Femoroacetabular Impingement and Acetabular Labral Tears – Part 2: Clinical Diagnosis, Physical Examination and Imaging

The clinical diagnosis of femoral acetabular impingement (FAI) continues to evolve as the understanding of normal and pathological hips progresses. Femoral acetabular impingement is currently defined as a syndrome in which the diagnosis consists of the combination of a previously-obtained comprehensive clinical history, followed by a consistent and standardized physical examination with specific orthopedic maneuvers. Additionally, radiographic and tomographic examinations are used for the morphological evaluation of the hip, and to ascertain the existence of sequelae of childhood hip diseases and the presence of osteoarthritis. The understanding of the femoral and acetabular morphologies and versions associated with images of labral and osteochondral lesions obtained through magnetic resonance imaging (MRI) contributes to the confirmation of this syndrome in symptomatic patients, and helps in the exclusion of differential diagnoses such as iliopsoas tendon snaps, subspine impingement, ischiofemoral impingement, and other hip joint pathologies.

Keywords
diagnosis; hip; radiography; femoroacetabular impingement

Authorship

Giancarlo Cavalli Polesello Address for correspondence Giancarlo Cavalli Polesello, MD, PhD, Hip Group, Department of Orthopedics and Traumatology, Faculty of Medical Sciences, Santa Casa deMisericórdia de São Paulo (FCMSCSP), Rua Dr. Cesário Motta Junior, 112, Vila Buarque, São Paulo, SP, 01221-020, Brazil (e-mail: giancarlohip@gmail.com; dot.quadril@hotmail.com).

Hip Group, Department of Orthopedics and Traumatology, Faculty of Medical Sciences, Santa Casa de Misericórdia de São Paulo (FCMSCSP), São Paulo, SP, BrazilSanta Casa de Misericórdia de São PauloBrazilSão Paulo, SP, BrazilHip Group, Department of Orthopedics and Traumatology, Faculty of Medical Sciences, Santa Casa de Misericórdia de São Paulo (FCMSCSP), São Paulo, SP, Brazil

http://orcid.org/0000-0002-9524-8871

Leandro Eisjman

Hip Group, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, BrazilUniversidade de São PauloBrazilSão Paulo, SP, BrazilHip Group, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil

http://orcid.org/0000-0002-9866-1960

Marcelo C. Queiroz

http://orcid.org/0000-0003-2347-0921

Bruno Alves Rudelli

http://orcid.org/0000-0002-0780-6811

Marco Rudelli

http://orcid.org/0000-0003-1106-0706

Walter Ricioli Junior

http://orcid.org/0000-0002-7676-5806

Address for correspondence Giancarlo Cavalli Polesello, MD, PhD, Hip Group, Department of Orthopedics and Traumatology, Faculty of Medical Sciences, Santa Casa deMisericórdia de São Paulo (FCMSCSP), Rua Dr. Cesário Motta Junior, 112, Vila Buarque, São Paulo, SP, 01221-020, Brazil (e-mail: giancarlohip@gmail.com; dot.quadril@hotmail.com).

Conflict of Interests

The authors declare that have no conflict of interests.

SCIMAGO INSTITUTIONS RANKINGS

Figures | Tables

Figures (3)
Tables (1)

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Fig. 1
(A) Pelvic version with the patient standing up and (B) sitting down. Pelvic version ranged 29° (from -7° to 22°). 1. T12/S1 lordosis: 21°, 2. SVA: 81 mm, 3. Sacral slope: 35°, 4. Pelvic view: 28°, 5. Pelvic version: -7°, 6. Cam gravitational line: 50 mm, 7. Sacral slope: 7°, 8. Pelvic view: 28°, 9. Pelvic version: 22°

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Fig. 2
(A) Positioning with hip flexion to achieve straightening of the lumbar lordosis. (B) DIRI maneuver, in which the examined hip is flexed (in this case the left hip), followed by internal rotation and adduction. (C) DIRE maneuver: in this case, with the lumbar spine already straightened, left hip abduction and concomitant internal rotation are performed to evaluate injuries or impingement at the upper and posterior regions.

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Fig. 3
Radiographic hip views in FAI research. (A) Anteroposterior view. (B) Ducroquet view. (C) Dunn view for the visualization of cam-type deformity. Note the rectification and prominence of the neck-head transition region. (D) X-ray image in Lequesne position.

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Table 1
Standardized interpretation of radiographs in the evaluation of natural hips. The analyzed parameters are shown according to the radiographic view

Fig. 1 (A) Pelvic version with the patient standing up and (B) sitting down. Pelvic version ranged 29° (from -7° to 22°). 1. T12/S1 lordosis: 21°, 2. SVA: 81 mm, 3. Sacral slope: 35°, 4. Pelvic view: 28°, 5. Pelvic version: -7°, 6. Cam gravitational line: 50 mm, 7. Sacral slope: 7°, 8. Pelvic view: 28°, 9. Pelvic version: 22°

Fig. 2 (A) Positioning with hip flexion to achieve straightening of the lumbar lordosis. (B) DIRI maneuver, in which the examined hip is flexed (in this case the left hip), followed by internal rotation and adduction. (C) DIRE maneuver: in this case, with the lumbar spine already straightened, left hip abduction and concomitant internal rotation are performed to evaluate injuries or impingement at the upper and posterior regions.

Fig. 3 Radiographic hip views in FAI research. (A) Anteroposterior view. (B) Ducroquet view. (C) Dunn view for the visualization of cam-type deformity. Note the rectification and prominence of the neck-head transition region. (D) X-ray image in Lequesne position.

Table 1 Standardized interpretation of radiographs in the evaluation of natural hips. The analyzed parameters are shown according to the radiographic view

Pelvic anteroposterior radiograph

1. Test quality: proper pelvic inclination and rotation

2. Lateral center-edge angle

3. Angle of inclination of the acetabular roof

4. Extrusion of the femoral head

5. Lateralization of the femoral head

6. Femoral neck-shaft angle

7. Medial and lateral joint space at the acetabular roof

8. Orientation of the acetabular walls

9. Orientation of the ischial spines

10. Sphericity of the femoral head

11. Positive findings: cysts, osteophytes, implants, stress fracture, periosteal reaction, medullary bone alterations, proximity of the trochanter to the ischium/acetabulum, prominent anterosuperior iliac spine

Dunn 45º and lateral frog views

1. Shape of the acetabulum shape

2. Sphericity of the femoral head

3. Alpha angle

4. Positive findings

False Lateral Lequesne View

1. Shape of the acetabulum

2. Sphericity of the femoral head

3. Variation from posterior to anterior of the thickness of the joint cartilage

4. Center-anterior border angle

5. Positive findings, especially anterosuperior or posteroinferior arthrosis

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Femoroacetabular Impingement and Acetabular Labral Tears – Part 2: Clinical Diagnosis, Physical Examination and Imaging

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[1] Address for correspondence Giancarlo Cavalli Polesello, MD, PhD, Hip Group, Department of Orthopedics and Traumatology, Faculty of Medical Sciences, Santa Casa deMisericórdia de São Paulo (FCMSCSP), Rua Dr. Cesário Motta Junior, 112, Vila Buarque, São Paulo, SP, 01221-020, Brazil (e-mail: giancarlohip@gmail.com; dot.quadril@hotmail.com).