Understanding Hip Impingement: Causes, Symptoms, and Treatment Options

Hip impingement, also known as femoroacetabular impingement (FAI), is a condition where the top of the femur (the ‘ball’) makes contact with the acetabulum (the ‘socket’), causing joint pain. This often occurs due to an irregular shape of one of the hip bones, leading to friction that damages the labrum, the soft tissue surrounding the joint. In this guide, we'll explore the causes, symptoms, and potential treatments for hip impingement to help you better understand this condition and find relief from its discomfort.

What causes hip impingement?

The causes of hip impingement, or FAI, can be complex. In most cases, there are several causative factors that come together to create a “perfect storm” of pain and limited mobility. Let’s review some of the potential causes of hip impingement.

1. Bony abnormalities: Sometimes, either the head of the femur or the hip socket do not fit perfectly together. 
2. Soft tissue involvement: Soft tissue or cartilage can get stuck between the head of your femur and the socket, causing inflammation and pain.
3. Developmental factors: As you grow and your bones develop, an impingement could occur, especially if you play high-intensity sports that require a lot of hip rotation.  

Variations in the shape of the femur and the hip socket can often be seen on imaging, but those structural changes do not always mean that you will have an impingement. An impingement only occurs when you are experiencing pain or limited mobility, which can often be the result of a combination of the factors we listed above.

Recognizing the symptoms of hip impingement

The primary symptom of hip impingement is pain located in the groin area, which may occasionally radiate to the outer thigh. This pain typically intensifies during activities that involve rotating or flexing the hip, such as running, jumping, or even sitting for extended periods. Sports that require frequent hip rotation, bending, and lateral movements, such as football, ballet, and golf, can exacerbate the condition.

Patients often report stiffness in the hip joint and reduced range of motion. A clicking or locking sensation in the hip joint is another indicator of hip impingement. This can often be accompanied by a sharp, stabbing pain during movements. 

Types of hip impingement

1. Cam impingement: This type involves a deformity on the femoral head, which is the ball of the hip joint. The abnormal shape causes friction and can lead to joint damage over time, especially to the cartilage lining the socket, which can be pinched between the head and socket.
2. Pincer impingement: In pincer impingement, the problem lies in the hip socket, which extends too far over the femoral head, pinching the labral cartilage at the joint's edge. This type of impingement often leads to labral tears.
3. Combined impingement: Many individuals experience elements of both cam and pincer impingement, which, if untreated, can lead to earlier onset and more rapid progression of joint degeneration.

Conservative treatment options for hip impingement

Management of your symptoms should always be an individualized program based on your symptoms. There are many ways to manage hip impingement. Your physician and healthcare team can help guide you in finding the perfect treatment plan for you. 

Physical therapy 

Physical therapy can help manage symptoms of hip impingement, offering noninvasive solutions that address the root causes of the condition, including increasing joint stability and mobility.. 

Joint stability 

One primary way physical therapy helps manage hip impingement is by strengthening the muscles around the hip joint. Weak muscles around the hip can lead to inadequate support for the joint, which might increase the stress on it and exacerbate impingement symptoms. Physical therapists design targeted exercises that focus on strengthening the hip flexors, extensors, abductors, and adductors. Strengthening these muscles can help stabilize the hip joint, distribute forces more evenly, and prevent abnormal movements that could lead to impingement.

Core strength is also crucial for hip stability. The core muscles help control the pelvis's position and reduce the undue load on the hip joint. Physical therapists often incorporate exercises that strengthen the lower back, abdominals, and obliques, which support the upper body and help maintain proper posture and hip alignment. This integrated approach ensures that the hip joint is not subjected to irregular forces that could worsen impingement.

Hip mobility

Physical therapy is critical in improving the range of motion in patients with hip impingement. Limited mobility in the hip can exacerbate pain and functional impairments. Therapists use various techniques such as stretching exercises, manual therapy, and movements that extend the hip joint's range of motion without causing pain. These exercises are aimed at gradually increasing the hip's ability to move freely, which can significantly reduce the symptoms of impingement. Physical therapists may also use soft tissue mobilization techniques, which help break down fibrous muscle tissue, relieve pain, and reduce stiffness in affected muscles and joints. Soft tissue work improves lymphatic circulation and blood flow to the hip area, which can help reduce inflammation and promote healing.

Tight muscles, particularly the hip flexors and hamstrings, can pull on the pelvis and exacerbate impingement. Physical therapists guide patients through specific stretching routines that aim to loosen tight muscles and increase overall hip mobility. This not only helps in reducing the strain on the hip joint but also aids in achieving a more symmetrical movement pattern, which is vital for walking and other activities.

Education and activity modification

An integral part of management is educating patients on how to avoid movements that may exacerbate hip impingement symptoms. Your healthcare team should provide advice on posture, ergonomic adjustments, and activity modifications to ensure that daily activities do not put unnecessary strain on the hip joint. This educational aspect helps patients manage their condition more effectively and avoid behaviors that could lead to further complications.

Injections

Hip injections can be an effective treatment for reducing symptoms of hip impingement. These injections typically contain a corticosteroid to decrease inflammation and an anesthetic to provide pain relief, helping to improve mobility and alleviate discomfort. 

Exercises for hip impingement 

Your physical therapy program will include exercises for you to practice in the clinic and at home. Here are some examples of exercises your therapist might include. If you want to try any of these at home, consult your healthcare professional to ensure it is safe for you to do so. 

Half-kneeling hip flexor stretch: 2 sets of 3 reps daily, hold for 30 sec each 

• Begin in a half-kneeling position with one knee bent in front of your body.
• Tighten your abdominals, tilt your pelvis backward, and gently push your hips forward. You should feel a stretch in the front of your hip.
• Make sure to keep your hips facing forward and back straight during the exercise.

Supine figure 4 piriformis stretch: 2 sets of 3 reps daily, hold for 30 sec each

• Begin lying on your back with both legs bent and your feet on the ground.
• Lift one leg and place that ankle on your opposite knee, then apply gentle pressure to your bent knee with your hand. You should feel a stretch in your buttocks.
• Make sure to keep your lower back flat on the floor during the stretch.

Bridge with hip abduction and resistance: 3 sets of 10 reps, 5x weekly 

• Begin lying on your back with your feet resting on the ground, arms by your sides, and a resistance band looped around your legs above your knees.
• Tighten your abdominals and lift your hips off the ground so your body is in a straight line. Hold this position and move your knees apart, pulling against the band.
• Keep your movements slow and controlled. Make sure not to let your hips rotate to either side or drop down during the exercise.

Clam with resistance: 3 sets of 10 reps, 5x weekly 

• Begin lying on your side with your knees bent, feet in line with your trunk, and a band looped around your legs.
• Activate your stomach muscles and lift your top knee upward, keeping your feet together. Return to the starting position and repeat.
• Make sure to keep your stomach muscles active and do not let your hips roll forward or backward during the exercise.

Sidelying reverse clamshell: 3 sets of 10 reps, 5x weekly 

• Begin lying on your side with your knees bent.
• Rotate your top foot upward, then lower it back to the starting position and repeat.
• Make sure to keep your knees together as you move your foot.

Quadruped fire hydrant: 3 sets of 10 reps, 5x weekly 

• Begin on all fours with your hands under your shoulders and your knees under your hips.
• Lift your leg out to your side, keeping your knee bent, then return to the starting position and repeat.
• Make sure to engage your core and do not let your hips rotate or drop to either side.

Quadruped hip controlled articular rotations: 3 sets of 10 reps, 5x weekly

• Begin on your hands and knees.
• Lift your leg into as much hip bend as possible, then out to the side as far as you can. Then rotate your thigh so that your ankle moves laterally away from your body. From this position, continue the circular motion of your hip as you straighten it out to your maximum. When your hip is as straight as it can be, control the leg back to the starting position. Then reverse each of these motions. Lift your leg off the ground, driving your knee forward and bending at your hip. Then, bring your knee out to the side as far as you can. Next, rotate your thigh so that your ankle moves away from your body, your knee faces the floor, and the bottom of your foot stamps the ceiling. Continue the circular motion of your hip as you extend your hip as much as you can. Next, bring your leg back down and reverse the entire motion. Return to the starting position and repeat the exercise.
• Keep your core muscles active so that your trunk remains in a neutral position throughout the entire exercise.

Sidestepping with resistance at ankles: 3 sets of 10 reps, 5x weekly

• Begin standing upright with a resistance band looped around your ankles. Bend your knees slightly so you are in a mini squat position.
• Slowly step sideways, maintaining tension in the band.
• Make sure to keep your feet pointing straight forward and do not let your knees collapse inward during the exercise.

Physical therapy not only helps in pain management but also enhances the overall function of the hip joint, allowing individuals to enjoy a higher quality of life. If you're experiencing symptoms of hip impingement, consulting with a physical therapist could be a critical step toward recovery and long-term hip health. 

Surgical treatments for hip impingement

Deciding to undergo surgery for hip impingement is a significant step that typically comes after other, less invasive treatments have failed to relieve symptoms. While physical therapy, medication, and lifestyle adjustments can be effective for many, surgery may be necessary to correct structural abnormalities and prevent further joint damage in others. 

One of the primary indicators that surgery might be necessary is persistent pain that significantly affects daily activities and quality of life. If hip impingement symptoms continue to cause considerable discomfort despite exhaustive non-surgical treatments, surgical intervention could be considered. Additionally, when hip impingement restricts essential activities such as walking, sitting for extended periods, or climbing stairs, and these limitations do not improve with conservative management, surgery may be required to restore functionality and reduce pain. If there is little to no improvement after a dedicated period of conservative treatments, such as physical therapy and anti-inflammatory medications, this might suggest that the structural issues causing the impingement require surgical correction to alleviate symptoms and prevent further deterioration.

Advanced imaging techniques like MRI and X-rays play a crucial role in determining the extent of joint damage. Surgery might be necessary if images reveal significant joint damage, such as severe cartilage wear, bone spurs, or labral tears that are not likely to heal with non-surgical treatments.

Types of surgical options

Arthroscopic surgery is a procedure often used to treat hip impingement. It involves making small incisions and using a camera to guide miniature surgical instruments. During the procedure, the surgeon can shave off the bony growth on the femoral head or trim the hip socket to prevent the bones from rubbing against each other. They can also repair or trim the damaged labrum. This type of surgery generally has a quicker recovery time compared to open surgery.

Should I consider surgery?

Younger, active individuals may benefit from surgery to maintain their lifestyle and prevent the progression of joint damage. Conversely, older adults or those with significant health issues may need to weigh the potential risks of surgery more carefully.

Patients should discuss the potential long-term benefits and risks of hip surgery with their healthcare provider. The goal of surgery is not only to alleviate current symptoms but also to prevent the progression of osteoarthritis and preserve the hip joint's function for the future. For many, surgery can provide significant relief and a return to normal activity levels, making it a viable option to consider when all other treatments have not provided sufficient relief.

Understanding the causes and symptoms of hip impingement is crucial for timely and effective treatment. Whether through conservative methods like physical therapy and medications or more invasive procedures such as arthroscopic surgery, managing hip impingement is possible, allowing individuals to return to their routine activities with improved joint function and reduced pain. Early consultation with a healthcare provider is essential to determine the best treatment plan tailored to individual needs and conditions. Physical therapy is often an essential part of managing any type of hip impingement - our team at EW Motion Therapy loves helping those with FAI to move better with less pain. If you’re curious whether physical therapy is the right treatment option for you, click the button below to download our answers to 20 frequently asked questions.