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2/2/2016

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Managing the Athletic Hip

Jill Monson, PT, OCS

University Orthopaedics Therapy Center – Fairview

TRIA Conference

February 6th, 2016

Disclosures

• No disclosures

© Jill Monson | MOC, LLC 2016

Overview

• Key factors identified in individuals with hip

pain

• Screening and examination strategies for

athletes with hip pain

• Treatment strategies and progressions for

athletes with hip pain


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3 Fair Statements

• Sparse literature investigating the relationship between hip dysfunction and measures of physical strength, movement & performance

• Lack of high level literature examining non-operative management of FAI-associated hip pain

• Post-operative outcomes (success/failure) largely associated with PRO’s (patient reported outcomes) and return to sport data, NOT objective measures of strength & performance


Why We ALL Care…

Pain-free Athlete with FAI

Pain-free Athlete with FAI

Sport/Training Exposure

Sport/Training Exposure

Painful Athlete with FAI

Painful Athlete with FAI

InterventionIntervention


Treatment Guiding Questions

Question 1:

• What are the physical performance

profiles of individuals with hip pain (FAI

or other) compared to those without?


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Question 2:

• Are we ACTUALLY changing anything

with our interventions?

– How are we measuring change?

• Patient reported (subjective)

• Clinical measures (objective)



Question 3:

• If we change physical performance

variables (in measurable, clinically

significant ways), do patients get better?

(function, symptoms)

– Non-operatively?

– Post-operatively?


Characteristics of the Painful Hip

Mosler et al. Which factors differentiate athletes with hip/groin pain from those without? A systematic review with

meta-analysis. BJSM 2015

• Hip/Groin Pain (not specifically FAI)

• 17 total studies; 10 high quality

Diamond et al. Physical impairments and activity limitations in people with femoroacetabular impingement: a systematic

review. BJSM 2014

• Symptomatic FAI: Asymptomatic FAI: Controls

• 16 moderate to high quality studies


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Characteristics of the Painful Hip

ROM Muscle Function Pain, Symptoms

Mosler ��Hip IR, FABER ROM

• Hip ER ROM =

controls

��strength

w/Adductor squeeze

test

• Altered trunk

control (see box)

(+) Adductor

Squeeze test

• PRO’s

Diamond ��Hip ROM w/gait

(frontal & sagittal

plane)

�� Pelvic rotation @

max squat depth

• Hip Flex, IR ROM =

asymptomatic FAI

�ADD, ABD, ER, Flex

strength

�TFL activation

w/max HF effort

(no ∆ for rectus

femoris)• Thinner TA at ratiosrest

• Delayed onset of TA with SLR

• Altered trunk flexion/extension © Jill Monson | MOC, LLC 2016

Diamond et al. BJSM 2014

• Response to intervention

– Conservative:

• No significant changes in hip ROM after 25-28 month 4-stage

tx program in individuals w/radiographic, symptomatic FAI

– Ill-defined treatment protocol, exercise compliance not tracked

– Post-Arthroscopy Findings

• Increased max hip IR

• Improved ROM observed with gait & squatting

• No change in hip ROM w/stairs

• Some findings of NO change in ROM post-op


Return to Sport

Casartelli et al. Return to sport after hip

surgery for femoroacetabular

impingement: a systematic review.

BJSM 2014

• 18 case series L4 evidence

• Moderate to high quality


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Casartelli et al: Return to Sport

Average 87% Return to sport post-op

82% at same level as prior to symptom onset

Higher rate for professional athletes compared to

recreational, college (level of play, resources)

Reduced RTP rates observed on longer term f/u 1-3 years (of

those who originally returned in the 1st year/season post-

op)


Casartelli et al: Return to Sport

“Diffuse hip OA”

at time of surgery

interferes with

return to sport

outcomes


Performance Testing the Hip

Kivlan BR, Martin RL Functional performance testing of the hip in athletes: a systematic review

for reliability and validity. IJSPT 2012

• 74 articles reviewed

• 4 categories:

– Movement (18), balance (24), hop/jump (26), agility (6)


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Kivlan et al. IJSPT 2012

Test

Validity,

Normative

Data

(+) Diagnostic

Association

(pain)

(+) Association

w/ ABD muscle

function

Single Leg

Stance

X G. Med

Tendonopathy

Single Limb

Squat

X X

Deep Squat X FAI

SEBT X X

Hop Tests


Non-Operative Management

Austin AB, Souza RB, Meyer JL, Powers CM.

Identification of abnormal hip motion

associated with acetabular labral pathology.

JOSPT 2008;38:558-565.

• Single subject case study

• FAI patient

• Hip exam and motion analysis


Austin AB, et al. JOSPT 2008

• Pt. demonstrated increased hip

IR, ADD & pain with:

– Single leg step down

– Running

– Drop Jump

• IR, ADD, and pain reduced in

single session with use of SERF

strap

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Non-Operative Management

Yazbek PM, Ovanessian V, Martin RL, Fukuda TY.

Nonsurgical treatment of acetabular labrum

tears: A case series. JOSPT 2011;41(5):346-353.

• Case series w/4 patients w/confirmed labral

pathology

• Hip exam, strength measures


Yazbek PM, et al. JOSPT 2011

• 3 phase non-operative progression over

approx. 12 weeks

– Improved function

– Decreased pain

– Correction of muscular imbalance

– Increased muscle strength (hip flexors, ABD,

extensors)


Yazbek PM, et al. JOSPT 2011

• Phase I:

– Pain control

– Basic trunk stabilization

– Correction of abnormal mvmt patterns

• Phase II:

– Muscle strengthening

– Restoration of ROM

– Sensory motor training

– Correction of muscular imbalance (LSI% 100%)

• Phase III:

– Advanced sensory motor training

– Sport-specific functional progressions


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PT Problem Solving

Create your HypothesisCreate your Hypothesis

Confirm your

hypothesis

Confirm your

hypothesis

Apply Intervention

Apply Intervention

Did anything change??


PT Problem Solving

Posture & Movement

Screen

Posture & Movement

Screen

Tabletop Exam

Tabletop Exam

Treat what you find

Treat what you find

Re-assess:

1) Did you improve any measurable objectives??

2) Do they function or feel better as a result??© Jill Monson | MOC, LLC 2016

Bryan Kelly, MD, HSS “Layer Model”

Layer 4

Layer 3

Layer 2

Layer 1

• “Neurokinetic”

• Lumbosacral plexus, lumbopelvic structures

• “Dynamic”

• Contractile structures

• Dynamic stability

• “Inert”

• Labrum, Ligament/Capsular complex

• “Osteochondral”

• Bony structures (true FAI)


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Bryan Kelly, MD | HSS Layer Model

• Determine to “driver”/layer of the pathology

per a combined appraisal of:

– Radiographic Findings

– Basic Clinical Exam

– Dynamic Mobility, Kinetic Chain Assessment

– Differential Diagnosis

– Patient response to intervention (or lack of)


Contralateral Pelvic Collapse

• Hip weakness, activation deficit

• Lateral trunk weakness

• Poor postural stability

• Poor kinematic control, motor strategies





• Restricted sagittal plane foot/ankle

mobility (DF) = transfer motion to frontal

plane (hip)

• Poor proprioceptive control

• Restricted sagittal plane foot/ankle

mobility (DF) = transfer motion to frontal

plane (hip)


• Quadriceps muscle weakness,

dysfunction

• Knee pain = not wanting to flex @ knee in

sagittal plane = transfer motion to frontal

plane (hip)


dysfunction

• Knee pain = not wanting to flex @ knee in

sagittal plane = transfer motion to frontal

plane (hip)


Contralateral Pelvic Hike

• Adductor, TFL tone/tightness

• Restricted hip mobility


• Hip pain




• Adductor, TFL tone/tightness

• Restricted hip mobility


• Hip pain




• Restricted/poor weight acceptance into

foot/ankle in frontal plane


• Restricted/poor weight acceptance into

foot/ankle in frontal plane



dysfunction?


dysfunction?


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Posture & Movement Screen

• Static posture (frontal & sagittal views)

• Dynamic movement (squat, lunge)

• Trunk rotation assessment

• Gait

• Athletic movement screen


Static Posture Observations


Rotational Movement Screen


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Dynamic Movement Screening

• This screening should be ONGOING

• Repeat throughout your rehab progressions

• Continue to look at all planes of motion

• Modify treatment per observations

Mobility/Flexibility Screen


Assess Accessory Mobility:

T-spine Rotation


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Hip Special Testing


Tabletop Exam• Palpate

– Zero in on painful structure

– Corroborate with other clinical exam findings

• Screen proximal distal joint mobility

– Foot/ankle, knee, spine

• Strength, Stability:

– Hip, trunk

• Differential screening prn:

– Neural

– Segmental mobility at spine

– SIJ© Jill Monson | MOC, LLC 2016

Key Treatment Progressions

Honor symptoms ALWAYS

Progress Motor Learning & Demand:

Load, repetition, complexity & speed

Normalize functional kinematics

Address fundamental impairments

Change the pain/Protect Joint


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Manipulate Symptoms

Change the pain/Protect joint

Activity (temporary) Modification

Movement Pattern Maximization

Manual interventions at relevant structures:

• Soft tissue work for tone

• Joint mobilizations for pain control (reduce impingement moments)


Address Fundamental Impairments


Range of Motion

Full, pain-free, controlled, well-distributed:

Foot/Ankle � Hip � Spine

Muscular weakness, dysfunction:

360˚ Hip, Core


Kinetic Chain Mobility Deficits

Ankle DF– Alters sagittal plane kinematics (squatting, stairs, gait)

Hip ABD, ER– Inability to pull out of valgus movement tendency

– Transfers rotational movement demand to other joints

Hip ADD, IR-Inability to load transfer effectively into the hip for single limb

tasks

-Alters hip functional hip arthrokinematics

Spine Rotation– Transfers rotational movement demand to other joints


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Address Fundamental Impairments


Range of Motion

Full, pain-free, controlled, well-distributed:

Foot/Ankle � Hip � Spine

Muscular weakness, dysfunction:

360˚ Hip, Core


How do we work target muscles?

Distefano et al. JOSPT 2009• % of max volitional isometric

contraction achieved (MVIC)

• SL hip ABD

– 81% G. Med

– 39% G. Max

• SL hip ER

– 38-40% G. Med

– 34-39% G. Max


Gluteus Maximus Strengthening

Ekstrom et al. JOSPT 2007

(% of MVIC with EMG)

– Quadruped Arm/Leg lift

• 56% G. Max

– Single Leg Bridge

• 40% G. Max


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Hip Strength and Core

Ekstrom et al. 2007(% of MVIC with EMG)

• Side Bridge:

– 74% G. Med

– 21% G. Max

– 69% External

Oblique


CKC Glut Max and Glut Med

Distefano et al. JOSPT 2009(% of MVIC with EMG)

• Single limb squat:

– 64% G. Med

– 59% G. Max


CKC Strength and Proprioception

Single Limb Dead Lift:59% MVIC at G. Max58% MVIC at G. Med

DiStefano, 2009


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Thoughtful Strength Progressions

Phillippon MJ, et al. Rehabilitation exercise

progression for the Gluteus Medius Muscle with

Consideration for Iliopsoas Tendinitis: An In Vivo

Electromyography Study. AJSM 2011. 39:1777.


Recommendations per

Philippon AJSM 2011

• Phase I

(First 4-8 weeks):

– Prone resisted TKE

– Prone HS curl

– 2 leg bridge


Recommendations per

Philippon AJSM 2011

• Phase II

(Next 4 weeks):

– Resisted hip extension

– Stool hip IR

– SL Hip ABD wall slides


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Recommendations per

Philippon AJSM 2011

• Phase III (Next 4 weeks):

– Prone heel squeeze

– SL Hip ABD w/femoral IR

– Single leg bridging


















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Athletic Treatment Progressions

Mobility

• Get full, pain-free ROM

• Keep full, pain-free ROM

• Use full, pain-free ROM OKC�CKC

Strength, Power, Endurance

• Establish OKC base

• Progress OKC&CKC

• Increase Load

• Increase Speed

• Increase Reps

Motor Complexity

• Unisegmental�

Multi-segmental

• Uniplanar�

Multi-planar

• Planned�Reactive


Triple Flexion<>Triple Extension


Excursion


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Multi-Planar, Multi-Segment,

Rotational Control


Sport-Specific Movements & Postures


Athletics

�� External loads

�� External loads

�� Speed�� Speed

�� Excursion�� Excursion�� Duration�� Duration

�� Task Complexity, Reactivity

�� Task Complexity, Reactivity


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Athletic Progressions

Reproduce athletic

challenges with

therapy

progressions




Motor Learning Progressions & Demand:






My hip still hurts…• When?

– During which motions, postures?

– For how long?

• Where/What?

– Anterior hip region: HF imbalance with rectus femoris, anterior hip

capsule hanging postures

– Lateral hip: G. Med overload (too short, too long), imbalance in hip mm.

actions (ABD<>ADD balance?)

– Groin: Lack of motion into ADD/IR still? (joint mobilizations, ADD STM)

• How?

– Sharp pinch, aching, tightness??

• Allows you to suspect the correct layer of involvement per symptom

nature


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PT Problem Solving

Posture & Movement

Screen

Posture & Movement

Screen

Tabletop Exam

Tabletop Exam

Treat what you find

Treat what you find

Re-assess:

1) Did you improve any measurable objectives??

2) Do they function or feel better as a result??© Jill Monson | MOC, LLC 2016

In Summary…

• We do not yet fully understand the physical performance profiles of individuals with hip pain, FAI or not– Strength, movement patterns, etc.

• We have very preliminary evidence of the effectiveness of PT interventions for managing pain & returning athletes to play– More post-operative than non-operative evidence

• Effective examination & treatment of the hip require good working knowledge of the entire kinetic chain


References• Austin AB, Souza RB, Meyer JL, Powers CM. Identification of abnormal hip motion

associated with acetabular labral pathology. J Orthop Sports Phys Ther. 2008;38:558-565. http:// dx.doi.org/10.2519/jospt.2008.2790

• Casartelli NC, Maffiuletti NA, Item-Glatthon JF, Staehli S, Bizzini M, Impellizzeri FM, Leunig M. Hip muscle weakness in patients with symptomatic femoracetabularimpingement. Osteoarthritis and Cartilage. 2011;19(7):816-821.

• Enseki KR, Martin RL, Draovitch P, Kelly BT, Philippon MJ, Schenker ML. The hip joint: arthroscopic procedures and postoperative rehabilitation. J Orthop Sports Phys Ther. 2006;36:516-525. http://dx.doi.org/10.2519/ jospt.2006.2138

• Casartelli, Nicola C., et al. "Return to sport after hip surgery for femoroacetabularimpingement: a systematic review." British journal of sports medicine (2015): bjsports-2014.

• Distefano L, Blackburn J, Marshall S, Padua D. Gluteal muscle activation during common therapeutic exercises. J. Ortho & Sports Phys Ther. 2009; 39(7): 532-540.

• Diamond, Laura E., et al. "Physical impairments and activity limitations in people with femoroacetabular impingement: a systematic review." British journal of sports medicine (2014): bjsports-2013.


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References

• Ekstrom R, Donatelli R, Carp K. Electromyographic analysis of core trunk, hip and thigh muscles during 9 rehabilitation exercises. J. Ortho & Sports Phys Ther. 2007; 37(12): 754-762.

• Kivlan, Benjamin R., and RobRoy L. Martin. "Functional performance testing of the hip in athletes: a systematic review for reliability and validity." International journal of sports physical therapy 7.4 (2012): 402.

• Kapandji A. [Articulate Physiology. Volume 2: Lower Limb]. 5th ed. Sao Paulo, Brazil: Guanabara Koogan Guanabara Koogan; 2001.

• Kennedy MJ, Lamontagne M, Beaule PE. Femoroacetabular impingement alters hip and pelvic biomechanics during gait: Walking biomechanics of FAI. Gait & Posture 2009;30:41-44

• Kennedy MJ, Lamontagne M, Beaule´ PE. The effect of cam femoroacetabularimpingement on hip maximal dynamic range of motion. Journal of Orthopedics 2009;1(1):41–50.

• Lewis C, Sahrmann S. Acetabular Labral Tears. Physical Therapy. 2006;86(1):110-121.

• Lewis CL, Sahrmann SA, Moran DW. Anterior hip joint force increases with hip extension, decreased gluteal force, or decreased iliopsoas force. J Biomech. 2007;40:3725-3731. http:// dx.doi.org/10.1016/j.jbiomech.2007.06.024


References• Mosler, Andrea B., et al. "Which factors differentiate athletes with hip/groin pain from those

without? A systematic review with meta-analysis." British journal of sports medicine 49.12

(2015): 810-810.

• Phillippon MJ, et al. Rehabilitation exercise progression for the Gluteus Medius Muscle with

Consideration for Iliopsoas Tendinitis: An In Vivo Electromyography Study. AJSM 2011.

39:1777.

• Philippon M, Schenker M, Briggs K, Kuppersmith D. Femoroacetabular impingement in 45

professional athletes: associated pathologies and return to sport following arthroscopic

decompression. KSSTA 2007;15:908-914. http://dx.doi.org/10.1007/ s00167-007-0332-x

• Stalzer S, Wahoff M, Scanlan M. Rehabilitation following hip arthroscopy. Clin Sports Med

2006;25:337–57.

• Wahoff M, Ryan M. Rehabilitation after hip femoracetabular impingement arthroscopy. Clin

Sports Med 2011;30:463-482.

• Wahoff MS, Briggs KK, Philippon MJ. Hip arthroscopy rehabilitation: evidence-based practice.

In: Kibler B, editor. Orthopedic knowledge update: sports medicine 4. Lexington (Kentucky):

AAOS; 2008. p. 273–81, 23.

• Yazbek PM, Ovanessian V, Martin RL, Fukuda TY. Nonsurgical treatment of acetabular labrum

tears: A case series. JOSPT 2011;41(5):346-353.


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