Initial Treatment for Femoroacetabular Impingement Syndrome
The initial treatment for femoroacetabular impingement syndrome should be a structured 3-month conservative approach focused on activity modification, physical therapy, and pain management before considering surgical intervention. 1
Understanding Femoroacetabular Impingement Syndrome (FAIS)
FAIS is characterized by abnormal contact between the femoral head-neck junction and the acetabular rim, resulting from altered bone morphology. This condition causes:
- Groin pain (primary symptom), which may also be felt in the back, buttock, and thigh 1
- Clicking, catching, buckling, stiffness, giving way, and limited hip range of motion 2
- Progressive damage to the acetabular labrum, chondrolabral junction, and articular cartilage 2
Diagnosis
Diagnosis should combine:
- Symptoms (primarily groin pain)
- Clinical signs (positive FADIR test - flexion, adduction, internal rotation)
- Imaging findings (never diagnose based on imaging alone) 1
Imaging evaluation includes:
- Initial radiographs: AP pelvis and lateral femoral head-neck views 1
- MRI without IV contrast for comprehensive assessment of both osseous structures and soft tissues 1
Conservative Management Protocol
1. Physical Therapy (First-Line Treatment)
A structured physical therapy program should include:
- Core strengthening
- Hip girdle muscle strengthening
- Range of motion exercises
- Aerobic activity
- Individualized exercise progression every 1-2 weeks based on tolerance 1
2. Activity Modification
- Adapt to a safe range of movement
- Perform activities of daily living with minimal friction 3
- Avoid high-impact activities and positions that provoke symptoms 4
3. Pain Management
- Paracetamol (up to 4g/day) as first-line analgesic for mild-moderate pain
- NSAIDs at lowest effective dose for inadequate response to paracetamol 1
4. Patient Education
- Education on FAI pathology
- Activity modification guidance
- Pacing strategies 1
Effectiveness of Conservative Management
Conservative treatment has shown promising results:
- Success rate of approximately 53-78% return to play in athletes 1
- In a prospective study of 93 hips, 82% were successfully managed non-operatively with significant improvements in outcome scores at 2-year follow-up 5
- In another study of 37 patients, 33 (89%) avoided surgery with conservative management, with mean Harris Hip Score improving from 72 to 91 at 24-month follow-up 3
When to Consider Surgical Management
If conservative treatment fails after a structured 3-month approach, surgical options may be considered:
- Hip arthroscopy is the preferred surgical approach for patients who:
- Are under 50 years of age
- Have minimal or no osteoarthritis
- Have no inflammatory arthritis 1
Surgical procedures may include:
- Correction of bony abnormalities
- Labral repair
- Addressing cartilage damage 1
Risk Factors for Conservative Treatment Failure
Patients more likely to require surgical intervention include:
- Those with cam impingement or combined cam-pincer impingement (4.4 times more likely to need surgery than those with pincer deformities alone) 5
- Athletes participating in high-impact sports 5
Follow-up Recommendations
Regular follow-up (at least annually) is necessary to monitor:
- Progression of symptoms
- Development of early osteoarthritis
- Functional status 1
Without proper treatment, FAIS can lead to progressive joint damage and early osteoarthritis 1, highlighting the importance of early intervention and appropriate management.