FAI hip problem - Physiotherapy or Surgery?

Q: I am at a crossroads in my life. I have a hip problem called FAI and trying to make good decisions about treatment. I am actively involved in college sports and I don't want to give that up. But my surgeon tells me if I keep reinjuring myself and repetitively pinching the hip with activities, I could end up with early arthritis. She has suggested I try physiotherapy first if I don't want to be on the bench for the season while recovering from surgery. Maybe I should just take the plunge and have the surgery. Get it over and done with. What do you think?

A: FAI refers to femoroacetabular impingement (FAI). Impingement refers to some portion of the soft tissue around the hip socket getting pinched or compressed. Femoroacetabular tells us the impingement is occurring where the femur (thigh bone) meets the acetabulum (hip socket). There are several different types of impingement. They differ slightly depending on what gets pinched and where the impingement occurs.

Repetitive pinching of the labrum (rim of fibrous cartilage around the hip socket) can lead to more injuries of the joint and eventual arthritic changes. The condition affects many athletes who are interested in getting back to a pre-injury level of sports participation.

Many orthopedic conditions can be treated conservatively (without surgery) and that is often the first step with femoroacetabular impingement (FAI). Antiinflammatory medications are often prescribed. Activity modification is advised. Exactly what and how to change your activities is usually determined by a physiotherapist.

The therapist also helps the patient regain soft-tissue mobility, hip muscle strength, neuromuscular control, and postural balance. Core training, adjustments in posture, and improved control over movements can cause changes in spinal and pelvic alignment. Even small improvements in the position of the lumbar spine and pelvis can reduce the amount of impingement present.

Currently, there aren't enough published studies providing evidence that nonoperative management of this condition is effective. That doesn't mean it isn't helpful -- we just need more research in this area to prove it. Patients who have a favorable outcome are pleased with the results and report high patient satisfaction. Treatment failure is most common among patients with significant early osteoarthritis.

If nonoperative care does not yield the desired results, then surgical correction is an option. Surgery can be done with an open incision or with the less invasive arthroscopic approach. The surgeon's choice depends on the patient's age, type and severity of impingement, and amount of damage to the hip cartilage. The main objectives of surgery are to relieve pain, improve function (including return to daily and/or sports activities), and prevent hip arthritis.

Femoroacetabular impingement (FAI) is probably the most common cause of early cartilage and labral damage in the hip of young athletes complaining of hip pain. The ability of these areas to heal is limited by the lack of blood supply. Early intervention is important to avoid early joint degenerative changes and arthritis.

Treatment (whether conservative or surgical) can help correct the problem, thus relieving pain and preventing further damage to the hip joint. With correct treatment early on, up to 90 per cent of athletes affected by FAI can return-to-sports successfully.

Reference: Asheesh Bedi, MD, and Bryan T. Kelly, MD. Current Concepts Review. Femoroacetabular Impingement. In The Journal of Bone and Joint Surgery. January 2, 2013. Vol. 94A. No. 1. Pp. 82-92.