Postoperative hip bracing reduces kinesiophobia in patients undergoing hip arthroscopy: a randomized-controlled trial.

INTRODUCTION: Detailed postoperative rehabilitation protocols after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) are still a matter of debate. Adjunctive hip bracing represents a promising tool to improve early patients' mobilization. To present, the effect of hip brace therapy on postoperative functional outcomes and specific patient individual psychologic factors remains controversially discussed. Consequently, we aimed to report postoperative outcomes focusing on hip function, pain and kinesiophobia between braced and unbraced patients. MATERIALS AND METHODS: A prospective, randomized-controlled trial was conducted, including patients undergoing hip arthroscopy for FAIS. After exclusion, a final study cohort of 36 patients in the intervention group (postoperative hip brace) and 36 patients in the control group (no hip brace) were compared for kinesiophobia (Tampa Scale of Kinesiophobia), pain (Visual analog scale) and joint function (International Hip Outcome Tool-12) within the first six postoperative months. RESULTS: Hip arthroscopy significantly improved all patient-reported outcomes in both groups. Intergroup analysis revealed significantly lower levels of kinesiophobia in braced patients at 6-months follow up (30.7 vs. 34.1, p = 0.04) while not negatively affecting pain and joint function. No intra- and postoperative complications occurred within both groups. CONCLUSIONS: This study could demonstrate that bracing after hip arthroscopy can positively influence kinesiophobia, while the brace did not negatively impact postoperative pain and quality of life. Thus, hip bracing could be a viable assistive therapy in the postoperative rehabilitation phase after hip arthroscopy.

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.

Short-term Outcomes After Hip Arthroscopic Surgery in Patients Participating in Formal Physical Therapy Versus a Home Exercise Program: A Prospectively Enrolled Cohort Analysis.

BACKGROUND: Physical therapy is frequently utilized in the postoperative care of femoroacetabular impingement syndrome (FAIS). There has been limited research into the efficacy of a structured home exercise program (HEP) compared with formal physical therapy (FPT) in this patient population. PURPOSE/HYPOTHESIS: The purpose was to evaluate the short-term outcomes of patients utilizing FPT versus an HEP after hip arthroscopic surgery for FAIS. It was hypothesized that both groups would show similar improvements regarding outcome scores, which would improve significantly compared with their preoperative scores. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients undergoing hip arthroscopic surgery for FAIS at a single center between October 2020 and October 2021 were prospectively enrolled. Patients were allowed to self-select FPT or an HEP and were administered a survey preoperatively and at 1 month, 3 months, 6 months, and 12 months postoperatively. The survey included the Single Assessment Numeric Evaluation, visual analog scale for pain, 12-item International Hip Outcome Tool, Patient-Reported Outcomes Measurement Information System Physical Function, and patient satisfaction with physical therapy and overall care. Statistical analysis was conducted between the 2 groups and within groups to compare preoperative and postoperative scores. RESULTS: The patients' mean age was 32.6 ± 10.4 years, with 47.2% being female and 57.4% choosing the HEP. At 12 months postoperatively, no significant differences were reported between the FPT and HEP groups regarding the Single Assessment Numeric Evaluation score (P = .795), visual analog scale for pain score (P > .05), Patient-Reported Outcomes Measurement Information System Physical Function T-score (P = .699), 12-item International Hip Outcome Tool score (P = .582), and patient satisfaction (P > .05). Outcome scores at 12 months postoperatively were significantly improved from the preoperative scores across all measures in both groups (P < .001). CONCLUSION: There were no significant differences regarding patient outcomes between FPT and the HEP at 1-year follow-up after hip arthroscopic surgery for FAIS when patients selected their own treatment, with both groups demonstrating significant improvements in their outcome scores from their preoperative values. These findings suggest that a structured HEP may be a viable alternative to FPT after hip arthroscopic surgery in patients who prefer a self-directed rehabilitation program.

Dynamic joint stiffness in individuals with femoroacetabular impingement syndrome pre- and post-hip arthroscopy.

BACKGROUND: Patients with hip-related pain often fail to return to their desired level of activity following hip arthroscopy. Lasting biomechanics alterations may be one potential explanation. Dynamic joint stiffness assesses the mechanistic controls of the lower limb during high impact movements, and thus, may provide valuable clinical targets to improving movement and optimizing return to activity after surgery. METHODS: Twenty-five participants (13 females) with hip-related pain underwent 3D motion capture during a drop jump task before surgery and six months post-operatively. Nineteen healthy controls (9 females) were collected for comparison. Sagittal plane dynamic joint stiffness was calculated during the initial landing phase. Baseline and 6-month dynamic joint stiffness data were compared 1) between males and females with hip-related pain and 2) between individuals with hip-related pain and controls using Wilcoxon Signed-Rank and Mann Whitney U tests. Sexes were analyzed separately. FINDINGS: From baseline to 6 months post-operatively, females with hip-related pain demonstrated decreased dynamic ankle stiffness (2.26 Nm/deg. [0.61] to 1.84 Nm/deg. [0.43]) (p = .005) and males with hip-related pain demonstrated increased dynamic hip stiffness (2.73 [0.90] to 3.88 [1.73]) (p = .013). There were no differences in dynamic stiffness at any joint between individuals with hip-related pain at either timepoint when compared to controls (p ≥ .099). INTERPRETATION: Females and males with hip-related pain may demonstrate unique changes in dynamic joint stiffness after surgery, indicating return to activity may follow different trajectories for each sex. Additional work should examine the relationship between hip joint stiffness and treatment outcomes and identify additional movement-related rehabilitation targets.

Running Alterations Pre- and Postarthroscopy for Femoroacetabular Impingement Syndrome and Labral Tears.

ABSTRACT: Freemyer, B, Beeler, D, Crawford, S, Durkin, R, and Stickley, C. Running alterations pre- and postarthroscopy for femoroacetabular impingement syndrome and labral tears. J Strength Cond Res 38(3): 501-509, 2024-Running is essential to sports participation and activity over the lifespan; however, running biomechanics are not fully described in patients with femoroacetabular impingement (FAIS). The purpose was to compare FAIS patient report outcome surveys (PRO) and running biomechanics preoperatively and 6 months postoperatively with controls. Nineteen subjects (FAIS, n = 10 and age-matched controls, n = 9) were included. The UCLA, Hip Outcome Score activity of daily living (HOS ADL ) and sports subscale (HOS SS ), and 3-D running biomechanics were evaluated. Statistical parametric mapping was conducted on biomechanics data. Statistical significance was set at p ≤ 0.05. Femoroacetabular impingement had similar UCLA activity scores compared with controls by 6 months (FAIS: 8.4 ± 1.7, CON: 8.6 ± 2.0, p = 0.80), despite lower HOS ADL (FAIS-Six: 89.3 ± 6.3, CON: 100 ± 0, p = 0.04) and HOS SS (FAIS-Six: 82.6 ± 18.5, CON: 100 ± 0, p = 0.05). The FAIS group had lower knee adduction moments (KAM) around 22-27% of stance ( p = 0.05) and lower sagittal plane ankle power generation during the final 5% of stance compared with the controls ( p = 0.04) preoperatively. The FAIS also had lower vertical ground reaction forces the first 2% of stance ( p = 0.05) and lower KAM from 20 to 30% stance ( p = 0.03) at the postoperative time vs. controls. Femoroacetabular impingement had higher hip external rotation angles the first 5% stance ( p = 0.05) and the last 20% of stance ( p = 0.01) vs. controls. This is the first study to describe FAIS running pre- and postoperatively. Despite higher activity and health 6 months postarthroscopy, the patients with FAIS had altered running biomechanics. Clinicians should consider these findings when creating rehabilitation protocols and during running progressions across the postoperative care of patients with FAIS.

Use and Effectiveness of Physical Therapy After Hip Arthroscopy for Femoroacetabular Impingement.

BACKGROUND: Limited literature exists regarding how postoperative physical therapy (PT) may affect outcomes in patients with femoroacetabular impingement syndrome (FAIS) undergoing hip arthroscopy. Additionally, it is unknown how PT measures relate to traditional orthopaedic patient-reported outcomes (PROs). PURPOSE: To evaluate how the duration of PT may correlate with outcomes in patients with FAIS using both the Lower Extremity Functional Scale (LEFS) and standard orthopaedic PRO measures. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients from a single institution who underwent primary hip arthroscopy for FAIS between 2013 and 2016 were identified. Patients with a minimum 2-year follow-up and fully documented PT notes were included and stratified into 3 cohorts based on timing of PT discharge: 0 to 3 months, 3 to 6 months, and 6 to 12 months. Predictive regression models were developed to analyze the rate of improvement (ROI) in LEFS score as it relates to (1) postoperative day (POD) and (2) postoperative PT session number. Two-year PROs were collected, correlated with LEFS scores, and compared among cohorts. RESULTS: A total of 95 patients were included (mean ± SD age, 34.6 ± 11.7 years; range, 14-55 years). Mean LEFS scores increased significantly from the initial score at 6 weeks, 3 months, and the time of PT discharge (P < .01 for all). The predicted ROI in LEFS score was 3.39% per PT session for sessions 0 to 13, 1.43% for sessions 14 to 27, and 0.37% for sessions 28 to 40. Patients who underwent 3 to 6 months of PT had significantly better Hip Outcome Score (HOS) relative to the 0- to 3-month cohort and significantly better visual analog scale (VAS) scores for satisfaction relative to the 6- to 12-month cohort. The predicted ROI in LEFS score was 0.96% per day from POD 0 to 45, 0.22% from POD 46 to 139, and 0.03% after POD 139. Moderate correlations were seen between LEFS score at the time of discharge and all 2-year PROs as follows: HOS Activities of Daily Living subscale (r = 0.488), HOS Sports-Specific subscale (r = 0.500), modified Harris Hip Score (r = 0.465), 12-item International Hip Outcome Tool (r = 0.494), VAS pain score (r = -0.346), and VAS satisfaction score (r = 0.459). CONCLUSION: Patients undergoing hip arthroscopy for FAIS derived substantial benefit from each PT visit during their first 13 PT sessions and then a smaller, yet still meaningful benefit from sessions 13 through 27. After session 40, or approximately 4.5 to 5 months, patients no longer benefited from additional PT sessions. Based on PRO scores, patients discharged from PT between 3 and 6 months had the best 2-year outcomes. LEFS score had moderate correlation with orthopaedic PRO scores.

What is the Rate of Response to Nonoperative Treatment for Hip-Related Pain? A Systematic Review With Meta-analysis.

OBJECTIVE: We aimed to (1) determine the rate of satisfactory response to nonoperative treatment for nonarthritic hip-related pain, and (2) evaluate the specific effect of various elements of physical therapy and nonoperative treatment options aside from physical therapy. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: We searched 7 databases and reference lists of eligible studies from their inception to February 2022. STUDY SELECTION CRITERIA: We included randomized controlled trials and prospective cohort studies that compared a nonoperative management protocol to any other treatment for patients with femoroacetabular impingement syndrome, acetabular dysplasia, acetabular labral tear, and/or nonarthritic hip pain not otherwise specified. DATA SYNTHESIS: We used random-effects meta-analyses, as appropriate. Study quality was assessed using an adapted Downs and Black checklist. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: Twenty-six studies (1153 patients) were eligible for qualitative synthesis, and 16 were included in the meta-analysis. Moderate certainty evidence suggests that the overall response rate to nonoperative treatment was 54% (95% confidence interval: 32%, 76%). The overall mean improvement after physical therapy treatment was 11.3 points (7.6-14.9) on 100-point patient-reported hip symptom measures (low to moderate certainty) and 22.2 points (4.6-39.9) on 100-point pain severity measures (low certainty). No definitive specific effect was observed regarding therapy duration or approach (ie, flexibility exercise, movement pattern training, and/or mobilization) (very low to low certainty). Very low to low certainty evidence supported viscosupplementation, corticosteroid injection, and a supportive brace. CONCLUSION: Over half of patients with nonarthritic hip-related pain reported satisfactory response to nonoperative treatment. However, the essential elements of comprehensive nonoperative treatment remain unclear. J Orthop Sports Phys Ther 2023;53(5):1-21. Epub 9 March 2023. doi:10.2519/jospt.2023.11666.

Why Is There a Range in Time Returning to Preoperative Activity Habits After Femoroacetabular Impingement Treatment in Recreational Athletes?

CONTEXT: Professional athletes showed excellent results after hip preserving procedures. However, there is still a lack of knowledge regarding the rate of return to activity and the rehabilitation time of recreational athletes. Thus, the aim of this study was to investigate factors that were associated with an extended return-to-activity time in nonprofessional athletes. DESIGN: Retrospective, quantitative case-control study. METHODS: This study included 47 cases (45 nonprofessional athletes), which were divided according to return-to-activity time (short term: 0.0-7.0 mo vs long term: >7.0 mo). The clinical outcome were evaluated with the modified Harris hip score, the nonarthritic hip score, the Western Ontario and McMaster Universities Osteoarthritis Index, and the University of California, Los Angeles activity score. For statistical analysis between both groups, an unpaired student t test and a paired Wilcoxon test were used. In addition, the sports behavior, intraoperative findings, and surgical procedures were also assessed. RESULTS: After a mean follow-up of 4.3 years (±0.6; 3.4-5.6), the overall postoperative modified Harris hip score was 81.8 points, the nonarthritic hip score was 75.8 points, the Western Ontario and McMaster Universities Osteoarthritis Index was 36.7 points, and the University of California, Los Angeles activity score was 7.9. Compared with the preoperative results, all scores improved significantly (P < .001). Patients of the short-term return-to-activity group showed a higher preoperative activity diversity and, postoperatively, a higher rate in high-impact sports (P = .024). CONCLUSIONS: After mini-open arthrotomy for femoroacetabular impingement syndrome treatment, 92.5% of the recreational athletes returned to sports activity. The findings did not detect factors influencing the return-to-activity time. However, a higher preoperative diversity of activities and a shift to high-level impact sport activities might support a shorter rehabilitation.

Biomechanical measures of clinician-defined unsteadiness during a forward stepdown task in individuals post-arthroscopy for femoroacetabular impingement syndrome.

BACKGROUND: Patients with femoroacetabular impingement syndrome can present with aberrant movement patterns including unsteady balance. Balance training is included in rehabilitation after hip arthroscopy and may improve quality of movement; however, specific biomechanical measures associated with clinician-defined balance impairments are unknown. We aimed to understand these associations as they may inform targeted rehabilitative interventions. METHODS: The forward stepdown is a clinical test used to evaluate movement quality, including balance. 23 individuals at least one-year post-arthroscopy for femoroacetabular impingement syndrome and 15 healthy comparisons performed the forward stepdown, recorded by 3-dimensional motion capture and 2-dimensional video. Three physical therapists graded the 2-dimensional video for steadiness. Two-way analyses of variance were used to evaluate the interaction of group (post-arthroscopy/healthy comparison) by steadiness (steady/unsteady), for center of pressure medial-lateral excursion, center of pressure path length, and lateral trunk, pelvis, and lower extremity joint excursions. FINDINGS: Six (26.1%) participants post-arthroscopy and five (33.3%) healthy comparisons were categorized as unsteady. The odds of being categorized as unsteady were not greater for participants post-arthroscopy (P = 0.72). There were no significant interactions; however, participants with clinician-defined unsteady balance, regardless of group, had significantly greater frontal plane trunk excursion, greater hip excursion, and greater center of pressure path length than those with steady balance (P ≤ 0.006). INTERPRETATION: The odds of being categorized as unsteady were not greater for individuals post-arthroscopy for femoroacetabular impingement syndrome. Clinician-defined unsteadiness was associated with greater frontal plane trunk and hip motion which may be rehabilitation targets to improve balance during a dynamic single-leg task.

Criteria for Return to Play After Hip Arthroscopy in the Treatment of Femoroacetabular Impingement: A Systematic Review.

BACKGROUND: Femoroacetabular impingement (FAI) is a common pathology in athletes that often requires operative management in the form of hip arthroscopy. PURPOSE: To systematically review the rates and level of return to play (RTP) and the criteria used for RTP after hip arthroscopy for FAI in athletes. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of the literature, based on the PRISMA guidelines, was performed using PubMed, Embase, and Scopus databases. Studies reporting outcomes after the use of hip arthroscopy for FAI were included. Outcomes analyzed were RTP rate, RTP level, and criteria used for RTP. Statistical analysis was performed using SPSS software. RESULTS: Our review found 130 studies, which included 14,069 patients (14,517 hips) and had a mean methodological quality of evidence (MQOE) of 40.4 (range, 5-67). The majority of patients were female (53.7%), the mean patient age was 30.4 years (range, 15-47 years), and the mean follow-up was 29.7 months (range, 6-75 months). A total of 81 studies reported RTP rates, with an overall RTP rate of 85.4% over a mean period of 6.6 months. Additionally, 49 studies reported the rate of RTP at preinjury level as 72.6%. Specific RTP criteria were reported in 97 studies (77.2%), with time being the most commonly reported item, which was reported in 80 studies (69.2%). A total of 45 studies (57.9%) advised RTP at 3 to 6 months after hip arthroscopy. CONCLUSION: The overall rate of reported RTP was high after hip arthroscopy for FAI. However, more than one-fourth of athletes who returned to sports did not return at their preinjury level. Development of validated rehabilitation criteria for safe return to sports after hip arthroscopy for FAI could potentially improve clinical outcomes while also increasing rates of RTP at preinjury levels.

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)

Associations Between Movement Impairments and Function, Treatment Recommendations, and Treatment Plans for People With Femoroacetabular Impingement Syndrome.

OBJECTIVE: The purpose of this study was to describe movement impairments for persons with femoroacetabular impingement syndrome and their association with function, treatment recommendations, and treatment plans. METHODS: This report is a secondary, observational analysis of a clinical trial dataset in which participants received an interdisciplinary evaluation from a surgeon and physical therapist. The therapist documented frontal and sagittal plane movement impairments across 6 functional tasks. Associations between number of impairments in each plane and function (33-item International Hip Outcome Tool [iHOT33]) were evaluated using Pearson or Spearman correlations. Joint provider recommendations (physical therapist and surgeon) and participant-reported treatment plans were dichotomized based on the inclusion of physical therapy or not. Logistic regressions were used to examine the effects of (1) iHOT33, total movement impairments, and previous physical therapist treatment on joint provider recommendation and (2) these same variables along with joint provider recommendation on participant treatment plan; prevalence ratios and 95% CIs were reported for significant contributors. RESULTS: Thirty-nine participants demonstrated an average iHOT33 of 35.0 (SD = 19.5) and presented with a median 5 frontal and 3 sagittal plane impairments. More frontal plane impairments were associated with worse iHOT33 scores. Twenty-seven participants received a joint provider recommendation that included physical therapy; no significant contributors to these recommendations were identified. Twenty-four of the 27 participants with a physical therapist recommendation included physical therapy in their treatment plan. Two additional participants did not receive a physical therapist recommendation but included physical therapy in their plan. Joint provider recommendation was the only significant contributor to the participant-reported plan (prevalence ratio = 7.06; 95% CI = 3.25-7.97). CONCLUSION: Persons with femoroacetabular impingement syndrome displayed clinically observable movement impairments that were associated with worse function. Joint provider recommendations strongly influenced participants' treatment plans to pursue physical therapy. IMPACT: Physical therapists contribute new information to surgical examinations regarding movement. Joint recommendations from the physical therapist and the surgeon can influence patients' decisions to pursue physical therapy.

Rehabilitation Protocol After Hip Arthroscopy: A 2015-2020 Systematic Review.

OBJECTIVE: Although many rehabilitation protocols after hip arthroscopy have been described, there is still significant variability about duration, goals, restrictions, and techniques to apply by the physical therapy after the surgical procedure. The aim of the study was to systematically review rehabilitation after hip arthroscopy. DESIGN: The data sources were PubMed, Scopus, and Cochrane Library. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used for the systematic review. Level I-IV evidence clinical studies and clinical reviews that focused on rehabilitation protocols after hip arthroscopy have been used as study eligibility criteria. Major limitations include the retrospective nature of most of the studies selected (level IV evidence) and the use of different clinical scores to report the outcomes. RESULTS: This review showed that although a standardized guideline on rehabilitation after hip arthroscopy is still missing, the most recent studies and clinical trials are focusing on a four-phase program, which includes goals, recommendations, and a progression of exercises. CONCLUSIONS: Rehabilitation after hip arthroscopy is strongly suggested, but different authors recommended different rehabilitation programs. There is not a defined program, but as of today, the current standard of care is composed of phase-based programs.

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.

Age and Outcomes in Hip Arthroscopy for Femoroacetabular Impingement: A Comparison Across 3 Age Groups.

BACKGROUND: Limited evidence exists concerning the effect of age on hip arthroscopy outcomes for femoroacetabular impingement (FAI). PURPOSE/HYPOTHESIS: The purpose was to investigate patient-reported outcomes (PROs) and clinical failure rates across various age groups in patients undergoing hip arthroscopy for FAI. We hypothesized that older patients would experience lower improvements in PROs and higher clinical failure rates. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 109 of 130 eligible consecutive patients underwent hip arthroscopy for FAI with a minimum 5-year follow-up. Patients were stratified into 3 groups for comparison (ages 15-34, 35-50, and 51-75 years). Clinical survival rates to revision surgery or total hip arthroplasty (THA) were determined by Kaplan-Meier analysis, and PROs were assessed using analysis of variance. Regression analysis was used to determine factors associated with clinical failure and ΔPROs from baseline to 5 years. RESULTS: The 5-year survival-to-revision rate was 71% (survival time, 69.2 months; 95% CI, 62.8 to 75.5 months). A significant difference in survival to THA was found between groups (P = .030). Being in the older group versus the young and middle-aged groups predicted increased risk of THA conversion (hazard ratio, 5.7; 95% CI, 1.1 to 28.6; P = .035). Overall modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) improved from baseline to 5 years (mHHS, P < .001; NAHS, P < .001). Body mass index (mHHS: beta, -1.2; 95% CI, -2.2 to -0.3; P = .013; NAHS: beta, -1.6; 95% CI, -2.6 to -0.5; P = .005) and baseline PROs (mHHS: beta, -0.8; 95% CI, -1.1 to -0.4; P < .001; NAHS: beta, -0.7; 95% CI, -1.1 to -0.4; P < .001) were predictive of 5-year ΔPROs. A decrease was seen in minimal clinically important difference rates in middle-aged (P = .011) and old (P = .030) groups from 6-month to 5-year outcomes. CONCLUSION: Although hip arthroscopy for FAI yielded improvements in PROs regardless of age, middle-aged and older patients experienced greater declines in clinical outcomes over time than younger patients. Older patients remain good candidates for arthroscopy despite a greater risk for conversion to THA.

Return to Sports After Joint Preservation Hip Surgery.

Femoroacetabular impingement results from a mismatch of congruency between the femoral head and the acetabulum. This condition is most common among young, active patients and may lead to pain, decreased quality of life, and inability to participate in athletics. Hip preservation surgery is widely performed is used as a definitive treatment option in athletes at all levels of competition. Athletes have reported high rates of return to play and satisfaction and expect rehabilitation to require approximately 4 to 6 months. This article provides an overview of femoroacetabular impingement, including diagnosis and treatment, with focus on athletes and return to play.

Running with Femoral Acetabular Impingement: Operative Vs Nonoperative Treatment.

A 31-year-old female lawyer presents with right hip pain starting approximately 3 years ago and worsening over the past 2 to 3 months. She is an avid runner, running 20 to 30 miles weekly, and noticed that her pain started after a running program training for the marathon. Her pain is primarily over the lateral aspect of her hip with some radiation into the groin. The pain is made worse with impact exercises such as running and made better with walking and cycling. She has done physical therapy for the past 3 months without any significant improvement. She has not had any injections or taken anti-inflammatories because of a history of gastric ulcer disease. On physical examination she has mild tenderness over her right greater trochanter and her range of motion tests are full in terms of flexion, internal rotation, and external rotation. She has a positive FADIR (flexion-adduction-internal rotation) impingement that causes both groin and lateral hip pain. Radiograph of the right hip revealed preservation of the joint space and an anterior cam lesion with reduced offset at the femoral head neck junction. Magnetic resonance imaging (MRI) of the right hip revealed a tear at the anterior superior labrum at the 1 to 2 o'clock position along with subjacent bone marrow edema in the femoral head that is likely reactive. Computed tomography (CT) scan of the right hip confirmed a combined cam and pincer type femoral acetabular impingement of the right hip with overcoverage of the femoral head. There was 15° of femoral anteversion and the coronal lateral center of edge angle (LCEA) is 34°. Dr. Peter Moley argues that a focused rehabilitation program to restore strength and motor control of the deep hip stabilizers will provide optimal functional recovery. Dr. Jakub Tatka argues that right hip arthroscopy with labral repair and possible osteochondralplasty are indicated in order to prevent early hip arthritis and prevent long-term sequela of femoral acetabular impingement.

Improving function in people with hip-related pain: a systematic review and meta-analysis of physiotherapist-led interventions for hip-related pain.

OBJECTIVE: To report the effectiveness of physiotherapist-led interventions in improving pain and function in young and middle-aged adults with hip-related pain. DESIGN: Systematic review and meta-analysis. DATA SOURCES: A comprehensive, reproducible search strategy was performed on five databases in May 2019. Reference lists and grey literature were also searched. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Population: people aged ≥18 years with hip-related pain (with or without a diagnosis of femoroacetabular impingement syndrome). INTERVENTION(S): physiotherapist-led interventions for hip pain. Comparators: sham treatment, no treatment or other treatment (eg, hip arthroscopic surgery). OUTCOMES: primary outcomes included patient-reported hip pain and function. Secondary outcomes included physical function measures. RESULTS: 1722 papers were identified. After exclusion criteria were applied, 14 studies were included for analysis. They had varied risk of bias. There were no full-scale placebo-controlled randomised controlled trials (RCTs) of physiotherapist-led treatment. Pooled effects ranged from moderate effects (0.67 (95% CI 0.07 to 1.26)) favouring physiotherapist-led intervention over no treatment post-arthroscopy, to weak effects (-0.32 (95% CI 0.57 to 0.07)) favouring hip arthroscopy over physiotherapist-led treatment. CONCLUSION: Physiotherapist-led interventions might improve pain and function in young and middle-aged adults with hip-related pain, however full-scale high-quality RCT studies are required. PROSPERO REGISTRATION NUMBER: CRD42018089088.

There Is Limited and Inconsistent Reporting of Postoperative Rehabilitation for Femoroacetabular Impingement Syndrome: A Scoping Review of 169 Studies.

OBJECTIVE: To evaluate the reporting of rehabilitation guidelines in studies of postoperative outcomes of patients with femoroacetabular impingement (FAI) syndrome and/or labral tear. DESIGN: Scoping review. LITERATURE SEARCH: A computer-assisted literature search was conducted of the MEDLINE, CINAHL, and Embase databases on June 17, 2018. Using key words related to FAI syndrome/labral tear and both open and arthroscopic surgical outcomes, we identified 169 studies that included 16 675 patients. Separate authors calculated and verified the prevalence of reported outcomes. STUDY SELECTION CRITERIA: We included intervention and observational studies that were prospective or retrospective in design. Studies must have included patients with a primary diagnosis of FAI syndrome and/or labral tear. DATA SYNTHESIS: We calculated the mean ± SD prevalence for continuous variables, where possible. RESULTS: Hip arthroscopy was the primary surgical procedure (76% of studies). The mean ± SD age of participants was 34.8 ± 9.2 years and the mean ± SD follow-up time was 27 ± 15.3 months. Of the 169 included studies, 74 (44%) discussed phases of rehabilitation, 49 (29%) reported details on goals between phases, 1 in 3 described details on rehabilitation progression, and fewer than 1 in 10 reported sufficient detail to replicate the rehabilitation protocol. Weight-bearing and range-of-motion restrictions were poorly reported and variable in duration. CONCLUSION: Surgical outcome studies do not provide sufficient detail or consistency for practicing clinicians to replicate a postoperative rehabilitation protocol for patients with FAI syndrome/labral tear. J Orthop Sports Phys Ther 2020;50(5):252-258. doi:10.2519/jospt.2020.9189.