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

Treatment Options for Femoral Acetabular Impingement (FAI) Syndrome

Treatment for Femoral Acetabular Impingement syndrome should begin with conservative management including structured exercise therapy, education, and pain management, with surgery reserved for patients who fail conservative treatment or have significant structural abnormalities.

Diagnosis and Clinical Evaluation

FAI syndrome requires a combination of:

• Groin pain (may also radiate to back, buttock, and thigh)
• Positive clinical signs (FADIR test - flexion, adduction, internal rotation)
• Imaging findings showing cam or pincer deformities 1

Common symptoms include:

• Pain
• Clicking or catching sensations
• Buckling or giving way
• Stiffness
• Limited range of motion 2

Conservative Management

1. Exercise Therapy

Exercise therapy should be the first-line treatment for most patients with FAI syndrome 1:

• Core strengthening exercises
• Hip girdle muscle strengthening
• Range of motion exercises
• Aerobic activity
• Individualized progression every 1-2 weeks based on tolerance

Exercise principles should follow:

• Small amounts often
• Linking exercises to daily activities
• Starting within capability and gradually building up 1

2. Patient Education

Education should be comprehensive and include:

• Explanation of FAI pathology using visual aids
• Activity modification strategies
• Pacing techniques
• Multiple delivery formats (individual sessions, written materials, multimedia resources) 1

3. Pain Management

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

4. Lifestyle Modifications

• Weight management
• Appropriate footwear
• Consideration of walking aids if necessary 1

Conservative treatment has shown moderate to large effect sizes for both pain and function, with success rates of approximately 53-78% for return to play in athletes 1.

Surgical Management

Surgery should be considered when conservative management fails after an adequate trial period (typically 3-6 months) 1, 2.

Hip Arthroscopy

Currently the preferred surgical approach for patients meeting these criteria:

• Age <50 years
• Minimal or no osteoarthritis
• No inflammatory arthritis 1

Surgical procedures typically include:

1. Correction of bony abnormalities (reshaping the femoral head-neck junction for cam deformities or trimming the acetabular rim for pincer deformities)
2. Labral repair (superior to debridement for long-term outcomes)
3. Addressing cartilage damage when present 1, 2

Other Surgical Options

• Joint-preserving procedures such as cartilage repair techniques for specific cases 1
• Surgical dislocation and débridement through a greater trochanteric flip osteotomy may be used in select cases, though this is less common than arthroscopy 3
• Total hip arthroplasty reserved for severe cases with significant joint destruction 1

Treatment Algorithm

1. Initial Presentation:

   • Confirm diagnosis with symptoms, clinical tests, and imaging
   • Assess severity of symptoms and functional limitations

2. Conservative Treatment (3-6 month trial):

   • Structured exercise program
   • Patient education
   • Pain management
   • Activity modification

3. Re-evaluation:

   • If improved: Continue conservative management
   • If inadequate improvement: Consider surgical options

4. Surgical Decision-Making:

   • Age <50 with minimal/no OA: Consider hip arthroscopy
   • Severe cartilage damage or advanced OA: Consider total hip arthroplasty

Prognosis and Complications

• Without proper treatment, FAI can lead to progressive joint damage and early osteoarthritis 1
• Patients with severe acetabular cartilage damage at the time of surgery have poorer outcomes and higher rates of progression to osteoarthritis 3
• The presence of significant cartilage damage at the time of intervention is the most important prognostic factor 4

Follow-up and Monitoring

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

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

MRI without IV contrast is the most appropriate imaging modality for evaluating new onset pain in patients with FAI history 1.

Key Pitfalls to Avoid

1. Relying solely on imaging for diagnosis (clinical symptoms and examination findings are essential)
2. Delaying treatment, which may lead to progressive cartilage damage
3. Failing to address underlying biomechanical issues in conservative management
4. Inadequate rehabilitation following surgical intervention

Early recognition and appropriate management of FAI syndrome are crucial to prevent progression to osteoarthritis and preserve hip function.