Working Diagnosis:
Left Hip FAI, Osteochondral Defect of the Femoral Head, and Synovial Hypertrophy

Treatment:
Arthroscopic labral repair, acetabuloplasty, femoroplasty
PRP
High Volume Injection/Capsular distention and lavage twice
Steroid Injection

Outcome:
Given concern for early arthritic changes, PRP was attempted to decrease pain however this was non-beneficial from a pain or functional standpoint.
He was then evaluated for possible orthobiologic intervention. An ultrasound evaluation revealed extensive synovitis in the hip joint that impinged when dynamically flexed to end range of motion.
Based on the ultrasound findings, he underwent high volume injection (HVI)/capsular distension and lavage. This led to pain reduction, improved range of motion, , and he was able to return to doubles play. A repeat HVI was performed three months later due worsening function again with temporary results.
A steroid injection was performed 2 months later as he wished to finish senior season. He may consider hip resurfacing or stem cell treatment following season.

Author's Comments:
While FAI is a common cause of decreased hip range of motion in young athletes, sequela from years of repetitive motion from FAI, such as labral tears, osteochondral disease, or synovitis can play a role in affecting athletes overall hip function.1
It provides a challenging problem in this athlete as hip synovitis contributes to overall progression of osteoarthritic disease and the treatment options are limited in a young, athletic population.
In addition, any effects of regenerative interventions that could optimize the microenvironment of the joint have limited data to guide outcomes.

Editor's Comments:
There are two types of FAI which can lead to the development of hip pain. In a cam impingement, the morphologic changes are noted at the femoral head-neck junction on the anterolateral surface. When the hip is flexed and internally rotated, this can lead to shearing forces at the chondrolabral junction. In a pincer impingement, the morphologic changes are noted at the acetabulum. The overcovering of the femoral head leads to impaction of the labrum and subsequently labral and cartilage damage. A cam and pincer deformity may coexist. Cam deformities are more prevalent in males, and particularly in male athletes (up to 89% in one study in comparison to 9% in non-athlete controls). Pincer deformities are more prevalent in females.


For the diagnosis of FAI there must be a combination of hip pain and symptoms. A cam lesion is more likely to be associated with intra-articular pathology. Athletes who participate in sports requiring repetitive hip flexion and internal rotation may be more likely to develop hip pain as a result of an underlying cam deformity. The shearing forces at the acetabular chondral junction can lead to intra-articular pathology, from softening of the cartilage to cartilage delamination from the subchondral bone. Cam deformities are associated with the development of hip osteoarthritis whereas the evidence of pincer lesions leading to future osteoarthritis is less consistent.


Early diagnosis of FAI is critical. Since there is no gold standard diagnosis in those where there is a concern for FAI the diagnosis relies on a combination of clinical signs (limited internal rotation, positive FADIR ) and classic radiographic features. Those who present with hip pain and are subsequently diagnosed with FAI should be encouraged to avoid the position of impingement. Improving neuromuscular control at the hip to reduce impingement should be a component of treatment. While it is known that certain deformities can lead to hip pathology, there is currently no strong recommendation for prophylactic surgery in those with deformities associated with FAI who do not yet have symptoms such as hip or groin pain. (3)

References:
1. Bedi A., Chen, N., Robertson, W., Kelly, B. (2008). The Management of Labral Tears and Femoroacetabular Impingement of the Hip in the Young, Active Patient. 24(10):1135-45. doi: 10.1016/j.arthro.2008.06.001.
2. Steffes,M. Abbasi, D. Femoroacetabular Impingement https://www.orthobullets.com/knee-and-sports/3130/femoroacetabular-impingement?expandLeftMenu=true
3. Brukner & Khan’s Clinical Sports Medicine. 5th Edition. Chapter 31: Hip Pain, pages 607-610.

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