Clinical tips and tricks for Femoroacetabular Impingement Syndrome (FAIS)

In my native country of Canada ice hockey is a big deal. Behind concussions, the second most common issue I see in hockey players is Femoroacetabular Impingement Syndrome – known as FAI syndrome or FAIS. I also commonly see this in strength training patients as well; this condition has only recently received significant attention in the rehab world, as compared to say osteoarthritis or back pain, and it’s important to address as it can significantly affect patients’ function and quality of life. So, in this piece I’m going to share several jewels for the management of FAIS.

If you’d like to know how the experts manage FAIS, watch Dr Joanne Kemp’s excellent Masterclass HERE.

1 – Minimise (temporarily) active extension/Anterior Pelvic Tilt (APT) of the back

This part will get me tarred and feathered by some. As I’ve written about before, posture and APT aren’t the big, bad boogeymen many people have made them out to be. That said, there is some research (1) showing a link between FAIS and dynamic APT. Just to clarify, by dynamic I’m referring to actively extending the low back and going into APT… I’m not as concerned about resting posture, which can be variable from person to person.

In Jo Kemp’s brilliant Physio Network Masterclass on FAI, one key assessment tip involves measuring trunk control. Jo recommends both single leg rise (similar to a pistol box squat) and side plank tests to help measure strength and control. Something like a max push-up or plank test can also be helpful in this area. Anecdotally, I have found that teaching people to avoid hyperextending the back when doing tasks and exercises is a good first step, and helps give patients more immediate pain relief, which helps achieve buy-in and subsequently assist in the rehab process. It’s important to note that repeated lumbar movement is often negative in patients with FAI syndrome, however I’m more concerned about active lumbar extension when combined with aggravating hip movements such as hip flexion and/or internal rotation.

2 – Hammer core and glutes

Flowing on from tip one, core and glute exercises that don’t involve a lot of hip flexion, internal rotation or lumbar extension usually work well for most (not all) patients. Examples of these include:

• For core: planks, push-ups,
• For glutes: bridges, hip thrusts and hip hinge movements done within a pain-free range

3 – Temporarily dial back the stretching, then gradually re-introduce it

Another step I take right from the get-go is dialing back the stretching. As with tip one, this will likely generate some controversy – I do see too many people with FAIS doing a lot of stretching, particularly involving hip flexion and/or internal rotation, which often increases their pain and inhibits desensitisation. I am not saying to avoid these stretches or movements forever – just to dial them back in terms of volume, and keep them within a pain-free range of motion. In situations where patients are concerned about maintaining mobility, I often prescribe internal rotation stretches in a lower level of hip flexion (at or below 45 degrees, whichever is pain-free) just to help with flexibility and allow things to calm down without encouraging fear-avoidant behaviours.

4 – Don’t get hung up on morphology

As mentioned in Jo’s Masterclass, many people with the trademark cam and/or pincer morphologies are asymptomatic (2-4). A mistake I’ve seen clinicians and patients make is getting too focused on the structural morphology of the hip joint and forgetting everything else.

We may not be able to change the structural morphology of the hip, however we can work on:

• Posture and movement strategies to reduce pain
• Exercise to improve strength, flexibility and control of the hip and surrounding muscles
• Manual therapy
• Activity modification and graded return to activity

To steal a common saying in tendon rehab – treat the donut not the hole!

5 – Tweak to fit the individual

People’s hips are shaped and angled differently which can impact how much hip flexion and rotation range they can anatomically achieve, and which angles will allow them their best mobility. This applies a lot to squatting and lifting movements. For example – some may be better off with their feet close together and facing forward in a squat, whereas others may do better with a wider stance and toes pointing out.

These tweaks to common lower body exercises and day-to-day movements echo some of the tips that Mike Studer has mentioned in his Behavioural Economics Masterclass. I’ve seen lots of these cases where people were squatting, hip hinging and stretching with minimal improvement – sometimes a few tweaks here and there can help to make activities easier; having a different and more tolerable way to do these movements is, as Mike states, a great tactic.

6 – Find ways to stay generally active

The two most common cohorts I see FAIS in are ice hockey players and people who lift weights – the former using a lot of hip flexion, adduction and internal rotation, and the latter sometimes using a more extended posture.

With hockey players it can be trickier. If pain is intermittent and only provoked after a certain amount of hockey, then I’m usually fine with letting patients continue to play hockey in pain-free volumes. However, in situations where any amount of aggressive skating is painful, I usually recommend gentle skating, puck passing and shooting to maintain sports skill, as well as activities to maintain fitness such as sled dragging, swimming, incline treadmill walking, or walking with the treadmill turned off (props to strength coach Matt Wenning for this gem!).

In terms of lifting, movements with reduced hip flexion such as pin squats, high box squats, rack pulls, block pulls, and high-handle trap bar deadlifts MAY be ways to train the lower body while avoiding aggravation. As with tip three above, once symptoms calm down then activity can be gradually re-introduced.

7 – Osteoarthritis prevention

In the Masterclass, Jo discusses osteoarthritis prevention, as well as the link between FAIS and osteoarthritis. While this interaction is complex, taking proactive measures like staying active, maintaining a healthy body weight, limiting inflammation and body fat levels, as well as keeping the hip strong are, in my opinion, never a bad thing!

8 – Be realistic with surgical outcomes

As the research suggests, the outcomes with hip arthroscopy surgery for FAIS are pretty similar to those with conservative care (5-9). It is important with this surgery, and all surgeries, to make sure to communicate realistic outcomes. In my experience these surgeries have a long recovery time of up to 12-18 months. It’s important to communicate that recovery can take a long time, it requires commitment, and that outcomes can be variable.

9 – Graded return … can’t avoid it

Let’s face it – the vast majority of popular sports around the world require some degree of hip flexion and/or internal rotation at some point. Whether it’s doing a deep snatch squat, changing direction on the hockey rink, or sprinting out of the blocks, it’s likely that your patient can’t stay away from their aggravating factors forever if they want to return to play.

I’m generally a fan of Tim Gabbett’s work and believe in the Acute:Chronic Workload Ratio (ACWR). Please refer to these two papers if you’re not familiar with it (10-11). A few notes to consider:

1. Athletes starting from ground zero may progress at a faster rate than recommended in the ACWR.
2. As Gabbett suggests – every athlete responds differently to the same relative increase in workload. The ACWR is a guideline and is not the be-all and end-all.
3. Speed needs to be accounted for too. Fast hip flexion (i.e., sprinting) or fast internal rotation (i.e., a hockey goalie save) can load the hip more and needs to be accounted for in workload management.

Wrapping up

I hope this article shares some useful tips for FAIS. As always – thanks for reading.

FAIS can be a really tricky thing to treat as physios, the lack of high-quality evidence and rehab protocols makes it really hard to know where to start! Lucky we have expert physios like Jo Kemp to lead the way – watch her full Masterclass HERE.