Article by Alex Proctor QTS, BA (HONS) HPAC

Me and my FAI

My relationship with this condition started 9 years ago when my professional dance career abruptly ended when my ‘sore’ hip turned into not being able to walk without a limp let alone dance. After limping into my GP surgery and telling him ‘I have a labral tear and a hip impingement’ I then went through months of Physiotherapy, specialists, and scans until I finally got my diagnosis. ‘Labral tear and FAI CAM deformity’. I chose to go through surgery and had a fairly good experience and got on with my rehabilitation and Pilates teaching. 2 years later, then came the pain I recognised so well. This time in the other hip. More physiotherapy, more specialists, and more scans later they then found that I had the exact same thing in my left hip, and I had the same surgery again.

After 10 years working as a sports therapist, Pilates and dance instructor and now studying for my MSc in Physiotherapy I have seen so many FAI’s and I just find them interesting, rewarding cases to work with, so I hope to pass some of that knowledge on to you all working in the fitness industry.

What is an FAI?

Even if you haven’t ever heard of the term ‘femoral-acetabular impingement’, as a fitness professional statistically you are very likely to come across them with your clients and may even grow one of your very own at some point in your career. FAI’s are incredibly common in sporty, active, athletic individuals as well as middle aged (Particularly female) people for different reasons. They are also one of the most complex musculoskeletal pathologies purely because they can cause so much pain that someone can only walk with a limp, resulting in surgery or… they may not have any symptoms whatsoever.

FAI is the impingement or ‘catching’ of the head of the femur (The ball) with the acetabulum (The socket) in your hip. This can be caused by bony outgrowths or deformity of the socket. Middle aged populations are more likely to have a ‘Pincer’ impingement which presents on scans as an over coverage of the anterolateral acetabular rim relative to the femoral head creating an articular impingement caused by changes in the socket depth. Younger, sporty people are more likely to get a CAM deformity which is a bony outgrowth at the edge of the femoral neck preventing full rotation. Both these types of impingements can then damage the surrounding cartilage and soft tissue (Particularly the labrum) and can also cause an intraarticular (Inside the joint) cyst which will all contribute to pain and symptoms. Long term impingements could even contribute to Osteoarthritis.

When should we suggest a visit to the Physio or GP?

If your client is experiencing some or all these symptoms, then start to think about referring.

  • Pain in the front, back or side of the hip during certain movements such as squatting, jumping, or running.
  • A deep ache into the hip, particularly after sitting for longer periods.
  • Hip giving way.
  • Clicking, popping, or catching sensation coupled with pain.
  • A series of injuries around the hip such as groin strains and hamstring tears
  • Low back pain
  • Limping
  • A pinching sensation when bringing the hip to full flexion (Knee to chest), internal rotation or external rotation. For those of you teaching mobility work they may complain of it feeling very uncomfortable in these ranges
  • Hypermobility can be a contributor so look out for the bendys!

But remember… not all FAI’s cause pain. In fact, many people are walking around with an FAI and have absolutely no pain or symptoms. They might just not have great internal and external rotation. If that’s the case, they are nothing to worry about. Its only when they become painful when it is a problem.

What happens after diagnosis? 

After a Femoral Acetabulum impingement has been diagnosed the patient will be given the opportunity to manage the impingement conservatively with Physiotherapy which may include strengthening adductors, abductors, and glute complex as well as pain management and behavioural change interventions. If the joint and surrounding tissues are severely affected or symptoms aren’t reduced with conservative treatment then they may be given surgery options which may range from arthroscopic bone shaving to improve the joint articulation, through to resurfacing or full hip replacement if the joint has developed osteoarthritic changes. The studies around the success of these conservative arthroscopies to shave the bone are highlighting that they are often not that successful so many people choose to manage the condition with exercise.

What do I need to do if my client has been diagnosed with an FAI?

As they are so common and often managed conservatively it is highly likely that these individuals will wonder into your Pilates class or come to you looking for PT sessions. They may have been diagnosed with an FAI and decided to manage it conservatively or they may even be waiting for surgery. It is therefore worth understanding how to help these clients manage their condition in your sessions. So here are a few tips.

  • Firstly, remember you are not a hip surgeon. You cannot ‘Fix’ the hip, but you absolutely can improve the symptoms. If the client is in some pain, then working alongside their Physiotherapists will give the best outcomes.
  • Remember that pain is a good indicator that their hip is being impinged in that movement or position so pushing through pain will only exacerbate issues. If they feel pain, they need to stop and try something else. Internal and external rotation of the hip may be very problematic for them.
  • Studies show that strengthening the glute complex and particularly adductors will help them for conservative treatment as well as both pre and post-surgery. Just always work within their comfort levels.
  • Very (very) gentle mobility work might feel easing for the client but generally a lot of hip mobility work and stretching will not only be counterproductive but may make the condition worse. You can’t ‘mobilise a joint that has bony changes.
  • Work on strengthening the deep core stabilisers of the spine
  • Work on good lumbar pelvic hip complex biomechanics
  • Know when to stop. If your client is conservatively managing their condition but they are experiencing more and more pain when exercising it may be time for them to look at other surgery options. That doesn’t mean you’ve failed, that just means that their condition may have worsened and become unmanageable. If you’re knowledgeable about their condition no doubt these people will come straight back to you to help rehabilitate them after surgery!
  • Help them to recognise when they are overdoing it. Once that pain starts, they may need to dial back on their training or switch to something less aggravating.

Don’t be scared to talk to your clients more about their pain, symptoms, and experience with their FAI’s as that is how you’ll learn. As a fitness professional you can really help a client to drastically improve their symptoms if managed with care and careful programming. Just remember that if in doubt, always refer on and where possible work alongside their Physiotherapist to get great results for your client.

If you want to know and understand more about musculoskeletal conditions and injury, why not take our Level 4 Therapy Exercise Course

Alex Proctor QTS, BA (HONS) HPAC

Alex started her Pilates journey when she was 18 at University where she studied BA (hons) Dance and Theatre, followed by Post graduate secondary teacher training. After retiring from a 16 year long career in dance, aerial and acrobatics she began teaching Pilates whilst retraining as a Sports Therapist and medic. Over the last 9 years she has spent her time teaching clinical Pilates matwork and apparatus, tutoring in Pilates for Drummond Education as well as looking after the players at Rams RFC, Bracknell RFC and Berkshire County RFU. She is now completing her MSc in Physiotherapy alongside her FREC medic qualifications.