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Hip pain & FAI

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• Based on Physio Edge podcast 074 with @JoannaLKemp
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In 2016 the Warwick agreement (Griffin et al.) defined femoroacetabular

impingement (FAI) syndrome as a triad of findings. For a diagnosis of FAI
to be made the following must all be present:
1. Symptoms associated with FAI such as hip and groin pain
2. Positive imaging findings which may include morphological changes
or soft tissue findings
3. Signs associated with FAI - impingement tests such as a positive
FADIR, reduced muscle strength, reduced range of movement and
poor performance on functional tests

There are 3 types of FAI morphology:
1. Cam - Extra bone growth on the junction between the femoral head and
femoral neck which is most common in athletic populations
2. Pincer - Extra bone growth on the acetabulum
3. Mixed - combination of cam and pincer

Cam and pincer morphology can both be measured on plain x-ray. An AP

pelvic view and Dunn lateral views allow for a 3-dimensional view of the
head and neck junction. Currently within the literature there is a lack of
consensus with different authors suggesting different values for cam and
pincer deformity.

The alpha angle is used to identify the presence of a cam deformity. An

alpha angle greater than 60 degrees is considered a positive finding. A
measurement greater than 78 degrees is considered pathological and is
associated with a high risk of developing hip OA in later life. A pincer
deformity can be identified by the lateral center edge angle. A larger angle

FAI with Joanna Kemp

means a deeper acetabulum. A measurement greater than 40 degrees
represents a pincer deformity.

The most common site for impingement is the anterior superior region. The
development of FAI requires a combination of morphology and activity. A
patient may have altered morphology of the acetabulum but if their
movement patterns do not take them into end of range positions then they
may never develop FAI.

Is FAI a normal finding?

In isolation cam morphology is not a medical finding or a pathology and is
only relevant in patients who are symptomatic. If a patient does not have
symptoms, then they do not have FAI. The prevalence is higher in
symptomatic non athletes (45-50%) than asymptomatic non athletes (20-

However, the relationship between morphology and symptoms is more

complex in the athletic population. Systematic reviews have shown that
66% of athletes will have cam morphology regardless of symptoms. This
has lead us to question if cam morphology is associated with loading and
athletic activity rather than the presence of hip pain. It is not currently
known if changes in hip morphology are normal finding in athletes.

A study by Agricola et al. (2014) concluded that in male soccer player’s

cam deformities gradually develop during skeletal maturation and are
stable from the time of growth plate closure. This suggests that if a cam
deformity is going to develop it will be between 10 and 15 years of age.

FAI with Joanna Kemp

Surgery or Conservative Management?

The optimal management of patients with FAI is still unknown. There has
been a significant increase in the number of hip arthroscopies performed
across Europe, USA and Australia in recent years. Currently there are no
published randomized controlled trials looking at the effectiveness of
surgery but some studies are due to be published soon.

Following surgery quality of life scores may improve but surgery does not
resolve the problem. Patients will still be impaired compared to healthy age
matched controls. Outcomes following surgery are reduced in patients who
are over 40, have OA or significant cartilage damage at the time of surgery.

Conservative management

There is also a lack of high quality evidence for conservative treatment of

patients with FAI. Joanna is currently recruiting for a randomized
controlled trial called the physio first study which looks to compare best
practice physio with usual care. In the absence of good quality evidence,
conservative treatment should target the impairments that patients with
FAI present with. Anecdotally patients with FAI have good improvements
with targeted physiotherapy interventions.

Clinical presentation
Patients with FAI will present with hip or anterior groin pain. This may also
be combined with buttock pain, pelvic/lower back pain or pain that refers
into the thigh. Pain often presents from the age of 16 onwards in those who
play sports involving flexion and rotation such as football, hockey, water
polo and tennis. This pain may have developed gradually over a period of
months or years.

Symptoms are usually aggravated with sporting activities involving flexion

and rotation but may also be present with prolonged periods of sitting.
Patients may report pain at rest or at night which is thought to be caused
by synovitis. Patients may have had treatment from a variety of clinicians
previously with limited benefit.

FAI with Joanna Kemp

Subjective Assessment
During the subjective assessment, identify the patients’ previous activity
levels, specifically during adolescence, as this may be associated with an
increased risk of developing FAI. Ask if there is a family history of hip
problems or hip replacements, as there may be a genetic predisposition to
developing a cam morphology.

Red flags
There should be a high index of suspicion of a slipped upper femoral
epiphysis (SUFE) in adolescents presenting with hip or groin pain. These
typical occur in overweight males between the ages of 10-13, however, can
occur in females. They commonly present with hip pain or knee pain, and
on assessment, patients have a shortened or rotated leg. It may be
appropriate to refer for further imaging to rule out the presence of a SUFE
in adolescents (8-14 year olds) presenting with hip or groin pain

Pelvic or femoral stress fractures may present in females with a low body
mass index, especially those with risk factors for female athlete triad. The
clinician should also be cautious of malignancy, especially in patients with
a past medical history of cancer. Ask about past history of cancer during
the subjective assessment and always refer these patients on if there are
any concerns.

Objective Assessment
• Hip flexion and internal rotation range of movement
• Impingement tests such as FADIR
• Exclude other pathologies such as gluteal tendinopathy, lumbar spine,
extra articular structures including adductor related groin pain,
iliopsoas groin pain and inguinal related groin pain
• Hip muscle strength testing with a handheld dynamometer
• Trunk muscle strength testing - side plank
• Performance tests such as single leg rise test and hopping tasks

FAI with Joanna Kemp

Special tests for FAI have high levels of sensitivity and poor specificity. If
impingement tests are negative then we can be confident that the patient
does not have FAI. These tests should be performed at the start of an
examination to screen out FAI and direct the assessment towards other
structures such as the lumbar spine. Pain provoked with lumbar spine
movements and straight leg raise suggest the source of pain may be the
lumbar spine and not the hip.

Measuring hip flexion range of movement

Hip flexion range of movement is associated with improved outcomes in

patients with FAI. To measure, position the patient in supine with their legs
flat and instruct them to actively extend the opposite leg into the bed. Place
an inclinometer 5 cm above the patellar and ask the patient to actively bend
their knee as far as comfortable towards their chest. Flexion range of
movement should be used as an objective marker to assess the
effectiveness of treatment interventions.

Treatment interventions should aim to address the impairments an
individual presents with such as reduced strength, range of movement or
functional performance.


Teach the patient about their condition and that surgery is not always
required. Instead changes to a patient’s movement patterns, daily activities
and hip joint loading may reduce their symptoms. Reassure patients that
flare ups are normal and will settle with time. Patients may have some
symptoms with activity, however, this does not equate to further damage.
Guide the patient during exercise by using the traffic light system of pain.
The aim is to empower the patient, so they become less fearful of activity.

FAI with Joanna Kemp


Strength can be measured in clinical practice with a handheld

dynamometer. Patients with FAI have impaired hip muscle strength,
specifically hip adduction, abduction and extension. Patients with FAI may
also present with reduced trunk muscle endurance which may increase hip
joint loading. Exercises should be prescribed to target these muscle groups.

Functional tasks

Patients may present with impaired function and endurance during tasks
such as hopping, landing, squatting and single leg squatting. These can be
addressed by incorporating functional and plyometric training into

Cardiovascular training

A progressive cardiovascular training program should be prescribed to

improve fitness and load tolerance in patients with FAI.

Range of movement

FAI includes a large biological component and manual therapy should be

used as an adjunct to exercise therapy. Techniques targeting iliopsoas,
glute med, piriformis, lumbopelvic area and hip adductors can help to
reduce pain and improve range of movement in patients with FAI. Joint
mobilizations and manual traction techniques may provide patients with
short term relief and improve exercise compliance.

When to refer for a surgical opinion?

All patients should try a period of conservative management for at least 3
months before considering a surgical opinion. Ensure that patients have
been provided with the best quality conservative management before
onward referral.

FAI with Joanna Kemp

If there is no improvement in 3 months and the patient has been exposed

to the best quality conservative management then consider other options.
Referral for a surgical opinion should be a shared decision with the patient.
Provide the patient with a realistic view of the outcome of surgery,
recovery timescales and the likelihood of achieving their goals of returning
to sport or other activities.

FAI and OA
Patients with a cam morphology are 10 times more likely to develop hip OA
but only 5% of them go onto develop OA. There is no evidence that
prophylactic surgery is beneficial in patients with hip pain. To reduce the
risk of developing OA, advise patients to maintain a healthy bodyweight,
keep their muscles strong and continue to perform weight bearing physical

Sports Injuries Virtual Conference

As mentioned in this episode Joanna will be part of the sports injury virtual
conference. Her pre conference presentation will discuss FAI and the
diagnostic process in more detail. Her main conference presentation on
FAI will discuss:
• Conservative management of FAI
• Specific exercise progressions you can use
• Return to sport for athletes