What are the treatment options for Femoroacetabular Impingement (FAI)?

Treatment Options for Femoroacetabular Impingement (FAI)

A structured 3-month conservative approach should be implemented before considering surgery for FAI, with a focus on activity modification, physical therapy, and pain management. 1

Initial Assessment and Diagnosis

• FAI syndrome diagnosis requires a combination of:
  • Symptoms: primarily groin pain (may also be felt in back, buttock, and thigh)
  • Clinical signs: positive FADIR test (flexion, adduction, internal rotation)
  • Imaging findings: radiographic evidence of cam or pincer deformities
• Diagnosis should never be made using imaging alone 1
• Initial imaging should include AP pelvis and lateral femoral head-neck radiographs 1
• MRI without contrast is recommended if radiographs are negative or equivocal 1

Conservative Management (First-Line Treatment)

Conservative treatment has shown moderate to large effect sizes for both pain (SMD 0.91) and function (SMD 0.80) 2. The comprehensive approach should include:

1. Patient Education

   • Explanation of FAI pathology
   • Activity modification strategies
   • Pacing of activities 1

2. Exercise Therapy

   • Core strengthening
   • Hip girdle muscle strengthening (especially quadriceps and proximal hip muscles)
   • Range of motion exercises
   • Aerobic activity
   • Individualized progression every 1-2 weeks based on tolerance 1
   • Exercise should follow principles of:
     • "Small amounts often" (pacing)
     • Linking exercises to daily activities
     • Starting within capability and building up gradually 3

3. Pain Management

   • Paracetamol (up to 4g/day) as first-line analgesic
   • NSAIDs at lowest effective dose if inadequate response to paracetamol 1

4. Lifestyle Modifications

   • Weight management if overweight/obese
   • Appropriate footwear
   • Consideration of walking aids if needed 3

Surgical Management

If conservative treatment fails after 3 months, surgical options should be considered:

1. Hip Arthroscopy (preferred surgical approach for patients who meet criteria):

   • Age <50 years
   • Minimal or no osteoarthritis
   • No inflammatory arthritis 1
   • Procedures include:
     • Correction of bony abnormalities (osteochondroplasty)
     • Labral repair (superior to debridement)
     • Addressing cartilage damage 1, 4

2. Open Surgical Approaches:

   • Surgical hip dislocation
   • Anterior mini-open approach
   • These approaches have shown good results even in patients over 30 years of age 5

3. Total Hip Arthroplasty:

   • Reserved for severe cases with significant joint destruction 1

Expected Outcomes

• Conservative treatment success rate: approximately 53-78% return to play in athletes 1
• Without proper treatment, FAI can lead to progressive joint damage and early osteoarthritis 1
• Open surgical treatment has shown significant improvement in modified Harris hip scores (from 61 to 87 points) 5
• Potential complications of surgery include adhesions between capsule and reshaped femoral head-neck area 5

Follow-up Recommendations

Regular follow-up (at least annually) is necessary to monitor:

• Progression of symptoms
• Development of early osteoarthritis
• Functional status 1

Common Pitfalls to Avoid

1. Diagnosing FAI based on imaging alone without clinical correlation
2. Rushing to surgery without adequate trial of conservative management
3. Failing to address contributing factors like core weakness or activity modification
4. Not providing comprehensive patient education about the condition
5. Inadequate post-surgical rehabilitation

The evidence strongly supports starting with a comprehensive conservative approach for all FAI patients before considering surgical intervention, as this can provide significant improvements in pain and function while potentially avoiding the risks associated with surgery.