As we're starting, my disclosures are listed in the handout or at least on the website. Oh, thank you very much. Again, my disclosures are available. I think to reflect on what Shane was speaking about, I would more accurately reframe this topic as it's not just about pincer and cam or even just the imaging. Chris spearheaded the topic, the data that we reported from the NFL Combine, where 90% of the athletes coming through the NFL Combine have some radiographic feature of FAI, so oftentimes fairly ubiquitous. Where do we see asymptomatic, evaluate asymptomatic FAI the most? And it's when we see somebody who has an asymptomatic contralateral hip when we're assessing their painful side, and there's three observations I tend to make on this. First of all, as the surgical side recovers, oftentimes they figure out that that asymptomatic side wasn't so asymptomatic after all, and it tells you how painful this disorder is that oftentimes patients willingly want to subject themselves to the operation on the other side. I tell them not to get too stressed out if the asymptomatic side starts to have symptoms during the early postoperative recovery. Most times that will settle down as the surgical side recovers. Then third, if the other side becomes symptomatic in the future, any decisions you're going to make are going to be largely influenced by how satisfied they are with the first side that you've operated on. So what's the number one indication for hip arthroscopy? Well it's pain, and oftentimes it's functional impairment, but it's functional impairment secondary to pain. And the only thing you have to remember from this talk is that it's hard to make someone who's asymptomatic feel better. But asymptomatic is a relative term that we'll reflect on more in a moment or so. Duration of symptoms are important because there are numerous studies reporting poor results with longer duration of symptoms, and implies that maybe we should be intervening earlier is preferable, but do you really need to operate on these right away? But remember, FAI is a chronic process. Regardless of the suddenness of the onset of their symptoms, it's still the culmination of the cumulative effect of a disorder that's been present since childhood, and they've been compensating for it long before the hip joint first became symptomatic. These compensatory problems oftentimes obscure the presence of the underlying joint problem, and probably explains John Clohissy's observation that young adults with non-arthritic hip disorders see an average of 4.2 healthcare providers before a diagnosis is established. Gans talks about cam being the silent killer of the hip as it selectively destroys the relatively adenuroarticular cartilage before the densely innervated labrum starts to fail. But looking at it in a different, this old fable about it, that if you take a frog and drop it in a pan of boiling water, it's just going to jump out. But if you take a frog and put it in that water and slowly increase the temperature, they'll sit there and cook themselves to death, not being aware of what's happening around them, and that's what happens a lot of times with FAI. We use in-office ultrasonography a lot. Most of these hip problems are not isolated. It gives you a real-time assessment for the clinician, oftentimes more importantly the patient, to understand how much of their pain is coming from inside the hip. Remember we talked about asymptomatic as a relative term. Because of the insidious onset, substantial damage occurs before they realize there's an issue, and oftentimes they're not cognizant of how bad a problem is going on in their hip. So that's where you inject their joint and go, wow, that's what a normal hip's supposed to feel like. It helps you to establish a clinical relevance of imaging, just like in the shoulder. We know MRI changes are the normal consequence of aging, so not all of it needs surgery. But also to paraphrase Dr. Andrews, he talks about if you want an indication to operate on a professional thrower's shoulder, just get an MRI because it'll all show damage. Well, if you want an indication to operate on an NHL hockey player's hip, just get an MRI because they all show evidence of damage. That door swings both ways. We see young girls with pincher impingement where the labrum is getting crushed and painful literally for years before it ever tears badly enough to show up on an MRI. They're crying wolf because of the pain long before you see obvious imaging evidence that damage has occurred. So lastly, the concept of FAI is too simple. It easily explains why some people get into trouble with their hip. But how are other individuals' lifelong compensators with FAI morphology that never develop FAI pathology? To me, it's very much a perfect storm. You have enough factors coming together just wrong to get these people into trouble. And as a clinician, you may never identify all of the factors. But if you can identify enough to reach critical mass and successful treatment of that individual, that may be the best that you can hope for. Functional version is a big deal, both positively and negatively influencing problems with FAI. Functional orientation of the pelvis is a big deal. That's much harder to quantitate with any of our dynamic assessments. And that's very much influenced by lumbar lordosis and kyphosis. Subspine impingement I think sometimes is a little bit in the eye of the beholder. Clinically, we talk about isolating subspine with pain with straight flexion of the hip versus rim impingement with flexion, adduction, and internal rotation. In my hands, that's never been reliable. I can't really distinguish it based on that. But one thing we have encountered is if there's a subspine component, sometimes they don't get the positive response to the anesthetic effect of an intra-articular injection that you would expect because that's an extra-capsular form of FAI. So in conclusion, yes, asymptomatic FAI exists. I think it's ill-advised to operate on asymptomatic patients, but asymptomatic can mean a lot of different things. At the very least, these warrant a cautious, watchful approach. You don't want to just send them out of your office and tell them to come back when it's really bad because by then, they may have developed substantial damage that is no longer reversible. Thank you very much.

femoroacetabular impingement

asymptomatic FAI

hip arthroscopy

MRI changes

pelvis orientation