femoroacetabular impingment: evidence based tratment
DESCRIPTION
Evidence based treatment and diagnosis of FAITRANSCRIPT
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