Femoroacetabular Impingment: Evidence Based Tratment

Elizabeth Evans, PT, MPT Susan Fain, PT, DMA Bridgit Finley, PT, DPT, OCS Casey Kirkes, PT, DPT

Clinical Question In patients with FAI, is manual therapy more effective for reducing pain and functional limitations than exercise alone?

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

Overview This presentation will review: Anatomy Clinical Exam Non-operative Management Manual Therapy Interventions Therapeutic 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.

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

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

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.

Etiology Developmental factors: Coxa profunda Protrusio acetabuli Asphericity of femoral head Reduced femoral head-neck offset Maloriented acetabulum Samora (2011)

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)

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

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)

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)

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

Pincer Zone of injury: anterior acetabular labrum with “countrecoup” chondral injury in posterior-inferior acetabular rim Provocative test: Hip extension, ER Samora (2011)

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)

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)

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)

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

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

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 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

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

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)

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.

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

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?

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)

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 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)

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

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.

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.

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

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.

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. 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.

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

Femoroacetabular Impingment: Evidence Based Tratment

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