Accepted Manuscript

Title: Impaired hip muscle strength in patients with

femoroacetabular impingement syndrome

Authors: Signe Kierkegaard, Inger Mechlenburg, Bent Lund,

Kjeld Søballe, Ulrik Dalgas

PII: S1440-2440(17)30434-6
DOI: http://dx.doi.org/doi:10.1016/j.jsams.2017.05.008
Reference: JSAMS 1526

To appear in: Journal of Science and Medicine in Sport

Received date: 26-9-2016

Revised date: 6-4-2017
Accepted date: 15-5-2017

Please cite this article as: Kierkegaard Signe, Mechlenburg Inger, Lund Bent,
Søballe Kjeld, Dalgas Ulrik.Impaired hip muscle strength in patients with
femoroacetabular impingement syndrome.Journal of Science and Medicine in Sport
http://dx.doi.org/10.1016/j.jsams.2017.05.008

This is a PDF file of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its final form. Please note that during the production process
errors may be discovered which could affect the content, and all legal disclaimers that
apply to the journal pertain.
Impaired hip muscle strength in patients with femoroacetabular impingement syndrome

Signe Kierkegaard a*, Inger Mechlenburg b,c, Bent Lund a, Kjeld Søballe b & Ulrik Dalgas d

a
Department of Orthopaedic Surgery, Horsens Hospital, Horsens, Denmark
b
Department of Orthopaedic Surgery, Aarhus University Hospital, Denmark
c
Centre of Research in Rehabilitation (CORIR), Department of Clinical Medicine, Aarhus University,
Denmark
d
Section for Sport Science, Department of Public Health, Aarhus University, Aarhus, Denmark

* Corresponding author:
Signe Kierkegaard, MSc, PhD-student
Department of Orthopaedic Surgery, Horsens Hospital
Sundvej 30, DK-8700 Horsens, Denmark
Email: signekierkegaard@hotmail.com
Phone: +45 2490 1231

Words: 2993

ABSTRACT
Objectives: Patients with femoroacetabular impingement (FAI) experience hip pain as well as
decreased function and lowered quality of life. The aim was to compare maximal isometric and
isokinetic muscle strength (MVC) during hip flexion and extension and rate of force development
(RFD) during extension between patients with FAI and a matched reference group. Secondary, the aim
was to compare patient hips and subgroups defined by gender and age as well as to investigate
associations between hip muscle strength and self-reported outcomes.
Design and method: Sixty patients (36 ±9 years, 63% females) and 30 age and gender matched
reference persons underwent MVC tests in an isokinetic dynamometer.
Results: During hip flexion and extension, patients’ affected hip showed a strength deficit of 15-21%
(p < 0.001) and 10-25% (p < 0.03) compared with reference MVC, respectively. Patient’s affected hip
was significantly weaker than their contralateral hip. RFD was significantly decreased for both patient
hips compared to the reference group (p < 0.05). While age had less effect on MVC, female patients
were more affected than male patients. Self-reported measures were associated with isometric hip
muscle strength.
Conclusions: Patients with FAI demonstrate decreased hip flexion and extension strength when
compared to 1) reference persons and 2) their contralateral hip. There seems to be a gender specific
affection which should be investigated further and addressed when planning training protocols.
Furthermore, self-reported measurements were associated with isometric muscle strength, which
underlines the clinical importance of the reduced muscle strength.
Keywords: Femoracetabular Impingement, Hip joint, Muscle Strength Dynamometer

1
Introduction
Hip pain and decreased hip function has increasingly been linked to femoroacetabular impingement
(FAI), a condition with bony abnormalities of the femoral head and/or acetabulum. 1 Patients with FAI
are at risk of developing hip osteoarthritis (OA). 1 Reduced hip muscle strength is associated with an
increased risk of injuries and pain2 and has been linked to pathologies such as hip OA 3 and FAI 4.
Consequently, training protocols for these patients often aim to strengthen the hip muscles 2 and hence
knowledge on maximal muscle strength in this patient group in of great importance. In patients with
FAI, earlier studies have mainly compared isometric hip muscle strength to matched healthy controls.
These, investigations demonstrate that patients experience decreased hip abductor strength, whereas
conflicting results have been found for other muscle groups. 4-6 In the sagittal plane, Diamond et al. 6
found no deficits in hip flexion or extension strength, while Casartelli et al. 4 demonstrated a deficit in
hip flexion, compared to matched healthy controls. The conflicting results may be explained by small
sample studies with risk of type II errors. Another explanation could be differences in patient
characteristics, where higher age has been associated to poorer outcome of surgery7 and FAI has been
described to affect the genders differently in studies of clinical and self-reported data.8,9 Furthermore,
the existing evidence does not clarify how different contraction modes are affected by FAI, despite the
importance when designing training protocols. Another important mechanical muscle ability to
investigate is the rate of force development (RFD), which is a measure of the ability to perform fast
explosive contractions. RFD could have important implications for return to sport 10 – which is a
frequent request for patients with FAI undergoing treatment.11 However, this has similarly only been
investigated sparsely in patients with FAI. 6,12
Hence, the primary aim of the study was to investigate the hypothesis that patients with
FAI experience significantly decreased maximal isometric and isokinetic muscle strength and RFD
during hip flexion and extension compared to a matched reference group. Secondary, we aimed to
explore possible differences between patient hips, subgroups differences defined by gender and age
and to investigate associations between hip muscle strength and self-reported outcomes.

Methods
The design of the study was a cross-sectional, comparative study enrolling patients with
FAI and age and gender matched reference persons. The Central Denmark Region Committee on
Biomedical Research Ethics (1-10-72-239-14) and the Danish Data Protection Agency (1-16-02-499-
14) approved the study. Before inclusion, all participants have their written, informed consent in
accordance with the Declaration of Helsinki II. 13 The study was registered at www.clinicaltrials.org
(ID: NCT02306525) and a full study protocol has been published. 14 A sample size of 60 patients and
30 reference persons was calculated based on maximal hip flexor muscle strength data from Casartelli
et al.4 Further details are described in in the protocol. 14
Participants were investigated in a laboratory setting at Aarhus University, Denmark.
All participants were recruited and tested between December 2014 and April 2016 by the same tester
(SK). The inclusion criteria for the patients were: scheduled arthroscopic hip surgery at Horsens
Hospital, Denmark; a diagnosis of cam and/or pincer impingement; for patients with cam, an alpha
angle ≥55° on an anteroposterior (AP) standing radiograph; for patients with pincer, a center edge
angle >25° on an AP radiograph; no signs of retroversion in the lower 2/3 of the hip joint on an AP
radiograph; no posterior wall sign on an AP radiograph; OA grade 0–1 according to Tönnis’
classification15 joint space width of >3 mm on all viewa and age between 18 and 50 years. The
exclusion criteria were: previous corrective hip surgery of the included hip; FAI secondary to other hip
conditions such as the Legg-Calvé-Perthes disease and epiphysiolysis; alloplastic surgery at the hip,
knee or ankle region (both legs); cancer or neurological diseases that affect movement pattern;
inability to speak or understand Danish or if they were pregnant at the time of inclusion.

2
 The references persons consisted of volunteers responding to advertisements at Aarhus
University Hospital or Aarhus University. Volunteers were eligible as a reference person if they had
no known hip pain/problems and no back, knee or ankle pain/problems during the past year.
Exclusion: previous major surgery in hips, knees or ankles, any disease that may affect functional
performance (e.g., neurological diseases). The included reference persons were gender and age
matched in a reference person to patient ratio of 1:2.
Participants performed a 5 minute warm-up on a bicycle ergometer before maximal
strength testing. Participants laid supine on the dynamometer chair (Humac Norm, CSMi, Stoughton,
Massachusetts, USA) with the chair back inclined 15° and the dynamometer rotation axis aligned with
the hip rotation centre (greater trochanter).4 The order of test of the hips and the starting muscle group
was determined by randomisation. Prior to testing, the mass of the tested limb was measured to adjust
for gravity. The muscle groups were then tested in the following order: isometric, then alternating
concentric and eccentric. For all three contraction types, participants completed two submaximal
familiarization trials followed by three Maximum Voluntary Contraction (MVC) trials (4 trials if the
3rd trial deviated >10% from no. 1 and 2). Isometric testing was performed with participants lying with
the hip flexed to 45° (from horizontal).4 Participants were instructed to perform maximally and build
up the contraction as hard as possible. The contraction was held for 3-4 seconds depending on when
the participant reached a steady plateau. Standardised, verbal encouragement was provided. After
isometric testing, participants had their isokinetic strength assessed in the range of hip motion from
10–80° at an angular velocity of 60°/s. The participants were instructed to perform a concentric
contraction as fast and hard as possible, immediately followed by an eccentric contraction at -60°/s.
There was a resting period of 30 seconds between all tests. The reliability of isometric and isokinetic
(60°/s) strength test of the hip flexors and extensors in healthy persons using an isokinetic
dynamometer has been demonstrated to be high (ICC 0.77-0.99). 16 A measurement was excluded if
the patient rotated the leg while performing a trial. Patients were asked to rate their pain during each
test on a 0-100 mm visual analogue scale immediately after each test. Participants had their body mass
and fat percentage measured with a Tanita (SC-330MA, Tanita Corporation of America, Illinois,
USA).
The maximal peak torque (Nm), sampled at 100 Hz, divided by body mass (kg) was the
primary outcome measure. Differences in percentage were calculated as: (reference right hip - affected
patient hip)/reference right hip in analyses of patient vs. reference and as: (contralateral hip-affected
hip)/contralateral hip in analyses of affected hip vs. contralateral hip.
During isometric hip extension, RFD data was sampled at 1000 Hz. Torque (Nm) at 0,
30, 50, 100 and 200 milliseconds was extracted and the mean of 2-4 measurements scaled to body
mass and maximal strength was calculated. Contraction onset was defined as when the torque level
increased by more than 7.5 Nm from the resting level17.
Participants completed the Copenhagen Hip and Groin Outcome Score (HAGOS).
HAGOS consists of the subscales Pain, Stiffness, Activities of Daily Living (ADL), Sport, Physical
Activity (PA) and Quality of Life (QOL) and is constructed for and validated in a population of
younger persons with hip/groin pain.18 Furthermore, participants answered general questions (e.g.
years with hip pain, comorbidities) as described in the protocol. 14 Raw scores from the HAGOS
questionnaires were converted to a 0-100 scale.19
Comparisons between patients and reference persons were made with multiple
regression analysis adjusted for age and gender (for which they were matched). The same statistical
approach was applied for unpaired data in the subgroup analyses and investigations of associations,
except for the adjustments of age and gender. For paired data, student’s paired t-test was applied. A
5% level of significance was applied and all statistical analyses were made with Stata 13 ®.

Results

3
Sixty patients (age: 36 ±9 years, 63% females) and 30 age and gender matched reference persons were
included in the study. A flowchart is presented in supplementary figure 1 and participant
characteristics are shown in table 1.
--- Please insert table 1 around here ---
The affected hip of the patients was significantly weaker than for reference persons during all
MVC tests (table 2). During hip flexion and extension, mean patient MVC of the affected hip was 15-
21% and 10-25% lower than the MVC of reference persons, respectively. RFD measured during
isometric hip extension was impaired for both patient hips when compared to the reference hips
(figure 1, stars indicate time points with significant differences). Mean difference [95% confidence
interval] between affected patient leg and reference leg was 0.21 [0.17;0.25], 0.06 [0.01;0.12] and 0.07
[0.02;0.13] at 50, 100 and 200 milliseconds, respectively.
--- Please insert table 2 around here ---
--- Please insert figure 1 around here ---

Patients’ affected hip was 7-13% weaker than their contralateral hip except for
eccentric hip extension (table 2). Subgroup analyses of bilaterally affected (16 patients) vs. unilaterally
affected (34 patients) showed that patients being unilaterally affected had significantly weaker affected
hip compared to their contralateral hip.
Patient age was weakly associated with isometric (coefficient: -0.02, p = 0.03, R2 =
0.08) and eccentric hip flexion of the affected patient hip (coefficient: -0.02, p = 0.02, R2 = 0.11).
Subgroup analyses of muscle strength for male vs. female patients revealed that female
patients experienced muscle strength deficits of 19-36% of the affected hip compared to reference
females. This was not demonstrated for male patients (Supplementary table 1).
Better scores on HAGOS subscales (except PA) were associated with greater isometric
flexion and extension MVC. Furthermore, better scores on the subscales, pain, symptoms and ADL
was associated with greater concentric extension strength (Supplementary table 2). There were no
significant associations between pain measured during strength testing and MVC (data not shown).
There was a significant difference in body mass between patients and reference persons.
Hence, a sensitivity analysis was made removing the persons with the largest body mass (10%
heaviest) from the data set, eliminating this difference but keeping the same age and gender
distribution. Hereafter analyses were repeated showing no overall differences in the results.

Discussion
This well-powered cross-sectional study, comparing maximal hip flexion and extension muscle
strength in patients with FAI syndrome to matched reference persons, showed a significant strength
deficit for the patients. Furthermore, the affected hip of the patients was significantly weaker than the
contralateral hip (except during eccentric hip extension). There was a tendency suggesting a potential
difference in the level of muscle strength impairments seen in male and female patients. Finally, self-
reported outcomes were associated with the isometric flexion and extension strength of the affected
patient hip.
This study adds to the growing body of evidence characterizing patients with FAI.
Similar to our findings, Casartelli et al. 4 reported a strength deficit in the hip flexor muscles in patients
with FAI (26%), but this is the first study to demonstrate extensor weakness as well. The deficits from
the extensors in our study were most pronounced during concentric contractions (25%), whereas
isometric contractions (16%) and eccentric contractions (10%) were less impaired. Another tendency
was that concentric hip extension was the most impaired movement. This could be linked to the

4
decreased RFD found in our patients. When performing the concentric test procedure, patients had to
rapidly contract their hip muscles while the dynamometer arm was running at 60°/s. Hence, if patients
were slow at initiating the movement, they also lacked time to gain their maximal force production. Of
note, both hips demonstrated decreased RFD. This suggests a central, protective mechanism where
patients protect their hip joints during maximal contractions, possibly limiting their ability to perform
and react during sport and daily activities.17 These findings are in line with earlier studies
demonstrating a decreased degree of activation of the musculus (m.) tensor fascia latae and a
decreased time to react for the m. gluteus maximus in patients with FAI. 4,20 It would be of interest to
determine important determinants of muscle strength in terms of the voluntary degree of activation
compared to the maximal attainable degree of activation as well as the cross sectional area of the hip
muscles. This could help clarify how much of the muscle deficits in patients with FAI is determined
by actual loss of muscle mass and how much is determined by protective neural mechanisms. While
the patients in the present study underwent tests, many of them actually noted that they “felt unable to
activate their hip muscles”. Future studies investigating these underlying aspects are therefore
warranted, when aiming to gain a better understanding of how to optimize training protocols. This
would also clarify whether the main focus in training protocols ought to be on relearning muscle
activation of the hip muscles and/or on inducing muscle hypertrophy by resistance training.
As in earlier studies,4,6 we recorded pain during muscle strength testing, to investigate if
pain severity affected MVC. We did not find any association between MVC and pain during testing. In
this regard, we recently discussed if pain measured on a VAS is in fact a valid measure of pain in
patients with FAI.21 Where VAS is a single measure, which is subject to much variability, more
“disease specific” questionnaires validated in patients with FAI, such as HAGOS, might better
describe patient symptoms. HAGOS pain was significantly associated with isometric MVC and as this
score asks about different aspects of pain over a period of time, it could provide a better reflection of
the way patients preserve their hip during the day.
A novel finding of the current study concerns the impact of patient demographics on
muscle strength outcomes. Female patients had more pronounced muscle strength impairments than
seen in male patients. Keeping in mind that our study was not powered to look at gender differences,
the finding is still interesting as it raises some fundamental questions. Should genders be treated
differently during training protocols? While the study by Casartelli et al.4, in accordance with our
findings, also reported deficits in hip flexion strength, Diamond et al. 6 found no deficits in neither hip
flexion nor extension strength. However, the Diamond-study was, similar to Casartelli et al.4, based
upon a relatively small patient sample and most patients were males (73%). While symptom duration
was similar to our study, all HAGOS scores in the Diamond-study were better than in our study. Since
we found that better HAGOS scores were associated with greater isometric muscle strength (which
Diamond et al.6 tested), it could be that these factors (a high percentage of males and better HAGOS
scores) help explain why the study found no differences between patients and reference persons in
MVC of the hip flexor and extensor muscles. A study with a large number of patients (229 patients)
investigated gender differences in self-reported physical function before and after hip surgery. 9 It was
demonstrated that females reported lower functional scores before surgery than males, but that there
was no difference after surgery. Hence, it is interesting to investigate if muscle strength will follow
this pattern after treatment protocols in patients with FAI, with females showing an impairment level
similar to males.
Nepple et al.22 found side differences among patients with FAI where the affected hip
was weaker than the contralateral. In our study, a similar difference between hips was found.
However, side differences between the right and left hip were also present for some tests performed in
reference persons. Kemp et al.2 investigated hip muscle strength in recreational persons and found no
differences between dominant and non-dominant hips in isometric hip muscle strength. Nepple et al.22
suggested that side differences of more than 10% could likely reflect a pathological difference.
However, 33-53% (depending on the test) of the participants in our reference group demonstrated side
differences of more than 10%, indicating that side differences in hip muscle strength could be a
frequent finding in the reference population. Consequently, from the present findings, it is not clear if

5
side differences are a pathological condition or not in FAI and whether or not this can be used by the
clinician when defining relevant rehabilitation goals.
A strength of the study is the prospective, consecutively included patient group
allowing generalisability to the broad patient group seen in the clinics. However, the following
limitations should be kept in mind: First, reference persons did not undergo any imaging, and it is
therefore unknown if they were radiologically healthy despite having no clinical signs of hip
abnormalities. This restriction made us categorise them as a “reference group” rather than a “healthy
control group”. Hence, the finding of more than 10% side difference in some reference persons could
be related to persons not being “healthy”. However, the recently published Warwick agreement 23
states that FAI syndrome should be diagnosed based on a combination of symptoms, clinical signs and
imaging findings. Furthermore, it states that it is currently unknown whether asymptomatic imaging
findings lead to FAI syndrome. Consequently, we believe that our reference group represent a fair
comparator although addition of imaging could have further strengthened the description of the group.
Second, there was a difference in body weight between patients and reference persons. However, we
performed a sensitivity analysis which gave similar results as our primary analysis, why the influence
of this seems to be limited. Third, some patients were unable to complete the isokinetic strength tests
due to pain and discomfort. This fact may also impact on the analyses of associations to self-reported
outcomes, since data on the possibly most affected patients were not available for inclusion in this
analysis. Fourth, side differences between affected and contralateral leg could not be demonstrated in
patients bilaterally affected with FAI. However, the sample of bilateral patients consisted only of 16
patients which limits the power of this analysis, why a larger group should be investigated. Finally, the
cross sectional design did not allow us to investigate the development in muscle strength over time in
patients with FAI.

Conclusion
Patients with FAI experience impaired maximal muscle strength of the hip flexors and extensors and
reduced RFD during extension when compared to matched reference persons. The affected patient hip
was significantly weaker than the contralateral hip during most tests. While age had little effect on
muscle strength outcomes, a potential gender-specific effect was observed suggesting a higher
impairment level in female patients. Self-reported outcomes where associated with particularly
isometric hip flexion and extension.

Practical implications
- Patients with femoroacetabular impingement experience decreased maximal hip flexion and
extension strength compared to matched references persons with no hip problems
- Most impaired is concentric contraction and rate of force development during maximal
contraction
- There could be a gender specific pattern in maximal muscle strength with female patients
being more impaired than male patients
- Maximal isometric hip flexion and extension strength is associated with self-reported
outcomes underlining the clinical relevance of the impairments

Contributors
All authors helped design the study. SK collected data and wrote the initial draft for the manuscript,
UD helped revise it into a full version. IM, KS and BL gave their input hereafter and all authors
approved the final version of the manuscript.

6
Acknowledgements
The authors declare no competing interests. This work was supported by the Danish Rheumatism
Association, the Aase & Ejnar Danielsen Foundation, the Augustinus Foundation, the AP Møller
Foundation, the Hede Nielsen Foundation, the Gurli & Hans Engell Friis Foundation, the Madsen
Foundation and the Horsens Hospital, Denmark. The funding parties had no role in writing the
manuscript, interpreting results or approving the manuscript before submission.

7
References
1. Agricola R, Heijboer MP, Bierma-Zeinstra SM, et al. Cam impingement causes osteoarthritis of the
hip: a nationwide prospective cohort study (CHECK). Ann Rheum Dis 2013;72(6):918-23 doi:
10.1136/annrheumdis-2012-201643.
2. Kemp JL, Schache AG, Makdissi M, et al. Greater understanding of normal hip physical function
may guide clinicians in providing targeted rehabilitation programmes. J Sci Med Sport
2013;16(4):292-6 doi: 10.1016/j.jsams.2012.11.887.
3. Arokoski MH, Arokoski JP, Haara M, et al. Hip muscle strength and muscle cross sectional area in
men with and without hip osteoarthritis. J Rheumatol. 2002;29(10):2185-95.
4. Casartelli NC, Maffiuletti NA, Item-Glatthorn JF, et al. Hip muscle weakness in patients with
symptomatic femoroacetabular impingement. Osteoarthritis Cartilage. 2011;19(7):816-21
doi: 10.1016/j.joca.2011.04.001
5. Harris-Hayes M, Mueller MJ, Sahrmann SA, et al. Persons With Chronic Hip Joint Pain Exhibit
Reduced Hip Muscle Strength. J Orthop Sports Phys Ther 2014:1-30 doi:
10.2519/jospt.2014.5268.
6. Diamond LE, Wrigley TV, Hinman RS, et al. Isometric and isokinetic hip strength and
agonist/antagonist ratios in symptomatic femoroacetabular impingement. J Sci Med Sport
2015 doi: 10.1016/j.jsams.2015.10.002.
7. Philippon MJ, Schroder ESBG, Briggs KK. Hip arthroscopy for femoroacetabular impingement in
patients aged 50 years or older. Arthroscopy 2012;28(1):59-65 doi:
10.1016/j.arthro.2011.07.004.
8. Lindner D, El Bitar YF, Jackson TJ, et al. Sex-Based Differences in the Clinical Presentation of
Patients With Symptomatic Hip Labral Tears. Am J Sports Med 2014;42(6):1365-9 doi:
10.1177/0363546514532226.
9. Joseph R, Pan X, Cenkus K, et al. Sex Differences in Self-Reported Hip Function Up to 2 Years
After Arthroscopic Surgery for Femoroacetabular Impingement. Am J Sports Med
2016;44(1):54-9 doi: 10.1177/0363546515610535.
10. Maffiuletti NA, Aagaard P, Blazevich AJ, Folland J, Tillin N, Duchateau J. Rate of force
development: physiological and methodological considerations. Eur J Appl Physiol. 2016 doi:
10.1007/s00421-016-3346-6
11. Mannion AF, Impellizzeri FM, Naal FD, Leunig M. Fulfilment of patient-rated expectations
predicts the outcome of surgery for femoroacetabular impingement. Osteoarthritis Cartilage
2013;21(1):44-50.
12. Casartelli NC, Leunig M, Item-Glatthorn JF, et al. Hip flexor muscle fatigue in patients with
symptomatic femoroacetabular impingement. Int Orthop 2012;36(5):967-73 doi:
10.1007/s00264-011-1385-5.
13. The World Medical Association. WMA Declaration of Helsinki – Ethical Principles for Medical
Research Involving Human Subjects. Helsinki, Finland: The World Medical Association;
1964 [updated 2013, localised: 04.03.17]. https://www.wma.net/policies-post/wma-
declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/
14. Kierkegaard S, Lund B, Dalgas U, et al. The Horsens-Aarhus Femoro Acetabular Impingement
(HAFAI) cohort: outcome of arthroscopic treatment for femoroacetabular impingement.
Protocol for a prospective cohort study. Bmj Open 2015;5(9) doi: ARTN e008952
10.1136/bmjopen-2015-008952.
15. Tonnis D, Heinecke A. Acetabular and femoral anteversion: relationship with osteoarthritis of the
hip. J Bone Joint Surg Am 1999;81(12):1747-70 1999/12/23.
16. Meyer C, Corten K, Wesseling M, et al. Test-retest reliability of innovated strength tests for hip
muscles. PloS one 2013;8(11):e81149 doi: 10.1371/journal.pone.0081149
17. Aagaard P, Simonsen EB, Andersen JL, et al. Increased rate of force development and neural drive
of human skeletal muscle following resistance training. J Appl Physiol (1985)
2002;93(4):1318-26 doi: 10.1152/japplphysiol.00283.2002.

8
18. Thorborg K, Holmich P, Christensen R, et al. The Copenhagen Hip and Groin Outcome Score
(HAGOS): development and validation according to the COSMIN checklist. Br J Sports med
2011;45(6):478-91 doi: 10.1136/bjsm.2010.080937.
19. HAGOS Scoring file 2011. Availible at koos.nu  HAGOS. Accessed 26 September 2016.
20. Seijas R, Alentorn-Geli E, Alvarez-Diaz P, et al. Gluteus maximus impairment in
femoroacetabular impingement: a tensiomyographic evaluation of a clinical fact. Arch Orthop
Trauma Surg 2016 doi: 10.1007/s00402-016-2428-6.
21. Kierkegaard S, Langeskov-Christensen M, Lund B, et al. Pain, activities of daily living and sport
function at different time points after hip arthroscopy in patients with femoroacetabular
impingement: a systematic review with meta-analysis. Br J Sports med 2017;51(7):572-79 doi:
10.1136/bjsports-2016-096618
22. Nepple JJ, Goljan P, Briggs KK, et al. Hip Strength Deficits in Patients With Symptomatic
Femoroacetabular Impingement and Labral Tears. Arthroscopy 2015 doi:
10.1016/j.arthro.2015.04.095.
23. Griffin DR, Dickenson EJ, O'Donnell J, et al. The Warwick Agreement on femoroacetabular
impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports
med 2016;50(19):1169-76 doi: 10.1136/bjsports-2016-096743.

9
Figure legends
Figure 1: Rate of force development (mean and standard deviations) during maximal isometric hip
extension.

10
Tables
Patients References
Table 1: Participant characteristics
(n = 60) (n = 30)
Age (years) 36 ±9 36 ±9
Gender distribution (% females) 63 60
Body mass (kg) 76 ±15 68 ±9
Height (cm) 174 ±8 174 ±8
Demographics

Fat mass (%) 27 ±10 23 ±12

Alcohol intake (median units of
1 to 5 1 to 5
alcohol/week)
Smokers (%) 18 7
Sick leave due to hip problem (yes:no) 07:53 -
Comorbidities (yes:no) 15:45 08:22
VAS back pain (mm) 16 [5;49] -
VAS knee pain (mm) 19 [1;51] -
Self-reported physical activity level (weekly
1 [0;4] 3.5 [2;4]*
hours)
6640 6869*
Steps per day, level ground (n)
[5619;8703] [5285;7696]
Symptoms
Hip (right:left) 36:24
Positive faber (%) 81
Positive 90 degree impingement (%) 86
Positive 120 degree impingement (%) 95
Alpha angle from AP radiograph 81 ±10
Center edge angle from AP radiograph 31 ±6
Alpha angle from CT scan 52 ±10
Center edge angle from CT scan 33 ±6
Time since first symptoms (years ago) 3 [1.5;7.5]
Use of pain killers (yes:no) 35:25
Affected hip

Copenhagen Hip and Groin Outcome Score

Pain 51 ±20 100 [100;100]
Symptoms 47 ±17 100 [96;100]
ADL 53 ±24 100 [100;100]
Sport 34 ±18 100 [100;100]
Physical function 21 ±23 100 [100;100]
QoL 31 ±15 100 [100;100]
Pain level during strength testing (VAS 0-100)
Flexion Concentric (mm) 25 [5;50]
Isometric (mm) 22 [7;51]
Eccentric (mm) 25 [5;50]
Extension Concentric (mm) 20 [0;44]
Isometric (mm) 15 [0;43]
Eccentric (mm) 22 [0;44]
Symptoms
Contralateral hip

Bilateral FAI (n)¹ 16

Pain level during strength testing (VAS 0-100)
Flexion Concentric (mm) 0 [0;16]
Isometric (mm) 0 [0;0]
Eccentric (mm) 0 [0;8]
Extension Concentric (mm) 0 [0;0]
Isometric (mm) 0 [0;0]

11
 Eccentric (mm) 0 [0;0]
Mean ±standard deviation or median [quartiles]. n: number of participants. * Non-significant difference
between patients and references. For the pain level during strength test the number of patients is
corresponding to the numbers displayed in table 2. For other measures, full dataset was available. Faber:
flexion, abduction, external rotation test. VAS: visual analogue scale. ADL: activities of daily living. QoL:
hip related quality of life. ¹Patients having surgery in contralateral hip before project, under project or listed
for surgery

12
 Table 2: Hip flexion and extension muscle strength in Nm/kg during different contraction modes in patients with FAI and in healthy controls.
A positive mean difference means the affected leg was weaker than the contralateral leg (for patients), that the left leg was weaker than the right leg (for reference persons)
and that the patient leg was weaker than the reference person leg (in patient vs. reference person comparisons).
Mean ±standard deviation. Pt.: patients. Ref.: references. Mean difference [95% CI] (95% confidence interval). Diff: difference. n: number of participants

Patients vs. reference

Patients References Patients: affected vs. contralateral
persons
n (pt., ref.) Mean diff % diff Mean diff
Affected Right hip p-value p-value % diff
[95%CI] [95% CI]
Flexion (Nm/kg)

Concentric 50, 29 1.4 ±0.6 1.8 ±0.4 0.4 [0.2;0.6] <0.001 21 0.2 [0.1;0.3] <0.001 13
Isometric 60,30 1.5 ±0.7 1.9 ±0.4 0.4 [0.2;0.6] <0.001 21 0.1 [0.05;0.2] 0.002 10
Eccentric 50,29 2.1 ±0.7 2.5 ±0.6 0.4 [0.2;0.6] <0.001 15 0.3 [0.1;0.4] <0.001 12
Contralateral Left hip References: right vs. left
Concentric 57,28 1.5 ±0.6 1.7 ±0.4 0.2 [-0.03;0.3] 0.101 9 0.1 [0.03;0.2] 0.014 -8
Isometric 60,30 1.6 ±0.6 1.8 ±0.4 0.2 [0.03;0.4] 0.022 11 0.1 [-0.1;0.2] 0.231 -5
Eccentric 57,28 2.3 ±0.8 2.4 ±0.6 0.1 [-0.2;0.3] 0.718 2 0.2 [-0.1;0.3] 0.127 -8
Patients vs. reference
Patients References Patients: affected vs. contralateral
persons
Mean diff % diff Mean diff
Affected Right hip p-value p-value % diff
[95% CI] [95% CI]
Extension (Nm/kg)

Concentric 54,29 2.1 ±1.0 2.8 ±0.7 0.7 [0.3;1.1] <0.001 25 0.2 [0.1;0.3] 0.009 7
Isometric 60,30 2.5 ±1.1 3.0 ±0.8 0.5 [0.1;0.8] 0.006 16 0.1 [0.002;0.3] 0.047 7
Eccentric 54,29 4.0 ±1.2 4.4 ±1.1 0.5 [0.1;0.9] 0.024 10 0.07 [-0.2;0.3] 0.532 1
Contralateral Left hip References: right vs. left
Concentric 58,27 2.2 ±0.9 2.7 ±0.6 0.5 [0.2;0.9] 0.001 19 0.03 [-0.2;0.1] 0.748 1
Isometric 60,30 2.6 ±0.9 2.9 ±0.7 0.2 [-0.1;0.5] 0.159 8 0.1 [0.02;0.3] 0.021 -6
Eccentric 58,27 3.9 ±1.1 4.3 ±0.8 0.3 [-0.04;0.7] 0.078 8 0.1 [-0.1;0.4] 0.353 -3

13