Impingement Tests of the Hip

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Impingement Tests of the Hip

Femoro-Acetabular Impingement

Hip impingement, also known as femoro-acetabular impingement (FAI), was first described by Smith-Petersen (1936).  FAI is a condition in which there is abnormal and wearing contact between the ball and socket of the hip joint.  The result is increased friction during hip movements that damage the joint.  Individuals who are at risk tend to be younger individuals active in tasks involving pivoting with internal rotation.  For example, gymnastics, soccer, hockey, and swimming breaststroke are activities that fulfill the risk criteria.

There are two types of FAI: cam and pincer.  Cam impingement is an osseous abnormality (bone bump) at the femoral head-neck junction.  It is an abnormality of the femur and the impact can damage the articular cartilage.  Pincer impingement is an abnormality of the bony acetabulum leading to over-coverage of the femoral head, i.e. acting like tweezers or pincers around the femoral head.  This damages the labrum.  There are two animated videos on “youtube” that describe the differences in these types of FAI:

FAI Signs & SymptomsC sign 2  C sign 1

Patients often complain of pain in the groin after prolonged sitting or walking.  Many athletes describe pain in the groin with deep flexion or rotation of the hip during activity.  Occasionally, a popping or clicking in the front of the hip is described.  Pain may also radiate along the lateral thigh and in the buttocks.  The C-sign was described by Byrd (2005) and is a simplistic indication of FAI.  The patient makes a shape of a ‘C’ with his/her hand and places the hand right on the hip joint, i.e. the location of the pain. It is important to rule out other causes of pain in this area which may originate in the low back or abdomen. 

FAI Clinical Tests

Many of the physical tests for FAI are very similar.  As one might expect, they incorporate common motions or positions.  These tests are: the DEXRI, DIRI, impingement, FAbER, and FAdIR.

DEXRI & DIRI TestsDEXRI  DIRI

The DEXRI (Dynamic External Rotation Impingement) and DIRI (Dynamic Internal Rotation Impingement) tests involve scouring the hip through a defined arc of motion.  The DEXRI is performed in supine with the involved leg flexed to 90° at the hip and knee.  The hip is passively taken through an arc of hip abduction and ER.  The DIRI is also performed in supine with the involved leg flexed to 90° at the hip and knee but the hip is passively taken through an arc of hip adduction and IR.  Some clinicians recommend holding the contralateral limb in a flexed position beyond 90 degrees to stabilize the pelvis.  Together, these two tests function to scour the entire hip socket.  Unfortunately, neither test has any statistical data reported to identify it as a screening or diagnostic tool. 

Impingement Test Impingement Test

Likewise, the impingement test attempts to reproduce pain into the groin.  In supine, the patient is passively taken into a position of hip/knee flexion to 90/90 and then into IR (no adduction).  Some clinicians recommend adding axial compression and/or over-pressure into IR.  However, these additional maneuvers do not appear to enhance the statistical values.

Stats - Impingement 3

FAbER & FAdIR TestsFAdIRFAbER Test

The FAbER (Flexion, Abduction, External Rotation) and FAdIR (Flexion, Adduction, Internal Rotation) tests are similar to the DEXRI and DIRI tests with regard to the combination of motions.   The FAbER test, also known as the Patrick test, is used to assess a wide array of musculoskeletal problems: hip/SI pathology, labral damage, or FAI.  The position is known as the “figure – 4” position.  In supine, the patient is passively taken into a position of hip flexion, abduction, and ER hip, i.e involved ankle is placed on opposite knee.  The lateral malleolus is placed on the contralateral distal thigh.  Overpressure is applied to the medial border of the flexed knee.  Given the number of tissues challenged by the FAbER test, a positive test can take many forms.  Pain assuming the position may be due to a problem with the Sartorius muscle.  Pain once in the position may be due to hip impingement or SI/low back pathology.  If the knee is more than 4 cm from the surface, the labrum may be the problem.  Thus, regardless of the tissue being tested, the FAbER test, by itself, is a poor diagnostic tool.

The FAdIR is performed in supine just like the DIRI.  The hip and knee is passively flexed to 90/90 and the adducted with hip IR.  As the femoral head comes in contact with the acetabular rim, a positive test for FAI would be pain in the groin region.  The FAdIR test only has statistics for sensitivity and the value is high (88-100%).   Likewise, when the FAbER and FAdIR are both negative, sensitivity is 90-100% (excellent screening combination).

Summary

Although none of these tests are strong diagnostic tools, they can be used to rule-out impingement.  If these tests are positive, the mechanism of injury and the pain referral pattern may help to confirm the diagnosis.  For more cutting edge orthopedic information in iOrtho+ Premium Mobile App, please visit https://iortho.xyz/

 

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