HIP FAI TPTA v2 handout - Continuing EDcontinuing-ed.cc/.../uploads/2015/10/HIP-FAI-TPTA-v2-handout.pdf · The Elements of Patient/Client Management Leading to Optimal Outcomes

Evidence‐Based Management of Femoroacetabular Impingement Syndrome

TPTA Annual Conference – Arlington, TXOctober 23, 2015

Ed Mulligan, PT, DPT, OCS, SCS, ATCUT Southwestern School of Health Professions 1

Evidence-Based Management of Femoroacetabular Impingement Syndrome Presenters

Ed Mulligan, PT, DPT, OCS, SCS, ATC Associate Professor; Residency Programs Director

UT Southwestern Medical Center School of Health Professions Department of Physical Therapy - Dallas, TX

UT Southwestern Medical Center – Dallas, TXOrthopedic, Neurological, and Sports Residency Programs Presentation Objectives

1. Define and differentially diagnose acetabular labral pathology and describe the epidemiology and risk factors associated with femoroacetabular impingement

2. Conduct a comprehensive subjective history and objective examination to manage intra‐articular hip pathology

3. Describe the intervention strategy, sequence, and points of emphasis for the non‐operative and post‐surgical management of labral pathology and athletic pubalgia

4. Select and utilize appropriate self‐report outcome tools for athletic hip problems and implement return to sports activities and criteria

Disclosure Statement

Neither I, Edward P. Mulligan, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation

DiagnosisOutcome Measures

InterventionConservative and Post‐Op

Prognosis

Return to Activity

ExaminationHistory – Systems Review –Physical Exam ‐ Imaging

Evaluation

Presentation AgendaThe Elements of Patient/Client Management Leading to Optimal Outcomes




Femoroacetabular Impingement

Abnormal, pathological femoral acetabular contact or shearing that occurs within a normal ROM secondary to bony deformities or spatial malorientation that eventually manifests as symptomatic

15-year trend in publications on FAI

1 2 3 4 1018 20

38 40

81

99

142

173

251236

FAI is an intra-articular, non-arthritic hip pathology

Possible anatomical variants that may predispose to injury

– Femoral neck anomalies– Structural instability– Femoral or acetabular torsion/version

Resultant Symptomatic Pathologies

– Acetabular labral tears– Osteochondral lesions– Loose bodies– Ligamentum teres tears

Variants and pathologies are not mutually exclusive

Common Injuries

Acetabular (fibrocartilaginous rim) Labral Tears– radial flap (most common), radial fibrillated, longitudinal

peripheral, and abnormally mobile (partially detached)

Osteochondral Lesions– focal loss of cartilage on the articular surfaces

Ruptured Ligamentum Teres– strong intrinsic ligament stabilizer that resists hip joint

subluxation particularly when the hip is externally rotated in flexion or internally rotated in extension

Loose Bodies– small fragments of bone or cartilage within the joint from

osteochondritis or synovial chondromotosis

Mechanisms of Injury

Traumatic

– Twisting/Pivoting (golf, gymnastics, hockey, baseball, etc)

most often hip extension and ER

– Repetitive Hyperflexion (soccer, diving, running, etc)

Structural/Congenital Predisposition

– Femoral Acetabular Impingement (FAI)

Cam – large femoral head

Pincer – abnormal acetabulum with over coverage

– Capsular Laxity (congenital vs. acquired)

Down’s or Ehlers‐Danlos Syndrome

– Acetabular dysplasia

Structural Variants




Imaging

Standard x‐ray views– AP– Frog‐Leg Lateral View

MRA/MRI– Much better SN for labral pathology with MRA than MRI (90 vs. 30%)

Major Radiographic Findings in FAI

How do the radiographic findings correlate with the physical exam

Dunn Viewlateral, cross-table, frog-leg Radiographic Findings

Cam Impingement – femoral head/neck profile exceeds the radius curvature of the acetabulum

– Alpha angle > 55‐60° No absolute cut‐off value

only an indicator of the size of the bony anomaly

A high alpha angle in an asymptomatic patient should be be considered an incidental finding

– Head‐neck offset ratio < 0.14(more in a minute)

Alpha Angle

On axial oblique MRI sequence, angle formed by a line parallel to the femoral neck axis and line from center of the femoral head to the transition of the femoral head into the femoral neck (neck radius exceeds head radius)

Abnormal > 55‐60° indicates cam deformity

Cam abnormal contact between femoral head/neck and acetabular margin

Prevalent in asymptomatic patients indicating that activity level is an important variable and that diagnosis is based on the clinical exam – not the image




Cam = “Pistol Grip Deformity” abnormal contact between femoral head/neck and acetabular margin

Cam

– Asphericity of the femoral head creating a prominent bump on the anterosuperior head‐neck junction (pistol grip)

Can be secondary to epiphyseal injury or SCFE

wave sign

Resultant Pathology abnormal contact between femoral head/neck and acetabular margin

Cartilage in area of asphericity is delaminated from the bony acetabulum

• Convex bump (yellow arrowheads) at anterior femoral head-neck junction• Area of chondral loss (red arrows) present on the acetabular side of the joint• Subtle subchondral degenerative changes (red arrowhead) located on the

corresponding femoral side of the joint

Cam femoroacetabular impingement varieties

Head-Neck Offset RatioFemoral Morphology SummaryAlpha Angle and Head/Neck Offset

< 9 mm offset is considered abnormal

Dunn View

CAM Lesionvideographic explanation of pathological process Pincer Impingement

Increased Acetabular Depth

– Coxa profunda (lateral center‐edge angle > 35°)

– Fossa acetabuli is medial to Kohler’s line (deepsocket)

– Acetabular protrusion

– Femoral head is medial to Kohler’s (ilioischial) line

red line = ilioischial (Kohler’s) line




Center Edge Angle (coxa profunda)

angle formed by a vertical line and a line connecting the femoral head center with the lateral edge of the acetabulum

Abnormal > 39° indicating pincer deformity

Radiographic Findings

• Acetabular Retroversion

― Crossover sign (indicating anterosuperior over coverage)

― Posterior acetabular rim does not lie lateral to the anterior wall on AP view

Crossover Signacetabular overcoverage secondary to retroversion

AP X-ray demonstrating bilateral acetabular retroversion as determined by crossover of the anterior and posterior acetabular walls (dotted lines)

Acetabular Version Anomalies Summary

Acetabular retroversion – anterior overcoverage of femoral head; posterior undercoverage

– Early contact with anterosuperior labrum when hip is internally rotated and flexed

Acetabular anteversion – posterior overcoverage of femoral head; anterior undercoverage

– Early contact with anterosuperior labrum when hip is externally rotated and extended

Clinical Recognition of Transverse Plane Hip Structure

AntevertedRetroverted• Femoral Anteversion

– torsion angle > 15°– toeing in

Femoral Retroversion– torsion angle < 8°– toeing out

NormalCraig’s Test and/or proportional hip ROM to identify presence




Femoral Version Impact

Decreased femoral torsion allowing impingement in IR

Increased femoral torsion allowing impingement in ER

NORMAL

anterior head/neck junction closer to anterior acetabular rim

posterior head/neck junction closer to posterior acetabular rim

Structural Instability

Extraphysiologic motion of traumatic, atraumatic, or microtraumatic origin

– Shallow acetabulum

– Excessive femoral torsion or acetabular version

– Dysplasia (congenital or developmental)

More common in females than males

Sex Prevalence in FAI ImagingMixed Cam-Pincer on A/P and Lateral Frog Leg

20-30 yo

30-40 yo

Diagnostic Imaging Reminder

Morphology Pathology Cam/Pincer are structural findings but do not

automatically cause pathology

– Only implies that shape could allow abnormal contact particularly with repetitive loading

Evaluation of the Hip subjective history

Age and Sex

– Hip injuries tend to be age specific

Chief Complaint

Functional Disabilities

Patient's Goal‐Expectation(s)

“… Stop squirming, Mr. Silcox. The sooner we fill out these forms, the sooner we’ll find out exactly what’s wrong with you.”




Hip InjuriesDifferential Diagnosis based on Age

AGE

0‐2 Development Dysplasia

4‐8 Legg‐Calves‐Perthes

9‐15 SCFE; Apophysitis

14‐25 Overuse Injuries – Strains, Sports Hernia, Stress Fractures

20‐40 Labral Pathology*

35‐55 GTPS; Snapping Hips

55+ DJD and Hip Fractures

Acetabular Labral Mechanism of Injury

Degenerative in older patients

Traumatic or overuse in youth

Increased risk if dysplastic or structural anomalies

Acetabular Labral Tears

Epidemiology

– Usually presents in 20s to 40s

– 20% of athletes with chronic or unresolved groin pain; 55% of adults with undiagnosed mechanical hip pain

– deep, intermittent groin pain with “mechanical” presentation during or after activity

– Most common area is anterior‐superior labrum (in U.S.)

Anterosuperior Posterosuperior Anteroinferior Posteroinferior

Acetabular labral lesion locations in order of frequency

subjective history

FAI hip pain location– Typically in the anterior or medial groin area

• Lateral pain is trochanteric or L4 referred

• Posterior may be SIJ, piriformis, or L5‐S1 referred

• Hip pain can also extend down the thigh towards the knee (pseudoradiculopathy)

C sign – classic representation of FAI-related pathology

Absence of groin pain helps rule out FAI because of its high sensitivity (0.96‐1.00)Byrd JW, N Am J Sports Phys Ther, 2007Keeney et al, Clin Ortho Relat Res, 2004,McCarthy et al, Orthopedics, 1995




Acetabular Labral Symptom Presentation

Pain Location– 92% groin;

59% lateral hip; 52% anterior thigh/medial knee; 38% buttock area

– 85%+ have sharp pain with activity and painful mechanical lockingBurnett RS, J Bone Joint Surg, 2006

Clicking/Catching– 100% specificity/85% sensitivity

Narvani, Knee Surg Sport Traumatol Arthrosc, 2003

Symptoms Seem Activity Dependent

Pain Characteristics % Involvement

Sharp 73

Ache 73

Burn 25

Numb 10

Constant 46

Intermittent 42

Rest 35

Prevents Sleep 42

Wakes from Sleep 19

Aggravating Factors % Involvement

Activity related 71

Running 69

Pivoting 63

Walking 58

Sitting 65

Standing 44Clohisy JC, Clin Orthop Relat Res, 2009

Typical Onset and Nature of Complaint

65% insidious vs. 35% specific incident

65% have “mechanical” symptom

Mechanical Feature % Involvement

Pop 46

Snap 44

Catch (Crackle) 33

Lock 29

Subluxation/Instability 19Clohisy JC, Clin Orthop Relat Res, 2009

Cam Related Postural and Activity Related Complaints/Exacerbations

Prolonged Sitting (low chairs or driving)

– should get up and move every 5‐10 minutes

Activities that require repetitive, end‐range hip flexion

– uphill running

– stair ascent

– sprinting

– kicking

– recumbent cycling

Getting in/out of car

Pincer Related Postural and Activity Related Complaints/Exacerbations

Repeated hip hyperextension

– downhill walking

Weight bearing pivoting

– particularly towards side of involvement

Intercourse positionsLeft side

involvement

Right side involvement




Activity Related Complaints

Walking-Stairs ADLs

ADL – Functional Activity

Limp at any time 73%

Limb Severity Slight Moderate Severe/Need Assistance

57% 14% 2%

Limited in Walking distance 37%

Distance Limitation > 6 blocks > 2 blocks Limited to indoors

22% 12% 2%

Require Use of Bannister on Stairs 39%

Clohisy JC, Clin Orthop Relat Res, 2009

Activity Related Complaints

Sitting/Dressing Tolerance

ADL – Functional Activity

Sitting Tolerance

Time One hour > 30 minutes < 30 minutes

37% 20% 43%

Donning shoes and socks 35%

Difficulty Difficult Unable

31%% 4%

Clohisy JC, Clin Orthop Relat Res, 2009

Subjective Self-Report Outcome Measures

Region Specific

HOS*

HAGOS

iHOT‐33

LEFS

Dimension Specific

• FABQ

• TKS

• GROC

Disease/Condition Specific• WOMAC – Osteoarthritis

• Oxford and Harris Hip Scores – Post‐op

* Note: The HOS was specifically developed to assess young patients with labral pathology

Q of L

PSFS

• SF‐36

• SF‐12

Self-report Outcome Tool Clinimetrics

Reliability – “repeatedly consistent”

– ICC > 0.75 is “good”

Validity – measures what it intends to measure

– Construct: quantitative assessment of relationship to a similar variable

– Pearson (r) > 0.40 is a “strong” correlation

Responsiveness – ability to detect a change over time when meaningful change has occurred

– MCD ‐ statistically reliable change of the tool

– MCID ‐minimal clinical change perceived as important

– SEM ‐ standard deviation of the distribution sample

HOS

Hip, ADL and Sports subscales

On the ADL subscale, the items related to sitting and putting on socks and shoes are not scored

17 items scored from 0‐4 with a max total of 68

Must answer at least 14 of 19

Sports subscale is optional and has max of 36 points

Highly reliable (ICC > 0.9)

MCID – 9 pt. ADL and 6 pt. sports subscale

Copenhagen Hip and Groin Outcome Score (HAGOS)

Newer region specific outcome measure tool designed for active younger to middle age patients with hip/groin pain

100 point questionnaire with 6 subscales of function

Construct Validity ‐ r = 0.37‐0.73

Test‐retest reliability ‐ ICC = 0.82‐0.92

MCID ± 5.2 on any of the 6 subscales

Thorborg et al, Br J Sports Med, 2014




International Hip Outcome Tool-33 iHOT-33

Region specific 100 point VAS questionnaire for young active patients

Construct validity

― r = 0.81

Test‐retest reliability

― ICC = 0.78

MCID ± 6 Mohatadi et al, Arthroscopy, 2012

International Hip Outcome Tool-12 iHOT-12

Excellent agreement with iHOT‐33

Equivalent sensitivity to change

Automated versions available at:

http://www.nsmoc.com/pdf/ihot.pdf

http://www.scottfaucettmd.com/ihot/

Griffin DR et al, Arthroscopy, 2012

Lower Extremity Functional Scale (LEFS) Lower Extremity Functional Scale (LEFS)

Self report of functional ability via region specific 20‐item Likert scale questionnaire

Construct validity (r = 0.64‐0.80)

Reliable test‐retest measure (ICC = 0.80‐0.94)

SEM: 5 point margin of error

MCID ± 9

Low ceiling effect

Widely used in research and clinically

Binkley et al, Phys Ther, 1999

PSFS Patient Specific Functional Scale

3 self‐selected functional items rated on 0‐10 scale from unable to fully able to perform

Sum of 3 scores/3

MCD = 3 points single item; 2 points on average

MCID based on GROC satisfaction

– Small + change = ~ 1 point

– Medium + change = ~ 2 points

– Large + change = ~ 3 points




Outcome Tool Clinimetric Summary

Thorborg K, Tijssen M, Habets B, Bartels EM, Roos EM, Kemp J, Crossley KM, Hölmich P. Patient‐Reported Outcome (PRO) questionnaires for young to middle‐aged adults with hip and groin disability: a systematic review of the clinimetric evidence. Br J Sports Med. 2015 Jun;49(12):812. doi: 10.1136/bjsports‐2014‐094224. Epub 2015 Jan 13.

Differential Diagnoses

Hip Dysplasia (age)

Lumbogenic Origin (posture/trunk motion)

Snapping Hip (symptom location/quality)

Trochanteric bursitis (age, sex, symptom location)

Piriformis Syndrome (symptom location/quality)

Sports Hernia (symptom location and provocation)

Osteoarthritis (age, stiffness)

Stress fracture (age, activity level)

Objective Examination You can see a lot by looking …

• Posture

― Sagittal, A/P, and transverse planes

• Limb Length Discrepancies

― No known correlation between limb length and FAI structural abnormalities on long or short limb

Patel SH, ISHA Annual Meeting, 2014

Hip ROM/Flexibility Assessment

Thomas Test –One/Two Joint Hip Flexors

PiriformisHip Rotators

AdductorsHamstringsOber Test –TFL/ITB

Quads/Rectus Femoris

Contrast may be important

Hip Rotations in Flexion and Extension

Contrast amounts of internal and external hip rotation in positions of flexion and extension

Cam lesions tend to limit mobility in flexion but not extension

Could also simply differentiate capsular and muscular mobility about the hip




Hip Joint ROM

MOTION Normal ROM

Flexion (end feel) 0‐120°

Extension 0‐20°

Abduction 0‐45°

Adduction 0‐30°

External Rotation 0‐45°

Internal Rotation (end feel) 0‐45°

Common activities that may require substitution motions secondary to Cam deformities

Tie Your Shoes 120˚ flexion

Sit in Chair 110˚ flexion

Fig 4 Sit 120˚ flexion/20˚ Abd/ER

Put Pants On 90˚ flexion

FAI Physical Exam: Motion Summary

Terminal Motions Lost

– Limited IR (< 20°) when hip is flexed to 90°

Kubiak‐Langer M et al, Clin Orthop Relat Res, 2007

– Hip elevation maneuvers often limited (flexion and abduction)

– Obligatory hip external rotation with end‐range hip flexion (Drehmann’s sign)

Abnormal Arthrokinematics Excessive anterior femoral glide during ASLR

Because of the articular congruity there should be minimal glide of the femoral head in the acetabulum during sagittal plane motion

If anterosuperior glide is detected with familiar groin pain it may indicate overactive TFL and labral provocation

– Concordant sign may be relieved by allowing slight hip abduction and ER during the maneuvers

This is a theoretical, unproven construct

Harris‐ Hayes, Sahrmann, & Van Dillen, 2009; Van Dillen et al., 2000

Palpable anterior glide during SLR or passive hip/knee flexion

Improper Recruitment in Hip Extension

Encourage participation of the gluteals in extension

Excessive anterior motion of the trochanter may indicate hip IR and inadequate firing of the gluteals or overdependence upon the hamstrings

Train for the hamstrings and gluteals to turn on simultaneously to see if that minimizes or eliminates anterior hip pain

Lewis and Sahrmann suggest that hamstrings may cause anterior glide while gluteals will prevent forward migration of the femoral head in the acetabulum

Lewis CL et al, J Biomech, 2007; Clin Biomech, 2009; J Athl Train, 2009

FAI Movement Dysfunctions

subjects tend to avoid hip flexion and provide movement in spine rather than flexing the hip –avoiding lordotic positions




Quadruped Rock Assessment

Hip flexion posterior capsule tightness may be suspected with quadruped ischial height asymmetry (or lateral shift away from tight side).

Hip Manual Muscle Testing

Hip Flexors–Iliopsoas vs. TFL

Hip Rotators Internal vs. External

Hip Extensors-Gluteus Maximus

Hip Abductors –Gluteus Medius

Hip Adductors

Impact of strength deficits

Significant strength deficits (8‐9%) in hip flexion and abduction were common (40‐50%)and correlated (r = 0.37) with loss of function

Hip Muscular Endurance Test

Symmetry in hold times or number of metronome paced repetitions without compensatory substitutions

FAI Special TestsHip Area PainClassification-Based Treatment

Lumbopelvic

HipLog Roll

Intra-articularTraumatic

ImpingementFADIR

Hypermobility

Hypomobility

Pediatric

Extra-articular:Strains – Tendinopathy –

Bursitis

Pelvic

Lumbosacral

R/O with lumbar mobility and repeated movements and SIJ provocation testing

R/O log roll, scouring, and FABER‐FADIR maneuvers

R/I with symptom location/palpation




Differential Diagnosis

Extra‐articular

– Internal/external snapping hips

– Greater Trochanter Pain Syndrome

Pelvic‐Hip Mimickers

– Rectus abdominis strains

– Athletic pubalgia/sports hernia

– Adductor tendinosis

– Genitourinary nerve entrapment

Differentiating Athletic Pubalgia

Retrospective case series found 86% of subjects undergoing surgery for sports hernia had radiographic evidence of FAI

Econompoulos, Sports Health, 2014

Prospective case series showing 94% of athletes with recalcitrant adductor pain had radiographic signs of FAI

Weir A, Brit J Sports Med, 2011

Identyifying Athletic Pubalgia

Reiman MP, Brit J Sports Med, 2013

Log Roll TestDifferentiate Intra from extra-articular involvement

Gently rolling the femur into IR/ER ROM (femoral head rolls on stationary acetabulum)

Moving the femoral head in relation to the acetabulum doesn’t significantly challenge myotendinous or nervous structures

+ test rules in intra‐articular hip pathology however a negative test is not sensitive enough to rule out an intra‐articular hip problem

Byrd et al, 2007

reliability = 0.61

Martin RR, J Orthop Sports Phys Ther, 2008

Scouring (Quadrant Test)

Circumduction, rotation and/or ab‐adduction of the hip joint while in 90‐140°of flexion concurrent with long axis compression along the femur

clears for hip OA and may aggravate labral pathology in quadrants of involvement

…however, single study that evaluated diagnostic accuracy for IA hip pain found

SN = 50; SP = 29; +LR = 0.70; ‐LR – 1.4

Maslowski E, et al, PM R, 2010

Femoroacetabular/Labral Pathology Tests

Anterior Hip Impingement Test Methodologies

– F‐ADD‐IR

– F‐IR

– F‐IR with axial compression

– F‐ADD with axial compression




Anterior Labral Test

Flexion-ABduction-External Rotation Flexion-ADduction-Internal Rotation

Femoral Acetabular Impingement Position

Highly SN (> .80‐.99) but very poor SP(.08 ‐ .43) in pooled analysis for FAITijjsen M, et al, Arthrscopy, 2012 and Reiman M, Br J Sports Med, 2015

Femoroacetabular/Labral Pathology Tests

Lateral Rim Hip Impingement

– Flexion, ABduction, and External Rotation of hip (Patrick’s sign) by placing distal lateral leg on the opposite anterior distal thigh

– extremity should fall parallel to the table with‐ out an increase in SIJ or anterior groin discomfort

– High SN (.80 in pooled analysis) but poor SP (.18 ‐ .24) for FAI

Tijjsen M, et al, Arthroscopy, 2012

• Also may indicate adductor/hip flexor injury, osteitis pubis, sports hernia, or SIJ pathology

Posteroinferior Impingement TestParvizi J et al, J Amer Acad Ortho Surg, 2007

External rotation in supine with hips at edge of table to allow maximal extension

Positive test is reproduction of familiar deep groin pain

Unknown diagnostic accuracy

Clinical-Radiographic Correlation

Physical Exam Findings Radiographic Findings Interpretation

FADIR with IR

Acetabular Index > 0°Anterosuperior acetabular overcoverage

Lateral Center Edge Angle > 39° Acetabular retroversion

Alpha Angle > 50° Anterosuperior cam

FABER with EREdge of anterior acetabular wall well medial to posterior wall

Acetabular anteversion

FADIR/FABER with IR/ER

Medial acetabular wall touches or passes ilioischial (Kohler’s) line

Acetabular profunda

Medial femoral head passes the ilioischial (Kohler’s) line

Acetabular protrusio

Clinical-Radiographic Correlation

Physical Exam Findings Radiographic Findings Interpretation

Apprehension and

ER/IRFemoral head extrusion index > 25°Lateral Center Edge Angle < 25°

Global undercoverage

Apprehension with ER

Edge of anterior acetabular wall well medial to posterior wall

Acetabular anteversion

Apprehension with IR

Crossover sign Acetabular retroversion

Stinchfield TestResisted SLR

General test of hip intra‐articular pain/irritation by resisted a straight leg raise

SN = 0.59

SP = 0.32




FAI Impingement Exam Reliability

Ratzlaff C et al,. Arthritis Care Res , 2013

TEST Kappa Value (95% CI)

FABER 0.63 (0.43 – 0.83)

FADIR 0.58 (0.29 – 0.87)

Log Roll 0.61 (0.41 – 0.81)

Martin RR, J Orthop Sports Phys Ther, 2008

IROP was performed at 90 degree flexion so essentially a F-IR test.


Flouroscopic guided IA hip injection with lidocaine and bupivacaine injection as gold standard and evaluated pain level on VAS and estimated % of pain relief

Poor diagnostic SP but good SN

IROP was performed at 90 degree flexion so essentially a F-IR test.


Flouroscopic guided IA hip injection with lidocaine and bupivacaine injection as gold standard and evaluated pain level on VAS and estimated % of pain relief

Poor diagnostic SP but good SNWhy specificity may be so low

Broad inclusion criteria and wide spectrum of radiographic findings in study population explains the poor specificity

PT n = 34

OS n = 32

OR n = 30

McCarthy Sign: Passive hip flexion to extension in external rotation

84 76 68

McCarthy Sign: Passive hip flexion to extension in internal rotation

78 89 84

Fitzgerald Anterior Labrum: FLEX‐ABD‐ER to EXT‐ADD‐IR 89 62 76 Fitzgerald Posterior Labrum; FLEX‐ADD‐IR to EXT‐ABD‐IR 87 39 62 Scouring in full flexion with simultaneous axial compression and internal rotation

89 97 81

Eccentric Hip Flexion (controlled lowering) 46 54 54 Resisted Straight Leg Raise 62 60 62 Resisted Straight Leg Raise in external rotation 87 73 70

Additional Labral Examination Techniques

% of positive findings for Physical Therapist (PT), Orthopedic Surgeon (OS), and Orthopedic Residents (OR)

Springer B et al, NAJSPT, 2009

observational gait analysis

lurch or lateral trunk flexion in midstance to side of weight bearing or dysfunction

pelvic drop away in midstance gait or unilateral stance

excessive lumbar lordosis or flat back

alterations in angle or base of gait

altered stance limb stability and timing




Trendelenburg Sign

Glut Med Tendinopathy– reliable test with SN of 73%

using MRI evidence of torn tendon as reference standard

Bird PA et al, Arthritis Rheum. 2001

Osteoarthritis– SN = 55; SP = 70

– +LR = 1.8; ‐LR = 0.82Reiman MP et al, Br J Sports Med, 2015

Functional Movement Screen (FMS™)www.functionalmovement.com

Each test scored on a 0‐3 scale

0 – too painful to complete

1 – significant deviations

2 – limited abilities or notable movement deviations

3 – normal (no compensations or limitations)

Highly reliable and very specific but poorly sensitive in predicting sports injury

Full Squat In‐line LungeHurdle Step Active Leg Raise Trunk Stability Push Up

Quadruped Rotational Reach

Behind Back Reach

FAI Intervention

• FAI• Hip dyplasia • Acetabular labral tears • Chondral injuries• Loose bodies

60% (3 of 5) experimental studies reported favorable outcomes for non‐op treatment

65% (31 of 48) review articles felt non‐op treatment was appropriate with activity modification and various forms of exercise therapy being cited most frequently– Increase strength, motor control, mobility, and flexibility of hip and

trunk muscles

– Avoid motion extremes and teach activity and technique modifications

Non-Operative Management Case Series

Case series demonstrating con‐servative success in 4 subjects

Phase I:― modalities; core stabilization

Phase II: ― manual therapy and hip strengthening

Phase III:― unstable surface dynamic, activity‐specific training

Yazbek PM, et al, May 2011 issue




My Perspective/Experience Managing Hip Pain

Grade I/II Mobilization

Electrotherapeutic Modalities

LLLT

Needling/Acupressure

Evidence for Dry Needling

reduce trigger point hypersensitivity

Dry Needling RCT

Neither dry needling or placebo needling of gluteals altered straight leg raise or hip internal rotation ROM

Both techniques showed short‐term reduction in pain but no difference between actual and sham interventions

Activity Modifications

Caution and/or avoidance with:

resisted hip flexion– symptomatic SLRs or sitting knee lifts

end range activities

lunges

weight‐bearing rotations

prolonged sitting

bent‐knee sit ups

cycling (particularly low seat)

Manual Therapyto improve joint mobility




Experiences

Posterior glides in positions of tolerance

– important that the patient feel the stretch in the posterior‐lateral hip and not report anterior pinching pain

Quadruped rocks and lunge steps with lateral distraction

Passive hip flexion generally tolerated better than active hip flexion secondary to potential iliopsoas irritation

Manual Therapy Techniques

Distraction

Posterior GlideAnterior GlideFABER Anterior Glide

Inferior GlideLong Axis DistractionInferior Glide

Distraction Self-MobsQuadruped Lateral Distraction with Hip Rotation Self-Mobs

Neutral Internally Rotated Externally Rotated

Inferior Long Axis Glide Self-Mobs Posterior Glide Self Mobs

Flexion Based Obligate Posterior at End Range Extension




Anterior Glide Self Mobs Post-manual therapy augmentation

Follow up with PNF, motor control, and functional retraining within the newly acquired range— Contract‐Relax

— Hold‐Relax

— Functional diagonals

— Mobilization with movement

Manipulative Manual TherapyWhy it Works?

Manipulation to the lumbopelvic spine and/or hip

o Neurophysiological effects

o Alter afferent input to the CNS, possible changes in the ascending and descending pain‐modulating elements

o Central suppression

o Improved recruitment?

o Superior gluteal nerve (L4‐S1)

o Inferior gluteal nerve (L5‐S2)

Boal R, et al, J Manip Physiol Ther, 2004

Jayaseelan DJ, Int J Sports Phys Ther, 2014Level V evidence—Knee Adjunctive Treatment

Soft tissue mobilization

Gluteal/Piriformis sustained pressure release Iliopsoas Release

● Fingers gradually sink into tissue finding psoas about 1/3 the distance between the ASIS and umbilicus

● No evidence (that I can find) to support the notion that sustained pressure in a shortened position is therapeutic




Taping/Bracing/Strapping

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Step Down Running Drop Jump

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*

* *

p = .003 p = .001 p = .011

0

1

2

3

4

5

6

Femoral Strap No Strap

VA

S P

ain

Sco

re

50% Pain Reduction

Maintain Hip ER

Significant Glut Max EMG activity

• Strapping device to facilitate improved lower quarter biomechanics and minimize excessive hip internal rotation, adduction, and/or knee valgus motion(s)

femoral strap

no strap

Stability through External Rotation of Femur Strap

Souza RB et al, Physiotherapy, 2008Austin AB et al, J Orthop Sports Phys Ther, 2008

Hip Kinesio Taping

No effect on hip or knee kinematics and kinetics during running

Howe A, Scand J Med Sci Sports, 2015

No effect on hip shear forces during landing in ballet dancers

Hendry D et al, Scand J Med Sci Sports, 2015

Broader Perspective on Evidence for Kinesio Taping

Does KT effect muscle strength in healthy adults? NO.– Meta‐analysis of 19 studies with 530 subjects

Is KT better than other interventions in treating chronic musculoskeletal pain and disability? NO.– No significant differences in 17 controlled trials. In fact the title of this article asks “Is it time to

peel off the tape and throw it out with the sweat?”

Does the evidence support the use of KT in a variety of common conditions. NO.– Systematic review of 12 studies and nearly 500 subjects for shoulder, knee, back, neck, and foot

conditions found no difference between KT and sham taping or placebos.

Can KT prevent injuries in sports. Probably NOT.– Meta‐analysis revealed only one study of athletes in a poorly designed study. Authors concluded

their was little to no quality evidence to support the contention that KT prevents injuries.

Can KT impact lymphatic system and reduce swelling in ankle sprains. NO.– According to a randomized control trial

the bigger the claim … the bigger the need for proof –

so I call for a potential

– No compelling evidence to suggest that KT positively influences strength, pain, disability, swelling, strength, or likelihood of injury




Exercise Therapy Progression

NWB to WB

Lower to higher EMG levels

Bilateral to Unilateral

Single plane to multiplanar

Stable to labile surfaces

< 20% MVIC <20-40% 40-60% MVIC > 60% MVIC

Mulligan EP et al, Phys Ther Sport, 2015

NWB Gluteus Medius

WB Gluteus Medius WB Gluteus Medius




Hip Extension Exercises

Gluteal training lacks high quality evidence for efficacy as well

particularly for specific types of exercise training or exercise selection for specific type of pathology

Possible Rehab Complications

Hip flexor/adductor tendonitis

Joint irritation/edema

Faulty movement patterns

Lumbopelvic pain

Usual Cause

– joint overload – aggressive return to ADLs

Alter-G Treadmill Training

• Decreased GRF allows for safe acceleration of functional activity

• Improved gait without minimal alterations in normal mechanics

Cutuk A et al, J Appl Physiol, 1985

No research to support to this intervention perspective but it does seem to make intuitive sense

Similar or Concurrent Presentations

Athletic Pubalgia Internal Snapping Hip




Sports Hernia

Athletic pubalgia without a true herniation– Weakening of the abdominal wall in the area of the inguinal canal– Possible entrapment of the genitofemoral nerve

Pain with twisting/turning in single limb stance; resisted adduction; sit‐ups

+ Rocker Test

Valsalva type maneuver may be provocative – forcible exhalation against a closed airway

Rest or surgical repair with emphasis on restoration of abdominal strength, adductor flexibility, and a gradual resumption of activity

Sports HerniaProposed Treatment Algorithm

YES YES

NONOIs initial pain rating >7?

Is hip rotation or abduction ROM limited?

Strength and Stability Training

Pain Control: activity mods, PROM, soft tissue techniques, nitro patches

ROM Training

Hegedus EJ et al, Phys Ther Sport, 2013Ellsworth AA et al, Int J Sports Phys Ther, 2014Kachingwe AF et al, J Ortho Sports Phys Ther, 2008

Internal Snapping Hip

Audible “snap” deep in anterior groin area with movement

Internal

– Iliopsoas tendon crossing iliopectineal eminence when uncrossing the legs from a flexed, abducted, externally rotated position

– Ludloff sign – active SLR from sitting in chair where RF is actively insufficient

Snapping Hip Treatment

Address identified impairments

Correct LLD

Strengthen weak gluteal muscles

Train core trunk stability

Hip Mobilization

Stretch tight muscles

– ITB (external) and Iliopsoas (internal)

Tolerance for Conservative Treatment

Failed conservative intervention over 4‐6 weeks is probably a good indicator that arthroscopic hip surgery should be considered

Surgical Intervention




Post-Op Rehabilitation Considerations

PWB for first 2‐4 weeks dependent upon resection vs. repair

Careful of end range motions during the first couple of weeks

Expect full PROM in 2‐6 weeks

Isometrics can begin 2nd post‐op day; AROM in most planes at about 2 weeks

Weight bearing PREs can began as tolerated when non‐antalgic FWB gait

Summary of Weight-Bearing Status/Progression, CPM, and Orthoses Recommendations

Debridement, excision, removal, etc

Repairs, …plasties, etc Microfracture

Weight‐BearingImmediate post‐op WBAT

Flat‐foot PWB

Flat‐Foot (< 20 lbs) PWB

WB Progression FWB by 1‐2 wks 2‐4 weeks 6‐8 weeks

CPM UtilizationCPM or self ranging on bike optional

50% yes4‐8 hours/day for 2‐4 wks

Braces/Orthoses No33% yes to limit unwanted sagittal or transverse plane end range

based on systematic review from 14 studies ‐ Grzybowski JS et al, Frontiers Surg, 2015www.bryankellymd.com

“Excise” Protocol

Phase I ‐ Acute Phase II ‐ Subacute Phase III ‐ Return to Sport

Time 0‐2 to 4 weeks 4‐8 weeks 8 weeks +

ROM Bike freewheelingLog Rolls/Stool rotationsPROM

Hip MobilizationsLE Stretching

Dynamic StretchingProprioceptive work

Exercise Isometrics → IsotonicsPelvic TiltsSupine Bridging

Glute Med ProgressionGlute Max ProgressionTreadmill Progression

Elliptical

“Repair” Protocol

Phase I ‐ Acute Phase II ‐ Subacute Phase III ‐ Return to Sport

Time 0‐4 weeks 4‐12 weeks 12 weeks +

ROM Bike freewheeling/CPMLog Rolls/Stool RotationsPROM – limit extension/ER

AROM (minimal mobs)LE Stretching

Dynamic StretchingProprioceptive work

Exercise Isometrics → Isotonics (no flexion)Pelvic TiltsSupine Bridging

Glute Med ProgressionGlute Max ProgressionTreadmill Progression

Elliptical

Precautions and Progression Criteria

Phase I – Acute0‐4 weeks

Phase II – Subacute4‐12 weeks

Phase III ‐ Return to Sport12+ weeks

Progression Criteria

Normal gait70‐80% PROMControllable symptoms

Pain‐free ADLsSymmetric ROMCORE control/stability

AvoidanceSLRsPassive end range activities: (F/E; IR/ER; Ab/Add)

Ballistic stretching

PrecautionsIliopsoas irritationSynovitisGTPS

Careful with walking progressions

based on systematic review from 14 studies ‐ Grzybowski JS et al, Frontiers Surg, 2015www.bryankellymd.com

Good resource for post-op guidelines

www.bryankellymd.com




Functional Testing for the Hip So, what do we do?

Shift from impairment‐based rehab to performance‐based rehab driven by results of functional assessment when:

• healing time is adequate

• NPRS levels are controlled

• ROM and motor control goals are achieved

• gait mechanics have normalized

Best-evidence is Expert Opinion Progression Criteria

Return to Sport Phases

– Step Down Mechanics

– Plank Test Performance

– Self‐Report Outcomes (HOS)

– Isokinetic Torque Symmetry

– Functional Tests

Y‐Balance, Hop Tests, Tuck Jumps

Wahoff M et al, Int J Sports Phys Ther, 2014

Vail Hip Sports Test

Wahoff M, Clin Sports Med, 2011

Selected FMS Tests

15/18 minimum to RTS




Return to Sport

Systematic review of 18 case series (moderate to high

quality) involving almost 1000 hips of professional, collegiate, high school, and recreational athletes

– mean age: 28 (15‐41)

– 76% male

87% return to sport

82% at same level of competition

Casartelli NC et al, Br J Sports Med, 2015

Return to Sport Guidelines

Low impact loading and deep squatting exercises generally begin at 3 months with return to sport at 4‐6 months

McDonald JE et al, Arthroscopy, 2013

McCormick F et al, Arthroscopy, 2012

Stafford GH et al, Hip Int, 2011

Byrd JW et al, Arthroscopy, 2011

Horisberger M et al, Arthroscopy, 2010

Outcomes

Study LOE Subjects Study design Intervention Primary outcome

McDonald 3Elite athletes

Case‐control Microfracture RTS: 77% in microfracture vs. 84% in non‐microfracture (p > 0.05)

Krych 1 Females RCTLabral repair vs. debridement

• Better HOS (ADL, sport) in repair group (p < 0.05 for both)

• Better subjective outcome in repair group (p < 0.05)

McCormick 3labral tears

Case‐controlLabral repair vs. debridement

• Presence of OA at arthroscopy predicts worse outcome

• Age >40 years predicts worse outcomes

Philippon 4FAI11–16

Case seriesFAI ‐ labral treatment

• Significant improvement in mHHS at 3 yrs• 13% (all girls) need repeat arthroscopy for adhesions

Malviya 4FAI, 14–75

Case seriesFAI ‐ labral treatment

• Significant (p < 0.05) improvement in QoL• 74% of patients happy with results

Grzybowski et al, Front Surg, 2015

Outcomes

Study LOE Subjects Study design Intervention Primary outcome

Byrd 4 FAI Case seriesFAI and labral treatment

Significant (p < 0.001) improvement in mHHS at 2 years

Nho 4High‐level athletes, FAI

Case seriesFAI and labral treatment

• Significant improvements in mHHS and HOS at 2 years

• 79% return to sports at mean 9.4 months

Philippon 4FAI, 38–44

Case seriesFAI and labral treatment

• Significant improvements in mHHS at 2 years

Streich 4Labral tears, no FAI

Case series Labral treatment

• Significant improvements in Larson hip score and mHHS

• Presence of acetabular chondral defect worse prognosis

Stafford 4FAI, chondral defect

Case seriesMicrofracture with cartilage repair

Significant (p < 0.001) improvement in mHHS at 2 years

Grzybowski et al, Front Surg, 2015

Interpretation

Address all defects (microfracture and repair as needed)

Worse outcomes if older or osteoarthritic

Significantly better at 2 years according to self‐report

Good chance for RTS in athletic subjects

Documents

HIP FAI TPTA v2 handout - Continuing EDcontinuing-ed.cc/.../uploads/2015/10/HIP-FAI-TPTA-v2-handout.pdf · The Elements of Patient/Client Management Leading to Optimal Outcomes