What is the management for a 28-year-old patient with left hip femoroacetabular impingement (FAI) and associated focal edema involving the left femoral head and neck junction, likely from a contusion without bony injury?

From the Guidelines

For a 28-year-old patient with left hip femoroacetabular impingement (FAI) with focal edema at the femoral head-neck junction from contusion without bony injury, I recommend a comprehensive conservative management approach initially. This approach is based on the most recent and highest quality study available, which emphasizes the importance of conservative management for hip-related pain in young to middle-aged active adults 1. The patient should start with activity modification to avoid painful movements, particularly those involving hip flexion and internal rotation. Some key points to consider in the management of this patient include:

• Prescribing NSAIDs such as ibuprofen 400-600mg three times daily or naproxen 500mg twice daily for 1-2 weeks to reduce inflammation and pain
• Initiating physical therapy promptly, focusing on core strengthening, hip stabilization exercises, and improving range of motion without aggravating symptoms
• Applying ice for 15-20 minutes several times daily during acute phases
• Considering an intra-articular corticosteroid injection (such as methylprednisolone 40mg with lidocaine) for temporary relief if pain persists despite 4-6 weeks of conservative treatment
• Imaging follow-up with MRI may be warranted after 3 months to assess healing Surgical options, including arthroscopic repair, should be considered only if conservative measures fail after 3-6 months of dedicated treatment, as suggested by studies on joint-preserving surgical options for management of chondral injuries of the hip 1.

From the Research

Management of Femoroacetabular Impingement

The management of a 28-year-old patient with left hip femoroacetabular impingement (FAI) and associated focal edema involving the left femoral head and neck junction likely from a contusion without bony injury can be approached in the following ways:

• Conservative Treatment: Conservative treatment is typically considered first-line treatment for mild to moderate FAI syndrome 2. This may include physical therapy, hip strengthening, hip joint manual therapy techniques, functional activity-specific retraining, and education 3.
• Surgical Treatment: If nonoperative management fails, surgical treatment is often done arthroscopically and with good results 4, 5, 6. The most common surgical treatment option for FAI is done arthroscopically 2.
• Arthroscopic Femoral Osteoplasty/Chielectomy: For cam-type FAI, arthroscopic femoral osteoplasty/chielectomy can be an effective treatment option 4.
• Restoring Femoral Head-Neck Offset: Treatment generally focuses on restoring the femoral head-neck offset by removing the excess bone 4.

Diagnostic Considerations

• Physical Examination: Patients with FAI will typically have a positive FADIR test (flexion, adduction, internal rotation), also known as a positive impingement sign 2.
• Imaging Studies: 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 2.
• Clinical Tests: Restricted internal hip rotation in 0° hip flexion with or without pain was best to rule in FAI syndrome, whereas no pain in Flexion Adduction Internal Rotation test or no restricted range of motion in Flexion Abduction External Rotation test compared with the unaffected side were best to rule out 3.