Evidence‐Based Management of Femoroacetabular Impingement Syndrome TPTA Annual Conference – Arlington, TX October 23, 2015 Ed Mulligan, PT, DPT, OCS, SCS, ATC UT Southwestern School of Health Professions 1 Evidence-Based Management of Femoroacetabular Impingement Syndrome Presenters Ed Mulligan, PT, DPT, OCS, SCS, ATC Associate Professor; Residency Programs Director UT Southwestern Medical Center School of Health Professions Department of Physical Therapy - Dallas, TX UT Southwestern Medical Center – Dallas, TX Orthopedic, Neurological, and Sports Residency Programs Presentation Objectives 1. Define and differentially diagnose acetabular labral pathology and describe the epidemiology and risk factors associated with femoroacetabular impingement 2. Conduct a comprehensive subjective history and objective examination to manage intra‐articular hip pathology 3. Describe the intervention strategy, sequence, and points of emphasis for the non‐operative and post‐surgical management of labral pathology and athletic pubalgia 4. Select and utilize appropriate self‐report outcome tools for athletic hip problems and implement return to sports activities and criteria Disclosure Statement Neither I, Edward P. Mulligan, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation Diagnosis Outcome Measures Intervention Conservative and Post‐Op Prognosis Return to Activity Examination History – Systems Review – Physical Exam ‐ Imaging Evaluation Presentation Agenda The Elements of Patient/Client Management Leading to Optimal Outcomes
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Evidence‐Based Management of Femoroacetabular Impingement Syndrome
Ed Mulligan, PT, DPT, OCS, SCS, ATCUT Southwestern School of Health Professions 1
Evidence-Based Management of Femoroacetabular Impingement Syndrome Presenters
Ed Mulligan, PT, DPT, OCS, SCS, ATC Associate Professor; Residency Programs Director
UT Southwestern Medical Center School of Health Professions Department of Physical Therapy - Dallas, TX
UT Southwestern Medical Center – Dallas, TXOrthopedic, Neurological, and Sports Residency Programs Presentation Objectives
1. Define and differentially diagnose acetabular labral pathology and describe the epidemiology and risk factors associated with femoroacetabular impingement
2. Conduct a comprehensive subjective history and objective examination to manage intra‐articular hip pathology
3. Describe the intervention strategy, sequence, and points of emphasis for the non‐operative and post‐surgical management of labral pathology and athletic pubalgia
4. Select and utilize appropriate self‐report outcome tools for athletic hip problems and implement return to sports activities and criteria
Disclosure Statement
Neither I, Edward P. Mulligan, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation
DiagnosisOutcome Measures
InterventionConservative and Post‐Op
Prognosis
Return to Activity
ExaminationHistory – Systems Review –Physical Exam ‐ Imaging
Evaluation
Presentation AgendaThe Elements of Patient/Client Management Leading to Optimal Outcomes
Evidence‐Based Management of Femoroacetabular Impingement Syndrome
Ed Mulligan, PT, DPT, OCS, SCS, ATCUT Southwestern School of Health Professions 2
Femoroacetabular Impingement
Abnormal, pathological femoral acetabular contact or shearing that occurs within a normal ROM secondary to bony deformities or spatial malorientation that eventually manifests as symptomatic
15-year trend in publications on FAI
1 2 3 4 1018 20
38 40
81
99
142
173
251236
FAI is an intra-articular, non-arthritic hip pathology
Possible anatomical variants that may predispose to injury
– Femoral neck anomalies– Structural instability– Femoral or acetabular torsion/version
Ed Mulligan, PT, DPT, OCS, SCS, ATCUT Southwestern School of Health Professions 3
Imaging
Standard x‐ray views– AP– Frog‐Leg Lateral View
MRA/MRI– Much better SN for labral pathology with MRA than MRI (90 vs. 30%)
Major Radiographic Findings in FAI
How do the radiographic findings correlate with the physical exam
Dunn Viewlateral, cross-table, frog-leg Radiographic Findings
Cam Impingement – femoral head/neck profile exceeds the radius curvature of the acetabulum
– Alpha angle > 55‐60° No absolute cut‐off value
only an indicator of the size of the bony anomaly
A high alpha angle in an asymptomatic patient should be be considered an incidental finding
– Head‐neck offset ratio < 0.14(more in a minute)
Alpha Angle
On axial oblique MRI sequence, angle formed by a line parallel to the femoral neck axis and line from center of the femoral head to the transition of the femoral head into the femoral neck (neck radius exceeds head radius)
Abnormal > 55‐60° indicates cam deformity
Cam abnormal contact between femoral head/neck and acetabular margin
Prevalent in asymptomatic patients indicating that activity level is an important variable and that diagnosis is based on the clinical exam – not the image
Evidence‐Based Management of Femoroacetabular Impingement Syndrome
Ed Mulligan, PT, DPT, OCS, SCS, ATCUT Southwestern School of Health Professions 4
Cam = “Pistol Grip Deformity” abnormal contact between femoral head/neck and acetabular margin
Cam
– Asphericity of the femoral head creating a prominent bump on the anterosuperior head‐neck junction (pistol grip)
Can be secondary to epiphyseal injury or SCFE
wave sign
Resultant Pathology abnormal contact between femoral head/neck and acetabular margin
Cartilage in area of asphericity is delaminated from the bony acetabulum
• Convex bump (yellow arrowheads) at anterior femoral head-neck junction• Area of chondral loss (red arrows) present on the acetabular side of the joint• Subtle subchondral degenerative changes (red arrowhead) located on the
corresponding femoral side of the joint
Cam femoroacetabular impingement varieties
Head-Neck Offset RatioFemoral Morphology SummaryAlpha Angle and Head/Neck Offset
< 9 mm offset is considered abnormal
Dunn View
CAM Lesionvideographic explanation of pathological process Pincer Impingement
Increased Acetabular Depth
– Coxa profunda (lateral center‐edge angle > 35°)
– Fossa acetabuli is medial to Kohler’s line (deepsocket)
– Acetabular protrusion
– Femoral head is medial to Kohler’s (ilioischial) line
red line = ilioischial (Kohler’s) line
Evidence‐Based Management of Femoroacetabular Impingement Syndrome
Acetabular labral lesion locations in order of frequency
subjective history
FAI hip pain location– Typically in the anterior or medial groin area
• Lateral pain is trochanteric or L4 referred
• Posterior may be SIJ, piriformis, or L5‐S1 referred
• Hip pain can also extend down the thigh towards the knee (pseudoradiculopathy)
C sign – classic representation of FAI-related pathology
Absence of groin pain helps rule out FAI because of its high sensitivity (0.96‐1.00)Byrd JW, N Am J Sports Phys Ther, 2007Keeney et al, Clin Ortho Relat Res, 2004,McCarthy et al, Orthopedics, 1995
Evidence‐Based Management of Femoroacetabular Impingement Syndrome
Ed Mulligan, PT, DPT, OCS, SCS, ATCUT Southwestern School of Health Professions 11
Outcome Tool Clinimetric Summary
Thorborg K, Tijssen M, Habets B, Bartels EM, Roos EM, Kemp J, Crossley KM, Hölmich P. Patient‐Reported Outcome (PRO) questionnaires for young to middle‐aged adults with hip and groin disability: a systematic review of the clinimetric evidence. Br J Sports Med. 2015 Jun;49(12):812. doi: 10.1136/bjsports‐2014‐094224. Epub 2015 Jan 13.
Ed Mulligan, PT, DPT, OCS, SCS, ATCUT Southwestern School of Health Professions 12
Hip Joint ROM
MOTION Normal ROM
Flexion (end feel) 0‐120°
Extension 0‐20°
Abduction 0‐45°
Adduction 0‐30°
External Rotation 0‐45°
Internal Rotation (end feel) 0‐45°
Common activities that may require substitution motions secondary to Cam deformities
Tie Your Shoes 120˚ flexion
Sit in Chair 110˚ flexion
Fig 4 Sit 120˚ flexion/20˚ Abd/ER
Put Pants On 90˚ flexion
FAI Physical Exam: Motion Summary
Terminal Motions Lost
– Limited IR (< 20°) when hip is flexed to 90°
Kubiak‐Langer M et al, Clin Orthop Relat Res, 2007
– Hip elevation maneuvers often limited (flexion and abduction)
– Obligatory hip external rotation with end‐range hip flexion (Drehmann’s sign)
Abnormal Arthrokinematics Excessive anterior femoral glide during ASLR
Because of the articular congruity there should be minimal glide of the femoral head in the acetabulum during sagittal plane motion
If anterosuperior glide is detected with familiar groin pain it may indicate overactive TFL and labral provocation
– Concordant sign may be relieved by allowing slight hip abduction and ER during the maneuvers
This is a theoretical, unproven construct
Harris‐ Hayes, Sahrmann, & Van Dillen, 2009; Van Dillen et al., 2000
Palpable anterior glide during SLR or passive hip/knee flexion
Improper Recruitment in Hip Extension
Encourage participation of the gluteals in extension
Excessive anterior motion of the trochanter may indicate hip IR and inadequate firing of the gluteals or overdependence upon the hamstrings
Train for the hamstrings and gluteals to turn on simultaneously to see if that minimizes or eliminates anterior hip pain
Lewis and Sahrmann suggest that hamstrings may cause anterior glide while gluteals will prevent forward migration of the femoral head in the acetabulum
Lewis CL et al, J Biomech, 2007; Clin Biomech, 2009; J Athl Train, 2009
FAI Movement Dysfunctions
subjects tend to avoid hip flexion and provide movement in spine rather than flexing the hip –avoiding lordotic positions
Evidence‐Based Management of Femoroacetabular Impingement Syndrome
Ed Mulligan, PT, DPT, OCS, SCS, ATCUT Southwestern School of Health Professions 16
FAI Impingement Exam Reliability
Ratzlaff C et al,. Arthritis Care Res , 2013
TEST Kappa Value (95% CI)
FABER 0.63 (0.43 – 0.83)
FADIR 0.58 (0.29 – 0.87)
Log Roll 0.61 (0.41 – 0.81)
Martin RR, J Orthop Sports Phys Ther, 2008
IROP was performed at 90 degree flexion so essentially a F-IR test.
Maslowski E, et al, PM R, 2010
Flouroscopic guided IA hip injection with lidocaine and bupivacaine injection as gold standard and evaluated pain level on VAS and estimated % of pain relief
Poor diagnostic SP but good SN
IROP was performed at 90 degree flexion so essentially a F-IR test.
Maslowski E, et al, PM R, 2010
Flouroscopic guided IA hip injection with lidocaine and bupivacaine injection as gold standard and evaluated pain level on VAS and estimated % of pain relief
Poor diagnostic SP but good SNWhy specificity may be so low
Broad inclusion criteria and wide spectrum of radiographic findings in study population explains the poor specificity
PT n = 34
OS n = 32
OR n = 30
McCarthy Sign: Passive hip flexion to extension in external rotation
84 76 68
McCarthy Sign: Passive hip flexion to extension in internal rotation
78 89 84
Fitzgerald Anterior Labrum: FLEX‐ABD‐ER to EXT‐ADD‐IR 89 62 76 Fitzgerald Posterior Labrum; FLEX‐ADD‐IR to EXT‐ABD‐IR 87 39 62 Scouring in full flexion with simultaneous axial compression and internal rotation
89 97 81
Eccentric Hip Flexion (controlled lowering) 46 54 54 Resisted Straight Leg Raise 62 60 62 Resisted Straight Leg Raise in external rotation 87 73 70
Additional Labral Examination Techniques
% of positive findings for Physical Therapist (PT), Orthopedic Surgeon (OS), and Orthopedic Residents (OR)
Springer B et al, NAJSPT, 2009
observational gait analysis
lurch or lateral trunk flexion in midstance to side of weight bearing or dysfunction
pelvic drop away in midstance gait or unilateral stance
excessive lumbar lordosis or flat back
alterations in angle or base of gait
altered stance limb stability and timing
Evidence‐Based Management of Femoroacetabular Impingement Syndrome
60% (3 of 5) experimental studies reported favorable outcomes for non‐op treatment
65% (31 of 48) review articles felt non‐op treatment was appropriate with activity modification and various forms of exercise therapy being cited most frequently– Increase strength, motor control, mobility, and flexibility of hip and
trunk muscles
– Avoid motion extremes and teach activity and technique modifications
Non-Operative Management Case Series
Case series demonstrating con‐servative success in 4 subjects
Phase I:― modalities; core stabilization
Phase II: ― manual therapy and hip strengthening
Phase III:― unstable surface dynamic, activity‐specific training
Yazbek PM, et al, May 2011 issue
Evidence‐Based Management of Femoroacetabular Impingement Syndrome
Ed Mulligan, PT, DPT, OCS, SCS, ATCUT Southwestern School of Health Professions 21
Taping/Bracing/Strapping
0
50
100
150
200
250
300
350
Step Down Running Drop Jump
% c
han
ge in
EM
G a
cti
vity)
-8
-6
-4
-2
0
2
4
6
8
10
12
14
Step Down Running Drop Jump
Hip
Ro
tati
on
An
gle
(E
R -
/ I
R +
)
Femoral Strap
No Strap
*
* *
p = .003 p = .001 p = .011
0
1
2
3
4
5
6
Femoral Strap No Strap
VA
S P
ain
Sco
re
50% Pain Reduction
Maintain Hip ER
Significant Glut Max EMG activity
• Strapping device to facilitate improved lower quarter biomechanics and minimize excessive hip internal rotation, adduction, and/or knee valgus motion(s)
femoral strap
no strap
Stability through External Rotation of Femur Strap
Souza RB et al, Physiotherapy, 2008Austin AB et al, J Orthop Sports Phys Ther, 2008
Hip Kinesio Taping
No effect on hip or knee kinematics and kinetics during running
Howe A, Scand J Med Sci Sports, 2015
No effect on hip shear forces during landing in ballet dancers
Hendry D et al, Scand J Med Sci Sports, 2015
Broader Perspective on Evidence for Kinesio Taping
Does KT effect muscle strength in healthy adults? NO.– Meta‐analysis of 19 studies with 530 subjects
Is KT better than other interventions in treating chronic musculoskeletal pain and disability? NO.– No significant differences in 17 controlled trials. In fact the title of this article asks “Is it time to
peel off the tape and throw it out with the sweat?”
Does the evidence support the use of KT in a variety of common conditions. NO.– Systematic review of 12 studies and nearly 500 subjects for shoulder, knee, back, neck, and foot
conditions found no difference between KT and sham taping or placebos.
Can KT prevent injuries in sports. Probably NOT.– Meta‐analysis revealed only one study of athletes in a poorly designed study. Authors concluded
their was little to no quality evidence to support the contention that KT prevents injuries.
Can KT impact lymphatic system and reduce swelling in ankle sprains. NO.– According to a randomized control trial
the bigger the claim … the bigger the need for proof –
so I call for a potential
– No compelling evidence to suggest that KT positively influences strength, pain, disability, swelling, strength, or likelihood of injury
Evidence‐Based Management of Femoroacetabular Impingement Syndrome
Ed Mulligan, PT, DPT, OCS, SCS, ATCUT Southwestern School of Health Professions 24
Sports Hernia
Athletic pubalgia without a true herniation– Weakening of the abdominal wall in the area of the inguinal canal– Possible entrapment of the genitofemoral nerve
Pain with twisting/turning in single limb stance; resisted adduction; sit‐ups
+ Rocker Test
Valsalva type maneuver may be provocative – forcible exhalation against a closed airway
Rest or surgical repair with emphasis on restoration of abdominal strength, adductor flexibility, and a gradual resumption of activity