Learn the Basics of Femoroacetabular Impingement (FAI)

The hottest topic in the field of orthopedics is femoroacetabular impingement (FAI).  Dozens of new surgeons each year are training in fellowships with today’s top hip arthroscopists in Vail, Los Angeles, New York, Nashville, Seattle, and San Francisco.

Your younger students or patients who have hip pain may receive the diagnosis of FAI, and you’ll not only need to know what that means, you’ll need to know how to protect them from exercises that could be dangerous for their condition.

Let’s start with the definition.  Femoroacetabular impingement (FAI) is a condition where the bones of the hip are abnormally shaped. Because they do not fit together perfectly, the hip bones bang into each other, putting pressure on the fibrocartilage of the labrum and even tearing it.  Further, this condition can be the precursor to osteoarthritis (OA).   That’s why doctors are hopeful that arthroscopy for FAI can stop the progression toward OA. There are three types of FAI:  pincer, cam, and a combination of the two.  The pincer is an extra bony growth on the edge of the acetabulum, the socket side of the hip joint.  The cam is a bony formation on neck of the femur.

Interestingly, 30% of the world’s population has FAI and may have a torn labrum, but they don’t even know it.  Without hip pain or dysfunction, this condition does not need to be surgically repaired.  But athletes with FAI who take their hips through extreme ranges of motion, such as kick boxers, ballet dancers, or water polo players, will likely find they need the surgery, for their activities have greatly damaged their hip joints.

The most dangerous exercises for those with FAI are deep lunges and maximum hip flexion.  Therefore, you’ll want to review your exercises and either modify or eliminate any of them that fit into that category.  For instance, we have a 4-Way Hip Exercise in which students or patients lift their straight leg to the front (1), to the rear (2), out to the side (3), and across the standing leg (4).  We have modified this exercise for those with FAI so that they do a 3-Way Hip Exercise reaching to the side (1), backward at a 45-degree angle (2), and straight backward (3).

In addition to protecting people with FAI from dangerous exercises, you want to put an emphasis on gluteal strengthening.  So use all the exercises you have that help with that.  If you have to skip one of your standard exercises, offer extra reps to focus on the gluts.

We have helped many people with FAI regain a functioning hip even though they had a torn labrum that wasn’t repaired.  Did the labrum heal itself? No, but they stopped doing the movements that hurt their hip and focused on gluteal strengthening exercises.  If the pain is gone and they can do the non-abusive activities they enjoy, they don’t have to go to surgery.

For those of us who spend our lives doing aquatic rehab, our hope is to prevent as many surgeries as possible.  But there will be those who do need the surgery.  By coming to your classes, these people will have improved their strength and range of motion prior to the surgery; and they will bounce back more quickly afterward. Their surgeon will likely allow them back into your pool two weeks later, where they will be protected both by the water and your knowledge of how to work with post-op FAI.

Here’s what the surgeons do inside the joint:

• They gain entry to the joint through two small puncture sites and insert pencil-sized surgical instruments through those portals.
• They repair or even reconstruct the torn labrum. They might use part of an iliotibial band to replace labral tissue.  They suture the labrum back into place and anchor it to the bone.
• They shave down the offending bone, either cam or pincer.
• They trim out inflamed synovium (the tissue lining the joint).
• They remove their instruments and use one stitch to close the puncture site.

And what they have left behind is a joint that will now move smoothly without impingement.  By doing this, the expectation is that they have stopped the deterioration of the hip joint, possibly for a lifetime.

This new surgery requires that we create new protocols for patients who come to our pool following FAI repair and possible labral reconstruction. Here’s a good rule of thumb to follow: No deep squats, no deep lunges, and no extreme ranges of hip motion. Just like any surgical fixation, it must be protected for six weeks, then gradually brought back to full function as tolerated.