Objective examination
The patient walked into the clinic independently mobile with no walking aid but had a slight bilateral Trendelenberg walking pattern and stood predominantly weight bearing through the left leg. Initial observations were that the patient stood in a sway back posture (viewed from a lateral aspect, the greater trochanter of her hips bilaterally was positioned anterior to both the lateral aspect of the shoulder and lateral malleolus), with hyperextended knees and bilaterally pronated feet. On sitting she had her legs tightly crossed, with her feet tucked around one of the chair legs. The Beighton’s hypermobility scale was 7/9 [3, 33, 34] with negative findings only for her thumb joints. The scale was explained to the patient and she reported this had never been performed on her before and she had never been told about hEDS in any of her past healthcare experiences. A preliminary hypermobility discussion ensued and it was explained that some patients experience a range of common co-morbidities. This resulted in the patient disclosing that she bruised easily, had unexplained stretch marks on the skin around her trunk, widened atrophic scars from wounds from childhood injuries (from falling over), suffered recurrent ankle sprains, previous left wrist subluxations, allergies, and that she experienced dizziness and light headedness upon standing (and on a few occasions had fainted and fallen). She expressed how she often did not tell people about all of her symptoms as she was afraid of not being believed and being labelled as a hypochondriac.
Isometric muscle strength tests of the hips using a Hand-Held Dynamometer (HHD) were carried out to record pre-operative benchmark measurements. The testing protocol used was as per the Hip Arthroscopy Pre-habilitation Intervention (HAPI) study [35] with the addition of hip internal rotation in prone described by Thorborg et al [36]. Measurements are presented in Table II . Hip flexion and hip extension strength tests were not recorded due to the patient’s high pain level with these movements. Functional movements such as squatting, bridges, one leg balance, single leg squat, step-ups, and gait were observed, alongside assessment of proprioception and motor control. All of these highlighted significant weakness, poor proprioception and poor neuromuscular control. Due to her history of recurrent ankle sprains, clinical observation of bilateral foot pronation and the understanding of the importance of ankle push-off function in reducing pressures through the anterior hip joint [37], the feet and ankles were assessed in detail. Passive tests of the ankles and feet showed excessive range of motion and ligament laxity [38]. Joint hypermobility can be found in joints outside of the Beighton score so a whole-body approach was adopted [20, 34]. Single leg calf raise ability, in supported one leg stance, was a total of 5 repetitions on each side before fatigue set in, which is a significantly lower value than would be expected in an average healthy adult [39]. It is normal following peri-acetabular osteotomy surgery for a patient to use crutches and to have a weight restriction through the operated leg [40]; thus, the non-operated leg must be of sufficient strength to cope with this.