Femoroacetabular Hip impingement (FAI) & Chronic Low Back Pain: A Silent Connection
A 31 year old male dealing with chronic low back pain for 6 years has tried everything; physical therapy, spinal injections, chiropractic adjustments, etc. Was told he had to wear minimalist shoes and strengthen his core. He has been doing that for 4 years and has had no improvement.
A 25 year old female with a 3 year history of low back pain following a minor car accident. Did not respond to previous physical therapy or cortisone injections. The MRI of her spine is “not that bad” so the doctors didn’t want to do surgery. Instead, it was suggested she do a nerve ablation to basically “fry” the nerve to turn off the pain. She was also encouraged to get a very expensive Platelet-rich plasma (PRP) injection.
What do these patients have in common? They both were suffering from a silent etiology that continued to antagonize their spines: undiagnosed hip impingement.
What is Femoroacetabular impingement (FAI)?
Hip impingement that is caused by a bony abnormality in the ball or socket of the hip joint. This abnormality can cause the ball and socket to rub against each other, leading to reduced range of motion and eventually pain in the hip.
There are two main types of hip impingement: cam impingement and pincer impingement.
Cam impingement is caused by a bony abnormality in the ball of the hip joint. This abnormality can cause the ball to rub against the socket of the hip joint, leading to pain and inflammation. Cam impingement is more common in athletes who participate in sports that involve high-impact movements, such as running, jumping, and pivoting.
Pincer impingement (see photo above) is caused by an abnormality in the socket of the hip joint. This abnormality can cause the socket to be too shallow or narrow, which can pinch the ball of the hip joint as it moves in and out of the socket. Pincer impingement is more common in people who have certain hip conditions, such as osteoarthritis or dysplasia.
In some cases, people can have both cam and pincer impingement. This is called mixed impingement.
Who gets hip impingement?
Bony hip impingement is more common in athletes who participate in sports that involve high-impact movements, such as running, jumping, and pivoting. Especially during the growth years, the collision of the hip ball and socket may cause the bone to overdevelop and effectively create spurring. It can also be caused by congenital hip abnormalities or injuries to the hip joint. Males are more likely to have a congenital hip impingement.
How does hip impingement contribute to Low Back Pain?
One of the most concerning aspects of hip impingement is that it can often go undetected. This is because the symptoms of hip impingement can be similar to those of other conditions, such as arthritis, bursitis, and tendonitis. As a result, many people with hip impingement may go years without receiving a diagnosis.
One of the biggest problems with undiagnosed hip impingement is that it can lead to chronic back pain. This is because a lack of hip mobility can cause the spine to compensate through compression. Since the hip is a much more robust joint, it often takes a while for pain to develop. The lumbar spine is much less tolerant to excessive force and will often break down much faster. Therefore, chronic low back pain becomes the predominant complaint.
Without diagnosing the hip impingement, the driver of the problem, treatment often becomes ineffective. Physical therapy techniques and/or surgeries are often effective at treating low back pain in isolation. Unfortunately, they often fail when the hip continues to compress and antagonize the spine.
Treatment for hip impingement
The treatment for hip impingement will vary depending on the severity of the condition. However, most treatment plans will focus on reducing pain and inflammation, improving hip mobility, and strengthening the surrounding muscles.
Treatment options may include:
Physical therapy: Physical therapy is often the first line of treatment for hip impingement. A physical therapist can mobilize your hips to hopefully restore some range of motion, teach you exercises to improve your hip mobility and strength.
Injections: Injections of corticosteroids or hyaluronic acid can be used to reduce inflammation and pain.
Surgery: Surgery may be necessary in severe cases of hip impingement. Surgery can involve removing any bone spurs or other abnormalities that are causing the impingement.
The Big Takeaway
If you are dealing with chronic low back pain, look away from the spine for its cause! In almost every case of chronic low back pain, I have found there has been a significant lack of hip mobility that has not been addressed. Sometimes this leads to a discovery of FAI that the patient never knew they had. If you have chronic low back pain and what to find out hip the hip(s) are the problem, here is what you can do:
Ask for an x-ray of the hips. This is a bony abnormality so it should easily show up on the film. This is a low cost way to diagnose hip impingement.
Get a cortisone shot in the hip; if both are potentially affected, choose the worst hip. This will do a few things for you:
If your low back pain reduces, you have found the source of your pain! Now you know what should be treated.
Pay attention to how long that pain stays down, this will be helpful in figuring out the long term plan. If the pain stays away for quite awhile, you may want to continue conservative measures like physical therapy to manage remaining symptoms. If pain comes back quickly, this suggests that the hip impingement is an active problem. You may want to consider more aggressive treatment options sooner rather than later.
Above all, your physical therapy plan should not just be about doing exercises and hoping things will work. Your Physical Therapist should be analyzing what's going on with you, monitoring your progress (or lack thereof) and thinking critically. Remember, the human body is the most complex machine on the planet; simplistic explanations often are not the answer. Lack of thinking by your medical team can lead to you wasting time, energy, money and potentially your sanity!
Rehab SMARTER, not HARDER with Jason the PT! Schedule Online here!
For more information, check out these links:
American Academy of Orthopedic Surgeons
Yale Medicine
(P.S. I sent the 31 year old male to a hip doctor after his evaluation with me. The orthopedic Specialist looked at his x-ray and told him that he had the worst hip impingement he had seen in a decade. Since the hips were not painful, the team elected to hold off on surgery for a while. He emailed to thank me for finding his real problem. He no longer had to drive himself crazy searching for answers and spending money on ineffective treatments.
I talked the 25 year old female out of the nerve ablation at the last minute and then the subsequent PRP injection offering from her previous medical team. I am very happy I did; neither of those treatments would have worked out well. The photo above is the actual x-ray she sent me of her pincer hip impingement. She got a cortisone shot in her right hip and her low back and hip pain reduced substantially. Unfortunately, it came back rather quickly and she is exploring surgery.)
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