The patient was a 22-year-old female Caucasian (height 160 cm, weight 70 kg) living in the United Kingdom with bilateral developmental dysplasia of the hip (DDH) with a radiographic Lateral Centre Edge Angle (LCEA) of 15  on the right and 17 . An LCEA of <20  is considered to be dysplastic. She had been referred for preoperative physiotherapy by her hip surgeon, in preparation for a right hip periacetabular osteotomy. The right hip operation was scheduled in 16 weeks' time and the left hip operation a year later; providing surgical outcomes were satisfactory on the right side. The patient has formally consented to her case being published, having considered and approved this manuscript.
The patient completed self-reported questionnaires, namely the international Hip Outcome Tool (iHOT-33), EuroQol 5 dimensions (EQ-5D-5L), and numerical pain rating scale (NPRS) as displayed in Table 1. She described right hip pain with a 9-month history, in a "C-sign distribution" (groin, lateral hip, and buttock). Pain was reported at night and affected all activities, including sitting and standing (both limited to 20 min), which affected her being able to work in her office job. Yoga used to be her favorite form of exercise as she could adopt to the positions easily but that was also now painful. She tried physiotherapy locally for the last 8 months, but the exercises caused her hip pain to flare up, so she stopped doing any exercise. Physiotherapy exercises previously prescribed had aimed to improve gluteal strength. 
In addition to her DDH, she reported endometriosis, polycystic ovaries, hay fever, irritable bowel syndrome, heartburn, reflux, depression, and chronic fatigue. Medications taken were Codeine for pain relief 15 mg once a day, Paracetamol 200 mg, 2-3 times a day, Cymbalta 60 mg once a day, and Medroxyprogesterone 25 mg once a day.
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 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 comorbidities. 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 lightheadedness 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 labeled as a hypochondriac.
Isometric muscle strength tests of the hips using a Hand-Held Dynamometer (HHD) were carried out to record preoperative benchmark measurements. The testing protocol used was as per the Hip Arthroscopy Pre-habilitation Intervention study with the addition of hip internal rotation in prone described by Thorborg et al. Measurements are presented in Table 2. 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 the 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, the feet and ankles were assessed in detail. Passive tests of the ankles and feet showed the excessive range of motion and ligament laxity. Joint hypermobility can be found in joints outside of the Beighton score so a whole-body approach was adopted. Single-leg calf raise ability, in supported one-leg stance, was a total of five repetitions on each side before fatigue set in, which is a significantly lower value than would be expected in an average healthy adult. It is normal following periacetabular osteotomy surgery for a patient to use crutches and to have a weight restriction through the operated leg; thus, the nonoperated leg must be of sufficient strength to cope with this.
Poor proprioceptive awareness
Unable to improve preoperative function and strength, due to pain
Safety concerns with dizziness, lightheadedness, and fainting episodes, combined with reduced mobility
Low mood due to decreased function
After discussion, and with the patient's explicit consent, a letter was written to their Primary Healthcare Physician, General Practitioner (GP), to request a referral to a specialist Rheumatologist who dealt regularly with EDS and other connective tissue disorders. Following a thorough Rheumatology assessment and screening to exclude any other possible diagnoses, the specialist Rheumatologist diagnosed the patient with hEDS using the 2017 International Classification and they also suspected PoTS. Therefore, they made an onward referral to a Cardiologist and for a tilt table test. The consultant Rheumatologist also liaised with the patient's orthopedic hip surgeon as there is a strong correlation between joint hypermobility and hip dysplasia. The patient reported that she felt listened to, felt the value of understanding her own body better, and felt having a "label" helped her explain her problems to family, friends, and work colleagues. She shared with us that she had previously "lost her faith" in physiotherapy, as exercises prescribed by past practitioners had caused pain exacerbation, so it was important for us to build trust and a relationship to help find a way of improving her strength, proprioception, and function.
To address the issues listed on the problem list we suggested a trial of DEFO leggings, which not only provide compression to aid blood pressure in the legs but also provide proprioceptive feedback to aid her postural control. With this patient, we wanted to reduce her sway back posture and knee hyperextension as we found that this decreased her pain. Sway back posture has been reported to increase the joint pressure around the anterior acetabulum, the area that is often inadequately covered by the hip socket in DDH. The patient's decreased awareness of her body posture meant she was unable to maintain the position, which decreased her pain; therefore, we wanted to assess to see whether a DEFO, in the form of leggings, which also encompassed the hip and pelvic region, could assist in reducing her sway back posture. Core control, hip, lower limb, breathing, and proprioceptive exercises were tailored to her needs so that they were manageable; paced to accommodate her pain, chronic fatigue, and dizziness; and were relevant to helping her function postoperatively. In a systematic review of exercise programs for hEDS patients, a period of 4-8 weeks was commonly reported in studies. Our exercise program had a longer timespan (16 weeks) as it was dictated by the planned surgery date.
Patient measurements were reassessed at 8 and 16 weeks, postintervention (Tables 1 and 2). Both subjective and objective outcome measurements showed positive improvements with the iHOT-33 score increasing by 31 points. The minimal clinically important difference (MCID) of the iHOT-33 is 6 points. The patient felt less pain and reported the DEFO made her feel more coordinated and stable. This resulted in her being able to engage in her physiotherapy exercises to prepare for hip surgery. Increases in muscle strength were demonstrated by HHD tests with her hip abductors, hip adductors, hip internal, and hip external rotators. Reduction in her symptoms of light-headedness, dizziness, and palpitations were notable and promising in respect of improvements to her safety and prevention of falls. Figure 1 are photographs showing the patient without the orthoses and their sway back posture and a comparative photograph to show her posture changes while wearing the orthoses. Her posture in standing while wearing the orthotics was significantly more vertically aligned. These improvements also carried over into her walking posture; and most importantly, resulted in decreased pain and heightened body awareness.