For Doctors in a Hurry
- Researchers investigated whether targeted strengthening provides superior quality of life outcomes compared to standardized stretching for patients with femoroacetabular impingement syndrome.
- This assessor blind randomized trial enrolled 154 participants aged 18 to 50 years to receive six months of supervised physical therapy.
- Groups showed no significant difference in quality of life scores, with a mean difference of 0.2 (95% CI -5.9 to 6.3).
- The authors concluded that neither intervention was superior for quality of life, though strengthening yielded greater perceived pain improvement (OR 2.36).
- Clinicians may utilize either approach to achieve clinically meaningful improvements in hip related quality of life for patients with this syndrome.
Optimizing Conservative Strategies for Femoroacetabular Impingement Syndrome
Femoroacetabular impingement syndrome remains a primary driver of hip-related disability in active young and middle-aged adults, frequently requiring long-term clinical management [1, 2]. While arthroscopic surgery is common, its superiority over conservative care is debated. Long-term data at 38 months indicate that surgery may yield higher scores on the Hip Outcome Score Activities of Daily Living (a measure of functional capacity in daily tasks) compared to physical therapy, with a mean difference of 8.9 points (95% CI 7.0 to 10.8) [3, 4]. However, the implementation of conservative protocols is often hindered by poor reporting. A systematic review found that 29 of 52 exercise studies provided no description of the intervention, resulting in a median Consensus on Exercise Reporting Template score (a 19-item checklist for intervention transparency) of only 12 [5]. Furthermore, the efficacy of general exercise for hip conditions is often modest, with some meta-analyses showing negligible effects on pain and function in related conditions like hip osteoarthritis [6]. To address these gaps, a recent randomized controlled trial investigated whether a personalized strengthening program provides superior hip-related quality of life compared to a standardized stretching protocol [7].
Comparing Targeted Strengthening and Standardized Stretching Protocols
The PhysioFIRST study was designed as an assessor-blinded, limited disclosure, parallel, superiority randomized controlled trial to determine if specific exercise modalities offer distinct advantages for patients with femoroacetabular impingement syndrome. By utilizing an assessor-blinded approach (where the evaluating clinicians do not know which treatment the patient received) and limited disclosure (where patients are not fully informed of the specific study hypotheses to prevent bias), the researchers aimed to rigorously compare two distinct physical therapy strategies. The team recruited 154 participants between the ages of 18 and 50 years who met the clinical and imaging criteria for the condition. These individuals were randomly allocated in a 1:1 ratio to receive one of two 6-month, physiotherapist-led interventions. The targeted-strengthening group (STRENGTH) consisted of 79 participants (53% women) with a mean age of 35 years (SD 9). The standardized-stretching group (STRETCH) included 75 participants (45% women) with a mean age of 36 years (SD 9). To maintain the integrity of the superiority design, the trial utilized an intention-to-treat analysis, a statistical method where all participants are analyzed in their originally assigned groups regardless of whether they completed the full treatment course.
The primary outcome was the change in hip-related quality of life at 6 months, measured by the International Hip Outcome Tool-33 (iHOT-33). This instrument uses a 0 to 100-point scale to quantify the impact of hip pathology on a patient's daily life, with higher scores indicating better quality of life. Additionally, the researchers employed the Global Rating of Change (GROC), a self-reporting tool that allows patients to quantify their perceived improvement or worsening over time. For this study, the GROC was divided into two specific domains: GROC-pain, which measures the patient's perception of pain relief, and GROC-function, which captures the patient's assessment of their physical capabilities. By utilizing these patient-reported metrics, the trial aimed to identify which conservative approach most effectively addresses the subjective burden of femoroacetabular impingement syndrome in routine clinical practice.
Equivalent Quality of Life Improvements Across Interventions
The primary analysis of the trial demonstrated that neither intervention was superior in enhancing hip-related quality of life at the 6-month follow-up. The researchers found no difference between groups for change in hip-related quality of life, reporting a mean difference of 0.2 points on the International Hip Outcome Tool-33 (95% CI -5.9 to 6.3). This lack of statistical divergence extended to the patients' own assessments of their progress. There was no difference between groups for patient-perceived global improvement in pain, with a Global Rating of Change score for pain of 0.2 (95% CI -0.2 to 0.7, p=0.23). Similarly, the data indicated no difference between groups for patient-perceived global improvement in function, yielding a Global Rating of Change score for function of 0.3 (95% CI -0.1 to 0.6).
Despite the absence of a superior modality, both the targeted strengthening and standardized stretching protocols resulted in substantial longitudinal gains. Both groups improved in International Hip Outcome Tool-33 scores over 6 months, and the researchers noted that hip-related quality of life improved in both cohorts by clinically meaningful amounts. Specifically, the STRENGTH group improved by 19.2 points (95% CI 15.7 to 22.8) on the 100-point scale. The STRETCH group improved by 20.8 points (95% CI 17.1 to 24.5) over the same period. For clinicians, these findings suggest that while the physiological mechanisms of the two exercises differ, the resulting impact on a patient's daily life and subjective well-being is comparable when administered through a structured, physiotherapist-led program.
Secondary Advantages for Pain Perception and Muscle Force
While the primary outcomes showed parity in overall quality of life, the researchers conducted a secondary analysis that included dichotomized Global Rating of Change scores (a statistical approach that categorized patients into binary groups of either "improved" or "not improved") alongside objective measures of hip muscle strength. This analysis revealed that the targeted strengthening protocol offered distinct advantages for specific clinical markers. Notably, 72% of the STRENGTH group were improved for Global Rating of Change in pain compared with 52% of the STRETCH group. This difference in patient-perceived recovery was statistically significant, with the odds ratio for improvement in pain in the STRENGTH group reaching 2.36 (95% CI 1.15 to 4.84).
Beyond subjective pain perception, the physiological impact of the interventions diverged during the 6-month follow-up period. The researchers found that the STRENGTH group had greater improvements than the STRETCH group in hip strength, suggesting that the resistance-based protocol successfully addressed the muscular deficits often associated with femoroacetabular impingement syndrome. For practicing physicians, these findings imply that while both stretching and strengthening are effective for improving general quality of life, a targeted strengthening approach should be prioritized for patients whose primary clinical goals include maximizing force production and achieving a higher likelihood of perceived pain reduction.
References
1. Kemp JL, Mosler A, Hart HF, et al. Improving function in people with hip-related pain: a systematic review and meta-analysis of physiotherapist-led interventions for hip-related pain. British Journal of Sports Medicine. 2020. doi:10.1136/bjsports-2019-101690
2. Impellizzeri FM, Jones D, Griffin D, et al. Patient-reported outcome measures for hip-related pain: a review of the available evidence and a consensus statement from the International Hip-related Pain Research Network, Zurich 2018. British Journal of Sports Medicine. 2020. doi:10.1136/bjsports-2019-101456
3. Schwabe M, Clohisy JC, Cheng AL, et al. Short-term Clinical Outcomes of Hip Arthroscopy Versus Physical Therapy in Patients With Femoroacetabular Impingement: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Orthopaedic Journal of Sports Medicine. 2020. doi:10.1177/2325967120968490
4. Palmer A, Fernquest S, Rombach I, et al. Medium-term results of arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of femoroacetabular impingement syndrome: a multi-centre randomised controlled trial. British Journal of Sports Medicine. 2024. doi:10.1136/bjsports-2023-107712
5. Estberger A, Kemp JL, Thorborg K, Pålsson A, Ageberg E. Are Exercise Therapy Protocols For The Treatment of Hip-Related Pain Adequately Described? A Systematic Review of Intervention Descriptions. International Journal of Sports Physical Therapy. 2023. doi:10.26603/001c.68069
6. Schleimer T, Teichert F, Henriksen M, et al. Effectiveness of exercise therapy for osteoarthritis: an overview of systematic reviews and randomised controlled trials. RMD Open. 2026. doi:10.1136/rmdopen-2025-006275
7. Kemp JL, Johnston R, Coburn S, et al. Physiotherapist-led treatment for femoroacetabular impingement syndrome (the PhysioFIRST study): a protocol for a participant and assessor-blinded randomised controlled trial. BMJ Open. 2021. doi:10.1136/bmjopen-2020-041742
