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Femoroacetabular Impingment: Evidence Based Tratment


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Evidence based treatment and diagnosis of FAI

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Femoroacetabular Impingment: Evidence Based Tratment

  1. 1. Elizabeth Evans, PT, MPT Susan Fain, PT, DMA Bridgit Finley, PT, DPT, OCS Casey Kirkes, PT, DPT
  2. 2. Clinical Question <ul><li>In patients with FAI, is manual therapy more effective for reducing pain and functional limitations than exercise alone? </li></ul>
  3. 3. Objectives <ul><li>To describe FAI, its etiology, anatomy and two types </li></ul><ul><li>To discuss the connection between FAI and labral tears </li></ul><ul><li>To investigate the ramifications of non-treatment </li></ul><ul><li>To see FAI in imaging: X-rays and MRI </li></ul><ul><li>To describe the clinical presentation of FAI </li></ul><ul><li>To list appropriate special tests and outcome measures </li></ul><ul><li>To discuss associated impairments with FAI </li></ul><ul><li>To present evidence for using manual therapy in treating patients with FAI </li></ul>
  4. 4. Overview <ul><li>This presentation will review: </li></ul><ul><li>Anatomy </li></ul><ul><li>Clinical Exam </li></ul><ul><li>Non-operative Management </li></ul><ul><li>Manual Therapy Interventions </li></ul><ul><li>Therapeutic Exercise </li></ul>
  5. 5. Femoroacetabular Impingement (FAI) <ul><li>Definition: </li></ul><ul><li>Contact between the femoral head-neck junction and the acetabular rim. </li></ul><ul><li>Impingement occurs with the combined movement of hip flexion, adduction, and internal rotation. </li></ul>
  6. 6. Introduction <ul><li>Recent advances in treatment of hip joint pathology, specifically with respect to acetabular tears: </li></ul><ul><ul><li>Better diagnostic procedures </li></ul></ul><ul><ul><li>Improved arthroscopic instrumentation and techniques </li></ul></ul><ul><ul><li>Femoral Acetabular Impingement (FAI) is one of several hip joint abnormalities that can be addressed during arthroscopic procedures </li></ul></ul><ul><li>Physical therapists have integral role to play in the treatment of patients with FAI </li></ul>
  7. 7. Prevalence <ul><li>Younger population (20-40) (Tannast et al), especially dancers, other sports. 10-15% prevalence rate (Leunig et al) </li></ul><ul><li>Gender differences (Ganz et al) </li></ul><ul><ul><li>Cam-type FAI - young males. </li></ul></ul><ul><ul><li>Pincer-type FAI - middle-aged women. </li></ul></ul><ul><li>Sink et al study of 35 adolescents with anterior groin pain and (+) impingement test: 51% had FAI as demonstrated through radiographic findings </li></ul><ul><li>Nogier et al study of 292 males (ages 16-50) with mechanical hip pathology: 63% demonstrated FAI </li></ul>
  8. 8. Precursor to early hip O-A <ul><li>Acetabular labral pathology secondary to femoroacetabular impingement (FAI) </li></ul><ul><li>Acetabular labral pathology is frequently present in highly active individuals 20-40 year olds. </li></ul><ul><li>Gradual on-set with repetitive microtrauma. </li></ul>
  9. 9. Etiology <ul><li>Developmental factors: </li></ul><ul><ul><li>Coxa profunda </li></ul></ul><ul><ul><li>Protrusio acetabuli </li></ul></ul><ul><ul><li>Asphericity of femoral head </li></ul></ul><ul><ul><li>Reduced femoral head-neck offset </li></ul></ul><ul><ul><li>Maloriented acetabulum </li></ul></ul><ul><ul><li>Samora (2011) </li></ul></ul>
  10. 10. Etiology <ul><li>Morphologic changes in proximal femur or acetabulum lead to abnormal contact during hip flexion. </li></ul><ul><li>Abnormal abutment of femoral head-neck junction and acetabular rim leads to pain and decreased hip ROM. </li></ul><ul><li>Can lead to tearing at chondrolabral junction, cartilage delamination and eventual progression to OA. </li></ul><ul><li>Samora (2011) </li></ul>
  11. 11. Acetabular Labral Tears <ul><li>Common complaint of pain, clicking, locking, catching, instability, giving way and/or stiffness (Martin, 2006) </li></ul><ul><ul><li>Anterior groin pain 96-100% of cases </li></ul></ul><ul><ul><li>Report of hip locking 58% of cases </li></ul></ul><ul><ul><li>Predisposing factor: Coxa Valga 87% of cases </li></ul></ul><ul><ul><li>c/o clicking in the hip (+)LR 6.67 </li></ul></ul><ul><li>MOI: Hip external rotation + extension </li></ul>
  12. 12. Anatomy <ul><li>Cam </li></ul><ul><ul><li>Aspherical femoral head </li></ul></ul><ul><ul><li>Bony prominence at anterolateral head-neck junction </li></ul></ul><ul><ul><li>Impinges on rim of acetabulum </li></ul></ul><ul><ul><li>Leads to superior OA </li></ul></ul><ul><ul><li>Young athletic males </li></ul></ul><ul><ul><li>Samora (2011) </li></ul></ul>
  13. 13. <ul><li>Pincer </li></ul><ul><ul><li>Overcoverage of femoral head by acetabulum </li></ul></ul><ul><ul><li>Acetabulum impinges on neck of femur </li></ul></ul><ul><ul><li>Leads to posterior-inferior or central OA </li></ul></ul><ul><ul><li>Middle-aged females </li></ul></ul><ul><ul><li>Samora (2011) </li></ul></ul>
  14. 14. Will have loss of ROM and early arthritic changes <ul><li>CAM </li></ul><ul><li>Zone of injury: anterior-superior aspect of acetabulum with fraying/detachment of labrum and delamination of cartilage </li></ul><ul><li>Provocative test: hip flexion, adduction, IR </li></ul><ul><ul><ul><li>Samora (2011 </li></ul></ul></ul>
  15. 15. <ul><li>Pincer </li></ul><ul><li>Zone of injury: anterior acetabular labrum with “countrecoup” chondral injury in posterior-inferior acetabular rim </li></ul><ul><li>Provocative test: Hip extension, ER </li></ul><ul><li>Samora (2011) </li></ul>
  16. 16. X-ray <ul><li>CAM: </li></ul><ul><ul><li>Anterolateral bony prominence on femoral neck with AP or lateral x-ray; “pistol grip deformity” </li></ul></ul><ul><li>PINCER: </li></ul><ul><ul><li>“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 </li></ul></ul><ul><li>Cam and Pincer impingement are two basic mechanisms and rarely occur in isolation. </li></ul><ul><ul><li>Samora (2011) </li></ul></ul>
  17. 17. MRI <ul><li>May demonstrate labral tear, but often the bony articular pathology are missed </li></ul><ul><li>Only 22% sensitivity for cartilage delamination </li></ul><ul><li>Gold standard is magnetic resonance arthrogram </li></ul><ul><li>Samora (2011) </li></ul>
  18. 18. Clinical Presentation <ul><li>Persistent insidious deep groin, lateral, or buttock pain </li></ul><ul><ul><li>Anterior groin pain most common </li></ul></ul><ul><li>Increased with prolonged sitting or standing and hip flexion-type movements </li></ul><ul><li>Decreased hip ROM </li></ul><ul><li>Insidious on-set 50% of cases. </li></ul><ul><li>Samora (2011) </li></ul>
  19. 19. Hip Special Tests <ul><li>Martin et al </li></ul><ul><li>JOSPT July 2006 </li></ul><ul><li>Intra-articular Tests </li></ul><ul><li>FABER Test </li></ul><ul><li>FADIR Test </li></ul><ul><li>Scour Test </li></ul><ul><li>Resisted SLR </li></ul><ul><li>Log Roll Test </li></ul><ul><li>Distraction </li></ul><ul><li>FAI </li></ul>
  20. 20. Special Tests <ul><li>FADIR impingement test: flexion, adduction, IR </li></ul><ul><ul><li>Sensitivity=75%, specificity=43% in identifying patients with labral tears Austin </li></ul></ul><ul><li>FABER </li></ul><ul><ul><li>88% sensitive for intra-articular hip pathology Martin et al </li></ul></ul><ul><li>Resisted SLR – assesses labral loading Martin et al. </li></ul><ul><li>Log Roll </li></ul><ul><ul><li>Interrater reliability=0.63 Austin </li></ul></ul>
  21. 21. Log Roll Test <ul><li>The examiner passively moves the patient’s lower extremity through the maximal available range of hip external (A) and internal rotation (B). </li></ul><ul><li>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 </li></ul>
  22. 22. Impingement Test <ul><li>The examiner passively moves the patient’s lower extremity into a position of hip flexion, adduction, and internal rotation. </li></ul><ul><li>A positive test is reflected by increased hip or groin pain. </li></ul><ul><ul><li>80-90 degree flexion + IR + Adduction </li></ul></ul><ul><ul><li>Assesses anterior/superior labrum </li></ul></ul><ul><ul><li>High correlation to arthroscopic dx </li></ul></ul><ul><li>Confirmation </li></ul><ul><ul><li>Arthroscopy: Gold Standard </li></ul></ul><ul><ul><li>MRA </li></ul></ul><ul><ul><ul><li>Sn 66-95% </li></ul></ul></ul>
  23. 23. Exam: Special Tests <ul><li>Trendelenburg Test – hip abductors </li></ul><ul><ul><li>+ if hips become unlevel, dropping of opposite side </li></ul></ul><ul><ul><li>Indicative of stance side weakness in glut medius </li></ul></ul><ul><li>90-90 Test </li></ul><ul><ul><li>A test of hamstring tightness </li></ul></ul><ul><ul><li>+ if unable to extend knee to within 20’ of full extension </li></ul></ul><ul><li>Thomas Test </li></ul><ul><ul><li>a supine test of hip flexor tightness </li></ul></ul><ul><ul><li>+ if straight leg rises off table </li></ul></ul>
  24. 24. Pain and Function Questionnaires <ul><li>Western Ontario & McMaster Universities OA Index (WOMAC) </li></ul><ul><ul><li>Pain, Stiffness, and Physical Exam </li></ul></ul><ul><li>Harris Hip Score </li></ul><ul><ul><li>Pain, Gait, Mobility, Deformity (ROM Loss) </li></ul></ul><ul><ul><li>Scored by PT </li></ul></ul>
  25. 25. Labral tear <ul><li>Repetetive microtrauma can lead to labral tear </li></ul><ul><li>Patients with labral tear complain of clicking, locking, or catching </li></ul><ul><li>Clicking: </li></ul><ul><ul><li>Sensitivity=100% </li></ul></ul><ul><ul><li>Specificity=85% </li></ul></ul><ul><ul><li>Lewis (2006) </li></ul></ul>
  26. 26. Arthroscopic Debridement <ul><li>Tear of the labrum is only part of the pathology. </li></ul><ul><li>Labrum is a source of pain. </li></ul><ul><li>Debridement of the tear without attention to the impingement may explain the poor results of the surgery. Bardakos et al. </li></ul>
  27. 27. Impairments <ul><li>Weakness </li></ul><ul><ul><li>Hip abductors, gluts </li></ul></ul><ul><li>Tightness </li></ul><ul><ul><li>Hamstring, Adductors </li></ul></ul><ul><li>Gait </li></ul><ul><ul><li>Decreased hip flexion, knee hyperextension, LE ER </li></ul></ul><ul><li>Movement Analysis </li></ul><ul><ul><li>Single leg step down; jump and land on both LE’s </li></ul></ul><ul><ul><ul><li>May demonstrate excessive hip IR/add </li></ul></ul></ul><ul><ul><li>Martin et el, Austin </li></ul></ul>
  28. 28. Evidence for FAI and Manual Therapy <ul><li>Our PICO question yielded a lack of evidence for manual therapy in the treatment of FAI. </li></ul><ul><li>Rather than leaving it at that, we asked another question. </li></ul><ul><li>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? </li></ul>
  29. 29. Hip OA and FAI <ul><li>Clinical Presentation </li></ul><ul><ul><li>Both present with positive special tests for FABER and FADIR </li></ul></ul><ul><ul><li>Both present with a decrease in hip flexion and internal rotation ROM </li></ul></ul><ul><ul><li>Cibulka, et al (2009) </li></ul></ul><ul><ul><li>Philippon, et al (2007) </li></ul></ul>
  30. 30. Hip OA and FAI <ul><ul><li>Patients with hip OA often develop osteophytic changes and bony over-growth of the acetabular rim and femoral head. </li></ul></ul><ul><ul><li>This would create femoral actabular impingement in and of itself. </li></ul></ul><ul><ul><li>Cibulka (2009) </li></ul></ul>
  31. 31. Hip OA and FAI <ul><li>There is a strong association between FAI and early hip OA. </li></ul><ul><li>Manual therapy techniques have been shown to increase hip joint ROM and decrease pain in patients with hip OA. </li></ul><ul><li>Hoeksma (2004) </li></ul>
  32. 32. Manual Therapy for Hip OA <ul><li>Hoeksma et al, reported a success rate for manual therapy of 81% versus 50% for exercise. </li></ul><ul><li>Manual techniques included </li></ul><ul><ul><li>Stretching of the muscles of the hip joint. </li></ul></ul><ul><ul><li>Traction of the hip. </li></ul></ul><ul><ul><li>Traction manipulation of the hip joint. </li></ul></ul><ul><li>Patients treated twice weekly for five weeks / 9 treatments </li></ul>
  33. 33. Hip Manipulation <ul><li>Video </li></ul><ul><li>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. </li></ul>
  34. 34. Case Report Cook et al. <ul><li>Conservative Management of a Young Adult With Hip Arthrosis </li></ul><ul><li>Young female with CAM lesion and early OA </li></ul><ul><li>(+) Impingement Tests </li></ul><ul><li>Treated with manual therapy </li></ul><ul><ul><li>Long Axis Traction </li></ul></ul><ul><ul><li>P-A Figure Four Hip Mobilization </li></ul></ul><ul><ul><li>Hip Distraction with Mobilization belt </li></ul></ul><ul><ul><li>Psoas Release with Prone Rolling with basketball </li></ul></ul><ul><li>Three Month Follow-up </li></ul><ul><ul><li>MCD of reports of decreased pain </li></ul></ul><ul><ul><li>Improved Hip Flexion to 120 degrees </li></ul></ul><ul><ul><li>Normal Hip Strength </li></ul></ul><ul><ul><li>Negative Impingement Test </li></ul></ul><ul><ul><li>Significant Change on Hip Harris Score </li></ul></ul><ul><li>Weak Evidence – Expert Level 5 </li></ul><ul><ul><li>Until more research is done will have to rely on using manual therapy to treat impairments of patients with FAI and early OA changes. </li></ul></ul>
  35. 35. Hip Arthroscopy <ul><li>When to refer to surgeon….. </li></ul><ul><li>May be indicated if the patient fails to improve with physical therapy </li></ul><ul><li>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. </li></ul><ul><li>Joint injection further assists ruling in (Illgen 2006) that an intraarticular lesion may be the pain generator. </li></ul><ul><li>Contraindication – advanced DJD </li></ul>
  36. 36. Summary <ul><li>In the last decade, injury to the labrum has been recognized as a cause of mechanical hip pain. </li></ul><ul><li>Increased ability to diagnose FAI </li></ul><ul><li>Very little evidence to guide Rehabilitation </li></ul><ul><li>Anecdotal and Case Reports are positive but more research needs to be done. </li></ul><ul><li>Recommend: Impairment Based Rehabilitation </li></ul><ul><li>Therapeutic exercise and manual therapy to address impairments. </li></ul>
  37. 37. References <ul><li>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. </li></ul><ul><li>Cleland J. Orthopedic clinical examination: an evidence-based approach for physical therapists. Carlstadt, Icon, 2005. </li></ul><ul><li>Lewis, C.L. & Sahrmann, S.A. (2006). Acetabular labral tears. Physical Therapy, 86 , 1:110-121. </li></ul><ul><li>Martin, D.E. & Tashman, S. (2010). The biomechanics of femoroacetabular impingement. Oper Tech Orthop, 20 :248-254. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  38. 38. <ul><li>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. </li></ul><ul><li>Hip Morphology </li></ul><ul><li>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. </li></ul><ul><li>Tannast M, Siebenrock KA, et al. Femoroacetabular Impingement: Radiographic Diagnosis – What the Radiologist Should Know. Am. J. Roentgenol. Jun 2007; 188: 1540 - 1552. </li></ul><ul><li>Leunig M, Ganz R. Femoroacetabular impingement: A common cause of hip complants leading to arthrosis (in German). Unfallchirurg 2005; 108:9-17. </li></ul>
  39. 39. <ul><li>Petersilge CA. MR arthrography for evaluation of the acetabular labrum. Skeletal Radiol. 2001;30(8):423‐430. </li></ul><ul><li>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 </li></ul><ul><li>Cook et al. Conservative Management of a Young Adult With Hip Arthrosis. J Orthop Sports Phys Ther 2009:39(12):858-866 </li></ul><ul><li>Philippon MJ, Maxwell RB, Johnston TL, Schenker M, Briggs KK. Clinical presentation of femoroacetabular impingement. Knee Surg Traum Arthro. 2007;15:1041-1047 </li></ul><ul><li>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. </li></ul><ul><li>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 </li></ul>