FAI: The New ImpingementTraining options to help your

client
By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS
Introduction
Hip pain has been typically perceived in older adults, however, can be
present in young adults or even athletes. A new dysfunction of the hip
has been talked about recently in the medical field and in various
health & fitness journals. This is femoral acetabular
impingement(FAI). What is FAI? Femoral acetabular impingement is
not necessarily a disease but rather a pathomechanical process in
which abnormal contact stresses can cause potential joint damage
around the hip(Leunig, Beaule, & Reinhold 2009). This article will
review the background on FAI, clinical presentation & pathology, the
types of FAI and
the medical and physical therapy treatment approach. Provide the
latest evidenced based research about how FAI can lead to labral
pathologies, while reviewing conservative vs. surgical interventions.
Effective programming will be discussed using periodization training
principles guiding the personal trainer to utilize the most effective
training strategies and exercises.
Clinical presentation & Pathology
Someone who is suffering from FAI is frequently aggravated by
athletic activities and movements that require excessive hip flexion,
or prolonged walking, pivoting on the affected side, prolonged sitting
or driving. Common symptoms include; localized deep ache pain
typically in the groin and in the front of the hip. Occasionally pain can
also be referred to the outside of hip, buttock and thigh area.
Mechanical symptoms from the hip such as painful locking or giving
way are common presenting feature if a labral tear is
present(Hossain. M. et al. 2008). Femoroacetabular impingement
(FAI) is a pathologic process caused by abnormality of the shape of
the acetabulum, the femoral head, or both, predisposing to the
development of osteoarthritis and labral degeneration.
How FAI develops and contributing risk factors
There are many theories on the cause of how an individual
develops FAI. One proposed theory is that during development, there
may be structural abnormalities of the hip such as hip dysplasia.
Which is where the femur becomes dislocated. Physical
stresses(trauma) such as a femoral neck fracture is seen commonly in
active middle aged adults, specifically males in such sports as hockey,
tennis and soccer.(Jones et al. 2011). Genetics has been examined and
discussed as potential factor(Leunig, Beaule, & Reinhold 2009). One
things is certain. The research indicates that FAI occurs when there is

an abnormality of the femoral head with respect to the congruency to

the acetabulum.
FAI causes hip pain and develops over time. Repeated and
excessive hip flexion and internal rotation places maximal contact
between the anterosuperior femoral head-neck junction and the
acetabular labrum, especially when there is not enough clearance to
avoid friction. This repetitive movement and compressive load creates
a torsion affect on the internal structures inside the hip socket. A
person with FAI that progresses will develop a movement pattern that
is abnormal, asymmetrical and accommodative. These are important
things to consider why a person develops femoral acetabular
impingement.(Emara, K, et al. 2011)
Common contributing factors include; previous trauma to
femur/hip, muscle imbalances, structural abnormalities of the femoral
head, depravation of oxygen/nutrients to the femoral head and
repetitive stressors/loads(ie. dancing) There is also substantial
evidence supporting the hypothesis that osteoarthritis of the hip is a
major etiologic factor in FAI(Clohisy, J et al. 2010). Patients with
excessive range of movement of the hip can suffer from impingement
can potentially predisposing them to FAI due to the biomechanical
stressors.
Review of hip pathomechanics
The hip joint is a ball and socket joint enabling a wide range of
movement designed to function by providing weight bearing for
locomotion and movement. Anatomically, the iliopsoas, glute medius,
glute minimus, glute maximus all provide anterolateral stability as
seen in figure 1 & 2. However, if muscle imbalances develop this can
lead to dysfunction at the hip. For example, it is common to observe in
clients tight(postural) hip flexors, quadriceps and weaker(phasic)
glute medius, glute minimus and hamstrings. This alters load transfer
throughout the kinematic chain in placing excessive load to the joint
altering the movement pattern of the individual.
In the sagittal plane, during hip flexion(~120 degrees), the femoral
head translates down as the glute maximus creates a downward pull.
During hip extension(~20 degrees) iliopsoas is eccentrically
lengthened. In the frontal plane, during hip abduction(~40 degrees),
glute medius contacts pulling the femur up which then translates
down. During hip adduction(~(25 degrees), the femur glides down
and out as the tensor fascia latae, ischiofemoral ligament and glute
medius is eccentrically lengthened.

Figure 1. Anterior hip complex

Complex

Figure 2. Posterior Hip

Comparison of two types of FAI: Pincer and Cam Impingement

Impingement at the hip can occur with extremes of movement, lack of
movement(mobility) or as a result of a combination of both. The
contributing factors previously described provide a deeper
understanding of FAI and the two types of FAI Impingement.
There are two different types of impingement: pincer and cam
impingement. Pincer impingement occurs from a bony prominence of
the front of the acetabulum placing excessive pressure from the
labrum against the neck of the femur. Thus impacting ones range of
motion leading to pain. Pincer lesions are more common seen in
middle-aged active women. Occurring through repeated contact
between the normal femoral neck junction and the acetabular rim.
This repeated contact results in labral degeneration, iossification of
the acetabular rim and deepening of the acetabular rim(Banjeree &
Mclean 2011). The causes of pincer impingement include;
developmental changes, structural changes such as a retroverted
acetabulum, trauma and post traumatic deformity of the
acetabulum(Banjaree & Mclean 2011).
In contrast, cam impingement, is more common in active men. The
cam is attributed to a non-spherical portion of the femoral head
placing excessive pressure against the acetbular rim. This is most
noticeable with active hip flexion and external rotation. In which the
position of the femoral head is too large to pass in the acetabulum,
and when the hip is flexed, this stresses the rim of the labrum(Laude,
F. et al. 2007) This is seen in figure 3.
The causes of cam impingement include: developmental(non spheric
femoral head, perthes disease, which involves inadequate blood
supply and slipped capital femoral epiphysis, which is a separation of

the ball of the hip joint from the thigh bone). Trauma such as femoral
neck fractures and chondral lesions especially in the acetabulum can
play a role(Banjaree & Mclean 2011).

Figure 3. Cam and Pincer Impingement

Medical and Physical Therapy Treatment Approach
Conservative management is initially recommended for most
individuals with modification of activities, avoiding excessive hip
movement and taking non-steroidal anti-inflammatory(NSADIS) which
may provide some relief. The role of physical therapy is to improve
passive range of motion, soft tissue joint mobility, lateral and
posterior strengthening of weak musculature, improve core stability
and education of cross training(yoga, swimming). However, if
symptoms continue and do not improve, then the patient may be a
candidate for surgery.
Evidenced Based Research
FAI can predispose a hip not only for osteoarthritis, but also lead to
degenerative labral tears due to the repetitive compression and sheer
forces placed on the hip. Despite the time of impingement, overuse by
the patient/athlete, this will continually stress internal structures such
as the capsules, supporting ligaments and connective tissue. This
repetitive stress activates the pain fibers within the joint and
dependent on the pain threshold of the patient, physical conditioning,
body type, muscle balances, pain can be acute or insidious in nature.
Excessive hip flexion with external rotation or excessive hip flexion
with internal rotation of the hip places excessive compression and
torsional forces on the hip, particular the labrum. This is seen in
dancers and other sports. Lastly, muscle imbalances(tightness)
particularly in the hip flexors, adductors, piriformis, quadriceps and
ITB, all contribute to compressive loading of the hip joint,
predisposing it further to mechanical stress. Once pain as mentioned

previously affects daily activities, ability to play sport, a person has

two choices. Conservative treatment begins with physical therapy. The
choice is based on the patient and physician, however, the literature
has show that conservative management can be very effective.
If surgery is required, the most common procedure is hip arthoscopy.
Here, the surgical process begins visualizing the hip while the patient
is positioned supine with traction applied, and 3 standard portals
providing the surgeon with a deeper view of the underlying
abnormalities. The underlying hip joint is debrided and involves
reshaping the head of the femur. After being bone has been reshaped
to recreate the normal concave relationship at the junction of the
articular surface, this eliminates the cam or pincer lesion.
Postoperative Rehabilitation for Arthoscopy
Reshaping of the femoral head/neck junction necessitates some
precautions. The patient is allowed to bear full weight, but crutches
are used to during the first 4 weeks. Full bony remodeling takes 3
months, during which time some precautions are necessary to avoid
high-impact or torsional forces. During this time, gentle range of
motion is emphasized to stimulate the healing process. At 3 months,
specific precautions are lifted and functional progression is allowed.
The speed with which the athlete advances is variable and may
require another 1 to 3 months for full return. Thus, patients and
athletes are generally advised that return to sports after surgical
correction of FAI at ~ 4 to 6 months(Byrd & Jones 2011).
Another surgical option is the open procedure which again is intended
is to correct deformities with either an osteoplasty(surgical repair
using bone from another part of the body) or involves trimming of the
acetabular rim. The torn labrum can be resected or refixated. Any
delaminated cartilage is debrided to a stable edge. The open
technique is performed using a trochanteric flip osteotomy or a
limited anterior approach combined with arthroscopy to address the
labral and chondral injuries.
The labral fixation procedure involves cutting through the fascia that
interconnects the glute medius. In athletic patients, a release is made
in the front of the gluteus maximus while being performed proximally
close to the iliac crest. An osteotomy(bone removal) is performed near
the greater trochanter along to vastus lateralis. Retraction of the
subcutaneous tissue is made and a 15 mm incision is made from the
tip of the trochanter to the proximal vastus lateralis. A thin oscillating
saw is used to remove the front portion of the lateral aspect of the
upper portion of the greater trochanter. Then a retractor is used to
expose the hip joint further. The hip capsules is exposed and cut in a Z

shaped manner exposing the femoral head. Titanium anchors are

placed from the labrum into the acetabulum. Non-absorbable sutures
are used while knots are tied on the outer capsular surface with the
suture being placed through the base of the labrum. The acetabulum
is irrigated to remove debris. The capsule is closed with single
stitches can be used while the trochanter is anatomically reduced and
fixed with two or three 3.5 or 4.5-mm cortical screws aimed toward
the lesser trochanter. Thereafter, the various soft-tissue layers are
closed (Espinosa et al. 2007)
The research shows that patients who underwent labral resection vs.
labral fixation had significantly poorer clinical outcomes at a 2-yr
follow-up. Results indicate that the patients at 2 years with labral
resection reported 28% excellent results, 48% good, 20% moderate
and 4% poor. While those who underwent labral refixation reported
80% excellent, 14% good, 6% moderate, and 0% poor (NG, V et al
2010).
Programming
Exercise prescription with a client with FAI is individualized. The
emphasis should be on the quality of exercises not quantity. To avoid
irritating the client, but most importantly, to achieve clients goals
and optimal fitness outcomes. Working with a client who has FAI
should begin by first understanding what type the client has.
Understanding the pathology, surgical procedure and communicating
with the physical therapist and rehabilitation team is fundamental.
For optimal outcomes with a client who underwent FAI surgery,
consult the clients physical therapist with any questions.
One of the most important variables to consider when designing a
training program is the results of the fitness/movement assessment,
age of the client, lifestyle, prior/present exercise habits and medical
history. These variables are important to consider when designing the
program. Because a personal trainer must consider how all of these
affect anatomical, biomechanical, physiological and neurophysiogical
demands on the body. General programming approach should focus on
lengthening the tight musculature via stretching, yoga, pilates, self
stretching followed with stabilizing the weaker phasic
musculature(glutes, hamstring and core)combined with aqua therapy,
and cardio vascular training to holistically train the client.
The individualized exercise program should be based on the principles
previously reviewed. Initially, teaching single plane exercises, such as
horizontal leg press progressed to inverted leg press(avoiding end
range), leg curls and hip extension as examples. This will create a
foundation & base for more advanced exercises. Then progressing the

client to two plane axis exercises(ie. diagonal reverse lunge, diagonal

forward lunge challenging the nervous system, dynamic muscle
recruitment for stability while targeting the weaker sagittal stabilizers
needed in every day movement. Progressed further to compound
exercises such as mini squat with mid row, reverse lunge with
overhead medicine ball chop, forward lunge with trunk rotation with
medicine ball as examples.
There are several exercises that should be avoided based on
science. The deep squat at end range places excessive compressing
loading to the hip joint, nerve endings and connective tissue) placing
potential risk for pain. Exercises that involved excessive hip flexion
with internal rotation or hip flexion with external rotation both place
stress on the joint capsule, nerve endings and hip joint. Plyometrics,
particularly box jumps, box jumps with outward land-run, creates
excessive loading, compressive forces that could irritate the client.
Any exercise that the client has pain with should also be avoided.
Training strategies
It is essential to have the client perform a comfortable cardiovascular
program using machines such as the elliptical. Which will provide
physiological benefits to the CV system but also assist with increasing
circulation. Strength training should focus on weaker phasic muscles
such as; glute maximus, glute medius/minimus and
hamstrings>quadriceps. The choice of exercise and type of equipment
depends on several factors; the clients experience with exercise,
time, body type, goals and whether or not the client had or underwent
surgery.

Figure 4. Reverse lunge

with wood chop

Figure 5. D1 Extension to
flexion with cable

Stretching should focus on tight hip flexors, quadriceps and ITB in a

controlled manner with the patient having a home program as well to

perform independently of the training. Core stabilization training

should focus on weaker phasic external oblique, quadratus lumborum
and multifidi. Exercises such as bridging with ball, standing trunk
rotation with cable or medicine ball progressed to partial lunge with
trunk rotation with medicine ball is ideal. Integrating more
challenging exercises such as wood chop with reverse lunge is ideal
as seen in figure 4. Cross training with yoga and pilates can not only
improve flexibility and breathing but core strength in multi directions
and progressed as appropriate. Swimming also can serve to
compliment training due to the buoyancy principle and how relaxing it
can feel.
Most importantly, when working with any client, if there is uncertainty
whether an exercise will cause pain or damage ask a physiotherapist,
their physician or do not perform the exercise.
Case Study-dancer
A 28 year old woman who worked as an engineer came to my office
~2 years ago with a referral with the diagnosis(Dx) of Femoral
Acetabular Impingement. After evaluating her, reviewing her history
& medical history, she told me that her hip pain was ongoing
fluctuating in discomfort to pain for the last 6 months without trauma
or recent injuries. One interesting bit of information was that she was
a dancer for Disney World for 15 years. She complained of focal deep
ache pain along the front of the hip, lateral to the greater trochanter
and pain that went into the groin region. From a patient profile
perspective, she was an engineer, who sat quite a bit but was
otherwise active, exercising frequently with cardio and weights 2-3x
week and performed other outdoor activities. Her pain was
aggravated with jumping and twisting, prolonged sitting and
movement that internally rotated her hip with trunk rotation. She had
relief with heat, water therapy and yoga that was short lived.
Otherwise her health was unremarkable.
She complained of localized deep ache pain typically in the groin and
in the front of the hip.
Was limited in hip flexion, adduction and external rotation, had
increased muscle tightness in hip flexors, adductors, pirformis and
quadriceps. After throughouly evaluating her and mutual goal setting,
the focus of my treatment was on restoring her hip mobility. Using
soft tissue/manual therapy addressing the shortened myofascial in her
ITB, glute medius, lumbo-pelvic girdle accompanied with having her
stretch at home. I integrated using recumbent bike to assist with
improving blood flow and enhance mobility. As her mobility improved,
joint mobilizations were used to improve the ability of the femoral
head to glide down with both hip flexion and abduction. This was

followed with myofascial release to the piriformis and surrounding

tissue. Because of her exercise experience, core strengthening
commenced with single leg bridging progressed to bridging with ball,
single leg bridge with ball and bridging with ball with hamstring
curls. Then challenging her to SLS on ground to having her on roll
then catching a ball. Strengthening her glutes by using theraband
standing initially was performed and progressed to diagonal reverse
lunges holding a medicine ball. Then progressed to forward lunges
with medicine ball twists.
After 6 weeks of physical therapy, she made significant improvements
from when she was first evaluated. Accomplishing >90% of our
mutual goals, had mild ache & pain in her hip compared to the
moderate to severe pain initially. Functionally she was able to perform
most functional activities and even start to perform some dancing in
short bouts that was improving each week.
Summary
Hip pain can be experienced by older adults, younger or even athletes
rendering debilitating effects. Because FAI is a pathomechanical
process due to abnormal stresses affecting the hip joint,
understanding the dynamic anatomy and muscles around the hip
complex and their synergistic role can provide greater insight into
understanding FAI. Effective programming using periodization
training principles is fundamental. Training approaches can make a
difference or can do serious damage when the exercise professional
does not have a clear picture of the movement pathology,
muscles/joint involved and proper exercise prescription and
periodization training required. Working with this type of client can
be initially challenging but embrace the challenge, and the rewards
and patient appreciation will be plentiful.

REFERENCES
Banjaree, P & Mclean, CR 2011, Femoroacetabular Impingement:
a review of diagnosis and Management Current Reviews in
Musculoskeletal Medicine, vol. 4, no. 1, pp. 22-32.
Byrd, T & Jones, K, 2011, Arthroscopic Management of
Femoroacetabular Impingement in Athletes, American Journal of
Sports Medicine, vol. 39, supplemental 1, pp. 7-13.
Clohisy, J et al. 2010. Surgical Treatment of Femoroacetabular
Impingement: A Systematic Review of the Literature, Clinical
Orthopedic Related Research. pp. 555-564.
Emara, K, et al. 2011, Conservative treatment for mild
femoroacetabular impingement, Journal of Orthopedic Surgery,
vol.19, no. 1, pp. 41-45.
Espinosa, N, et al. 2007, Treatment of Femoro-Acetabular
Impingement: Preliminary
Results of Labral Refixation, Journal of Bone and Joint Surgery, vol.
89A, supp. 2, pp. 36-52.
Hossain, M. et al. 2008, Current management of femoro-acetabular
impingement, Current Orthopaedics, vol. 22, pp. 300-310.
Laude, F. et al. 2007, Anterior femoroacetabular impingement,
Journal of Joint Bone
Spine, vol. 74, issue 2, pp. 127-132.
Leunig, M, Beaule, P, & Reinhold, G, 2009, The Concept of
Femoroacetabular Impingement Current Status and Future
Perspectives, Clinical Orthopedic Related Research, vol. 467, no. 3,
pp. 616622.
NG, V, 2010, Efficacy of Surgery for Femoral Acetabular
Impingement: a systematic review, American Journal of Sports
Medicine, vol. 38, no. 11, pp. 2337-2345.
Crawford,N.R.&Villar,R.N.2005,Currentconceptsinthemanagementof
femoroacetabularimpingement,JournalofBoneandJointSurgery,vol.87B,no.11,

pp.14591462.
Jacobs, C, et al. 2007, Hip abductor function and lower extremity landing kinematics:
sex differences, Journal of Athletic Training, vol. 42. no. 1, pp. 76-83.
Keogg, M & Batt, M, 2008, A Review of Femoroacetabular Impingement in Athletes,
Journal of Sports Medicine, vol.38, no. 10, pp. 863-878.
Page,P,2006,Sensorimotortraining:Aglobalapproachforbalancetraining,
JournalofBodyworkandMovementTherapies,vol.10,pp.7784.
Pollard,T,2011,APerspectiveonFemoracetbularImpingement,SkeletalRadiology,
vol.40,pp.815818.
Prins, M, & Van der Wurff, P, 2009, Females with patellofemoral pain syndrome have
weak hip muscles: a systematic review, Australian Journal of Physiotherapy, Vol.55, pp.
9-14.
Yuan, B, Sierra, R & Trousdale, R, 2008, Femoral-Acetabular Impingement,
Journal of Orthopedics, Vol.31, No. 9, pp. 890