Young Adult Hip Pathology and FAI - c.ymcdn.com · Structures • Neurovascular ... – Under G....

Young Adult Hip Pathology and FAI: Physical Therapy Management for

Non-Operative and Post-Operative Patients

Jill Monson, PT, OCS

Monson Orthopaedic Consulting, LLC

BASICSCIENCE

My “A-Ha” Moment •  Closely observing dynamic squatting in

patients with primary c/o knee pain

•  Knee squatters

•  Cued to sit into hip flexionàCOULD NOT

•  Put them on plinth for ROM and “A-Ha”

•  Have you ever had groin pain or clicking at your hip?

Poor, Lost Souls

•  Young adult hip patients – Saw an average of 4.2± 2.9 health care

providers before a definitive diagnosis was made

– Experienced symptoms for a mean of 3.1 years prior to obtaining a definitive diagnosis

•  Clohisy JC. Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement. Clin Orthop Relat Res 2009.

Anatomy Exploration •  Bony Construct

•  Articular Surface

•  Hip Capsule/Ligaments

•  Musculotendinous Structures

•  Neurovascular Structures

Bony Anatomy of the Hip: Normal •  Acetabulum:

–  Ilium –  Ischium –  Pubis

•  Femur: –  Femoral head

•  Fovea Capitus –  Femoral Neck –  Greater Trochanter –  Lesser Trochanter

Anatomy: Acetabulum

•  Develops as early as 8 wks of gestation

•  Fully formed by 11 weeks gestation –  Watanabe R. Clin Orthop 1974

•  Acetabular formation in response to presence of contact w/femoral head

Acetabulum

•  Triradiate cartilage at the confluence of ilium, ischium, pubis – Fuses fully by 16-18 y/o (**May be late)

•  Ponseti J. Bone Joint Surg Am 1978

•  VascularSupplytoAcetabulum:–  InternalIliaca.

FemoralHead&Neck

•  VascularSupplyFemoralHead– Medialfemoralcircumflex

AvascularNecrosis(AVN)

•  TraumaHcAVNviadislocaHons– Medialcircumflexarteryistorn

•  Non-traumaHcAVNAssociaHons– ETOH– Steroiduse– Chemotherapy

Fibrocartilage: Acetabular Labrum

•  Consists of both fibrocartilage and dense connective tissue

–  Peterson W. Arch Orthop Trauma Surg 2003

•  Creates a circumferential seal around the hip joint

•  Nerve endings indicate nociceptive and proprioceptive capabilities @ labrum

•  Kim YT. Clinic Orthop 1995 © Monson Orthopaedic Consulting, LLC

2012 11

Thickest@anterosuperiorrim(greatestloadshere)

Acetabular Labrum Circumferential Seal of the Labrum

•  Enhances joint stability through a suction effect and contributes to a fluid-enhanced force distribution

•  Contributes to homeostasis at joint for lubrication, nutrition and load sharing with articular cartilage

Labrum, Cont. •  Blood supply via the obturator a., superior and inferior

gluteal aa., medial femoral circumflex a.

•  Blood vessels only detected in the peripheral 1/3 of the labrum; internal portion avascular

–  Peterson et al. immunostaining study; Arch Orthop Trauma Surg 2003

•  Some capacity for labral healing has been observed in basic science and ovine experimental studies

–  Seldes et al. Clin Orthop 2001 –  Philippon Arthroscopy 2007 –  Miozzari H Osteoarthritis and Cartilage 2004

Capsular Anatomy

•  Extends from acetabular rim to anterior intertrochanteric line at anterior aspect of proximal femur

Capsular Anatomy: Ligamentous

3 Extra-articular ligaments

•  All taut in extension •  All lax in flexion

Extra-capsular Ligaments •  Iliofemoral (strongest, thickest)

–  AIIS to anterior intertrochanteric line –  Tight in ER and ADD

•  Pubofemoral –  Superior pubic ramus to inferior femoral neck –  Tight in ER and ABD

•  Ischiofemoral (weakest, thinnest) –  Ischium to posterior inferior femoral neck –  Tight in IR and ABD

Extracapsular Ligaments

Anterior View Posterior View

Intra-capsular: Ligamentum Teres

•  Acetabular notch to fovus capitis (fovea) of femur –  Tight in ADD, Flex, ER

OtherLigamentousStructures•  InguinalLigamant

Bursae

•  Trochanteric(“Gluteal”):–  BetweentendonofG.Maxandgreatertrochanter

•  Synoviallined,severallayersb/twtendonlayersofG.Med&Min

•  Ischiogluteal:–  UnderG.MaxjustposteriortoIschialTuberosity

•  IliopecHneal:–  BetweenPsoasMajortendonandIliopecHnealeminence

Dermatomes

-HipJointisanL3structure

-Consider:Traveling/sweepingpain

Contained/localizedpain

Hip Musculature •  Tremendous functional cross-over at the hip

musculature

•  Function contingent on: –  Hip joint position –  Trunk position –  CKC/OKC function

•  Tremendous interplay with proximal and distal segments –  Pelvis, L-spine, Knee joint

Musculature: Flexors •  Psoas Major & Iliacus (Iliopsoas)

–  Flex, ADD, ER

•  Tensor Fascia Latae –  Flex, ABD, IR

–  Rectus Femoris

Muscles:Extensors

•  Gluteus Maximus –  ABD, Ext, ER

•  Hamstrings

Musculature: Abductors –  Gluteus Maximus

•  ABD, Ext, ER

–  Gluteus Medius •  Anterior Fibers

–  ABD, Flex, IR •  Posterior Fibers

–  ABD, Ext, ER

–  Gluteus Minimus •  ABD, IR

–  TFL •  ABD, Flex, IR

Musculature: Adductors –  Adductor Magnus –  Adductor Longus

•  ADD, Flex, ER

–  Adductor Brevis •  ADD, Flex, ER

–  Gracilis •  ADD, Ext, IR

–  Pectineus •  ADD, Flex, ER

Musculature

•  Adductor Magnus –  Pubic ramusàLinea Aspera

•  Flex, ADD, ER

–  Isch TubàADD tubercle •  Ext, ADD, IR

Musculature: Deep External Rotators

•  Obturator internus •  Obturator externus •  Superior gemellus •  Inferior gemellus •  Piriformis •  Quadratus femoris

*All but Piriformis ADD hip *Think rotator cuff

Musculature: Deep Internal Rotators

•  Gluteus Medius – Anterior fibers

•  Gluteus Minimus

PalpaHon:AnteriorPelvis

•  ASIS–  TFLorigin–  Sartoriusorigin–  Inguinalligament

•  AIIS–  RectusFemorisorigin

*Note*

•  RectusFemoris–  AppreciatetheproximityofitsoriginattheAIIStotheanterosuperioraspectoftheacetabulum

PalpaHon:PosteriorPelvis

•  Sacralborder–  Gluteusmaximusorigin

•  IliacWing–  Gluteusmediusorigin–  Gluteusminimusorigin

GluteusMaximus•  Origin

–  Sacrum,dorsalsacroiliacligaments,smallareaofiliumnearPSIS,sacrotuberousligament

•  InserHon–  Upper½@lateralporHonofTFL,ITB–  Lower½@dividedinserHonintoITBanddeeperfibersattheglutealtuberosity(lateralextensionoflineaaspera)

•  BursabetweentendonandGT

GluteusMedius

•  Origin– Mostlyliesundertheglutmax,butanteriorfibersarenotcovered

– Upperlateralsurfaceoftheiliacwing(b/twA/Pgluteallines)&anteriorlyatthefascia

•  InserHon– Greatertrochanter

GluteusMinimus

•  Origin– Lowerpartoflateralsurfaceofwingofilium(b/twanteriorandinferiorgluteallines)

•  InserHon–  GreaterTrochanter

Piriformis

•  Origin– Pelvicsurfaceofsacrum

•  InserHon–  InnersurfaceofupperpartofGT– FillsthesciaHcforamen

PalpaHon:PosteriorPelvis

•  IschialTuberosity– Semitendinosis

•  Nearsacrotuberouslig.InserHon

– BicepsFemoris•  Mostlateral

– AdductorMagnus•  Mostmedial

PalpaHon:PubicRegion•  PubicTubercle(anterosuperiorsurfaceofpubicbody)

– Rectusabdominus(Superiorly)–  Inguinalligament(Laterally)– Adductorlongus(Inferiorly)

•  SuperiorPubicRamus–  PecHneus

•  InferiorPubicRamus–  Gracilis–  AdductorMagnus(atbonysegwaytoischialramus)

PalpaHon:ProximalFemur

•  Greatertrochanter(superior&posterioraspect)–  GluteusmediusinserHon–  GluteusminimusinserHon

•  Justanteriortomedius

•  GlutealTubercle(justdistaltogreatertrochanter)–  GluteusmaximusinserHon

PalpaHon:ProximalFemur

•  Posteriortrochantericfacet–  DeephiprotatorsinserHonpoint

•  LesserTrochanter–  Iliopsoas

LAB:Palpa*on

•  ASIS–  Resistedhipflexion+IR(TFL)

•  AIIS–  Resistedhipflexion(RectusFemoris)

•  PubicBone–  ResistedhipADD(ADDlongus,PecHneus,Gracilis)

•  IschialTuberosity–  Resistedkneeflexion(Hamstring)

•  GreaterTrochanter–  ResistedhipABD

•  Proximal:Gluteusmedius•  Distal:Gluteusmaximus

•  IliacCrest–  ResistedhipABD(Gluteusmedius,minimus)

Biomechanics vs. Kinematics

•  Biomechanics –  “I see dead people”/anesthetized

•  Biomechanical laboratory studies –  Dissected cadaver Hips: Hemi-pelvis, transected femurs

•  Kinematics –  “I see living people”

•  Motion analysis laboratory kinematic studies –  Real, moving humans with completely intact proximal and

distal anatomy and active musculoskeletal interactions

Surgery vs. Rehabilitation •  What can a surgeon change with their tool

set? – Bony anatomy –  Ligamentous, Fibrocartilage fixation

•  What can a physical therapist change? – Dynamic muscular control

•  Strength, proprioception – Static Tissue quality:

•  Stretching, joint/soft tissue mobilizations

In Vivo Hip Joint Force Measurements Bergmann G, Deuretzbacher G, Heller M, et al. Hip contact forces and gait patterns from routine activities.

Journal of Biomechanics 2001.

•  Implanted pressure transducers with THA components

•  All forces acting on the hip accounted for •  Muscle tension •  Ligamentous tension •  WB load

Bergmann Study, cont. •  In vivo hip joint force measurements

– 300% BW with slow walking – 350-400% BW with quick walking – Up to 500% with jogging – 800% during “stumbling”

– 2 legged stance = 80-100% BW •  Attributed to persistent muscle tension at hips

during FWB stance

Gait Kinematics: Stance •  Initial Contact

–  30 deg hip flexion •  Loading Response

–  30 deg hip flexion –  5-10 deg ADD, IR

•  Mid-stance –  0 deg flex/ext

•  Terminal Stance –  10 deg hip extension –  Neutral ABD/ADD

Stance, Cont. •  3-D Musculoskeletal Models

– Hip joint contact forces directed anteriorly during the last 20-30% of stance

•  Stansfield and Nicol. Clinical Biomechanics 2002

–  Important consideration for: •  Injury location at labrum •  Observing and progressing gait with non-op

and post-op rehabilitation

Gait Kinematics: Swing

•  Initial Swing –  20 deg hip flexion

•  Midswing: –  20-30 deg hip flexion –  5 deg ABD

•  Terminal swing –  30 deg hip flexion

Warning:

We are now leaving the world of normal hips

FAI FAI = Femoral Acetabular Impingement

•  First described by Ganz in 1995 (Bern, Switzerland)

•  Not published/presented in English literature until 1999

Myers SR, Eijer H, Ganz R. Anterior femoracetabular impingement after periacetabular osteotomy. Clinical Orthopaedics and related research

Femur: Cam Deformity

•  Pathology at the femoral head and/or head-neck junction

–  Asphericity of the femoral head

–  Decreased femoral head-neck offset

CamDeformity•  RadiologicDefiniHon:

– Crosstablelateral&Frogleglateralradiographs• Alphaangle•  >50.5degreesconsidered(+)forcamdeformity

–  NotzliHPetal.JBJSBr2002

Radiology:AlphaAngle

•  Perfectcirclearoundfemoralhead

•  Drawlinealongthecenteroffemoralneck

•  Otherlineatthecenterofthefemoralhead–  Compareanglegeneratedb/twthoselines

CamDeformityImpingement

Acetabulum: Pathoanatomy •  Acetabulum:

– Pincer Impingement (3 types) •  Focal anterior overcoverage

–  Associated with normal superior and posterior acetabular coverage

•  Relative anterior overcoverage –  Acetabular retroversion (normal=20-40° anteversion) – Decreased posterior coverage

•  Global acetabular overcoverage – Coxa profunda –  Protusio acetabuli

»  Larson, C Sport Med Arthrosc Rev 2010

Pincer Deformity •  Acetabular overcoverage

of the femoral head

AcetabularPathology

•  Profunda(Deep)– Baseofthenotchispasttheilioischialline– Headisseateddeepintheacetabulum/pelvis

•  Protrusio(Deeper)– Femoralheadispasttheilioischialline– Morepronouncedovercoverage– DeeperseaHngoffemoralheadwithinthepelvis/acetabulum

Radiology:LateralCenterEdgeAngle

PincerDeformityImpingement

Other Bony Variables at the Femur •  Anteversion:

–  Rotation of the femoral neck relative to the shaft –  Normal=10-15° anteversion –  Abnormal is usually increased anteversion

(W-sitters) •  Neumann DA. Mosby 2002

•  Angle of Inclination: –  Angle b/tw femoral neck and shaft of femur –  Normal=125° –  Dysfunction may be a higher or lower angle (Coxa Vara/Valga)

•  Coleman SS. Mosby 1978

OtherBonyHipPathology

•  Slippedcapitalfemoralepiphysis

•  AvascularNecrosis

•  Legg-Calve-Perthesdisease

•  “Dysplasia”

•  Most commonly presents as combined bony pathologies at both the femur and acetabulum

•  Beck M et al. JBJS Br 2005 •  Allen D et al. JBJS Br 2009

Male:Female

•  “Pure”camdeformitymorecommonlyobservedinmales

•  “Pure”pincerdeformitymorecommonlyobservedinfemales

–  BeckM,KalhorM,LeunigM,GanzR.JBJSBr2005

EHology:CamDeformity

•  Sub-clinicalslippedcapitalfemoralepiphysis(SCFE)

•  FraitzlCRetal.JBJSBr2007•  GoodmanDAetal.JBJSAm1997

•  Growthabnormalityattheepiphysis

•  SiebenrockKAetal.ClinOrthopRelatRes2004

CamDeformity:Healthy,AsymptomaHcPopulaHon

Cam-TypeFAIbonyalignmentobservedinINDIVIDUALSWITHOUTHIPPAIN

•  CopenhagenOsteoarthriHsStudy(N=3,202)–  Cam-typeFAIresentin17%ofasymptomaHcmen–  Cam-typeFAIpresentin4%ofasymptomaHcwomen

•  GosvigKKetal.ActaRadiol2008

•  HackKetal.JBJSAm2010(N=200)–  Presentin25%ofasymptomaHcmen

•  OfthepopulaHonfoundw/CamtypeFAI,79%weremale–  Presentin5%asymptomaHcwomen

•  Laborieetal.,Radiology2011(N=2081)–  PrevalenceofCam-typemorphologyinhealthypopulaHon–  35%ofMales,10%ofFemales

CamDeformity•  Elitemaleandfemale

soccerplayers(N=95)–  67%prevalenceofFAI–  Cam-typeFAI:68%Males,

50%Females–  Meanalphaangle

Males=66°,Females=53°•  Gerhardtetal.,AJSM2012

•  Higherprevalence(89%)inbasketballplayersw/historyofhighintensityplayduringadolescence

•  SibenrockKAetal.ClinOrthopRelatRes2011

CamDeformity•  Malecollegiatefootballplayers

(N=67)–  95%FAI–  >70%cam-typeFAI

•  Petersetal,JBJSAm2011

•  NFLprospects(NFLCombine)(N=239)–  90%radiographicFAI–  75%Cam-typeFAI

•  Larsonetal.,(SubmiOedArthroscopy2012)

“FuncHonalHipImpingement”??

EHology:PincerDeformity

•  Pincerdeformitytheories–  Retrotorsionofthehemipelvis–  Congenital/developmental

•  Hipdysplasia–  Congenital– Males4.3%–  Females3.6%

•  (CopenhagenCohort)Gosvigetal.,JBJSAm2010

PincerDeformity•  Leunigetal.,CORR2009

–  CohortofOAptswithprotrusio(globalovercoverage)

–  87%(27/31pts)ofprotrusioptswerefemale

•  CopenhagenCohort(N=3620)

–  Coxaprofunda&protrusio•  19.4%ofFemales•  15.2%ofMales

–  Globalovercoverage=riskfactorforthedevelopmentofOA

–  Gosvigetal.,JBJSAm2010

DevelopmentalHipDysplasia•  Morecommoninfemales:

–  78childrenwithDDH•  17.9%Males&82.1%Females

–  Milasinovicetal.,ActaChirTraumatolCech2011

–  3613randomlyselectednewborns(USeval)•  HigherproporHonofgirlsvsboyshadimmaturehips,minordysplasia(4.5%vs1.0%),&majordysplasia(1.2%vs0.2%)

–  Rosendahletal.,PediatrRadiol1996

–  8145infants(clinicalexaminaHon)•  FemalegendersignificantriskfactorforDDH

–  Stein-ZamirCetal.,PediatrInt2008

OAProgressionData

•  Caucasions/EuropeanDescent

•  Males>Females(slight)

•  Obesityassociatedw/fasterprogressionofOAratherthanonset

•  CibulkaMRetal.JOSPT2009

ClinicalCriteriaforOADiagnosis

•  HipIR<15degreesalongwith:–  Hipflex≤115deg–  Age>50y/o

OR•  HipIR≥15degalongwith:

–  Painw/hipIR–  DuraHonofmorningsHffnessofhip≤60min–  Age>50y/o

–  AmericanCollegeofRheumatology–  CibulkaMRetal.JOSPT2009

OAProgression

•  AcetabularlabralpathologysecondarytoFAIisaprecursortoearlyonsethipOA

•  BeaulePEetal.JOrthopRes2005•  BeckMetal.JBJSBr2005•  KimKCetal.ClinOrthopRelatRes2007•  McCarthyJetal.ClinOrthopRelatRes2003•  McCarthyJCetal.ClinOrthopRelatRes2001•  MurphySetal.ClinOrthopRelatRes2004•  PfirrmanCWetal.Radiology2006•  TanzerM,NoiseuxN.ClinOrthopRelatRes2004•  TonnisD,HeineckeA.JBJSAm1999

Synovial/CapsularCondiHons

•  Osteochondromatosis

•  PigmentedvillonodularsynoviHs

•  SynoviHs

•  CapsularInstability

Capsular Pathology

•  Atraumatic Capsular Laxity

– Global •  Connective tissue disorders

– Focal Rotational •  Results from excessive, forceful hip external

rotation •  Can lead to iliofemoral ligament insufficiency •  Can contribute to increased stress at the labrum

–  Philippon MJ. Clin Sports Med 2001

LabralPathology

•  MostcommonbonyabnormaliHesassociatedw/labralpathology:– Acetabularretroversion

– Decreasedfemoralhead-neckoffset(Cam)

– CoxaValga •  Wegneretal.ClinOrthopRelatRes2004

Labral Tears

•  Anterior Tears –  More common in US and European countries

–  May be due to poorer vascular supply at anterior labrum

•  McCarthy et al. Clin Orthop 2001

–  This region has the least bony constraint of femoral head anteriorly

•  Rely on labrum, capsule and ligaments for stability

LabralTears

•  Posterior Tears

–  More common in Japan

–  Different lifestyle: more squatting, floor sitting

•  Hase T. Arthroscopy 1999

Articular Surface Pathology

•  Labrum –  Tearing –  Detachment –  Cystic changes

•  Articular Cartilage –  Localized lesions: Gr I-IV –  Delamination

Chondral Pathology

•  73% of patients with labral pathology have chondral damage

–  McCarthy et al. Clin Orthop Relat Res 2001

•  Presence of chondral lesions of the femur or acetabulum is associated with poorer prognosis following hip scope

–  Byrd JW. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy. 2000

Soft Tissue Pathoanatomy •  Tendinopathy

•  Snapping Hip Syndrome Iliopectineal Eminence

2012 82

ClinicalImaging

•  RadiologyGoldStandards–  A/PPelvis(standardized)–  Falseprofileview

•  Standingoblique•  Showsanteriorcoverageofacetabulum

–  Crosstablelateral–  Frogleglateral

ClinicalImaging

•  MRIGoldStandards–  Arthrogramw/gatolinium

–  Highquality3TMRI

Young Adult Hip Pathology and FAI - c.ymcdn.com · Structures • Neurovascular ... – Under G....

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