Femoroacetabular Impingment: Evidence Based Tratment

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Evidence based treatment and diagnosis of FAI

Evidence based treatment and diagnosis of FAI

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  • Most patients are diagnosed with snapping hip or psoas muscle strain or bursitis
  • Feel end-feel. Should be capsular, not empty or painful.
  • Used to assess FAI – exactally like the shoulder impingement test. Same ball and socket joint. Always test this prior to having a patient stretch the piriformis muscle

Transcript

  • 1. Elizabeth Evans, PT, MPT Susan Fain, PT, DMA Bridgit Finley, PT, DPT, OCS Casey Kirkes, PT, DPT
  • 2. Clinical Question
    • In patients with FAI, is manual therapy more effective for reducing pain and functional limitations than exercise alone?
  • 3. Objectives
    • To describe FAI, its etiology, anatomy and two types
    • To discuss the connection between FAI and labral tears
    • To investigate the ramifications of non-treatment
    • To see FAI in imaging: X-rays and MRI
    • To describe the clinical presentation of FAI
    • To list appropriate special tests and outcome measures
    • To discuss associated impairments with FAI
    • To present evidence for using manual therapy in treating patients with FAI
  • 4. Overview
    • This presentation will review:
    • Anatomy
    • Clinical Exam
    • Non-operative Management
    • Manual Therapy Interventions
    • Therapeutic Exercise
  • 5. 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.
  • 6. Introduction
    • Recent advances in treatment of hip joint pathology, specifically with respect to acetabular tears:
      • Better diagnostic procedures
      • Improved arthroscopic instrumentation and techniques
      • Femoral 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
  • 7. Prevalence
    • Younger 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
  • 8. Precursor to early hip O-A
    • Acetabular 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.
  • 9. Etiology
    • Developmental factors:
      • Coxa profunda
      • Protrusio acetabuli
      • Asphericity of femoral head
      • Reduced femoral head-neck offset
      • Maloriented acetabulum
      • Samora (2011)
  • 10. Etiology
    • Morphologic 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)
  • 11. Acetabular Labral Tears
    • Common complaint of pain, clicking, locking, catching, instability, giving way and/or stiffness (Martin, 2006)
      • Anterior groin pain 96-100% of cases
      • Report of hip locking 58% of cases
      • Predisposing factor: Coxa Valga 87% of cases
      • c/o clicking in the hip (+)LR 6.67
    • MOI: Hip external rotation + extension
  • 12. Anatomy
    • Cam
      • Aspherical femoral head
      • Bony prominence at anterolateral head-neck junction
      • Impinges on rim of acetabulum
      • Leads to superior OA
      • Young athletic males
      • Samora (2011)
  • 13.
    • Pincer
      • Overcoverage of femoral head by acetabulum
      • Acetabulum impinges on neck of femur
      • Leads to posterior-inferior or central OA
      • Middle-aged females
      • Samora (2011)
  • 14. Will have loss of ROM and early arthritic changes
    • CAM
    • Zone of injury: anterior-superior aspect of acetabulum with fraying/detachment of labrum and delamination of cartilage
    • Provocative test: hip flexion, adduction, IR
        • Samora (2011
  • 15.
    • Pincer
    • Zone of injury: anterior acetabular labrum with “countrecoup” chondral injury in posterior-inferior acetabular rim
    • Provocative test: Hip extension, ER
    • Samora (2011)
  • 16. X-ray
    • CAM:
      • 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)
  • 17. MRI
    • May demonstrate labral tear, but often the bony articular pathology are missed
    • Only 22% sensitivity for cartilage delamination
    • Gold standard is magnetic resonance arthrogram
    • Samora (2011)
  • 18. Clinical Presentation
    • Persistent insidious deep groin, lateral, or buttock pain
      • Anterior groin pain most common
    • Increased with prolonged sitting or standing and hip flexion-type movements
    • Decreased hip ROM
    • Insidious on-set 50% of cases.
    • Samora (2011)
  • 19. Hip Special Tests
    • Martin et al
    • JOSPT July 2006
    • Intra-articular Tests
    • FABER Test
    • FADIR Test
    • Scour Test
    • Resisted SLR
    • Log Roll Test
    • Distraction
    • FAI
  • 20. Special Tests
    • FADIR impingement test: flexion, adduction, IR
      • Sensitivity=75%, specificity=43% in identifying patients with labral tears Austin
    • FABER
      • 88% sensitive for intra-articular hip pathology Martin et al
    • Resisted SLR – assesses labral loading Martin et al.
    • Log Roll
      • Interrater reliability=0.63 Austin
  • 21. 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
  • 22. 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%
  • 23. Exam: Special Tests
    • Trendelenburg Test – hip abductors
      • + if hips become unlevel, dropping of opposite side
      • Indicative of stance side weakness in glut medius
    • 90-90 Test
      • A test of hamstring tightness
      • + if unable to extend knee to within 20’ of full extension
    • Thomas Test
      • a supine test of hip flexor tightness
      • + if straight leg rises off table
  • 24. Pain and Function Questionnaires
    • Western Ontario & McMaster Universities OA Index (WOMAC)
      • Pain, Stiffness, and Physical Exam
    • Harris Hip Score
      • Pain, Gait, Mobility, Deformity (ROM Loss)
      • Scored by PT
  • 25. Labral tear
    • Repetetive microtrauma can lead to labral tear
    • Patients with labral tear complain of clicking, locking, or catching
    • Clicking:
      • Sensitivity=100%
      • Specificity=85%
      • Lewis (2006)
  • 26. Arthroscopic Debridement
    • Tear 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.
  • 27. Impairments
    • Weakness
      • Hip abductors, gluts
    • Tightness
      • Hamstring, Adductors
    • Gait
      • Decreased hip flexion, knee hyperextension, LE ER
    • Movement Analysis
      • Single leg step down; jump and land on both LE’s
        • May demonstrate excessive hip IR/add
      • Martin et el, Austin
  • 28. Evidence for FAI and Manual Therapy
    • Our 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?
  • 29. Hip OA and FAI
    • Clinical 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)
  • 30. 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)
  • 31. Hip OA and FAI
    • There 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)
  • 32. Manual Therapy for Hip OA
    • Hoeksma 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
  • 33. Hip Manipulation
    • Video
    • 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.
  • 34. Case Report Cook et al.
    • Conservative Management of a Young Adult With Hip Arthrosis
    • Young female with CAM lesion and early OA
    • (+) Impingement Tests
    • Treated 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.
  • 35. Hip Arthroscopy
    • When to refer to surgeon…..
    • May be indicated if the patient fails to improve with physical therapy
    • The 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
  • 36. Summary
    • In the last decade, injury to the labrum has been recognized as a cause of mechanical hip pain.
    • Increased ability to diagnose FAI
    • Very little evidence to guide Rehabilitation
    • Anecdotal and Case Reports are positive but more research needs to be done.
    • Recommend: Impairment Based Rehabilitation
    • Therapeutic exercise and manual therapy to address impairments.
  • 37. 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.
  • 38.
    • N. V. Bardakos, J. C. Vasconcelos, and R. N. Villar Early outcome of hip arthroscopy for femoroacetabular impingement: THE ROLE OF FEMORAL OSTEOPLASTY IN SYMPTOMATIC IMPROVEMENT J 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.
  • 39.
    • 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