Table 1

Protocol components

Core 1Patient assessment
  • Full history.

  • Examination; including hip muscle stability, strength, ROM and impingement signs.

  • Although not formally a treatment, this component underpins the individualised treatment programme. While useful adjuncts to clinical assessment, goniometers and hand-held dynamometers were not deemed essential by the core study group. Further details of what should be included in the patient assessment are available in the PHT manual (see online supplementary file D).

Core 2Patient education and advice
  • Advice about posture, gait and lifestyle behaviour modifications.

  • Advice about activities of daily living to try to avoid FAI (reducing/avoiding deep flexion, adduction and internal rotation of hip).

  • Advice about relative rest for acute pain.

  • 13 additional comments from questionnaire respondents suggested that physiotherapists should provide patient specific education and advice about FAI with an indication that this should focus on lifestyle modification, advice on how to undertake different forms of exercise and how to undertake common activities such as walking, cycling, etc.

  • Advice particularly with respect to activity modification was a feature of the published literature.26 41

  • The core study group felt that education and advice would be regarded as a core component of best practice among physiotherapists managing any musculoskeletal condition.

  • Both lifestyle and activity modification draws on relevant theory, that is, behavioural modifications that might lead to reduced functional impingement and should result in reduced symptoms.42

Core 3Help with pain relief
  • Use of oral analgesics , including non-steroidal anti-inflammatory medication for 2–4 weeks.

  • Engagement in and adherence to an exercise programme.

  • This was a feature of the first protocol, to which 44% of the physiotherapists agreed.26 41

  • Analgesia is an established treatment for musculoskeletal pain.43 44

Core 4Exercise-based hip programme
  • An exercise programme that has the key features of individualisation, progression and supervision.

  • A phased exercise programme that begins with muscle control work, and progresses to stretching and strengthening with increasing ROM and resistance.

  • Muscle control/stability exercise (targeting pelvic and hip stabilisation, gluteal and abdominal muscles).

  • Strengthening/resistance exercise first in available range (pain-free ROM), and targets: gluteus maximus, short external rotators, gluteus medius and abdominal muscles.

  • Stretching exercise to improve hip external rotation and abduction in extension and flexion (but not vigorous stretching—no painful hard end stretches). Other muscles to be targeted if relevant for the patient include iliopsoas, hip flexors and rotators.

  • Exercise progression in terms of intensity and difficulty, gradually progressing to activity or sport-specific exercise where relevant.

  • A personalised and written exercise prescription that is progressed and revised over treatment sessions.

  • 37 comments from questionnaire respondents endorsed hip specific and more general exercises. Of these, core or stability exercises (focusing on the activation of the hip and gluteal muscles, as well as the abdominal and paraspinal muscles targeting the restoration of control and coordination of these muscles) were the most common (n=21 additional comments).

  • Feedback suggested that the exercise programme should be individualised to the patient (based on clinical assessment), supervised and progressed in clinic over time from core stability exercises and stretching to strengthening/resistance exercises. The exercises were to be practised at home by patients.

  • 21 template exercises were suggested. Physiotherapists could individualise patient care by selecting a range of these to target individual movement impairments. The exercises should be progressed in terms of difficulty and intensity over time, as well as selection of different exercises to address the key findings from patient reassessment at each treatment session. The final selection of exercises is available in online supplementary file C.

  • Exercise was a predominant feature in the published literature for managing FAI non-operatively.26 41 45

  • Exercise is an effective treatment for many other musculoskeletal pain problems32 33 and exercise-based programmes can produce similar improvements in symptoms to surgery.30

Optional 1Treat coexisting symptoms
  • Examples of this might include treating coexisting low back pain.

Optional 2Orthotics
  • Patients can be assessed for biomechanical abnormalities and have these corrected by the treating physiotherapist. Alternatively, they can be referred to other allied healthcare professionals such as podiatrists for custom-made insoles, etc.

Optional 3Corticosteroid hip joint injection
  • Potentially useful in patients who are unable to engage in the exercise-based programme due to severe pain.

Optional 4Manual Therapy
  • Hip joint mobilisations, for example, distraction, distraction with flexion, anteroposterior glides.

  • Trigger point work.

  • FAI, femoroacetabular impingement; PHT, Personalised Hip Therapy; ROM, range of motion.