Treatment of Femoroacetabular Impingement (FAI)
Initial conservative management with physical therapy should be the first-line treatment for FAI, consisting of patient education, activity modification, manual therapy, and strengthening exercises for at least 3 months before considering surgical intervention. 1, 2
Initial Conservative Treatment Protocol
Conservative management should include the following core components:
Patient education addressing the nature of FAI as a mechanical condition caused by abnormal bone morphology, expected recovery timeframe, and the principle that pain does not equal tissue damage but reflects mechanical irritation 1, 2
Activity modification to reduce repetitive hip flexion and internal rotation movements that provoke impingement 2, 3
Prescribed physiotherapy program including:
- Hip and core strengthening exercises, particularly targeting hip girdle muscles 4, 2
- Manual therapy techniques 2
- Range of motion and stretching exercises using "small amounts often" principle, linking exercises to daily activities 4, 5
- Movement retraining for athletes to address biomechanical patterns contributing to repetitive impingement 5
Footwear modification to reduce adverse mechanical loading 4, 5
Evidence for Conservative Management
Physical therapy demonstrates moderate to large effect sizes with statistically significant improvements in both pain (SMD 0.91, p=0.030) and function (SMD 0.80, p=0.001) for FAI 2. Conservative treatment should be maintained for at least 3 months before reassessing for surgical candidacy 1.
Role of Intra-Articular Injections
Intra-articular hip injections serve both diagnostic and therapeutic purposes 1. However, they demonstrate only small effect sizes for pain (SMD 0.29, p=0.710) and small to moderate effect sizes for function (SMD 0.49, p=0.040), making them less effective than physical therapy alone 2. Consider injections as an adjunct when physical therapy provides inadequate relief after 4-8 weeks 6.
When to Consider Surgical Management
Hip arthroscopy should be considered when conservative management fails after 3 months and quality of life remains impaired 4, 1. Three out of four randomized controlled trials favor surgery over conservative care alone, with superior short-term results 7.
Surgical indications include:
- Persistent hip-related pain affecting quality of life despite 3 months of optimal conservative treatment 4, 1
- Documented FAI morphology on imaging (alpha angle elevation, lateral center edge angle abnormalities) combined with positive clinical signs 1, 8
- Progressive functional limitation despite adherence to physical therapy 7
Critical Diagnostic Considerations Before Treatment
Diagnosis must never be based on imaging alone but requires integration of clinical examination, imaging findings, and patient symptoms 1. This is crucial because:
- Incidental labral tears and FAI morphology are common in asymptomatic individuals 1
- A positive FADIR test has high sensitivity but low specificity 1
- Competing diagnoses must be excluded, including lumbar spine pathology, hip intra-articular pathology other than FAI, and serious pathology 5, 1
Common Clinical Pitfalls to Avoid
Do not diagnose FAI based solely on radiographic findings of cam or pincer morphology without corresponding clinical symptoms and positive examination findings 1
Do not proceed directly to surgery without a trial of conservative management unless there is severe structural damage or acute complications 4, 1
Ensure proper diagnostic workup including anteroposterior pelvis and lateral femoral head-neck radiographs, with MR arthrography if labral pathology assessment is needed 1
Recognize that many patients have coexisting conditions, particularly labral and chondral pathology, which may require addressing during treatment planning 1