What are the treatment options for Femoral Acetabular Impingement (FAI) syndrome?

Treatment Options for Femoral Acetabular Impingement (FAI) Syndrome

The treatment of Femoral Acetabular Impingement syndrome should begin with a 3-month conservative management program, including individualized exercise therapy, activity modification, and appropriate analgesics, with surgical intervention reserved for patients who fail to respond to conservative measures. 1

Diagnostic Approach

• Diagnosis requires a combination of:

  • Symptoms: Pain with hip flexion, adduction, and internal rotation
  • Clinical signs: Positive FADIR test (flexion, adduction, internal rotation)
  • Imaging findings: AP pelvis and lateral femoral head-neck radiographs, with MRI for labral tears and chondral damage 1

• FAI classifications:

  • Cam: Aspherical femoral head deformity
  • Pincer: Acetabular overcoverage
  • Mixed: Combination of both morphologies 2

Conservative Management

First-Line Treatment

1. Structured Rehabilitation Program (6-12 weeks minimum):

   • Frequency: At least 3 times per week
   • Duration: 30+ minutes per session
   • Components:
     • Core strengthening
     • Hip girdle muscle strengthening
     • Aerobic activity
     • Range of motion/stretching exercises 1
   • Progression: Individualized exercise advancement every 1-2 weeks based on tolerance

2. Activity Modification:

   • Pacing strategies
   • Avoiding positions that exacerbate symptoms (especially hip flexion, adduction, and internal rotation)
   • Using appropriate and comfortable footwear 1

3. Pain Management:

   • First-line: Paracetamol (up to 4g/day)
   • Second-line: NSAIDs at lowest effective dose 1

4. Patient Education:

   • Information about FAI pathology
   • Activity modification strategies
   • Setting realistic short and long-term goals 1

Monitoring and Follow-up

• Evaluate treatment response after 3 months of optimal conservative management
• Assessment should include:
  • Pain levels
  • Functional improvement
  • FAI-related quality of life 1

Surgical Management

Surgical intervention should be considered only after failure of a complete 3-month conservative management program 1.

Surgical Options

1. Arthroscopic Surgery (preferred approach):

   • Indications:
     • Age <50 years
     • Minimal/no osteoarthritis
     • No inflammatory arthritis
     • Failed conservative management
   • Procedures:
     • Correction of bony abnormalities (osteoplasty)
     • Labral repair (superior to debridement for long-term outcomes)
     • Addressing chondral damage 1, 3

2. Cartilage Repair Techniques:

   • Microfracture:

     • For focal, contained lesions <4 cm²
     • Involves debridement of friable cartilage and creation of perpendicular holes in subchondral bone 1

   • Mosaicplasty:

     • For focal, full-thickness lesions <3 cm²
     • Patients <45 years without osteoarthritis 1

   • Osteochondral Allograft Transplantation (OAT):

     • For larger defects (>2.5 cm²)
     • Patients ≤50 years with no evidence of osteoarthritis 1

3. Open Surgical Dislocation:

   • Less commonly used but may be appropriate for complex cases
   • Involves greater trochanteric flip osteotomy and anterior dislocation of the femoral head 4

4. Total Hip Arthroplasty:

   • Reserved for severe cases with significant joint destruction 1

Treatment Outcomes

• Conservative treatment success rate: ~53-78% return to play in athletes who complete rehabilitation 1

• Surgical outcomes:

  • Arthroscopic treatment shows improvement in pain and function comparable to open procedures 5
  • Harris hip score improvement from 70 points preoperatively to 87 points at final follow-up has been reported 4
  • Patients with severe acetabular cartilage damage have poorer outcomes and higher rates of progression to osteoarthritis 4

Important Considerations

• Premature surgical intervention should be avoided without completing a full conservative management program
• Regular follow-up (at least annually) is necessary to monitor for progression of symptoms and development of early osteoarthritis 1
• The presence of significant articular cartilage damage at the time of surgery is associated with poorer outcomes and may predict earlier progression to osteoarthritis 4

Return to Sport and Activity

• Assess sport-specific activities to guide return to sport decisions
• Use objective measures (e.g., accelerometers) to quantify physical activity and guide rehabilitation 1
• Post-surgical rehabilitation should follow similar principles to conservative management, with appropriate progression based on healing timelines