What is Femoroacetabular impingement syndrome?

Femoroacetabular impingement (FAI) syndrome is a movement-related problem of the hip, often leading to pain in the hip or groin region. It is caused by abnormal or premature contact between the top of the thigh bone and the hip socket during movement, or in certain positions.

For the syndrome to be properly diagnosed, three main criteria are required:

A patient must report symptoms, such as hip or groin region pain, clicking, catching, or giving way
Certain clinical signs must be present, for instance, reduced range of motion of the hip
Certain ‘features’ must be seen on x-ray of the hip: usually a ‘cam’ or ‘pincer’ lesion

hip cam

Anatomy of femoroacetabular impingement syndrome:

The hip is a ball and socket joint. The socket is called the acetabulum and is part of the pelvis. The ball is at the very top of the femur (thigh bone) and is called the ‘head of the femur.’

In FAI syndrome, one or two features are seen on x-ray:

A ‘cam’ shape: a ‘bump’ of bone may be seen at the junction of the ‘head’ and the ‘neck’ of the femur bone, causing an area of convexity
A ‘pincer’ shape: the acetabulum (socket) has too much coverage or overhang over the top of femur
A mix of the two features above

These bone features can be responsible for reducing the amount of ‘clearance’ within the hip joint, causing abnormal contact to occur between femur and the socket. Over time, this contact may lead to inflammation within the hip (synovitis), as well as potential damage to the cartilage within the joint, particularly the labrum, which is a ring of fibrocartilage that lines the rim of the socket.

What are the symptoms of femoroacetabular impingement syndrome?

The primary symptom of FAI syndrome is movement related, or positional related pain in the hip or groin region. However, pain may also be felt in the lower back, buttock or thigh. In addition to pain, patients may also describe stiffness, clicking, catching, locking or giving way.

These symptoms are often felt either during or after vigorous physical activity, such as sports including AFL and soccer, or sports that require a lot of range of movement of the hip, such as dance, gymnastics and calisthenics. However, since symptoms can be related to certain positions of the hip, those who live more sedentary lifestyles can also experience symptoms, for example, when sitting for too long.

Do I have femoroacetabular impingement syndrome?

Just having the features of FAI on x-ray, such as a ‘cam’ or ‘pincer’ lesion does not mean that you have FAI syndrome.

For the syndrome to be present, you must also be experiencing the symptoms of FAI as mentioned above, as well as the ‘clinical signs’ present when your hip is examined by a doctor or physiotherapist, such as reduced range of motion, or pain that is provoked with certain clinical tests.

Other tests such as MRI or CT scan may be required, especially if any surgery is planned. Sometimes, a local anaesthetic injection may be used in the hip may be used to help determine whether your symptoms are arising from within the hip, or from many of the other structures around the hip.

Treatment of femoroacetabular impingement syndrome:

FAI syndrome can be treated by conservative care, rehabilitation or surgery.

Conservative care involves education, monitoring of symptoms over time and lifestyle and activity modification.

Physiotherapy based rehabilitation aims to improve hip stability, hip muscle strength, range of motion and movement patterns.

Surgery, which is usually performed arthroscopically (keyhole), aims to improve the hip joint shape (morphology) and repair any damaged tissue in the hip, such as the labrum (cartilage).

A recently published, large clinical trial in the UK (The ‘FASHIoN Study’), showed positive outcomes from both physiotherapy-led and surgical treatment options for FAI syndrome.

Without treatment, symptoms of FAI syndrome will probably worsen over time. The long-term outlook for patients with FAI syndrome is unknown. However, it is likely that having a cam shape is associated with the development of hip osteoarthritis

Differential diagnosis:

It is important a proper diagnosis is performed, as FAI syndrome must be differentiated from other conditions that may cause hip and groin pain, such as:

Hip joint instability or hip joint dysplasia (eg. a ‘shallow’ hip socket)
Gluteal (buttock muscle) tendon problems
Adductor (groin muscle) tendon problems
Iliopsoas (hip flexor muscle) tendon problems
Inguinal hernia

5 tips for self-managing FAI syndrome:

Avoid sitting in cross-legged positions (especially where one knee is crossed over the other)
Avoid sitting in positions where the hips are positioned ‘lower’ than the knees, for example, sitting on a low couch. Always try to have your hips higher than the knees.
When performing stretching exercises for the back and leg muscles, always ensure that you are feeling a good stretch in the desired muscle. If you experience deep hip or groin region pain when stretching, rather than a muscle stretch, this may be counter-productive.
Avoid excessively deep squats and lunging-type movements.
If you are a side sleeper, try sleeping with a pillow between your knees to ensure your thigh does not cross over the other during the night

Return to activity:

In patients who are treated for FAI syndrome, symptoms frequently improve, and they return to full activity, including sports.

References:

The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Griffin DR, et al. Br J Sports Med 2016;50:1169–1176.

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Hip Physiotherapists

Vestibular, Musculoskeletal, Women's and men's health, Continence and Pelvic Floor, - Bachelor of Applied Science Physiotherapy, Post Graduate Certificate Continence and Pelvic Floor

Nevine brings over 28 years of clinical experience as a Physiotherapist, including five years as a practice manager. She has specialized in vestibular rehabilitation for 18 years and continence and pelvic floor physiotherapy for 22 years. Her diverse career spans hospitals, private practice, community health, rehabilitation services, and research, including her work on the TELKO study at Melbourne University.

Nevine is bilingual in Egyptian and speaks some Italian, enhancing her ability to connect with clients from diverse backgrounds. Her clinical expertise includes managing spinal and musculoskeletal conditions, shoulder injuries, pelvic girdle and hip pain, whiplash, sports injuries, vestibular and neurological disorders, paediatric care, bladder and bowel health, as well as adult and geriatric rehabilitation.

She is highly skilled in delivering a variety of physiotherapy programs, such as spinal rehabilitation, core stability, Pilates, functional restoration for chronic low back pain, continence rehabilitation, falls prevention, vestibular and balance therapy, and strength training. Nevine uses evidence-based practices and outcome measures to identify the root causes of her clients’ issues, empowering them to reduce pain, stiffness, weakness, leakage, and dizziness, and improve their overall strength, mobility, and balance.

Clinical Interests/Special Interests

Vestibular Rehabilitation: Nevine has completed extensive vestibular training, including three vestibular certifications and an intensive competency-based course at Monash University. She uses advanced tools like Frenzel goggles to assess and treat conditions such as BPPV, vestibular neuritis, migraines, and balance disorders.
Continence and Pelvic Floor Physiotherapy: With a Postgraduate Certificate in Continence and Pelvic Floor Rehabilitation from Melbourne University, Nevine helps clients manage bladder and bowel conditions, pelvic organ prolapse, and post-surgical recovery.
Musculoskeletal and Ante/Postnatal Care: She supports clients with pelvic girdle pain, sacroiliac joint dysfunction, lumbosacral instability, diastasis recti, and perineal tears.

Nevine is dedicated to educating and empowering her clients, helping them achieve better health and well-being through personalized care.

What is Femoroacetabular impingement syndrome?

Anatomy of femoroacetabular impingement syndrome:

What are the symptoms of femoroacetabular impingement syndrome?

Do I have femoroacetabular impingement syndrome?

Treatment of femoroacetabular impingement syndrome:

Differential diagnosis:

5 tips for self-managing FAI syndrome:

Return to activity:

References:

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Hip Physiotherapists

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