Femoroacetabular impingement (FAI) is a condition that presents as pain in the groin or front of the hip. It is an under-recognised condition that has become more commonly diagnosed and treated in the last 20 years (2). It is caused by bony anatomical variations around the hip which may result in increased contact of the ball and socket joint during movement of the hip. This, in turn, can cause irritation of the bone and soft tissues around this area which may result in pain (2).
There are two types of bony variation that may lead to symptoms of femoroacetabular impingement. A “cam” deformity, relating to the femoral head-neck contour (top of the thigh bone) not being completely round, and a pincer deformity which is an over-coverage of the acetabulum (socket of the hip joint). These changes to the structure of the ball and socket joint rarely occur in isolation and are often combined. Patients with femoroacetabular impingement might have a higher risk of developing osteoarthritis (OA) of the hip (3). Therefore, early identification of patients with groin pain related to this condition is important to delay or even prevent the development of osteoarthritis.
The primary symptom of femoroacetabular impingement is movement-related or position-related pain in the hip or groin, alongside a limited range of movement in certain positions (2). Having the hip fully bent with the knee turned inwards (internal rotation) is the position that is most frequently identified as symptomatic. Pain is typically worse on doing activities such as squatting, twisting of the hip and after prolonged periods of sitting (1,2).
Patients with the condition will describe a constant dull ache that is worse after activity. They may also describe a ‘catching’, ‘locking’ and ‘clicking’ sensation with aggravating activities. The longer symptoms go on and the more significant the irritation, the wider the area these symptoms can be experienced. It is often the case that symptoms can ‘refer’, or travel, as far down as the inside of the knee.
This is not an exhaustive list. These factors could increase the likelihood of someone developing femoroacetabular impingement. It does not mean everyone with these risk factors will develop symptoms.
Research has suggested that in the general population symptoms related to femoroacetabular impingement arise in less than 1% of people (4). However, the results of a systematic review in 2015 showed that cam and pincer deformities are present in a significant number of young adults, regardless of being an athlete or not, with up to 23.1% of people in their mid-20s having a cam deformity on imaging (5). It is more common in young athletes (between the ages of 15-30) who are heavily involved in sports that comprise of high load bending and twisting movements at the hip such as basketball, football, hockey and rugby. For example, in young footballers who train more than 12.5 hours per week, there has been shown to be an increased risk of the structural changes that could lead to symptoms of femoroacetabular impingement (4).
A musculoskeletal physiotherapist can provide you with an accurate and timely diagnosis by obtaining a detailed history of your symptoms. A series of specialised physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities. Any tests done will be considered alongside your symptoms to ensure an accurate working diagnosis.
Your physiotherapist will want to know how your condition affects your day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made.
It is not necessary in most cases to order an immediate scan or X-ray, as physiotherapy will most likely be the first line of treatment. If symptoms persist or get worse, an X-ray may be considered as the first port of call which can assess the hip joint and check for the presence of cam and/or pincer deformity (6). This can be arranged in collaboration with your GP. Magnetic resonance imaging (MRI) is typically requested in circumstances where the surrounding cartilage needs examination or if surgery is being discussed.
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your femoroacetabular impingement. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
It is widely agreed that the best starting point in the management of femoroacetabular impingement is physiotherapy led rehabilitation (2). This will focus on optimising the movement, flexibility, strength and stability around the lumbar spine, pelvic and hip regions.
This programme focuses on strengthening muscles around the hip joint and aiming to increase the flexibility of muscles that may have become tighter due to pain. It must be understood that whilst pain during and after these exercises cannot be totally avoided, a significant increase in pain is not desirable. Pain should not exceed 3/10 on your self-perceived pain scale whilst completing this exercise programme.
This is the next progression. More focus is given to developing lower limb strength and stability. This programme may be performed every other day as tolerated. It is important to maintain dialogue with your physiotherapist if symptoms change because of the exercises. Pain should not exceed 3/10 on your pain scale.
This programme is a further progression with a focus on return to sporting activities and dynamic loading to ensure that your hip can tolerate the fast, high load activities required in your sport without an increase in symptoms. Pain should not exceed 3/10 on your pain scale.
In patients who are treated for femoroacetabular impingement symptoms frequently improve, and they return to full activity, including sports. Without treatment, symptoms will most likely worsen over time. The long-term outlook for patients with femoroacetabular impingement remains unclear. However, it is likely that cam morphology is associated with the development of hip osteoarthritis. It is currently unknown whether treatment for femoroacetabular impingement prevents hip osteoarthritis.
As previously mentioned, where physiotherapy is unsuccessful in reducing symptoms and allowing a normal active lifestyle, surgery can be an option. Arthroscopy (keyhole surgery) is the most common surgical procedure for femoroacetabular impingement discussed in the literature. The exact nature of each surgery varies according to the treating surgeon’s clinical judgement but will typically involve trimming and reshaping the acetabular rim (socket edge), labral repair/debridement (articular cartilage) and/or reshaping the femoral head/neck (2).
It should be noted that at this stage, there has been no significant difference found between the outcomes of surgery and physiotherapy and, as such, it is recommended that physiotherapy should almost always be the first option for patients with femoroacetabular impingement (2,7).
Please book an appointment with one of our physiotherapists if you think you are suffering from this condition and would like to find out more.
We have Pure Physiotherapy clinics across the country including Norwich, Ipswich, Manchester, Bolton, Wakefield and Sheffield. Please view our clinics to find the closest physiotherapy clinic for you.
Lower back pain caused by structures in the back, such as joints, bones and soft tissues.
Sciatica is a symptom describing pain and/or pins and needles down the back of the leg.
Lumbar discs sit between each of the bones of the spine. Problems can occur when these discs become irritated.
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