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Hip pain: A comparison of Osteoarthritis and Femoroacetabular Impingement
Kristine Flais, PT, DPT
Prevalence of Hip OA
• Most common
cause of hip pain
in older adults
Risk Factors
• Age
• Gender
• Race
• Developmental disorders
• Genetics
• Occupation
• Sports exposure
• Previous injury
• Body mass index
• Leg length discrepancy
Pathoanatomical
Features of OA
• Entire joint structure is affected:
• Joint capsule shortening thickening& lengthening
• Osteophytes/spur development
• Sclerosis of subchondral bone
• Muscle weakness
Imaging Findings
• Joint space narrowing
• Osteophytes/spurs
• Subchondral sclerosis
Clinical prediction rule
for OA
• 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
Patient Profile
• 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
Examination
• 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
• Assess hip strength
• SLR x 4
• Hip IR/ER MMT
Examination
• Trendelenburg sign/
lurch
• https://www.youtube.c
om/watch?v=IuEeKzqs
fmk&feature=player_d
etailpage
Examination
• Patrick’s test
• + if reproduces pt’s sx
• https://www.youtube.c
om/watch?v=wPZboW
KG7lc&feature=player
_detailpage
Examination
• Scour test
• + scour test with
adduction causes
lateral hip or groin pain
• https://www.youtube.c
om/watch?v=WOB2es
GaPLM&feature=play
er_detailpage
Prognosis
• OA progresses slowly
with THR/THA the
primary clinical
endpoint
• Dependent upon the
severity and
progression of OA
Interventions
• Patient Education
• Gait & Balance training
• Manual treatment
• Hip joint mobilizations
• Caudal glide with hip
flexion
• Lateral glide with IR
• FABER mob
• Long Axis Distraction
Caudal glide with hip FL
FABER mobilization Long-axis distraction
Lateral glide w/hip IR
Hip mobilizations
Interventions
• Exercise
• Stretching techniques
of shortened muscles
• Aerobic conditioning
• Strengthening
• hip abductors
Single Knee to chest –self
mobilization technique
Femoroacetabular
Impingement
• Abnormal contact
between the femoral
head/neck and the
acetabular margin
Categories of
Impingement
Pincer impingement:
• Acetabular
abnormalities
Cam impingement:
• Femoral head/neck
abnormalities
Combination:
• Most common
Risk Factors
• Genetics
• Sex
• Pincer lesions
• 30-40 y/o active women
• Cam impingement
• 20-30 y/o athletic men
• Sports
• Hockey players –Goalies
• Butterfly style
Radiographic Findings
Pincer Impingement:
• Increase acetabular
depth
• Coxa Profunda
• Acetabular Protrusion
• Decreased acetabular
depth
• Acetabular retroversion
Radiographic Findings
Cam Impingement:
• Increased femoral neck
diameter
• Increased thickness of
femoral head-neck
junction
Patient Profile
• Patient profile: • Healthy active 25-50 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
Examination:
Posture
• Swayback posture
• Lengthened external
oblique & iliopsoas
• Shortened rectus femoris
and tensor fascia latae
• Disuse atrophy
• Gluteal musculature:
Examination:
ROM
• Limited hip flexion,
IR, &/or adduction
compared to opposite
side
• Insufficient posterior
glide/joint play during
hip flexion
Examination:
Muscle Length/Strength
• MMT:
• Iliopsoas, Gluteus
medius, Gluteus
maximus, Hamstrings,
TFL
• Commonly iliopsoas
long & weak
• TFL short
• Glut max short & weak
Examination: Special
Tests
• FADIR impingement test:
• Hip & knee flexion 90º combine with hip adduction and IR • + sign sudden, sharp pain
which replicates sx
• https://www.youtube.com/watch?feature=player_detailpage&v=ZdE_0VNPjkw
Examination:
Special Tests
• Thomas test
• https://www.youtube.c
om/watch?v=NbRXi-
nZVJs
• Ober’s test
• https://www.youtube.c
om/watch?v=3iZ57sm
17-M
Examination:
Movement analysis
• Forward Bending
• Single leg stance
• Single leg step down
• SLR –hip extension
• Quadruped rock back
• Gait Analysis
• Walking & running
Clinical Course
• FAI is proposed to
contribute to OA
• Surgical management
• Arthroscopic procedures
• Labral tear resection or
repair
Interventions
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
Conservation Treatment
Goals
• 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
Final Comparison
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
• 25-50 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)
Questions?
References
• 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. 2011.
• 3.Dooley, P. Femoroacetabular impingement syndrome. Canadian Family Physician. 2008;54:42-47.
• 4.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; 2:174-181.
• 6.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): 542-550.
• 7.Tibor L, Sekiya J. Differential Diagnosis of Pain Around the Hip Joint. Arthroscopy:The Journal of Arthroscopic and related Surgery. 2008; 24(12):1407-1421.
• 8. MedBridge Education: Hip Osteoarthritis: An Evidence-Based Approach Ben Hando, PT, DSc, FAAOMPT