Hip pain: A comparison of Osteoarthritis and Femoroacetabular Impingement Kristine Flais, PT, DPT

Transcription

1 Hip pain: A comparison of Osteoarthritis and Femoroacetabular Impingement Kristine Flais, PT, DPT

2 Most common cause of hip pain in older adults Prevalence of Hip OA

3 Age Gender Race Developmental disorders Genetics Occupation Sports exposure Previous injury Body mass index Leg length discrepancy Risk Factors

4 Entire joint structure is affected: Joint capsule shortening thickening& lengthening Osteophytes/spur development Sclerosis of subchondral bone Muscle weakness Pathoanatomical Features of OA

5 Joint space narrowing Osteophytes/spurs Subchondral sclerosis Imaging Findings

6 4 out of the 5 indicates a strong prediction of OA + LR 24.3: Probability of OA 91% Squatting increased symptoms Lateral hip pain with active hip FLEX Scour test with ADD causes lateral hip/groin pain Pain with active hip EXT PROM IR < to 25º Clinical prediction rule for OA

7 Patient profile: Greater than 60 y/o Pain description, location, behavior: Morning stiffness hip & groin Improves in less than an hour Lateral hip pain hip flexion weight bearing Posterior hip pain with squatting Aggravating factors: Walking Standing Squatting Stairs Kneeling Patient Profile

8 Assess hip ROM and joint mobility Limited passive hip joint motion in at least 3 of 6 motions Hip flexion < 115 Hip IR < 25º Examination

9 Assess hip strength SLR x 4 Hip IR/ER MMT Examination

10 Trendelenburg sign/ lurch om/watch?v=iueekzqs fmk&feature=player_d etailpage Examination

11 Patrick s test + if reproduces pt s sx om/watch?v=wpzbow KG7lc&feature=player _detailpage Examination

12 Scour test + scour test with adduction causes lateral hip or groin pain om/watch?v=wob2es GaPLM&feature=play er_detailpage Examination

13 OA progresses slowly with THR/THA the primary clinical endpoint Dependent upon the severity and progression of OA Prognosis

14 Patient Education Gait & Balance training Manual treatment Hip joint mobilizations Caudal glide with hip flexion Lateral glide with IR FABER mob Long Axis Distraction Interventions

15 Caudal glide with hip FL Lateral glide w/hip IR FABER mobilization Long-axis distraction Hip mobilizations

16 Exercise Stretching techniques of shortened muscles Aerobic conditioning Strengthening hip abductors Interventions

17 Single Knee to chest self mobilization technique

18 Abnormal contact between the femoral head/neck and the acetabular margin Femoroacetabular Impingement

19 Pincer impingement: Acetabular abnormalities Cam impingement: Femoral head/neck abnormalities Combination: Most common Categories of Impingement

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21 Genetics Sex Pincer lesions y/o active women Cam impingement y/o athletic men Sports Hockey players Goalies Butterfly style Risk Factors

22 Pincer Impingement: Increase acetabular depth Coxa Profunda Acetabular Protrusion Decreased acetabular depth Acetabular retroversion Radiographic Findings

23 Cam Impingement: Increased femoral neck diameter Increased thickness of femoral head-neck junction Radiographic Findings

24 Patient profile: Healthy active y/o Involved in athletics Pain description, location, behavior: Anterior groin pain Sharp, catching, pinching C sign Aggravating factors: Running Excessive hip flexion Worst after/with sitting Squatting Twisting maneuvers Recumbent bike Patient Profile

25 Swayback posture Lengthened external oblique & iliopsoas Shortened rectus femoris and tensor fascia latae Disuse atrophy Gluteal musculature: Examination: Posture

26 Limited hip flexion, IR, &/or adduction compared to opposite side Insufficient posterior glide/joint play during hip flexion Examination: ROM

27 MMT: Iliopsoas, Gluteus medius, Gluteus maximus, Hamstrings, TFL Commonly iliopsoas long & weak TFL short Glut max short & weak Examination: Muscle Length/Strength

28 FADIR impingement test: Hip & knee flexion 90º combine with hip adduction and IR + sign sudden, sharp pain which replicates sx m/watch?feature=player_ detailpage&v=zde_0vn Pjkw Examination: Special Tests

29 Thomas test om/watch?v=nbrxinzvjs Ober s test om/watch?v=3iz57sm 17-M Examination: Special Tests

30 Forward Bending Single leg stance Single leg step down SLR hip extension Quadruped rock back Gait Analysis Walking & running Examination: Movement analysis

31 FAI is proposed to contribute to OA Surgical management Arthroscopic procedures Labral tear resection or repair Clinical Course

32 Physical Therapy Manual therapy Stretching Strengthening Neuromuscular Re-ed Activity modification: Avoid activities that place the hip joint in positions that create impingement End range flexion, internal rotation, and adduction Interventions

33 Improve ROM Hip mobs Strengthen hip musculature Prone hip extension with knee flexion Side-lying hip lateral rotation Side -lying hip abduction with ER Ckc: lunges, standing hip hikes, single leg squats, forward step ups Correct faulty movement patterns Increasing step rate Decreased hip extension at terminal Use softer surfaces Avoid treadmill or narrow trail Dynamic warm-up Do NOT run consecutive days for 1st month Cross train Conservation Treatment Goals

34 Hip OA Greater than 60 y/o Morning stiffness hip & groin Lateral hip pain with WB and/or hip flexion (Trendelenburg gait) Squatting increased symptoms Lateral hip pain with active hip FLEX Scour test with ADD causes lateral hip/groin pain Pain with active hip EXT PROM IR < or = to 25º FAI y/o Involved in athletics Anterior groin pain Sharp, catching, pinching No lateral thigh pain Worst after/with sitting Pinching Limited hip flexion, IR &/or adduction compared to opposite side +Impingement test (FADIR) Final Comparison

35 Questions?

36 1.Cibulka M, White D, Woehrle J, Harris-Hayes M, Enseki K, Fagerson T. Hip Pain and Mobility Deficits- Hip Osteoarthritis: Clinical Guidelines Linked to the International classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association. J Ortho Sports Phys Ther. 2009;A1-A25. 2.Cleland J, Koppenhaver S. Netter s Orthopaedic Clinical Examination:An Evidence- Based Approach. 2nd Edition. Elsevier, Inc Dooley, P. Femoroacetabular impingement syndrome. Canadian Family Physician. 2008;54: Enseki K, Harris-Hayes M, White D, Cibulka M, Woehrle J, Fagerson T. Nonarthritic Hip Joint:Clinical Guidelines Linked to the International classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association. J Ortho Sports Phys Ther. 2014;A1- A32. 5.Maslowski E, Sullivan W, Harwood J, Gonzalez P, Kaufman M, Vidal A. The Diagnostic Validity of Hi Provocation Maneuvers to Detect Intra-Articular Hip Pathology. PM R. 2010; 2: Sutlive T, Lopez H, Schnitker D, Yawn S, Halle R, Mansfield L. Development of a Clinical Prediction Rule for Diagnosing Hip Osteoarthritis in Individuals with Unilateral Hip Pain. J Ortho Sports Phys Ther. 2008; 38(9): Tibor L, Sekiya J. Differential Diagnosis of Pain Around the Hip Joint. Arthroscopy:The Journal of Arthroscopic and related Surgery. 2008; 24(12): MedBridge Education: Hip Osteoarthritis: An Evidence-Based Approach Ben Hando, PT, DSc, FAAOMPT References