From the Guidelines
Management of femoroacetabular impingement (FAI) in the Emergency Department should focus on symptom control and appropriate referral, with initial treatment including rest, activity modification, and pain management with NSAIDs, as recommended by the International Hip-related Pain Research Network in 2020 1. The goal of treatment is to reduce pain and inflammation, while also addressing the underlying cause of the condition. According to the consensus recommendations from the International Hip-related Pain Research Network, Zurich 2018, FAI syndrome is the most common hip condition in young and middle-aged active adults presenting with hip-related pain 1.
- Initial treatment includes:
- Rest and activity modification to avoid exacerbating hip pain
- Pain management with NSAIDs such as ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily for 5-7 days
- Ice application for 15-20 minutes several times daily to reduce inflammation
- Patients should avoid activities that exacerbate hip pain, particularly those involving hip flexion and internal rotation, as these movements can worsen the condition 1.
- Provide crutches if the patient has significant pain with weight-bearing to reduce stress on the hip joint. The ED physician should arrange orthopedic follow-up within 1-2 weeks, as definitive management typically requires specialist evaluation, and advanced imaging like MRI or CT is usually arranged by orthopedics 1.
- Imaging in the ED is generally limited to plain radiographs to rule out fractures or other acute pathology. Patient education should include explaining that FAI is caused by abnormal contact between the femoral head and acetabulum during movement, often due to bony abnormalities, and that while symptoms can be managed conservatively, some patients may eventually require surgical intervention such as arthroscopic repair 1.
From the Research
Management of Femoroacetabular Impingement at the ED
- The treatment of Femoroacetabular Impingement (FAI) syndrome begins with noninvasive nonoperative modalities such as patient education and supervised exercise-based physical therapy 2.
- For recalcitrant symptoms, various injections have been explored for both diagnostic and therapeutic purposes; however, the efficacy of these interventions have generally not been demonstrated outside of the short term 2.
- Intra-articular hip injection can be used for diagnostic and therapeutic purposes, with hyaluronic acid being the most effective at providing pain relief 3.
- A negative response to intra-articular hip injection was a strong predictor for poor surgical outcomes 3.
Diagnosis of Femoroacetabular Impingement
- FAI syndrome is diagnosed by a triad of symptoms, clinical signs, and imaging findings 2.
- The primary imaging modality for diagnosing FAI is a plain radiograph of the pelvis, which can be used to measure the alpha angle and the lateral center edge angle used to quantify severity 4.
- Radiographic signs associated with FAI, such as acetabular cross-over sign, prominent posterior wall sign, and pistol grip deformity, can guide referral to a hip specialist for further assessment 5.
Classification and Treatment Options
- FAI syndrome can be organized into three classifications; cam, pincer, or mixed, referring to the characteristic morphological changes of the bony structures 4.
- Conservative treatment is typically considered first-line treatment for mild to moderate FAI syndrome; however, the outcomes following postoperative surgical intervention have demonstrated excellent results 4.
- The most common surgical treatment option for FAI is done arthroscopically 4.