Therapeutic exercise approaches to nonoperative and postoperative management of femoroacetabular impingement syndrome

Key points

1. 01Nonoperative and postoperative FAIS rehab programs align on four pillars: posture, core strength, hip strength and motor control, and functional range of motion
2. 0270% of adolescent and young adult athletes with FAIS were successfully treated with structured nonoperative therapy, activity modification, and rest
3. 03A meta-analysis of 5 RCTs found nonoperative treatment is an effective initial option for FAIS management
4. 04Hip arthroscopy showed a mean iHOT-33 score advantage of 6.8 points over nonoperative care at 12 months (P = .009), but with more adverse effects
5. 05Return-to-sport rates after arthroscopy range from 57% to 93% depending on how strictly return-to-sport is defined

How it was conducted

Design

Narrative current concepts review with referenced exercise protocols

Population

Patients with femoroacetabular impingement syndrome (FAIS), including adolescent and adult athletes

Interventions reviewed

Nonoperative exercise programs and postoperative hip arthroscopy rehabilitation

Outcome measures

Patient-reported outcomes including iHOT-33, mHHS, return-to-sport rates, hip strength, ROM, and core stabilization benchmarks

Key referenced trials

UK FASHIoN RCT (Griffin et al), Hoit et al meta-analysis of 5 RCTs, Mansell et al active-duty military RCT, Pennock et al 76-athlete nonoperative cohort

What they found

• In the UK FASHIoN RCT, both hip arthroscopy and personalized physiotherapy groups reported improved iHOT-33 scores at 12 months; mean difference was 6.8 points in favor of arthroscopy (P = .009)
• Hip arthroscopy was associated with more adverse effects than nonoperative treatment in the UK FASHIoN RCT
• Mansell et al found improved Hip Outcome Score values in both surgical and physical therapy groups with no difference between groups at 2 years, though high crossover rates limited conclusions
• Hoit et al meta-analysis of 5 RCTs found nonoperative treatment focused on hip and core strengthening in a supervised setting resulted in better patient-reported outcomes
• Pennock et al reported 70% success with nonoperative structured therapy in 76 adolescent and young adult athletes
• Elite-level athletes showed return-to-sport rates of 84% to 93% after arthroscopy; Ishoi et al found only 57% returned to preinjury sport level using a stricter definition
• Participants in a 5-phase postoperative rehabilitation program reported mHHS of 80.1 plus or minus 19.9 (in the good range of 80-89) at 12 months postoperatively
• 12 weeks of physical therapy including hip and core strengthening, manual therapy, and lifestyle education improved iHOT-33 scores
• An 8-week core strengthening program improved hip flexion and hip adduction strength
• The average time for return to sport after arthroscopy is approximately 7 months

Limitations

• This is a narrative review, not a systematic review or meta-analysis, so selection and interpretation bias are possible
• Formal high-evidence nonoperative protocols for FAIS are scarce; most cited studies are small or have methodological limitations
• Patient-reported outcome measures lack standardization, making comparisons between studies difficult
• High crossover rates from nonoperative to surgical groups in RCTs reduce the ability to draw definitive conclusions about which treatment is superior

Why it matters

For patients

Patients with FAIS can expect that both non-surgical and post-surgery rehab will focus on the same core exercise areas, and that trying structured physical therapy first is a reasonable approach before considering surgery.

For clinicians

Clinicians should individualize FAIS rehab around four pillars (posture, core stability, hip strength and motor control, functional ROM), monitor pain throughout, and use objective benchmarks such as Y-balance test and hop symmetry tests to guide return-to-sport decisions.

For readers

This review provides a practical, protocol-level framework for FAIS management that is useful for athletic trainers and sports medicine practitioners, though it highlights the ongoing need for standardized outcome reporting in this field.