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Does femoroacetabular impingement syndrome affect range of motion? A systematic review with meta-analysis

Review written by Dr Joshua Heerey info

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Key Points

  1. Patients with femoroacetabular impingement syndrome (FAIS) have reduced hip joint range of motion (ROM) when compared to healthy controls.
  2. Clinically relevant deficits in internal rotation (0 degrees and 90 degrees hip flexion), abduction (0 degrees hip flexion) and adduction (90 degrees hip flexion) ROM were found in patients with FAIS.
  3. Hip joint ROM testing should be included in the clinical assessment of young to middle-aged people with hip-related pain.

BACKGROUND & OBJECTIVE

Femoroacetabular impingement syndrome (FAIS) is a common cause of hip-related pain in young to middle-aged individuals (1). FAIS can lead to intra-articular damage (e.g. labral tears and cartilage defects) and expediate the development of hip osteoarthritis (2).

When present, FAIS can affect physical function and quality of life (1), as well as result in musculoskeletal impairments including reduced muscle strength and joint range of motion (ROM) (3). Hip joint ROM is of particular interest in clinical practice as it can be used in the diagnosis of FAIS and appears to have a relationship to hip OA development (2,4).

Further, operative, and non-operative treatments often focus on improving hip joint ROM in patients with FAIS. Despite this growing interest in the role of hip ROM in FAIS, several studies have reported conflicting findings (3). Greater clarity on the link between FAIS and hip joint ROM may improve treatment selection and patient outcomes.

This systematic review and meta-analysis sought to investigate the association between FAIS and hip joint ROM.

Femoroacetabular impingement syndrome can lead to intra-articular damage and expediate the development of hip osteoarthritis.
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When deficits in hip joint range of motion exist, clinicians should undertake further clinical and imaging tests to confirm the presence of Femoroacetabular impingement syndrome.

METHODS

  • The authors pre-registered the systematic review protocol and used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Meta-analysis (PRISMA) of Observational Studies in Epidemiology guidelines.

  • Several medical databases were searched for cross-sectional, case-control and cohort (prospective and retrospective) studies.

  • Studies were eligible for inclusion if the included one of the following comparisons:

    1. FAIS vs healthy controls;
    2. FAIS vs healthy controls with cam, pincer or mixed morphology; or
    3. healthy controls vs healthy controls with cam, pincer or mixed morphology.

  • Two reviewers evaluated each study for overall quality and assessed certainty of evidence.

  • When at least two studies reported the same hip joint ROM outcome (e.g. hip abduction) the data was combined, and meta-analysis performed.

  • As several different measurement instruments were used across studies, the authors also conducted subgroup analyses for each instrument.

RESULTS

17 cross-sectional studies (including 1702 hips) were included in this review. Close to half of the included hips (48%) had FAIS, with 47% of hips classified as asymptomatic (i.e. healthy controls). The remaining 88 hips (5%) were asymptomatic with either cam, pincer or mixed morphology. The median age across studies was 33 years, with a higher proportion of men investigated. Study quality ranged from fair (n=7) to good (n=10)

Reduced hip joint ROM was found in hips with FAIS when compared to healthy controls. Specifically, clinically relevant differences (>10%) in ROM were evident in internal rotation (0 degrees and 90 degrees hip flexion/moderate certainty), abduction (0 degrees hip flexion/moderate certainty) and adduction (90 degrees hip flexion/high certainty) ROM in hips with FAIS.

Clinically relevant deficits in internal (90 degrees hip flexion/moderate certainty) and external (0 degrees hip flexion/moderate certainty) rotation ROM were found in hips with FAIS when compared to controls with cam, pincer or mixed morphology. Hip ROM did differ between controls with and without cam, pincer or mixed morphology.

LIMITATIONS

Across the 17 studies, there was considerable variability in the methods used to measure hip ROM, patient positioning and the classification of FAIS and associated hip morphology. Importantly, the authors were aware of study variability and conducted several additional analyses (subgroup and sensitivity) to confirm their findings.

CLINICAL IMPLICATIONS

This review suggests that hip joint ROM is reduced in patients with FAIS when compared to healthy controls (with and without hip morphology). Of interest, there appears to be no difference in pain-free individuals with and without hip morphology. In young to middle aged adults with hip pain, hip joint ROM testing should form part of the clinical assessment to help understand the underlying cause of symptoms. When deficits in hip joint ROM exist (e.g. internal rotation in 0 degrees and 90 degrees hip flexion) clinicians should undertake further clinical and imaging tests to confirm the presence of FAIS.

Hip joint ROM is often a target for operative and non-operative treatments. It remains unclear which treatment approach is superior for improving hip joint ROM and if indeed greater ROM is associated with improved outcomes in patients with FAIS. In many patients, reduced hip ROM may be related to altered hip morphology (cam, pincer or mixed morphology) that cannot be modified through stretching, soft tissue technique or other passive approaches. Clinicians need to carefully consider the underlying reason for reduced hip joint ROM and educate their patient appropriately.

+STUDY REFERENCE

Albertoni D, Gianola S, Bargeri S, Hoxhaj I, Munari A, Maffulli N, Castellini G (2023) Does femoroacetabular impingement syndrome affect range of motion? A systematic review with meta-analysis. British Medical Bulletin, 145(1), 45–59.

SUPPORTING REFERENCE

  1. Reiman, M. P., Agricola, R., Kemp, J. L., Heerey, J. J., Weir, A., van Klij, P., Kassarjian, A., Mosler, A. B., Ageberg, E., Hölmich, P., Warholm, K. M., Griffin, D., Mayes, S., Khan, K. M., Crossley, K. M., Bizzini, M., Bloom, N., Casartelli, N. C., Diamond, L. E., … Dijkstra, H. P. (2020). Consensus recommendations on the classification, definition and diagnostic criteria of hip-related pain in young and middle-aged active adults from the International hip-related pain research network, Zurich 2018. British Journal of Sports Medicine, 54(11), 631–641.
  2. Griffin, D. R., Dickenson, E. J., Donnell, J., Agricola, R., Awan, T., Beck, M., Clohisy, J. C., Dijkstra, H. P., Falvey, E., Gimpel, M., Hinman, R. S., Hölmich, P., Kassarjian, A., Martin, H. D., Martin, R., Mather, R. C., Philippon, M. J., Reiman, M. P., Takla, A., … Bennell, K. L. (2016). The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): An international consensus statement. British Journal of Sports Medicine, 50(19), 1169.
  3. Mosler, A. B., Kemp, J., King, M., Lawrenson, P. R., Semciw, A., Freke, M., Jones, D. M., Casartelli, N. C., Wörner, T., Ishøi, L., Ageberg, E., Diamond, L. E., Hunt, M. A., Di Stasi, S., Reiman, M. P., Drew, M., Friedman, D., Thorborg, K., Leunig, M., … Lewis, C. L. (2020). Standardised measurement of physical capacity in young and middle-aged active adults with hip-related pain: Recommendations from the first International Hip-related Pain Research Network (IHiPRN) meeting, Zurich, 2018. British Journal of Sports Medicine, 54(12), 702–710.
  4. Agricola, R., Heijboer, M. P., Bierma-Zeinstra, S. M. A., Verhaar, J. A. N., Weinans, H., & Waarsing, J. H. (2013). Cam impingement causes osteoarthritis of the hip: A nationwide prospective cohort study (CHECK). Annals of the Rheumatic Diseases, 72(6), 918.
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