What is the management for Femoroacetabular Impingement (FAI)?

Management of Femoroacetabular Impingement (FAI)

The management of Femoroacetabular Impingement (FAI) should begin with a structured 6-12 week physiotherapist-led rehabilitation program focusing on core strengthening, active exercises, and pain management before considering surgical intervention. 1

Diagnosis and Assessment

FAI syndrome is diagnosed by a triad of:

• Symptoms (typically anterior hip or groin pain)
• Clinical signs (positive anterior hip impingement test)
• Imaging findings (cam, pincer, or mixed morphology) 2, 1

Important considerations:

• Diagnosis should never be made on imaging alone but combined with clinical symptoms and examination findings 1
• Incidental labral tears are common in asymptomatic individuals 1
• A negative flexion-adduction-internal rotation test helps rule out hip-related pain, though its clinical utility is limited 2

Treatment Algorithm

1. Initial Conservative Management (First 3 Months)

A. Structured Physiotherapy Program

• Duration: Minimum 6-12 weeks
• Frequency: At least 3 times per week for 30+ minutes per session
• Components:
  • Core strengthening
  • Hip girdle muscle strengthening (quadriceps and proximal hip)
  • Aerobic activity and exercise
  • Range of motion/stretching exercises
  • Individualized exercise progression every 1-2 weeks based on tolerance 2, 1

B. Pain Management

• First-line: Paracetamol (up to 4g/day)
• Second-line: Short-term NSAIDs if paracetamol is insufficient
• Last resort: Opioid analgesics only when other options are contraindicated, ineffective, or poorly tolerated 1

C. Patient Education

• Information about FAI pathology
• Activity modification and pacing
• Addressing adverse mechanical factors (appropriate footwear)
• Setting realistic short-term and long-term goals 2, 3

2. Evaluation After 3 Months of Conservative Management

Assess:

• Pain levels
• Functional improvement
• FAI-related quality of life 1

3. Management of Persistent Symptoms

If symptoms persist despite 3 months of appropriate conservative management:

• Consider advanced imaging (MR arthrography is gold standard with 90-95% sensitivity for labral pathology) 1
• Surgical consultation

4. Surgical Intervention Options

• Arthroscopic labral repair (superior to debridement for long-term outcomes)
• Correction of underlying pathology (e.g., cam or pincer deformity)
• For associated chondral lesions:
  • Small lesions (<2.5 cm²): Arthroscopic debridement with curettage or mosaicplasty
  • Large lesions (>2.5 cm²): Osteochondral allograft transplantation 1

Follow-up and Monitoring

• Regular follow-up (at least annually)
• Monitor for:
  • Progression of symptoms
  • Development of early osteoarthritis
  • Functional status 1

Common Pitfalls to Avoid

1. Premature surgical intervention: Ensure completion of a full 3-month conservative management program before considering surgery 1, 4

2. Diagnosis based solely on imaging: FAI is a clinical syndrome requiring symptoms, clinical signs, AND imaging findings 2, 1

3. Neglecting associated conditions: FAI often coexists with labral tears and chondral lesions that may require specific management 1

4. Inadequate physiotherapy: Exercise programs should be individualized, progressive, and supervised for optimal outcomes 2, 1

5. Overlooking biopsychosocial factors: Assessment should include physical status, activities of daily living, participation in work/leisure, and mood 2

While three out of four recent studies favor surgical approaches for superior short-term results compared to conservative care alone 4, a structured conservative approach should always be attempted first, as it may provide sufficient symptom relief and functional improvement while avoiding surgical risks.