The Physician and Sportsmedicine

ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsm20

Femoroacetabular impingement: a common cause

of hip pain

Travis J Menge & Nathan W Truex

To cite this article: Travis J Menge & Nathan W Truex (2018): Femoroacetabular
impingement: a common cause of hip pain, The Physician and Sportsmedicine, DOI:
10.1080/00913847.2018.1436844

To link to this article: https://doi.org/10.1080/00913847.2018.1436844

Accepted author version posted online: 06

Feb 2018.

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Femoroacetabular impingement: a common cause of hip pain

Travis J Menge1 and Nathan W Truex2

1) Regional Health Medical Center - Orthopedic Surgery, Rapid City, South Dakota,
United States

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2) University of South Dakota Sanford School of Medicine - Orthopedic Surgery,

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Vermillion, South Dakota, United States

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Abstract

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Femoroacetabular impingement (FAI) is a common cause of hip pain that can affect a

wide range of patients. It is due to altered bony morphology of the proximal femur and
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acetabulum, resulting in decreased function and progression to early osteoarthritis. Until

the early 2000s, little was known or understood about the significance of FAI as a
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clinical entity. The field of hip preservation has grown exponentially since that time,
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and has led to many advances in caring for those with symptomatic impingement. This

review details the early diagnosis and proper management of femoroacetabular

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impingement for the sports medicine practitioner.

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Keywords: Arthroscopy, Femoroacetabular Impingement, Labral Debridement, Labral

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Repair

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Introduction

Femoroacetabular impingement (FAI) is a common cause of hip pain, decreased

function, and progression to early osteoarthritis. It was first described by Ganz et al. as

“abnormal contact that may arise as a result of either abnormal morphological features

or as the result of subjecting the hip to excessive and supraphysiological range of

motion” [1]. The Warwick Agreement later expanded this definition to include a triad of

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symptoms, clinical signs, and imaging findings [2]. FAI is due to altered bony anatomy

of the acetabulum and proximal femur, which can be further sub-classified based on the

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type of specific deformity present. Asphericity of the femoral head and neck is

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described as cam-type impingement, whereas global or focal over-coverage of the

acetabulum results in pincer-type FAI [3, 4]. The most common form of FAI, however,
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is combined-type impingement where there are features of both cam and pincer

morphology [5]. Repetitive abnormal contact between these structures can damage the
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labrum and articular cartilage if not properly treated [1].

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It wasn’t until the early 2000s when Ganz and colleagues described FAI as a cause for
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osteoarthritis of the hip, leading to significant interest in the concept of hip preservation

[1]. Since that time, there has been a rapid increase in literature investigating the role of
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FAI as an important etiology of hip pain. There is a number of non-surgical treatment

options available, and surgical management is often indicated when these modalities
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fail. With a better understanding of hip pathology and the development of technology

aimed at treating it, the practice of hip arthroscopy has grown exponentially. Bozic et al

[6] reported a greater than 600% increase in the utilization of hip arthroscopy in the

United States from 2006-2010.

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The purpose of this manuscript was to review the literature regarding the diagnosis and

treatment of symptomatic femoroacetabular impingement.

Diagnosis

History

All patients presenting with hip pain should undergo a thorough history and physical

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examination at time of initial presentation. Pain is the primary complaint of those with

symptomatic FAI, and can range from mild to severe in nature. It is commonly located

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deep in the groin, but can also be described as affecting the low back, buttock, lateral

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hip, and posterior thigh regions [7, 8]. Although pain can occur following an acute or

traumatic event, a majority of patients report an insidious onset of symptoms unrelated

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to a specific event [7].
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In addition to pain, patients can report mechanical symptoms such as clicking, popping,

or subjective instability of the hip. Their symptoms are classically aggravated with
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activities that involve deep bending, squatting, or twisting of the hip, and are alleviated
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with rest or avoidance of activity. Furthermore, patients may complain of decreased

function and inability to continue their current level of activity or sport due to their hip
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symptoms [9, 10]. Discussion of the patient’s current and desired level of activity can

help guide treatment options to meet their goals and expectations.

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Physical Examination

A detailed physical exam should begin with a general assessment of the hip, including

inspection, palpation, range of motion, and gait evaluation. It is always helpful to

compare the affected hip to the contralateral side, and document any differences

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between the two. In those with FAI, the affected hip often demonstrates reduced range

of motion, particularly in flexion and internal/external rotation. A common finding in

those with an intra-articular cause of hip pain is the ‘C sign.’ [11]. The patient

characteristically holds their hand in the shape of a ‘C’ and places it around the affected

hip above the level of the greater trochanter to describe the location of pain.

Additionally, gait abnormalities associated with FAI include a Trendelenburg or

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antalgic gait., indicative of abductor weakness on the affected side [12].

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Physical examination findings indicative of femoroacetabular impingement include a

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positive anterior impingement and/or flexion-abduction-external rotation (FABER) test

[13, 14]. A positive anterior impingement test is often defined as groin pain with 90
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degrees of hip flexion, followed by adduction and internal rotation (FADIR testing).

Hananouchi et al [14] prospectively evaluated the usefulness of this test in 69 patients

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with hip pain and found a positive predictive value of 95.7%. Although the sensitivity
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did not reach a sufficient level for detecting lesions of the anterosuperior labrum, this is

an easily reproducible test that signals further investigation should be performed when
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positive. Additionally, a recent meta-analyses involving 9 studies showed a pooled

sensitivity for FADIR testing ranging from 94% to 99% [15].

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The FABER test is also commonly utilized for the diagnosis of FAI. In order to perform
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this test, the affected lower extremity is first placed in a figure-of-four position while

the patient is lying supine. The distance between the lateral aspect of the knee and the

examination table is recorded. This process is then repeated with the contralateral non-

affected lower extremity. A positive test is defined as asymmetry between the affected

and non-affected extremities, with a greater distance present on the side of the affected

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lower extremity [7]. In the Reiman meta-analysis, FABER testing showed a much lower

sensitivity and specificity than FADIR testing, with a pooled sensitivity of 51.5% and a

pooled specificity of 49.1% [15]. However, a 2016 meta-analysis showed a much higher

sensitivity for FABER testing at 82%. The specificity remained low at 25% in the 2016

meta-analysis [13].

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Other specific tests for femoroacetabular impingement and intra-articular hip pathology

include the dynamic internal rotatory impingement (DIRI) test and dynamic external

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rotatory impingement test (DEXRIT) [16]. The DIRI test is performed by placing the

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hip in 90 degrees or greater of flexion, then performing a wide arc of dynamic passive

internal rotation and adduction. The Scour Test is performed in the same manner as the
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DIRI, with the exception that pressure is applied at the knee, thereby increasing pressure

on the hip joint [17]. The DEXTRIT, on the other hand, is performed in a similar
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fashion to the DIRI and Scour tests; however, with the hip in 90 degrees or greater of
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flexion, dynamic passive external rotation and abduction is performed. These tests are

considered positive if the patient experiences pain or a feeling of instability in the

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affected hip. While a literature search revealed no studies detailing diagnostic accuracy

of DIRI or DEXTRIT tests, both the Reiman and Pacheco-Carrillo meta-analyses

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reported sensitivities of 50% and 62% respectively for Scour testing. Specificities for

Scour testing in the Reiman and Pacheco-Carrillo meta-analyses ranged from 29% to
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38%, respectively [13, 15].

Radiographic Assessment

In 2016, the Warwick Agreement on femoroacetabular impingement syndrome

established guidelines with regard to radiographic assessment of FAI. It stated that

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radiographs of the affected hip should be obtained in all patients with clinical suspicion

for FAI. Initial radiographs should consist of anteroposterior (AP) pelvis, lateral and

false profile views to identify cam or pincer lesions, as well as identify other causes of

hip pain [2]. The AP-pelvis is commonly obtained to evaluate acetabular morphology,

which can contribute to pincer-type FAI. Key features to assess are acetabular

orientation, depth, and coverage. The lateral center edge angle (LCEA) is one of the

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most commonly utilized measurements to define the amount of acetabular coverage. A

normal LCEA is typically between 20-39 degrees, whereas < 20 degrees represents

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acetabular dysplasia and > 40 degrees is defined as global overcoverage [18].

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Features of cam-type impingement can be appreciated on this view, including a pistol-
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grip deformity, lateral bump, and fibrocystic change of the anterosuperior femoral neck

[19]. Joint space is also measured on the AP view, which has been shown to correlate
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with postoperative outcome measures. Philippon et al. demonstrated the importance of

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well-preserved joint space, as those with less than 2 millimeters are more likely to have

a lower modified Harris hip score following arthroscopic surgery and are 39 times more
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likely to progress to a total hip replacement [20].

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In order to further assess the proximal femur morphology, a lateral radiograph of the

affected hip should be obtained. The nonspherical portion of the femoral head is
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typically located at the anterosuperior aspect of the head-neck junction, and can be best

evaluated using this view [19]. The most commonly used parameter to measure this

deformity is the alpha angle as described by Notzli et al. [21] It is generally agreed

upon that an alpha angle larger than 50 degrees represents an abnormal femoral head-

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neck offset deformity. A false profile view can also be obtained to further evaluate

proximal femur morphology, anterior acetabular coverage, and hip joint congruity [16].

Again, according to the Warwick agreement, cross-sectional imaging is appropriate for

the characterization of cartilage and labral lesions where plain films are insufficient [2].

Magnetic resonance imaging (MRI) can be obtained to evaluate for the presence of

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labral tearing, chondral injury, soft tissue lesions, and other pathology in or around the

hip joint. Although magnetic resonance arthrography (MRA) has traditionally been

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thought to better demonstrate labral and chondral injuries [22], advances in imaging

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technology have resulted in comparable results using MRI without contrast [23]. This

has greatly benefited patients in terms of cost, availability, and invasiveness of the
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imaging procedure. Computed tomography (CT) is another three-dimensional modality

to evaluate the bony architecture of the hip. While it provides better detail than plain
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radiographs, its use is controversial given the degree of radiation exposure [18].
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Diagnostic Therapeutic Injections

Recently, it has been shown that relief from intra-articular steroid injections may have a
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correlation with an FAI diagnosis, thus making it a potential diagnostic tool [24, 25].

Kivlan et al. found that patients with an eventual FAI diagnosis experienced 85% relief
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from an intra-articular steroid injection compared with 64% mean relief in patients

without an eventual FAI diagnosis. Additionally, pain relief from injections was not
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affected by coexisting extra-articular pathologies such as iliopsoas, bursae, or gluteal

muscle pathologies which may also cause hip pain [25].

Treatment

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Management of FAI consists of both non-operative and operative treatment modalities

[12]. In patients presenting with hip pain that have not undergone any formal treatment,

conservative management is often the first step in addressing their symptoms. Physical

therapy directed at movement pattern retraining, muscle flexibility, hip and core

strengthening, and pain management has been shown to be effective for many patients

[26, 27]. In 2014, the American Physical Therapy Association (APTA) released

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recommendations for the treatment of non-arthritic hip pain, such as FAI [28]. These

recommendations included a) patient education, counseling, and avoidance of symptom-

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provoking activities b) manual therapy for capsular restrictions without end-range

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flexion and internal rotation c) therapeutic stretching and strengthening and d)

neuromuscular education focusing on multi-joint patterns to improve movement

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coordination.
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Much like osteoarthritis, the use of oral anti-inflammatories (NSAIDs) can be used to
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decrease inflammation caused by FAI and therefor help reduce pain. A number of

NSAIDs are commonly used, ranging from over the counter to prescribed medications.
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Some of the more frequently recommended options are ibuprofen, naproxen,

meloxicam, Celebrex, and diclofenac. However, the most effective formulation,

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duration and dose of NSAID are controversial in the literature [29].

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More recently, the use of imaging guided intraarticular injections with either

corticosteroids or hyaluronic acid have been shown to be effective as both a diagnostic

and therapeutic modality. A 2014 systematic review evaluated 8 studies involving 281

hips [24]. These cases were further stratified into either diagnostic, therapeutic, or

prognostic categories. Diagnostically, it showed that patients who obtained pain relief

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from an intra-articular hip injection were more likely to have an FAI diagnosis than

those who obtained no relief from the same injection. The mean relief in those with FAI

was 85% compared to 64% in those without FAI. Furthermore, 98% of patients reported

clinic-based ultrasound guided injections to be more convenient and less painful than

hospital-based fluoroscopic injections. In addition, ultrasound guided injections have

become more favorable due to greater accessibility, compact size, lack of radiation

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exposure, superior visualization of soft tissue structures, and greater accuracy of

delivery. Therapeutically, intraarticular injection of hyaluronic acid (32 mg) provided

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clinically significant improvement that was sustained for 12 months. In contrast,

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corticosteroid injection (40 mg methylprednisolone with local anesthetic), provided

relief in only 15% of patients, with an average duration of pain relief being 9.8 days.
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Only 6% of patient reported relief at 6 weeks. In terms of prognosis, a negative response

to an intra-articular hip injection was a strong predictor of lower patient-reported

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outcome scores following surgical treatment.

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In patients that continue to have symptoms despite proper conservative management,

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surgical treatment is often indicated [30]. A 2017 meta-analysis involving 108 studies

and over 10,000 patients used diagnostic criteria to search the literature for studies
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reporting surgical indications [31]. In their study, Peters et al found 56% of studies

reported the combination of positive physical exam tests, clinical symptoms, and
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radiographic findings as three criteria that warranted an indication for surgery.

Furthermore, 35% of studies reported two out of three of these criteria as a surgical

indication, and only 9% used one out of three criteria.

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Stratifying by individual symptom, Peters et al [31] found that 75% of studies cited

some sort of debilitating hip pain as a surgical indication. However, the duration of pain

ranged from greater than 1 year to less than three months. Clinical symptoms were

reported in 74% of studies and included limited range of motion, as well as positive

physical exam findings. Diagnostic imaging was cited in surgical indications in 92% of

studies, with the alpha angle >50° the most commonly reported criterion (68%). Finally,

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failed prior non-surgical treatment was cited in 44% of cases [31]. To summarize,

criteria for surgical intervention regarding FAI are fairly inconsistent. The most

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common reported surgical criteria are symptomatic hip pain, decreased range of motion,

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a positive impingement sign, and an alpha angle >50°.
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The goals of FAI surgery are to eliminate the pathologic contact between the proximal

femur and acetabular rim [32, 33, 34, 35, 36]. This is done by removing the areas of
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bony impingement and addressing any concomitant soft tissue pathology. In pincer
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deformities, acetabular rim trimming is performed. Cam deformities, on the other hand,

are corrected by femoral neck osteoplasty. These measures are important to prevent
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further mechanical impingement and subsequent damage to the labrum. It is also

paramount to address the damage, if any, which has occurred to the labrum.
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Arthroscopic surgical treatment options for labral pathology include labral debridement,

repair, and reconstruction [37]. Debridement is preferred with peripheral tears, where

enough viable tissue is present to maintain the suction-seal of the hip, thereby

maintaining stability of the joint [37, 38, 39, 40]. Typically, these involve degenerative

labral tears without chondrolabral detachment, small tears involving the lateral 50% of

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the labrum, and tears that propagate through the substance of the labral body with

insufficient tissue to hold suture.

Labral repair is indicated when the labrum is torn at the chondrolabral junction, which

compromises the suction-seal mechanism of the hip. These are usually found at the base

of the labrum and have been associated with greater chondral damage adjacent to the

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tear. The repair is achieved with sutures anchored into the acetabular rim, with the

number of sutures dependent on the size of the tear. Labral reconstruction is indicated

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when the labrum is severely damaged or deficient. In these cases, the labrum is

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unamenable to holding sutures for repair due to extensive damage, and must be

reconstructed using auto- or allograft tissue.

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A recent study by Menge et. al [3] evaluated long term survivorship and outcomes 10
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years following hip arthroscopy for FAI in 145 patients. The patients in this study
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demonstrated significant improvements in postoperative clinical outcome scores

regardless of the labral procedure performed. Additionally, they investigated hip

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survival rate, defined as time to Total Hip Arthroplasty (THA) in those that failed

arthroscopic management. Factors that led to lower hip survival rates were preoperative
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joint space of ≤ 2 mm, greater age, and microfracture of the acetabulum. Of note, 89%
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of those with a joint space of ≤ 2 mm required a THA before 10 years, with a mean hip

survival rate of 3.8 years (HR 4.26 CI 1.98 – 9.21, p<0.001). This is in comparison to

those with a joint space of > 2 mm, in which only 15% required a THA within 10 years.

These findings underscore the important of preoperative joint space as a prognostic

factor for long term outcomes.

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Postoperative Rehabilitation

Proper postoperative rehabilitation protocols are imperative to allow the patient to

safely return to preoperative activity levels as soon as possible following surgery.

Grzybowski et al. [41] performed a systematic review to evaluate the evidence on

different rehabilitation programs following hip arthroscopy. They found that while

many studies support restrictions on weight bearing and hip mobility in the early

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postoperative period, protocols were widely variable and there is little consensus on

whether one type of rehabilitation program is superior to others.

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Although there is not a defined consensus on one specific postoperative protocol in the

literature, it is generally agreed upon that patients should begin a supervised program
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shortly after surgery [41, 42, 43]. Studies have shown that brace immobilization and

restricted weight bearing (20 pounds of toe-touch weight bearing on the operative leg)
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employed in the first 2-3 weeks to protect the surgical repair with early passive range of
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motion to reduce the risk of intra-articular adhesion formation has been very effective in

the rehabilitation process [9, 10]. Standard protocols then recommend advancing to full
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active range of motion around 6 weeks, followed by progressive strength and

conditioning exercises. Additional recommendations and modalities can be utilized at

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the discretion of the physician in conjunction with the patient and physical therapist on

a case by case basis.

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Future Directions

The understanding and treatment of FAI vastly grown in recent years. From 2005 to

2010, there was an exponential growth of publications related to FAI, with a peak in

2013. The rates of publication on the topic of FAI have linearly decreased since then,

presumably due to increased adoption and now a need for refinement of technique and

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diagnosis [44]. This is due to the rapid increase of arthroscopically treated cases of FAI.

Recent studies suggest arthroscopic FAI surgery rates among newly trained orthopedic

surgeons has increased by over 600% [45, 46]. However, because of this rapid rise, a

majority of FAI literature is of low methodological quality. This early research has laid

the framework for high-quality studies, and with more surgeons being trained in the

management and arthroscopic treatment of FAI, higher powered studies will become

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more feasible. In addition, multiple randomized controlled trials are currently in

progress [47, 48, 49]. In the near future, the level of evidence for arthroscopic

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management of FAI will shift as these higher quality large scale studies are completed.

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Conclusions

Femoroacetabular impingement results from abnormal bony morphology of the

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acetabulum and proximal femur. It represents a significant cause of hip pain and

dysfunction, resulting in damage to the labrum, cartilage, and normal joint architecture.
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Patients should undergo a thorough clinical and radiographic evaluation at the time of

initial presentation. Once a diagnosis of FAI has been established, many patients can be
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successfully managed with conservative treatment. For those that continue to have
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symptoms, surgical treatment is an effective option that has demonstrated excellent

mid- to long-term outcomes.

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Transparency

Declaration of funding

None.

Declaration of financial/other interests

The authors have no relevant affiliations or financial involvement with any organization
or entity with a financial interest in or financial conflict with the subject matter or
materials discussed in the manuscript. This includes employment, consultancies,
honoraria, stock ownership or options, expert testimony, grants or patents received or

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pending, or royalties. Peer reviewers on this manuscript have no relevant financial
relationships or otherwise to disclose.

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