Non-arthritic anterior hip pain in the younger patient: examination and intervention strategies Melodie Kondratek, PT, DScPT, OMPT Bryan Kuhlman, PT, DPT, OMPT Oakland University Orthopedic Spine and Sports Therapy-Auburn Hills Objectives At the completion of this course the participant will be able to: 1. List the pathologies that may produce anterior hip pain. 2. Identify pathological findings in the diagnostic images (MRI, 3D CT, radiographs) of select patient cases. 3. Identify/list interview questions that may be included in the history for an individual with the chief complaint of anterior hip pain. 4. Identify red flags that indicate the need for referral back to the physician 5. List and describe symptom localization strategies that may be used to determine if symptoms are coming from an extra- or intra-articular source. 6. Explain the rationale for each impairment-based test demonstrated and interpret the findings. 7. Based upon an analysis of the history and clinical exam for select cases, identify the key impairments that likely contribute to the functional limitations reported by the patient. 8. Compare and contrast the difference between hip dysplasia and hip hypomobility due to soft tissue, muscle and joint pathologies that may lead to anterior hip pain. Introduction Anterior hip pain Population focus: 2 nd through 4 th decades (teens through 30s) Non-arthritic anterior hip pain This group fits 2 general categories of symptoms: Hip hypomobility Hip hypermobility
Symptoms may be caused by both intra and extra-articular sources, both directly and indirectly Incidence of individual pathologies varies Common complaints Characteristics of pain: Anatomy Time dependent: Mechanism: prolonged sitting, standing, and/or walking; sleep may be interrupted Quality: often described as achy Intensity: often increases as time in the position increases Onset: time to onset often reduces over a period of time (weeks, months or years) Movement dependent: Bony and soft tissue structures Pathology Mechanism: specific hip positions and/or movement patterns Quality: often sharper or more sudden onset in nature Intensity: relatively consistent for the provoking position or movement Onset: with time, the individual becomes more keenly aware of the verge of pain. Femoroacetabular Impingement (FAI) vs Hip Dysplasia Definition: specific structural or morphology irregularities that cause a change to the osseous configuration with combined cartilage damage and possible labral tears. Potential causes: anterior hip pain Irregularities of morphology: Cam and pincer lesions Acetabular version: retroversion/anterversion
Labral tear Acetabular depth and shape Femoral neck-shaft angle: coxa vara/valga Femoral shaft torsions Anterior and/or medial soft tissue irritation Capsular restriction Nerve root irritation (L1-5) Cam and pincer lesions Pincer Impingement Cam Impingement Alpha angle 76 Degrees and 57 Degrees examples Acetbular version: retroversion Retroversion -11 Degrees Acetabular rim coverage Lateral center - edge angle Angle of inclination Represents the superior weight-bearing surface of the acetabulum Measured by Tönnis angle: formed between a horizontal line and a tangential line extending from the medial edge to the lateral edge of the acetabular sourcil Acetabular depth Acetabular dysplasia: shallow, abnormally shaped or improperly oriented acetabulum Femoral neck-shaft angle: coxa vara/valga Coxa valga: view of a patient with a valgus alignment at neck-shaft angle that exceeds 125. Increased portion of the femoral head that is uncovered Angle of torsion- femoral version
Hip acetabulum & labrum Labral tear Labral tear in the coronal view Labral repair Pre-Op and Post-Op examples Soft tissue irritation: etiology Anterior soft tissue: lliopsoas tendonopathy of the tendon over head of the femur, lesser trochanter or iliopectineal eminence Iliofemoral ligament over head of femur Abnormal muscle recruitment patterns: Secondary movers assuming primary role Over use of secondary movers may result in tendinopathy Swelling and tendinopathy Swelling Tendinopathy Axial view of psoas tendon Capsular restrictions Anterior capsule/iliofemoral ligament thickness History: interview questions Questions: past and present When did the symptoms begin? Who has helped you manage the situation up to this point? Do medications help? Is sleep affected? What is their occupation?
What type of leisure activities are they currently involved in? Symptom investigation Location (s) of symptoms Intensity of symptoms in each location Quality of symptoms in each location Provoking factors for each location/type/quality of pain Alleviating factors for each location/type/quality of pain Symptom localization Symptom localization: definition A structured framework for investigating the relationship between symptom complaints and the mechanism behind the provoking movement patterns and/or positions. Contributes to building support for the PT-diagnoses. For the purpose of identifying the: body region, joint and/or soft tissue structures, And/or spinal segments that generate the symptoms Symptom localization: methods Examination of these impairments looks at the quality of tissues, such as muscle fiber length, nerve irritation, or joint mobility. The structures could include muscle, tendon, ligament, cartilage, joint capsular tissue, neural (nerve) and/or soft tissue. Methods Used Straight-lined (translatoric) forces as compression, traction and/or gliding Soft tissue lengthening by movement of adjacent structures to increase or decrease stress on specific tissues based on the function with or without palpation Soft tissue contraction with or without palpation Test structures that cross multiple regions eg: peripheral nerves
Symptom localization: guidelines Use movement patterns that replicate the functional impairment Interpretation the examination tests help to identify sources of pain that are significant to the patient s symptoms Systematically use both provocation (to increase) and alleviation (to reduce or eliminate) signs and symptoms Symptom localization: sequence Patient identifies the point in which the movement or contraction is painful or intensifies Provocation: 1. Painful function is reproduced to confirm pain 2. Then released to just out of symptoms called to verge of pain (VOP) 3. The therapist provides a movement or force that further stresses a specific region, segment or tissue Alleviation: 1. Painful function is reproduced to just into symptoms called the point of pain (POP) 2. The therapist provides or takes away a force that further alleviates the stress on a specific region, segment or tissue Investigation of symptoms: Hip structural localization Superior joint surface: traction - compression Specific anterior FAI pain with Passive Flexion. Flexion hip until reach the POP Then examiner performs caudal traction of the superior surface of the coxofemoral joint Medial joint surface: traction - compression Specific anterior/medial pain with Flexion/IR Passively Flexion and IR as necessary Until reach the POP Then examiner performs lateral traction of the medial surface of the coxofemoral joint
Iliopsoas: bowstring Palpate location of pain Press into the area of pain to VOP Passively bring the patient into extension and IR into POP Release pressure Adductors: bowstring Palpate location of pain Press into the area of pain to VOP Passively bring the patient into abduction into POP Release pressure Examining for Dural / Neural Irritability & Mobility There are several neurodynamic tests which can be performed when examining the lumbar spine. These include the slump test, straight leg raising test, prone knee bending test (a.k.a. femoral nerve test), and their variations. These tests check the dynamics of the nervous system assessing both the mobility and sensitivity of the nervous tissues. Investigation of impairments: Motion examination Pelvic-hip complex: PROM Internal and External Rotation Cardinal and Combined Planes Hip joint play Directions of testing: Longitudinal traction Medial/Lateral Anterior/Posterior
Suggestions to maximize information gained from testing: Appreciate both the quantity and the quality of displacement Appreciate the tension of the region by palpating specific structures Use pads of fingers for specific hand contact Use the whole hand for general hand contact Superior hip joint surface: translatoric joint play Coxofemoral Traction and Compression joint play with concomitant Provocation and Alleviation of the superior inert tissue in resting and more closed packed Medial hip joint surface: translatoric joint play Coxofemoral traction of the medial joint inert tissue Medial with concomitant Provocation and Alleviation of the medial inert tissue in resting and more closed packed Anterior/posterior hip joint surfaces: translatoric joint play Coxofemoral Anterior and Posterior glide joint play in resting and more closed packed Rationale for testing Investigation of impairments: Muscle palpation Hip region External obliques General soft tissue mobility Quadratis lamborum Rectus abdominals Transverse abdominals Internal obliques Psoas major Iliacus Iliopsoas tendon Adductors Intervention
Intervention Functional Massage Specific muscle training Muscle stretching Joint mobilization Functional movement based patterns FM iliacus FM adductors FM Psoas FM adductors FM Gluteus Medius Muscle lengthening iliopsoas and stretching anterior capsule Specific muscle training considerations Frontal Plane Sagittal Plane Transverse Plane Functional movement based patterns Case examples Case example #1 Case example #2 Case example #3 Case example #4 Referral back to physician Summary / conclusion Questions