Nonoperative Management of Femoroacetabular Impingement: A Prospective Study

Abstract

Background: The literature has given little attention to the nonoperative management of femoroacetabular impingement (FAI) syndrome despite a rapidly expanding body of research on the topic. Purpose: To perform a prospective study utilizing a nonoperative protocol on a consecutive series of patients presenting to our clinic with FAI syndrome. Study Design: Cohort study; Level of evidence, 2. Methods: Between 2013 and 2016, patients meeting the following criteria were prospectively recruited in a nonoperative FAI study: no prior hip surgery, groin-based pain, a positive impingement test, and radiographic FAI syndrome. The protocol consisted of an initial trial of rest, physical therapy, and activity modification. Patients who remained symptomatic were then offered an image-guided intra-articular steroid injection. Patients with recurrent symptoms were then offered arthroscopic treatment. Outcome scores were collected at 12 and 24 months. Statistical analysis was performed to identify risk factors for the need for operative treatment and to determine patient outcomes based on FAI type and treatment. Results: Ninety-three hips (n = 76 patients: mean age, 15.3 years; range, 10.4-21.4 years) were included in this study and followed for a mean ± SD 26.8 ± 8.3 months. Sixty-five hips (70%) were managed with physical therapy, rest, and activity modification alone. Eleven hips (12%) required a steroid injection but did not progress to surgery. Seventeen hips (18%) required arthroscopic management. All 3 groups saw similar improvements in modified Harris Hip Score ( P = .961) and nonarthritic hip score ( P = .975) with mean improvements of 20.3 ± 16.8 and 13.2 ± 15.5, respectively. Hips with cam impingement and combined cam-pincer impingement were 4.0 times more likely to meet the minimal clinically important difference in modified Harris Hip Score ( P = .004) and 4.4 times more likely to receive surgical intervention ( P = .05) than patients with pincer deformities alone. Participants in team sports were 3.0 times more likely than individual sport athletes to return to competitive activities ( P = .045). Conclusion: A majority (82%) of adolescent patients presenting with FAI syndrome can be managed nonoperatively, with significant improvements in outcome scores at a mean follow-up of 2 years. Clinical Relevance: A nonoperative approach should be the first-line treatment for young active patients with symptomatic FAI syndrome.

Operative Versus Nonoperative Treatment of Femoroacetabular Impingement Syndrome: A Meta-analysis of Short-Term Outcomes

“…12 Furthermore, inferences can only be made as to the early effectiveness of FAI treatment for quality of life, pain, and function and do not extend to the potentially prophylactic effects on the development of hip arthritis associated with radiographic features of FAI. 13 There is also evidence that patients with labral tears and FAI can be successfully managed with physical therapy, pain management, and activity modification, in combination with intra-articular injections: In a prospective study by Pennock et al, 14 76 of 93 adolescents (82%) with FAI syndrome were successfully managed nonoperatively at a mean follow-up of 2 years. Although the osseous structures involved in FAI are thought to cause pain through bony impingement, studies have also shown that soft-tissue (weakened hip flexors, external rotators, and hip abductors 15,16 ) and biomechanical contributors (abnormalities in gait biomechanics, pelvic obliquity, and pelvic tilt 15,[17][18][19][20][21][22][23] ) lead to increased loading of the acetabular labrum and pain mechanisms.…”

Hip muscle atrophy in patients with acetabular labral joint pathology

“…Surgery to correct the bony alignment and repair or resect the damaged acetabular labrum has been advocated, with good outcomes reported postoperatively (Kemp et al, ; Kierkegaard et al, ) although recent research has indicated that function and participation in sport and physical activity is still reduced 1 year after surgery (Thorborg et al, ). More recently, conservative nonsurgical management approaches focusing on improving neuromuscular function around the hip have been proposed as an alternative (Casartelli et al, ; Casartelli et al, ; Casartelli et al, ; Pennock et al, ).…”

Clinical Outcomes of Physiotherapy for Patients with Acetabular Labral Tears: An Analysis According to Severity of Injury

“…In recent years, several studies on conservative treatment for patients with acetabular labral tears and FAI have been reported [9][10][11]. However, the diagnostic accuracy of acetabular labral tear was relatively low in most studies because the diagnosis of labral tear was only dependent on bone morphology and anterior impingement test.…”

“…Regarding the conservative therapy, however, there is no consensus on the usefulness of physiotherapy to treat acetabular labral tears. Previous studies reported that physiotherapy can improve clinical symptoms [9][10][11], but outcome scores of conservative treatments have been reported to have no difference or to be signi cantly lower than those of arthroscopic surgery [12,13].…”