What is the recommended evaluation and treatment plan for a young active patient with cam-type femoroacetabular impingement of the hip?

Cam-Type Femoroacetabular Impingement: Evaluation and Treatment

Initial Diagnostic Approach

Begin with anteroposterior pelvis and lateral femoral head-neck radiographs (Dunn, frog-leg, or cross-table views) to confirm cam morphology, combined with clinical examination showing groin pain and positive FADIR test. 1, 2

Clinical Presentation to Confirm

• Groin pain is the hallmark symptom, worsened by hip flexion, adduction, and internal rotation activities 2
• Pain may radiate to back, buttock, or thigh but groin predominance is essential 2
• Positive FADIR test (flexion-adduction-internal rotation) supports the diagnosis, though limited specificity 1, 2
• Limited hip internal rotation and flexion on examination 2
• Symptoms are motion-related and activity-dependent 2

Critical Exclusions Required

• Rule out lumbar spine pathology first, as radicular pain mimics hip-related pain 2
• Exclude serious pathology including tumors, infections, stress fractures, and slipped capital femoral epiphysis before proceeding 1
• Screen for competing musculoskeletal conditions of the pelvis 1

Imaging Protocol

• Initial imaging: AP pelvis and lateral femoral head-neck radiographs to identify cam morphology (loss of femoral head-neck offset) 1, 2
• Never diagnose based on imaging alone—imaging must correlate with symptoms and clinical signs, as cam morphology is common in asymptomatic individuals 1, 2
• Advanced imaging (MRI or MR arthrography) is indicated when conservative treatment fails and surgery is considered, to assess labral tears, chondral damage, and ligamentum teres pathology 1, 2, 3

Treatment Algorithm

First-Line Conservative Management (3-6 Months)

All young active patients with cam-type FAI should undergo a mandatory 3-6 month trial of conservative treatment before considering surgery. 2, 3

• Activity modification: Reduce or eliminate repetitive hip flexion activities that provoke symptoms 2, 3
• Physiotherapist-led rehabilitation program focusing on hip muscle strengthening and movement quality 1
• NSAIDs for symptomatic pain relief 2, 3

The evidence for physiotherapist-led treatment shows improvements in pain, function, and quality of life, though specific exercise parameters require individualization based on patient response 1

Surgical Indications

Proceed to arthroscopic hip surgery when: 2, 3

• Conservative management fails after 3-6 months with persistent hip-related groin pain
• Positive clinical examination findings persist (positive FADIR test, limited ROM)
• MRI or MR arthrography confirms labral tears or chondral damage requiring concurrent treatment

Surgical Technique

Hip arthroscopy with femoral osteoplasty (femoroplasty) is the preferred surgical approach for cam-type FAI. 4, 5, 6

• Arthroscopic femoral osteoplasty removes excess bone at the femoral head-neck junction to restore normal offset 4, 5, 6
• Comprehensive fluoroscopic assessment using 6 anteroposterior views (3 in extension at varying rotations, 3 in 50° flexion) performed before, during, and after resection 5
• Dynamic assessment of impingement-free range of motion in extension/abduction, flexion/abduction, and flexion/internal rotation positions 5
• Address associated pathology: labral debridement or repair (17-32% require repair), acetabular rim lesions (83% of cases) 7
• Chondral lesion management: microfracture for grade 2-3 lesions <3 cm², consider matrix-assisted autologous chondrocyte implantation for larger defects 3

Expected Outcomes

• Modified Harris Hip Score improvements of approximately 20 points at 12-24 months follow-up 6
• 78-88% return to full sporting activity with high satisfaction rates 7
• Low complication rates (1.5%) with arthroscopic approach 6
• Residual impingement deformity is a leading cause of surgical failure, emphasizing the importance of thorough intraoperative assessment 5

Critical Pitfalls to Avoid

• Never treat imaging findings alone—cam morphology without corresponding symptoms and positive clinical signs does not warrant intervention 1, 2
• Incomplete posterior femoral resection is a common cause of surgical failure; use hip positioning (flexion with internal rotation for posterolateral access, extension for posteromedial access) to achieve complete correction 5
• Failure to exclude lumbar spine pathology leads to misdiagnosis and inappropriate treatment 2
• Proceeding to surgery without adequate conservative trial (minimum 3-6 months) contradicts guideline recommendations 2, 3