169. FAI (Femoroacetabular Impingement)

In this episode, we break down femoroacetabular impingement (FAI) for PTs and students—what it is, how it shows up clinically, and how it’s typically diagnosed. We walk through cam, pincer, and mixed morphologies, quick assessment ideas (including FADIR/FABER and when imaging matters), and what PT treatment commonly focuses on. We also touch on when injections or surgery may come into play and key considerations for helping patients succeed with rehab.

00:00 Welcome to PT Snacks

01:10 FAI Defined and Diagnosed

02:27 Cam Pincer and Mixed Types

05:03 Clinical Assessment Tests

07:26 Imaging and Key Angles

08:31 PT Treatment Priorities

11:14 Injections and Surgery Options

12:20 Key Takeaways and Wrap Up

13:16 Resources Newsletter and Promo

14:10 Final Sign Off

Transcript

 📍 Hey everyone. Welcome to PT Snacks. This is Kasey, your host, and if you're tuning in for the very first time, what you need to know is that this show is actually meant for physical therapists and physical therapist students who are looking to grow your fundamentals in small segments of time so that you have time to do whatever else in life that you need to do. Today we're gonna be covering FAI or femoral acetabular impingement. You'll probably hear me say FAI more, but essentially covering what exactly this is and how do we clearly define it, and then what do we do about it? So real quick though, if you've been listening to the show for at least three episodes and you found it to be pretty helpful, if you wouldn't mind just pausing wherever you're listening to this. So whether it's on YouTube or Spotify or Apple, just pausing and leaving a review or hit follow or subscribe if you are not already doing that. That way you get to keep up with all the new updates. I'm playing with technology a little bit on just making things easier to take in and, and understand. So stay tuned. And also feedback is always appreciated too as well. But with that being said, let's dive right into it and just go into brief overview of what FAI is and then we'll go in a little bit deeper. So this is essentially defined as a movement related disorder where abnormal contact between the femoral head and the acetabulum can cause hip pain, labral chondral damage. And for some patients it may even accelerate osteoarthritis. Another definition, if you don't like that one I took these right from research journals but essentially it's symptomatic premature contact between the proximal femur and acetabulum due to a cam, pincher, or a mixed morphology. How we define this is typically a triad of symptoms, clinical signs and imaging. According to the Warwick agreement, um, which if you're not familiar with, it's basically, a group of people tried to get together and actually define what this is and how to diagnose it so that we're all on the same page. So typical symptoms are gonna be motion or position related groin pain, sometimes with clicking, catching, giving way. Could have stiffness, limited range of motion and limited sport or ADL participation. As a brief review. Our hip, remember, is a ball and socket joint. So if we are going to just do a brief review over the common impingement that people's hips can get, um, I'm gonna group it into three. The three that I already mentioned actually. So we have our cam impingements, pincher and mixed. When we're talking about cam, this is an aspherical femoral head from a bony overgrowth along the head and neck junction. So for people who have impingement, this makes up about 37%. It's more common in males and in skeletally, immature athletes in high intensity sports with hip loading, like running, jumping, and kicking. Some people think that it may be from a, a response to repetitive injury to the proximal femoral isis, so hip flexion and internal rotation can cause shearing on the acetabular cartilage and labrum along the anterior superior joint and injure this area. So Cam, I think of like a C shape. So I think of, it makes me think of the femoral head. That's how I remember which is which. Whereas pincher, I picture like a big claw essentially. The acetabulum has increased coverage of the femoral head. So we have our pincher. The alum was pinching over it. That's how I remember. Again, you can choose your own way of remembering that, but it can often be associated with acetabular retroversion. And this makes up 67% of prevalence with similar rates in. Both our general population and our athletic population. And I say about 67% and you'll see why. Over coverage, can cause labral damage as it gets impinged, and that can also lead to inter label calcification or os aceta. So our third one is a mixture. You'd have both of these. So it's a combination of cam and pincher and more common than either type alone. So percentages get weird here because in those earlier percentages that I mentioned, some of those might be if they have a cam or not, or if they have a pincher or not. There's an overlap on people who have both in those percentages, if you're confused. So how do we assess for it? Well, other than our general, our range of motion, our strength testing of hip, when someone is complaining about these, it's always good to screen out the joints that are above and below. For instance, making sure that if they're having pain in the hip, it's not coming from the back or things like that. But that screening should take like not very much time at all. So when I, I'm gonna assume we've already screened those out, so we've already got an idea of what they need to do and we have a good idea in our head of the movements that are causing pain for them. Again, if they're coming into your clinic, they're probably gonna complain of motion or position related groin pain. They may have clicking, catching, giving away some stiffness that it could have gotten worse with time. They may have already been predisposed to it. They might have limited range of motion and reduced ability to do the sports. And beyond that, they may have a limited ability to do anything from, I'm going up and down the stairs to, I'm struggling with intimacy. I'm having pain with sitting in the car for a long period of time to, I can't cut Sprint. I can't do any of that. So make sure that you're asking your patient what they're having a hard time with and where do they have it? Assuming that we've gotten all that information, we've screened out the areas above and below the hip. We want to look at things like a fader. So flexion adduction, internal rotation. You can slowly wind this up into this position. You don't crank them into that, especially if they're having pain. This has high sensitivity and low specificity, meaning that with this test, if you do a fader on your patient and they don't have pain, it's probably not FAI. A higher specificity test would've captured that. You can also look at Faber. So flexion abduction, external rotation, range of motion. You can, if you're trying to differentiate on is it an active tissue or a passive tissue, well, this would probably be more painful on the passive tissues. Look at their range of motion. Look at their imaging. Some of them may or may not all already had that, but if they've had an x-ray, an MRI or an MRA, those can all be really helpful to see if they have a cam or a pinch or morphology or even labral or chondral injury. So an x-ray, they'll typically do an AP view or a lateral view, which could be a cross table lateral or a modified Dunne. They might have like a frog leg view. But for cam morphology, they're usually gonna try and quantify the alpha angle. The downside of this is there's not really a specific definition on the value of what that alpha angle should be to call this a cam. So it's been proposed at least 50 to 60% to increase specificity, whereas for pincher morphologies, they might use a lateral center edge angle. So values greater than 40 degrees indicate increased superior lateral acetabular coverage of the femoral head. So. Our patient has impingement. What do we do about it? Well, typically these patients are gonna start off in PT first, and a lot of what PT will focus on would be hip strength, balancing control if they need it, range of motion and movement if they need it. You're. Wanna make sure that you're looking at what is my patient having a hard time with? 'cause there can be a spectrum of these different things. Some may struggle more with range of motion than others be able to purely put their hip in a position, um, or others. If. Especially if they've had hip pain for a long period of time, they might be a little bit weaker. And some people propose that there might be a little bit of dynamic impingement that happens when those hip muscles are weaker, um, and they're not able to help support the hip through dynamic positions, sports, et cetera. So look at what your patient needs. You can test their hip. Abduction, extra rotation, flexion, extension, abduction. A lot of times abduction gets kind of left out. Do they need neuromuscular control? Uh, are they having a lot of giving away or balance issues? That could be its own form of exercise. Right. In terms of topics, the programs that tended to help shared education and modification for. Activities that were painful. So for instance, trying to avoid deep flexion, uh, or like a fader position, prolonged sitting, deep squats and pivots. This also includes educating coaches or trainers who I've, I've had patients who are told they must go in a specific position and it was causing them pain. So for instance, some people are taught to squat in a very specific way. But it's not specific to what their body natural range of motion is inclined towards. So being able to do those different positions, or maybe they don't squat as deep, et cetera, maybe they need to heel lift. That kind of stuff can help to create a more healing environment while we're working on the hip. And maybe. Depending on the activity, it's something they can eventually do. Maybe it's something where they just modify and it fits their lifestyle. And then things like manual therapy, mobility, again, don't force their hip through motions that they can't go through, but you're using it for pain management. So, uh, the good thing about these programs is 70 to 82% managed without surgery at over the two year mark with pretty good outcome gains. That's a pretty good sign. Patients may also get injections, corticosteroids, PRP, those are very common and they can also be very good diagnostic aspects to see. If you inject it in the hip and it goes away, that's a good sign that it's in the hip. Versus if it didn't change, maybe we're not treating the correct thing. Um, and then surgery typically in, especially in younger patients, it's gonna be an arthroscopy. Typically it's gonna be an arthroscopy. So typically, typically it's gonna be an arthroscopy, which return to sport after an arthroscopy was 85.4% or. An average of 6.6 months after surgery. So that's a pretty good outcome. Uh, the one caveat would be that if someone has a Tonnis of a grade one or a joint space of two millimeters or less, that might be a bit too much degeneration happening in the hip according to a systemic review by Dom et al to benefit from an arthroscopy. So those patients might instead get like a, a total hip replacement. So, um, what you should have gotten from this talk was what FAI is how we define it, and the different types of impingement that can be a part of an impingement. Beyond that. What do we do about it? And what are some potential other outcomes that people can go for if PT doesn't work for them? So one thing I would say that if you are treating these patients, making sure that if they are feeling any muscle soreness or, fatigue, seeing if they're actually feeling it in their glutes. 'cause sometimes they feel it in all the other muscles and then they fail pt, but they may need a little bit of help. Getting proper glute activation in a way that is not just aggravating the hip itself. So. Just, um, something to think about. But that's it for today, guys. I hope that was helpful to you. Um, if you have any questions at all, feel free to reach out. ptsnackspodcast@gmail.com. If you haven't already, feel free to join the newsletter where I send out updates once a week. Just make sure that you actually confirm your email or you're not gonna get any emails. So I do that to make sure that if. You signed up, you actually really want emails that are getting them not just a bunch of spam mail. So beyond that, if you want to take deeper dives into really this topic or any other topic, med Bridge is actually offering listeners over a hundred dollars off their year subscriptions on. Almost all of the different tiers that they offer. So they have some for students, clinicians, and also clinicians who want an HEP builder that's pretty good. So it has a ton of CEU courses, specialty exam prep, et cetera. But you would just use PT snacks as your promo code or you can just use the link below. But other than that, I hope you guys have a great rest of your day, and until next time.