Today we’re highlighting an article titled “The Warwick Agreement on Femoroacetabular Impingement Syndrome (FAI Syndrome): an international consensus statement.” [1] Click here for a link to the full article (free access).
The purpose of this agreement was “to build an international, multidisciplinary consensus on the diagnosis and management of patients with FAI syndrome.” This panel was made up of physicians, PTs, surgeons, and radiologists, all of which play an integral role in management of this condition. Prior to the meeting, 7 questions were agreed upon and discussed to come to consensus on each of them. The questions and their associated consensus answers are included in table 1 located at the bottom of this post.
This article provides a great collection of literature relevant to the diagnosis, management, prognosis, and treatment of patients with FAI syndrome. Personally, I like reading and referencing these types of articles for several reasons. In addition to developing a consensus best practice, they often standardize the language we as clinical practitioners use to communicate with patients. They gather the most relevant articles for a given diagnosis or condition into one place (much like systematic reviews). Because not all information included is directly related to the physical therapy management of patients with FAI, it is a way for me to learn more about how other types of healthcare practitioners manage this condition. And finally, they highlight areas where research is weakest.
Regarding the content of this article and the consensus statements in response to each of the questions the panel posed, I have little to add. This panel had a high degree of consensus they reached with each of their answers leaving little to nitpick or discuss further on those topics.
However, I do have a few thoughts regarding the role of PT in the management of FAI. In the article they reference a study that asserts the PT treatment of FAI to include neuromuscular control, hip stabilization, and optimizing movement patterns. True enough. They also reference the wide ranging targets of rehab including mutli-planar hip strengthening, hip ROM, and lumbopelvic hip dissociation. Once again, these are common and good priorities for rehabilitation. However, the authors go on to reference a common and fair criticism that these methods have not been well tested and that different physical therapists are treating FAI (non-operatively and post-operatively) differently. Additionally, the research we do have is typically of lower level and quality.
Heterogenous practices and outcomes are not limited to FAI and is a common complaint of insurance companies and researchers in the PT realm. Heterogeneity in treatment leads to varying and inconsistent outcomes and patient experiences. While it’s important to recognize the differences in each patient and treat them individually, we should still be striving to establish best clinical practice that achieves the most consistent and optimal patient outcomes. Part of this should include standardizing how we measure progress in the clinic through the use of valid and reliable outcomes and benchmarks.
Whether it is ACLR, hamstring strain injury, FAI, or any other number of injuries and conditions, we are seeing more and more that criterion-based rehab is a means to achieve more optimal and consistent outcomes. These criterion based rehab ‘protocols’ are a means to aiding clinicians to sift through the noise and identify relevant signals that can be practically applied in the clinic.
I often ask my DPT student interns to go through an exercise of writing a framework from day 1 to discharge outlining the rehab progressions for a particular patient. This forces them to reason through what processes and interventions they plan to use to accomplish whatever goals they and the client have collectively outlined. Setting benchmarks (criteria) can serve as roadblocks that guide clinical decision making and ensure the rehab plan is successful.
Outlining these valid and reliable benchmarks was not the object of this post. However, it has led me down the path of making a future post on the subject. Stay tuned! And checkout the consensus statements from the Warwick Agreement below!
| What is FAI syndrome? | FAI syndrome is a motion-related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings. It represents symptomatic premature contact between the proximal femur and the acetabulum. |
How should FAI syndrome be diagnosed? | Symptoms: The primary symptom of FAI syndrome is motion-related or position-related pain in the hip or groin. Pain may also be felt in the back, buttock or thigh. In addition to pain, patients may also describe clicking, catching, locking, stiffness, restricted range of motion or giving way. Clinical Signs: Diagnosis of FAI syndrome does not depend on a single clinical sign; many have been described and are used in clinical practice. Hip impingement tests usually reproduce the patient’s typical pain; the most commonly used test, flexion adduction internal rotation (FADIR), is sensitive but not specific. There is often a limited range of hip motion, typically restricted internal rotation in flexion. |
| What is the appropriate treatment for FAI syndrome? | FAI syndrome can be treated by conservative care, rehabilitation or surgery. Conservative care may involve education, watchful waiting, lifestyle and activity modification. Physiotherapy-led rehabilitation aims to improve hip stability, neuromuscular control, strength, range of motion and movement patterns. Surgery, either open or arthroscopic, aims to improve the hip morphology and repair damaged tissue. The good management of the variety of patients with FAI syndrome requires the availability of all of these approaches. |
| What is the prognosis for FAI syndrome? | In patients who are treated for FAI syndrome, symptoms frequently improve, and they return to full activity, including sports. Without treatment, symptoms of FAI syndrome will probably worsen over time. The long-term outlook for patients with FAI syndrome is unknown. However, it is likely that cam morphology is associated with hip osteoarthritis. It is currently unknown whether treatment for FAI syndrome prevents hip osteoarthritis. |
| How should someone with an asymptomatic hip with cam or pincer morphology be managed? | It is not known which individuals with cam or pincer morphologies will develop symptoms and, therefore, FAI syndrome. Preventive measures may have a role in higher risk populations, but it is rarely indicated to offer surgery to these individuals. |
| Which outcome measures should be used to assess treatment for FAI syndrome? | Specifically designed and well-validated patient-reported outcome measures should be used to assess treatment for FAI syndrome. The international Hip Outcome Tool (iHOT), Hip and Groin Outcome Score (HAGOS) and Hip Outcome Score (HOS) are recommended. |
Citations:
[1] Griffin DR, Dickenson EJ, O’Donnell J, et alThe Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statementBritish Journal of Sports Medicine 2016;50:1169-1176.
[2] Mendiguchia J, Brughelli M. A return-to-sport algorithm for acute hamstring injuries. Phys Ther Sport. 2011 Feb;12(1):2-14. doi: 10.1016/j.ptsp.2010.07.003. Epub 2010 Aug 21. PMID: 21256444.
[3] Spencer-Gardner L, Eischen JJ, Levy BA, Sierra RJ, Engasser WM, Krych AJ. A comprehensive five-phase rehabilitation programme after hip arthroscopy for femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2014 Apr;22(4):848-59. doi: 10.1007/s00167-013-2664-z. PMID: 24077689.
[4] Wahoff M, Dischiavi S, Hodge J, Pharez JD. Rehabilitation after labral repair and femoroacetabular decompression: criteria-based progression through the return to sport phase. Int J Sports Phys Ther. 2014 Nov;9(6):813-26. PMID: 25383249; PMCID: PMC4223290.
