Jospt 2018 7941
Jospt 2018 7941
JOANNE L. KEMP, PT, PhD1 • SALLY L. COBURN, PT1 • DENISE M. JONES, PT1 • KAY M. CROSSLEY, PT, PhD1
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.
drome (FAIS) is unknown. tients (17%) were lost to follow-up. All participants motion and strength in people with FAIS
UUOBJECTIVES: To determine the feasibility of an
and the tester remained blinded, and the control were associated with better quality of
intervention was acceptable to participants. The
RCT investigating the effectiveness of a physical life.14 Therefore, nonsurgical interven-
between-group mean differences in change scores
therapy intervention for FAIS. tions to reduce the disease burden of FAIS
were 16 (95% confidence interval [CI]: –9, 38) for
UUMETHODS: Participants were 17 women and the iHOT-33 and 0.24 (95% CI: 0.02, 0.47) Nm/ appear to have potential and should be a
7 men (mean ± SD age, 37 ± 8 years; body mass kg for hip adduction strength, favoring the FAIS- research priority.31
index, 25.4 ± 3.4 kg/m2) with FAIS who received specific physical therapy group. Using an effect
To our knowledge, no large randomized
physical therapy interventions provided over 12 size of 0.61, between-group improvements for the
weeks. The FAIS-specific physical therapy group iHOT-33 suggest that 144 participants are required controlled trial (RCT) has evaluated the
received personalized progressive strengthen- for a full-scale RCT. effectiveness of physical therapy to reduce
ing and functional retraining. The control group UUCONCLUSION: A full-scale RCT of physical pain and improve function and physical
received standardized stretching exercises. In therapy for FAIS is feasible. A FAIS-specific physi- impairments in young adults with FAIS. If
addition, both groups received manual therapy, cal therapy program has the potential for a moder- effective, such an intervention would have
progressive physical activity, and education. The ate to large positive effect on hip pain, function,
primary outcome was feasibility, including integ- an important impact at the personal and
and hip adductor strength.
rity of the protocol, recruitment and retention, societal levels. Therefore, the primary aim
outcome measures, randomization procedure, UULEVEL OF EVIDENCE: Therapy, level 2b. of this study was to determine the feasibil-
and sample-size estimate. Secondary outcomes J Orthop Sports Phys Ther 2018;48(4):307-315.
doi:10.2519/jospt.2018.7941
ity of conducting an RCT evaluating the
included hip pain and function (international
effects of a FAIS-specific physical therapy
Hip Outcome Tool-33 [iHOT-33]) and hip muscle UUKEY WORDS: FAIS, femoroacetabular impinge-
strength. Poststudy interviews were conducted ment syndrome, hip 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: [email protected] t Copyright ©2018 Journal of Orthopaedic & Sports Physical Therapy®
T
he study was a double-blind of age with symptomatic FAIS (impinge- liver either intervention to participants.
superiority pilot RCT with 2 paral- ment-related hip or groin pain of greater Development of the FAIS-specific
lel groups, conducted according to than 3/10 on a visual analog scale for at physical therapy intervention was based
the SPIRIT3 and Australian good clinical least 6 weeks) and radiographic FAIS (an on current knowledge of characteristic
Downloaded from www.jospt.org at on September 2, 2023. For personal use only. No other uses without permission.
practice guidelines. The study protocol alpha angle of 60° or greater on either physical impairments seen in individuals
was approved by the La Trobe Univer- anterior/posterior pelvic or Dunn 45° with FAIS. It consisted of hip joint man-
sity Human Research Ethics Committee hip radiographs) were recruited. Radio- ual therapy techniques, specific strength-
(approval number 15-076), and pro- graphs were taken of the symptomatic ening exercises for the hip (adductor,
spectively registered with the Australian hip (bilaterally if both hips were symp- abductor, extensor, external rotator) and
New Zealand Clinical Trials Registry tomatic). Potential participants were ex- trunk muscles, and functional activity–
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
(ACTRN12615001218583). cluded according to the following criteria: specific retraining and education target-
(1) received physical therapy treatment in ed to the individual participant’s physical
Procedures the past 3 months, (2) had previous hip impairments. Treatment for the FAIS-
Potential participants were recruited surgery or other major hip injury, (3) had specific intervention group was tailored
through advertisements in clinic waiting other musculoskeletal conditions includ- to each participant’s clinical presentation
rooms, gymnasiums, and sporting clubs, ing rheumatoid arthritis, (4) were unable (eg, strength, pain severity, and sporting
and via social media, designed to recruit to perform testing procedures, (5) were and functional needs) and comorbidities
participants 18 to 50 years of age who unable to attend a 12-week treatment (eg, back and other lower-limb pain or
had activity-related hip pain and were program or baseline and follow-up as- pathology) and progressed based on the
Journal of Orthopaedic & Sports Physical Therapy®
interested in taking part in a clinical trial sessments, or (6) had contraindications participant’s response to exercise load,
of physical therapy. No details regarding to radiographs (including pregnancy). maximizing the training effects.
radiographic features of hip pain or FAIS The control group received hip joint
were mentioned in the advertisements. Interventions manual therapy, muscle stretching, and
Volunteers contacted the project coordi- Eligible participants were randomized to health education. Both groups performed
nator (S.L.C.) and were initially screened 1 of 2 intervention groups, one receiving the full exercise program in the super-
via telephone interview. A clinical and an active, semi-standardized FAIS-spe- vised gym sessions. Treating therapists
radiological examination was used to cific intervention and the other a control recorded treatment for the clinic and su-
confirm the presence of FAIS and other intervention. The interventions were pervised gym sessions. The full exercise
eligibility criteria. delivered according to the Template for protocol for both groups is detailed in the
Participants completed a written, Intervention Description and Replication APPENDIX (available at www.jospt.org).
informed-consent form, then provided guidelines.9 Individuals in both groups
demographic data and completed patient- attended 8 physical therapy treatment Primary Outcomes
reported outcome measures. Participants sessions over a 12-week period, and 12 The primary outcome of the study was
were then assessed for hip physical im- weekly supervised gym visits. Partici- feasibility of a full-scale RCT.2,20 Specific
pairments.8,18,19 Following the baseline as- pants were also asked to complete 2 addi- aspects of feasibility that were monitored
sessment, participants were randomized tional unsupervised exercise sessions per are listed below.
to 1 of 2 treatment groups. Block random- week at a location of their convenience. Integrity of the Study Protocol This in-
ization was utilized with a 2:1 ratio, using Adherence to the exercise protocol was cluded the appropriateness of inclusion
a randomization schedule that was gener- monitored using the mobile phone exer- criteria, training of the staff, clinic acces-
ated and maintained centrally at La Trobe cise application Physitrack (Physitrack sibility for the participants, acceptability
University (Australia). Following baseline Ltd, London, UK) or paper-based train- of the intervention to participants and
assessment, the randomization schedule ing diaries. The physical therapy treat- physical therapists, and time burden re-
was revealed to the treating physical ther- ments were delivered for both groups by quired for participants and facilities to
the prescribed exercises), and participant Change in Hip Muscle Strength and analysis. All statistical analyses were per-
losses to follow-up (goal of at least 80% of Range of Motion Hip adduction, abduc- formed in SPSS Version 23.0 software
participants completing the follow-up). tion, extension, and external rotation (IBM Corporation, Armonk, NY), and
Outcome Measures Questionnaires, strength, measured as peak torque nor- significance was set at P<.05.
physical impairment measures, and malized for body weight (Newton meters
methods to measure exercise interven- per kilogram), and hip joint range of mo- RESULTS
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tion compliance (measured via exercise tion (flexion) were assessed using previ-
B
diaries) were used to determine com- ously published methods.19 etween November 2015 and May
pleteness of outcome data collected. Change in Functional Task Perfor- 2016, 48 people responded to ad-
Randomization Procedure Appropri- mance Single-leg hop for distance and vertisements and expressed interest
ateness of the methods used to ensure the side-bridge test of trunk endurance in participating in the study. Of those, 8
blinding of participants and the outcome were assessed using previously published did not respond to follow-up phone calls
measurement assessor was determined methods.17 and e-mails after making initial contact
through poststudy interviews asking Nonmodifiable Covariables Participant with the project coordinator (eligibility
whether they were aware of the group al- demographics, including age, sex, and unknown). During telephone screening, 3
Journal of Orthopaedic & Sports Physical Therapy®
location and whether they felt treatment body mass index, were recorded. were excluded because they did not have
was credible. time to commit to the 12-week interven-
Primary Outcome Measure Selection of Statistical Analysis tion, 1 was excluded due to pregnancy,
the most appropriate primary outcome Results of primary outcome measures and 1 was excluded due to past history
measure for a full-scale RCT was de- were provided descriptively in tables, of Perthes disease. Following clinical and
termined by using the patient-reported compared to the a priori established goals. radiological screening, 4 were excluded
outcome measure with the largest be- To provide a recommendation for estimat- because their pain was located only in the
tween-group effect size, as long as the be- ed sample size for a future full-scale RCT, lumbar spine, 1 participant was excluded
tween-group difference was greater than between-group effect sizes and 95% CIs due to hip pain of less than 3/10, and 6
the previously reported minimal impor- with Hedges correction were calculated were excluded based on an alpha angle
tant change for that outcome measure. for change in the secondary outcomes that was smaller than 60° (FIGURE 1). Twen-
Sample-Size Estimate The sample size of of quality of life, hip-related symptoms, ty-four participants (50% of those who
a future, fully powered study via sample- and hip muscle strength. The mean ± SD inquired, 100% of those with known eli-
size calculations was estimated using the score for each of the subscales was used gibility) were recruited into the study and
effect-size data from this pilot study. in the calculation of the effect size. Esti- underwent baseline testing procedures.
mated sample size was then determined During the course of the study, 4 peo-
Secondary Outcomes using the between-subject effect size, with ple were lost to follow-up (17%) and did
Change in Hip-Related Symptoms and a minimum of 90% power (α = .05). The not undergo final testing at the primary
Quality of Life This was measured us- sample size was increased to allow for an end point. Reasons for stopping partici-
ing the international Hip Outcome Tool- estimated 20% dropout rate. This dropout pation were the participant’s decision to
33 (iHOT-33), the Hip disability and rate is based on a previous pilot physical have hip arthroscopy surgery during the
Osteoarthritis Outcome Score (HOOS) therapy RCT.25 trial, pregnancy, major abdominal sur-
quality of life subscale (HOOS-Q),27 and Statistical methods for the second- gery due to illness, and not responding
the HOOS pain subscale (HOOS-P).27 ary outcome measures were evaluated to repeated attempts at follow-up.
Enrollment
for the FAIS-specific group was 37 ± 8 Excluded, n = 13
years and for the control group was 38 • No time, n = 3
• Pregnant, n = 1
± 10 years. Of both the FAIS group and • Past history of Perthes
Underwent telephone screening with
control group, 71% were women. The project coordinator, n = 48 disease, n = 1
average ± SD height of the FAIS-specific • Did not respond after
group and the control group was 1.70 ± making initial contact,
n=8
0.07 m and 1.69 ± 0.10 m, respectively.
Fulfilled all telephone-based
Weight and body mass index of the FAIS- inclusion criteria and underwent Excluded, n = 11
specific group was 73.2 ± 13.2 kg and 25.1 clinical and radiograph screening, • Alpha angle <60°,
± 3.7 kg/m2, respectively, compared to n = 35 n=6
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74.7 ± 7.3 kg and 26.1 ± 2.4 kg/m2 for the • Pain located only in
control group. the lumbar spine,
n=4
Included in the study and underwent • Pain of less than 3/10,
Aims baseline assessment, n = 24 n=1
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 Randomized to FAIS-specific Randomized to control group,
each of the secondary outcome measures group, n = 17 n=7
Allocation
for each group are reported in TABLE 2. The • Received allocated • Received allocated
intervention, n = 17 intervention, n = 7
effect sizes for between-group differences • Did not receive allocated • Did not receive allocated
for each of the secondary outcome mea- intervention, n = 0 intervention, n = 0
sures are reported in FIGURE 2, and mean
differences for the change scores between
groups are reported in TABLE 3.
Lost to follow-up, n = 1 Lost to follow-up, n = 0
• Did not respond to repeated Discontinued intervention,
Journal of Orthopaedic & Sports Physical Therapy®
DISCUSSION
Follow-up
T
n=2 due to illness
he results of this study suggest
• Hip anthroscopy surgery
that a full-scale RCT on physical ther- • Pregnancy
apy management of FAIS is feasible,
with a required sample of 144 participants
to demonstrate a clinically meaningful
Analyzed, n = 14 Analyzed, n = 6
functional improvement based on the Excluded from analysis, n = 3 Excluded from analysis, n = 1
Analysis
excessive
All participants felt that the facilities in which the interventions were delivered were appropriate
Recruitment and retention procedures Forty-eight people responded to advertisements over a 5-month inclusion period. Of these, 50% fulfilled inclusion
• Goals for minimum requirement for adequate recruitment criteria, and all were included in the study at a single physical therapy clinic
and retention: at least 80% of participants attended 75% of Of the 24 participants, 17 attended all physical therapy and supervised gym sessions; 1 attended at least 80% of, but
appointments and completed 75% of the prescribed exercises 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
Testing of outcome measurement collection At the end of the study, all 20 participants who finished the study completed patient-reported outcome question-
• Determined by completeness of outcome data collected, and naires, and physical impairment measures were collected on all participants by the blinded outcome assessor,
through poststudy interviews with no missing data
Journal of Orthopaedic & Sports Physical Therapy®
Appropriateness of randomization procedure and methods used The randomization procedure was appropriate, with the treating physical therapist informed of group allocation in a
to ensure blinding timely manner
• Determined during poststudy interviews of treating physical The blinded outcome measurement assessor was not aware of group allocation of any participants
therapist, blinded outcome assessor, and 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
Selection of the most appropriate primary outcome measure for The iHOT-33 (0.68), as a measure of hip symptoms and quality of life, and adductor strength (1.03) were selected
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 A sample size of 94 participants (47 in each group) provides a minimum of 90% power (α = .05) and is required
• Based on the iHOT-33 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)
Abbreviations: FAIS, femoroacetabular impingement syndrome; iHOT-33, international Hip Outcome Tool-33; RCT, randomized controlled trial.
addition, people in the current study had The FAIS-specific intervention used also had moderate to large gains in hip
iHOT-33 and HOOS-Q scores of less than in this study was the first, to our knowl- abductor (effect size, 0.54) and exten-
55 points out of 100 at baseline, indicat- edge, to utilize supervised, regular sor (effect size, 0.66) strength, but not
ing that hip-related quality of life was very gym-based strengthening exercises for in hip adductor strength, external rota-
poor. Our eligibility criteria specified that the hip and trunk, as well as functional tor strength, or trunk endurance. While
participants must not have had physi- retraining. Within-group effect sizes the FAIS-specific physical therapy group
cal therapy treatment in the previous 3 for gains in strength in all hip muscle underwent targeted muscle strength
months, but it is unknown which other groups and trunk endurance in the training for each hip muscle group and
treatment they might have sought in the FAIS-specific group were large (0.79- the trunk, both groups undertook a pro-
time prior to the previous 3 months. 1.09). Interestingly, the control group gressive cardiovascular loading program,
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)
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®
Adduction strength
Abduction strength
Extension strength
External rotation strength
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
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- spond differently to interventions, future physical therapy intervention may have a
spite options for statistical imputation full-scale RCTs may wish to account for positive effect on improving hip adductor
of missing data, minimizing the dropout types of FAIS: cam morphology, pincer strength, reducing pain, and improving
rate should be a priority in future studies. morphology, mixed cam and pincer mor- function. Adequately powered and im-
A potential weakness of the study, con- phology, or coexisting pathology such as proved studies may increase the effective-
sistent with the pilot nature of the work, labral and chondral pathology.7,26,29 ness of physical therapy for people with
is the small sample size, which precludes FAIS. t
any strong interpretation regarding the CONCLUSION
effectiveness of our intervention. Future 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.
Abbey Pryor, and Kerryn Webb, for assis- outcomes with and without femoral osteoplasty. impingement in symptomatic patients, athletes,
tance in delivering the physical therapy Br J Sports Med. 2012;46:632-643. https://doi. and asymptomatic individuals: a systematic
org/10.1136/bjsports-2011-090428 review. Eur J Radiol. 2016;85:73-95. https://doi.
intervention. The authors also thank the
12. K
emp JL, Collins NJ, Roos EM, Crossley KM. org/10.1016/j.ejrad.2015.10.016
participants for taking part in this study. Psychometric properties of patient-reported 23. Moher D, Hopewell S, Schulz KF, et al.
outcome measures for hip arthroscopic surgery. CONSORT 2010 explanation and elaboration:
Am J Sports Med. 2013;41:2065-2073. https:// updated guidelines for reporting parallel group
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amepre.2009.02.002 motion? Knee Surg Sports Traumatol Arthrosc. physiotherapy intervention for early-onset hip
3. Chan AW, Tetzlaff JM, Gøtzsche PC, et al. SPIRIT 2016;24:3955-3961. https://doi.org/10.1007/ osteoarthritis [abstract]. Osteoarthritis Cartilage.
2013 explanation and elaboration: guidance for s00167-015-3679-4 2015;23 suppl 2:A371-A372. https://doi.
protocols of clinical trials. BMJ. 2013;346:e7586. 15. K
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https://doi.org/10.1136/bmj.e7586 MG, Pollard TC, Crossley KM. Hip chondropathy 26. Nepple JJ, Riggs CN, Ross JR, Clohisy JC.
4. Eldridge SM, Chan CL, Campbell MJ, et al. at arthroscopy: prevalence and relationship to Clinical presentation and disease characteristics
CONSORT 2010 statement: extension to labral pathology, femoroacetabular impingement of femoroacetabular impingement are sex-
randomised pilot and feasibility trials. BMJ. and patient-reported outcomes. Br J Sports dependent. J Bone Joint Surg Am. 2014;96:1683-
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5. Frank JM, Harris JD, Erickson BJ, et al. bjsports-2013-093312 27. Nilsdotter AK, Lohmander LS, Klässbo M,
Prevalence of femoroacetabular impingement 16. K
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imaging findings in asymptomatic Crossley KM. A phase II trial for the efficacy of outcome score (HOOS) – validity and
volunteers: a systematic review. Arthroscopy. physiotherapy intervention for early-onset hip responsiveness in total hip replacement. BMC
2015;31:1199-1204. https://doi.org/10.1016/j. osteoarthritis: study protocol for a randomised Musculoskelet Disord. 2003;4:10. https://doi.
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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®
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.
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.
CONTROL GROUP
Journal of Orthopaedic & Sports Physical Therapy®
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.