Introduction
Femoroacetabular impingement (FAI), abnormal contact between the femoral head and the acetabular rim during hip movement, and labral tears, damage to the fibrocartilaginous ring that deepens the hip socket, were barely recognised diagnoses 20 years ago and are now among the most common reasons for hip arthroscopic surgery in active adults and athletes. Whether this represents improved diagnosis of a genuine pathology or, in part, over-medicalisation of radiological findings that may be incidental is an active debate. The evidence is clear that many people have FAI morphology on imaging without symptoms; that labral tears are common in asymptomatic individuals; and that the outcomes of surgery versus well-designed physiotherapy are more similar than the surgical enthusiasm for this condition would suggest. This guide explains the anatomy, the symptoms, and the evidence for treatment.
Whether you are dealing with a recent flare-up or something that has nagged you for years, understanding why your body hurts is the most important first step. This guide draws on the latest pain science, physiotherapy research, and practical coaching wisdom meticulously validated and referenced to give you peace of mind.
Understanding the Anatomy
The hip joint is a ball-and-socket joint, the femoral head (the ball) sits within the acetabulum (the socket). The acetabular labrum is a ring of fibrocartilage that attaches to the acetabular rim, deepening the socket by approximately 20%, providing hydraulic sealing that maintains intra-articular fluid pressure, and contributing to hip stability. FAI occurs in two patterns: cam FAI (an aspherical femoral head, a bony prominence on the femoral head-neck junction that impinges on the acetabular rim during flexion and internal rotation) and pincer FAI (an over-coverage of the femoral head by the acetabulum). The impingement creates shear forces on the labrum, which is the most common cause of labral tears in non-dysplastic hips. FAI morphology is common in athletes who performed hip loading activities during adolescence (football, hockey, ballet, martial arts).
Key structures involved: Iliacus and psoas (hip flexors, often symptomatic in FAI due to impingement with flexion), Adductor longus (groin pain, frequently coexists with FAI), Gluteus medius and minimus (often weak in FAI, hip stability deficit), Short external rotators (piriformis, obturator internus, often hypertonic in FAI), Core stabilisers (lumbo-pelvic stability reduces the hip impingement forces).
Why Does It Hurt? Root Causes
Modern pain science reminds us that pain is your nervous system's threat response, not simply a damage signal. That said, there are real, identifiable drivers.
1. CAM Morphology and Athletic Development
Cam FAI morphology (the bony bump on the femoral head-neck junction) develops during adolescence in response to high-load hip activities, football, hockey, and martial arts. Multiple large studies show that elite footballers have significantly higher rates of cam morphology than controls. The morphology itself is structural and irreversible, but symptoms are not inevitable and depend on the interaction between morphology, hip musculature, movement patterns, and load.
2. Labral Tears. Pathological vs Incidental
Labral tears are found on MRI in approximately 68% of young adults with hip pain and in a significant proportion of asymptomatic individuals. This makes the attribution of symptoms to a labral tear complex, a clinically detected labral tear may be the cause of symptoms, or may be an incidental finding in a symptomatic patient whose actual cause is soft tissue restriction, intra-articular synovitis, or adductor tendinopathy. Clinical examination is more diagnostically important than imaging in FAI.
3. Surgery vs Physiotherapy
The FAIT trial (Griffin et al. 2018), the first RCT comparing hip arthroscopy to physiotherapy for FAI syndrome, showed no significant difference between the two interventions in patient-reported outcomes at 8 months. Both groups improved significantly. This finding does not mean surgery is never appropriate, some structural situations require surgical correction, but it does mean that a well-designed physiotherapy programme should be the first treatment for most FAI syndrome presentations.
How Massage Helps
Massage for FAI and labral tears is primarily directed at the muscles that are symptomatic as a consequence of the underlying hip pathology. The hip flexors (psoas, iliacus) are frequently hypertonic in FAI, the impingement in flexion creates a protective increase in flexor tone. The short external rotators (piriformis, obturator internus) are also commonly hypertonic. Adductor massage addresses the coexisting groin pain that accompanies FAI in many athletes. Reducing this hypertonia through massage improves the quality of physiotherapy rehabilitation exercises and reduces the symptom burden. Massage over the greater trochanter and lateral hip should be approached carefully, a symptomatic labral tear can refer pain laterally and direct pressure over the hip may be uncomfortable.
Beyond specific mechanical effects, massage floods the nervous system with safe, rich sensory input, downregulating the threat response and creating conditions in which healing becomes easier.
Stretches to Try
Consistency matters far more than intensity. Gentle, daily stretching with calm breathing reduces perceived tightness and signals safety to the nervous system.
Hip Flexor Stretch (with caution)
Kneeling lunge, upright trunk. Hold 30 seconds per side. Avoid deep hip flexion (below 90 degrees) in symptomatic FAI, this is the impingement position. Benefit: Addresses hip flexor tension without moving into the impingement zone, the modifications for FAI stretching are important to observe.
Adductor Stretch
Seated butterfly, soles of feet together, knees open. Hold 30 seconds. Benefit: Addresses the adductor tension that coexists with FAI in athletes, groin symptoms often respond to adductor lengthening alongside hip rehabilitation.
Strengthening Exercises
Loading tissues progressively tells your nervous system they are capable and resilient.
Deep Core Activation
Supine abdominal hollowing (gentle transversus abdominis activation), dead bugs, and bird-dogs performed with strict lumbar neutral. Benefit: Improving lumbo-pelvic stability reduces the hip impingement forces by stabilising the pelvis, a primary focus in FAI rehabilitation.
Hip Abductor and External Rotator Strengthening
Clamshells, side-lying hip abduction, and banded monster walks. 3 sets of 15. Benefit: Glute med and short external rotator strengthening improves hip centration, the optimal position of the femoral head within the acetabulum that reduces impingement forces.
Avoiding Impingement Positions During Loading
During the rehabilitation period, avoid squat depth below 90 degrees, sitting with the knees higher than the hips, and pigeon pose, all of which place the hip in the impingement position. Benefit: Load management for FAI means avoiding end-range hip flexion and internal rotation during loaded exercise, this is the primary biomechanical modification.
Practical Self-Care
- Avoid the impingement positions (deep hip flexion, combined flexion and internal rotation) during symptomatic flares.
- If you sit for prolonged periods, a slightly elevated seat (hips above knees) reduces the sustained hip flexion that irritates FAI.
- The FAIT trial evidence supports starting with physiotherapy before considering surgery, get an expert physiotherapy assessment.
- FAI morphology on imaging does not mean you will need surgery, many people with cam morphology never develop symptoms.
- The quality of your rehabilitation, specifically the lumbo-pelvic stability and hip muscle strength, more reliably predicts outcome than the surgical decision.
When to See a Professional
- Hip pain with clicking, locking, or giving way, intra-articular pathology; MRI assessment.
- Hip pain in a young athlete not responding to physiotherapy after 3 to 4 months, consider hip arthroscopy consultation.
- Significant mechanical symptoms interfering with daily life or sport despite optimised rehabilitation.
- Hip pain in an older adult with groin referral, hip OA must be excluded by imaging before FAI management is pursued.
A qualified physiotherapist, sports therapist, or massage therapist can identify the specific drivers of your pain.
References and Further Reading
- Griffin DR et al. Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement (UK FAIT): a multicentre randomised controlled trial. The Lancet. 2018.
- Agricola R et al. Cam impingement in elite football, a prospective study. BJSM. 2012.
- Nepple JJ et al. Surgical experience and training may influence outcomes of hip arthroscopy. Clinical Orthopaedics. 2013.
- Kemp J et al. Physiotherapy for people with femoroacetabular impingement: clinical guidelines. BJSM. 2020.
- Ingraham P. FAI and labrum tears. painscience.com.
Content is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional before beginning any new exercise or treatment programme.