What is the initial treatment for hip impingement?

Initial Treatment for Hip Impingement

The initial treatment for hip impingement should focus on a comprehensive non-pharmacological approach including exercise therapy, activity modification, and education on self-management strategies before considering pharmacological or surgical interventions. 1

Assessment and Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Diagnosis typically requires AP pelvic and lateral femoral head-neck radiographs (such as Dunn view, frog-leg view, or cross-table view) 1
• MRI/MRA or CT scan may be needed for detailed assessment of three-dimensional morphology and intra-articular structures 1
• Positive FADIR test (flexion, adduction, internal rotation) often reproduces the pain 2

Non-Pharmacological Treatment Algorithm

First-Line Interventions (Highest Priority)

1. Patient Education and Self-Management

   • Provide information about the condition, its causes, and prognosis 1
   • Teach activity modification to avoid positions that cause impingement 3
   • Instruct patients to adapt activities of daily living to their safe range of movement 3
   • Avoid prolonged sitting, leaning forward, and pivoting movements 2

2. Individualized Exercise Program

   • Implement strength training focusing on hip girdle and quadriceps muscles 1
   • Include aerobic activities and flexibility exercises 1
   • Exercise dosage should be adequate with appropriate progression 1
   • Start with manageable levels and build up gradually over several months 1

3. Physical Therapy

   • Manual therapy combined with supervised exercise 1
   • Focus on improving range of motion without causing impingement 3

Second-Line Interventions

1. Weight Management

   • For overweight or obese patients, provide support for weight loss 1
   • Include structured approaches to diet and physical activity 1

2. Mechanical Interventions

   • Consider appropriate footwear 1
   • Evaluate need for walking aids to reduce pain and increase participation 1

Pharmacological Management

If non-pharmacological approaches are insufficient, consider:

1. Acetaminophen (first-line pharmacological option) 1
2. Oral NSAIDs 1
3. Intra-articular corticosteroid injections 1
4. Tramadol (for those who cannot take NSAIDs or have insufficient relief) 1

Treatment Effectiveness and Progression

Conservative treatment has shown good results in patients with mild femoroacetabular impingement (alpha angle <60°), with significant improvements in Harris Hip Score and pain reduction 3. In a study of 37 patients with mild impingement, only 4 required surgery after conservative management failed 3.

When to Consider Surgical Referral

Consider surgical options (typically arthroscopy) when:

• Conservative treatment fails after an adequate trial period 3, 2
• Pain significantly limits activities of daily living despite conservative management 2
• Advanced imaging confirms structural abnormalities amenable to surgical correction 1

Important Considerations and Pitfalls

• Avoid misdiagnosis: Hip impingement symptoms can mimic other conditions; ensure proper imaging before finalizing diagnosis 1
• Don't rely solely on imaging: Diagnosis should never be made on imaging alone, as incidental findings are common in asymptomatic individuals 1
• Manage expectations: Conservative treatment may improve function and symptoms but might not improve range of hip movement 3
• Individualize exercise delivery: Select mode of delivery (individual sessions, group classes, aquatic vs. land-based) according to patient preference and local availability 1
• Emphasize long-term adherence: For exercise to be effective, it must become part of the patient's lifestyle rather than a temporary intervention 1

By following this structured approach to hip impingement treatment, clinicians can maximize the chance of symptom improvement while potentially delaying or avoiding the need for surgical intervention.