When I moved to Boston about seven years ago, I was working at a stylish downtown gym. One day off, Eric Cressey and I took a drive to Worcester to join an informal workshop led by orthopedic surgeon Dr. Chris Vinton at the College of the Holy Cross on femoral acetabular impingement, or FAI.
If you’re seeing this for the first time, you might be thinking, “FAI—what’s that?” In plain terms, FAI is a problem of too much friction in the hip joint. The ball (the femoral head) and the socket (the acetabulum) rub unnaturally, which can damage the joint’s cartilage and the labrum.
FAI comes in a few forms. Cam is a bony overgrowth on the femoral head itself; Pincer is an overgrowth on the rim of the acetabulum; and Mixed is a combination of both. Back then, FAI didn’t seem common in the athletic or fitness world, and I don’t recall any current or former client who fit the profile.
Fast forward to today, and it feels like nearly everyone has some degree of FAI—hockey players, baseball players, soccer players, even people you’d never expect. Eric recently mentioned a study suggesting that more than 90 percent of high school hockey players show some level of FAI. I’ll try to confirm the study with him. Update: Kevin Neeld has discussed the topic.
I don’t think a new disease has appeared. I do think athletes today—especially younger ones—often fall into two patterns:
1) They specialize in one sport year-round without breaks, which can lead to pattern overload.
2) They don’t move as much in daily life anymore—texting and screens have replaced many everyday activities, and physical play has waned.
In other words, our lifestyle may contribute, to some degree. Still, we’ve gotten much better at screening for FAI and recognizing symptoms.
As a strength coach, I’m not diagnosing anything. I use simple screens to help guide programming and I’ll usually refer someone to a more qualified professional for a thorough exam and possibly an MRI. If an athlete or active person complains of persistent hip pain—especially if they play rotational sports or experience pain when squatting—I’ll run a quick screen.
The screen is pretty basic. Have the person lie on their back with their lower back pressed into the table. Move the affected leg into flexion, adduction, and internal rotation. If they grimace or react strongly, that suggests they may have FAI. You can ask them to brace their abs to promote a posterior pelvic tilt; if that helps, it’s more likely an alignment issue rather than a severe problem. If tilting the pelvis doesn’t relieve the discomfort, it’s time to refer out for a more in-depth assessment and possibly imaging. True diagnosis usually comes from a combination of screens, tests, and imaging like an X-ray or MRI.
So what can you do in the meantime? A lot, but don’t assume you’ll “solve” the issue. The goal is to work around it and maintain training effect.
FAI is a condition, not a disease. Here are a few points to consider:
1) The first rule is to avoid deep squats. You won’t get far as a trainer if you push someone with FAI too hard. That said, you could still squat above about 90 degrees of hip flexion. Squatting below 90 degrees is generally not advisable for someone with Cam or Pincer changes.
2) You can still train the lower body hard with movements that don’t require deep hip flexion, such as rack pulls, trap-bar deadlifts, conventional deadlifts, and barbell glute bridges.
3) Single-leg work is often okay, including Bulgarian split squats. These can help a person find a pain-free range of motion. Some cases, like femoral glide syndrome, may require adjustments, but single-leg training can be very effective.
4) Consider reading Kevin Neeld’s writings on FAI for more guidance.
Ultimately, it’s in our best interest as coaches to know when to refer and to stay within our scope of practice. At the same time, we should be able to assess and screen clients so we can still provide a solid training effect without making them feel like patients. There is still a lot we don’t know about FAI, and this isn’t a definitive guide. My aim is to raise awareness and share practical considerations.
