Femoroacetabular Impingement Syndrome (FAI)
Kristen Ignaszewski, SPT
Background
In April 2016 while on my second clinical rotation, Amy Dougherty, PT, provided me with the fortunate opportunity to observe Allston J. Stubbs IV, MD, MBA in the operating room at Wake Forest Baptist Medical Center as he performed two arthroscopic hip surgeries for the treatment of femoroacetabular impingement syndrome (FAI). After the surgeries, Dr. Stubbs met with us to discuss everything from FAI diagnosis and surgical procedures to the course of development for a postoperative rehabilitation protocol. Needless to say, I became interested in learning more about FAI. Though this condition was touched upon in the Musculoskeletal II (PHYT 734) course, I decided to use the Evidence Based Practice II (PHYT 752) course and subsequently this capstone project to delve deeper into the condition of FAI. In Evidence Based Practice II, I completed my Critically Appraised Topic (CAT) on the comparison of conservative versus surgical management of FAI for the young, healthy, active individual. The research used in my CAT (which can be accessed here: Critically Appraised Topic Ignaszewski FAI Capstone) offered a basis for the development of this capstone project.
Project Overview/Purpose
The exact prevalence of FAI is unknown, as it is possible to have the bony deformity at the hip (on the femoral or acetabular aspect of the joint) without the presentation of symptoms.1 Although there are conservative management options such as activity modification and strengthening of the surrounding musculature, since the bony abnormality is present in individuals with FAI, there is no true way to prevent the development of this condition.1 FAI is becoming increasingly recognized as a precursor to arthritis, yet research continues to be limited in determining the best treatment intervention.2 While arthroscopic surgical techniques are continuing to improve, little research has been completed in assessing the effectiveness of conservative management of FAI.2,3 In addition, though surgical treatment has been shown in the short-term to improve pain for individuals with FAI, there is limited research in finding baseline characteristics that may predict long-term successful or failed treatment outcomes.4 As a clinician, it is important to understand the clinical implications of conservative versus surgical intervention for FAI, to educate patients properly regarding this condition, and to create appropriate plans of care for the most optimal patient outcomes. In addition to physical therapists, primary care physicians and orthopedic surgeons should remain up-to-date on this research to educate and provide evidence-based care to their respective patients.
From discussions with classmates, physical therapists, patients, and Dr. Stubbs, it became clear that public, student, and clinician knowledge is limited on the condition of FAI, its treatment options, and the available resources. In hopes of bridging this gap, I decided to create accessible material to be used with a variety of populations to improve overall understanding of FAI.
Capstone Project Products
For my capstone project, I created three separate products to use as education tools for three populations (healthcare professionals, healthcare students, and patients/families). The materials focus on the overview of FAI along with its clinical presentation, treatment options, differential diagnosis, and available resources.
Due to the large file size of these products, the images have been compressed resulting in a reduced quality. If you would like a copy of the original file in PDF format for better image quality, please email me at Kristen_Ignaszewski@med.unc.edu.
- I created an iBook, which can be downloaded from the iTunes App Store on any Apple device (https://itunes.apple.com/us/book/id1229188384) or accessed here (iBook Ignaszewski FAI Capstone) as a PDF. Due to the detail and language included in this product, it may be more appropriate for healthcare professionals and students, but as a result of its easy accessibility it is also certainly available to patients looking for further explanation.
- I created a patient brochure, which can be accessed here (Patient Brochure Ignaszewski FAI Capstone) as a PDF. The information in this product is condensed/limited in terms of detail and is presented as a patient education tool using more patient-friendly language, taking health literacy concerns into account. References are not included on the patient brochure in hopes of keeping it neat and less overwhelming to patients, but can be accessed on a separate document located here (Brochure References Ignaszewski FAI Capstone).
- I created a PowerPoint, which can be accessed here (PowerPoint Ignaszewski FAI Capstone) as a PDF. The information in this product is comprised of the same level of detail as the iBook and is more appropriate for healthcare professionals and students as in-service or lecture material.
Additionally for evaluation purposes, I created a feedback response form (which can be accessed here: Feedback Response Form Ignaszewski FAI Capstone) to be used after an in-service presentation to receive comments and recommendations regarding the presentation material.
Evaluation & Self Reflection
Evaluation regarding the effectiveness of these capstone materials will be provided upon completion of an in-service presentation after receiving comments on the feedback response form. The feedback form seeks to obtain information regarding the flow of the presentation and its effectiveness, the content, and the use of appropriate language along with any general comments. Additionally, the feedback form includes six objectives and a ranking scale from 0-10 (0 meaning the objective is not met, 10 meaning the presentation exceeds expectations) with space for further comment.
I sought information and recommendations from my advisor and committee members throughout the semester. I have received positive feedback and believe the materials are appropriate for the respective intended populations. With the assistance of my committee members, I used this opportunity to develop a new product outside of my comfort zone; I am happy with the outcome of the iBook as well as the additional education materials that were created. Over the course of this project, I expanded my knowledge of FAI and various technological tools for the development of these clinician/student/patient education products.
Acknowledgements
I would like to begin by acknowledging my committee members (Amy Dougherty, PT and Allston J. Stubbs IV, MD, MBA) and my advisor (Michael Gross, PT, PhD, FAPTA).
Amy first introduced me to Dr. Stubbs and facilitated numerous connections for the development of this capstone project. Amy was incredibly responsive in providing valuable feedback and guidance during this process, enabling me to create a high quality product. I can’t thank you enough for your support and look forward to your continued mentorship.
Dr. Stubbs allowed me to observe him during surgery last year, effectively piquing my interest in the topic of FAI. Dr. Stubbs took time out of his busy schedule to provide me with feedback as well as the recommendation to further this project into the creation of an iBook. Thank you for your insight, forward-thinking, and valuable input during this process of professional development.
Mike Gross was not only my advisor for this capstone project, but for the entire DPT program. Mike offered suggestions to include additional detail for improved audience understanding and an enhanced overall product. Thank you for going the extra mile in your willingness to communicate and your dedication to student advancement.
I would like to extend my appreciation to several individuals responsible for the creation of the images seen throughout my final capstone products. My cousin, Sarina Cannizzaro, utilized her remarkable artistic skills to draw several images for me on short notice during her spring break; Forrest Best was a willing participant in the role of the patient for the hip “special tests”; John Graham provided me with X-ray and arthroscopic images of his hip, offering an in-depth understanding of the bony abnormalities that occur with FAI; Kelly Ballard, Molly Higgins, and Mike Ignaszewski provided me with sports-related images demonstrating vulnerable positions for the hip during athletic activities.
Additionally, I would like to acknowledge the members of the Outer Banks Physical Therapy and Seaside Physical Therapy teams for acting as a sounding board and allowing me to use their facility.
Finally, I would like to thank my family, friends, and UNC DPT 2017 family for their unwavering encouragement and support over the last three years. I couldn’t have made it through this program without you and owe a debt of gratitude to each of you for helping me fulfill my dream.
References
- Femoroacetabular Impingement. OrthoInfo http://orthoinfo.aaos.org/topic.cfm?topic=a00571. Updated November 2016. Accessed November 22, 2016.
- Hunt D, Prather H, Harris Hayes M, Clohisy JC. Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders. PM R. 2012; 4(7): 479-487. doi: 10.1016/j.pmrj.2012.03.012
- Diamond LE, Dobson FL, Bennell KL, Wrigley TV, Hodges PW, Hinman RS. Physical impairments and activity limitations in people with femoroacetabular impingement: A systematic review. Br J Sports Med. 2015; 49(4): 230-242. doi: 10.1136/bjsports-2013-093340
- Saadat E, Martin SD, Thornhill TS, Brownlee S, Losina E, Katz JN. Factors associated with failure of surgical treatment for femoroacetabular impingement: Review of the literature. Am J Sports Med. 2014; 42(6): 1487-1495. doi: 10.1177/0363546513500766
4 Responses to “Femoroacetabular Impingement Syndrome (FAI)”
Kristen Ignaszewski
Thank you all for your positive feedback and kind words!
Chloe: The choice for conservative versus surgical management has the typical “it depends” mantra. Unfortunately, prior to an increase in knowledge and understanding of FAI many individuals went undiagnosed for a period of time, undergoing conservative management and hoping for a positive outcome. From my understanding after reading the research, it’s common for individuals to begin with conservative treatment and then progress to surgical intervention. While surgery isn’t the ideal first option in the line of defense, the issue seems to be that those who have surgery earlier have more positive outcomes due to less joint damage. Again, it may be on a case-by-case basis regarding when to refer back to a physician, but typically six months or so of activity modification and non-aggravating exercises will provide the patient, therapist, and physician with an indication of prognosis and any necessary “next steps”.
Will: I had no idea your wife had FAI, bilaterally no less! I am sure the rehab process was intense. Out of curiosity, do you remember what the differentiating factor was for the 6 weeks versus 4 weeks of NWB after her surgeries? I am glad to hear she was able to return to (almost) full activity and that the material I created was helpful in understanding the approach to exercise with and without surgical intervention. I hope she continues to remain active; she’s in good hands with you as her personal physical therapist!
Elizabeth: I have to thank Dr. Stubbs for the recommendation; an iBook was not on my radar as a capstone product and certainly not something I ever imagined myself creating! I can’t believe that you know Dr. Stubbs personally and through your sister’s labral repair, such a small world. I completely agree with you that FAI and labral damage seem to be a chicken versus egg situation, as they are so closely associated. This was quite the learning experience for me. I appreciate that you also acknowledged that if conservative management still requires additional surgical intervention, physical therapy prior to surgery will assist in the recovery and overall post-op outcome…almost like “prehab” for joint replacements!
Elizabeth Huber
Kristen,
Impressive Capstone products! An iBook was such a good idea (good job to both you and Dr. Stubbs on that collaboration), and I’m sure it’s easy accessibility will come in handy for so many students and clinicians. Your page especially caught my eye for a few reasons—I know Dr. Stubbs personally and he actually did a labral repair on my sister a few years ago, I wrote my final paper for Advanced Ortho on labral tears, and I also worked with a patient in my first clinical who had both hip dysplasia and FAI and underwent a labral repair and periacetabular osteotomy. You did a great job compiling everything in an organized fashion, which will be such a helpful resource to us in the future. FAI is something about which we are not as educated or aware. Just as labral tears are often misdiagnosed as other hip, groin, or low back pathologies, I would assume FAI runs into a similar issue of misdiagnosis.
This iBook provides some useful screening resources, though, that will hopefully allow us to recognize this condition in the clinic if we run into a patient who presents with the common signs and symptoms. The list of special tests, outcome measures, differential diagnoses, and the conservative treatment “timeline” should allow for earlier recognition and in-depth knowledge about how to intervene conservatively if the patient does not need to be referred to a surgeon.
My sister was never given the diagnosis of FAI, but, to me, FAI and labral damage seem to be “the chicken and the egg.” Acetabular labral impingement is a causative factor of FAI, but FAI can also lead to labral impingement and labral tears, so it seems difficult to know which caused which. Even if bony abnormalities make surgery necessary, though, I learned through my sister’s experience that PT prior to surgery (even if it does not ultimately prevent surgery) can at least lead to improved flexibility, strength, and coordination of surrounding musculature, which will only help for post-op rehab and recovery. PTs definitely have an important role in treatment of this condition! Awesome job on your project!
Will Harrison
Hi Kristen,
Excellent job on your capstone project! I especially found your project interesting because my wife has actually had surgery for FAI on both hips. She has always been active and had the first surgery done about seven years ago, and almost exactly a year after recovering, she determined that she needed the other hip done as well. I can tell you that the rehab process was grueling! She was non-weight bearing for 6 weeks after the first surgery and 4 weeks after the second surgery, and it took almost two years of rehab and conditioning for her to be able to return to full activity (although she no longer participates in long-distance running).
One thing that I have always been confused about is that her physical therapist (after surgery) told her to avoid full range of motion deep squats. This never made sense to me, and since I have been in PT school I basically told her to disregard that advice. And lo and behold, your booklet seemed to clear up some of the confusion! It appears that deep squats are contraindicated for conservative management in patients who will not receive surgery. However, in post-surgical patients, one long-term goal is return to full range of motion, strength, and sport-specific training. The main guidelines (as you address in the booklet) are to avoid regression which includes pain, stiffness, and weakness. My wife never has pain with squats, and she actually subjectively reports that her hips feel better after strenuous exercise. The only time that she ever reports pain or stiffness is with prolonged sitting with her hips in greater than 90 degrees of flexion (long car rides) or if she doesn’t exercise for 2-3 days. Thank you for a great project- I will definitely keep these materials and refer to them in the future if I treat patients with this condition!
Thanks,
Will
Chloe Smith
Kristen-
WOW! This is an incredible project, and a great resource for your classmates as we head out into the clinical world. I have never had the honor of evaluating or treating a patient with FAI, so I know that this will be a great resource to return to if I have a patient with a suspected FAI. Do patients typically undergo conservative treatment and physical therapy prior to opting for the surgery or is surgery recommended at the initial diagnosis? If the patient chooses to try the conservative route first, how long is the recovery expected to take and after how long should a PT treat the patient prior to referring the patient back to the physician to inquire about other methods of treatment? Thanks for creating this amazing presentation. I will surely be referring back to it as necessary. Good job!!