NONARTHRITIC HIP PAIN · Implications for PT intervention first • Studies have suggested that the...

NONARTHRITIC HIP PAIN Causes or Effects Trends in Intervention How PT Impacts EMG Evidence and Biomechanics of Primary Hip Stabilizers

Causes or Effects of Nonarthritic Hip Pain • Structural – Femoroacetabular Impingement (FAI)

•  Morphology – Cam, undercoverage; Pincer, overcoverage

•  Instability – Extraphysiologic Motion •  Traumatic, Atruamatic •  Labral Tears •  Ligamentous laxity •  Undercoverage •  Muscle weakness

• Other Considerations: •  Femoral Version, Ligamentum Teres, Chondral Lesions, Loose

Bodies, Activity/Participation, CT Disorders •  Dysfunction from the hip causing impairments up or down the chain

(ex. ACL, PFPS, LBP) or visa versa

Review of 2014 CPG Key Points • Recommendations based on expert opinion:

•  Interventions of non-surgical management •  Education •  MT •  Exercise •  Neuromuscular Re-Ed

•  Risk Factors – Not clearly understood, exception of trauma •  Differential Diagnosis – Use clinical findings and imaging

• Recommendations based on weak evidence: •  Diagnosis/ Classification

• Recommendations based on strong evidence: •  Outcome Measures – HOS, HAGOS, iHOT-33

Causes or Effects of Nonarthritic Hip Pain • Structural – Femoroacetabular Impingement (FAI)

•  Morphology – Cam, Pincer Lesions

“Prevalence of Abnormal Hip Findings in Asymptomatic Participants” 2012 • Purpose: To assess asymptomatic cohort to determine

the prevalence of hip lesions • Asymptomatic volunteers had > 50% chance of labral

tear • Study also showed an association between cam

impingement and labral/chondral lesions. •  Unclear when and why this conflict causes symptoms

“FAI Surgery is on the Rise – But what is the next step?” 2016

Strong opinions by Reiman, et al in JOSPT and British Journal of Medicine

• Challenges accepting surgery as the automatic gold standard treatment for FAI and accepting morphology as pathology.

• Calls to reform the surgical decision-making process: • Bolster basic science studies examining FAI.

“Nonoperative Treatment for Femoroacetabular Impingement: A Systematic Review of the Literature” 2013

• Only 5 articles summarized experiments that evaluated nonoperative treatment

•  3 reported favorable outcomes

• Nearly half of 53 articles promoted PT as a treatment, (23)

• Suggests surgery is associated with early relief of pain and improved function •  Improvement in hip function

was noted in all studies • The role of nonsurgical management has not been defined.

“Surgical Treatment for Femoroacetabular Impingement: A Systematic Review of the Literature” 2010

Where surgical vs nonsurgical systematic review recommendations come together?

Nonsurgical

•  “Nonoperative treatment regimens, particularly physical therapy, need to be evaluated more extensively and rigorously, preferably against operative care, to determine the true clinical effectiveness.”

Surgical

•  “Most importantly, future clinical trials are needed to determine the relative efficacy of nonsurgical and surgical treatment.

• Predictors of treatment outcome and the efficacy of various surgical techniques need to be established in well-designed clinical trials.”

Implications for PT intervention first •  Studies have suggested that the abnormal movement at the hip

joint occurring secondary to femoral acetabular impingement may lead to labral lesions and cartilage damage (Enseki, et al 2014)

•  Altered gait patterns lead to subconsciously adopted impingement and pain avoidance behavior (Briton, et al, 2013)

•  Femoral head-neck malformations in FAI may be developmental in response to repetitive stress… from aggressive sport activity during skeletal growth (Clohisey, et al)

•  A slight change in muscle length (ex TFL vs Psoas) or limited joint play (< posterior glide) will alter the normal joint motion pathway (Sahrmann, 2002)

“Kinematic and kinetic differences during walking in patients with and without symptomatic femoroacetabular impingement” June 2013 • Compared spatiotemporal, kinematic, and kinetic

variables in symptomatic FAI to p! free control group.

•  FAI group: Exhibited less max hip extension, adduction, & internal rotation during stance; As well as less flexion and external rotation moments.

• Recommendation: Focused neuromuscular reconditioning across all movement directions.

“Conservative management of femoroacetabular impingement (FAI) in the long distance runner” 2014

• Purpose: Discuss conservative treatment approach to be attempted prior to surgical management.

• Concepts: Treatment should attempt to restore function in all three planes of movement given the importance of three-dimensional control of the hip with running

• Primary Goals of conservative management: •  Improve posterior glide of femur; •  Strengthen hip musculature in open and closed chain and •  Correct faulty movement patterns.

“Conservative management…” 2014 Increase Femoral Posterior Glide

Ex. Supine PL hip mob

Standing posterior-lateral hip self-mobilization.

Quadruped rock back with belt lateral distraction.

“Conservative management…” 2014 Increase Strength OKC CKC & Correct Movement Patterns • Gluteus medius and maximus strengthening should begin

in non-weight-bearing positions, focusing on form and endurance of the muscle.

• Should be able to elicit contraction of the deep lumbopelvic stabilizers when performing open-chain hip exercises. •  Examples: prone hip extension with knee flexion, prone hip lateral

rotation, and sidelying hip abduction with lateral rotation.

“Conservative management…” 2014 Increase Strength OKC CKC & Correct Movement Patterns • Neuromuscular re-education of the lumbar and pelvic

stabilizers is a foundation of treatment for most runners.

• Closed chain exercises are clinically appropriate for the running athlete. •  Lunge exercise provides high level gluteus medius and gluteus

maximus muscle activation •  Other examples: standing hip hikes, single-leg squats, and the

forward step-up

• Plyometric exercises may be indicated, if tolerated, to improve propulsion power and speed.

“An evidence-based review of hip-focused neuromuscular exercise interventions to address dynamic lower extremity valgus. ” 2015

•  The purpose of the review was to identify and discuss hip-focused exercise interventions that aim to address dynamic lower extremity valgus.

• Examined recruitment of Gmed and Gmax during: • Common non-weightbearing exercises • Common weigthbearing exercises • Common functional exercises

• Recommendation: Developing evidence to support progression of exercises with varying bases of support, sports-related tasks with external load, and resisted bands.

Common Non-Weightbearing Exercises

Common Weightbearing Exercises

“Progressive hip rehabilitation: the effects of resistance band placement on gluteal activation during two common exercises.” 2012 •  The aim of this study was to compare gluteal muscle

activity across four squatting exercises commonly prescribed to rehabilitate and prevent knee injuries.

Common Functional Exercises

“Progressive hip rehabilitation: the effects of resistance band placement on gluteal activation during two common exercises.” 2012 • Objective: To examine the effects of altering

resistance band placement during 'Monster Walks' and 'Sumo Walks.’

• Distal band placements offered a significantly higher activation level of gluteal muscles, when compared to the proximal conditions

•  The foot condition created an external rotation moment • Also, facilitated a stiffened and neutral spine as measured

by secondary joint angle analysis

Plyometric Exercises •  Glute Med:

• Highest during single-limb sagittal plane hurdle hops double-limb sagittal plane hurdle hops and split squat jumps

•  Lesser activation during non-sagittal plane double-limb landings in the frontal and transverse planes. (40-47%)

•  Glute Max: • Highly activated during

double-limb and single-limb sagittal plane landings

•  Less active in other planes (<40% MVIC).

“An evidence-based review of hip-focused neuromuscular exercise interventions to address dynamic lower extremity valgus. ” 2015

Wouldn’t it be nice? Examples. • A protocol for study design…

• Efficacy of a physiotherapy rehabilitation program for individuals undergoing arthroscopic management of femoroacetabular impingement – the FAIR trial: a randomised controlled trial protocol

• Two-year outcomes after arthroscopic surgery compared to physical therapy for femoracetabular impingement: A protocol for a randomized clinical trial

• Movement-Pattern Training to Improve Function in People With Chronic Hip Joint Pain: A Feasibility Randomized Clinical Trial