A bony abnormality of the hip called Femoral Acetabular Impingement Syndrome (FAIS), where the head of the femur (the thigh bone) is found to be irregularly shaped rather than its “normal” spherical shape, is sometimes treated with a surgical procedure to shave the head of the femur. FAIS can affect young individuals in contrast to osteoarthritis (OA) of the hip which usually occurs in older patients. It is thought that FAIS can cause pain in the hip, and can in addition if left untreated, result in OA.
The surgery is being done more often and some surgeons are questioning the appropriateness of the procedure. Two important questions are:1. How often is a non-spherical femoral head found in patients without any hip pain? and 2. Does reshaping the femoral head with surgery actually reduce the frquency of OA of the hip. A study of the hips of 50 patients (100 hips) who had no history of hip pain, who had received computerized tomography (CT scan) for other problems, found that 74% of the femoral heads were non-spherical. So just finding a misshapened femoral head does not mean that it is the cause of the pain since so many people have it without pain. As for FAIS causing OA, a study of 96 patients for a mean of 18.5 years, showed no increase in the incidence of OA with FAIS and concluded that there is no justification for preventive surgery in patients with FAIS who do not have pain.

I saw a 26 year old man complaining of left hip pain who had been diagnosed with FAIS. He had been advised that surgery would help. I examined him using electrical stimulation to identify muscles that might be the cause of his pain. I found that the Quadratus Lumborum, Gluteus Medius, Piriformis, Tibialis Anterior, Peroneus, Gastrocs, Extensor Digitorum Longus, and Multifidus were contributing to his pain. When injected, over the course of three weeks, into the attachments (where the muscle begins and ends, generally where it attaches to bone) followed by a simple physical therapy protocol, his pain was gone. He still had imaging (x-ray, CT) evidence to make the diagnosis of FAIS but he no longer had hip pain.

Perhaps there are patients who would benefit from shaving their femoral head. This one wouldn’t have because his pain wasn’t caused by the bone; it was caused by muscles. Unless we add muscle assessment and treatment to the standard of care not only for FAIS but for all chronic pain conditions, we will not be able to cost effectively address the problem of persistent pain in the US. Teaching the skills necessary to examine muscles and the knowledge to provide effective treatment protocols to medical students and post graduate MDs would be a good start.

~ Norman Marcus, MD
Norman Marcus Pain Institute, New York NY
“Your New York City Pain Relief Doctor”

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