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Femoroacetabular impingement (FAI) syndrome is an important condition that can be managed by physiotherapists, together with other health professionals. ‘Failed conservative care’ for FAI syndrome is a reason for surgery being introduced into the shared decision-making process with the patient. Two recent landmark randomised controlled trials (RCTs) have brought new data to that patient-centred discussion—‘Would you consider surgery for this condition? What is the likelihood that your impairments will be appreciably improved with arthroscopic hip surgery followed by rehabilitation?’1 2 As clinicians delivering exercise therapy, we need to reflect on the question ‘are we providing high-quality, outcome driven, exercise therapy programs to these patients?’
Contemporary exercise therapy should be informed by patient needs and preferences, and address patient-specific impairments. Specific hip-related impairments in FAI syndrome include hip muscle weakness, particularly hip adductors3; lower trunk strength bilaterally3; poor dynamic single-leg balance3; and lower functional task performance3 in non-operative, preoperative and postoperative groups. None of these impairments can be corrected by surgery alone. These impairments could be best addressed with graded exercises.3
In this editorial, we question whether the non-surgical treatment programmes evaluated in the recent RCTs included the type, dose and progression of exercises needed to generate a meaningful change in strength and function. In both studies, the physiotherapist-led groups did show some improvement (14% in both studies); however, patients still remained impaired at the conclusion of the programmes (hip-related quality of life scores: 45–49 points out of 100).1 2 We therefore raise three questions regarding what constitutes (1) contemporary ‘optimal non-surgical care’ for patients with FAI syndrome, (2) contemporary ‘optimal post-surgical rehabilitation’ and (3) an effective, contemporary return to sport programme for patients with FAI syndrome.
What constitutes contemporary ‘optimal non-surgical care’ for patients with FAI syndrome?
The physiotherapist-led exercise therapy programmes used in the recently published RCTs were designed prior to 2012; thus, they may not represent current best practice. The comparison arm in the study by Mansell et al was delivered over 6 weeks and comprised mostly of mobility and therapeutic motor control exercises.2 The control arm of the Full Randomised Controlled trial of A rthroscopic Surgery for Hip Impingement versus best CoNventional (FASHIoN) study (‘personalised hip therapy (PHT)’)4 was developed to comply with National Health Service requirements. Additionally, ‘the intervention was developed based on the experiences of clinicians treating patients with FAI syndrome and not by targeting the deficiencies, observed in patients with FAI syndrome, reported in the literature’.4 Sixty-six per cent of participants attended less than eight physiotherapist-led sessions, with an average of five physiotherapist-led sessions delivered over 12–24 weeks.1 There was no information provided on whether participants completed exercise outside of these sessions. This dose (on average biweekly or monthly visits) would be considered insufficient to resolve muscle strength and activity impairments.5 The content of the control arm of the FASHIoN study seems closer to current best practice than that of the Mansell et al’s study. However, the prescription of primarily non-functional, low-load exercises would likely be of insufficient stimulus5 to address the deficits in strength and functional performance that are known to exist in patients with FAI syndrome. Because our knowledge regarding optimal exercise interventions for patients with FAI syndrome has grown substantially over the past 7 years, we feel that neither of the physiotherapist-led exercise programmes in the recent RCTs would still be considered current best practice.
What constitutes contemporary ‘optimal post-surgical rehabilitation’ for patients with FAI syndrome?
Following hip arthroscopy, people often demonstrate impairments in strength, functional performance and balance.3 In addition, postsurgical outcomes remain poor when compared with healthy control populations. Postsurgical outcomes might be enhanced if postoperative rehabilitation programmes were targeted to individualised impairments, contained exercise-based interventions that were adequately progressed and included relevant strategies to facilitate return to sport. At a recent consensus meeting held in Warwick, UK, it was suggested that professions delivering exercise therapy need to step up to the challenge of designing and testing such high-quality postoperative rehabilitation programmes in rigorous RCTs.
The postoperative rehabilitation programmes in the Mansell et al 2 and Griffin et al 1 RCTs were not described and are unknown. In addition, the results of these studies indicate that (1) postarthroscopy patients with FAI syndrome have important impairments in activities, function and quality of life; and (2) improvements in these impairments did occur, but were less encouraging than originally anticipated.6 Improvements in the quality of physiotherapist-led exercise therapy following surgery could enhance outcomes. To achieve this aim, RCTs are needed to evaluate optimised physiotherapist-led postoperative rehabilitation programmes.
What constitutes an effective, contemporary return to sport programme for patients with FAI syndrome?
Many patients with FAI syndrome have a strong desire to return to sport.6 7 Neither of the two RCTs completed to date adequately addressed this issue. Return to sport or activity was not considered by Mansell and colleagues.2 In the personalised hip programme delivered in the FASHIoN trial, it was only considered when it was felt to be appropriate by the treating physiotherapist, with an unclear description of how return to sport was achieved.4 It has recently been documented that sport participation is markedly reduced 1 year following surgery,7 with only 57% of athletes returning to sport, and of those that do only 30% return to optimal performance. Therefore, rehabilitation programmes must incorporate relevant strategies from the treatment onset to facilitate successful return to sport.8 However, current best practice enabling successful return to sport for athletes with hip pain remains unclear.
Where to from here?
Clinicians providing contemporary exercise therapy must rise to the challenge in optimising the management of FAI syndrome. How do we best develop, test and implement high-quality, high-value exercise-based interventions for patients with FAI syndrome in both non-operative and postoperative scenarios? Such trials are under way, the results of which will greatly inform this discussion. These studies include (1) ‘The physiotherapy for Femoroacetabular Impingement Rehabilitation STudy (PhysioFIRST): A participant and assessor blinded randomised controlled trial of physiotherapy to reduce pain and improve function for hip impingement’ (https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373525&isReview=true); (2) ‘Femoroacetabular Impingement (FAI): The Effectiveness of Physical Therapy’ (https://clinicaltrials.gov/ct2/show/NCT03077022); (3) ‘Muscular and Functional Performance in FAIS Patients’ (https://clinicaltrials.gov/ct2/show/NCT03669471); and (4) ‘Movement Pattern Training in People With Intra-articular, Prearthritic Hip Disorders’ (https://clinicaltrials.gov/ct2/show/NCT02913222). Ultimately, we believe carefully considering these factors will lead to improved outcomes, and assist patients and clinicians in making an informed, shared decision to deliver the most appropriate and effective care.
Footnotes
Contributors JLK and KMC developed the concept. JLK drafted the manuscript. All authors contributed to and approved the final version of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Patient consent for publication Not required.