Therapeutic exercise approaches to nonoperative and postoperative management of femoroacetabular impingement syndrome

Key Points

1. Therapeutic exercise approaches for conservative and post-operative exercise management of femoroacetabular impingement (FAI) carry significant overlap, as the principles and goals are nearly identical.
2. The treatment of FAI requires program individualization and careful exercise progression in order to correct functional deficits and restore pain-free motion.
3. A therapeutic exercise approach for FAI should focus on hip strength, hip mobility, postural control, and core strength, while integrating functional compound movements.

BACKGROUND & OBJECTIVE

The use of hip arthroscopy to treat femoroacetabular impingement (FAI) has risen substantially over the last 15 years. Current evidence may not support the recent exponential rise in hip arthroscopy, as non-operative treatment has been shown to be an effective and oftentimes underutilized first line of care (1).

Exercise therapy for FAI focuses on postural control, core stabilization, hip strength, and hip mobility. Exercise strategies do not differ considerably between post-operative and non-operative patients. The goal of the authors’ current concepts review was to present an up-to-date clinical overview of FAI, and to review trends in exercise protocols for conservative and post-operative management of FAI.

The use of hip arthroscopy to treat FAI has risen substantially over the last 15 years.

In order to ensure continued adaptation, it is important to regularly test the limits of a patient’s threshold and incorporate more challenging exercises as they make improvements.

METHODS

The authors utilized 47 articles in their review. They did not report on any criteria regarding their search and selection process. Their aim was to put together information on the anatomical and biomechanical underpinnings of FAI, common symptoms and presentation, tests and measures, and exercises and treatment of FAI. This current concepts review was not meant to be a clinical practice guideline or definitive paper on FAI.

RESULTS

FAI is characterized by premature contact of the femur and acetabulum during hip motion. Morphologic variations in hip anatomy predispose certain individuals to greater hip joint contact, less hip range of motion, and greater challenge performing certain movement patterns such as the squat or lunge. Aspherical deformation of the femoral head occurs with cam deformity, whereas pincer deformity presents with excessive prominence of the outer rim of the acetabulum.

With clinical exam tests that are highly sensitive and not very specific, the term FAI is used to describe the condition where patients typically feel pain with combined movements of flexion, adduction, and internal rotation of the hip. The term deformity has been used less frequently in recent years, as variations in hip morphology are seen in high rates amongst the asymptomatic population, and many individuals are sensitive to tests designed to screen for FAI (2).

The rise of FAI surgery over the past two decades has been remarkably similar to previously seen trends in arthroscopic surgery for knee meniscus injuries and shoulder impingement (3,4). In both aforementioned cases, hindsight and strong study design featuring sham surgery helped bring to question the indications for surgical intervention. Regarding FAI, current evidence shows surgical intervention to be warranted for patients whose symptoms do not resolve within 3 to 6 months (5). For many non-operative patients, routine maintenance and continuance of therapeutic exercise is recommended. A recurrence of low-level symptoms over many years that do not result in decreased sport participation is not a strong indication for FAI surgery (6).

LIMITATIONS

The authors chose not to perform a systematic review or meta-analysis. Despite its utility for clinicians, this paper carries a low strength of evidence due to its lack of statistical rigor.

The authors focused heavily on exercise intervention techniques. Exercise is an inherently difficult intervention to study, as its prescription should not be standardized for any two different people, let alone an entire population or study cohort.

Future FAI research should be directed at improving clinical examination, history taking, and diagnostic techniques to identify individuals who are strong candidates for conservative management.

CLINICAL IMPLICATIONS

With an increasing understanding of the effectiveness of conservative care for FAI, it is essential that clinicians have a wide variety of non-surgical management options at their disposal. The first step in non-operative management is to reduce pain and restrict any painful or potentially aggravating activities. This may include limiting high impact activity, as well as movement patterns that involve concomitant flexion and rotation of the hip, i.e. squat and lunge patterns. Ideally, patients should not exercise through significant pain or experience increased pain following exercise therapy. An experimentation process of finding movements that do not bring on pain is essential.

In order to ensure continued adaptation, is important to regularly test the limits of a patient’s threshold and incorporate more challenging exercises as they make improvements. Common exercise approaches start with core stabilization and trunk positioning movements, for example planks, bird dogs, dead bug variations, half kneeling rotations and presses, and bridges (double and single leg). Exercise progressions then typically move to more specific hip mobility and strengthening, including more challenging bridge and hip extension progressions, a large focus on hip abduction (including side planks, clamshells, standing hip band exercises), as well as single leg balance. Integration of core positioning, core stability, hip mobility, and hip strengthening exercises is essential. The final exercise progressions for the treatment of FAI should be focused on the individual and their activity or sport demands.

Clinicians helping patients with FAI should be well equipped with knowledge on evaluation, program individualization, and exercise progressions to assist patients in making improvements in strength, mobility, and functional performance.

+STUDY REFERENCE

Terrell S, Olson G, Lynch J (2020) Therapeutic Exercise Approaches to Nonoperative and Postoperative Management of Femoroacetabular Impingement Syndrome. Journal of athletic training.

SUPPORTING REFERENCE

1. Reiman MP, Thorborg K. (2015). Femoroacetabular impingement surgery: are we moving too fast and too far beyond the evidence? BJSM.
2. Mosler AB, Agricola R, Thorborg K, Weir A, Whiteley RJ, Crossley KM, Hölmich P (2018). Is Bony Hip Morphology Associated With Range of Motion and Strength in Asymptomatic Male Soccer Players? JOSPT
3. Judge A, Murphy RJ, Maxwell R, Arden NK, Carr AJ. (2014). Temporal trends and geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England. The bone & joint journal.
4. Montgomery SR, Ngo SS, Hobson T, et al. (2013). Trends and demographics in hip arthroscopy in the United States. Arthroscopy
5. Basques B, Waterman B, Ukwuani G, et al. (2019). Preoperative symptom duration is associated with outcomes after hip arthroscopy. Am J Sports Med.
6. Kunze K, Beck E, Nwachukwu B, Ahn J, Nho S. (2019). Early hip arthroscopy for femoroacetabular impingement syndrome provides superior outcomes when compared with delaying surgical treatment beyond 6 months. Am J Sports Med.