NONARTHRITIC HIP PAIN Causes or Effects Trends in Intervention How PT Impacts EMG Evidence and Biomechanics of Primary Hip Stabilizers

Causes or Effects of Nonarthritic Hip Pain • Structural – Femoroacetabular Impingement (FAI)

•  Morphology – Cam, undercoverage; Pincer, overcoverage

•  Instability – Extraphysiologic Motion •  Traumatic, Atruamatic •  Labral Tears •  Ligamentous laxity •  Undercoverage •  Muscle weakness

• Other Considerations: •  Femoral Version, Ligamentum Teres, Chondral Lesions, Loose

Bodies, Activity/Participation, CT Disorders •  Dysfunction from the hip causing impairments up or down the chain

(ex. ACL, PFPS, LBP) or visa versa

Review of 2014 CPG Key Points • Recommendations based on expert opinion:

•  Interventions of non-surgical management •  Education •  MT •  Exercise •  Neuromuscular Re-Ed

•  Risk Factors – Not clearly understood, exception of trauma •  Differential Diagnosis – Use clinical findings and imaging

• Recommendations based on weak evidence: •  Diagnosis/ Classification

• Recommendations based on strong evidence: •  Outcome Measures – HOS, HAGOS, iHOT-33

Causes or Effects of Nonarthritic Hip Pain • Structural – Femoroacetabular Impingement (FAI)

•  Morphology – Cam, Pincer Lesions

“Prevalence of Abnormal Hip Findings in Asymptomatic Participants” 2012 • Purpose: To assess asymptomatic cohort to determine

the prevalence of hip lesions • Asymptomatic volunteers had > 50% chance of labral

tear • Study also showed an association between cam

impingement and labral/chondral lesions. •  Unclear when and why this conflict causes symptoms

“FAI Surgery is on the Rise – But what is the next step?” 2016

Strong opinions by Reiman, et al in JOSPT and British Journal of Medicine

• Challenges accepting surgery as the automatic gold standard treatment for FAI and accepting morphology as pathology.

• Calls to reform the surgical decision-making process: • Bolster basic science studies examining FAI.

“Nonoperative Treatment for Femoroacetabular Impingement: A Systematic Review of the Literature” 2013

• Only 5 articles summarized experiments that evaluated nonoperative treatment

•  3 reported favorable outcomes

• Nearly half of 53 articles promoted PT as a treatment, (23)

• Suggests surgery is associated with early relief of pain and improved function •  Improvement in hip function

was noted in all studies • The role of nonsurgical management has not been defined.

“Surgical Treatment for Femoroacetabular Impingement: A Systematic Review of the Literature” 2010

Where surgical vs nonsurgical systematic review recommendations come together?

Nonsurgical

•  “Nonoperative treatment regimens, particularly physical therapy, need to be evaluated more extensively and rigorously, preferably against operative care, to determine the true clinical effectiveness.”

Surgical

•  “Most importantly, future clinical trials are needed to determine the relative efficacy of nonsurgical and surgical treatment.

• Predictors of treatment outcome and the efficacy of various surgical techniques need to be established in well-designed clinical trials.”

Implications for PT intervention first •  Studies have suggested that the abnormal movement at the hip

joint occurring secondary to femoral acetabular impingement may lead to labral lesions and cartilage damage (Enseki, et al 2014)

•  Altered gait patterns lead to subconsciously adopted impingement and pain avoidance behavior (Briton, et al, 2013)

•  Femoral head-neck malformations in FAI may be developmental in response to repetitive stress… from aggressive sport activity during skeletal growth (Clohisey, et al)

•  A slight change in muscle length (ex TFL vs Psoas) or limited joint play (< posterior glide) will alter the normal joint motion pathway (Sahrmann, 2002)

“Kinematic and kinetic differences during walking in patients with and without symptomatic femoroacetabular impingement” June 2013 • Compared spatiotemporal, kinematic, and kinetic

variables in symptomatic FAI to p! free control group.

•  FAI group: Exhibited less max hip extension, adduction, & internal rotation during stance; As well as less flexion and external rotation moments.

• Recommendation: Focused neuromuscular reconditioning across all movement directions.

“Conservative management of femoroacetabular impingement (FAI) in the long distance runner” 2014

• Purpose: Discuss conservative treatment approach to be attempted prior to surgical management.

• Concepts: Treatment should attempt to restore function in all three planes of movement given the importance of three-dimensional control of the hip with running

• Primary Goals of conservative management: •  Improve posterior glide of femur; •  Strengthen hip musculature in open and closed chain and •  Correct faulty movement patterns.

“Conservative management…” 2014 Increase Femoral Posterior Glide

Ex. Supine PL hip mob

Standing posterior-lateral hip self-mobilization.

Quadruped rock back with belt lateral distraction.

“Conservative management…” 2014 Increase Strength OKC CKC & Correct Movement Patterns • Gluteus medius and maximus strengthening should begin

in non-weight-bearing positions, focusing on form and endurance of the muscle.

• Should be able to elicit contraction of the deep lumbopelvic stabilizers when performing open-chain hip exercises. •  Examples: prone hip extension with knee flexion, prone hip lateral

rotation, and sidelying hip abduction with lateral rotation.

“Conservative management…” 2014 Increase Strength OKC CKC & Correct Movement Patterns • Neuromuscular re-education of the lumbar and pelvic

stabilizers is a foundation of treatment for most runners.

• Closed chain exercises are clinically appropriate for the running athlete. •  Lunge exercise provides high level gluteus medius and gluteus

maximus muscle activation •  Other examples: standing hip hikes, single-leg squats, and the

forward step-up

• Plyometric exercises may be indicated, if tolerated, to improve propulsion power and speed.

“An evidence-based review of hip-focused neuromuscular exercise interventions to address dynamic lower extremity valgus. ” 2015

•  The purpose of the review was to identify and discuss hip-focused exercise interventions that aim to address dynamic lower extremity valgus.

• Examined recruitment of Gmed and Gmax during: • Common non-weightbearing exercises • Common weigthbearing exercises • Common functional exercises

• Recommendation: Developing evidence to support progression of exercises with varying bases of support, sports-related tasks with external load, and resisted bands.

Common Non-Weightbearing Exercises

Common Weightbearing Exercises

“Progressive hip rehabilitation: the effects of resistance band placement on gluteal activation during two common exercises.” 2012 •  The aim of this study was to compare gluteal muscle

activity across four squatting exercises commonly prescribed to rehabilitate and prevent knee injuries.

Common Functional Exercises

“Progressive hip rehabilitation: the effects of resistance band placement on gluteal activation during two common exercises.” 2012 • Objective: To examine the effects of altering

resistance band placement during 'Monster Walks' and 'Sumo Walks.’

• Distal band placements offered a significantly higher activation level of gluteal muscles, when compared to the proximal conditions

•  The foot condition created an external rotation moment • Also, facilitated a stiffened and neutral spine as measured

by secondary joint angle analysis

Plyometric Exercises •  Glute Med:

• Highest during single-limb sagittal plane hurdle hops double-limb sagittal plane hurdle hops and split squat jumps

•  Lesser activation during non-sagittal plane double-limb landings in the frontal and transverse planes. (40-47%)

•  Glute Max: • Highly activated during

double-limb and single-limb sagittal plane landings

•  Less active in other planes (<40% MVIC).

“An evidence-based review of hip-focused neuromuscular exercise interventions to address dynamic lower extremity valgus. ” 2015

Wouldn’t it be nice? Examples. • A protocol for study design…

• Efficacy of a physiotherapy rehabilitation program for individuals undergoing arthroscopic management of femoroacetabular impingement – the FAIR trial: a randomised controlled trial protocol

• Two-year outcomes after arthroscopic surgery compared to physical therapy for femoracetabular impingement: A protocol for a randomized clinical trial

• Movement-Pattern Training to Improve Function in People With Chronic Hip Joint Pain: A Feasibility Randomized Clinical Trial