Raiyyan Tahsan

Raiyyan Tahsan
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TC(1081).(05).Orthopedics Case No 157:- Femoroacetabular Impingement Syndrome

Femoroacetabular Impingement Syndrome — FAI

1) Definition / সংজ্ঞা

Femoroacetabular impingement syndrome হলো hip joint–এর একটি motion-related painful disorder, যেখানে femoral head–neck junction এবং acetabular rim–এর মধ্যে abnormal bony contact হয়। এই repeated contact থেকে labral tear, chondral damage, pain, stiffness এবং early hip osteoarthritis হতে পারে। রোগ নির্ণয়ে শুধু X-ray morphology যথেষ্ট নয়; symptoms + positive clinical signs + imaging findings—এই তিনটি একসাথে থাকতে হয়। Warwick Agreement এ এটিই consensus definition হিসেবে ব্যবহৃত হয়েছে।

AAOS অনুযায়ী hip joint হলো ball-and-socket joint; acetabulum socket, femoral head ball, আর acetabular rim-এর fibrocartilage ring হলো labrum। FAI-তে extra bone বা abnormal shape এর কারণে hip movement-এ bones rub করে এবং cartilage/labrum damage হতে পারে।

3) Cause / Etiology — কারণগুলো

FAI সাধারণত developmental hip morphology–এর কারণে হয়; অর্থাৎ childhood/adolescent growth period-এ hip bone shape এমনভাবে তৈরি হয় যে পরে movement-এর সময় impingement হয়। AAOS-ও বলছে FAI সাধারণত childhood growing years-এ hip bones abnormal shape নেওয়ার কারণে হয়।

A. Cam type

  • Femoral head-neck junction গোল না থাকা
    Femoral head perfectly spherical না হলে flexion/internal rotation-এ acetabular rim-এর সঙ্গে ঘষা লাগে।
  • Cam bump / pistol-grip deformity
    Femoral head-neck junction-এ bony prominence থাকে; এটি acetabular cartilage ও labrum-এ repetitive shear injury করে।
  • Athletic adolescent hip loading
    Football, hockey, cricket fast bowling, martial arts, deep squat/lunge-heavy training—adolescence-এ repeated high hip flexion/loading cam morphology-এর risk বাড়াতে পারে। Exercise FAI “cause” করে—এটা সরলভাবে বলা ঠিক নয়; বরং abnormal morphology থাকলে symptoms earlier আসে। AAOS বলছে athletic people hip joint বেশি vigorously use করলে pain earlier শুরু হতে পারে, কিন্তু exercise নিজে FAI cause করে না।

B. Pincer type

  • Acetabular overcoverage
    Acetabulum femoral head-কে অতিরিক্ত cover করলে femoral neck rim-এ বারবার লাগে।
  • Acetabular retroversion / crossover morphology
    Socket-এর orientation abnormal হলে anterior rim impingement হয়।
  • Coxa profunda / protrusio acetabuli
    Deep socket morphology-তে pincer impingement হতে পারে।

C. Combined type

  • Cam + pincer একসাথে থাকে। Clinically এটি খুব common; labral tear ও cartilage damage বেশি হতে পারে।

D. Secondary / acquired associations

  • SCFE / slipped capital femoral epiphysis–এর পর residual deformity
  • Legg-Calvé-Perthes disease–এর sequelae
  • Malunited femoral neck fracture
  • Post-traumatic deformity
  • Previous pelvic/femoral osteotomy বা iatrogenic overcoverage
  • Genetic/familial hip morphology tendency

4) Symptoms — লক্ষণগুলো

AAOS অনুযায়ী FAI-তে common symptoms হলো pain, stiffness, limping; pain সাধারণত groin area-তে হয়, তবে lateral hip-এও হতে পারে; twisting/squatting sharp pain trigger করতে পারে।

  • Groin pain / anterior hip pain
    সবচেয়ে classic symptom। রোগী অনেক সময় “C-sign” দিয়ে hip joint ধরে pain দেখায়।
  • Activity-related pain
    Squatting, sitting low chair, getting in/out of car, stairs, running, kicking, cycling, prolonged sitting—এসবের পরে pain বাড়ে।
  • Deep flexion pain
    Hip flexion + adduction + internal rotation position-এ pain বাড়ে।
  • Clicking / catching / locking sensation
    Labral tear থাকলে mechanical catching, painful click, giving-way হতে পারে।
  • Stiffness / reduced ROM
    Internal rotation ও flexion কমে যায়; socks/shoes পরা কষ্টকর হতে পারে।
  • Limping / altered gait
    Pain বেশি হলে antalgic gait হয়।
  • Buttock বা lateral hip referred pain
    সব pain groin-এ থাকবে এমন নয়; gluteal/lateral thigh pain হতে পারে।
  • Symptoms fluctuate
    Rest দিলে কমে, high-load activity করলে বাড়ে।

5) Clinical diagnosis — clinically কীভাবে diagnose করবেন

FAI syndrome diagnose করতে history + examination + imaging মিলিয়ে সিদ্ধান্ত নিতে হবে। Warwick Agreement অনুযায়ী diagnosis-এর জন্য appropriate symptoms, positive clinical signs ও imaging findings দরকার।

A. History

  • Young adult / active adult hip pain
  • Groin-dominant pain
  • Pain with sitting, squatting, pivoting, sports
  • Mechanical symptoms: click, catch, lock
  • Previous SCFE/Perthes/hip trauma history
  • Red flags: fever, night pain, weight loss, acute inability to bear weight, malignancy/infection suspicion

B. Examination

  • Gait assessment: antalgic gait, Trendelenburg gait
  • ROM: hip flexion, internal rotation, adduction—বিশেষ করে internal rotation কমে যায়
  • FADIR test
    Flexion + Adduction + Internal Rotation করলে groin pain reproduce হলে positive। AAOS impingement test-এ knee chest-এর দিকে এনে inward rotate করলে pain reproduce হলে positive বলে।
  • FABER test
    Hip/SI pathology differentiate করতে useful; anterior groin pain হলে intra-articular hip pathology support করে।
  • Log-roll test
    Intra-articular hip irritability assess।
  • Scour test / quadrant test
    Labral/chondral pathology suspicion।
  • Stinchfield resisted straight-leg raise
    Intra-articular hip pain reproduce হতে পারে।
  • Neurovascular + lumbar spine exam
    Lumbar radiculopathy, SI joint, athletic pubalgia exclude করতে হবে।

6) Investigations — specific workup

First-line imaging

  • Plain X-ray pelvis AP view
    Cam/pincer morphology, joint space, osteoarthritis, dysplasia assess।
  • Dunn lateral view 45° or 90° / frog-leg lateral / cross-table lateral
    Cam lesion, alpha angle, head-neck offset assess।
  • Key radiographic parameters
    • Alpha angle: commonly >55° suspicious for cam morphology.
    • Lateral center-edge angle, LCEA: >40° pincer/overcoverage suggest করতে পারে; <20–25° dysplasia suggest করে।
    • Crossover sign, ischial spine sign, posterior wall sign: acetabular retroversion/pincer clues।
    • Tönnis grade + joint space: OA severity; joint space <2 mm হলে arthroscopy outcome poor হতে পারে।

Updated review অনুযায়ী FAI assessment-এ plain radiograph primary imaging modality; alpha angle ও lateral center-edge angle severity quantify করতে ব্যবহৃত হয়।

Soft tissue imaging

  • MRI hip
    Labral tear, cartilage lesion, bone marrow edema, alternative diagnosis।
  • MR arthrogram
    Labral tear detect করতে conventional MRI-এর চেয়ে বেশি sensitive হতে পারে।
  • CT scan / 3D CT
    Pre-operative bony morphology mapping, femoral/acetabular version, cam resection planning।

AAOS বলছে X-ray abnormal bone shape/arthritis দেখাতে পারে, CT exact abnormal shape দেখায়, MRI labrum ও articular cartilage damage identify করতে সাহায্য করে।

Diagnostic injection

  • Image-guided intra-articular local anaesthetic injection
    Injection-এর পরে temporary pain relief হলে pain source hip joint হওয়া support করে। AAOS এটিকে diagnostic confirmation হিসেবে উল্লেখ করেছে।

Lab tests

Routine FAI diagnosis-এ lab test লাগে না। তবে inflammatory/infective/red flag থাকলে CBC, ESR, CRP, RF/anti-CCP, HLA-B27, uric acid, etc. clinical context অনুযায়ী করা যায়।

7) Differential diagnosis

  • Hip osteoarthritis
  • Acetabular labral tear without FAI
  • Developmental dysplasia of hip
  • Avascular necrosis of femoral head
  • Stress fracture femoral neck
  • Iliopsoas tendinopathy/snapping hip
  • Greater trochanteric pain syndrome
  • Lumbar radiculopathy
  • Sacroiliac joint pathology
  • Athletic pubalgia / sports hernia
  • Inflammatory arthritis, septic arthritis, transient synovitis—context অনুযায়ী

8) Complications — রোগের জটিলতা

  • Acetabular labral tear
    Repeated impingement labrum-কে compress/shear করে। এতে clicking, catching, locking pain হয়।
  • Chondral damage
    Acetabular cartilage ক্ষয় শুরু হয়; joint surface rough হয়ে pain বাড়ে।
  • Early hip osteoarthritis
    Untreated symptomatic FAI দীর্ঘদিন চললে cartilage breakdown থেকে early OA হতে পারে। AAOS-ও বলছে extra bone contact labral tear ও articular cartilage breakdown ঘটাতে পারে।
  • Reduced hip ROM
    Internal rotation/flexion কমে daily activity সীমাবদ্ধ হয়।
  • Activity limitation / sport restriction
    Running, squatting, long sitting, pivoting sports সীমিত হয়।
  • Secondary back/knee pain
    Altered gait ও hip mechanics-এর কারণে low back, SI joint, knee pain develop করতে পারে।
  • Psychological impact
    Young active patient-এ chronic pain, sports withdrawal, sleep disturbance, anxiety/frustration হতে পারে।

9) Treatment management — guideline-based approach

FAI structural morphology drug দিয়ে “cure” হয় না। Drug treatment হলো pain/inflammation control; core treatment হলো activity modification + structured physiotherapy, এবং refractory structural symptomatic cases-এ hip preservation surgery।

A. Conservative treatment — first line

AAOS nonsurgical treatment হিসেবে activity modification, NSAID, physical therapy উল্লেখ করেছে; conservative therapy mild–moderate cases-এ first-line হিসেবে ব্যবহৃত হয়।

  • Activity modification
    • Deep squat, low chair, cross-leg sitting, aggressive pivoting, high hip flexion drills temporarily avoid।
    • Pain-free ROM-এর মধ্যে activity maintain।
  • Physiotherapy: 8–12 weeks minimum
    • Hip abductor, external rotator, gluteal strengthening
    • Core stabilization
    • Pelvic control, neuromuscular training
    • Hip flexor/adductor overuse কমানো
    • Movement retraining: squat, lunge, running mechanics
    • Avoid forceful end-range impingement stretching
  • Weight optimization
    • Hip joint load কমায়।
  • Ice/heat
    • Acute flare-এ ice; muscle spasm/stiffness-এ heat।
  • Image-guided injection
    • Diagnostic + short-term therapeutic role; repeated steroid injection cartilage risk বিবেচনায় cautious।

B. Surgical management — when needed

  • Indication
    • 3–6 months good conservative care সত্ত্বেও persistent pain/function limitation
    • Imaging-confirmed cam/pincer morphology + labral/chondral lesion
    • Patient young/active and no advanced OA
  • Procedures
    • Hip arthroscopy
    • Femoral osteochondroplasty/cam resection
    • Acetabuloplasty/pincer rim trimming
    • Labral repair/refixation; debridement only selected cases
    • Chondral procedure if needed
  • Avoid/poor candidates
    • Advanced OA, severe cartilage loss, joint space <2 mm
    • Severe dysplasia without correction
    • Uncontrolled infection, systemic contraindication
  • AAOS বলছে অনেক FAI arthroscopic surgery দিয়ে treat করা যায়, যেখানে labrum/cartilage damage repair/clean করা এবং acetabular rim/femoral bump shave করা হয়।

10) Pharmacological management — Bangladesh prescription-focused

Important clinical note: নিচের drug list symptomatic treatment-এর জন্য। একসাথে একাধিক oral NSAID দেবেন না। CKD, PUD/GI bleed, uncontrolled HTN, IHD/stroke risk, anticoagulant use, asthma-NSAID sensitivity, pregnancy—এসব থাকলে NSAID avoid/modify করবেন।

1. Generic name: Paracetamol / Acetaminophen

  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Para-aminophenol derivative; central analgesic
  • Why used in FAI: Mild–moderate pain relief; anti-inflammatory effect weak, তাই inflammation dominant flare-এ NSAID বেশি effective হতে পারে।
  • Adult dose: 500–1000 mg orally every 6–8 hours PRN; maximum 3–4 g/day. MedEx Napa monograph adult dose 1–2 tablets every 4–6 hours, maximum 4 g/day উল্লেখ করেছে।
  • Duration: 3–7 days PRN; chronic daily use হলে LFT/risk review।
  • Bangladesh available brand examples: Napa 500 mg, Fast 500 mg, Feva 500 mg, M-Pol 500 mg, Acep 500 mg, Fast XR 665 mg. MedEx-এ Napa 500 mg Beximco, Fast 500 mg ACME, Feva 500 mg, M-Pol 500 mg ইত্যাদি listed আছে।
  • Side effects: Usually mild; rash, allergy, rare thrombocytopenia/leucopenia; overdose → severe hepatotoxicity.
  • Interactions: Alcohol, barbiturates, anticonvulsants, rifampicin-type enzyme inducers hepatic toxicity risk বাড়াতে পারে; warfarin with prolonged high-dose use INR বাড়াতে পারে। MedEx alcohol/enzyme inducer interaction উল্লেখ করেছে।

2. Generic name: Ibuprofen

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Non-selective NSAID; propionic acid derivative
  • Why used in FAI: Acute painful inflammatory flare, synovitis-like pain, activity-related pain কমাতে।
  • Adult dose: 400 mg orally 2–3 times daily after food; maximum 1200 mg/day for short-term routine use. MedEx adult 200–400 mg single dose 3–4 times/day, max 1200 mg/day উল্লেখ করেছে।
  • Duration: 3–5 days; severe flare হলে 7–10 days with review।
  • Bangladesh available brand examples: Advel 400 mg, Alflam 400 mg, Anaflam 400 mg, Brofen 400 mg, Flamex suspension/tablet. MedEx ibuprofen brand listে এগুলো listed আছে।
  • Side effects: Dyspepsia, GI ulcer/bleeding, dizziness, headache, edema, renal impairment, bronchospasm in NSAID-sensitive asthma. MedEx common side effects headache, vertigo, fatigue, GI ulcer উল্লেখ করেছে।
  • Interactions: Warfarin/antiplatelet/SSRI/steroid → GI bleeding risk; ACEI/ARB + diuretic → AKI risk; lithium/methotrexate toxicity; avoid other NSAIDs. MedEx এ ACE inhibitors, diuretics, lithium, warfarin, antiplatelets, methotrexate, corticosteroids interaction উল্লেখ আছে।

3. Generic name: Naproxen / Naproxen sodium

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Non-selective NSAID; propionic acid derivative
  • Why used in FAI: Longer duration NSAID; sports-related hip pain flare, inflammatory pain, nocturnal ache কমাতে।
  • Adult dose: 250–500 mg orally twice daily after food; maximum 1000 mg/day. MedEx adult osteoarthritis/ankylosing spondylitis dose 500–1000 mg/day in two divided doses উল্লেখ করেছে।
  • Duration: 5–10 days; chronic use avoid unless monitored।
  • Bangladesh available brand examples: Naproxen 500 mg, Naproxin 250/500 mg, Naxin 250/500 mg, Nuprafen 250/500 mg, Naprox/Napryn gel 10% w/w. MedEx brand listে এসব listed আছে।
  • Side effects: Heartburn, abdominal pain, nausea, diarrhea, dyspepsia, headache, vertigo, drowsiness, edema/palpitation.
  • Interactions: Warfarin/SSRI → GI bleed; methotrexate toxicity; ACE inhibitor effect কমাতে পারে; diuretic effect কমে; aspirin adverse effects বাড়ে।

4. Generic name: Diclofenac sodium

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Non-selective NSAID; phenylacetic acid derivative
  • Why used in FAI: Short acute flare, peri-articular soft-tissue inflammation, painful movement control।
  • Adult dose: 50 mg orally 2–3 times daily after food; SR 100 mg once daily; maximum 150 mg/day. MedEx diclofenac adult dose 75–150 mg/day in divided doses এবং SR 1 tablet daily উল্লেখ করেছে।
  • Duration: 3–5 days preferred; high CV/GI/renal risk হলে avoid।
  • Topical option: Diclofenac gel 1% 2–4 g locally 3–4 times/day; hip joint deep হওয়ায় effect limited, তবে superficial peri-trochanteric pain থাকলে helpful হতে পারে।
  • Bangladesh available brand examples: Diclofen 50 mg, Diclofen SR 100 mg, Diclorex 50 mg/75 mg injection, Fastfit gel 1%, Fengel gel/tablet. MedEx diclofenac sodium brand listে এসব listed আছে।
  • Side effects: Epigastric pain, nausea, diarrhea, dizziness, headache, edema, rash; GI ulcer/bleed, renal injury, CV risk.
  • Interactions: Lithium/digoxin ↑, anticoagulant bleeding risk, cyclosporine nephrotoxicity, methotrexate toxicity, quinolone seizure risk, other NSAID/steroid adverse effect ↑।

5. Generic name: Etoricoxib

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Selective COX-2 inhibitor NSAID
  • Why used in FAI: NSAID-needed pain flare, comparatively less gastric irritation tendency; তবে CV/HTN risk বেশি বিবেচ্য।
  • Adult dose: 60 mg once daily for musculoskeletal inflammatory pain; severe short flare 90 mg once daily selected cases. Use lowest effective dose.
  • Duration: 3–7 days; post-dental pain dose 90 mg daily max 3 days MedEx-এ উল্লেখ আছে; OA dose 30–60 mg daily।
  • Bangladesh available brand examples: Oricox 30/60/90/120 mg, Etorix 60/90/120 mg, Recox 60/90/120 mg, Ribox 60/90/120 mg, Etovan 60/90/120 mg, Rito 60/90/120 mg. MedEx etoricoxib brand listে এগুলো listed আছে।
  • Side effects: Dyspepsia, edema, hypertension, headache, dizziness; MI/stroke risk, renal impairment, fluid retention.
  • Contraindication / avoid: IHD, stroke/TIA, peripheral arterial disease, uncontrolled hypertension, severe HF, pregnancy/lactation, significant renal/hepatic disease—MedEx contraindication listেও এসব উল্লেখ আছে।
  • Interactions: Warfarin/anticoagulant monitoring; ACEI/ARB/diuretic renal risk; lithium ↑; other NSAID avoid; steroid/antiplatelet GI risk।

6. Generic name: Aceclofenac

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; diclofenac analogue
  • Why used in Bangladesh prescriptions: Musculoskeletal pain, osteoarthritis-type pain, lumbago/trauma pain—Bangladesh practice-এ commonly used.
  • Adult dose: 100 mg orally twice daily after food; SR 200 mg once daily.
  • Duration: 3–7 days; longer হলে renal/GI/CV monitoring।
  • Bangladesh available brand examples: Flexi 100 mg/SR 200 mg, Movex 100 mg/SR 200 mg, Mervan 100 mg/SR 200 mg, Reservix SR 200 mg, Paino 100 mg, Nofenac 100 mg. MedEx aceclofenac brand listে এগুলো listed আছে।
  • Side effects: Dyspepsia, abdominal pain, nausea, diarrhea, dizziness; GI bleed, renal impairment, edema, BP rise.
  • Interactions: Same NSAID class—warfarin/antiplatelet/SSRI/steroid bleeding risk, ACEI/ARB+diuretic AKI risk, lithium/methotrexate toxicity, other NSAID avoid।

7. Generic name: Pantoprazole

  • Therapeutic category: Anti-ulcerant, gastroprotective
  • Pharmacological class: Proton pump inhibitor — PPI
  • Why used in FAI prescription: NSAID-induced gastritis/ulcer risk কমাতে, বিশেষ করে dyspepsia/PUD history/age/high-dose NSAID/steroid/anticoagulant use থাকলে।
  • Adult dose: 40 mg orally once daily 30 minutes before breakfast while NSAID is used; high-risk patientsে duration individualized.
  • Duration: NSAID course চলাকালীন 5–14 days; established ulcer/GERD থাকলে 4–8 weeks.
  • Bangladesh available brand examples: Pantonix 20/40 mg, Pantid 20/40 mg, Pantobex 20/40 mg, Pantogut 20/40 mg, Pantolok 20/40 mg, Pantoraz 20/40 mg; IV forms 40 mg/vial available. MedEx pantoprazole sodium brand listে এগুলো listed আছে।
  • Side effects: Headache, diarrhea/constipation, nausea, abdominal discomfort; long-term useে hypomagnesemia, B12 deficiency, fracture risk, C. difficile risk.
  • Interactions: Clopidogrel interaction concern omeprazole-এর তুলনায় pantoprazole কম; warfarin/MTX high dose monitoring; acid-dependent absorption drugs যেমন ketoconazole/itraconazole কমতে পারে।

8. Generic name: Triamcinolone acetonide injection

  • Therapeutic category: Anti-inflammatory steroid injection
  • Pharmacological class: Synthetic glucocorticoid corticosteroid
  • Why used in FAI: Image-guided intra-articular hip injection হিসেবে short-term pain relief এবং diagnostic/therapeutic support; definitive cure নয়।
  • Dose: Hip joint intra-articular 20–40 mg single injection, usually ultrasound/fluoroscopy guided; local anaesthetic mixed হতে পারে। Repeat injection cautious; frequent repeated steroid injection avoid।
  • Bangladesh available brand examples: Alfacort 40 mg/ml, Cenolon 40 mg/ml, Cynocort 40 mg/ml, Emicort 40 mg/ml, Intracort 40 mg/ml, Trialon 40 mg/ml, Triamon 40 mg/ml, Trimcort 40 mg/ml. MedEx IM/IA injection listে এগুলো listed আছে।
  • Drug description: Synthetic glucocorticoid with anti-inflammatory action; MedEx বলছে formulation IM ও intra-articular use-এর জন্য suitable।
  • Side effects: Post-injection flare, infection, skin/subcutaneous atrophy, transient hyperglycemia, facial flushing, BP rise, rare avascular necrosis/tendon rupture; systemic steroid effects possible.
  • Interactions: Warfarin response alter করতে পারে; antidiabetic dose adjustment লাগতে পারে; NSAID + steroid → GI risk ↑; enzyme inducers যেমন phenytoin/carbamazepine/rifampicin steroid level কমায়; ketoconazole/macrolide steroid effect বাড়াতে পারে।

9. Generic name: Methylprednisolone acetate injection

  • Therapeutic category: Anti-inflammatory steroid injection
  • Pharmacological class: Glucocorticoid corticosteroid
  • Why used in FAI: Triamcinolone alternative হিসেবে intra-articular steroid injection; synovitis-like inflammatory pain short-term reduce করতে।
  • Dose: 20–40 mg intra-articular hip single dose, image-guided; specialist procedure.
  • Bangladesh available brand examples: Depo-Medrol 40 mg/ml, Depo-Medrol 80 mg/2 ml, Depo-pred 40 mg/ml, Depomed 40 mg/ml or 80 mg/2 ml, Medrol 40 mg/ml or 80 mg/2 ml, Methsolon 40 mg/ml, Uni-Medrol 80 mg/2 ml. MedEx methylprednisolone acetate brand listে এগুলো listed আছে।
  • Side effects/interactions: Similar to corticosteroids above—hyperglycemia, infection risk, flare, skin atrophy, adrenal suppression if systemic exposure, warfarin/antidiabetic/NSAID interactions.

10. Generic name: Lidocaine / Lignocaine injection

  • Therapeutic category: Local anaesthetic
  • Pharmacological class: Amide-type local anaesthetic
  • Why used in FAI: Diagnostic intra-articular injection—pain relief হলে hip joint pain generator confirm করতে সাহায্য করে; steroid injection-এর সাথে short-term anaesthesia।
  • Dose: 1–2% lidocaine, usually 2–5 ml intra-articular under image guidance; total safe dose patient weight অনুযায়ী calculate করতে হবে।
  • Bangladesh available brand example: Lidocaine 2% injection; MedEx product page-এ Lidocaine 2% injection listed এবং amide local anaesthetic with fast onset হিসেবে described।
  • Side effects: Local numbness, allergy rare; intravascular injection/overdose → tinnitus, metallic taste, seizures, arrhythmia, hypotension.
  • Interactions: Class I antiarrhythmics, beta-blockers/cimetidine may increase toxicity risk; other local anaesthetic additive toxicity।

11) Bangladesh doctor prescription pattern — FAI-তে commonly used drug list

Bangladesh orthopaedic/PMR practice-এ FAI suspected hip painের জন্য সাধারণত drugগুলো symptom control-এর জন্য দেওয়া হয়:

  • Paracetamol 500 mg — baseline pain control; NSAID contraindicated হলে safer option।
  • NSAID short course — Ibuprofen 400 mg / Naproxen 500 mg / Diclofenac 50 mg / Aceclofenac 100 mg / Etoricoxib 60–90 mg
    Purpose: inflammatory pain, movement pain, activity flare কমানো।
  • PPI gastroprotection — Pantoprazole 40 mg
    Purpose: NSAID-induced gastritis/ulcer prevention।
  • Topical NSAID — Diclofenac gel 1%
    Purpose: superficial peri-hip soft tissue tenderness থাকলে adjunct।
  • Image-guided intra-articular steroid injection — Triamcinolone acetonide 40 mg/ml বা Methylprednisolone acetate 40 mg/ml
    Purpose: persistent pain flare, diagnostic-therapeutic trial; repeated routine use নয়।
  • Local anaesthetic injection — Lidocaine 1–2%
    Purpose: diagnostic confirmation of intra-articular pain source।

Not routine for FAI: antibiotics, uric-acid lowering drugs, pregabalin, opioids, glucosamine/chondroitin, long-term muscle relaxant—unless separate diagnosis থাকে।

12) Prevention — কীভাবে করবেন

FAI morphology পুরোপুরি prevent করা যায় না, কারণ bone shape সাধারণত growth period-এ তৈরি হয়। তবে symptoms/flare এবং joint damage risk কমানো যায়।

  • Deep squat, extreme hip flexion, forced internal rotation avoid/modify
  • Sports technique correction
    • Running stride, kicking mechanics, bowling action, gym squat depth modify।
  • Strength program
    • Gluteus medius/maximus, hip external rotator, core strengthening।
  • Mobility but not aggressive impingement stretching
    • Painful end-range stretching labrum irritate করতে পারে।
  • Training load management
    • Sudden high-volume running/cycling/squatting avoid।
  • Healthy body weight
    • Hip load কমায়।
  • Early evaluation
    • Groin pain + clicking + reduced internal rotation থাকলে early X-ray/MRI evaluation।
  • Post-treatment rehab adherence
    • Surgery হলেও rehab ছাড়া outcome poor হতে পারে।

Overview / Summary

FAI হলো symptomatic hip impingement যেখানে cam, pincer বা combined bony morphology repeated contact তৈরি করে। Core diagnosis: symptoms + clinical signs + imaging। Main symptoms: groin pain, stiffness, clicking/catching, squat/sitting/twisting pain। Untreated symptomatic FAI labral tear, cartilage damage এবং early OA করতে পারে। Treatment প্রথমে activity modification + structured physiotherapy; drug হলো pain control only; persistent structurally confirmed casesে hip arthroscopy/labral repair/osteochondroplasty বিবেচ্য।

Actionable Plan / Steps

  1. History + exam: C-sign groin pain, FADIR/FABER, ROM, gait, lumbar/SI screen।
  2. Initial imaging: AP pelvis + Dunn lateral/cross-table lateral X-ray।
  3. If symptoms persist: MRI/MR arthrogram for labrum/cartilage।
  4. Start conservative care: 8–12 weeks supervised physiotherapy + activity modification।
  5. Medication: Paracetamol ± one NSAID short course; high GI risk হলে pantoprazole।
  6. Diagnostic uncertainty: Image-guided intra-articular local anaesthetic ± steroid injection।
  7. Refer hip preservation/orthopaedic surgeon: persistent pain >3–6 months, imaging-confirmed cam/pincer, labral tear, no advanced OA।
  8. Avoid: repeated steroid injections, long-term NSAID without monitoring, multiple NSAIDs together।

Reference List — Textbook + Guideline + DOI

Textbooks

  • Apley & Solomon’s System of Orthopaedics and Trauma, latest available edition, Hip disorders / young adult hip pain / femoroacetabular impingement section.
  • Campbell’s Operative Orthopaedics, latest available edition, Hip arthroscopy and femoroacetabular impingement chapters.
  • Gray’s Anatomy: The Anatomical Basis of Clinical Practice, latest available edition, Hip joint anatomy chapter.
  • Essentials of Musculoskeletal Care, AAOS, hip pain / femoroacetabular impingement section.

Guidelines / Consensus

  • Griffin DR, Dickenson EJ, O’Donnell J, et al. The Warwick Agreement on femoroacetabular impingement syndrome: an international consensus statement. British Journal of Sports Medicine. 2016;50:1169–1176. DOI: 10.1136/bjsports-2016-096743.
  • AAOS OrthoInfo. Femoroacetabular Impingement. Anatomy, symptoms, diagnosis, imaging and treatment overview.

Peer-reviewed journals with DOI

  • Gómez-Verdejo F, Alvarado-Solorio E, et al. Review of femoroacetabular impingement syndrome. Journal of Hip Preservation Surgery. 2024;11(4):315–322. DOI: 10.1093/jhps/hnae034.
  • Fortier LM, Popovsky D, et al. An Updated Review of Femoroacetabular Impingement Syndrome. Orthopedic Reviews. 2022;14(3). DOI: 10.52965/001c.37513.
  • Pennock AT, Bomar JD, Johnson KP, et al. Nonoperative Management of Femoroacetabular Impingement. American Journal of Sports Medicine. 2018;46(14):3415–3422. DOI: 10.1177/0363546518804805.
  • Zhu Y, Su P, Xu T, Zhang L, Fu W. Conservative therapy versus arthroscopic surgery of FAI syndrome: systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2022;17:296. DOI: 10.1186/s13018-022-03187-1.
  • Gatz M, Driessen A, Eschweiler J, Tingart M, Migliorini F. Arthroscopic surgery versus physiotherapy for femoroacetabular impingement: meta-analysis. European Journal of Orthopaedic Surgery & Traumatology. 2020;30:1151–1162. DOI: 10.1007/s00590-020-02675-6.

Md.Rafiqul Islam Lipu,Date:-24-06-2026 Wednesday,Time:-04-22-12 Pm

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