[ research report ]

JOANNE L. KEMP, PT, PhD1  •  SALLY L. COBURN, PT1  •  DENISE M. JONES, PT1  •  KAY M. CROSSLEY, PT, PhD1

The Physiotherapy for Femoroacetabular

Impingement Rehabilitation STudy
(physioFIRST): A Pilot Randomized
Controlled Trial
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F
emoroacetabular impingement syndrome (FAIS) is a common for FAIS results in significant cost and
cause of hip and groin pain in young and middle-aged risks, and its efficacy is unknown.13 Phys-
individuals.7 The condition consists of a triad of imaging ical therapy, a nonsurgical intervention,
may provide an effective, low-risk, and
findings, symptoms, and clinical signs and is thought to be
low-cost treatment option to reduce the
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

characterized by excessive bone formation at the femoral head-neck symptoms of FAIS.

junction, which can cause aberrant joint forces during hip movement Reduced hip muscle strength6,18 and
and damage to the cartilage lining of the joint. Arthroscopic hip surgery functional task performance requiring
is the most commonly used intervention for FAIS. However, surgery balance6,8 have been found in individu-
als with FAIS compared to age-matched
UUSTUDY DESIGN: A pilot double-blind random- to determine potential improvements for future controls.6 These individuals also report
ized controlled trial (RCT). studies. greater pain, and lower physical activity
UUBACKGROUND: The effectiveness of physical UURESULTS: Twenty-four (100%) patients with participation, and quality of life scores.11,15
therapy for femoroacetabular impingement syn- known eligibility agreed to participate. Four pa- Finally, in previous studies, better hip
Journal of Orthopaedic & Sports Physical Therapy®

drome (FAIS) is unknown.
UUOBJECTIVES: To determine the feasibility of an
RCT investigating the effectiveness of a physical
therapy intervention for FAIS.
UUMETHODS: Participants were 17 women and
7 men (mean ± SD age, 37 ± 8 years; body mass
index, 25.4 ± 3.4 kg/m2) with FAIS who received
physical therapy interventions provided over 12
weeks. The FAIS-specific physical therapy group
received personalized progressive strengthen-
ing and functional retraining. The control group
received standardized stretching exercises. In
addition, both groups received manual therapy,
progressive physical activity, and education. The
primary outcome was feasibility, including integ-
rity of the protocol, recruitment and retention,
outcome measures, randomization procedure,
and sample-size estimate. Secondary outcomes
included hip pain and function (international
Hip Outcome Tool-33 [iHOT-33]) and hip muscle
strength. Poststudy interviews were conducted
tients (17%) were lost to follow-up. All participants
and the tester remained blinded, and the control
intervention was acceptable to participants. The
between-group mean differences in change scores
were 16 (95% confidence interval [CI]: –9, 38) for
the iHOT-33 and 0.24 (95% CI: 0.02, 0.47) Nm/
kg for hip adduction strength, favoring the FAIS-
specific physical therapy group. Using an effect
size of 0.61, between-group improvements for the
iHOT-33 suggest that 144 participants are required
for a full-scale RCT.
UUCONCLUSION: A full-scale RCT of physical
therapy for FAIS is feasible. A FAIS-specific physi-
cal therapy program has the potential for a moder-
ate to large positive effect on hip pain, function,
and hip adductor strength.
UULEVEL OF EVIDENCE: Therapy, level 2b.
J Orthop Sports Phys Ther 2018;48(4):307-315.
doi:10.2519/jospt.2018.7941
UUKEY WORDS: FAIS, femoroacetabular impinge-
ment syndrome, hip
motion and strength in people with FAIS
were associated with better quality of
life.14 Therefore, nonsurgical interven-
tions to reduce the disease burden of FAIS
appear to have potential and should be a
research priority.31
To our knowledge, no large randomized
controlled trial (RCT) has evaluated the
effectiveness of physical therapy to reduce
pain and improve function and physical
impairments in young adults with FAIS. If
effective, such an intervention would have
an important impact at the personal and
societal levels. Therefore, the primary aim
of this study was to determine the feasibil-
ity of conducting an RCT evaluating the
effects of a FAIS-specific physical therapy
intervention compared to a control inter-
vention to reduce pain and improve func-

La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Australia. The protocol for this study was approved by the La Trobe University Human
1

Research Ethics Committee (approval number 15-076). This trial was registered prospectively with the Australian New Zealand Clinical Trials Registry (ACTRN12615001218583).
The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials
discussed in the article. Address correspondence to Dr Joanne L. Kemp, La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC 3086
Australia. E-mail: j.kemp@latrobe.edu.au t Copyright ©2018 Journal of Orthopaedic & Sports Physical Therapy®

journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | 307

 [ research report
tion in people with FAIS. The secondary
aim was to explore the effect size of a
FAIS-specific physical therapy interven-
tion compared to a control intervention
for hip pain and function.
METHODS
Study Design
T
he study was a double-blind
superiority pilot RCT with 2 paral-
lel groups, conducted according to
the SPIRIT3 and Australian good clinical
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practice guidelines. The study protocol
was approved by the La Trobe Univer-
sity Human Research Ethics Committee
(approval number 15-076), and pro-
spectively registered with the Australian
New Zealand Clinical Trials Registry
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
(ACTRN12615001218583).
Procedures
Potential participants were recruited
through advertisements in clinic waiting
rooms, gymnasiums, and sporting clubs,
and via social media, designed to recruit
participants 18 to 50 years of age who
had activity-related hip pain and were
Journal of Orthopaedic & Sports Physical Therapy®
interested in taking part in a clinical trial
of physical therapy. No details regarding
radiographic features of hip pain or FAIS
were mentioned in the advertisements.
Volunteers contacted the project coordi-
nator (S.L.C.) and were initially screened
via telephone interview. A clinical and
radiological examination was used to
confirm the presence of FAIS and other
eligibility criteria.
Participants completed a written,
informed-consent form, then provided
demographic data and completed patient-
reported outcome measures. Participants
were then assessed for hip physical im-
pairments.8,18,19 Following the baseline as-
sessment, participants were randomized
to 1 of 2 treatment groups. Block random-
ization was utilized with a 2:1 ratio, using
a randomization schedule that was gener-
ated and maintained centrally at La Trobe
University (Australia). Following baseline
assessment, the randomization schedule
was revealed to the treating physical ther-
308 | april 2018 | volume 48 | number 4 | journal of orthopaedic & sports physical therapy
apist (J.L.K.) via telephone. A blinded in-
vestigator (D.M.J.) performed all outcome
assessments at baseline and the primary
end point (3 months post randomization).
Participants were blinded to their group
allocation.
Participants
Men and women between 18 and 50 years
of age with symptomatic FAIS (impinge-
ment-related hip or groin pain of greater
than 3/10 on a visual analog scale for at
least 6 weeks) and radiographic FAIS (an
alpha angle of 60° or greater on either
anterior/posterior pelvic or Dunn 45°
hip radiographs) were recruited. Radio-
graphs were taken of the symptomatic
hip (bilaterally if both hips were symp-
tomatic). Potential participants were ex-
cluded according to the following criteria:
(1) received physical therapy treatment in
the past 3 months, (2) had previous hip
surgery or other major hip injury, (3) had
other musculoskeletal conditions includ-
ing rheumatoid arthritis, (4) were unable
to perform testing procedures, (5) were
unable to attend a 12-week treatment
program or baseline and follow-up as-
sessments, or (6) had contraindications
to radiographs (including pregnancy).
Interventions
Eligible participants were randomized to
1 of 2 intervention groups, one receiving
an active, semi-standardized FAIS-spe-
cific intervention and the other a control
intervention. The interventions were
delivered according to the Template for
Intervention Description and Replication
guidelines.9 Individuals in both groups
attended 8 physical therapy treatment
sessions over a 12-week period, and 12
weekly supervised gym visits. Partici-
pants were also asked to complete 2 addi-
tional unsupervised exercise sessions per
week at a location of their convenience.
Adherence to the exercise protocol was
monitored using the mobile phone exer-
cise application Physitrack (Physitrack
Ltd, London, UK) or paper-based train-
ing diaries. The physical therapy treat-
ments were delivered for both groups by
]
an experienced sports physical therapist
(J.L.K.) at a private physical therapy
clinic in regional Victoria, Australia. The
supervised gym visits were delivered by
other physical therapists at the same
private physical therapy clinic. All treat-
ing physical therapists underwent two
2-hour training sessions in the delivery of
both interventions, and were able to de-
liver either intervention to participants.
Development of the FAIS-specific
physical therapy intervention was based
on current knowledge of characteristic
physical impairments seen in individuals
with FAIS. It consisted of hip joint man-
ual therapy techniques, specific strength-
ening exercises for the hip (adductor,
abductor, extensor, external rotator) and
trunk muscles, and functional activity–
specific retraining and education target-
ed to the individual participant’s physical
impairments. Treatment for the FAIS-
specific intervention group was tailored
to each participant’s clinical presentation
(eg, strength, pain severity, and sporting
and functional needs) and comorbidities
(eg, back and other lower-limb pain or
pathology) and progressed based on the
participant’s response to exercise load,
maximizing the training effects.
The control group received hip joint
manual therapy, muscle stretching, and
health education. Both groups performed
the full exercise program in the super-
vised gym sessions. Treating therapists
recorded treatment for the clinic and su-
pervised gym sessions. The full exercise
protocol for both groups is detailed in the
APPENDIX (available at www.jospt.org).
Primary Outcomes
The primary outcome of the study was
feasibility of a full-scale RCT.2,20 Specific
aspects of feasibility that were monitored
are listed below.
Integrity of the Study Protocol  This in-
cluded the appropriateness of inclusion
criteria, training of the staff, clinic acces-
sibility for the participants, acceptability
of the intervention to participants and
physical therapists, and time burden re-
quired for participants and facilities to
 deliver the interventions. These data were
gathered by interviews of participants and
practitioners/therapists on their willing-
ness to participate in the study, and their
opinions on the research process.
Recruitment and Retention Recruit-
ment and retention data included proce-
dures for participant enrollment (goal of
at least 80% of eligible participants ac-
cepting to enroll), participant adherence
to the intervention (goal of at least 80%
of participants attending 75% of treat-
ment sessions and completing 75% of
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the prescribed exercises), and participant
losses to follow-up (goal of at least 80% of
participants completing the follow-up).
Outcome Measures  Questionnaires,
physical impairment measures, and
methods to measure exercise interven-
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tion compliance (measured via exercise
diaries) were used to determine com-
pleteness of outcome data collected.
Randomization Procedure Appropri-
ateness of the methods used to ensure
blinding of participants and the outcome
measurement assessor was determined
through poststudy interviews asking
whether they were aware of the group al-
Journal of Orthopaedic & Sports Physical Therapy®
location and whether they felt treatment
was credible.
Primary Outcome Measure  Selection of
the most appropriate primary outcome
measure for a full-scale RCT was de-
termined by using the patient-reported
outcome measure with the largest be-
tween-group effect size, as long as the be-
tween-group difference was greater than
the previously reported minimal impor-
tant change for that outcome measure.
Sample-Size Estimate  The sample size of
a future, fully powered study via sample-
size calculations was estimated using the
effect-size data from this pilot study.
Secondary Outcomes
Change in Hip-Related Symptoms and
Quality of Life  This was measured us-
ing the international Hip Outcome Tool-
33 (iHOT-33), the Hip disability and
Osteoarthritis Outcome Score (HOOS)
quality of life subscale (HOOS-Q),27 and
the HOOS pain subscale (HOOS-P).27
journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | 309
The iHOT-33 is scored out of 100 points,
with 100 as the best possible score. It is
reliable (intraclass correlation coefficient
[ICC] = 0.93; 95% confidence interval
[CI]: 0.87, 0.96), has a low standard
error of measurement (6 points out of
100), and is valid and responsive,12 with
a minimal clinically important difference
of 10 points.12,24 Both the HOOS-Q and
the HOOS-P are scored out of 100 points
(100 is the best possible score) and have
appropriate psychometric properties for
use in this population.12
Change in Hip Muscle Strength and
Range of Motion  Hip adduction, abduc-
tion, extension, and external rotation
strength, measured as peak torque nor-
malized for body weight (Newton meters
per kilogram), and hip joint range of mo-
tion (flexion) were assessed using previ-
ously published methods.19
Change in Functional Task Perfor-
mance  Single-leg hop for distance and
the side-bridge test of trunk endurance
were assessed using previously published
methods.17
Nonmodifiable Covariables  Participant
demographics, including age, sex, and
body mass index, were recorded.
Statistical Analysis
Results of primary outcome measures
were provided descriptively in tables,
compared to the a priori established goals.
To provide a recommendation for estimat-
ed sample size for a future full-scale RCT,
between-group effect sizes and 95% CIs
with Hedges correction were calculated
for change in the secondary outcomes
of quality of life, hip-related symptoms,
and hip muscle strength. The mean ± SD
score for each of the subscales was used
in the calculation of the effect size. Esti-
mated sample size was then determined
using the between-subject effect size, with
a minimum of 90% power (α = .05). The
sample size was increased to allow for an
estimated 20% dropout rate. This dropout
rate is based on a previous pilot physical
therapy RCT.25
Statistical methods for the second-
ary outcome measures were evaluated
by comparing change between groups.
Complete case analyses were conducted
to include outcomes from all participants
who completed baseline and follow-up
evaluations, as recommended in the Con-
solidated Standards of Reporting Trials
(CONSORT) guidelines.23 The between-
group difference in change scores for
each outcome measure from baseline to
follow-up was determined and reported
as mean and 95% confidence interval,
using an analysis of covariance. Covari-
ates of age and sex were included in the
analysis. All statistical analyses were per-
formed in SPSS Version 23.0 software
(IBM Corporation, Armonk, NY), and
significance was set at P<.05.
RESULTS
B
etween November 2015 and May
2016, 48 people responded to ad-
vertisements and expressed interest
in participating in the study. Of those, 8
did not respond to follow-up phone calls
and e-mails after making initial contact
with the project coordinator (eligibility
unknown). During telephone screening, 3
were excluded because they did not have
time to commit to the 12-week interven-
tion, 1 was excluded due to pregnancy,
and 1 was excluded due to past history
of Perthes disease. Following clinical and
radiological screening, 4 were excluded
because their pain was located only in the
lumbar spine, 1 participant was excluded
due to hip pain of less than 3/10, and 6
were excluded based on an alpha angle
that was smaller than 60° (FIGURE 1). Twen-
ty-four participants (50% of those who
inquired, 100% of those with known eli-
gibility) were recruited into the study and
underwent baseline testing procedures.
During the course of the study, 4 peo-
ple were lost to follow-up (17%) and did
not undergo final testing at the primary
end point. Reasons for stopping partici-
pation were the participant’s decision to
have hip arthroscopy surgery during the
trial, pregnancy, major abdominal sur-
gery due to illness, and not responding
to repeated attempts at follow-up.
 [ research report
There were no apparent between-
group differences in any of the partici-
pant characteristics. The mean ± SD age
for the FAIS-specific group was 37 ± 8
years and for the control group was 38
± 10 years. Of both the FAIS group and
control group, 71% were women. The
average ± SD height of the FAIS-specific
group and the control group was 1.70 ±
0.07 m and 1.69 ± 0.10 m, respectively.
Weight and body mass index of the FAIS-
specific group was 73.2 ± 13.2 kg and 25.1
± 3.7 kg/m2, respectively, compared to
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74.7 ± 7.3 kg and 26.1 ± 2.4 kg/m2 for the
control group.
Aims
The results of each aspect of the primary
aim of feasibility are provided in TABLE 1.
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Baseline, follow-up, and change scores for
each of the secondary outcome measures
for each group are reported in TABLE 2. The
effect sizes for between-group differences
for each of the secondary outcome mea-
sures are reported in FIGURE 2, and mean
differences for the change scores between
groups are reported in TABLE 3.
Journal of Orthopaedic & Sports Physical Therapy®
DISCUSSION
T
he results of this study suggest
that a full-scale RCT on physical ther-
apy management of FAIS is feasible,
with a required sample of 144 participants
to demonstrate a clinically meaningful
functional improvement based on the
iHOT-33. While feasible, our results also
suggest that some modifications to the
protocol may enhance retention of partici-
pants, access to the intervention, and ef-
fectiveness of aspects of the FAIS-specific
intervention in future studies.
In our pilot study, over a 6-month pe-
riod, 48 people responded to advertise-
ments, 24 (50%) of whom were eligible.
Therefore, at least 288 potential partici-
pants would be required to respond to
advertisements to obtain a sample of 144
participants. Also, 6 of these potential
48 participants were excluded based on
not meeting a radiological criterion (al-
pha angle of 60° or greater), suggesting
310 | april 2018 | volume 48 | number 4 | journal of orthopaedic & sports physical therapy
]
Responded to advertisements
between November 2015 and
May 2016, n = 48
Enrollment
Excluded, n = 13
• No time, n = 3
• Pregnant, n = 1
• Past history of Perthes
Underwent telephone screening with
project coordinator, n = 48 disease, n = 1
• Did not respond after
making initial contact,
n=8
Fulfilled all telephone-based
inclusion criteria and underwent Excluded, n = 11
clinical and radiograph screening, • Alpha angle <60°,
n = 35 n=6
• Pain located only in
the lumbar spine,
n=4
Included in the study and underwent • Pain of less than 3/10,
baseline assessment, n = 24 n=1
Randomized to FAIS-specific Randomized to control group,
group, n = 17 n=7
Allocation
• Received allocated • Received allocated
intervention, n = 17 intervention, n = 7
• Did not receive allocated • Did not receive allocated
intervention, n = 0 intervention, n = 0
Lost to follow-up, n = 1 Lost to follow-up, n = 0
• Did not respond to repeated Discontinued intervention,
Follow-up
follow-up contact n=1
Discontinued intervention, • Major abdominal surgery
n=2 due to illness
• Hip anthroscopy surgery
• Pregnancy
Analyzed, n = 14 Analyzed, n = 6
Excluded from analysis, n = 3 Excluded from analysis, n = 1
Analysis
• Surgery • Surgery
• Pregnancy
• Lost to follow-up
FIGURE 1. Flow chart of study participants. Abbreviation: FAIS, femoroacetabular impingement syndrome.
that 165 people would need to undergo people who responded to advertisements
radiographic screening to yield 144 par- to participate in the present study had
ticipants. This information will assist cam morphology, typically seen in FAIS
in planning the extent of and timelines where alpha angles are greater than 60°.1
for recruitment and budgets for future This suggests that many people aged 18 to
studies. 50 years in the community with hip pain
The diagnosis of FAIS is based on a may have FAIS. Our prevalence of cam
triad of typical imaging findings, symp- morphology is similar to what has previ-
toms, and clinical signs.7 Of great in- ously been reported in systematic reviews
terest, a large number (24/48, 50%) of of studies of symptomatic groups.5,22 In

TABLE 1 Results of Primary Aim (Feasibility)

Primary Aim/Criteria Results

Integrity of the study protocol
• Recruitment: minimum requirement of 80% of eligible partici-
pants entering study
• Validity of eligibility criteria
• Knowledge and credibility of intervention for treating physical
therapists
• Accessibility to intervention for participants
• Credibility and acceptability of intervention to participants
• Feasibility of study time requirement and study facilities for
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Inclusion criteria of the study protocol appear acceptable, with 50% of interested participants being eligible
100% of eligible participants enrolled in the study
The study eligibility criteria conform with those proposed by the Warwick Agreement on FAIS,7 which was published
after the development of the protocol for this study
During the poststudy interview, physical therapists stated that while 4 hours of prestudy training were appropriate,
ongoing communication with the study authors was essential to ensure that the protocol was followed throughout
the study
During the poststudy interview, participants raised the concern that with only 1 treating physical therapist, appoint-
ment availability was limited and few appointments were available outside of normal work hours. They felt that

participants more availability of appointments would enhance recruitment and retention

During the poststudy interview, participants in both groups stated that they believed the intervention was worthwhile,
and that they would participate in the study again. The treating physical therapists also felt that the treatments
offered were both credible and that they would take part in future studies. None of the control participants were
aware of group allocation, and none expressed resentment about being randomized to the control intervention
During the poststudy interview, while participants stated that a large time commitment was required to participate
in the study, they all acknowledged that this was necessary for improvement. None felt that the time burden was
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Recruitment and retention procedures
• Goals for minimum requirement for adequate recruitment
and retention: at least 80% of participants attended 75% of
appointments and completed 75% of the prescribed exercises
Testing of outcome measurement collection
• Determined by completeness of outcome data collected, and
through poststudy interviews
Journal of Orthopaedic & Sports Physical Therapy®
excessive
All participants felt that the facilities in which the interventions were delivered were appropriate
Forty-eight people responded to advertisements over a 5-month inclusion period. Of these, 50% fulfilled inclusion
criteria, and all were included in the study at a single physical therapy clinic
Of the 24 participants, 17 attended all physical therapy and supervised gym sessions; 1 attended at least 80% of, but
not all, physical therapy and supervised gym sessions; and 6 (4 of 6 lost to follow-up) attended less than 80% of
physical therapy and supervised gym sessions. No adverse events were recorded
Exercise intervention compliance was measured using either paper training diaries or a mobile phone exercise app
At the end of the study, all 20 participants who finished the study completed patient-reported outcome question-
naires, and physical impairment measures were collected on all participants by the blinded outcome assessor,
with no missing data

Appropriateness of randomization procedure and methods used
to ensure blinding
• Determined during poststudy interviews of treating physical
therapist, blinded outcome assessor, and participants
Selection of the most appropriate primary outcome measure for
a full-scale RCT
• Determined based on outcome measure with largest between-
group effect size
Estimation of required sample size for a fully powered study
• Based on the iHOT-33
Abbreviations: FAIS, femoroacetabular impingement syndrome; iHOT-33, international Hip Outcome Tool-33; RCT, randomized controlled trial.
The randomization procedure was appropriate, with the treating physical therapist informed of group allocation in a
timely manner
The blinded outcome measurement assessor was not aware of group allocation of any participants
All participants remained blinded to group allocation (did not know whether they were allocated to the control group)
for the duration of the study
The iHOT-33 (0.68), as a measure of hip symptoms and quality of life, and adductor strength (1.03) were selected
A sample size of 94 participants (47 in each group) provides a minimum of 90% power (α = .05) and is required
for an effect size of 0.68.28 To account for the difference in expertise of treating physical therapists in a full-scale
study, this effect was reduced by 10% to 0.61, resulting in a sample-size estimate of 116 participants. To account
for an estimated 20% dropout, the recommended sample size is 144 participants (72 in each group)

addition, people in the current study had
iHOT-33 and HOOS-Q scores of less than
55 points out of 100 at baseline, indicat-
ing that hip-related quality of life was very
poor. Our eligibility criteria specified that
participants must not have had physi-
cal therapy treatment in the previous 3
months, but it is unknown which other
treatment they might have sought in the
time prior to the previous 3 months.
The FAIS-specific intervention used
in this study was the first, to our knowl-
edge, to utilize supervised, regular
gym-based strengthening exercises for
the hip and trunk, as well as functional
retraining. Within-group effect sizes
for gains in strength in all hip muscle
groups and trunk endurance in the
FAIS-specific group were large (0.79-
1.09). Interestingly, the control group
also had moderate to large gains in hip
abductor (effect size, 0.54) and exten-
sor (effect size, 0.66) strength, but not
in hip adductor strength, external rota-
tor strength, or trunk endurance. While
the FAIS-specific physical therapy group
underwent targeted muscle strength
training for each hip muscle group and
the trunk, both groups undertook a pro-
gressive cardiovascular loading program,

journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | 311

 [ research report ]
which may explain the strength improve-
ments in the control group. In addition, Within-Group Change
TABLE 2
the FAIS-specific group reported large in Secondary Outcome Measures*
within-group improvements in pain and
quality of life. This is consistent with our Outcome Measure/Group Baseline Score Follow-up Score Change Score Within-Group ES†
previous work showing that patients with iHOT-33 (0-100)
FAIS pathology who have greater hip ad- FAIS specific 60 ± 26 87 ± 12 27 ± 26 1.34 (1.15, 1.53)
ductor strength following hip arthrosco- Control 56 ± 25 67 ± 24 11 ± 8 0.42 (0.00, 0.83)
py also have better hip-related quality of HOOS quality of life subscale (0-100)
life.14 Future fully powered RCTs should FAIS specific 54 ± 21 76 ± 13 22 ± 18 1.26 (1.07, 1.45)
explore whether greater improvements Control 50 ± 17 62 ± 24 12 ± 18 0.56 (–0.11, 0.72)
in pain and quality of life are associated HOOS pain subscale (0-100)
with hip muscle strength gains, particu- FAIS specific 63 ± 12 83 ± 11 20 ± 16 1.77 (1.57, 1.97)
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larly the hip adductors. Control 70 ± 19 79 ± 18 9 ± 15 0.45 (0.04, 0.87)

Two pilot RCTs of physical therapy Hip adduction strength, Nm/kg
for hip pain have recently been pub- FAIS specific 0.85 ± 0.17 1.10 ± 0.22 0.25 ± 0.25 1.04 (0.86, 1.22)
lished. The first study compared a Control 0.97 ± 0.24 0.98 ± 0.19 0.01 ± 0.13 0.04 (–0.37, 0.46)
6-week physical therapy intervention Hip abduction strength, Nm/kg
of manual therapy, advice, and super- FAIS specific 0.94 ± 0.23 1.16 ± 0.23 0.22 ± 0.31 0.80 (0.62, 0.98)
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

vised exercise to an information ses- Control 0.95 ± 0.33 1.12 ± 0.26 0.17 ± 0.27 0.54 (0.12, 0.96)
sion and home-based program in 15 Hip extension strength, Nm/kg

people with FAIS.30 Both the interven- FAIS specific 0.92 ± 0.28 1.17 ± 0.32 0.25 ± 0.29 0.79 (0.62, 0.97)

tion and control groups in that study Control 0.77 ± 0.20 0.94 ± 0.27 0.17 ± 0.16 0.66 (0.23, 1.08)

had improvements of 18 mm on a 100- Hip external rotation strength, Nm/kg

mm pain-rating scale that might have FAIS specific 0.48 ± 0.11 0.61 ± 0.12 0.13 ± 0.13 1.09 (0.91, 1.28)

resulted from the exercises assigned to Control 0.51 ± 0.27 0.57 ± 0.19 0.06 ± 0.18 0.24 (–0.18, 0.65)

both groups. The second study com- Hip flexion range of motion, deg

pared a targeted physical therapy inter- FAIS specific 109 ± 14 123 ± 9 14 ± 14 1.18 (1.00, 1.37)
Journal of Orthopaedic & Sports Physical Therapy®

Control 103 ± 21 112 ± 18 9 ± 10 0.43 (0.01, 0.85)

vention (manual therapy, hip and trunk
strengthening exercises, and education)
to a control intervention of education
only, for 12 weeks16 in 17 patients 6 to
12 months following hip arthroscopy
for hip impingement pathology. While
the primary aim of the study was to de-
termine feasibility, the secondary out-
comes of pain, function, and quality of
life did not show clinically meaningful10
improvements in the physical therapy
or the control group. In contrast, in the
current study, clinically meaningful im-
provements were seen in the secondary
outcomes of pain, function, and quality
of life, which were much larger than the
previously reported minimal clinically
important change for the iHOT-33 (6-
10 points out of 100), HOOS-P (9 points
out of 100), and HOOS-Q (11 points out
of 100).12,24 The improvements seen in
the control group were not statistically
significant, though they did exceed the
MIC. Our promising results support a
Single-leg hop for distance test, m
FAIS specific 1.14 ± 0.26 1.34 ± 0.32 0.20 ± 0.27 0.67 (0.47, 0.88)
Control 1.20 ± 0.36 1.24 ± 0.40 0.04 ± 0.33 0.10 (–0.34, 0.55)
Side-bridge test of trunk endurance, s
FAIS specific 59 ± 42 98 ± 35 39 ± 54 0.97 (0.76, 1.19)
Control 87 ± 55 68 ± 45 –19 ± 33 –0.35 (–0.80, 0.10)
Abbreviations: ES, effect size; FAIS, femoroacetabular impingement syndrome; HOOS, Hip disability
and Osteoarthritis Outcome Score; iHOT-33, international Hip Outcome Tool-33.
*Values are mean ± SD unless otherwise indicated. FAIS-specific group, n = 14 at follow-up; control
group, n = 6 at follow-up.
†
Values in parentheses are 95% confidence interval. A positive ES denotes an effect favoring the FAIS-
specific group over the control group.
future, fully powered RCT of physical the findings of our previously published
therapy for people with FAIS. pilot RCT evaluating physical therapy fol-
Strengths of this study include using lowing hip arthroscopy.10,16 The recruit-
the extension of the CONSORT state- ment into this study was achieved in an
ment for pilot and feasibility studies acceptable time frame, and less than 20%
when developing the protocol4,23 and of participants were lost to follow-up.
using the Preferred Reporting Items for Two of the 4 participants lost to follow-
Systematic Reviews and Meta-Analyses up reported unrelated medical conditions
statement when reporting the findings.21 (pregnancy, illness) and 1 opted for hip
In addition, our protocol and physical surgery. We used complete case analy-
therapy intervention were informed by ses, where 17% (4 of 24) of participants

312 | april 2018 | volume 48 | number 4 | journal of orthopaedic & sports physical therapy

 iHOT-33
HOOS quality of life
HOOS pain

Adduction strength
Abduction strength
Extension strength
External rotation strength

Flexion range of motion

Single-leg hop for distance

Side-bridge test of trunk endurance

–0.2 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6

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Effect Size

FIGURE 2. Effect sizes for between-group differences in change scores for secondary outcomes. The dashed line represents a large effect size, and the dotted line represents
a moderate effect size. A positive effect size denotes a difference in change score favoring the FAIS-specific physical therapy intervention group. Abbreviations: FAIS,
femoroacetabular impingement syndrome; HOOS, Hip disability and Osteoarthritis Outcome Score; iHOT-33, international Hip Outcome Tool-33.
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Between-Group Differences in Change Scores and Estimated Sample Size
TABLE 3
for Each of the Secondary Outcome Measures

FAIS-Specific Estimated Total Sample Size

Outcome Measure Group Change Score* Control Group Change Score* Mean Difference† for Outcome Measure, n‡
iHOT-33 (0-100) 27 ± 26 11 ± 8 16 (–9, 38) 94
HOOS quality of life subscale (0-100) 22 ± 18 12 ± 18 10 (–8, 29) 152
HOOS pain subscale (0-100) 20 ± 16 9 ± 15 11 (–6, 29) 96
Journal of Orthopaedic & Sports Physical Therapy®

Adduction strength, Nm/kg 0.25 ± 0.25 0.01 ± 0.13 0.24 (0.02, 0.47) 43
Abduction strength, Nm/kg 0.22 ± 0.31 0.17 ± 0.27 0.05 (–0.21, 0.37) 1644
Extension strength, Nm/kg 0.25 ± 0.29 0.17 ± 0.16 0.08 (–0.14, 0.30) 470
External rotation strength, Nm/kg 0.13 ± 0.13 0.06 ± 0.18 0.07 (–0.10, 0.24) 202
Flexion range of motion, deg 14 ± 14 9 ± 10 5 (–5.0, 15 9) 310
Single-leg hop for distance test, m 0.20 ± 0.27 0.04 ± 0.33 0.16 (–0.16, 0.47) 152
Side-bridge test of trunk endurance, s 39 ± 54 –19 ± 33 58 (5, 110) 36
Abbreviations: FAIS, femoroacetabular impingement syndrome; HOOS, Hip disability and Osteoarthritis Outcome Score; iHOT-33, international Hip
Outcome Tool-33.
*Values are mean ± SD unless otherwise indicated.
†
Values in parentheses are 95% confidence interval.
‡
Estimated sample size determined using Student t test sample-size calculation, without adjusting for anticipated dropouts and losses to follow-up (α = .05, β = .90).

were excluded due to missing data. De-
spite options for statistical imputation
of missing data, minimizing the dropout
rate should be a priority in future studies.
A potential weakness of the study, con-
sistent with the pilot nature of the work,
is the small sample size, which precludes
any strong interpretation regarding the
effectiveness of our intervention. Future
spond differently to interventions, future
full-scale RCTs may wish to account for
types of FAIS: cam morphology, pincer
morphology, mixed cam and pincer mor-
phology, or coexisting pathology such as
labral and chondral pathology.7,26,29
CONCLUSION
physical therapy intervention may have a
positive effect on improving hip adductor
strength, reducing pain, and improving
function. Adequately powered and im-
proved studies may increase the effective-
ness of physical therapy for people with
FAIS. t
KEY POINTS

T
full-scale RCTs may choose to subgroup his study demonstrated that a FINDINGS: A full-scale randomized con-
participants based on sex. In addition, full-scale RCT of physical therapy trolled trial for femoroacetabular im-
given that different types of FAIS may re- for FAIS is feasible. A FAIS-specific pingement syndrome is feasible.

journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | 313

 [ research report
IMPLICATIONS: A targeted physical therapy
intervention may improve function and
reduce pain in people with femoroac-
etabular impingement syndrome.
CAUTION: Due to the pilot nature of this
study, these results must be interpreted
with caution until replicated in a full-
scale study.
ACKNOWLEDGMENTS: The authors acknowl-
edge the staff of Lake Health Group, Bal-
larat, Australia, especially Michael Pierce,
Ryan Hobbs, Daniel Lewry, Jacob Monk,
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Abbey Pryor, and Kerryn Webb, for assis-
tance in delivering the physical therapy
intervention. The authors also thank the
participants for taking part in this study.
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
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journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | 315

 [ research report ]
APPENDIX

FAIS-SPECIFIC PHYSICAL THERAPY GROUP

Hip Exercises
Exercise/Phase Description Dosage and Progression
Extension
1 Prone hip extension: gluteal squeeze followed by hip extension, hold 3 to 5 s, and lower 1 × 30 repetitions
2 × 30 repetitions
2 × 30 repetitions with 1-kg cuff weight on ankle
2 Bridging: gluteal squeeze and lift up into bridge position, hold 3 to 5 s, and lower 1 × 20 repetitions
2 × 20 repetitions
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3 Bridging: gluteal squeeze and lift up into bridge position, hold 3 to 5 s, lift each heel alternately, 2 × 20 repetitions
and lower
4 Prone-hold hip extension: knees: from knees, move affected leg into hip extension, hold 3 to 5 s, 1 × 20 repetitions
and lower 2 × 20 repetitions
2 × 20 repetitions with 1-kg cuff weight on ankle
5 Prone-hold hip extension: toes: from toes, move affected leg into hip extension, hold 1 to 5 s, and 1 × 20 repetitions
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

lower 2 × 20 repetitions
2 × 20 repetitions with 1-kg cuff weight on ankle
6 Windmill with black Thera-Band under standing foot, held in each hand 2 × 30 repetitions
7 Single-leg deadlift with 2-kg hand weights, held in ipsilateral hand 2 × 30 repetitions
Abduction
1 Bridging with band: bridge with band around knees, gently abduct against light band, hold 3 to 5 1 × 20 repetitions, light band
s, and lower 2 × 20 repetitions, light band
2 × 20 repetitions, heavy band
2 × 40 repetitions, heavy band
2 Bridge with leg extension: start: lift up with 2 feet on ground, extend 1 leg, then the alternate leg, 1 × 20 repetitions
Journal of Orthopaedic & Sports Physical Therapy®

then lower with both legs on ground 2 × 20 repetitions

3 Bridge with leg extension: progression: extend 1 knee, lift up using other leg, hold 2 to 5 s, and 1 × 20 repetitions, each side
lower. Repeat on each side 2 × 20 repetitions, each side
2 × 20 repetitions, each side, unstable surface
2 × 30 repetitions, each side, unstable surface
3 pulses, 2 × 20 repetitions on unstable surface
3 pulses, 2 × 30 repetitions on unstable surface
4 Rearfoot elevated split squat: rest foot of unaffected leg back on step. Place stick behind neck for 2 × 40 repetitions, each side
balance. Bend the front knee, dropping the hips toward the ground. Straighten knee 2 × 40 repetitions, each side, 2-kg cuff weights
Adduction
1 In sidelying with affected leg down, keep leg in neutral alignment, small lift, hold 3 s, and lower 1 × 15 repetitions
1 × 30 repetitions
2 × 30 repetitions
2 × 30 repetitions with 1-kg cuff weight
2 Bridge position, heavy band around thigh, turning knee out: pull knee to midline against band and 1 × 30 repetitions
maintain position throughout. Lift bottom, hold 3 s, and lower 2 × 30 repetitions
3 Side bridge, unaffected leg on step, affected leg down: small lift, hold 3 s, and lower 1 × 20 repetitions
1 × 30 repetitions
4 Lie on affected side in side-plank position. Place top leg up on chair. Keep bottom leg straight and 2 × 20 repetitions, each side
lift it up to meet the top leg. Try to keep pelvis and trunk still 2 × 20 repetitions, each side, 1-kg cuff weight
Table continues on D2.

journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | d1

 [ research report ]
APPENDIX

Exercise/Phase Description Dosage and Progression

External rotation
1 Four-point kneel. Keep foot on ground. Keep trunk stable. Slide to turn foot in against band 1 × 30 repetitions
1 × 50 repetitions
2 × 50 repetitions
Heavy band
2 In prone, turn foot in against band 1 × 40 repetitions, light band
2 × 40 repetitions, light band
1 × 40 repetitions, medium band
2 × 40 repetitions, medium band
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1 × 40 repetitions, heavy band

2 × 40 repetitions, heavy band
Trunk Exercises
Exercise/Phase Description Dosage and Progression
Trunk strength
1 Side bridge 1 × 30 s, each side
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

1 × 50 s, each side
2 × 50 s, each side
2 × 80 s, each side
2 Side bridge with arm lifts 1 × 40 repetitions, each side
3 Side bridge with arm reach-under, then lift (rotate trunk) 2 × 40 repetitions, each side
2 × 60 repetitions, each side
4 Side plank with stability ball. Keep elbow below shoulder. Place 1 foot in front and 1 behind on ball 2 × 30 repetitions, each side
2 × 50 repetitions, each side
Functional Tasks
Exercise/Phase Description Dosage and Progression
Journal of Orthopaedic & Sports Physical Therapy®

1 Wall slides with gluteal activation: with band around distal thighs, slide down wall, activate gluteal 1 × 20 repetitions
muscles at 60° to 90° of knee flexion, hold 5 to 30 s, then push back up into standing 2 × 20 repetitions
2 Squats: flex at hips and squat to comfortable depth, tighten gluteal muscles to return to standing 1 × 30 repetitions
2 × 30 repetitions
3 Step-ups: with affected side on top of step, tighten gluteal muscles to step unaffected side up 1 × 30 repetitions
onto step 2 × 30 repetitions
4 Single-leg squats: stand on affected side, then squat down to comfortable level, ensuring 1 × 40 repetitions
adequate hip, knee, and ankle alignment. Tighten gluteals to return to standing 2 × 40 repetitions
5 Windmills 1 × 30 repetitions
2 × 30 repetitions
6 Single-leg squat on wobble board 1 × 30 repetitions
1 × 40 repetitions
1 × 40 repetitions, eyes closed
7 Jump down off box 20 repetitions, double-leg landing
20 repetitions, single-leg landing, each leg
20 repetitions, double-leg landing and bound
20 repetitions, single-leg landing and bound,
each leg
8 Lunge jump, 180°: take a large step forward and bend knee into a lunge. Push strongly up and 20 repetitions
turn 180° to land in opposite lunge position. Return to start
9 Multidirectional jumps, landing on toes first, allowing knees to bend 20 repetitions, double leg
20 repetitions, single leg, each leg
Table continues on D3.

d2 | april 2018 | volume 48 | number 4 | journal of orthopaedic & sports physical therapy

 APPENDIX

Cardiovascular Fitness
Phase Description Dosage and Progression
1 Cycling (stationary or road bike; no mountain bike), swimming (no breaststroke), other aquatic 10 min every second day
activity (water aerobics, water jogging; no egg-beater kick), walking (on flat terrain; no beach or 20 min every second day
bush walking), kayaking, rowing (if flexion range of motion >100°), elliptical cross-trainer 30 min every second day
30 min total, including 5 × 60 s of high intensity
every second day
30 min, including up to 10 × 60 s or 5 × 2 min of
high intensity every second day
45 min, including up to 15 min total of high
intensity every second day
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2 Dance, running, mountain biking, athletics, bush walking, netball, football (all codes), hockey, 15 min every second day (can be combined with
racquet sports 30 min of level 1 activity)
20 min every second day (can be combined with
25 min of level 1 activity)
30 min every second day (can be combined with
20 min of level 1 activity)
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

45 min every second day, including 10 min of

higher intensity (can be combined with 15 min
of level 1 activity)
50 min every second day, including 20 min of
high intensity (can be combined with 10 min of
level 1 activity)
Up to 1 h, 3 times per week, full load
Abbreviation: FAIS, femoroacetabular impingement syndrome.

CONTROL GROUP
Journal of Orthopaedic & Sports Physical Therapy®

STANDARDIZED EXERCISE PROGRAM: WEEKS 1 TO 12

Hip
(Each Week Contains 4 of Those Listed Below)
Description
Hip flexor stretch off
plinth
Short adductor stretch
Hamstring stretch
Iliotibial band stretch
Trunk rotation in supine
Single-leg trunk rotation
in supine
Lower Leg Trunk
(Each Week Contains 2 of Those Listed Below) (Each Week Contains 2 of Those Listed Below)
Dosage Description Dosage Description Dosage
Symptomatic LL: hold Gastrocnemius wall Symptomatic LL: hold Thoracic rotation in 5 × 5-s holds to each side
30 s, repeat 3 times. stretch 30 s, repeat 3 times. supine
Repeat on other LL Repeat on other LL
30-s hold, repeat 3 times Soleus stretch Symptomatic LL: hold Trunk rotation in supine 5 × 5-s holds to each side
30 s, repeat 3 times.
Repeat on other LL
Symptomatic LL: hold Tibialis anterior stretch Symptomatic LL: hold Single-leg trunk rotation Alternate sides, hold 40
30 s, repeat 3 times. 30 s, repeat 3 times. in supine s, repeat 3 times to
Repeat on other LL Repeat on other LL each side
Symptomatic LL: hold Calf roller stretch Symptomatic LL: hold 40 s Trunk rotation in standing 5 × 5-s hold to each side
30 s, repeat 3 times. × 2. Repeat on other LL
Repeat on other LL
5 × 5-s hold to each side Gastrocnemius stretch: Symptomatic LL: hold Latissimus dorsi and 40-s hold × 2
4-point kneel 30 s, repeat 3 times. trunk stretch in prone
Repeat on other LL kneel
Alternate sides, hold 30 General trunk stretch in 3 × 5-s holds
s, repeat 3 times to standing
each side
Table continues on D4.

journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | d3

 [ research report ]
APPENDIX

Hip Lower Leg Trunk

(Each Week Contains 4 of Those Listed Below) (Each Week Contains 2 of Those Listed Below) (Each Week Contains 2 of Those Listed Below)
Description Dosage Description Dosage Description Dosage
Hip flexor stretch in Symptomatic LL: hold Elbow prop 5 × 5-s holds
kneeling 40 s, repeat 3 times.
Repeat on other LL
Hold/relax short adductor At movement barrier, 20% Trunk rotation plus hip 5-s holds, repeat 3 times
stretch contraction × 3 flexion in standing to each side
Hold/relax hamstring At movement barrier, 20% Thoracic extension and 3 × 30-s hold
stretch (therapist contraction × 3 pectoralis stretch with
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assisted) towel
Gluteal stretch in supine Symptomatic LL: hold Salute to the sun 3 × 5-s hold at end-range
30 s, repeat 3 times. extension and flexion
Repeat on other LL
Adductor stretch in Symptomatic LL: hold Extension in lying 5 × 5-s hold
standing 30 s, repeat 3 times.
Repeat on other LL
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Quadriceps stretch in Symptomatic LL: hold

sidelying 30 s, repeat 3 times.
Repeat on other LL
Hamstring foam roller Bilateral, 40 s × 2
Gluteal stretch on wall Symptomatic LL: hold
30 s, repeat 3 times.
Repeat on other LL
Gluteal foam roller Symptomatic LL: 40 s × 2.
Repeat on other LL
Iliotibial band stretch with Symptomatic LL: 60
Journal of Orthopaedic & Sports Physical Therapy®

roller to 240 s, repeat on

other LL
Piriformis stretch in prone Symptomatic LL: hold
40 s, repeat 3 times.
Repeat on other LL
Abbreviation: LL, lower limb.

d4 | april 2018 | volume 48 | number 4 | journal of orthopaedic & sports physical therapy