What is the recommended management plan for a 10‑year‑old skeletally immature patient diagnosed with femoroacetabular impingement (FAI)?

Management of Hip Impingement in a 10-Year-Old Child

In a 10-year-old skeletally immature patient with suspected hip impingement, the absolute first priority is to exclude slipped capital femoral epiphysis (SCFE) and other serious pathologies before considering femoroacetabular impingement syndrome, followed by conservative physiotherapist-led rehabilitation if FAI is confirmed. 1, 2, 3

Critical First Step: Exclude Serious Pathology

Before proceeding with any FAI-specific workup or treatment, you must systematically rule out conditions that require urgent intervention in this age group:

• SCFE is the most critical diagnosis to exclude in a 10-year-old presenting with hip pain, as this represents a surgical emergency that can lead to avascular necrosis if missed 2, 3
• Look specifically for: external rotation deformity of the affected limb, antalgic gait, inability to bear weight, and limited internal rotation 3
• Other red-flag conditions to exclude: septic arthritis (fever, inability to bear weight, systemic symptoms), stress fractures, avascular necrosis, tumors (night pain, systemic symptoms), and Perthes disease 1, 2, 4

Diagnostic Workup

Initial Imaging

• Obtain AP pelvis and lateral femoral head-neck radiographs (Dunn, frog-leg, or cross-table views) immediately to evaluate for SCFE, Perthes disease, and to assess for cam or pincer morphology 1, 2
• These radiographs will identify loss of femoral head-neck offset (cam morphology defined as alpha angle >50.5°) or acetabular overcoverage (pincer morphology with LCEA >40°) 1

Clinical Examination

• Perform the FADIR test (flexion-adduction-internal rotation): a positive test supports intra-articular pathology, while a negative test helps exclude hip-related pain 1, 2
• Assess for limited hip internal rotation and flexion, which are common findings in FAI syndrome 1
• Screen the lumbar spine to exclude referred pain from L1-L3 radiculopathy, as this can mimic hip pathology 1, 2

Confirm the Diagnostic Triad

FAI syndrome can only be diagnosed when all three of the following are present:

1. Groin pain (may radiate to back, buttock, or thigh) 1
2. Positive FADIR test 1
3. Radiographic evidence of cam or pincer morphology 1

Critical caveat: Cam morphology is present in approximately 14% of asymptomatic individuals (24.7% of asymptomatic males), so imaging findings without symptoms do not justify treatment 1

Conservative Management Plan

Once serious pathology is excluded and FAI syndrome is confirmed, initiate a physiotherapist-led rehabilitation program as first-line treatment:

• Supervised physical therapy focusing on hip muscle strengthening and movement quality is the cornerstone of conservative management and leads to improvements in pain, function, and quality of life 5, 1, 6
• Activity modification and NSAIDs should be included as adjunct measures 1, 6
• Duration: minimum 3-6 months of conservative therapy before considering any surgical intervention 1, 6

Physical Therapy Components

• Active strengthening exercises (superior to passive therapy) 6
• Core strengthening programs 6
• Movement quality training 5

Advanced Imaging Indications

MRI or MR arthrography should only be obtained if:

1. Conservative management has failed after 3-6 months, AND
2. Surgical planning is being considered 1

These advanced studies evaluate labral tears, chondral damage, and ligamentum teres pathology 5, 1, 7

Surgical Considerations (Rarely Applicable at Age 10)

Arthroscopic hip surgery is indicated only when:

• A minimum 3-6 month trial of conservative care has failed, AND
• The patient continues to have persistent groin pain with positive FADIR test and limited range of motion 1

Important note: In a skeletally immature 10-year-old, surgical intervention for FAI is extremely rare and would require careful consideration of growth plate status and long-term implications 4

Common Pitfalls to Avoid

• Never base treatment decisions on imaging findings alone – cam morphology without corresponding symptoms and positive clinical signs does not merit treatment 1
• Do not proceed with FAI workup until SCFE is definitively excluded in this age group 2, 3
• Always screen the lumbar spine – radicular pain can mimic hip pathology 1, 2
• Recognize that early surgical intervention has diminished success once advanced degenerative changes occur, making timely conservative management critical 4, 8