From the Guidelines
The recommended approach to evaluate and treat hip impingement begins with a comprehensive clinical assessment, including a detailed history, physical examination, and appropriate imaging, followed by conservative measures such as physical therapy and activity modification, with surgical intervention considered if conservative treatment fails. This approach is supported by recent studies, including a 2020 consensus statement from the International Hip-Related Pain Research Network, which emphasizes the importance of developing and testing effective exercise therapies for hip-related pain 1.
Evaluation
The evaluation of hip impingement should include a detailed history, physical examination with specific provocative tests like the FADIR test (flexion, adduction, internal rotation), and appropriate imaging such as plain radiographs, MRI arthrogram, or CT scans to confirm diagnosis. The patient’s goals, expectations, physical activity, and occupational requirements should also be measured using quantitative and qualitative methods, as recommended by the first International Hip-Related Pain Research Network meeting 1.
Treatment
Initial treatment should focus on conservative measures, including activity modification, physical therapy targeting core strengthening and hip stabilization exercises, and anti-inflammatory medications like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for pain management. Physical therapy should emphasize improving hip range of motion, strengthening hip external rotators and abductors, and addressing any biomechanical abnormalities, typically for 6-12 weeks. The use of objective methods to measure physical activity, such as body-worn accelerometers or commercial devices like Fitbit, is also recommended to quantify physical activity levels and capture different dimensions of physical activity 1.
Surgical Intervention
If conservative treatment fails after 3-6 months, surgical intervention may be considered, with arthroscopic surgery being the most common approach to address labral tears, remove bone spurs, and reshape the femoral head or acetabulum. The decision for surgery should be based on symptom severity, functional limitations, and imaging findings. Post-surgical rehabilitation is crucial and typically involves protected weight-bearing for 2-4 weeks followed by progressive strengthening and return to activities over 3-6 months. Early intervention is important as untreated hip impingement can lead to labral tears, cartilage damage, and premature osteoarthritis due to the abnormal contact between the femoral head and acetabulum during hip movement.
Key considerations in the treatment of hip impingement include:
- Comprehensive clinical assessment
- Conservative measures, including physical therapy and activity modification
- Surgical intervention, if necessary
- Objective measurement of physical activity
- Patient-centered approach, considering goals, expectations, and occupational requirements.
From the Research
Evaluation of Hip Impingement
- The evaluation of hip impingement typically involves a combination of clinical assessment, imaging studies, and patient-reported outcome measures 2.
- A thorough history and physical examination are essential to identify the location and characteristics of hip pain, as well as to rule out other potential causes of pain 3.
- Imaging studies, such as radiography, ultrasonography, or magnetic resonance imaging, may be necessary to confirm the diagnosis and assess the extent of impingement 2, 3.
Treatment Options for Hip Impingement
- Conservative treatment, including modifications in activities of daily living and physical therapy, can be effective for mild cases of femoroacetabular impingement 4.
- Physiotherapy programs that focus on core strengthening, active strengthening, and supervised care have been shown to be more effective than unsupervised, passive, and non-core focused programs 5.
- Surgical options, such as open or arthroscopic hip surgery, may be necessary for more severe cases of impingement or when conservative treatment fails 4, 6.
- Iliopsoas tenotomy and revision of the acetabular component are both successful surgical options for treating iliopsoas impingement after total hip replacement 6.
Non-Operative Management
- Non-operative management, including physiotherapy and activity modification, can be an effective treatment option for patients with femoroacetabular impingement 5.
- A systematic review of 5 randomized controlled trials found that physiotherapy programs that focused on core strengthening, active strengthening, and supervised care resulted in statistically significant improvements in functional outcomes compared to controls 5.
Surgical Intervention
- Surgical intervention may be necessary for patients who do not respond to conservative treatment or who have more severe cases of impingement 4, 6.
- A study of 29 patients with iliopsoas impingement after total hip replacement found that operative treatment resulted in relief of pain in 81.8% of patients, with significant improvements in Harris Hip Scores 6.