What is the initial treatment for femoroacetabular impingement?

Initial Treatment for Femoroacetabular Impingement

The initial treatment for femoroacetabular impingement (FAI) should be a conservative approach consisting of physiotherapist-led rehabilitation including exercise therapy, patient education, and activity modification before considering surgical intervention. 1

Understanding FAI

Femoroacetabular impingement is a condition characterized by abnormal contact between the femoral head and acetabulum, which can lead to:

• Pain in the hip region
• Labral tears
• Cartilage damage
• Potential early development of osteoarthritis
• Decreased quality of life and physical function

FAI typically presents in young to middle-aged active adults (18-50 years) and can involve:

• Cam deformity (abnormal femoral head-neck junction)
• Pincer deformity (acetabular overcoverage)
• Combination of both deformities

Conservative Management Approach

First-Line Interventions

1. Exercise Therapy

   • Strengthening exercises for hip and core muscles
   • Specific focus on quadriceps and proximal hip girdle muscles
   • Aerobic activity and exercise
   • Range of motion/stretching exercises
   • Both land-based and aquatic exercises may be beneficial 1, 2

2. Patient Education

   • Information about FAI nature, causes, consequences, and prognosis
   • Activity modification to avoid positions of impingement
   • Self-management strategies
   • Education should be individualized according to the person's illness perceptions 1

3. Physical Therapy Techniques

   • Manual therapy
   • Pacing activities ("small amounts often")
   • Starting with exercises within individual capability and building up gradually 1

Pain Management

1. Analgesics

   • Acetaminophen/paracetamol as a first option 1, 2
   • Topical NSAIDs as first-line therapy 2
   • Oral NSAIDs if needed, with appropriate GI protection 1, 2

2. Intra-articular Injections

   • Corticosteroid injections may be considered for persistent pain 1
   • Image-guided injections are recommended for accuracy 1
   • May provide diagnostic information as well as therapeutic benefit

Efficacy of Conservative Treatment

Research has shown that conservative interventions for short-term periods are effective in reducing pain and improving function for FAI:

• Physical therapy demonstrates moderate to large effect sizes for both pain reduction and functional improvement 3
• Common effective treatments include patient education, activity modification, manual therapy, and strengthening 3

However, it's important to note that while conservative treatment can be effective in the short term, three out of four high-quality randomized controlled trials have shown superior outcomes with surgical intervention compared to conservative care alone 4.

When to Consider Surgical Intervention

Consider surgical referral when:

• Conservative treatment fails after an adequate trial (typically 3-6 months)
• Pain significantly impacts quality of life despite conservative measures
• Imaging confirms significant structural abnormalities
• Patient is young and active with high functional demands

Monitoring and Assessment

Regular assessment should include:

• Pain levels (both at rest and with activity)
• Functional status and quality of life
• Response to conservative interventions
• Progression of symptoms

Practical Considerations

• Footwear: Appropriate and comfortable shoes are recommended 1
• Assistive devices: Walking aids may be considered to reduce pain and increase participation 1
• Weight management: If the patient is overweight, weight loss should be encouraged as it can reduce joint stress 1, 2

Common Pitfalls to Avoid

1. Delayed diagnosis: FAI is often misdiagnosed or undertreated 5
2. Inadequate imaging: Standard radiographs may miss FAI; specialized views or advanced imaging may be needed 1
3. Premature surgery: Not allowing adequate time for conservative treatment to work
4. Overlooking activity modification: Continuing activities that aggravate symptoms can undermine treatment
5. Focusing only on pain relief: Addressing functional limitations and preventing progression are equally important

While surgical options (particularly arthroscopic approaches) have shown promising results 5, 6, the current evidence-based approach recommends starting with a comprehensive conservative treatment program before considering surgical intervention.