Diagnosis and management of femoroacetabular impingement (2024)

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Geraint ER Thomas, Antony JR Palmer, Antonio J Andrade, Thomas CB Pollard, Camdon Fary, Parminder J Singh, John O’Donnell and Sion Glyn-Jones

British Journal of General Practice 2013; 63 (612): e513-e515. DOI: https://doi.org/10.3399/bjgp13X669392

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Femoroacetabular impingement (FAI) is a pathological hip condition characterised by abnormal contact between the acetabulum and femoral head–neck junction.1 This can occur within the normal physiological range of motion as a result of osseous abnormalities described as either cam or pincer deformities. Cam deformities describe an abnormal anterosuperior femoral head–neck junction, whereas pincer deformities describe abnormalities in the shape or orientation of the acetabulum (Figure 1). Some patients have both deformities, designated mixed pathology.2 Impingement can also occur in a morphologically normal hip as a result of extreme range of motion activities, such as in ballet dancers or gymnasts.

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Figure 1

Illustrative lateral view of a hip showing a) cam deformity with additional bone at the anterior femoral headneck junction (shown in red) b) normal hip c) pincer deformity with additional bone at the anterior acetabular rim (shown in red). The deformities in a) and c) cause the femoral neck to impact against the labrum and acetabular rim on flexion and internal rotation.

Repeated abutment of the femoral neck against the acetabular rim can result in injury to the labrum and adjacent cartilage.3 Over time these focal lesions may progress to more extensive degenerative disease. There is increasing evidence implicating FAI in the development of osteoarthritis (OA).1,4 In a large population study, cam and/or pincer deformities were found in 71% of males and 37% of females with hip OA.5 Recent longitudinal studies also support this association.6


FAI commonly presents in healthy, active adults, most frequently between the ages of 25 and 50 years. In older patients it is more frequently accompanied by OA.

Deep intermittent discomfort, during or after activity is the most common presenting complaint. The first step in assessment involves a comprehensive pain history. Intermittent discomfort in the groin during or after repetitive or persistent hip flexion is characteristic of anterior impingement resulting from either cam or pincer deformities. Sprinting or kicking sports, hill climbing or prolonged sitting in low chairs are common exacerbating activities. Pain may be referred to the anterior thigh, symphysis pubis, or the ipsilateral testicl* in men.

Pincer deformities may also give rise to posterior impingement with pain experienced in the buttock or sacroiliac region and are often difficult to differentiate from pain referred from the low back or sacroiliac joint. Repeated hyperextension with such activities as fast-walking, or walking downhill are common exacerbating activities. Posterior hip pain during intercourse is also a frequent complaint in women.

Associated mechanical symptoms such as catching or clicking may be seen when labral tears are also present. Duration of symptoms is variable, and patients sometimes report an inciting event.


Antalgic or Trendelenberg-gait patterns may be observed.

Internal rotation with the hip at 90° of flexion is typically markedly limited. Flexion and abduction are also often limited, although this is a less consistent feature.

The hip impingement test is performed with the patient supine with hip and knee flexed to 90°, the hip is progressively rotated from external rotation to internal rotation while moving from abduction to adduction (Figure 2). A positive test elicits a sudden, sharp pain in the hip. Patients often report that the manoeuvre recreates their typical symptoms. A positive impingement test has been shown to be present in more than 90% of patients who go on to have FAI confirmed either radiologically or at the time of surgery,1,7 in addition it has a high positive predictive value for labral pathology.8

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Figure 2

Hip impingement test. FADIR = flexion, adduction, and internal rotation. FABER = flexion, abduction, and external rotation.


Plain radiology

Initially, an anteroposterior pelvis film with a cross-table lateral or Dunn view are all that are required. Morphological abnormalities as well as degenerative changes may be observed, although radiographic evidence can be subtle and the radiographs of patients with FAI are often reported as normal. This should not overshadow a convincing history and physical examination, and the need for appropriate management and referral remains. (Misdiagnosis and management as groin strain, low back pain, trochanteric bursitis, or early OA is not uncommon).

Magnetic resonance imaging (MRI) and computerised tomography (CT)

MRI arthrogram (MRA) with intra-articular contrast is the investigation of choice. In addition, intra-articular injection of local anaesthetic and steroid at the time of MRA is safe and of diagnostic value, particularly in the presence of early OA.

3D reconstruction of CT scans has proved useful in the recognition of subtle femoral deformities and in preoperative planning during the management of complex deformities.



A course of non-operative treatment for most hip pathology may be tried first. Patients presenting with FAI or labral pathology can try modification of activity, avoiding excessive ranges of hip movement, with regular non-steroidal anti-inflammatory medication. Pincer impingement may be amenable to sports therapy that focuses on modifying dynamic hip flexion by maintaining core stability and a more upright stance during activity.9


Operative management has been shown to be effective in providing symptomatic relief and functional improvement. Despite evidence that FAI predisposes to OA,10 thus far there is no evidence that intervention will alter the natural history of the disease or the future need for arthroplasty.


The arthroscopic approach is minimally invasive with faster rehabilitation and a lower incidence of complications, but access to some areas of the joint is difficult. Complications of this approach include transient neuropraxias and fluid extravasation.11

Labral repair is possible and areas of chondral damage can be debrided or regenerative techniques implemented such as microfracture. Osteochondroplasty can be performed in cam impingement to reshape the head–neck junction, while acetabular rim trimming can be used to reshape the acetabulum with reattachment of the labrum.

Open hip dislocation

All procedures that can be performed arthroscopically can also be performed with an open approach, and this approach also provides better access to the postero-inferior portion of the hip. However, this is a major operation and carries a longer rehabilitation period and slightly higher complication rate.12


FAI is a common, often unrecognised condition causing hip pain and degenerative hip disease.

Careful history and examination (a positive impingement test in particular) are key to the diagnosis and enough to alert the GP to the possibility of FAI.

Surgery has two main goals: to provide symptomatic relief and functional improvement in the short term, for which there is increasing evidence; and potentially modify the disease process and delay or even prevent the onset of OA.

GPs have an important role to play in the recognition and management of FAI.



Freely submitted; not externally peer reviewed.

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  • Received July 18, 2012.
  • Accepted November 2, 2012.
  • © British Journal of General Practice 2013


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British Journal of General Practice

Vol. 63, Issue 612

July 2013

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Diagnosis and management of femoroacetabular impingement (7)

Diagnosis and management of femoroacetabular impingement (8)

Diagnosis and management of femoroacetabular impingement (2024)


What is the diagnosis and management of femoroacetabular impingement? ›

Femoroacetabular impingement (FAI), also called hip impingement, is a condition where the hip joint is not shaped normally. This causes the bones to painfully rub together. This condition can be treated with corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, rest and surgery.

How do you fix femoroacetabular impingement? ›

How is femoroacetabular impingement treated?
  1. Activity modification. This involves reducing or avoiding activities that cause or aggravate symptoms.
  2. Nonsteroidal anti-inflammatory medications (NSAIDs). ...
  3. Steroid injections. ...
  4. Physical therapy.

Do I need surgery if I have a hip impingement? ›

Hip Impingement Treatment

Your doctor may first recommended conservative treatment, such as rest, activity modification, anti-inflammatory medications and sometimes physical therapy. However, if your pain does not improve with these interventions, you may be a candidate for surgery.

How to fix hip impingement without surgery? ›

Physical Therapy

In particular, building strength in core muscle groups—including those in the abdomen and back—provides extra support for your hips. It also takes some of the stress off the hip joints when you walk and exercise.

Can femoroacetabular impingement heal on its own? ›

Hip impingement—also known as femoroacetabular impingement, or FAI—is the result of a misshapen bone. That means it won't go away on its own. Over time, the pain caused by hip impingement can make it hard to run, squat, or sit.

How long does it take for hip impingement to heal? ›

The recovery time following arthroscopic surgery for hip impingement is typically about six months as patients need crutches for 3-6 weeks, followed by physical therapy exercises and treatments for several months. It's important not to overstress the joint by doing too much too soon.

What happens if femoroacetabular impingement is left untreated? ›

This causes the bone to develop an irregular shape. The number of people with FAI is unknown, as some people may have this condition with no symptoms. However, if pain is present and left untreated, more serious hip problems, such as hip osteoarthritis, may occur in the future.

Is walking OK for hip impingement? ›

In the early stages of FAI, you may be able to continue walking, running, or cycling with proper rest, stretching, and anti-inflammatories. But if the impingement progresses, cut back on these types of exercise or allow longer periods for rest and rehab.

How do doctors treat hip impingement? ›

An injection in the hip joint of anesthetic and a corticosteroid can provide some pain relief as well as additional diagnostic information in patients who have symptoms that are unresponsive to treatment. When surgery is necessary, hip impingement can usually be treated with hip arthroscopy or an osteotomy.

What can be mistaken for hip impingement? ›

Many other disorders of hip joint can superficially mimic impingement and dysplasia but they do not depend on articular deformity. Among these, we can list rheumatological diseases, osteonecrosis of femoral head, transient hip osteoporosis, stress fractures, infiltrative bone disease, articular hyperlaxity.

What aggravates hip impingement? ›

There are two main causes of hip impingement: A deformity of the ball at the top of the femur (called cam impingement). If the head is not shaped normally, the abnormal part of the head can jam in the socket when the hip is bent. This may occur during activities such as riding a bicycle or tying your shoes.

How bad does hip impingement hurt? ›

Movements that include twisting or squatting may result in a sharp or radiating pain along the affected area. In less severe cases of hip impingement, patients often report a dull aching sensation during these motions.

What not to do with hip impingement? ›

As a general rule, any exercise which causes the knee to move above the hip should be modified or not performed. Additionally, heavy weight or repeated impact on the hip joint can cause pain or more damage. These include: Deep squats (especially variations like sumo squats)

Can a cortisone shot help hip impingement? ›

For some people, a corticosteroid injection provides pain relief that lasts for many months; in others, the injection isn't effective. Most people experience some pain relief, lasting for a few weeks or months. Doctors recommend no more than a total of two or three corticosteroid injections in the hip joint.

Should you massage hip impingement? ›

The short answer is: Yes, absolutely! Massage therapy can be a highly effective means of relieving pain and tension in the hips and glutes. For starters, massage encourages muscle relaxation and releases tension. The glute and hip muscles can become tight and sore due to overuse, stress, or poor posture.

How do you diagnose hip impingement syndrome? ›

The hip impingement test is performed with the patient supine with hip and knee flexed to 90°, the hip is progressively rotated from external rotation to internal rotation while moving from abduction to adduction (Figure 2). A positive test elicits a sudden, sharp pain in the hip.

How is hip OA diagnosed? ›

Doctors may recommend X-rays in order to confirm a diagnosis of osteoarthritis of the hip. X-rays create detailed images of the inside of the body and can reveal a narrowing of the cartilage layer in the hip joint.

What is the diagnosis code for hip impingement? ›

FA34. 5 Impingement syndrome of hip - ICD-11 MMS.

What is the surgical treatment of femoroacetabular impingement? ›

Surgery for FAI can be performed using hip arthroscopy or open surgery. In hip arthroscopy, the hip is distracted and an arthroscope (a videocamera about the size of a pen) is used to look in the joint to see and treat damage that is found using two to five incisions that are about ¼ inch in size.

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