Clinical Sports Medicine Update

Physiotherapy as an Initial Treatment

Option for Femoroacetabular
Impingement
A Systematic Review of the Literature and Meta-analysis
of 5 Randomized Controlled Trials
Graeme Hoit,*y MD, Daniel B. Whelan,yz MD, MSc, Tim Dwyer,y§ MBBS, PhD, FRACS, FRCSC,
Prabjit Ajrawat,y H.BKin, and Jaskarndip Chahal,y|| MD, MSc, MBA, FRCSC
Investigation performed at University of Toronto Orthopaedic Sports Medicine (UTOSM),
Toronto, Ontario, Canada

Background: Femoroacetabular impingement is a common and debilitating source of hip pain in young adults. Although phys-
iotherapy is used as a mainstay of nonoperative care for femoroacetabular impingement, the evidence regarding different phys-
iotherapy practices is poorly understood.
Purpose: To collect and synthesize the best available evidence and arrive at a summary estimate of treatment effect for the utility
of physiotherapy in the management of femoroacetabular impingement.
Study Design: Meta-analysis.
Methods: A systematic review was performed on February 2, 2019, of PubMed, EMBASE, and Cochrane Library databases using
‘‘femoroacetabular impingement OR hip pain’’ and ‘‘physiotherapy OR nonoperative management’’ and their synonyms as
search terms. Central treatment themes were identified across protocols, and pooled analyses were conducted to assess for dif-
ferences in patient-reported outcome measures across these themes.
Results: A total of 5 randomized controlled trials met our inclusion criteria. The studies included 124 patients with a mean age of
35 years, of whom 24% were male. The average follow-up was 9.4 weeks (range, 6-12 weeks), and the follow-up rate across all
participants was 86%. Among these 5 studies, 4 studies used a physiotherapy protocol that focused on core strengthening ver-
sus no core strengthening, 4 studies compared active strengthening versus passive modalities, and 3 studies compared super-
vised versus unsupervised physiotherapy. Pooled analysis across all studies demonstrated improved outcomes in the treatment
groups compared with the controls (standardized mean difference [SMD], 0.76; 95% CI, 0.38-1.13; P \ .0001). Core strengthen-
ing (SMD, 0.82; 95% CI, 0.39-1.26; P = .0002), active physiotherapy (SMD, 0.70; 95% CI, 0.29-1.10; P = .0008), and supervised
physiotherapy (SMD, 0.58; 95% CI, 0.14-1.03; P = .01) were found to result in statistically significant improvements in functional
outcomes compared with no core strengthening, passive modalities, and unsupervised care, respectively.
Conclusion: Supervised physiotherapy programs focusing on active strengthening and core strengthening are more effective
than unsupervised, passive, and non–core focused programs. Future studies with longer term follow-up and validated femoro-
acetabular impingement specific outcome measures are required to determine prognostic factors for success with nonoperative
care as well as to determine the ideal patient profile and structured rehabilitation protocol.
Keywords: femoroacetabular impingement; nonoperative treatment; physiotherapy; nonoperative care; hip pain

Femoroacetabular impingement (FAI) is a condition caused and the acetabulum.10 The abnormal contact between an
by abnormal bone structure of the hip joint that leads to incongruent ball and socket joint results in a painful hip
impaired clearance between the femoral head-neck junction condition that can be significantly disabling.11 The overall
prevalence of FAI has been estimated to be 10% to 15% of
the population, most of whom are young active people,
aged 20 to 45 years.35 Given the affected age demographic,
The American Journal of Sports Medicine
the scope of the disease affects not only activity levels and
1–9
DOI: 10.1177/0363546519882668 quality of life but also economic productivity and the risk
Ó 2019 The Author(s) of opioid dependence.24 Moreover, FAI has been linked to

1
2 Hoit et al The American Journal of Sports Medicine

the development of hip osteoarthritis,1,10 a condition well core-based physiotherapy protocols will lead to improved
known to cause debilitating hip pain requiring invasive sur- patient-reported outcomes (PROs) in patients with FAI in
gical intervention in the form of hip replacement surgery. comparison with passive modalities or protocols without
Thus, the treatment of FAI may be critical not only to pro- core strengthening.
vide pain relief to symptomatic patients but also to preserve
the joint.
Current treatment for FAI includes both nonoperative METHODS
management and surgical intervention. Physiotherapy,
pain management, and activity modification remain the Literature Search
hallmarks of nonoperative care.4 Hip arthroscopy has
become the most popular method of surgical management This systematic review was conducted and prepared in
for FAI, where a minimally invasive approach is used to accordance with the PRISMA (Preferred Reporting Items
correct bony abnormalities and repair or debride soft tissue for Systematic Reviews and Meta-Analyses) statement.21
and chondral defects. The overarching goals of this surgery A systematic search was performed in MEDLINE (Ovid
are to improve patient symptoms and limit further degen- SP) using the following search strategy up to and inclusive
eration by correcting abnormal joint biomechanics. Across of February 2, 2019: (femoroacetabular impingement OR
the world, the rate of hip arthroscopy has increased expo- femoral acetabular impingement OR FAI) AND (rehabili-
nentially in recent years, with a 365% increase in the tation OR physio OR physiotherapy OR physical therapy
United States from 2004 to 2009 and a 250% increase OR conservative management OR non operative manage-
from 2007 to 2011.1,25 This rapid increase mandates a level ment OR nonoperative management). Ovid was programed
of precaution to ensure that hip arthroscopy is not being to perform a search of all Ovid databases as well as
delivered to a population who would benefit equally, if EMBASE from 1946 to the present. No language restric-
not more, from nonoperative care. tions were applied. Subsequently, an additional search
The evidence for physiotherapy as an effective treat- was performed in PubMed using the same search terms.
ment method for FAI has been unclear. It has been postu-
lated that muscle imbalances and biomechanical factors
contribute to pain in FAI, which provides the foundational Study Eligibility Criteria
basis for physiotherapy as a treatment.5,6,9,18 Weakness in
hip flexors, external rotators, and hip abductors in patients Level 1 and 2 randomized controlled trials (RCTs) or quasi-
with symptomatic FAI could theoretically worsen dynamic RCTs examining physiotherapy, physical exercise, or other
hip instability, and strengthening these muscle groups rehabilitation means as a treatment option for FAI were
may improve symptoms.8,19,20 Additionally, patients with included. We excluded observational studies, case series,
more significant abnormalities in gait biomechanics and cohort studies, or others with clearly nonrandom partici-
pelvic alignment have been shown to have more pain and pant allocation. ‘‘Prehabilitation’’ studies were also
have accordingly been targets of treatment protocols.5,8,15 excluded due to differences in patient expectations and
At this time, a paucity of clinical data are available to treatment goals.
support nonoperative treatment for FAI. A 2013 systematic
review of nonoperative treatment options demonstrated Study Selection
that although many experts recommend a trial of nonoper-
ative care before surgical intervention, little high-quality A preliminary screen based on title was performed by the
evidence is available regarding the efficacy of nonoperative primary author (G.H.) to eliminate any studies that were
treatment.32 As well, clarity is lacking in regard to which not relevant to the topic. A log of excluded studies was
elements should characterize an optimal nonoperative phys- kept with the rationale for exclusion. Subsequently, all
iotherapy regimen and the duration of such treatment. remaining abstracts were reviewed by the primary author,
Given the recent increase in popularity of treating FAI and the selection criteria were applied. Studies identified
and the associated evolution in literature and evidence for full-text review were assessed by 2 reviewers (G.H.,
addressing this condition, an updated review of the topic J.C.) for inclusion. Disagreement was resolved by discussion
is needed. The purpose of this study was to collect and syn- and consensus. Titles of journals and names of authors were
thesize the best available evidence and arrive at a summary not masked during study selection. A manual search of the
estimate of treatment effect for the utility of physiotherapy bibliographies of included studies was performed to ensure
in the management of FAI. We hypothesized that active, that the overall search was comprehensive and complete.

*Address correspondence to Graeme Hoit, MD, University Health Network - TWH, 399 Bathurst Street, East Wing, Room 447, Toronto, ON M5T 2S8,
Canada (email: [email protected]).
y
University of Toronto Orthopaedic Sports Medicine (UTOSM), Women’s College Hospital, Toronto, Ontario, Canada.
z
St Michael’s Hospital, Toronto, Ontario, Canada.
§
Mount Sinai Hospital, Toronto, Ontario, Canada.
||
University Health Network, Toronto, Ontario, Canada.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures
against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or respon-
sibility relating thereto.
AJSM Vol. XX, No. X, XXXX Physiotherapy for Femoroacetabular Impingement 3

Figure 1. PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) diagram for literature review.

Methodological Quality Assessment Treatment Analysis and Theme Extraction

of Included Studies
Each study’s treatment and control group protocols were
Quality of all studies was appraised by 2 reviewers (G.H., analyzed by 2 authors (G.H., J.C.) for similarities across
P.A.) independently using the Detsky scale (Appendix included studies. These extracted treatment themes were
Table A1, available in the online version of this article). analyzed independently for treatment effect.
Any disagreement was resolved by discussion and consen-
sus. The Detsky scale is a 21-point measure (22 for nega-
tive trials) of methodological rigor of RCTs based on
RESULTS
randomization, outcome measures, inclusion and exclusion
criteria, blinding, and appropriate statistical analysis.7 A
Literature Search
higher Detsky score correlates with greater quality of
methodological rigor.3 The results of the literature search are outlined in Figure
1. A total of 1015 articles were identified in database
searches. After title and abstract screening, 32 articles
Data Extraction and Analysis remained eligible for full-text screening. From these stud-
ies, 5 RCTs were deemed eligible for inclusion based on the
Data were extracted from included studies by 2 indepen- preestablished inclusion criteria.2,14,16,30,34
dent reviewers (G.H., J.C.) into a standardized collection
form using Microsoft Excel 2013. Data were imported
into a meta-analysis software program (RevMan 5.1) for General Study Characteristics
statistical pooling. Meta-analysis was planned across stud-
ies. Heterogeneity between studies was quantified through Among the 5 RCTs, a total of 124 patients participated (67
use of I2 values to determine suitability for fixed effect (I2 randomized to the intervention group, 57 randomized to
\ 50%) vs random effect (I2 . 50%) analyses. The sum- a control group) with a follow-up rate of 85.5% and a fre-
mary estimate of treatment effect was the standardized quency weighted mean duration of 9.4 weeks (range, 6-12
mean difference (SMD) with 95% confidence intervals. weeks). The frequency weighted mean age of participants
4 Hoit et al The American Journal of Sports Medicine

TABLE 1
General Study Characteristicsa

Sample Size, n Mean Age, y % Male Body Mass Index

Duration of Duration of Follow-up,
Lead Author Int Con All Int Con All Int Con All Int Con All Therapy, wk wk (% Completed)

Aoyama2 12 12 24 43 46 45 0 0 0 20 20 20 8 8 (83)
Harris-Hayes14 18 17 35 27 29 28 7 33 21 24 24 24 6 6 (91)
Kemp16 17 7 24 37 38 37 29 29 29 25 26 25 12 12 (83)
Smeatham30 15 15 30 36 33 34 47 33 40 NR NR NR 12 12 (77)
Wright34 7 8 15 31 36 34 43 12 27 26 24 25 6 7 (100)
Meanb 69 59 128 35 37 35 24 24 24 23c 23c 23c 9.4 (85.5)

a
Con, control group; Int, intervention group; NR, not reported.
b
Values are means for all 5 studies combined, except for sample size, which is the total number of participants.
c
Frequency weighted means were calculated based on provided data (Smeatham et al did not report body mass index).

was 35 years (range, 23-54 years), and 24% were male. identify a PROM as the primary outcome, the hip-specific
Individual study characteristics are provided in Table 1. outcome tool most used in the relevant literature was
selected for analysis. Table 3 identifies the outcome meas-
Quality Assessment ures used by each study.
We found that 2 studies used the International Hip Out-
The results of the Detsky scale quality assessment are pre- come Tool (iHOT); Kemp et al16 used the originally formu-
sented in Appendix Table A1 (available online). Specifi- lated iHOT-33, and Aoyama et al2 used the shortened
cally, randomization was conducted appropriately, and iHOT-12.2,13,16 For the studies by Smeatham et al30 and
strategies were adequately reported in 4 of the 5 studies; Wright et al,34 we selected the Hip Outcome Score (HOS)
the study by Aoyama et al2 assigned patients in a nonran- activities of daily living (ADL) domain for our pooled analysis
dom alternating fashion on the basis of patient presenta- due to its reliability and validity in FAI23 and because it was
tion. Treatment groups could not be concealed to the the primary outcome used in a recent FAI RCT by Palmer
investigators in any study based on the nature of the inter- et al.27 The Hip disability and Osteoarthritis Outcome Score
ventions. Outcome measurements and blinding to those was the PROM used by Harris-Hayes et al,14 from which we
conducting outcome statistics were adequate in all also selected the ADL domain for analysis for consistency
included studies. Statistical analysis was appropriate for with the HOS and its purpose in better serving our primary
all studies. No prestudy power calculations were per- interest of improving patients’ daily function.
formed for included trials, as all of them were designed
as pilot trials for the purposes of calculating necessary
sample sizes. All except Smeatham et al30 achieved the Outcomes: Heterogeneity,
threshold of 80% follow-up rate. Overall, all included stud- Patient-Reported Outcomes, Pooled Analysis
ies were found to be high quality (score .75%).3
Treatment Group vs Control Group. The patient-reported
data from the selected PROMs of all of the included studies
Interventions and Treatment Theme Analysis were pooled through use of SMD weighted for the number of
participants in each study. This demonstrated improved
Intervention and control group treatment protocols varied patient-reported outcomes in the intervention groups com-
among included studies (Table 2). After comparing the pro- pared with controls (5 studies [124 patients]; SMD, 0.76;
tocols, we identified 3 central themes as differences 95% CI, 0.38-1.13; P \ .0001; I2 = 0%) (Figure 2).
between the treatment and control groups that existed Pooled Analysis for Treatment Themes. SMD calcula-
throughout most but not all of the studies. Core strength- tions were performed for the studies comparing core
ening versus no core strengthening (4 studies),2,16,30,34 strengthening versus no core strengthening, active
active strengthening versus passive modalities (4 stud- strengthening versus passive modalities, and supervised
ies),14,16,30,33 and supervised physiotherapy versus un- versus unsupervised physiotherapy (Figures 3, 4, and 5,
supervised or no instruction (3 studies)14,30,34 were respectively). Core strengthening was found to be statisti-
identified and provided the basis of our statistical analysis. cally superior to no core strengthening in the pooled anal-
ysis (SMD, 0.82; 95% CI, 0.39-1.26; P = .0002) (Figure 3). A
Outcome Measurement similar pooled analysis demonstrated that active physio-
therapy resulted in improved functional outcomes versus
The PROM tools used varied between the included studies. passive modalities (SMD, 0.70; 95% CI, 0.29-1.10; P =
For the purpose of our statistical analysis, if the primary .0008) (Figure 4). Supervised physiotherapy was found to
outcome was identified as a PROM in the study, this was have significant benefit over unsupervised therapy (SMD,
selected in our pooled analysis. For studies that did not 0.58; 95% CI, 0.14-1.03; P = .01) (Figure 5).
AJSM Vol. XX, No. X, XXXX Physiotherapy for Femoroacetabular Impingement 5

TABLE 2
Study Interventions and Controlsa

Treatment
Lead Author Intervention Therapy Control Therapy Key Themes Duration, wk

Aoyama2 Hip and pelvic girdle exercises plus Hip and pelvic girdle exercises  Core strengthening vs no core 8
core exercises  Participants received training strengthening
 Participants received training and for hip abduction, buttock
demonstration in plank and bird-dog elevation, and pelvic tilt
exercises in addition to the exercises exercises.
assigned to the control group.  Participants were advised to
 Participants were advised to modify modify activities of daily living
activities of daily living to avoid to avoid squatting, prolonged
squatting, prolonged sitting, and sitting, and athletic activities
athletic activities causing groin pain. causing groin pain.
Harris-Hayes14 Movement pattern training Waitlisted patients  Active strengthening vs 6
 Six 1-h sessions over 6 wk involving  No specific intervention passive modality
task-specific training for basic and  Supervised vs unsupervised
patient-specific tasks reported to be PT
symptom provoking.
 Daily at-home and once-weekly PT-
supervised progressive
strengthening of hip muscles
targeting hip abductors, external
rotators, and hip flexors.
Kemp16 FAI-specific PT Standard hip PT, no  Core strengthening vs no core 12
 8 physiotherapy sessions and 12 strengthening strengthening
supervised gym visits over 12 wk  8 physiotherapy sessions and  Active strengthening vs
with 2 additional unsupervised 12 supervised gym visits over passive modality
sessions per week. 12 wk with 2 additional
 Interventions consisted of hip joint unsupervised sessions per
manual therapy, hip-specific week.
strengthening (adductors, abductors,  Hip joint manual therapy,
extensors, and external rotators), stretching, and health
and trunk muscle strengthening. education.
Smeatham30 Supervised PT Self-management  Core strengthening vs no core 12
 10 sessions over 12 wk  Analgesia and continuation of strengthening
 Manual therapy and exercise-based self-management; participants  Supervised vs unsupervised
rehabilitation at the discretion of were asked to refrain from PT
physiotherapist. seeing osteopath, chiropractor,
or physiotherapist for study
duration.
Wright34 Manual therapy and exercise Advice plus home exercise  Core strengthening vs no core 6
 Two 1-h sessions per week for 6 wk  Participants received handout strengthening
for manual therapy and supervised for 6 exercises focused on  Active strengthening vs
exercise plus home exercise. addressing gluteal strength passive modality
 Manual therapy consisted of thrust or and hip flexibility.  Supervised vs unsupervised
nonthrust manipulation at discretion  Participants were instructed to PT
of physiotherapist. avoid long-term sitting,
 Supervised exercise consisted of crossing legs, pivoting, deep
multimodal program of gluteal and squats, and cycling with
core muscle strengthening, increased hip flexion.
stretching, and neuromuscular
control.
 Participants received handout for 6
exercises focused on addressing hip
strength and flexibility.

a
FAI, femoroacetabular impingement; PT, physiotherapy.
6 Hoit et al The American Journal of Sports Medicine

TABLE 3
Patient-Reported Outcome Measurementsa

Lead Author Outcome Measure Description Other Outcome Measures Used

Aoyama2 iHOT-12  12-question PROM validated and reliable for FAI Modified Harris Hip Score,
 MCID 13.0b Vail Hip Score
Harris-Hayes14 HOOS  40-question PROM, domains for symptoms, QoL, Pain, Sports, ADL
 ADL domain = MCID 6c
Kemp16 iHOT-33  33-question PROM validated and reliable for FAI HOOS (QoL1Pain)
 MCID 10c
Smeatham30 HOS  26-question PROM, reliable and valid for FAI Non-Arthritic Hip Score,
 Domains for Sports and ADL Lower Extremity Function
 ADL domain = MCID 5c Score, visual analog scale
Wright34 HOS  26-question PROM, reliable and valid for FAI
 Domains for Sports and ADL
 ADL domain = MCID 5c

a
ADL, activities of daily living; FAI, femoroacetabular impingement; HOOS, Hip disability and Osteoarthritis Outcome Score; HOS, Hip
Outcome Score; iHOT, International Hip Outcome Tool; MCID, minimum clinically important difference; PROM, patient-reported outcome
measure; PT, physiotherapy; QoL, quality of life.
b
Nwachukwu et al.26
c
Kemp et al.17

Figure 2. Pooled analysis of treatment versus control groups for included studies. IV, instrumental variable; PT, physiotherapy.

Figure 3. Pooled analysis of studies comparing core strengthening versus no core strengthening. IV, instrumental variable; PT,
physiotherapy.

DISCUSSION that active core-based physiotherapy should be an integral

component in the initial management of such patients
The result of this meta-analysis of 5 RCTs suggests that before surgical intervention is considered.
patients treated with supervised, core-focused, and active As the number of patients with symptomatic FAI trea-
strengthening protocols reported significantly better out- ted with hip arthroscopy continues to increase worldwide,
comes than those treated with either unsupervised, non– there is a continued need to study the evidence base for
core focused, or passive modalities. Given the relatively both operative and nonoperative management pathways.
low risk and low cost of nonoperative care versus operative Before this review, insufficient consensus was available
treatments and the increasing number of young adult to establish an evidence base for physiotherapy guidelines
patients presenting with hip pain, our results demonstrate for an FAI-specific treatment protocol. In 2016, Wall et al31
AJSM Vol. XX, No. X, XXXX Physiotherapy for Femoroacetabular Impingement 7

Figure 4. Pooled analysis of studies comparing active strengthening versus passive modalities. IV, instrumental variable; PT,
physiotherapy.

Figure 5. Pooled analysis of studies comparing supervised versus unsupervised physiotherapy (PT). IV, instrumental variable.

described the creation of a nonoperative management pro- limitations. The sample size of each study was very small,
tocol for FAI—personalized hip therapy (PHT)—based on given that they were conducted as pilot studies. Even
best available evidence. PHT was primarily informed by taken together in meta-analysis, the total sample size is
Delphi method expert consensus rather than data from only 124 patients, lending to the possibility of type II error.
randomized studies, due to a lack of literature.31 This con- The population demographics of the study participants
clusion of the expert consensus aligns well with our find- may not represent the average patient treated for FAI, as
ings: that is, the creation of a protocol encompassing only 24% of the patients were male. It is unknown whether
active, supervised physiotherapy with an emphasis on sex as a factor could affect responsiveness to certain types
core strengthening. PHT served as the nonoperative treat- of physiotherapy, and we were not able to analyze this
ment protocol for the landmark FASHIoN trial—the larg- within our study. The average age of 35 could be older or
est RCT comparing hip arthroscopy versus physiotherapy younger than the typical patient referred for FAI depend-
for FAI.12 Issues that remain unclear are which compo- ing on practice.28,29 Patient expectations and response to
nents define core strength and which exact exercises therapy may be influenced by age, sex, and activity level,
should be incorporated to address any core strength defi- which are not captured in this analysis and could affect
cits in an efficient and targeted manner. the results. Because of the heterogeneity between the stud-
Recently, 3 randomized trials comparing physiotherapy ies, we were not able to analyze the effect of treatment
with hip arthroscopy for FAI have been published.12,22,27 duration on success of therapy. Additionally, the follow-
All studies demonstrated significant improvement in both up duration for each of the studies was quite short, with
groups beyond the minimum clinically important differ- the average duration 9.4 weeks and the longest duration
ence of their primary outcome. Mansell et al22 found no dif- 12 weeks. As such, we are unable to determine whether
ference between the 2 treatment options, admittedly with the effects were lasting or whether patients would benefit
significant crossover between the groups. The FASHIoN from therapy longer than 12 weeks. Furthermore, the
trial12 and FAIT trial27 both demonstrated improved out- treatment and control protocols differed across studies.
comes in the hip arthroscopy groups, although with a larger Although the 5 included studies did share similarities, as
complication rate in the surgical group. The findings of reflected in our thematic analysis discussed in the results,
these studies further demonstrate the need for an objective the significance of the pooled result must be interpreted in
and evidence-based physiotherapy protocol for patients broad context. There was no central theme across the 5
seeking improvement in their symptoms without having studies’ treatment and control groups other than a protocol
to face the potential risks of hip arthroscopy. We believe designed intentionally to treat FAI versus some consider-
this meta-analysis provides the necessary evidence to ation of ‘‘standard care.’’ Thus, it is helpful to analyze the
inform a supervised, core-based, active strengthening pro- studies based on the themes we used for determining sig-
tocol as a primary treatment option for FAI. nificance of intervention. This, however, resulted in
For this study, our review process was rigorous and the a decreased sample size within each analysis. Additionally,
strict inclusion criteria resulted in 5 studies that are with the exception of the study by Aoyama et al,2 which
randomized, recently published, and the best available evi- directly compared core strengthening versus no core
dence on the topic. However, our results have some strengthening, there is inevitable bias within each
8 Hoit et al The American Journal of Sports Medicine

thematic analysis, as each study’s intervention protocol 10. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Fem-
included more than just a comparison within that direct oroacetabular impingement: a cause for osteoarthritis of the hip. Clin
Orthop Relat Res. 2003;417:112-120.
theme. Further study is required to determine the best
11. Griffin DR, Dickenson EJ, O’Donnell J, et al. The Warwick Agreement
treatment protocol in terms of length and specific focus. on femoroacetabular impingement syndrome (FAI syndrome): an
Nonetheless, the current findings lay the foundation for international consensus statement. Br J Sports Med. 2016;50(19):
an active, core-based physiotherapy protocol that aims to 1169-1176.
ameliorate symptoms and improve function over an 12. Griffin DR, Dickenson EJ, Wall PDH, et al. Hip arthroscopy versus
extended time horizon. Future studies that are high- best conservative care for the treatment of femoroacetabular
quality, preferably multicenter RCTs with longer term impingement syndrome (UK FASHIoN): a multicentre randomised
controlled trial. Lancet. 2018;391(10136):2225-2235.
follow-up and validated FAI-specific outcome measures 13. Griffin DR, Parsons N, Mohtadi NG, Safran MR. A short version of the
are required to determine efficacy, duration of therapy, International Hip Outcome Tool (iHOT-12) for use in routine clinical
and prognostic factors as well as confirm the ideal struc- practice. Arthroscopy. 2012;28(5):611-616; quiz 616-618.
tured rehabilitation protocol. 14. Harris-Hayes M, Czuppon S, Van Dillen LR, et al. Movement-pattern
training to improve function in people with chronic hip joint pain:
a feasibility randomized clinical trial. J Orthop Sports Phys Ther.
2016;46(6):452-461.
CONCLUSION 15. Hatton AL, Kemp JL, Brauer SG, Clark RA, Crossley KM. Impairment
of dynamic single-leg balance performance in individuals with hip
Supervised physiotherapy programs focusing on active chondropathy. Arthritis Care Res (Hoboken). 2014;66(5):709-716.
strengthening and core strengthening are more effective 16. Kemp JL, Coburn SL, Jones DM, Crossley KM. The Physiotherapy
for Femoroacetabular Impingement Rehabilitation Study (physio-
than unsupervised, passive, and non–core focused pro-
FIRST): a pilot randomized controlled trial. J Orthop Sports Phys
grams. Future studies with longer term follow-up and val- Ther. 2018;48(4):307-315.
idated FAI-specific outcome measures are required to 17. Kemp JL, Collins NJ, Roos EM, Crossley KM. Psychometric proper-
determine prognostic factors for success with nonoperative ties of patient-reported outcome measures for hip arthroscopic sur-
care as well as determine the ideal patient profile and gery. Am J Sports Med. 2013;41(9):2065-2073.
structured rehabilitation protocol. 18. Kemp JL, Schache AG, Makdissia M, Pritchard MG, Sims K, Cross-
ley KM. Is hip range of motion and strength impaired in people with
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2014;14(3):334-342.
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