Physiotherapy and activity modification have been proposed as alternative nonoperative methods for managing FAI. Activity modification involves instructing patients to limit their activities to within their pain-free range of motion, to discontinue sport, to perform any activities of daily living with minimal friction, and/or to rest [14, 23, 42].

The goals of physiotherapy in the management of FAI can be to increase the pain-free range of motion (ROM) of the hip, to optimize the balance between muscle strength and length, and to reduce anterior femoral glide [14, 23]. In the literature discussing physiotherapy, there are discrepancies as to the recommended approaches for managing FAI. Many studies emphasize muscle strengthening (core, hip flexor, gluteus maximus) as the key component of physiotherapy [28, 35, 42]. Other literature also recommends that physiotherapy include stretches to address hip flexor and other generalized hip muscle tightness [22, 31]. Of note, however, few studies do exist suggesting that stretching may increase passive ROM and consequently worsen symptoms [15, 32].

The use of physiotherapy and activity modification as a modality to increase pain-free range of motion and, subsequently, return to sport has been controversial due to contradicting results of their efficacy. Within the four studies published reporting outcomes after using varying aspects of physiotherapy and activity modification, two found positive results, whereas two others found strikingly opposite results.

Using a stepwise treatment protocol, Hunt et al. [23] found that 11 of 18 patients progressed to eventual surgical intervention without demonstrating any temporary relief or increase of function despite active therapy and decreased activity. In keeping with these findings, 9 of 9 patients with radiographically confirmed FAI studied by Jager et al. continued to experience significant pain and hip dysfunction after a mean follow-up of 16.2 months after both consistent physiotherapy and NSAID use [25]. Although both of these studies reported limited to no efficacy for physiotherapy or activity modification, studies by Feely and Emara show applicability as selective patients obtain appreciable improvement. In the eight National Football League players treated by Feely et al., all eight players with FAI were able to return to play without a surgical intervention; however, there were limited outcomes reported pertaining to pain, ROM, or function [16]. Similarly, Emara et al. demonstrated a positive effect on patient-reported pain with a VAS score decrease from 6 to 2 and a functional increase with HHS of 91 compared to a baseline of 72 in 37 patients with “mild” FAI (alpha angle <60°) treated with both physiotherapy and activity modification over a 25–28-month period [14]. Pain reduction and increase in function were appreciable in most patients, as only 10 continued to have noticeable pain, of which only four opted for a surgical intervention [14].

Despite the contradicting evidence on the utility of physiotherapy and activity modification for FAI, these modalities are generally viewed as harmless, making the possibility of occasional positive outcomes attractive. Due to its non invasive nature and possibility of a good treatment response, 81 % and 48 % of narrative reviews and discussion articles recommend trials of activity modification and physiotherapy, respectively, prior to surgical interventions [45].

Current data from the literature suggests that the management of FAI using physiotherapy and/or activity modification approaches is beneficial for some patients. In some cases, these treatment options may be sufficient to allow athletes to return to sport; however, the current literature lacks evidence-based recommendations on specific activity modifications that can be made by athletes hoping to return to sport. Also, determining the extent of benefit to patients is limited by the quality of the current literature. Due to this, it is difficult to conclude to what extent a patient’s improvement can be attributed to physiotherapy or activity modification, as each study uses varying nonsurgical management.

Many studies that examine nonoperative management of FAI mention the use of NSAIDs [6, 14, 47] and advocate for their use in the nonoperative treatment of FAI. Many of these studies, however, do not focus on NSAID management alone [6, 14, 47] nor do they often describe the dosage or type of NSAID used [6, 47]. This makes it extremely difficult to determine the sole efficacy of NSAIDs as the usefulness seen is confounded by the use of other nonoperative treatments and an inability to determine a dose effect or minimum needed dose.

One study, Emara et al. [14], used diclofenac as part of their nonoperative management program for FAI. They used a dose of 50 mg, twice a day, in combination with avoiding excessive physical activity for 2–4 weeks. This was only the first stage in a four-stage nonoperative management program that also involved physiotherapy, determining a safe ROM to avoid FAI pain, and modification of activities of daily living. While dosing was provided in this case, it was not the only intervention implemented which makes it difficult to determine the beneficial effects of NSAID use. There are also potential issues with patient compliance with medication, given the well-known side effects of NSAID medication (e.g., gastrointestinal ulcer and bleeding).

Although the use of NSAIDs has been supported in multiple studies, none discuss it as a sole intervention, but more as an adjuvant to other nonoperative treatments. As part of a regime, NSAIDs are expected to decrease inflammatory-mediated pain and increase pain-free ROM allowing patients to tolerate symptoms or increase the efficacy of other treatment protocols. However, studies have failed to comment on the associated risks of prolonged NSAID use including hypertension, renal issues, and gastric ulcers which become an important risk given the age and comorbidities of many patients with FAI.

Exercise in general, be it cardiovascular, strengthening, resistance, etc., is another area to be considered in the nonoperative management of FAI. While physiotherapy and manual therapy are mentioned above and are similar, exercise programs should be considered as well. Often, patients who are being treated for FAI are young and active [6, 34], so exercise programs must be recognized as important in the nonoperative management of FAI.

Due to the mechanical nature of FAI pain, return to physical activity too quickly can reproduce symptoms of impingement. Loudon and Reiman [34] outline an exercise program to allow long-distance runners to return to running after nonoperative therapy. They suggest that, in addition to facility-based rehabilitation (i.e., physiotherapy, athletic therapy), the athlete should not be allowed to run until they have painless hip motion. The athlete should continue to be active but should avoid activities that involve flexion and internal rotation of the hip. Swimming and walking are suggested. When returning to running, they should implement this gradually and should build in appropriate warm-ups and rest. Wright and Hegedus [47] describe an exercise program that combines physiotherapy and home exercise which allowed the patient to improve “95 %” in their pain and functionality from their initial visit.

As previously commented by Hunt et al. and Wall et al. [23, 45], these studies both agree that there is limited data on the subject of exercise in this setting and that more research, including randomized control trials, need to be undertaken to have more clarity on the issue.

A systematic review of the literature on nonoperative treatment for FAI found that only 2 % (1 article) of the articles recommended osteopathy and chiropractic treatment [45]. Furthermore, to the best of the authors’ knowledge, there exists no experimental data on the results obtained from osteopathic or chiropractic treatment of FAI. Chakraverty and Snelling suggest that osteopathic treatment may be effective in symptom control, but it may not be as useful in preventing the recurrence of symptoms [10]. That being said the authors do not specify what osteopathic methods would be useful in the symptom management of FAI and do acknowledge that strong flexing mobilization maneuvers often used by osteopaths may cause further labral injury [10]. Emary suggests that the role of chiropractors in FAI management lies in the diagnosis and timely referral of a patient to an orthopedic surgeon for appropriate treatment given that a chiropractor who attempts to treat the patient through stretching, manipulating, or mobilizing the hip may actually worsen the symptoms [15]. Indeed Clohisy et al. reported in their study that chiropractors represented 5 % of the 220 health-care professionals seen by patients with hip pain later diagnosed to be FAI prior to referral to an orthopedic surgeon [11]. In summary, the usefulness of osteopathic and chiropractic treatment in the management of FAI is unclear, and further clinical evidence is required prior to any recommendation for or against their approaches.

Bizzini et al. mentioned in their paper that massage therapy was useful in temporarily reducing symptoms in five professional ice hockey players diagnosed with FAI. However, all ultimately progressed to requiring surgical management [7]. To the best of the authors’ knowledge, there is no other literature that presents primary data on massage and manual therapy in the management of FAI, and therefore, no informed conclusion can be reached on its effectiveness or lack thereof. In keeping, the applicability as a primary intervention does not appear substantiated; however, it may be useful in combination with more active therapies.

Additionally, as with several other musculoskeletal entities, many patients experience associated issues due to compensatory adaptations to function with their illness. These compensatory measures result in additional issues and pain that are not directly caused by the bony deformity of their FAI, but may be amenable to the discussed therapies.