Conservative Management of Femoroacetabular Impingement

The following is an article written for the online, video-based physical therapy continuing education company MedBridge

FAI Prevalence

As mentioned in my previous post on differential diagnosis of femoroacetabular impingement (FAI), hip pain is an all too common occurrence among older adults and adolescents.1

    • Older adults. According to a survey and subsequent study of 2,221 German respondents (predominantly female and > 40 years old), 15.2% reported hip pain and 3.5% reported bilateral hip pain.2
    • Adolescents. Spahn et al found that 6.5% of German adolescents reported hip pain. Women were more likely to be affected, along with individuals that consumed alcoholic beverages.3

A multitude of different pathologies and medical conditions explain the hip pain, but the more common cause is FAI. Young, active individuals with hip pain generally have very high incidence of FAI (as high as 87%).4

Is Conservative Care Effective for FAI?

With such a high prevalence, especially in athletes, clinicians must understand the evidence for conservative management.

To determine the effectiveness of therapy and other conservative care, Wall and colleagues conducted a systematic review of the available literature.5 Unfortunately, only 5 studies met the inclusion criteria due to the significant predominance of surgical interventions versus conservative care.

Benefits of Exercise and Activity Modification

That said, two studies with high-quality evidence found that patients can benefit from physical therapy and activity modification. The physical therapy programs included exercise-based staged rehabilitation focusing on the core hip musculature, education, and advice to help reduce the frequency of impingement.

In the first study, only 4 of 37 patients ended up undergoing surgical intervention.6 The remaining 33 subjects significantly improved their mean Harris Hip Score from 72 to 91 points at the 24-month follow-up.

The second study found no significant differences in pain and function when comparing conservative care to conservative care plus surgical intervention.7 Both groups showed improvement at the one-year follow-up.

Separately from this systematic review, a case report also found promising results for prescribing an augmented home exercise program of standing lateral glides and supine inferior glides of the hip using a belt.8

Interventions

Going back to the systematic review, the successful conservative FAI management programs included the following interventions.

  • An overwhelming emphasis was put on core and gluteal musculature training.
  • Most programs focused on pain-free stretching of the hip flexor muscle group.
  • PROM and stretching at end-ranges of hip flexion and internal rotation were avoided.

Interestingly, only one of the programs included joint mobilization or specific manual therapy interventions. Based on the evidence supporting manual therapy in other hip pathologies, and the general FAI pathomechanics, it would appear that joint mobilization techniques should significantly enhance FAI rehabilitation.9

However, more recently Wright and colleagues investigated the effectiveness of conservative management in the treatment of FAI with favorable results10. In this small pilot study, patients were randomly assigned to receive either manual therapy and supervised exercise or advise and a home exercise program. At the conclusion of the 6 week treatment period, there was not a significant difference between the two groups, however both groups showed significant improvements in pain.

Conservative management of FAI is horribly underrepresented in the literature, but the scarce evidence available does provide some optimism. With the lack of definitive evidence supporting specific interventions, therapists must rely on the remaining two pillars of evidence-based practice: experience and patient beliefs.

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