10/15/17. Acknowledgements. The Sporting Hip & Groin. TheSporting. SportingHip. The Sporting. The Sporting. The Sporting.

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Michael O Brien Physiotherapist Acknowledgements The TheSporting SportingHip Hip & Groin Impingement or instability? Andrew Wallis Alesha Coonan (Gledhill-Tunks) Melbourne Orthopaedic Group Mr.

2016 all rights reserved Please contact me if you would like copy of reference list or have questions Hip and groin pain is common in athletes, particularly in sports that involve high loads of

1 Michael O Brien Physiotherapist Acknowledgements The TheSporting SportingHip Hip & Groin Impingement or instability? Andrew Wallis Alesha Coonan (Gledhill-Tunks) Melbourne Orthopaedic Group Mr. Jit Balakumar Mr. Jon Bare The use of evidence based clinical reasoning in the assessment, diagnosis & management of pathology all rights reserved Please contact me if you would like copy of reference list or have questions Hip and groin pain is common in athletes, particularly in sports that involve high loads of running, direction change and kicking (Werner 2009, Holmich 2014, Walden Half of sub-elite male adult football players report pain in the hip and/or groin during a football season. (Thorborg, 2017) Certain sporting activities have been associated with a higher incidence of hip osteoarthritis (Vignon et al, 2006)) The clinic Michael O Brien info@thehipandgroinclinic.com 1

2 Where is this pain coming from? Past decade: increase awareness of subtle morphological abnormalities being potential pain sources and causes of OA Two main categories Femoroacetabular Impingement (FAI) Developmental Dysplasia of the Hip (DDH) / Instability Weir et al (2016) HIP PATHOLOGY Morphological abnormalities Chondropathy (birth to adolescent) Together with symptomatic presentation and clinical assessment, radiographic examination is an important component in diagnostic evaluation (Clohisy et al 2008) Labral pathology OA 2

3 HIP PATHOLOGY HIP PATHOLOGY FEMOROACETABULAR IMPINGEMENT (FAI) v DEVELOPMENTAL DYSPLASIA HIP (DDH) Potential for a mixed Impingement / Instability picture (Canham et al 2015) spectrum of symptoms from instability to impingement (Anderson et al 2011) Effectively Impingement v Instability Can be hard to differentiate ANATOMY ANATOMY 3

4 FUNCTIONAL IMPLICATIONS FEMOROACETABULAR IMPINGEMENT FEMOROACETABULAR IMPINGEMENT (FAI) 1. CAM 2. PINCER 3. MIXED 4. Dynamic overload (Dy et al 2012) FEMOROACETABULAR IMPINGEMENT Tannast et al

CAM Development CAM Development Cam deformity gradually acquired during skeletal maturation related to structural adaptation to shear stress (high impact

al 2011, ( Agricola et al 2012) Frank et al 2015, Nepple et al 2015) Appears to be a dose-response relationship (Tak et al 2015) No significant increase in

5 CAM Development CAM Development Cam deformity gradually acquired during skeletal maturation related to structural adaptation to shear stress (high impact sports) applied to the proximal femoral epiphysis Associated with adolescent male participation in intensive impact sports (Gosvig et al 2010, Siebenrock et al 2011, ( Agricola et al 2012) Frank et al 2015, Nepple et al 2015) Appears to be a dose-response relationship (Tak et al 2015) No significant increase in prevalence or severity of a Cam deformity after closure of the proximal femoral epiphysis (Agricola et al 2014b) CAM Development Agricola et al 2012 Roels et al

CAM Development CAM FAI Strongly associated with OA (Doherty et al 2008, Nicholls et al 2011, Age 12-14

et al 2013a) A larger α angle and hence more severe Cam lesion is associated with further increased risk of OA

increased risk of labral tear or acetabular / HOF chondral lesion (Nepple et al 2011) >78⁰ = Pathological CAM

6 CAM Development CAM FAI Strongly associated with OA (Doherty et al 2008, Nicholls et al 2011, Age acquired a flattening of the H-N Junction; age progression to a convexity (Agricola et al 2014b) Agricola et al 2013a) A larger α angle and hence more severe Cam lesion is associated with further increased risk of OA (Pollard et al 2010, Nicholls et al 2011, Agricola et al 2013a) Abnormal Alpha angle (>50⁰) associated with increased risk of labral tear or acetabular / HOF chondral lesion (Nepple et al 2011) >78⁰ = Pathological CAM HIP RADIOLOGY HIP RADIOLOGY α angle can be used with AP or lateral radiographs (Agricola et al 2014b) Agricola et al 2014a 6

7 CAM Morphology CAM Morphology Most individuals with radiographic evidence of a Cam lesion will not develop OA (Nicholls et al 2011, Agricola et al 2013a) Positive predictive value for development of OA range between 6-25% (Nicholls et al 2011, Agricola et al 2013a) addition of limited IR results in the PPV rising to over 50% (Agricola Other factors play a role in the development of OA (Agricola et al 2013b) et al 2013a) Overall prevalence of asymptomatic Cam deformity is 37% - 55% in the athletic population and 23% in the general population (Frank et al 2015) PINCER FAI PINCER FAI Pincer lesions present in 67% of asymptomatic hips Possibly due to : - relatively high prevalence of Pincer lesions in the general population that remain asymptomatic - heterogeneous definition of a Pincer deformity making quantification difficult (Agricola et al 2015) 50% in sporting population (Frank et al 2015) Radiographic findings consistent with Pincer impingement not associated with increased risk of labral tear or chondral lesion (Nepple et al 2011) At this stage there is no association with Pincer deformity and OA (Nicholls et al 2011, Agricola et al 2013b) 7

8 FEMOROACETABULAR IMPINGEMENT FEMOROACETABULAR IMPINGEMENT PRESENTATION OF FAI Diagnosis of FAI should be based on - symptoms / reduced function - clinical presentation consistent with FAI (Reiman and Thorborg 2014) Gradual onset Anterior hip pain may radiate laterally (trochanteric region) or medially (adductor region), and rarely in to the buttocks History of participation in work / sports requiring repetitive flexion +/- IR Agg s with flexion loading tasks Loss of lateral pelvic stability (LPS) and femoral rotational control (FRC) with single leg loading (Austin et al 2008, Kennedy et al 2009) FEMOROACETABULAR IMPINGEMENT Impaired muscle function in those with symptomatic FAI (Casartelli et al 2011, Casartelli et al 2014, Harris-Hayes et al 2014, Diamond et al 2015, Freke et al 2016) Symptomatic FAI doesn t seem to be associated with reduced hip ROM compared to controls (Freke et al 2016) Positive impingement testing HIP INSTABIILITY (Clohisy et al 2009a, Kappe et al 2012) 8

Atraumatic instability may be due to : - Bony

Connective tissue disorders (Ehlers-Danlos syndrome,

Down syndrome) - Ligamentous laxity - Iatrogenic

that stress the labrum and IFL resulting in increased

& Safran et al 2011) HIP RADIOLOGY Pain may arise

surface - ongoing instability overloads the dynamic

Lateral CEA of Wiberg - >40 over-coverage - Normal

9 Atraumatic instability may be due to : - Bony deficiency (DDH, acetabular retroversion, Perthes) - Connective tissue disorders (Ehlers-Danlos syndrome, arthrochalasis multiplex congenita, Marfan syndrome, Down syndrome) - Ligamentous laxity - Iatrogenic cause - Repetitive microtrauma associated with sports that stress the labrum and IFL resulting in increased HOF translation (Shindle et al 2006, Boykin 2011, Shu & Safran et al 2011) HIP RADIOLOGY Pain may arise from the capsule, synovium, labrum or chondral surface - ongoing instability overloads the dynamic stabilisers, such as Iliopsoas (Shindle et al 2006) Lateral CEA of Wiberg - >40 over-coverage - Normal 25-30⁰ - Possible dysplasia ⁰ - Definite dysplasia < 20⁰ Clohisy et al

posterior wall sign HIP RADIOLOGY Various other views and radiological markers / measures Important to be comprehensive In asymptomatic subjects the prevalence of

10 HIP RADIOLOGY HIP RADIOLOGY Acetabular retroversion FALSE PROFILE VIEW Anterior CEA of Lequesne <20 indication of structural instability >40 overcoverage A. ischial spine sign B. crossover sign C. posterior wall sign HIP RADIOLOGY Various other views and radiological markers / measures Important to be comprehensive In asymptomatic subjects the prevalence of DDH may be as high as 14% (Jacobsen and Sonne-Holme 2005, Gosvig et al 2010) Biomechanical faults with DDH are : 1. Poor coverage of the HOF 2. Relative lateralization of the hip centre of rotation 3. Smaller contact area between the dysplastic acetabulum and HOF and hence concentrated force 10

1 in 6 subjects with DDH may have acetabular retroversion (Li and Ganz 2003, Kohno et al 2015) DDH often accompanied by

structure : experiencing loads of up to 4 fold that of a normal hip, predominantly in the superior region (Henak et al 2014)

et al 2009, Nepple et al 2011, Nicholls et al 2011) Relationship of DDH to OA but development related more to the degree of

11 1 in 6 subjects with DDH may have acetabular retroversion (Li and Ganz 2003, Kohno et al 2015) DDH often accompanied by proximal femoral abnormality (Clohisy et al 2009b) In patients with DDH, the labrum plays a greater role as a load-bearing structure : experiencing loads of up to 4 fold that of a normal hip, predominantly in the superior region (Henak et al 2014) DDH is associated with labral pathology and to a lesser degree with chondropathy (Lane et al 2000, Lievense et al 2004, Jessel et al 2009, Nepple et al 2011, Nicholls et al 2011) Relationship of DDH to OA but development related more to the degree of subluxation rather than isolated X-Ray severity of DDH (Cooperman et al 1983, Murphy et al 1995, Jessel et al 2009, Harris-Hayes & Royer 2011) 11

Iliopsoas and the RF, whose reflected head inserts in to the anterior capsule, course anteriorly to the hip and provide dynamic stability in E PRESENTATION OF INSTABILITY Insidious onset of sharp or

12 Iliopsoas and the RF, whose reflected head inserts in to the anterior capsule, course anteriorly to the hip and provide dynamic stability in E PRESENTATION OF INSTABILITY Insidious onset of sharp or dull pain in the groin (+/buttock) > lateral hip > anterior thigh region (Nunley et al 2011) Common to describe hip impingement symptoms such as pain with flexion, prolonged sitting etc. Aggravated by extension loading (walking, running and standing) and to a lesser extent impact, pivoting and prolonged sitting (Shindle et al 2006, Shu & Safran 2011) Associated with mechanical symptoms of catching, clicking, popping or locking Often describe a feeling of instability as well as stiffness/tightness, weakness May display muscle fatigue / deactivation pattern Trendelenburg / Gluteus Medius gait Exhibit a form of sway posture Poor dynamic control of HOF during extension loading Loss of lateral pelvic stability and femoral rotational control with single leg loading Weakness on isolated testing of abductors and internal / external rotators (Harris-Hayes et al 2014) Positive apprehension testing Positive impingement testing Examination may include tests for generalized ligamentous laxity 12

FAI SURGERY SURGICAL MANAGEMENT FAI SURGERY FAI Surgery Labral refixation preferable to labral resection

evidence, massive increase in hip arthroscopy globally over past 10 15 years (Fairley, 2016) x4 in USA 2004

(Kemp et al, 2012) Less favourable outcome in presence of chondropathy or advance OA (Kemp et al, 2012,

13 FAI SURGERY SURGICAL MANAGEMENT FAI SURGERY FAI Surgery Labral refixation preferable to labral resection recover earlier with superior clinical and radiographic results (Espinosa et al 2006) Despite limited evidence, massive increase in hip arthroscopy globally over past years (Fairley, 2016) x4 in USA (Montogmery, 2013) x7 in England (Palmer 2016) Outcome findings are relatively short term (Kemp et al, 2012) Less favourable outcome in presence of chondropathy or advance OA (Kemp et al, 2012, 2014, 2015) the likelihood of progression to THA after arthroscopy is on average 2 years (Kemp et al 2015) Poor outcomes in DDH 13

PERIACETABULAR OSTEOTOMY PERIACETABULAR OSTEOTOMY

REHABILITATION HIP REHABILITATION TREATMENT MODEL

Strengthening Appropriate movement patterning Weight

pathology Reduce surrounding muscle hypertonicity

alignment Activation in well aligned and supported

14 PERIACETABULAR OSTEOTOMY PERIACETABULAR OSTEOTOMY Steppacher et al (2008) Beck and Ganz (2011) HIP REHABILITATION HIP REHABILITATION TREATMENT MODEL Education Activity modification Modified loading Strengthening Appropriate movement patterning Weight control TREATMENT Address / respect underlying pathology Reduce surrounding muscle hypertonicity Minimize aggravating activity Correct positional alignment Activation in well aligned and supported position Strengthening in appropriate functional positions Progress to high end function 14

STRENGTHENING Key take home points Postural correction of sway : bilateral unilateral Tx E stepping walking Emphasis on abductors & external rotators

technique & progression is fundamental Radiology plays large role Don t stretch/mobilise a morphologically restriction Avoid inappropriate hip scope

15 STRENGTHENING Key take home points Postural correction of sway : bilateral unilateral Tx E stepping walking Emphasis on abductors & external rotators Differentiate instability & impingement Important to consider all planes of movement & function Single plane then progress to multiplanar Good technique & progression is fundamental Radiology plays large role Don t stretch/mobilise a morphologically restriction Avoid inappropriate hip scope Early retraining of standing weight shift is crucial! Thank The clinic Michael O Brien info@thehipandgroinclinic.com 15

What is FAI? And Why are we getting Hip Problems?

What is FAI? And Why are we getting Hip Problems? Why is Hip pain so common NOW? Greater awareness More accurate imaging MRI Fashionable?? Geography Arthroscopy used to be OP now FAI! Why is Hip pain so