What is the treatment for Femoroacetabular Impingement (FAI)?

Treatment for Femoroacetabular Impingement (FAI)

The treatment for Femoroacetabular Impingement should begin with a structured physiotherapist-led rehabilitation program focusing on core strengthening, active exercises, and pain management before considering surgical intervention. 1

Initial Conservative Management

First-Line Approach

• Supervised physiotherapy program (6-12 weeks minimum)
  • Core strengthening exercises 2
  • Active strengthening of hip musculature 2
  • Individualized exercise progression every 1-2 weeks based on patient tolerance 1
  • Minimum frequency: 3 times per week for at least 30 minutes per session 1

Patient Education

• Activity modification to avoid positions that cause impingement 3
• Education about FAI pathology and management options 1
• Training to moderate-severe claudication pain may improve outcomes, though improvements are also achievable with lesser pain severities 1

Pain Management

• Pharmacological options:
  • Paracetamol (up to 4g/day) as first-line analgesic for mild-moderate pain 1
  • NSAIDs for short-term pain relief if paracetamol is insufficient 1
  • Opioid analgesics only when other options are contraindicated, ineffective, or poorly tolerated 1

Adjunctive Treatments

• Intra-articular injections may provide temporary relief but show smaller effect sizes (SMD 0.29) compared to physical therapy (SMD 0.91) 4
• Manual therapy techniques to improve joint mobility 4

Evaluation of Conservative Treatment Response

Assessment Timeline

• Evaluate treatment response after 3 months of optimal conservative management 1
• Assess pain, function, and FAI-related quality of life 1

Decision Points

1. If improved with conservative care: Continue with physiotherapy program
2. If inadequate response after 3 months of optimal treatment: Consider advanced imaging and surgical consultation

Surgical Management Options

Indications for Surgical Intervention

• Persistent symptoms despite 3 months of appropriate conservative management 1
• Impaired FAI-related quality of life 1
• Confirmed structural abnormalities on imaging 1

Surgical Approaches

• Arthroscopic treatment:
  • Labral repair using suture anchors 3
  • Addressing bony abnormalities (cam or pincer lesions) 3
  • Treatment of associated chondral lesions (<3cm²) with microfracture 3
  • Decompression of paralabral cysts if present 3

Evidence Quality and Considerations

• Recent systematic reviews show that both conservative and surgical approaches can be effective, but surgical intervention may offer superior short-term results in patients who fail conservative management 5
• Physical therapy demonstrates moderate to large effect sizes for both pain (SMD 0.91) and function (SMD 0.80) in the short term 4
• The British Journal of Sports Medicine consensus recommends physiotherapist-led treatment as the initial approach for young to middle-aged adults with hip-related pain 1

Important Caveats

• Incidental labral tears are common in asymptomatic individuals and should not be the sole basis for treatment decisions 3
• Diagnosis should never be made on imaging alone but combined with clinical symptoms and examination findings 3
• Early detection and management of focal chondral injuries may prevent degeneration of the entire joint 1
• Revascularization is not recommended for asymptomatic FAI 1

Follow-up Recommendations

• Regular follow-up (at least annually) to assess clinical and functional status 1
• Monitor for progression of symptoms or development of early osteoarthritis 1
• Adjust treatment plan based on patient response and functional goals

The evidence strongly supports starting with a structured physiotherapy program before considering surgical options, with surgery reserved for those who fail to respond to appropriate conservative management.