Will you get what you want? Treatment goals and expectations of patients with femoroacetabular impingement syndrome regarding physiotherapist-led treatment.

OBJECTIVE: To (i) investigate the goals and expectations of participants enrolled in a clinical trial of physiotherapist-led treatment for femoroacetabular impingement (FAI) syndrome and (ii) explore associations between their expectations and self-reported hip burden and kinesiophobia. METHODS: Data from 150 participants with FAI syndrome who participated in a clinical trial were analysed. Participants described their most important treatment goal and the expectation of achieving this goal throughout physiotherapy treatment. The International Hip Outcome Tool (iHOT-33) subscales were used to assess self-reported hip burden. The Tampa Scale for Kinesiophobia was used to assess kinesiophobia. Participants goals were qualitatively analysed using content analysis. Linear regression was used to explore associations between patient expectations and iHOT and Tampa Scale for Kinesiophobia scores. RESULTS: Participants with FAI syndrome reported goals relating to exercise (52%), improving activities of daily living quality (23%), improving physical function (15%), and reducing pain (10%). Negative expectations regarding physiotherapist-led treatment were reported by 68% of participants. Those with negative expectations reported worse scores for the iHOT-Total score (mean difference = 12 points, 95%CI = [4 to 19]), and iHOT-Symptoms (14 points, [7 to 21]) and iHOT-Social (11 points, [2 to 21]) subscales compared to those with positive expectations. Treatment expectations were not associated with iHOT-Sport, iHOT-Job, and Tampa Scale for Kinesiophobia scores (p > 0.05). CONCLUSION: Patients with FAI syndrome had a generally negative expectation of physiotherapist-led treatment. There was a mismatch between patients' goals and current treatment approaches. Participants with FAI syndrome and negative expectations reported worse quality of life, symptoms, and social concerns than those with positive expectations.

First-line treatment for femoroacetabular impingement syndrome and hip-related quality of life: study protocol for a multicentre randomised controlled trial comparing a 6-month supervised strength exercise intervention to usual care (the Better Hip Trial).

INTRODUCTION: Femoroacetabular impingement syndrome (FAIS) is a motion-related and position-related clinical condition of the hip associated with pain, reduced physical function and hip-related quality of life (QoL). Interestingly, higher maximal muscle strength is associated with less pain, better physical function and improved QoL in people with FAIS. Furthermore, preliminary evidence suggests that a proportion of patients with FAIS respond positively to strength exercise as first-line treatment. Nonetheless, there is little evidence supporting a specific exercise intervention offered as a first-line treatment. We will conduct a randomised controlled trial investigating the clinical effectiveness and cost-effectiveness of a 6-month strength exercise intervention compared with usual care as first-line treatment in patients with FAIS. METHODS AND ANALYSIS: This is a multicentre randomised controlled trial that will be conducted at hospitals and physiotherapy clinics across Denmark and Australia. A total of 120 patients with FAIS will be randomised (1:1) to 6 months of supervised strength exercise or usual care. The primary outcome is the change in hip-related QoL measured using the International Hip and Outcome Tool 33 (iHOT-33) from baseline to the end of intervention. A health economic evaluation will be conducted from a societal and healthcare perspective based on the data collection over a 12-month period starting at baseline. The analysis will calculate incremental cost-effectiveness ratios using quality-adjusted life-years and iHOT-33 scores while estimating costs using microcosting and cost questionnaires. Secondary outcomes include objectively measured physical function at baseline and after 6 months and patient-reported outcomes measured at baseline, 3-month, 6-month and 12-month follow-up. ETHICS AND DISSEMINATION: The trial has been approved by the Committee on Health Research Ethics in the Central Denmark Region (journal no 1-10-72-45-23) and La Trobe University Human Ethics Committee (HEC24042) and is registered at the Central Denmark Region List of Research Projects (journal no 1-16-02-115-23). Informed consent will be obtained from each participant before randomisation. Results will be published in international peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: NCT05927935.

Femoroacetabular impingement - What the rheumatologist needs to know.

Femoroacetabular impingement (FAI) syndrome is a common cause of hip and groin pain in young individuals. FAI syndrome is a triad of signs, symptoms, and imaging findings. Necessary but not sufficient for the diagnosis of FAI syndrome is the presence of cam and/or pincer morphology of the hip. However, pathological thresholds for cam and pincer morphologies are not well-established. Management of FAI syndrome is typically through either physiotherapist-led therapy or surgical intervention. Physiotherapist-led management involves exercises aimed to optimise movement patterns of the hip and pelvis to prevent impingement from occurring, activity modification and analgesia, whereas surgical management involves arthroscopic resection of the cam/pincer morphology and treatment of concomitant soft tissue pathologies such as labral tears, cartilage lesions or ligamentum teres tears. Careful consideration of intervention is required given that FAI syndrome may predispose those affected to developing future osteoarthritis of the hip. In most clinical trials, hip arthroscopy has been found to provide greater improvement in patient-reported outcomes in the short-term compared to physiotherapy, however it is unknown whether this is sustained in the long-term or affects the future development of hip osteoarthritis.

Current concepts in the diagnosis and management of Os Acetabuli.

PURPOSE: The aim of this review is to appraise the current evidence on the epidemiology, pathophysiology, diagnosis and management of os acetabuli. METHODS: A scoping review was conducted according to the Joanna Briggs Institute guidelines. A systematic search was performed on Medline (PubMed), Embase and Cochrane Library. Inclusion criteria comprised observational and interventional studies and review articles published in the English language that focused on patients with os acetabuli according to the PRISMA extension of scoping reviews checklist using the terms 'Os Acetabuli' or 'os acetabula' or 'acetabular ossicles'. A narrative synthesis of results was undertaken, and the included articles were divided into (i) definition, (ii) aetiology, (iii) diagnosis and imaging and (iv) management of os acetabuli. RESULTS: 107 articles were screened, with 22 meeting the eligibility criteria. A total of 8836 patients were considered, of which 604 had os acetabuli. The mean age was 32.8 years. The prevalence of os acetabuli ranged from 3.4 to 7.7%, with a higher prevalence in males compared to females. True os acetabuli was defined as an unfused secondary ossification centre along the acetabular rim. The aetiology of os acetabuli is thought to be secondary to acetabular dysplasia and/or femoroacetabular impingement. Standard of care for management of symptomatic os acetabuli is considered to be arthroscopic excision unless the excision results in acetabular undercoverage and/or instability, in which case, fixation is recommended. CONCLUSIONS: Successful management of os acetabuli depends on understanding the pathology and treating the underlying cause rather than treating the os acetabuli in isolation. Future work needs to focus on establishing clear diagnostic criteria, consensus on definition and an evidence-based treatment algorithm.

Clinical Equipoise in the Management of Patients With Femoroacetabular Impingement Syndrome and Concomitant Tönnis Grade 2 Hip Osteoarthritis or Greater: An International Expert-Panel Delphi Study.

PURPOSE: To gather global-expert opinion on the management of patients with femoroacetabular impingement syndrome (FAIS) and Tönnis grade 2 hip osteoarthritis (OA) or greater. METHODS: An internet-based modified Delphi methodology was used via an online platform (Online Surveys) using the CREDES (Conducting and Reporting Delphi Studies) guidelines. The expert panel comprised 27 members from 18 countries: 21 orthopaedic surgeons (78%), 5 physiotherapists (18%), and 1 dual orthopaedic surgeon-sport and exercise medicine physician (4%). Comments and suggestions were collected during each round, and amendments were performed for the subsequent round. Between each pair of rounds, the steering panel provided the experts with a summary of results and amendments. Consensus was set a priori as minimum agreement of 80%. RESULTS: Complete participation (100%) was achieved in all 4 rounds. A final list of 10 consensus statements was formulated. The experts agreed that there is no single superior management strategy for FAIS with Tönnis grade 2 OA and that Tönnis grade 3 OA and the presence of bilateral cartilage defects (acetabular and femoral) is a contraindication for hip preservation surgery. Nonoperative management should include activity modification and physiotherapy with hip-specific strengthening, lumbo-pelvic mobility training, and core strengthening. There was no consensus on the need for 3-dimensional imaging for initial quantification of joint degeneration. CONCLUSIONS: There is clinical equipoise in terms of the best management strategy for patients with FAIS and Tönnis grade 2 OA, and therefore, there is an urgent need to perform a randomized controlled trial for this cohort of patients to ascertian the best management strategy. LEVEL OF EVIDENCE: Level V, expert opinion.

Editorial Commentary: In Patients With Hip-Spine Syndrome, a Single Simple Solution May Not Apply: Occam's Razor Becomes Blunt.

The importance of hip-spine syndrome in a nonarthritic population, in which patients present with coexisting symptoms in both the hip and lumbar spine, is becoming more clear. Several studies have shown inferior outcomes in patients undergoing treatment for femoral acetabular impingement syndrome with coexisting spinal symptoms. The most important factor when treating HSS patients is understanding each patient's pathology. A history and physical examination with provocative tests for spinal and hip pathology often provide the answer. Routine standing and seated lateral radiographs are required to assess spinopelvic mobility. If the cause of pain is unclear, diagnostic intra-articular hip injections with local anesthetic and further imaging of the lumbar spine are recommended. In patients with degenerative spine disease with neural impingement, these symptoms may persist after hip arthroscopy, particularly if not improved by intra-articular injections. Patients should be appropriately counseled. If hip symptoms predominate, treatment of femoroacetabular impingement syndrome results in improved outcomes, even with coexisting neural impingement. If spine symptoms predominate, referral to an appropriate specialist may be required. In patients with HSS, Occam's razor becomes blunt; thus, a single simple solution may not apply, and we may need to consider treating each pathology separately.

No evidence exists on outcomes of non-operative management in patients with femoroacetabular impingement and concomitant Tönnis Grade 2 or more hip osteoarthritis: a scoping review.

PURPOSE: The purpose of this scoping review was to assess the outcomes of all the non-operative modalities of management for femoroacetabular impingement (FAI) and concomitant osteoarthritis (OA) Tönnis Grade 2 or more. METHODS: A systematic search of PubMed was performed from inception to December 1st 2021 for literature on outcomes of non-operative management strategies for young adults with symptomatic FAI using the PRISMA Extension for Scoping Reviews guidelines. Cohorts investigating FAI and concomitant hip OA Tönnis Grade 2 or more were considered eligible. Studies not written in English or German, below level 4 evidence, and reviews were excluded. A secondary analysis for FAI without OA stratification was conducted after the initial screening to allow identification of available non-operative interventions. RESULTS: No study reported outcomes separately for non-operative management of FAI with Tönnis Grade 2 OA or more and as such, did not fulfil the inclusion criteria. A secondary analysis included 24 studies that reported on outcomes for non-operative interventions for FAI irrespective of the degree of degeneration. Three studies investigated the efficacy of hyaluronic acid injection, 5 reports investigated corticosteroid injections, 2 studies evaluated the outcomes of hip bracing and 16 studies included a physiotherapy programme. Associations between the aforementioned interventions were analysed. There is level I evidence supporting the efficacy of activity modification and hip-specific physiotherapy for FAI and mild OA. Core-strengthening exercises are prevalent amongst successful regimens in the literature. Contradictory evidence questions the efficacy of hip bracing even for short-term outcomes. Corticosteroid injections have mostly failed in intention-to treat analyses but may be valuable in delaying the need for surgery; further studies are warranted. Reports on outcomes following hyaluronic acid injections are contradictory. CONCLUSION: No evidence exists on outcomes following non-operative management of FAI with concomitant Tönnis Grade 2 or more OA of the hip. Further studies are required and should explore the non-operative interventions that were employed for FAI and milder OA. There is strong evidence for a hip-specific physiotherapy program including activity modification and core strengthening exercises. Adjunct interventions such as corticosteroid injections and NSAID consumption may be valuable in delaying the need for surgery. LEVEL OF EVIDENCE: Level IV.

Mid-term outcomes of exercise therapy for the non-surgical management of femoroacetabular impingement syndrome: are short-term effects persisting?

OBJECTIVES: To investigate the mid-term outcomes of exercise therapy in patients with femoroacetabular impingement syndrome (FAIS). DESIGN: Follow-up study. SETTING: Clinical setting. PARTICIPANTS: Twenty-six patients with FAIS who completed a 12-week semi-standardized, progressive exercise therapy program. MAIN OUTCOME MEASURES: At a mid-term follow-up of 4.6 years, therapy outcome was assessed using (i) the Global Treatment Outcome questionnaire for hip pain, (ii) the Hip Outcome Score (HOS) for hip pain and function in activities of daily living (ADL) and Sport and (iii) the Hip Sports Activity Scale (HSAS) for sport activity level. Mid-term outcomes were compared to pre-symptomatic, pre-therapy, as well as to short-term follow ups (18 weeks). RESULTS: In patients who completed the exercise program and did not undergo hip surgery (N = 19), mid-term HOS ADL and HOS Sport (P = 0.002) were higher than pre-therapy, and comparable to the 18-week follow-up. Mid-term HSAS was lower than the pre-symptomatic status (P = 0.022), but comparable to the 18-week follow-up. CONCLUSION: At a mid-term follow-up of 4.6 years, FAIS patients with no subsequent hip surgery maintained the good exercise therapy outcomes and the level of sport activity achieved at short term.

[Femoroacetabular impingement syndrome in adolescents-How to adivse? How to treat?] / Femoroazetabuläres Impingement-Syndrom bei Adoleszenten ­ Wie beraten? Wie behandeln?

BACKGROUND: Femoroacetabular impingement syndrome (FAIS) is a relevant cause of groin pain in adolescents. Athletes are particularly affected. OBJECTIVES: The article shall provide an evidence-based background for FAIS counseling and therapy in adolescents. MATERIAL AND METHODS: On the basis of the current literature, an overview of the prevalence and pathogenesis, evaluation and diagnostics, as well as the therapeutic recommendations for FAIS in adolescents was compiled. RESULTS AND DISCUSSION: FAIS in adolescents primarily affects physically active patients. Certain sports favor the development of FAIS. Cam impingement, pincer impingement, and combined FAIS are the most common entities in this age group. Cam morphology occurs shortly before closure of the proximal femoral growth plate. In cam impingement, the slipped capital femoral epiphysis (SCFE) must be distinguished from the primary cam morphology. SCFE requires rapid surgical treatment with stabilization of the epiphysis, while primary cam impingement can be analyzed electively, and conservative treatment is first recommended. Damage to the labrum and cartilage is regularly observed. A systematic radiological evaluation using X­rays and MRI is mandatory in order to develop an adequate treatment plan. In adolescent patients with FAIS, a conservative attempt at therapy should always be made; if this is unsuccessful, surgical repair with hip arthroscopy is indicated. The postoperative results are very good in adolescents, with a rapid improvement in symptoms, few complications, and a high return-to-sport rate.

Fisioterapia de rehabilitación y pinzamiento femoroacetabular / Rehabilitation Physiotherapy and Femoroacetabular Impingement

Introducción: Durante los últimos 20 años el tratamiento del pinzamiento acetabular ha sido quirúrgico, sin embargo, se ha propuesto el manejo conservador y la aplicación de protocolos de fisioterapia individualizada como tratamiento para el pinzamiento femoroacetabular, lo cual es fundamental para reestablecer la función de la articulación. Objetivo: Comparar los resultados entre la fisioterapia de rehabilitación del pinzamiento femoroacetabular y el tratamiento quirúrgico. Métodos: El artículo se dividió en conceptos para facilitar la revisión bibliográfica de los últimos 5 años en la base de datos de Pubmed con el sistema MeSH, Embase, Cochrane Library, Medline y BVS. Se utilizaron las siguientes palabras clave en el buscador, combinadas con el operador AND: femoroacetabular impingement, fhysiotherapy AND femoroacetabular impingement, femoroacetabular impingement treatment, Non-operative Management of Femoroacetabular Impingement. Análisis y síntesis de la información: Se incluyeron en la revisión todos los metaanálisis, ensayos clínicos aleatorizados y controlados, estudios prospectivos y artículos de revisión que comparan el tratamiento quirúrgico versus la fisiopterapia de rehabilitación en el tratamiento del síndrome de pinzamiento femoroacetabular, así como los que proponen la fisioterapia como opción de tratamiento inicial para el pinzamiento femoroacetabular, con la finalidad de evidenciar el grado de beneficio que tiene el manejo con fisioterapia en comparación con el quirúrgico. Conclusiones: La fisioterapia de rehabilitación ofrece un efecto beneficioso para el mejoramiento de la sintomatología, lo que permite, la disminución del dolor de cadera, además de restablecer la función y fuerza de la articulación(AU)

Introduction: During the last 20 years the treatment of acetabular impingement has been surgical; however, conservative management and the application of individualized physiotherapy protocols have been proposed as treatment for femoroacetabular impingement. This is essential to re-establish joint function. Objective: To compare the results between rehabilitation physiotherapy of femoroacetabular impingement and surgical treatment. Methods: The article was divided into concepts to facilitate the bibliographic review of the last 5 years in the Pubmed database with the MeSH system, Embase, Cochrane Library, Medline and BVS. The keywords used in the search engine, combined with the AND operator were femoroacetabular impingement, fhysiotherapy AND femoroacetabular impingement, femoroacetabular impingement treatment, Non-operative Management of Femoroacetabular Impingement. Analysis and synthesis of the information: All meta-analyzes, randomized and controlled clinical trials, prospective studies and review articles comparing surgical treatment versus rehabilitation physiotherapy in the treatment of femoroacetabular impingement syndrome were included in the review, as well as those that propose physiotherapy as an initial treatment option for femoroacetabular impingement, in order to demonstrate the degree of benefit that physiotherapy management has compared to surgery. Conclusions: Rehabilitation physiotherapy offers a beneficial effect for the improvement of symptoms, which allows the reduction of hip pain, in addition to restoring the function and strength of the joint(AU)

Femoroacetabular impingement syndrome and labral injuries: grading the evidence on diagnosis and non-operative treatment-a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF).

This statement summarises and appraises the evidence on diagnostic tests and clinical information, and non-operative treatment of femoroacetabular impingement (FAI) syndrome and labral injuries. We included studies based on the highest available level of evidence as judged by study design. We evaluated the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation framework. We found 29 studies reporting 23 clinical tests and 14 different forms of clinical information, respectively. Restricted internal hip rotation in 0° hip flexion with or without pain was best to rule in FAI syndrome (low diagnostic effectiveness; low quality of evidence; interpretation of evidence: may increase post-test probability slightly), whereas no pain in Flexion Adduction Internal Rotation test or no restricted range of motion in Flexion Abduction External Rotation test compared with the unaffected side were best to rule out (very low to high diagnostic effectiveness; very low to moderate quality of evidence; interpretation of evidence: very uncertain, but may reduce post-test probability slightly). No forms of clinical information were found useful for diagnosis. For treatment of FAI syndrome, 14 randomised controlled trials were found. Prescribed physiotherapy, consisting of hip strengthening, hip joint manual therapy techniques, functional activity-specific retraining and education showed a small to medium effect size compared with a combination of passive modalities, stretching and advice (very low to low quality of evidence; interpretation of evidence: very uncertain, but may slightly improve outcomes). Prescribed physiotherapy was, however, inferior to hip arthroscopy (small effect size; moderate quality of evidence; interpretation of evidence: hip arthroscopy probably increases outcome slightly). For both domains, the overall quality of evidence ranged from very low to moderate indicating that future research on diagnosis and treatment may alter the conclusions from this review.

Arthroscopic Hip Surgery versus Conservative Therapy on Femoroacetabular Impingement Syndrome: A Meta-Analysis of RCTs.

To determine the outcome and differences between arthroscopic hip surgery and conservative therapy in patients suffering from femoroacetabular impingement syndrome, we searched articles from PubMed, Embase, Cochrane, Web of Science and Clinicaltrials.gov using a Boolean search algorithm. Only randomized controlled trials comparing arthroscopic hip surgery and conservative therapy were included in this meta-analysis of femoroacetabular impingement syndrome management. Two authors determined eligibility, extracted the needed data and assessed the risk of bias of eligible studies independently. Then we meta-analyzed three articles to assess pooled estimate size (ES) and 95% confidence interval for Hip Outcome Score of activities of daily living (HOS ADL subscale), Hip Outcome Score sport (HOS sports subscale) and International Hip Outcome Tool (iHOT-33) analyses were performed by using STATA version 14.0 MP (STATA, College Station, TX, USA) with the principal summary measures are mean between group difference, sample size, and standard deviation. We collected 52 articles in total after removing duplicates and screened by titles and abstracts. A total of three RCTs were included finally. There was definite evidence of additional benefit of arthroscopic hip surgery against conservative therapy in the field of improving quality of life (three trials, 575 participants, ES = 2.109, 95% CI: 1.373 to 2.845, I2  = 42.8%, P = 0.000) and activity of daily living (two trials, 262 participants, ES = 9.220, 95% CI: 5.931 to 12.508, I2  = 16.5%, P = 0.000). However, no significant difference could be seen in sports function improvement (two trials, ES = 7.562, 95% CI: -2.957 to 18.082, I2  = 60.1%, P = 0.159). In conclusion, this meta-analysis suggests that arthroscopic hip surgery provided essential benefit compared with conservative therapy in improving activity of daily living and quality of life.

Dolor de cadera en adolescentes: estudio y tratamiento / Hip pain in adolescent: assessment and treatment

En adolescentes que consultan por dolor de cadera o pelvis, es crucial una adecuada historia clínica para orientarnos sobre la etiología del dolor y comprender los mecanismos que lo generan. Es importante conocer y realizar un exhaustivo examen físico, con especial énfasis en la cadera, incluyendo pruebas específicas para diferentes patologías, además de comprender las indicaciones de los diferentes estudios de imágenes, para así lograr un correcto diagnóstico.Entre las causas más frecuentes de coxalgia en adolescentes debemos considerar la epifisiolisis, el pinzamiento femoroacetabular con o sin roturas del labrum, las lesiones avulsivas de la pelvis, la coxa saltans, entre otras. Aunque son poco frecuentes, patologías sistémicas como reumatológicas y oncológicas también deben ser descartadas en adolescentes. Un diagnóstico de certeza nos permitirá realizar una adecuada estrategia de tratamiento, a fin de lograr una rehabilitación precoz y evitar futuras complicaciones.

In adolescents presenting with hip or pelvis pain, an adequate medical history is crucial to guide the etiology and understand the mechanisms that generate it. It is important to know and carry out an exhaustive physical examination, with special attention to the hip, including specific tests for different pathologies, in addition to understand the indications of the different imaging studies, in order to achieve a correct diagnosis. Among the most frequent causes of hip pain in adolescents, we must rule out slipped capital femoral epiphysis, femoroacetabular impingement with or without labral tears, avulsion lesions of the pelvis, snapping hip, among others. Although rare, systemic pathologies such as rheumatologic and oncologic diseases must also be ruled out in adolescents. An accurate diagnosis will allow us to carry out an adequate treatment strategy, in order to achieve early rehabilitation and avoid future complications.

Six Meta-analyses on Treatments for Femoroacetabular Impingement Syndrome in a Year and Readers Are None the Wiser: Methods Advice for Researchers Planning Meta-analysis of Data From Fewer Than 5 Trials.

SYNOPSIS: In 2020, 6 meta-analyses comparing arthroscopic hip surgery to physical therapy were published. All included the same 3 randomized controlled trials, and none used methods suitable for the analysis of fewer than 5 studies. When there are fewer than 5 studies and heterogeneity, a random-effects model with the Hartung-Knapp-Sidik-Jonkman adjustment for a maximally conservative estimate should be employed; if reliable prior information is available, a Bayesian random-effects meta-analysis should be employed. Our re-analysis, which employed the appropriate model, found that there is currently insufficient evidence to conclude that surgery is superior to physical therapy for femoroacetabular impingement (FAI) syndrome. Further randomized controlled trials are required to resolve the clinical question of what the best treatment approach is for FAI syndrome. We provide readers with tools to conduct appropriate meta-analysis of fewer than 5 trials. J Orthop Sports Phys Ther 2021;51(5):201-203. doi:10.2519/jospt.2021.0107.

Physiotherapist-led treatment for femoroacetabular impingement syndrome (the PhysioFIRST study): a protocol for a participant and assessor-blinded randomised controlled trial.

INTRODUCTION: This double-blind, randomised controlled trial (RCT) aims to estimate the effect of a physiotherapist-led intervention with targeted strengthening compared with a physiotherapist-led intervention with standardised stretching, on hip-related quality of life (QOL) or perceived improvement at 6 months in people with femoroacetabular impingement (FAI) syndrome. We hypothesise that at 6 months, targeted strengthening physiotherapist-led treatment will be associated with greater improvements in hip-related QOL or greater patient-perceived global improvement when compared with standardised stretching physiotherapist-led treatment. METHODS AND ANALYSIS: We will recruit 164 participants with FAI syndrome who will be randomised into one of the two intervention groups, both receiving one-on-one treatment with the physiotherapist over 6 months. The targeted strengthening physiotherapist-led treatment group will receive a personalised exercise therapy and education programme. The standardised stretching physiotherapist-led treatment group will receive standardised stretching and personalised education programme. Primary outcomes are change in hip-related QOL using International Hip Outcome Tool-33 and patient-perceived global improvement. Secondary outcomes include cost-effectiveness, muscle strength, range of motion, functional task performance, biomechanics, hip cartilage structure and physical activity levels. Statistical analyses will make comparisons between both treatment groups by intention to treat, with all randomised participants included in analyses, regardless of protocol adherence. Linear mixed models (with baseline value as a covariate and treatment condition as a fixed factor) will be used to evaluate the treatment effect and 95% CI at primary end-point (6 months). ETHICS AND DISSEMINATION: The study protocol was approved (La Trobe University Human Ethics Committee (HEC17-080)) and prospectively registered with the Australian New Zealand Clinical Trials Registry. The findings of this RCT will be disseminated through peer reviewed scientific journals and conferences. Patients were involved in study development and will receive a short summary following the completion of the RCT. TRIAL REGISTRATION NUMBER: ACTRN12617001350314.

Femoroacetabular Impingement and Core Muscle Injury in Athletes: Diagnosis and Algorithms for Success.

Athletic hip injuries account for a substantial portion of missed time from sports in high-level athletes. For both femoroacetabular impingement (FAI) and core muscles injuries, a thorough history and physical examination are paramount to guide the treatment. While advanced imaging including computed tomography and magnetic resonance imaging are frequently obtained, a wealth of information can be ascertained from standard radiographs alone. For patients with isolated or combined FAI and core muscle injuries (CMIs), the initial treatment is often nonoperative and consists of rest, activity modification, and physical therapy of the hips, core, and trunk. Injections may then aid in both confirming diagnosis and temporary symptom abatement. Arthroscopic procedures for refractory FAI in experienced hands have been shown to be both safe and efficacious. While surgical repair options for CMIs are significantly more variable, long-term studies have demonstrated the rapid resolution of symptoms and high return to play rates. More recently, anatomic and clinical correlations between FAI and CMIs have been identified. Special attention must be paid to elite athletes as the incidence of concurrent FAI with CMI is extremely high yet with significant symptom variability. Predictable return to play in athletes with coexisting symptomatic intra-articular and extra-articular symptomatology is incumbent upon the treatment of both pathologies.

Therapeutic Exercise Approaches to Nonoperative and Postoperative Management of Femoroacetabular Impingement Syndrome.

Femoroacetabular impingement syndrome (FAIS) is characterized by premature contact of the femur and acetabulum during hip motion. Morphologic variations of FAIS present as either aspherical femoral deformity (cam femoroacetabular impingement) or overcoverage (pincer femoroacetabular impingement) or both. Patients with FAIS often describe discomfort with hip flexion, adduction, and internal rotation. The use of hip arthroscopy to treat FAIS has risen substantially over the last 15 years. Given that one practice domain of the athletic training profession involves injury prevention and wellness protection, optimal FAIS treatment and management strategies warrant discussion. Sports medicine professionals often help patients with FAIS explore nonoperative exercise strategies and direct rehabilitation exercises for those who pursue surgery. Both approaches demonstrate key pillars of exercise program design, which include postural control, core stabilization, hip strength and motor control, and mobility. The purpose of this article is 2-fold: to present an overview of FAIS, including common diagnostic strategies, and commonalities in therapeutic approaches between nonoperative and postoperative rehabilitation for the treatment and management of patients with FAIS.

The effectiveness of hip arthroscopic surgery for the treatment of femoroacetabular impingement syndrome: A systematic review and meta-analysis.

OBJECTIVE: To determine the effectiveness of hip arthroscopic surgery for the treatment of femoroacetabular impingement syndrome (FAI). DESIGN: Systematic review with meta-analysis. DATA SOURCES: We performed electronic database searches in MEDLINE, Embase, SPORTDiscus, CINAHL, Cochrane Central Register for Controlled Trials (CENTRAL), Web of Science, Scopus, the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov from their inception to July 10th 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included randomised controlled trials (RCTs) comparing hip arthroscopic surgery to a placebo/sham surgery and other non-operative comparators (e.g. no intervention, physiotherapy, etc.). Two authors independently selected studies, rated risk of bias, extracted data, and judged overall certainty of evidence using GRADE. Hip-specific quality of life (QoL) at 12 months was the primary outcome. RESULTS: We identified three RCTs (n = 650 participants). There is high certainty evidence from three RCTs (n = 574 participants) that hip arthroscopic surgery provided superior outcomes compared to non-operative care for hip-specific QoL at 12 months (mean difference (MD): 11.02 points, 95% CI 4.83-17.21). Low quality evidence suggests that arthroscopic surgery provided similar outcomes to non-operative care for hip-specific QoL at 24 months (MD: 6.3, 95% CI -6.1 to 18.7). CONCLUSION: Hip arthroscopic surgery for FAI provides superior outcomes compared to non-operative care at 12 months, but not at 24 months. Placebo trials are needed to establish the efficacy of hip arthroscopic surgery.