Physical Therapy For FAI — Femoroacetabular Impingement
Femoroacetabular Impingement, or FAI, is a condition of the hip that may affect upwards of 15% of the population, although the numbers in the physical therapy literature vary widely.
FAI occurs when there is extra bony growth in the hip joint. Skeletally, the hip is a ball and socket joint, with the socket called the acetabulum, and the ball is the head of the femur. The extra bony growth causing FAI can be on either part of the joint. If it is on the acetabulum, it is called a pincer impingement, and if it is on the femoral head it is called a cam lesion. Commonly, there is a combination of both types occurring at the same time. For expert guidance and treatment, PHYT Collective in Northeast DC provides specialized care for hip conditions like FAI.
Hips are a very complex joint and no 2 hips are the same.
This makes them a complicated (and interesting) joint to treat. Not only are there different types of impingements, but the size and location of the extra bony growth varies widely person to person and hip to hip. Beyond that, the acetabulum (socket of the joint) can be different in depth and even in angle where it sits on the pelvis. In turn, the femur (the long bone in the thigh that attaches to the pelvis) can have various torsions within the bone itself. This leads to a huge amount of variation in the way each individual hip is structured. Just spend a couple of minutes watching a crowd walk by and notice how each person steps a little differently. One reason for this can be because of variation in hip structure.
On top of the bones that make up the hip we have connective tissue and muscle. Muscle alignment, strength, flexibility, and imbalances all impact how your hip moves. In addition, the hip is a major weightbearing joint, so we can’t discount what is happening through the joints above and below the hip, especially the back and knee. There are so many factors that influence the way the hip moves that individual care is key to working through hip pain.
Now that you’ve had your anatomy lesson, what is impingement?
Through our body we have connective tissue that provides stability to our joints. In the hip we have what is called the labrum, which is a ring of cartilage-like tissue that encircles the socket part of the joint. When there is extra bony growth from either the cam or pincer (mentioned above), the labrum is vulnerable for getting pinched, or “impinged” in the joint. Over time this pinching can lead to inflammation, pain, and possibly tearing.
Not to fear! This all sounds very scary, however, there is a wide range of how FAI impacts each individual. Some people live a very full life, not impacted by FAI much at all. Other people get quite a bit of relief with physical therapy. And there are some who require surgical intervention. The first line of treatment should almost always be physical therapy. Why? It isn’t because I am a PT and biased towards therapy, rather the medical literature shows that a significant number of people get better with physical therapy! Also, for those who still require surgery, pre-operative physical therapy helps people go into surgery stronger and with better movement patterns, which is a great advantage in post-op rehab.
Femoroacetabular Impingement (FAI) – Signs and Symptoms
How do you know if you have FAI?
Getting this condition diagnosed isn’t always straight forward. Relatively speaking FAI is a “newer” medical diagnosis. Even though hip impingement was identified years earlier, technological advancements allowed for improved hip imagining and an explosion of FAI diagnosis in the early 2000’s. There was a dramatic uptick in surgery as well, and as with pretty much anything, there is a learning curve.
We will talk more about this later, but let’s just say that early surgeries for FAI and labral tears was not always successful.
FAI does present differently in different people, but there are some symptoms that are more common.
These include:
- Groin pain
- Buttock pain
- Pain with sitting
- Difficulty flexing knee towards chest and/or rotating leg
- Stiffness in the hip
- Limping
- Age mid 20s – mid 40s
- Higher incidence in females
A physical therapist or medical doctor specializing in hips can do a thorough clinical exam to identify hip impingement. Imaging such as an x-ray, MRI, ultrasound, and/or CAT scan may be obtained for assessment of the bony structure and soft tissue.
A combination of the clinical tests and imaging, as well as a discussion with your healthcare provider, will help you determine the best course of action for your care.
Surgical vs Non-Surgical Intervention for FAI
Just because you have FAI it absolutely does not mean you need surgery. The majority of cases don’t require surgery for people to live a very healthy and full life.
As previously mentioned, the incidence of FAI and labral tears dramatically increased between 2000-2016 due to improved diagnostic capability. Because of this, there was also a dramatic increase in surgical intervention involving repairing the labrum and performing what is called an osteotomy. An osteotomy is a procedure where bone is shaved down to create more space in the joint, with the goal being to eliminate the impingement.
Looking back on the surgeries done in this period of time, not all were successful. The hip is a complex joint and reshaping it surgically to correct for the impingement is very hard to do. The stress on the hip is very different in surgery compared to when someone is standing or walking, when all the muscles that support the hip come into play. As a result, the success rate for this surgery wasn’t great. But times have changed and medicine progresses, and currently the success rate is about 80% 2 years post-op. Success is deemed an 80% improvement in function. So, in all honesty this surgical repair of the labrum isn’t perfect and is still improving.
What seems to be the best practice for care is starting with physical therapy. So many people show improvement with focused PT. A combination of mobilizing tissue, strengthening, working on balance and control and learning how to move the hip and back to reduce stress on the joint is an excellent first line of treatment.
Medical interventions such as oral anti-inflammatories or an injection may be prescribed as well. However, sometimes surgery is necessary to repair the tear and correct the misshapen bones causing the impingement. If this is the case, it is crucial to use a surgeon who specializes in this surgery. Thank goodness there are more and more excellent surgeons with this training but do your homework to find who is the best fit for you. Talk to your physical therapist as well. PTs spends the most time with the patient after the surgery, so trust me, they know who the best surgeons for hip operations are in your area.
More articles from our physical therapy blog:
Exploring Manual Physical Therapy and Functional Dry Needling in Washington DC
Corrective Exercise & Neuromuscular Re-Education in Washington, DC
Aging & Resiliency Training Through Physical Therapy
Post-Operative Physical Therapy
Physical therapy after hip surgery for a labral tear and FAI is critical for a successful recovery. The moral of the post-op story is less is more. The early phase of rehab after surgery is pretty consistent across the board, following a protocol from the surgeon which involves a protective period. In general, crutches are used for a few weeks with protection in certain range of motions. After the precautions are lifted, there is a progression of exercise outlined in recovery.
However, the pace of recovery is specific to each person. I have seen rehab go sideways when a timeline is followed rather than the progression of the individual. My top tips for rehab are progressing based on quality of movement, pain, and strength. Also, understand this rehab is not linear. Often there are backslides and it is about managing the impact of a backslide by addressing it immediately.
Do not compare your rehab to what you read online, what the surgeons timeline is, and where you feel like you should be. Leave expectations at the door and understand this is about the long game. Find your team. It is important to have a surgeon and physical therapists who support you and you are comfortable with. Trust them, trust yourself and be patient. This leads to success after this surgery.