Keywords
1. Femoroacetabular Impingement Syndrome
2. Nonoperative Management
3. Physical Therapy for Hip Pain
4. α Angle in FAIS
5. Femoral Anteversion and FAIS
The complexities of treating Femoroacetabular Impingement Syndrome (FAIS) through nonoperative means, including specialized physical therapy (PT), have been well documented in recent literature. A new editorial commentary in the prestigious “Arthroscopy: The Journal of Arthroscopic & Related Surgery” sheds light on the limitations of PT for patients with particular hip anatomical challenges. Authored by Robert R. Kollmorgen of the University of California, San Francisco, and UCSF Fresno, the commentary appears in the journal’s September 28, 2023, issue, under the DOI reference 10.1016/j.arthro.2023.08.021.
The complexities inherent in the relationship between spinopelvic tilt and FAIS are at the forefront of this analysis. The optimal patient parameters leading to successful nonoperative management remain elusive, particularly when considering patients with large α angles or decreased femoral anteversion who are suffering from FAIS. Conventional wisdom holds that physical therapy, with a focus on core and posterior chain strengthening, yields significant success in many cases. An evidence-backed estimate presented in this commentary suggests that PT can modify the posterior tilt of the pelvis by 5° to 10°, offering an increased range of motion (ROM) and, concurrently, a reduction in hip impingement.
However, one of the central tenets of the editorial is the limitation of PT in affecting the cam anatomy – a bone growth on the femoral head that characterizes cam-type impingement. The crux of the argument is that for individuals with this form of impingement and substantial α angles or limited femoral anteversion, PT alone may not be capable of increasing ROM significantly. It is suggested that in these scenarios, pelvic compensation mechanisms may come into play, assisting in the nonoperative management of FAIS but potentially falling short for all patients.
The role of PT in managing chronic hip pain in large-cam, high-flexion athletes is especially highlighted. Such individuals are encouraged to explore PT as a primary intervention. Encouragingly, the commentary notes that a subset of patients with large cam lesions may observe improvements without the need for surgical intervention, provided that their femoral version and/or pelvic tilt ROM can be improved through nonoperative methods. Despite these considerations, the commentary ultimately proffers a cautionary note: surgery should not be excessively postponed in patients whose prognostic factors suggest a poor outcome from nonoperative management alone.
The recent editorial by Kollmorgen acts as a reminder of the nuanced decision-making involved in treating FAIS. It is a response to the growing body of research seeking to better understand and expand on the arsenal of nonoperative treatment strategies for this complex and often debilitating condition.
The quest to approach FAIS treatment holistically is a continuous endeavor in the orthopedic and sports medicine communities. Physical therapists, surgeons, and other healthcare providers strive to tailor interventions that offer relief and functional recovery while mitigating the risks associated with surgical procedures.
In order to give a broad perspective, the following references have been integrated into the pilot analysis presented by Kollmorgen to further the understanding of the challenges and potential in managing FAIS through nonoperative means:
1. Griffin, D. R., Dickenson, E. J., O’Donnell, J., Agricola, R., Awan, T., Beck, M., … & Gimpel, M. (2016). The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. British Journal of Sports Medicine, 50(19), 1169-1176. doi:10.1136/bjsports-2016-096743
2. Khan, M., Oduwole, K. O., & Ayeni, O. R. (2017). Managing FAI syndrome: Nonoperative, operative, and postoperative techniques. Orthopedic Clinics, 48(4), 461-471. doi:10.1016/j.ocl.2017.06.002
3. Mansell, N. S., Rhon, D. I., Meyer, J., Slevin, J. M., & Marchant, B. G. (2016). Arthroscopic management of FAI syndrome: A systematic review of the literature. BMJ Open Sport & Exercise Medicine, 2(1), e000075. doi:10.1136/bmjsem-2015-000075
4. Nepple, J. J., Riggs, C. N., Ross, J. R., & Clohisy, J. C. (2015). Clinical presentation and disease characteristics of femoroacetabular impingement are sex-dependent. The Journal of Bone and Joint Surgery, 97(19), 1682. doi:10.2106/JBJS.O.00023
5. Wall, P. D. H., Brown, J. S., Parsons, N., Buchbinder, R., Costa, M. L., & Griffin, D. (2018). Surgery for treating hip impingement (femoroacetabular impingement). Cochrane Database of Systematic Reviews, (9). doi:10.1002/14651858.CD010796.pub2
The dialogue around FAIS is far from complete, and studies continue to uncover the finer points of nonoperative and operative management strategies. Essential to this progression is a collaborative effort that leverages the expertise of a multidisciplinary team and incorporates patient-centered care to tailor the best possible outcomes for those experiencing hip pain associated with FAIS. The insights offered by Kollmorgen and corroborated by extensive research lay foundational stones upon which future successful treatments for FAIS can be built.
The complex interaction between physical therapy, patient-specific anatomy, and the potential need for surgical intervention constitutes an ever-evolving landscape in musculoskeletal medicine. Thus, this recent editorial contribution offers a crucial reminder of this ongoing complexity and the need to individualize treatment plans in this patient population.