Objectives. Objectives 9/26/2017. Evaluation and Rehab Management of the Patient with Hip Pain

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1 Evaluation and Rehab Management of the Patient with Hip Pain Joe Tupta, PT, OCS WPTA Fall Conference October 13 th, 2017 Objectives Screen the hip and adjacent regions for dysfunction that might be amenable to rehab management Be familiar with manual therapy techniques and exercise for the hip, lumbar spine, and pelvis that can positively impact functional outcomes in patients with non-arthritic hip pain Objectives Discuss and interpret hip joint radiographic assessment and use it to understand primary and secondary pain generators to help guide interventions and clinical decision making. 1

Intra-articular Acetabular labral tear Chondral injury FAI

of equipment with content mysterious to the user Of which there are

referral Sacroiliac/symphysis referral greater trochanteric pain

2 Intra-articular Acetabular labral tear Chondral injury FAI (femoroacetabu lar impingement) Extra-Articular Any complex piece of equipment with content mysterious to the user Of which there are many Musculotendinous hip, abdomen, pelvic floor Lumbar spine referral Sacroiliac/symphysis referral greater trochanteric pain syndrome Athletic pubalgia Bursitis Impingement: subspine, troch/pelvic, ischiofemoral 2

Summary of Practice Guidelines Consider osseous abnormalities and patient s activities as risk factors for hip pathology Intra-articular hip pain associated with: groin or generalized hip pain,

3 Summary of Practice Guidelines Consider osseous abnormalities and patient s activities as risk factors for hip pathology Intra-articular hip pain associated with: groin or generalized hip pain, +FABER, +FADIR, mechanical symptoms (clicking, popping), feelings of instability, +MR arthogram findings Joint mobilization when hard endfeel not present (flexion and IR restriction, abduction restrictions to be paid particular attention) Muscle strengthening to focus on gluteals and hip rotators Focus on neuromuscular re-ed and proproprioceptive training in presence of labral tears because the available evidence examining nonsurgical management of individuals with nonarthritic hip pain is limited, all of the interventions discussed in these guidelines are based on expert opinion 2 Group out of the UK put together a nonoperative protocol to be used in an RCT looking at hip arthroscopy personalized hip therapy : detailed assessment, education/advice, pain relief, and individualized exercise program 3

4 4

5 Lumbar Spine Exam AROM with overpressure Quadrant test Repeated motions Provocation testing Special tests Motor performance AROM; look at excursion and quality, is it painful? Flexion, but also extension, sidebending and rotation 5

6 6

7 Repeated motions Sets of 5-10 centralize/peripheralize Lumbar Repeated Motions Standing flexion sideglide extension Lumbar Repeated motions Prone Prone on elbows Prone press up Prone press up in sideglide 7

8 Try flexion if extension or sidebending doesn t work Segmental Mobility Assessment, pain provocation Unilateral or central Pain present/absent Kappa ( ) 8

Prone Instability Test Good to excellent

as shown or just actively as a quick screen

DF Straight Leg Raise Good reliability for

9 Prone Instability Test Good to excellent reliability Use this in conjunction with other instability findings: aberrant movement findings Slump Test Can do passive as shown or just actively as a quick screen Slouch, neck flexion, knee extension, ankle DF Straight Leg Raise Good reliability for identifying whether abnormal neurodynamics might be contributing 9

10 Assessing Muscle Performance, test ratios Back extensor tests (prone bridge, supine bridge) Lateral musculature tests (side plank or side bridge) Flexion endurance test (sustained seated flexion) Flexion/extension< 1 Lateral/extension <.75 Lateral tests symmetric (<.05) Assessing Muscle Performance ADIM in quadruped, 10 seconds ADIM in prone, 10 seconds ADIM with heel slide ADIM= abdominal drawing in maneuver Hip focused exam Hip PROM Hip special tests Palpatory findings strength testing 10

Hip PROM Flexion, usually 110-120 Abduction, 40 Internal rotation and external rotation at 90 hip flexion, 20-30 vs 40 Internal external rotation in neutral Prone extension Prone

Excessive hip IR/decreased hip ER: femoral anteversion Excessive hip ER/decreased hip IR: femoral retroversion Marked decrease in hip IR and flexion: FAI Excessive hip ROM: hip

11 Hip PROM Flexion, usually Abduction, 40 Internal rotation and external rotation at 90 hip flexion, vs 40 Internal external rotation in neutral Prone extension Prone internal and external rotation Pearls related to Hip ROM Pain in hip flexion, straight sagittal: subspine impingement PROM hip flexion produces hip ER: +Drehmann sign=fai Excessive hip IR/decreased hip ER: femoral anteversion Excessive hip ER/decreased hip IR: femoral retroversion Marked decrease in hip IR and flexion: FAI Excessive hip ROM: hip dysplasia Global decrease in hip ROM: DJD Hip Flexion If pain is anterior, may be getting some pinching of hip flexors, anterior labrum or anterior capsule + sub-spine impingement sign 11

12 Stinchfield Test resisted SLR at 45 + test indicates AIIS pathology: impingement vs tendinopathy FADIR test Considered an anterior impingement test Flexion, adduction, IR Axial compression (scour) FABER Flexion, abduction and external rotation 12

Superolateral or lateral FAI SI pain Iliopsoas

against femoral head Ischiotrochanteric impingement

excessive shearing of peritrochanteric soft tissues

tendinopathy and microtearing of gluteal tendons.

13 Superolateral or lateral FAI SI pain Iliopsoas pathology,ant capsule irritation or psoas impingement against femoral head Ischiotrochanteric impingement Greater Trochanteric Pain Syndrome 13 Described as excessive shearing of peritrochanteric soft tissues that leads to a continuum of bursitis up to DJD, with tendinopathy and microtearing of gluteal tendons. Hip Abduction Consider lateral rim impingement if pinching pain is present 13

14 Extension maneuvers (tested in supine) extension/hip ER, posterior hip pain: posterior impingement. Anterior hip pain= instability Posterior pain= Posterior impingement Ichiofemoral Impingement Tests 14 Long stride walking test Pain lateral to ischial tuberosity with long stride, alleviated with short stride. 14

Ichiofemoral Impingement Tests 14 Ichiofemoral Impingement (IFI) test Passive

Log-roll test (passive supine rotation test) Supine, roll leg Not much stress

(Dynamic Internal Rotatory Impingement Test) Unaffected leg in flexion beyond

15 Ichiofemoral Impingement Tests 14 Ichiofemoral Impingement (IFI) test Passive hip extension painful with hip neutral/adducted, alleviated with abduction Log-roll test (passive supine rotation test) Supine, roll leg Not much stress on joint If painful, strong indicator of intraarticular pathology DIRI (Dynamic Internal Rotatory Impingement Test) Unaffected leg in flexion beyond 90 Affected leg to 90, then passively taken through a wide arc of adduction and IR 15

test- IT band Thomas test- hip flexor tightness Resisted sit up- r/o hernia Assess hip rotator strength in multiple

16 DEXRIT (Dynamic EXternal Rotatory Impingement Test) Unaffected leg in flexion beyond 90 Affected leg to 90, then passively taken through a wide arc of abduction and ER Other Special Tests Hip distraction relieves pain: intra-articular source Ober test- IT band Thomas test- hip flexor tightness Resisted sit up- r/o hernia Assess hip rotator strength in multiple positions Neutral, shortened, lengthened ER and IR Per Cibulka et al 7 ER/ir, cam/pincer/retroversion IR/er, femoral anteversion 16

17 Assessing Glut Max Strength Palpate the gluteus maximus and hamstring for firing sequence Max is often inhibited Abductor/adductor strength Watch for substitution patterns Preferred Imaging Studies AP pelvis Dunn lateral False profile 17

The AP Pelvis Center Edge Angle Tonnis angle Cross-over sign Alpha angle

40+, pincer FAI Alpha angle Attempt the quantify how non lightbulb-like the

between center of femoral neck and where the contour of the femoral neck

18 The AP Pelvis Center Edge Angle Tonnis angle Cross-over sign Alpha angle Center edge angle <20, dysplasia 20-25, borderline dysplasia 25-39, normal 40+, pincer FAI Alpha angle Attempt the quantify how non lightbulb-like the morphology of the femoral head and neck is </= 55 normal >55 is cam Angle between center of femoral neck and where the contour of the femoral neck exceeds the radius of the femoral head Can look at this on both the AP and Dunn Lateral views 18

19 Tonnis Angle Measures WB surface of acetabulum, Also called the sourcil Normal is is dysplasia Indicates retroversion of acetabulum Crossover sign Dunn Lateral: hip at 45 and/or 90, abduct to 20, tibia parallel to Side of Table (no IR/ER) 19

20 False profile Shape of AIIS Anterior CEA False profile, anterior center edge angle SI provocation Testing Distraction Compression (sidelying) Thigh thrust Gaenslen s Sacral thrust (prone) Most of these are done in supine 20

Gaenslen s Test The pelvis is stressed with a torsion force by a superior/posterior force applied

towards the floor, transversely across the pelvis, compressing the SIJs.

21 Gaenslen s Test The pelvis is stressed with a torsion force by a superior/posterior force applied to the left knee and a posteriorly directed force applied to the right knee. This should be repeated on both sides. +if pain provoked Compression Test Vertically directed force applied to the iliac crest directed towards the floor, transversely across the pelvis, compressing the SIJs. + if pain provoked Sacral Thrust Test Vertically directed force applied to sacral midline at the apex of the curve of the sacrum, directed anteriorly, producing a shearing force at the SIJs. + if pain produced 21

Distraction Test Vertically oriented pressure applied to ASIS on both sides simultaneously and directed posteriorly. This distracts the SI joint.

+ if pain provoked Validity of Pain Provocation SI tests 3 or more positive tests, and pain that does not centralize with lumbar ROM Specificity of

22 Distraction Test Vertically oriented pressure applied to ASIS on both sides simultaneously and directed posteriorly. This distracts the SI joint. + if pain provoked Thigh thrust test One hand under the sacrum, then apply a vertically oriented force through the femur, directed posteriorly. + if pain provoked Validity of Pain Provocation SI tests 3 or more positive tests, and pain that does not centralize with lumbar ROM Specificity of 87% Sensitivity of 91% Can be considered a CPR that identifies a subgroup of patients that most likely has SI pain. from Laslett et al, reference 5 and 6 22

Mobility Stability Radiating/referred pain Stability Neuromuscular reeducation/alignment

sagittal Isometric Push one hip into flexion, pull the other in extension 5 sec hold, switch side to side

IS mobilization in Transverse plane Top picture, push medially on patient with body while they hold

23 Mobility Stability Radiating/referred pain Stability Neuromuscular reeducation/alignment Overcoverage/impingement undercoverage/instability Mobility vs strength proprioception IS mobilization - sagittal Isometric Push one hip into flexion, pull the other in extension 5 sec hold, switch side to side a couple of times. IS mobilization in Transverse plane Top picture, push medially on patient with body while they hold against you, stabilize with opposite hand on pelvis. Bottom picture, move hip into more flexion and adduction, pull the patient s hip into extension and ask them to resist. Again, stabilize with opposite hand on pelvis. 23

Sacral mobilization in transverse plane Uppermost hip flexed to 90,

Have patient push hip back into your hand, activating multifidus.

24 Sacral mobilization in transverse plane Uppermost hip flexed to 90, trunk moderately rotated. Have patient push hip back into your hand, activating multifidus. Then switch hand position to top leg, patient resists, activating piriformis. Sacral mobilization in sagittal plane Mobilize sacral base and sacral apex, pushing it into flexion/nutation and then into extension/ counternutation Pelvic Stability:Pelvic Force Closure 24

25 Pelvic Stability Work Lumbar stabilization work Hip rotational strengthening 25

26 Gluteal strength work Selkowitz et al, JOSPT, 2013 Therapeutic goal? Maximize gluteal activity/minimize hip flexor? Gluteal Strength work Target glut medius more than gluteus maximus? Target gluteus maximus more than medius? DiStefano et al, JOSPT 2009 Prone gluteal activation Pinch cheeks, straighten knee, point toe and hold. 26

27 Strengthening the psoas Mobility Muscle performance and stability Neuromuscular control 27

28 Hip mobilizations Hip mobilizations Hip flexion 28

29 Mobility exercises Mobility Exercise Mobility Exercise 29

stabilization, acceleration, deceleration, and kinesthesia that progress

30 Neuromuscular Re-Ed movement training progression that facilitates the development of multijoint neuromuscular engrams that combine joint stabilization, acceleration, deceleration, and kinesthesia that progress from low intensity movements focused in a single plane to multiplanar training Hewett et al 11 30

References 1. Malloy et al. Rehabilitation after hip arthroscopy. A movement controlbased perspective. Clin Sports Med 2016. 35;503-521. 2. Enseki et al.

31 References 1. Malloy et al. Rehabilitation after hip arthroscopy. A movement controlbased perspective. Clin Sports Med ; Enseki et al. Nonarthritic hip joint pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association. JOSPT (6); A1-A Prather H and Cheng A. Diagnosis and treatment of hip girdle pain in the athlete. PM R ; S45-S Wall et al. Personalised hip therapy: Development of a non-operative protocol to treat femoroacetabular impingement syndrome in the FASHIoN randomized controlled trial. Br J Sport Med ; Laslett M, Aprill CN, Young SB, McDonald B. Diagnosing painful SI joints: A validity study of a McKenzie Evaluation and sacroiliac joint provocation tests. Aust J Physiotherapy. 2003; 49:89-97 References 6. Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. Journal of Manual and Manipulative Therapy. 2008;16(3): Cibulka MT et al. Symmetrical and asymmetrical hip rotation and its relationship to hip muscle rotator strength. Clin Biomech 2010; 25: Distefano et al. Gluteal muscle activation during common therapeutic exercise. JOSPT 2009; 39(7): Selkowitz et al. Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. JOSPT 20013; 43(2): Kim and Azuma. The nerve endings of the acetabular labrum. Clin Ortho Rel Res 1995: Hewett et al. Strategies for enhancing proprioception and neuromuscular control of the knee. Clin Ortho Rel Res 2002: Jackson R. The Pelvis and Sacroiliac joint: physical therapy management using current evidence. APTA Orthopedic Section/Current Concepts. 4 th ed

32 References 13. Klauser AS et al.greater trochanteric pain syndrome. Semin Musculoskeletal Radiol 2013;17: Gomez-Hoyos et al. Tests for ischiofemoral impingement in patients with posterior hip pain and endoscopically confirmed diagnosis. Arthroscopy 2016;32(7): Poultsides LA, Bedi A, Kelly BT. An algorithm approach to mechanical hip pain. HSSJ 2012; 8:

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