure my posts will get shorter and shorter….

      Yes, you make a good point about the symptoms being manageable. I think fear can be instilled with these diagnosis…but we still need to have a diagnosis and educate about the condition…there is no doubt that this education is included too. Overcoverage sat in with me and glad you liked it.

      Harrison

      1. Dude that’s awesome. If I can answer any of those new dad questions, I’m in the trenches with you my friend. Here’s to being Dads!! Keep up the great clinic work and we’ll be in contact I’m sure over these blogs

  2. Nice article. Thank you. Part 2? And your treatment plan included (other then pt ed you mentioned)?

    1. John,
      Yes…more than this was done in treatment! I don’t know if I’ll get around to a part 2 but this is basically what I did:
      1. I am a big advocate of the pelvis have mobility in this condition…just like glenohumeral rhythm and scapula being highly involved in shoulder impingement…same idea in my opinion with FAI. Therefore, I did SMT to her SIJ, dry needling to the sacrotuberous and long dorsal ligament (she had pain back in this region too). Plus, mobility exercises for this region.
      2. I really wanted to strengthen her glutes too, so did several plinth exercises (S/L Abduction, bridges, etc) to start, then began the “runner’s six” program that you can see on Chris Johnson’s youtube page (https://www.youtube.com/watch?v=Z1gI_2pxVgE). I really like these…and she can do them in the gym too.

      Hv

  3. Thank you for sharing this. It was the first time that I’ve heard of FAI before. So FAI can be caused by the shape of the acetabulum and femoral head and neck plus overexertion of the muscles surrounding it. If FAI is the pt’s possible diagnosis, modifying her activities are one of the things that can be done. Thanks again for sharing. I’ve learned something today 🙂

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