Hip Impingement Location in Maximal Hip Flexion in Patients With Femoroacetabular Impingement With and Without Femoral Retroversion

Am J Sports Med. 2022 Sep;50(11):2989-2997. doi: 10.1177/03635465221110887. Epub 2022 Aug 29.


Background: Symptomatic patients with femoroacetabular impingement (FAI) have limitations in daily activities and sports and report the exacerbation of hip pain in deep flexion. Yet, the exact impingement location in deep flexion and the effect of femoral version (FV) are unclear.

Purpose: To investigate the acetabular and femoral locations of intra- or extra-articular hip impingement in flexion in patients with FAI with and without femoral retroversion.

Study design: Cross-sectional study; Level of evidence, 3.

Methods: An institutional review board-approved retrospective study involving 84 hips (68 participants) was performed. Of these, symptomatic patients (37 hips) with anterior FAI and femoral retroversion (FV <5°) were compared with symptomatic patients (21 hips) with anterior FAI (normal FV) and with a control group (26 asymptomatic hips without FAI and normal FV). All patients were symptomatic, had anterior hip pain, and had positive anterior impingement test findings. Most of the patients had hip/groin pain in maximal flexion or deep flexion or during sports. All 84 hips underwent pelvic computed tomography (CT) to measure FV as well as validated dynamic impingement simulation with patient-specific CT-based 3-dimensional models using the equidistant method.

Results: In maximal hip flexion, femoral impingement was located anterior-inferior at 4 o'clock (57%) and 5 o'clock (32%) in patients with femoral retroversion and mostly at 5 o'clock in patients without femoral retroversion (69%) and in asymptomatic controls (76%). Acetabular intra-articular impingement was located anterior-superior (2 o'clock) in all 3 groups. In 125° of flexion, patients with femoral retroversion had a significantly (P < .001) higher prevalence of anterior extra-articular subspine impingement (54%) and anterior intra-articular impingement (89%) compared with the control group (29% and 62%, respectively).

Conclusion: Knowing the exact location of hip impingement in deep flexion has implications for surgical treatment, sports, and physical therapy and confirms previous recommendations: Deep flexion (eg, during squats/lunges) should be avoided in patients with FAI and even more in patients with femoral retroversion. Patients with femoral retroversion may benefit and have less pain when avoiding deep flexion. For these patients, the femoral location of the impingement conflict in flexion was different (anterior-inferior) and distal to the cam deformity compared with the location during the anterior impingement test (anterior-superior). This could be important for preoperative planning and bone resection (cam resection or acetabular rim trimming) during hip arthroscopy or open hip preservation surgery to ensure that the region of impingement is appropriately identified before treatment.

Keywords: extra-articular hip impingement; femoral retroversion; femoral torsion; femoral version; femoroacetabular impingement (FAI); hip arthroscopy; subspine impingement.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cross-Sectional Studies
  • Femoracetabular Impingement* / diagnostic imaging
  • Femoracetabular Impingement* / surgery
  • Hip Joint / diagnostic imaging
  • Hip Joint / surgery
  • Humans
  • Pain
  • Retrospective Studies