Clinical Practice Guidelines Non Arthritic Hip Pain Michael T. Cibulka, PT, DPT, MHS, OCS, FAPTA Associate Professor Maryville University Program in Physical Therapy St. Louis, MO

Prevalence • So far no good evidence on the prevalence of femoral acetabular impingement (FAI) or on labral tears of the acetabulum

Risk Factors • FAI – Dysplasia (acetabular and femoral) – Genetics • May be related, more studies needed

– Sex • SCFE greater likelihood in men

• Structural Instability – Sex • Females more likely (hypermobile)

– Genetics • Dysplasia: • Congenital dislocation related dysplasia (femoral valgus and plana or shallow socket) • Acetabular profunda/protrusio (femoral varus and profunda or deep socket)

Development of the Proximal Femur and how dysplasia develops (vara/valga) • Abbreviations: • TGP= trochanteric growth plate • FNI= femoral neck isthmus • LGP= longitudinal growth plate • TRC=Triradiate cartilage

Apophysis • The growing parts of the bone include the physis and the epiphysis. • Two types of epiphyses are found in the extremities: traction and pressure. – Traction epiphyses (or apophyses) are located at the site of attachment of major muscle tendons to bone and are subjected primarily to tensile forces. – The apophysis of the tibial tubercle is an example.

• The apophysis contribute to bone shape but not to longitudinal growth.

• Femur grows proximally – One direction along the LGP promotes valgus growth – Another direction along the TGP and FNI promotes varus growth – Resultant balance net force results in a straight femur growth (normal)

Resultant force of growth

Pathoanatomical Features • Femoroacetabular Impingement (FAI) – Different structural variation of proximal femur and acetabulum – CAM (impingement) • Femoral neck bump

– Pincer (overcoverage) • Acetabular retroversion • Acetabular profunda and protrusia

– Structural instability • Extraphysiologic hip ROM

Hip impingement from hip dysplasia Pincer Type Dysplasia

Profunda & Protrusio

Acetabular Retroversion & Prominent Posterior wall

Cam Type Dysplasia

Gun Shape

Non Spheroidal Femoral Head

Pincer Type These are acetabulum problems: 1. Coxa Profunda 2. Coxa Protrusio 3. Acetabular Retroversion 4. Prominent Posterior wall

Pincer Type of Acetabulum • Pincer as in a pincer pliers, suggesting the opening of the acetabulum is pincer shaped – This shape results in the abutment of the femoral neck with the (anterior or posterior) walls of the acetabulum

Hypothetical: Impaction due to Pincer Impingement

Proposed mechanism of how retroverted femur decreases the clearance and exacerbates cam impingement

Conversely mechanism of how femoral anteversion can create possible posterior rim impaction

Cam Type Femoral head problems: 1.Pistol grip or gun deformity 2.Non Spherical Femoral Head

Normal Femur Lateral Neck Concavity

SCFE One cause of Cam Lesion

• SCFE creates a posteromedial displacement of the femoral head • This displacement places the metaphysis in an anterolateral position • During healing this leads to an anterolateral prominence (cam or bump) on the proximal femur • This bump can abut against the acetabulum and erode the labrum and create pain

SCFE creates Impaction type impingement in severe slips and Inclusion type in moderate slips

FAI Cam lesions 1-3 o’clock most common location

Pistol Grip or Gun Type Deformity

Gun shape or also called a pistol grip deformity •Loss of normal concavity of femoral neck •Pistol grip deformity – Etiology includes: •Growth abnormality of the capital femoral epiphysis •SCFE, LCPD, Abnormal fracture healing

Cam Lesion Seen best with frog leg view

Pincer and Cam Type of Dysplasia

Acetabular Labral Tears • Potential source of hip pain • Difficult to diagnose for many false positive and false negative diagnosis • Much research is needed to further elucidate the pathophysiology of labral tears

Chondral Lesions • Focal loss of cartilage on the articular surface • Many who have labral tears also have chondral lesions • Often related to a traumatic injury pattern with acute overloading through impact through the greater trochanter

Pain location from FAI

Diagnosis of FAI • Pain in the anterior hip/groin and/or lateral hip/trochanter region is reported • Pain is described as aching or sharp • The reported hip pain is aggravated by sitting • The reported pain is reproduced with the hip FADIR test • Hip internal rotation is less than 20° with the hip at 90° of flexion • Hip flexion and hip abduction are also limited • Mechanical symptoms such as popping, locking, or snapping of the hip are present • Conflicting clinical findings are not present • Radiographic findings: – Cam impingement

• Increased femoral neck diameter that approaches the size of the femoral head diameter – Alpha angle greater than 60° – Head-neck offset ratio less than 0.14 – Pincer impingement • Increased acetabular depth – Coxa profunda (lateral center-edge angle greater than 35°) – Acetabular protrusion • Decreased acetabular inclination – Tönnis angle less than 0° • Acetabular retroversion – Crossover sign indicating localized anterosuperior overcoverage – Ischial spine projection into the pelvis

Normal Radiographic Landmarks • AW= anterior rim of the acetabulum • PW = posterior wall of the acetabulum • IIL = ilioischial line • F = acetabular fossa • H = femoral head • LCE = lateral center edge

In Coxa profunda: The Acetabular Fossa (F) is touching or overlapping the Ilioischial line (IIL)

Tannast M et al. AJR 2007;188:1540-1552

©2007 by American Roentgen Ray Society

Coxa Protrusio When the acetabulum projects medial beyond the ilioischial line by 3mm in men or 5mm or more in women

Protrusion index of the femoral head is determined by measuring in mm the amount of the lateral part of the femoral head that is not contained by the acetabulum (A) and dividing this by the total width of the head (B). Therefore A/B_100 gives the percentage that is extruded or uncovered.

The Crossover Sign suggests: Acetabular Retroversion is present

Crossover Sign A Sign of Acetabular Retroversion • Normal: the anterior wall and posterior wall meet at the cranial aspect of the acetabulum. – Thus the AW- anterior wall is medial to the PWposterior wall of the acetabulum – When the anterior wall and posterior wall intersect: called a positive Crossover sign!

Crossover Sign

Ischial Spine Sign Suggesting acetabular retroversion

Diagnosis of structural instability • Anterior groin, lateral hip, or generalized hip joint pain is reported • Pain is reproduced by FADIR or FABER test • Hip apprehension test is positive • Hip IR is greater than 30° when the hip is flexed to 90°

• Mechanical symptoms of popping, locking, or snapping are present • Conflicting clinical findings are not present • Radiographic finding of: – Increased acetabular inclination – Tonnis angle > 10° – CE edge angle less than 25° – Anterior center edge angle less than 20°

Tonnis Index: Antero-medial Index

Figure 2 – The centre-edge angle of Wiberg is formed between two lines passing through the centre of the femoral head one of which extends to the lateral edge of the sourcil (A) and the other is a perpendicular to the teardrop line (B). The normal angle in an adult > 25°

CE Angle

Normal CE angle is 25° or more!

The Center Edge (CE) angle of Wiberg A measure of the amount of covering or congruence in the hip joint • As OA progresses the CE angle becomes progressively smaller. • CE angle Normal = 25° or greater. • With severe hip OA can be below 5°.

Anterior Center Edge

Projection of how the faux or false profile view is taken

Anterior CE angle

Anterior Center Edge Angle of Lequesne (VCA angle, faux or false profile view)

• Vertical line from center of femoral head to • Anterior rim of the sourcil – Or lateral rim of acetabulum

• Less than 20° considered abnormal • Anterior CE angle = 25-50° considered normal

Anterior Center Edge Angle of Lequesne (also called the faux or false profile view)

Differential Diagnosis • • • • • • • • • • • •

Referred pain from lumbar facets Referred pain from lumbar HNP Sacroiliac joint dysfunction Pubic symphysis dysfunction Lumbar spinal stenosis Hip OA Iliopsoas bursitis Adductor strain Obturator strain Inguinal hernia Prostatitis Metabolic bone disease

• • • • • • • • • • • •

Athletic pubalgia Osteonecrosis of femoral head Femoral or pelvic stress fracture Avulsion injury Myositis ossificans Gynecological problems Neoplasms LCP SCFE Osteomyletis Psoas abcess RA

Imaging • Besides what was already covered: – Crossover sign – MRI – not usually used! – MRA with contrast for labral tear

Recommended Outcome Measures • HOS (Hip outcome score) • Modified Harris Hip Score • WOMAC (Western Ontario and McMaster Osteoarthritis Index) • HAGOS (Hip and groin outcome score) • iHOT-33 (International hip outcome tool) • HOOS (Hip disability and osteoarthritis outcome score) – None specifically recommended over the other

Physical Impairment Measures • • • •

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Trendelenburg Sign Description: the purpose is to assess ability of the hip abductors to stabilize the pelvis during single-limb stance. • Measurement method68: from standing, the patient performs single-limb stance by flexing the opposite hip to 30° and holding for 30 seconds. Once balanced, the patient is asked to raise the nonstance pelvis as high as possible. From the posterior view, the examiner observes the angle formed by a line that connects the iliac crest and a line vertical to the testing surface. Observation: the test is negative if the pelvis on the nonstance side can be elevated and maintained for 30 seconds. The test is positive if 1 of the following criteria are met: (1) the patient is unable to hold the elevated pelvic position for 30 seconds, (2) no elevation is noted on the nonstance side, (3) the stance hip adducts, allowing the pelvis on the nonstance side to drop downwardly below the level of the stance-side pelvis. A false negative may occur if the patient is allowed to shift his or her trunk too far laterally over the stance limb.

Physical Impairment Measures • • • •

FABER test: Same as hip OA Supine, flex, abduct and ER Do both sides asking for symptoms and listening for sounds (clicking, etc.)

Physical Impairment Measures • FADIR Impingement Test • ICF category: measurement of impairment of body function: pain in joints and mobility of a single joint • Description: a test to assess for painful impingement between the femoral neck and acetabulum in the anterosuperior region. – The FADIR test has also been used to assess for specific pathology of the acetabular labrum

• Measurement method: the patient is positioned in supine. The hip and knee are flexed to 90°. Maintaining the hip at 90° of flexion, the hip is then internally rotated and adducted as far as possible. – The patient is asked what effect the motion has on symptoms. The test is considered positive if the patient reports a production of, or increase in the anterior groin, posterior buttock, or lateral hip pain consistent with the patient’s presenting pain complaint. If the test is negative, the test is repeated with the hip placed in full flexion.

Physical Impairment Measures • Log-Roll Test • Description: a test to determine ligamentous laxity • Measurement method: the patient is positioned in supine with the hip and knee in 0° of extension. The hip is passively rotated both internally and externally. – The examiner ensures the rotation is occurring at the hip and not at the knee or ankle. – The examiner notes any side-to-side difference in external rotation range of motion. – The test is positive for ligamentous laxity when the involved hip demonstrates greater external rotation range of motion than the uninvolved hip.

Physical Impairment Measures • Passive Hip Rotation – Same as hip OA – Limited hip IR related to FAI

• Hip Muscle Strength – Same as hip OA

Interventions • Patient Education and Counseling – FAI • Avoid activities that place hip where impingement can occur – end range hip flexion and IR

– Structural Instability • Avoid activities that place repetitive strain on hip especially forced extension and end range rotation

Intervention – Manual Therapy • Trial of manual therapy to restore limited passive hip rotation

Intervention - Stretching • Two patterns of asymmetrical hip rotation – Excessive hip ER with limited hip IR • Related to acetabular and femoral retroversion

– Excessive hip IR with limited hip ER

• Assess end-feel for boney block – Poor prognosis especially with very limited hip IR or ER (< 10°)

Intervention – Strengthening • Identify weakness of lower extremity and trunk through passive examination • Assess muscle strength especially of hip rotators – Those with excessive hip IR and decreased hip ER ROM will often exhibit weak hip IR – While those with ROM patttern of excessive hip ER and limited hip IR will often exhibit weak hip ER – Strengthen weak muscles within pain tolerance using progressive resistance program

Interventions Muscle Flexibility • Soft tissue restriction can be addressed through soft tissue mobilization and stretching • Don’t increase symptoms • Assess end-feel; stretch “muscular” end-feels while avoiding “hard” end-feels.

Interventions Cardiorespiratory • Those with non-arthritic hip pain may be deconditioned • Promote cardio-respiratory activities but limit stress on the hip within pain tolerance (avoid impact aerobic activity e.g. running, etc.)

Intervention Neuromuscular Reeducation • Proprioceptive/perturbation training may provide an effective intervention in nonarthritic hip pain • Dynamic stabilization may benefit those with labral tears • Little research performed here!