Hip Impingement: Do You Really Need Surgery?
What Hip Impingement Actually Is
It usually starts as a pinch. You drop into a deep squat, pull your knee toward your chest, or sink into a low car seat, and there it is: a sharp, deep pain right in the crease at the front of your hip. For a lot of the hockey players we see, it creeps back every October when the season ramps up. If that sounds familiar, you may be dealing with hip impingement, and the good news is that hip impingement treatment in Burlington does not have to start with a surgeon. At Pursuit Physiotherapy in Burlington, we see this regularly in active people in their 20s, 30s, and 40s, and most of them have already been told some version of "your hip is shaped wrong."
Hip impingement, known clinically as femoroacetabular impingement (FAI) syndrome, happens when the ball of the hip (the femoral head) and the rim of the socket (the acetabulum) meet earlier than they should as the hip bends and rotates. There are a few shapes involved:
Cam morphology - extra bone where the ball meets the neck of the thighbone, so the ball is less round than usual.
Pincer morphology - a socket that covers more of the ball than usual, so the rim makes contact sooner.
Mixed - a bit of both, which is common.
Here is the part most people never hear: having that hip shape is not the same as having a problem. Imaging studies of people with no hip pain at all regularly find cam and pincer shapes, and labral tears too. FAI syndrome is only diagnosed when three things line up: symptoms, matching findings on a physical exam, and the shape on imaging. The shape on its own is just a shape.
What Causes Hip Impingement?
The bony shape is usually set during the teenage years. Pain tends to show up later, when the load you put through the hip outpaces what it can tolerate. The usual contributors:
Heavy hip loading while still growing - High-volume hockey, soccer, and basketball during adolescence are linked with a higher rate of cam shape. It is a big reason we see so many hockey players with this.
Repeated deep flexion and rotation - Goalie butterflies, deep squats, hurdles, martial arts, and yoga poses that push the hip to its end range over and over.
Training spikes - A new season, a new program, or a sudden jump in volume gives an irritable hip no time to adapt.
Weak or poorly coordinated hip and trunk muscles - When the glutes and deep hip muscles are not controlling the joint well, the ball and socket meet in the wrong spots more often.
Long hours of sitting - Desk days with the hips bent at 90 degrees or more can keep a sensitive hip grumbling.
Plenty of the patients we see are recreational athletes who have had the same hip shape for 20 years and only started hurting after a change in what they were asking of it. That is useful information, because load is something we can work with.
Signs and Symptoms of Hip Impingement
FAI syndrome tends to follow a recognizable pattern:
Deep pain in the groin or front of the hip, sometimes felt along the side of the hip or in the buttock
The "C sign" - people often cup the side of the hip with the thumb in front and fingers behind when showing where it hurts
Pain with deep squats, getting in and out of a low car, putting on socks, or sitting for long periods
Clicking, catching, or a locking sensation, which can point to the labrum
Stiffness, especially when turning the hip inward
When It Might Be Something Else
Front-of-hip pain has a long list of possible sources: adductor and hip flexor strains, the lower back, early hip osteoarthritis, and in runners, bone stress injuries. Pain at night that will not settle, pain with walking that keeps getting steadily worse, fever, or unexplained weight loss all need a prompt visit to your doctor. If your pain sits more in the inner thigh than the hip crease, our post on groin pain in athletes is a better place to start.
Hip Impingement Surgery vs Physiotherapy: What the Research Says
This is the question almost everyone asks us: do I need surgery? It has been tested in several large randomized trials, and the answer is more interesting than a simple yes or no.
In the UK FASHIoN trial, 348 people with FAI syndrome across 23 hospitals were randomly assigned to either hip arthroscopy or a personalized physiotherapy program of 6 to 10 sessions over 12 to 24 weeks. Both groups improved meaningfully. At 12 months, the surgery group scored about 7 points higher on a 100-point hip quality-of-life scale, just past the threshold considered clinically important. Surgery cost roughly 20 times more per patient. (Griffin et al., The Lancet, 2018)
Other trials paint a similar picture. Here is how we read the evidence for our patients:
Both paths work. People improved with physiotherapy and with surgery. Physio is not just a holding pattern while you wait for an operation.
Surgery has a modest edge on average in the first year. The FAIT trial found a 10-point advantage for surgery at 8 months on a daily-activity score, just past its threshold for a meaningful difference.
The longer-term picture is mixed. A 2021 meta-analysis found the advantage at 12 months was no longer clear at 24 months, though the certainty of that evidence was low. The 3-year FAIT follow-up still favoured surgery for function, and found no difference between groups in arthritis progression on X-ray.
Averages hide a lot. Some people do very well with rehab alone. Others do not, and for them surgery is a reasonable next step. Researchers are still running placebo-controlled surgical trials to work out how much of the benefit comes from the operation itself.
An international group of hip researchers landed in a practical place: exercise-based, physiotherapist-led care for at least three months, focused on hip and trunk strength, should be the starting point for active adults with hip-related pain. That is exactly how we approach it. If you put in a genuine, well-dosed three months and you are still stuck, getting a surgical opinion makes sense, and the strength you built will not be wasted. Rehab is a big part of recovering from hip arthroscopy anyway.
Hip Impingement Treatment in Burlington: What Physiotherapy Looks Like
"Do some stretches" is not a treatment plan for FAI. Good femoroacetabular impingement physiotherapy is specific, progressive, and built around what your hip can handle right now and what you want it to do six months from now.
Getting the Diagnosis Right
We start by working out whether the hip joint is actually the main driver of your pain. That means testing hip range of motion and strength, using specific provocation tests like FADIR, and ruling the lower back, adductors, and hip flexors in or out. If you already have an X-ray or MRI, we will go through it with you in plain language and put it in context. If you do not, you usually do not need one to get started.
Calming the Hip Down
Early on, the goal is to settle irritation without shutting you down. That often means temporarily changing how deep you squat or sit, adjusting your training volume, and using manual therapy in Burlington to ease pain and stiffness enough that you can train comfortably. Hands-on care supports the exercise program. It does not replace it.
Building Strength and Control
The core of treatment is individualized exercise prescription: progressive strengthening of the glutes, deep hip rotators, adductors, and trunk, then retraining how you squat, lunge, skate, or land so the hip is not living at its end range all day. For athletes, the final phase is sport-specific, whether that is stride work for skaters, cutting and acceleration for soccer, or a clear return-to-play plan for your league.
Exercise does not change the shape of the bone, and it does not need to. The aim is to raise what your hip can tolerate and change how you load it, so the shape stops causing symptoms. That is why two people with nearly identical MRIs can have completely different outcomes.
What to Expect at Your First Appointment
Your first appointment is a full hour, one-on-one with Javier Diaz, a registered physiotherapist who also teaches medical acupuncture through McMaster University. We take a detailed history, do a thorough hip and spine assessment, and explain what we think is going on and why. You leave with a clear plan, realistic timelines, and your first exercises the same day. From there, follow-up visits focus on progressing your program and adjusting it as your hip responds.
Five Hip Impingement Tips You Can Start Today
Find your pinch point and work just short of it. If deep squats or pulling your knee to your chest set it off, stay a little above that range for now. It is a temporary adjustment, not a forever rule.
Start strengthening your glutes. Bridges and side-lying leg raises are simple starting points. Two to three sets, a few days a week, with effort you can feel but no sharp pain.
Change how you sit. Raise your chair or car seat slightly so your hips sit a little higher than your knees, and get up to move every 30 to 45 minutes.
Skip aggressive hip "opening" stretches. Forcing a pinchy hip into deep flexion or rotation usually makes it angrier. Gentle movement beats cranking on range.
Ease into your season. If hockey or indoor soccer is ramping up, build your training volume gradually instead of jumping in at full intensity, and give your hip a recovery day between hard sessions.
If any of these make your pain noticeably worse the next day, scale back and get assessed rather than pushing through.
When to See a Physiotherapist for Hip Pain
If your hip has been pinching for more than a few weeks, flares up every time you return to sport, or is starting to affect everyday things like sitting through a meeting or getting out of the car, it is time to get it looked at. The same goes if you have been told you "might need surgery" and want to know whether a proper rehab program makes sense first. Cam-type hip shape is also linked with a higher risk of hip osteoarthritis later in life (our post on hip osteoarthritis treatment covers that side of things), so a hip that has been sore for months deserves a proper look rather than a shrug.
We see people with hip pain from Millcroft, Waterdown, Aldershot, Oakville, Hamilton, and Milton, from beer-league hockey players and runners to people who just want to sit through a movie comfortably.
Ready to Get to the Root of It?
If hip impingement is keeping you off the ice or the field, or just making sitting miserable, book a one-on-one assessment at Pursuit Physiotherapy and get an honest answer about your options, surgery included. We are now at 1960 Appleby Line, Suite 25, in Burlington, at the corner of Appleby Line and Upper Middle Road. Call us at (905) 331-8993 or book your assessment online.
References
Griffin DR, Dickenson EJ, Wall PDH, et al. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. The Lancet. 2018;391(10136):2225-2235. Read the study
Palmer AJR, Ayyar Gupta V, Fernquest S, et al. Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicentre randomised controlled trial. BMJ. 2019;364:l185. Read the study
Palmer A, Fernquest S, Rombach I, et al. Medium-term results of arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of femoroacetabular impingement syndrome: a multi-centre randomised controlled trial. British Journal of Sports Medicine. 2025;59(2):109-117. Read the study
Ferreira GE, O'Keeffe M, Maher CG, et al. The effectiveness of hip arthroscopic surgery for the treatment of femoroacetabular impingement syndrome: a systematic review and meta-analysis. Journal of Science and Medicine in Sport. 2021;24(1). Read the study
Kemp JL, Risberg MA, Mosler A, et al. Physiotherapist-led treatment for young to middle-aged active adults with hip-related pain: consensus recommendations from the International Hip-related Pain Research Network, Zurich 2018. British Journal of Sports Medicine. 2020;54(9):504-511. Read the study
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