Elizabeth Evans, PT, MPTSusan Fain, PT, DMA

Bridgit Finley, PT, DPT, OCSCasey Kirkes, PT, DPT

Clinical Question

In patients with FAI, is manual therapy more effective for reducing pain and functional limitations than exercise alone?

ObjectivesTo describe FAI, its etiology, anatomy and two typesTo discuss the connection between FAI and labral

tearsTo investigate the ramifications of non-treatmentTo see FAI in imaging: X-rays and MRITo describe the clinical presentation of FAITo list appropriate special tests and outcome

measuresTo discuss associated impairments with FAITo present evidence for using manual therapy in

treating patients with FAI

OverviewThis presentation will review:AnatomyClinical ExamNon-operative ManagementManual Therapy InterventionsTherapeutic Exercise

Femoroacetabular Impingement (FAI)Definition:Contact between the femoral head-neck junction and the acetabular rim.Impingement occurs with the combined movement of hip flexion, adduction, and internal rotation.

IntroductionRecent advances in treatment of hip joint

pathology, specifically with respect to acetabular tears:Better diagnostic proceduresImproved arthroscopic instrumentation and

techniquesFemoral Acetabular Impingement (FAI) is one of

several hip joint abnormalities that can be addressed during arthroscopic procedures

Physical therapists have integral role to play in the treatment of patients with FAI

PrevalenceYounger population (20-40) (Tannast et al),

especially dancers, other sports. 10-15% prevalence rate (Leunig et al)

Gender differences (Ganz et al)Cam-type FAI - young males. Pincer-type FAI - middle-aged women.

Sink et al study of 35 adolescents with anterior groin pain and (+) impingement test: 51% had FAI as demonstrated through radiographic findings

Nogier et al study of 292 males (ages 16-50) with mechanical hip pathology: 63% demonstrated FAI

Precursor to early hip O-AAcetabular labral pathology secondary to

femoroacetabular impingement (FAI)Acetabular labral pathology is frequently

present in highly active individuals 20-40 year olds.

Gradual on-set with repetitive microtrauma.

EtiologyDevelopmental factors:

Coxa profundaProtrusio acetabuliAsphericity of femoral

headReduced femoral

head-neck offsetMaloriented

acetabulum

Samora (2011)

EtiologyMorphologic changes in proximal femur or

acetabulum lead to abnormal contact during hip flexion.

Abnormal abutment of femoral head-neck junction and acetabular rim leads to pain and decreased hip ROM.

Can lead to tearing at chondrolabral junction, cartilage delamination and eventual progression to OA.

Samora (2011)

Acetabular Labral TearsCommon complaint of pain, clicking, locking,

catching, instability, giving way and/or stiffness (Martin, 2006)Anterior groin pain 96-100% of casesReport of hip locking 58% of casesPredisposing factor: Coxa Valga 87% of casesc/o clicking in the hip (+)LR 6.67

MOI: Hip external rotation + extension

AnatomyCam

Aspherical femoral head

Bony prominence at anterolateral head-neck junction

Impinges on rim of acetabulum

Leads to superior OAYoung athletic males

Samora (2011)

PincerOvercoverage of

femoral head by acetabulum

Acetabulum impinges on neck of femur

Leads to posterior-inferior or central OA

Middle-aged females

Samora (2011)

Will have loss of ROM and early arthritic changesCAMZone of injury: anterior-

superior aspect of acetabulum with fraying/detachment of labrum and delamination of cartilage

Provocative test: hip flexion, adduction, IR

Samora (2011

PincerZone of injury: anterior

acetabular labrum with “countrecoup” chondral injury in posterior-inferior acetabular rim

Provocative test: Hip extension, ER

Samora (2011)

X-rayCAM:

Anterolateral bony prominence on femoral neck with AP or lateral x-ray; “pistol grip deformity”

PINCER:“Crossover sign” shows crossing of medial wall

of acetabulum over ilioischial line, or center of femoral head medial to posterior acetabular wall on AP x-ray

Cam and Pincer impingement are two basic mechanisms and rarely occur in isolation.

Samora (2011)

MRIMay demonstrate labral tear, but often the

bony articular pathology are missedOnly 22% sensitivity for cartilage delaminationGold standard is magnetic resonance

arthrogram

Samora (2011)

Clinical PresentationPersistent insidious deep groin, lateral, or

buttock painAnterior groin pain most common

Increased with prolonged sitting or standing and hip flexion-type movements

Decreased hip ROMInsidious on-set 50% of cases.

Samora (2011)

Hip Special TestsMartin et alJOSPT July 2006 Intra-articular Tests

FABER TestFADIR TestScour TestResisted SLRLog Roll TestDistractionFAI

Special TestsFADIR impingement test: flexion, adduction,

IRSensitivity=75%, specificity=43% in

identifying patients with labral tears Austin

FABER88% sensitive for intra-articular hip pathology

Martin et al

Resisted SLR – assesses labral loading Martin et al.

Log RollInterrater reliability=0.63 Austin

Log Roll Test The examiner passively moves

the patient’s lower extremity through the maximal available range of hip external (A) and internal rotation (B).

Eliciting a clicking or popping sensation may indicate an acetabular labral tear, while increased total range of motion when compared to the opposite side may indicate ligament or capsular laxity

Impingement Test The examiner passively moves

the patient’s lower extremity into a position of hip flexion, adduction, and internal rotation.

A positive test is reflected by increased hip or groin pain.

80-90 degree flexion + IR + Adduction

Assesses anterior/superior labrum High correlation to arthroscopic dx

Confirmation Arthroscopy: Gold Standard MRA

Sn 66-95%

Exam: Special TestsTrendelenburg Test – hip abductors

+ if hips become unlevel, dropping of opposite side

Indicative of stance side weakness in glut medius

90-90 TestA test of hamstring tightness+ if unable to extend knee to within 20’ of full

extensionThomas Test

a supine test of hip flexor tightness+ if straight leg rises off table

Pain and Function QuestionnairesWestern Ontario & McMaster Universities

OA Index (WOMAC)Pain, Stiffness, and Physical Exam

Harris Hip ScorePain, Gait, Mobility, Deformity (ROM Loss)Scored by PT

Labral tearRepetetive microtrauma can lead to labral tearPatients with labral tear complain of clicking,

locking, or catchingClicking:

Sensitivity=100%Specificity=85%

Lewis (2006)

Arthroscopic DebridementTear of the labrum is only part of the

pathology. Labrum is a source of pain.Debridement of the tear without attention to

the impingement may explain the poor results of the surgery. Bardakos et al.

ImpairmentsWeakness

Hip abductors, glutsTightness

Hamstring, AdductorsGait

Decreased hip flexion, knee hyperextension, LE ER

Movement AnalysisSingle leg step down; jump and land on both LE’s

May demonstrate excessive hip IR/add

Martin et el, Austin

Evidence for FAI and Manual TherapyOur PICO question yielded a lack of evidence

for manual therapy in the treatment of FAI.Rather than leaving it at that, we asked

another question.Due to the objective similarities between hip

OA and FAI, would manual therapy techniques used in the successful treatment of hip OA be beneficial for patients with FAI?

Hip OA and FAIClinical Presentation

Both present with positive special tests for FABER and FADIR

Both present with a decrease in hip flexion and internal rotation ROM

Cibulka, et al (2009)Philippon, et al (2007)

Hip OA and FAI

Patients with hip OA often develop osteophytic changes and bony over-growth of the acetabular rim and femoral head.

This would create femoral actabular impingement in and of itself.

Cibulka (2009)

Hip OA and FAIThere is a strong association between FAI

and early hip OA.

Manual therapy techniques have been shown to increase hip joint ROM and decrease pain in patients with hip OA.

Hoeksma (2004)

Manual Therapy for Hip OAHoeksma et al, reported a success rate for

manual therapy of 81% versus 50% for exercise.

Manual techniques included Stretching of the muscles of the hip joint.Traction of the hip.Traction manipulation of the hip joint.

Patients treated twice weekly for five weeks / 9 treatments

Hip ManipulationVideo

In the Cibulka et al guideline, the authors state that self-limiting pain may be an adverse reaction to manual therapy of the hip, but there are no documented serious risks associated with manual therapy of the hip.

Case Report Cook et al.Conservative Management

of a Young Adult With Hip Arthrosis

Young female with CAM lesion and early OA

(+) Impingement TestsTreated with manual therapy

Long Axis Traction P-A Figure Four Hip

Mobilization Hip Distraction with

Mobilization belt Psoas Release with Prone

Rolling with basketball

Three Month Follow-up MCD of reports of decreased

pain Improved Hip Flexion to 120

degrees Normal Hip Strength Negative Impingement Test Significant Change on Hip

Harris Score Weak Evidence – Expert Level

5 Until more research is done

will have to rely on using manual therapy to treat impairments of patients with FAI and early OA changes.

Hip ArthroscopyWhen to refer to surgeon…..May be indicated if the patient fails to improve

with physical therapyThe MRA is a more sensitive test for labral

lesions than standard MRI (Petersilge 2001) and would help to rule out intra-articular injury prior to the more invasive arthroscopy.

Joint injection further assists ruling in (Illgen 2006) that an intraarticular lesion may be the pain generator.

Contraindication – advanced DJD

SummaryIn the last decade, injury to the labrum has

been recognized as a cause of mechanical hip pain.

Increased ability to diagnose FAIVery little evidence to guide RehabilitationAnecdotal and Case Reports are positive but

more research needs to be done.Recommend: Impairment Based RehabilitationTherapeutic exercise and manual therapy to

address impairments.

References Austin, A.B., Souza, R.B., Meyer, J.L., & Powers, C.M. (2008).

Identification of abnormal hip motion associated with acetabular labral pathology. Journal of Orthopaedic & Sports Physical Therapy, 38(9): 558-565.

Cleland J. Orthopedic clinical examination: an evidence-based approach for physical therapists. Carlstadt, Icon, 2005.

Lewis, C.L. & Sahrmann, S.A. (2006). Acetabular labral tears. Physical Therapy, 86, 1:110-121.

Martin, D.E. & Tashman, S. (2010). The biomechanics of femoroacetabular impingement. Oper Tech Orthop, 20:248-254.

Martin, R.L., Enseki, K.R., Draovitch, P., Trapuzzano, T., & Philippon, M.J. (2006). Acetabular labral tears of the hip: Examination and diagnostic challenges. Journal of Sports & Orthopaedic Physical Therapy, 36(7): 503-515.

Samora, J.B., Ng, V.Y., & Ellis, T.J. (2011). Femoroacetabular impingement: A common cause of hip pain in young adults. Clin J Sport Med, 21: 51-56.

• N. V. Bardakos, J. C. Vasconcelos, and R. N. VillarEarly outcome of hip arthroscopy for femoroacetabular impingement: THE ROLE OF FEMORAL OSTEOPLASTY IN SYMPTOMATIC IMPROVEMENTJ Bone Joint Surg Br, December 1, 2008; 90-B(12): 1570 - 1575.

• Hip Morphology• Ganz R, Leunig M, et al. The etiology of osteoarthritis of the hip:

An integrated mechanical concept. Clin Orthop Relat Res. 2008 Feb;466(2):264-72.

• Tannast M, Siebenrock KA, et al. Femoroacetabular Impingement: Radiographic Diagnosis – What the Radiologist Should Know. Am. J. Roentgenol. Jun 2007; 188: 1540 - 1552.

• Leunig M, Ganz R. Femoroacetabular impingement: A common cause of hip complants leading to arthrosis (in German). Unfallchirurg 2005; 108:9-17.

Petersilge CA. MR arthrography for evaluation of the acetabular labrum. Skeletal Radiol. 2001;30(8):423‐430.

Illgen RL, Honkamp NJ, Weisman MH. The diagnostic and predictive value of hip anesthetic arthrograms in selected patients before total hip arthroplasty. J Arthroplasty. 2006;5:724‐730

Cook et al. Conservative Management of a Young Adult With Hip Arthrosis. J Orthop Sports Phys Ther 2009:39(12):858-866

Philippon MJ, Maxwell RB, Johnston TL, Schenker M, Briggs KK. Clinical presentation of femoroacetabular impingement. Knee Surg Traum Arthro. 2007;15:1041-1047

Cibulka MT, White DM, Woehrle J, Harris- Hayes M, Enseki K, Fagerson TL, Slover J, Godges JJ. Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the orthopaedic Section of the American Physical Therapy Associaion. JOSPT. 2009;39:A1-A25.

Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum. 2004;51:7722-729