A surgical technique pioneered in Pittsburgh offers relief from chronic hip pain for patients ordinarily much younger than the usual hip-replacement candidate.
Many Americans haven't heard of "femoralacetabular impingement," but most elite athletes are now familiar with FAI, thanks to surgeon Marc Philippon, who developed an arthroscopic technique for treating it as well as inventing instruments with which to perform the surgery.
In the hip joint, the "ball"-like top of the thigh bone (femur) fits into the "socket"-like area within the pelvis (acetabulum). Impingement means the ball and socket fit together too tightly, making it hard to move normally.
According to the American Academy of Orthopaedic Surgeons, hip impingement in young adults can lead to the development of osteoarthritis of the hip. Because surgery to treat arthritis in the hip (with artificial joints) and restore hip function is "both common and costly," the AAOS says there's growing interest in detecting FAI early and preventing the progression of the disease and preserving the natural hip joint.
Impingement can be caused by a deformity in either the ball at the top of the femur (cam impingement) or a deformity of the socket (pincer impingement). The femur top can jam in the socket when the hip is bent. An ill-formed socket can interfere with the femur as the hip moves.
Articular cartilage, a slippery tissue, covers the joint surfaces, helping it move smoothly. The acetabulum is ringed by a strong fibrocartilage (called labrum), which helps to keep the joint stable. Both the labrum or the cartilage can be torn by impingement.
Orthopedic research has found that cam impingement is most common in young male athletes. Pincer impingement occurs mostly in athletically active women in their 30s and 40s. It is not uncommon for both types to exist together.
"Because athletically active people may work the hip joint more vigorously, they may begin to experience pain earlier than those who are less active," says the orthopedic surgeons' website. It adds, "Exercise does not cause FAI."
However, bone abnormalities can develop during the childhood growing years, and activity can affect that, says John Christoforetti of the Allegheny Health Network, who has performed more than 1,000 arthroscopic surgeries to relieve FAI.
"Regular sports participation by young males may change their hip bone shape for the rest of their lives," Dr. Christoforetti said. Only about 12 percent of non-athletes suffer from FAI, but it is commonplace among elite male athletes.
When Dr. Christoforetti was training under Dr. Philippon at the Steadman Clinic in Vail, Colo., in 2006, he participated in a study that found hip bone abnormalities in half of the pitchers for the Colorado Rockies.
Elite athletes in many sports -- beginning with golfer Greg Norman in 2000 and including Pittsburgh sports legends Lynn Swann of the Steelers and Mario Lemieux of the Penguins -- have been patients of Dr. Philippon.
Dr. Christoforetti has treated pro athletes, too -- he's a consultant for the Pirates and the Riverhounds professional soccer team -- but focuses more on younger athletes.
"I had a severe pain in my buttocks for two years," said Connor Fitzmaurice, 19, a catcher on the St. Vincent College baseball team who had surgery in April to repair the labrum in his right hip. "I had a tough time walking."
After surgery, it "took three months to finally get to the point where I could exercise and run a little bit," Connor said. "Now I feel great.
"This fall season was the first time I played since the surgery," he said. "It was so much better than in high school. Back then I had a tough time squatting to get into my position."
Benito Mendizabal, 18, a shortstop for the Seton Hill University baseball team, also went to Dr. Christoforetti to repair the labrum in his right hip.
For more than a year beforehand, "I tried to rehab without seeing a doctor," Benito said. The athletic trainer for his high school baseball team in Clearwater, Fla., thought he had strained his quadriceps muscle.
His surgery was in August. He's just started working out again, but "a few weeks after the surgery, I could tell it was a lot better," Benito said.
The chief symptoms of FAI are pain in the groin area, the hip or the lower back. These also are symptoms of many other, mostly more common ailments (such as a muscle pull or hip flexor tendinitis), which is part of the reason many FAI sufferers go so long before seeking proper treatment.
Hip impingement also can be detected from X-rays and CT scans, and by an impingement test. The doctor brings your knee up toward your chest, then rotates it inward toward the opposite shoulder. If this recreates hip pain, the test is positive for impingement.
Dr. Philippon came to Pittsburgh in 2001 to be director of sports medicine/hip disorders at UPMC, and director of the University of Pittsburgh's golf medicine program. He left for the Steadman Clinic in 2005 but remains an adjunct associate professor of orthopedic surgery at the University of Pittsburgh School of Medicine.
Freddie Fu, chairman of orthopedic surgery at the med school, supervised Dr. Philippon during his time in Pittsburgh and is a fan but expressed skepticism about the value of the surgical procedure he invented.
"Just because there is a little bump doesn't mean you need to do anything about it," Dr. Fu said.
Dr. Fu also wondered whether the relief the surgery provides would be permanent: "If you shave the bone or the hip, how do you know whether it grows back?" Much more research needs to be done, he said.
Dr. Christoforetti agreed. "We're looking at a new procedure which doesn't save lives but improves the quality of lives," he said. "It demands that the physicians and the patients report their results accurately and transparently."
Research conducted to date has been enough to convince Medicare (in 2011), and subsequently all the major health insurance companies, to cover the procedure. That research indicates 80 percent of athletes who've had the surgery return to their sports at the same or higher level, Dr. Christoforetti said.
Most patients express satisfaction. After his surgery, Mr. Norman remembered telling his wife: "This is the first time in years that I'm going to be able to get out of bed without pain."
Surgery shouldn't be undertaken unless symptoms have persisted for at least six months and more conservative treatment options have failed, Dr. Christoforetti said. The UPMC website advises people with hip pain to modify their activity and consult with a primary care physician or orthopedic surgeon.
If you decide on surgery, select carefully the surgeon who will perform it, Dr. Christoforetti said. The surgeon should have advanced fellowship training in hip preserving techniques, he said, because "it takes about 300 cases for a surgeon to get through the learning curve."
The International Society for Hip Arthroscopy, established in 2008, maintains a roster of the most qualified physicians at www.isha.net.
Jack Kelly: firstname.lastname@example.org or 412-263-1476.