Acetabulo Femoral Hip Impingement Syndrome:Interview with Dr.Craig Liebenson

If you’re a personal trainer, strength coach or physical therapist who wants to be at the top of the industry and build your clientele with elite athletes or just become known for your ability to get results then chances are that you’ve come across Dr.Craig Liebenson and his work.

Founder of the the LA Sports and Spine Center, Dr. Liebenson boasts an impressive resume of  clients ranging from MLB, NBA, NFL and Olympic athletes to individuals who just couldn’t feel better no matter how many surgeries they were recommend or given.

His book, Rehabilitation of the Spine is a must have for anyone serious about treating or preventing back pain with their clients. Recently he’s released the Functional Training Handbook and DVD that is geared specifically for trainers and physical therapists and guides them in prescribing exercise after pain.

But enough about the good doctor. We’re talking about Acetabulo Femoral Hip Impingement Syndrome and why it’s becoming a pain condition in athletics.

Acetabulo Femoral Hip Impingement Syndrome

1. Recently Acetabulo-Femoral impingement syndrome has become one of the more common issues with athletes and active individuals and right now surgery is the overwhelming option. Can you give us an overview of what Acetabulo-Femoral amnesia is and how we can identify it? I’ve actually seen this in a few of my soccer clients lately and it’s very hard to diagnose if you don’t know what to look for.

Jimmy, you nailed it. Surgery is not the first choice, but last resort. The first step is accurate differential diagnosis. Acetabulo-Femoral Impingement(AFI) has to be distinguished from Hip Dysplasia (HD), and a Labral Tear (LT).

AFI is a wear & tear sports injury from repetitive strain. There are no specific diagnostic tests for it, however Groin pain is common. According to Philippon “A positive impingement test was defined as groin pain with 90 degrees of hip flexion and maximal internal rotation.”. But he also states that Faber Test can be positive – limited & painful abduction & external rotation. X-rays may show bony reaction on the femoral head or neck, and on the acetabular rim. An MRI can reveal fraying or tears of the cartilage and labrum.
HD is present if the hip socket -acetabulum – is too shallow for the ball – femoral head.  It is a congenital condition.This can be associated with tearing of the labral and articular cartilages. There should be laxity & instability.
A LT can be visualized on an MRI and can occur with AFI or HD. Like AFI, pain with hip flexion,  internal rotation and adduction are hallmarks. The MRI finding of a LT does not mean there is a clinical problem is it is present in many asymptomatic individuals.
Since tears can be asymptomatic and  dysplasia occurs with instability when we have restricted or painful motion AFI is a reasonable working diagnosis. Conservative care should always be considered option 1. In this regard activating the posterior chain in order to “check” uncontrolled or excessive hip flexion is a key. Additionally, integrated core activity with lower quarter control is a “no brainer”. Regarding acetabulo-femoral amnesia this is inspired by Eric Franklin’s movement education work  Most people have no idea where their hip is. When they learn it’s actual location it becomes much easier to train the hip hinge and activate the posterior chain. This is an example of the neuro-matrix whereby an new neural signature is created via motor control training.
2. Functionally, what muscles are being inhibited that are leading to this condition? Is it a class Janda lower cross pattern?
FAI is not caused by muscle imbalance or at least this is not proven. However, muscular compensations are sure to be present. Gluteal inhibition undoubtedly. I would not limit my focus to just the posterior chain, but also ensure frontal plane stability and functional core control.  Janda turned our attention to the gluteus maximus, gluteus medius & abdominal wall with his revolutionary work from the 1960’s. This is why he is considered the Father of Rehabilitation Medicine.
3.What are some functional movements and therapies that trainers and strength coaches can begin to integrate with their athletes and clients?
First of all identify quad dominance. Check where patients “feel” squats, lunges, balance reaches, etc.. Most feel their anterior thighs first. Then, commence a posterior chain facilitation program. There are “many roads to Rome”. Find what works best. I am not about methods, but principles. If you know the goal you will find the means. A few ideas though would include – 2 & 1 LDLs; functional reaches; 2 & 1 leg box squats; reverse lunge steps; Rear foot elevated split squats; monster walks, and bridges.
Second, ensure integrated core-lower quarter control. Planks; Supine foam roll marching with med ball chest press; 2/1 Hamstring bridges & curls with the gym ball; Kolar dying bug vs the wall; and Nordic or Russian eccentric hamstring lowers.
Third, determine if lateral hip stability is present. Check first in single leg balance if there is pelvic unleveling. Then, look at single leg squats to see if pelvic unleveling leading to medial knee collapse occurs. Third, check side lying hip abduction to determine if there is gluteus medius insufficiency or asymtric strength. Training can include clam shells; lateral band walks; posterior-lateral balance reaches (5:00 or 7:00).
If these 3 fundamental components can be mastered, then to maximize functional stability plyometric control must be ensured. This is essential for athletes as a functional test of improved stability resulting from the initial rehab. If the stretch-shortening cycle is sluggish overload will occur at the “weakest link” – achilles, anterior knee, or hip. Start with 2 legs jump squats; scissor lunges; and 360 degree jump squats. Progress to lateral hops, diagonal X-Hops; and single leg hop and holds.
For functional training once plyometric stability is ensured begin to build power by utilizing triple extension exercises such as Waterbury’s High Pull
 The key is to train for power by finding the athlete’s 10 RM then train only as many reps as can be performed at top speed without breaking form. The 1st set might by 6-7 reps. When performed as part of  circuit of perhaps 3 exercises with each successive set the reps performed will drop before speed or form decays. 5 sets are ideal and if the initial RM was chosen wisely a Russian Reverse Pyramid of training will have occurred naturally.
For instance, Set 1 – 6 reps; Set 2 – 5 reps; Set 3 – 4 reps; Set 4 – 3 reps; Set 5 – 2 reps. Grand Total of reps might be 15-20 reps. To increase power start by finding the 7-8 RM, so Set 1 at top speed is likely to be only 5 reps. Individualize this to the patient’s capabilities and demands.
That’s some fantastic stuff from Dr.Liebenson. He’ll be hosting a in-depth seminar at Peak Performance in NYC in October. Check out his seminar schedule to find when you can see him speak.
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