What is the recommended treatment approach for patients with Femoroacetabular Impingement (FAI) syndrome?

Treatment Approach for Femoroacetabular Impingement (FAI) Syndrome

The recommended first-line treatment for FAI syndrome is a conservative management approach including physiotherapist-led rehabilitation for at least 3 months, with surgical intervention reserved for cases that fail appropriate non-operative therapy. 1

Diagnosis

Proper diagnosis of FAI syndrome requires a combination of:

1. Appropriate symptoms:

   • Groin pain
   • Clicking, catching, buckling
   • Stiffness, giving way
   • Limited hip range of motion 2

2. Clinical signs:

   • Positive FADIR test (flexion, adduction, internal rotation)
   • Limited internal rotation in flexion 3

3. Imaging findings:

   • Initial imaging: AP pelvis and lateral femoral head-neck radiographs 4
   • Advanced imaging when needed: MRI without contrast for labral tears and chondral damage 4
   • CT for 3D morphological assessment when indicated 4

Important: Diagnosis should never be made using imaging alone but must combine symptoms, clinical signs, and imaging findings 4

Treatment Algorithm

Step 1: Conservative Management (First-Line)

A minimum 6-12 week rehabilitation program should include:

• Exercise therapy:

  • Frequency: At least 3 times per week
  • Duration: 30+ minutes per session
  • Components: Core strengthening, hip girdle muscle strengthening, aerobic activity, range of motion exercises 1
  • Progression: Individualized exercise advancement every 1-2 weeks based on tolerance

• Activity modification:

  • Implement pacing strategies ("small amounts often")
  • Avoid activities that exacerbate symptoms
  • Use appropriate footwear 1

• Patient education:

  • Information about FAI pathology
  • Activity modification and pacing
  • Setting realistic goals 1

• Pain management:

  • NSAIDs at lowest effective dose
  • Paracetamol (up to 4g/day) for mild-moderate pain 1

Step 2: Evaluate Treatment Response (at 3 months)

Assess:

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

Step 3: Decision Point

If symptoms persist despite 3 months of appropriate conservative management:

• Consider surgical consultation
• Advanced imaging if not already performed

Step 4: Surgical Management (for failed conservative treatment)

Arthroscopic intervention is currently the preferred surgical approach, which aims to:

• Correct bony abnormalities
• Repair or reconstruct labral lesions
• Address other intra-articular derangements 2

For severe cases with significant joint destruction, total hip arthroplasty may be recommended 1

Special Considerations

Physical Activity Assessment

• Quantify physical activity using objective measures (e.g., accelerometers) 4
• Document patient expectations regarding return to sport/activity 4
• Assess sport-specific activities to guide return to sport decisions 4

Imaging Pitfalls

• Incidental intra-articular findings are common in asymptomatic individuals 4
• MR arthrography or CT arthrography is appropriate when impingement is suspected 4
• Image-guided anesthetic injections can help determine if the hip is the source of pain when there are concurrent low back, pelvic, or knee pathologies 4

Outcomes

• Conservative treatment success rate: ~53-78% return to play in athletes who complete rehabilitation 1
• Arthroscopic labral repair is superior to debridement for long-term outcomes 1
• Premature surgical intervention should be avoided without completing a full conservative management program 1

By following this structured approach, clinicians can effectively manage patients with FAI syndrome, prioritizing conservative care first and reserving surgical interventions for those who fail to respond to appropriate non-operative treatment.