Written by Michael Silvestri
Introduction & What is FAI
As strength and conditioning professionals, part of the scope of practice is to work with athletes to manage and mitigate the risk of injury in sport. Having an athlete injured, or being an injured athlete is not a positive experience, as this would require the athlete to miss time away from their given sport. Although not all injuries can be prevented through training – particularly contact-related injuries – there are non-contact and overuse related injuries that strength and conditioning professionals should be aware of and work towards mitigating non-contact and overuse related injury is femoroacetabular impingement, or better known as FAI. The goal of this article is to educate on what FAI is, the prevalence in sport, treatment interventions, as well as a path forward for strength and conditioning professionals within the scope of FAI.
FAI is an abnormal osseous and contact at the proximal femur or at the acetabulum which creates further damage to the ligaments and tissue surrounding the hip within normal ranges of motion (2,8). FAI may also be caused by damage to the acetabulum as well as, or in combination with, the femoral head and neck (2). The group of Philippon et al., describe the variations of FAI in detail which can be classified into three types; i) cam deformities occur at the proximal femur, ii) pincer deformities occur at the acetabulum, and iii) both cam and pincer occurring at the same time (8). FAI may be diagnosed in athletes who experience a loss of range of motion combined with hip pain, as well as a loss in ability to perform their desired sport (8). The abnormalities associated with FAI can lead to increased damage of the chondrolabral structures within the hip during movement as well as the increased risk of developing osteoarthritis over extended periods of time (8).
Prevalence Amongst Various Sports
The risk of developing FAI is increased for athletic populations compared with general populations, with certain sports having a higher risk than others (7). Participation in a given sport will create many repetitions of movements over a large period of time, which increases the risk of overuse related injuries such as FAI (7). A given sport will cause specific repetitive actions on the athletes’ body, which can be seen in Table 1 (3). As shown in Table 1, sports will fall into specific categories of actions that are repetitive in nature and can place the athlete at an increased risk for developing FAI related injuries. Hockey, basketball, and jumping related sports, specifically during an athlete’s adolescent development years, have been linked to an increase in the likelihood of developing cam related deformities in males at a greater extent than females (7). These sports carry 1.9 to 8.0 times more likelihood of developing FAI related deformities compared to general populations (7). Ice hockey has been noted as the most at risk sport from the repetitive stress on the proximal femur due to extended periods of time being spent in hip flexion (7).
Table 1: Sport Classification System. Identification of variables and stressors on the body that various sport participation possesses in relation to FAI (3).
Surgery or No Surgery?
In dealing with FAI injuries, an athlete may elect for a surgical intervention or a more conservative approach following a specific rehabilitation and exercise based program (5). With surgical intervention comes the risk of the athlete not returning to play at the same level prior to surgical intervention, which brings up the case for a conservative rehabilitative and exercise approach to be sought prior to surgical intervention (5). In a study of 189 athletes combined of both male and females between 18 to 30 years of age, across various sports and levels, taken from the Danish Hip Arthroscopy Registry, only 26% performed at the same level of pre-surgical intervention with optimal performance and full participation following surgery (6). In a group of 41 athletes with a mean age of 29.6 years, coming from a variety of sports and skill levels, 45.2% returned to sport at the same level with only 3.2% returning at a higher level (1). Having an athlete with FAI injury undergo surgical intervention will likely not be within the decision making tree, can be seen in Figure 1, of the strength and conditioning professional, who is likely to deal with the repercussions of the decisions of the allied medical team – therapists, surgeons, and medical professionals. With this in mind, it is imperative to understand the phases of return to play following surgical evidence. When an athlete is returning from FAI related surgery a five phase approach should be taken to return the athlete to play at optimal levels (5). The group of Casartelli et al., explain in detail the five phases that should be followed which are; i) protection, ii) ambulation, iii) progression, iv) training, and v) return to sport. Within the i) protection phase, the main focus should be tissue healing and lymphatic drainage (5). Progressing to the ii) controlled ambulation phase which will entail achieving neuromuscular control for the trunk, pelvis, and lower limbs (5). The strength and conditioning professional should begin to work with the athlete, in either phase ii or phase iii of the return to play plan depending on the scope of the allied medical team. The iii) third phase will be to progress the ambulation and work to improve neuromuscular control as well as muscular strength (5). Phase four will be a iv) training phase to work with the athlete on specific physical measures to achieve prior to return to sport (5). The final phase in the rehabilitative approach will be the v) return to sport in which the specific preparation and technical skills for the sport will need to be trained (5). Following the five phase rehabilitative approach for returning an athlete back to sport with FAI related injuries will be ideal and provide a sound return to play plan.
Through the evidence, it is clear that the return to play for athletes after surgical intervention for FAI related injuries is challenging. With surgical intervention not always being necessary, a conservative approach should be engaged in as well as preventative exercises based upon the specific sport classifications, to limit the risk of FAI development over time. With the idea of a conservative and preventative approach to FAI injuries, this would now fall into a place in which the strength and conditioning professionals can be an important part of the allied sport staff.
Figure 1: FAI Intervention Decision Making Tree. Pathways in which FAI injury can be dealt with.
S&C Interventions and Training Modifications
When training to prevent the development of FAI related symptoms, the focus should be on achieving adequate ranges of motion as well as improving muscular deficiencies and weaknesses, which is also a main focus when FAI is present (2,4,9). The main areas to focus on in terms of muscular strength would be the core muscles and the muscles of the lower limbs (4). The development of a hip therapy exercise related protocol for dealing with FAI injury has been shown to be effective in treatment for impingement syndrome (9). Optimizing range of motion in the hip when FAI injury is present, should be a minimal yet important focus, however it is vitally important for the mobility work to not be overdone (2). In FAI related injuries bony structures have overgrown which naturally limits range of motion and causes pain for the individual (2,4). The use of mobility work to treat FAI injuries, has been argued as not appropriate and can aid in articular cartilage and labral damage (2,4). The ability to work in ranges of motion that the athlete identifies as pain free and do not aggravate the hip or surrounding area, will be the most important ranges of motion to train.
In terms of strengthening based exercises, it will be important to note for each individual what movements, patterns, and ranges of motion cause pain and to not further aggravate injury by training in these patterns. The main goal for treatment and prevention of FAI revolves around knowing what causes pain and to work the ranges that do not cause the athlete pain. For example, if we look at a bilateral squat, with FAI related injury, this potentially will be difficult for the athlete to perform and likely cause pain. In the event an exercise causes pain, the route of exercise modification should be explored, whether this is changes in mechanism of loading, movement range of motion, or substitution to an exercise that does not cause pain. By modifying the exercise to limit hip flexion, this will place less force in the area in which FAI is present and allow the athlete to perform a modified movement pattern without experiencing pain and limiting the risk for further injury (4). For the sake of the example, if an athlete performs a squat at 90 degree of hip flexion and experiences hip related pain, the athlete could try performing the squat with 60 degrees of hip flexion, in which the perception of pain and forces placed upon the hip joint may be sustainable for the athlete.
In modifying training programs to minimize the development of FAI related injuries, the athlete will need to have an increased emphasis on developing core and lower limb related muscular strength through various patterns, ranges of motion, and bilateral to unilateral based exercises (2,4,9). Examples of these exercises can be seen in the attached video below, it is important to note that this is not exhaustive and should be modified given the athlete’s current situation and physical capacities. In the development of an exercise regime that focuses on preventing as well as rehabilitating from FAI related injuries, this should include breath work related exercises, stability and range of motion patterning, as well as various strength progressions (2,4,9). The use of the breathing related exercises will be to train the deep core musculature to create adequate stability while in patterns of hip flexion that relate to FAI injuries. The stability and range of motion patterns will need to be specific to the given athlete’s capabilities but should cover hip internal and external rotation, hip flexion and extension, abduction and adduction, and single leg balance with proprioception. Strength based exercises should cover abduction and adduction patterns of the hip, flexion and extension, bilateral and unilateral movement patterns, isometric, eccentric, and concentric tempos, as well as cross body movement patterns that simulate at-risk positioning of the hip. These exercises can all be seen in the video which directly relates to this article. The video of the exercise demonstrations as well as explanations can be seen at the following link – CSCA FAI Article Video – Michael Silvestri – YouTube
When working with athletes who are at risk for developing FAI related injuries, it is important for the strength and conditioning professional to be aware of the pathways in dealing with injury and the training modifications that may be necessary. The strength and conditioning professional should be aware of the increased prevalence of FAI related injuries in sport and how to work against the development of FAI. It is also important to understand the premise of FAI being highly individual to each athlete and an individual approach must be taken to this complex injury. The ideas and exercise selection shown in this article have worked in helping aid in FAI related pain in an individual athlete’s case. The exercises shown could be used with other athletes, however, keep in mind the various types and severities of FAI related injuries and the need for training modifications to be made as well as an individual approach to be taken.
Michael is a strength and conditioning coach working in the private sector in Toronto, Ontario, as well as a PhD student at St. Mary’s University Twickenham in which his research revolves around the idea of finding ways to train the ice hockey athlete to skate at faster speeds. Michael is also heavily involved with the soccer community in which he works with Alliance United in League 1 On, Toronto High Park FC, as well Markham FC. Michael works with clients privately at his facility which range from high performing athletes in professional hockey, soccer, and lacrosse, collegiate level athletes across various sports, as well as high school aged athletes.
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