Femoroacetabular Impingement (FAI)
What is Femoralacetabular impingement (FAI)?
FAI is where there are changes to the bony morphology of the hip joint (a ball and socket joint). Changes to bony morphology can present in the following three presentations:
Cam lesion (changes to surface of the femoral head)
Pincer lesion (changes to the acetabulum)
Mixed presentation (a mix of cam and pincer lesions)
FAI is made as a diagnosis only when an individual has both changes to the hip joint on imaging(x-ray) and has clinically relevant symptoms of FAI such as pain in the hip/groin region and positive results with clinical physical tests. Changes on imaging alone is not always clinically relevant (we will discuss this more below).
What are the symptoms of FAI?
Symptoms of FAI include pain around the hip and groin region, which is often worse when the hip is flexed(bent) 90 degrees or more, rotated inward or when the leg is crossing midline. Pain can also be felt less frequently in the deep buttock region. Pain generally worsens with activities involving the above movements and the patient may also experience audible clicking or catching symptoms.
The changes to the bony morphology may have been present since childhood and were previously asymptomatic. It is likely that increased loading with sport/lifestyle changes; results in symptoms of FAI due to excessive/repetitive impingement on the cartilage of the hip joint.
How do we diagnose FAI?
As noted above Individuals will generally present with hip and groin pain. Your physiotherapist or other relevant medical professional will do a thorough assessment of your symptoms and past medical history. They will then physically palpate the region and take your hip through a battery of tests to determine the underlying cause. If the physiotherapist suspects FAI, they may then refer you for an x-ray. This in conjunction with your symptoms and the physiotherapists assessment will allow for a diagnosis of FAI. As noted above an x-ray with findings of Cam, Pincer or mixed lesions, is not sufficient evidence to diagnose FAI. This is as studies (see figure 1) have shown that when we x-ray both symptomatic and asymptomatic people there is a similar level of Cam, Pincer and mixed leisions found (Heerey, et. al. 2020).
What are the risk factors for FAI?
Factors that influence FAI can include inherited/genetic links and developmental/activity-related factors.
Genetic/hereditary links appear to be related to both Cam and Pincer type FAI while being of male sex results in a higher risk of Cam FAI (Chaudhry & Ayeni 2014).
Activity/developmental risk factors include participation in sports/activities that involve excessive hip flexion/abduction during developmental years. Evidence is limited here; however it suggests that high levels of exposure to these activities may alter the growth of the hip in response to those loads – resulting in changes to bony morphology,
What does the evidence suggest with regards to best practice for managing FAI?
The superior treatment choice for FAI is still controversial and both the use of conservative physiotherapy management and arthroscopic surgery have been shown to be successful in the management of FAI (Palmer, et. al. 2019 & Mallets, et. al. 2019).
Unfortunately, recent systematic reviews by Mok et.al. (2020) & Bastos, et. al. (2020) on the topic identify a lack of conclusive agreement on best practice care for these individuals.
A systematic review in 2020 by Mok, et. al. identified there was statistically significant positive outcomes in patients following arthroscopic surgery with regards to their quality of life and activities of daily living outcome measures vs conservatively managed patients. This study also identified that there was no difference in sports function when comparing conservatively managed vs surgically managed patients.
However, conversely, a systematic review conducted in 2020 by Bastos, et. al. noted there is evidence of moderate quality that surgery is of no benefit compared to conservative management in patients with FAI in the short-term and low-quality evidence that it is of no benefit compared to conservative management in the medium term.
The 2016 Warwick agreement (below Griffen et. al.) identified it is likely a combination of strategies may be required and best management of FAI should be individualised to the patient.
What does all this evidence mean, and does physiotherapy have a role?
Yes, physiotherapy will have a role!
What these articles most importantly demonstrate and agree upon is that both methods (conservative/physio and surgical) can be effective in management of FAI (Palmer, et. al. 2019).
Both conservative management via physiotherapy and surgical arthroscopic management were able to significantly improve patients quality of life, activity of daily living function and sports function in the majority of cases (Palmer, et. al. 2019, Bastos, et. al. 2020 & Mok, et. al. 2020).
In conclusion patients should be treated individually with the benefits and risk of both options to be taken into consideration. Physiotherapy will be a pillar of treatment for these patients regardless of whether they are managed surgically or not; as the patient will require rehabilitation post/preoperatively to maximise outcomes (Griffen, et. al. 2016).
In my opinion the infographic (on the following page) from the international agreement on the management of FAI from British Journal of Sports Medicine in 2016 (Griffen, et. al. 2016), clearly illustrates best practice in the management of these patients.
If you have any other questions regarding femoroacetabular impingement, please don’t hesitate to contact the clinic.
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Written by
Alanna Hickey
Owner & Physiotherapist
Korumburra Physiotherapy & Pilates Clinic
References
Bastos RM, de Carvalho Júnior JG, da Silva SAM, Campos SF, Rosa MV, de Moraes Prianti B. Surgery is no more effective than conservative treatment for Femoroacetabular impingement syndrome: Systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation. 2021;35(3):332-341. doi:10.1177/0269215520966694
Chaudhry, H., & Ayeni, O. R. (2014). The etiology of femoroacetabular impingement: what we know and what we don't. Sports health, 6(2), 157–161. https://doi.org/10.1177/1941738114521576
Griffin DR, Dickenson EJ, O'Donnell J, et al
The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. British Journal of Sports Medicine 2016;50:1169-1176.
Heerey, J., Agricola, A., Smith, A., Kemp, J., Pizzari, T., King, M., Lawerenson, P., Scholes., M & Crossley, K. The Size and Prevalence of Bony Hip Morphology Do Not Differ Between Football Players With and Without Hip and/or Groin Pain: Findings From the FORCe Cohort. Journal of Orthopaedic & Sports Physical Therapy 2021 51:3, 115-125
Mallets, E., Turner, A., Durbin, J., Bader, A., & Murray, L. (2019). SHORT-TERM OUTCOMES OF CONSERVATIVE TREATMENT FOR FEMOROACETABULAR IMPINGEMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS. International journal of sports physical therapy, 14(4), 514–524.
Mok, T.-N., He, Q.-y., Teng, Q., Sin, T.-H., Wang, H.-j., Zha, Z.-g., Zheng, X.-f., Pan, J.-h., Hou, H.-g. and Li, J.-r. (2021), Arthroscopic Hip Surgery versus Conservative Therapy on Femoroacetabular Impingement Syndrome: A Meta-Analysis of RCTs. Orthop Surg, 13: 1755-1764. https://doi.org/10.1111/os.13099
Palmer A J R, Ayyar Gupta V, Fernquest S, Rombach I, Dutton S J, Mansour R et al. Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicentre randomised controlled trial BMJ 2019; 364 :l185 doi:10.1136/bmj.l185