Treatment for Femoroacetabular Impingement Syndrome
Begin with a mandatory 3-month trial of conservative management combining structured exercise rehabilitation with activity modification before considering surgical intervention. 1
Initial Conservative Management Protocol
All patients with FAI syndrome should undergo at least 3 months of optimal medical treatment and exercise therapy before any consideration of surgery. 1 This approach successfully manages symptoms in approximately 50-68% of patients, avoiding surgical intervention entirely. 2, 3
Core Conservative Treatment Components
Structured exercise rehabilitation targeting hip range of motion, muscle strength (particularly hip flexors, extensors, and abductors), and neuromuscular control of the lumbo-pelvic-hip complex should be implemented. 1, 4, 5
Activity modification to reduce repetitive hip flexion and internal rotation movements that provoke impingement symptoms is essential. 1
Intra-articular corticosteroid injection combined with structured rehabilitation significantly improves outcomes, with 68% of patients avoiding surgery at 24 months when this combined approach is used. 3
Treatment Intensity and Duration
The rehabilitation program should average 12 weeks with treatment sessions adjusted based on symptom response. 3, 4 Patients categorized with primary mobility impairments require different interventions than those with primary neuromuscular control deficits—mobility-limited patients need targeted stretching and joint mobilization, while those with control deficits require motor control retraining. 4
Quality of Life Assessment and Surgical Decision-Making
After completing the 3-month conservative trial, formal assessment of hip-related quality of life is mandatory to guide surgical decision-making. 1 This is a critical checkpoint that determines whether revascularization—or in this context, surgical intervention—is warranted.
Indicators for Surgical Consideration
Persistent impaired quality of life after 3 months of optimal conservative management justifies consideration of arthroscopic surgery. 1
Early symptom recurrence (within 4 weeks post-injection) and worse baseline patient-reported outcome measures predict failure of conservative management. 3
Patients who report significant pain within the first 4 weeks after injection are more likely to require surgery (32% surgical conversion rate). 3
Surgical Management When Conservative Treatment Fails
Arthroscopic hip surgery should be considered only after documented failure of structured conservative management lasting at least 3 months. 6, 2 Three out of four Level I randomized controlled trials demonstrate superior short-term outcomes with surgery compared to conservative care alone in patients who fail initial conservative management. 6
Surgical Approach
Hip arthroscopy is the preferred surgical technique for addressing the bony morphology causing impingement and treating associated labral tears. 6 Surgery provides significant improvements in clinical outcome scores in patients unresponsive to conservative treatment. 2
Critical Diagnostic Prerequisites
Before initiating any treatment, confirm the diagnosis using:
Anteroposterior pelvis and lateral femoral head-neck radiographs as initial imaging. 1
MR arthrography for definitive diagnosis of associated labral tears and cartilage damage when surgical planning is needed. 1, 7
FADIR test (flexion-adduction-internal rotation) as the primary clinical screening tool, despite its limitations in diagnostic accuracy. 1
Common Pitfalls to Avoid
Never use imaging findings alone to make treatment decisions—imaging must be combined with clinical symptoms and physical examination findings, as incidental morphological findings are common in asymptomatic individuals. 1
Do not proceed directly to surgery without a documented trial of conservative management, as approximately half of patients will respond adequately to non-operative treatment. 2 The exception would be acute traumatic cases with significant structural damage, though this is rare in FAI syndrome.
Avoid isolated hip injections without concurrent structured rehabilitation—the combination therapy is significantly more effective than injection alone. 3