Hip Impingement (FAI) in Adults: Symptoms and Treatment
Hip impingement, or femoroacetabular impingement (FAI), is one of the most common causes of hip and groin pain in active adults, usually between their late teens and fifties. It's also one of the most commonly misunderstood, because the shape changes seen on scans are very common in people without any pain. This guide covers what FAI is, how it's diagnosed, and what the evidence says about treatment.
What is hip impingement?
In FAI, the ball of the hip (the femoral head) and the socket (the acetabulum) contact each other earlier than usual in some movements, particularly deep bending and turning the knee inwards. A cam shape is extra bone where the ball meets the neck of the thighbone. A pincer shape is extra coverage from the rim of the socket. Many people have a mix of both.
What is FAI syndrome?
An international consensus, the Warwick Agreement, defined FAI syndrome as a motion-related hip disorder with a triad of symptoms, clinical signs and imaging findings (Griffin et al., British Journal of Sports Medicine, 2016). All three need to be present. A cam or pincer shape on a scan without symptoms isn't FAI syndrome.
Who gets hip impingement?
It's most common in active adults, especially those who played sports involving repeated deep hip bending and twisting during adolescence, such as football, soccer, hockey, ice hockey, basketball and martial arts. Cam shapes are more common in men; pincer shapes are seen in both sexes. In BJJ and lifting, deep guard positions and deep squats often bring symptoms on.
What are the symptoms of hip impingement in adults?
The typical pattern is a deep ache or pinch in the groin or front of the hip, sometimes felt at the side of the hip or buttock. It's brought on by sitting for long periods in low chairs or car seats, deep squats, getting in and out of a car, putting on socks and shoes, and pivoting. Some people describe clicking or catching, which can point to a labral tear. Many people point to the front of the hip by cupping it in a 'C' shape with their hand.
See our posts on hip pain when sitting and hip pain when squatting.
How is FAI diagnosed?
Diagnosis starts with the history and a physical examination, including tests that bend, rotate and bring the hip across the body to reproduce the pinch. An X-ray shows the shape of the hip; MRI can show the labrum and cartilage. Imaging is interpreted alongside symptoms, not on its own.
Does a cam or pincer shape on my scan mean I have FAI?
Not necessarily. A systematic review of over 2,100 hips in people without symptoms found a cam shape in 37% (54.8% of athletes, 23.1% of the general population), a pincer shape in 67%, and labral tears on MRI in 68% of the hips where this was reported (Frank et al., Arthroscopy, 2015). These findings are common, so the scan needs to match your symptoms and examination.
Does hip impingement need surgery?
Not always. In the UK FASHIoN trial of 348 people with FAI syndrome, both hip arthroscopy and personalised physiotherapy-led hip therapy improved hip-related quality of life over 12 months. Arthroscopy improved it by more, by an average of 6.8 points on a 100-point scale, just above the threshold considered clinically important (Griffin et al., Lancet, 2018). Many people do well with conservative care, and it's a reasonable first step; surgery is an option for people with persistent symptoms despite good rehabilitation.
What does conservative treatment involve?
Education about which positions provoke the hip, adjusting activity and training so you avoid repeatedly loading the end of hip bending, and a progressive exercise program for the hip and trunk. Hands-on treatment can help ease pain and stiffness while you build strength. Most programs run for at least three to six months.
What exercises help hip impingement?
Exercises usually include bridges and single-leg bridges, side-lying leg raises and side planks for the gluteal muscles, hip flexor strengthening in comfortable ranges, step-ups and split squats, and core work. Squats and deadlifts can usually continue with a slightly wider stance, toes turned out and depth limited to a pain-free range for now.
See our post on high-bar versus low-bar squats.
What should I avoid?
For a while, avoid long periods in low, deep chairs, deep squatting under load, and positions that bring the knee up and across the body. Use a cushion to raise your seat, and in the car, tilt the seat back slightly. In BJJ, limit deep closed guard and positions that crank the hip into deep flexion until symptoms settle.
Will hip impingement lead to arthritis?
Cam shapes are associated with a higher risk of hip arthritis later in life, but many people with them never develop it. Staying active and strong is still recommended.
What else could it be?
Groin and front-of-hip pain can also come from the hip flexors, adductors, the pubic bone, the lower back, or a stress fracture of the hip. Pain on the outside of the hip is more often the gluteal tendons.
See our posts on tight hip flexors and gluteal tendinopathy.
How can an osteopath help?
We assess the hip, pelvis and lower back to work out whether FAI syndrome is the likely cause, review any imaging in context, treat hands-on, and build a progressive exercise and training plan. If symptoms persist despite good rehab, we'll discuss referral to a sports physician or orthopaedic surgeon.
When should I see a doctor?
See a doctor promptly for hip or groin pain after a fall, inability to bear weight, groin pain that's worsening with running or hopping, night pain, fever, or a hot, swollen joint.
See our hip and pelvic pain guide. Book an assessment at our Berwick clinic. A 60-minute initial consultation is $149, with no referral needed and HICAPS on-site.
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Book an initial consultation at RISE Sports & Spinal in Berwick. Clear diagnosis, hands-on treatment, and a plan that actually gets you better.
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