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Young Adult Hip Pathology and FAI: Physical Therapy Management for
Non-Operative and Post-Operative Patients
Jill Monson, PT, OCS
Monson Orthopaedic Consulting, LLC
BASICSCIENCE
My “A-Ha” Moment • Closely observing dynamic squatting in
patients with primary c/o knee pain
• Knee squatters
• Cued to sit into hip flexionàCOULD NOT
• Put them on plinth for ROM and “A-Ha”
• Have you ever had groin pain or clicking at your hip?
© Monson Orthopaedic Consulting, LLC 2012 3
Poor, Lost Souls
• Young adult hip patients – Saw an average of 4.2± 2.9 health care
providers before a definitive diagnosis was made
– Experienced symptoms for a mean of 3.1 years prior to obtaining a definitive diagnosis
• Clohisy JC. Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement. Clin Orthop Relat Res 2009.
© Monson Orthopaedic Consulting, LLC 2012 4
Anatomy Exploration • Bony Construct
• Articular Surface
• Hip Capsule/Ligaments
• Musculotendinous Structures
• Neurovascular Structures
© Monson Orthopaedic Consulting, LLC 2012 5
Bony Anatomy of the Hip: Normal • Acetabulum:
– Ilium – Ischium – Pubis
• Femur: – Femoral head
• Fovea Capitus – Femoral Neck – Greater Trochanter – Lesser Trochanter
© Monson Orthopaedic Consulting, LLC 2012 6
Anatomy: Acetabulum
• Develops as early as 8 wks of gestation
• Fully formed by 11 weeks gestation – Watanabe R. Clin Orthop 1974
• Acetabular formation in response to presence of contact w/femoral head
© Monson Orthopaedic Consulting, LLC 2012 7
Acetabulum
• Triradiate cartilage at the confluence of ilium, ischium, pubis – Fuses fully by 16-18 y/o (**May be late)
• Ponseti J. Bone Joint Surg Am 1978
• VascularSupplytoAcetabulum:– InternalIliaca.
© Monson Orthopaedic Consulting, LLC 2012 8
FemoralHead&Neck
• VascularSupplyFemoralHead– Medialfemoralcircumflex
© Monson Orthopaedic Consulting, LLC 2012 9
AvascularNecrosis(AVN)
• TraumaHcAVNviadislocaHons– Medialcircumflexarteryistorn
• Non-traumaHcAVNAssociaHons– ETOH– Steroiduse– Chemotherapy
© Monson Orthopaedic Consulting, LLC 2012 10
Fibrocartilage: Acetabular Labrum
• Consists of both fibrocartilage and dense connective tissue
– Peterson W. Arch Orthop Trauma Surg 2003
• Creates a circumferential seal around the hip joint
• Nerve endings indicate nociceptive and proprioceptive capabilities @ labrum
• Kim YT. Clinic Orthop 1995 © Monson Orthopaedic Consulting, LLC
2012 11
Thickest@anterosuperiorrim(greatestloadshere)
Acetabular Labrum Circumferential Seal of the Labrum
• Enhances joint stability through a suction effect and contributes to a fluid-enhanced force distribution
• Contributes to homeostasis at joint for lubrication, nutrition and load sharing with articular cartilage
© Monson Orthopaedic Consulting, LLC 2012 12
Labrum, Cont. • Blood supply via the obturator a., superior and inferior
gluteal aa., medial femoral circumflex a.
• Blood vessels only detected in the peripheral 1/3 of the labrum; internal portion avascular
– Peterson et al. immunostaining study; Arch Orthop Trauma Surg 2003
• Some capacity for labral healing has been observed in basic science and ovine experimental studies
– Seldes et al. Clin Orthop 2001 – Philippon Arthroscopy 2007 – Miozzari H Osteoarthritis and Cartilage 2004
© Monson Orthopaedic Consulting, LLC 2012 13
Capsular Anatomy
• Extends from acetabular rim to anterior intertrochanteric line at anterior aspect of proximal femur
© Monson Orthopaedic Consulting, LLC 2012 14
Capsular Anatomy: Ligamentous
3 Extra-articular ligaments
• All taut in extension • All lax in flexion
© Monson Orthopaedic Consulting, LLC 2012 15
Extra-capsular Ligaments • Iliofemoral (strongest, thickest)
– AIIS to anterior intertrochanteric line – Tight in ER and ADD
• Pubofemoral – Superior pubic ramus to inferior femoral neck – Tight in ER and ABD
• Ischiofemoral (weakest, thinnest) – Ischium to posterior inferior femoral neck – Tight in IR and ABD
© Monson Orthopaedic Consulting, LLC 2012 16
Extracapsular Ligaments
Anterior View Posterior View
© Monson Orthopaedic Consulting, LLC 2012 17
Intra-capsular: Ligamentum Teres
• Acetabular notch to fovus capitis (fovea) of femur – Tight in ADD, Flex, ER
© Monson Orthopaedic Consulting, LLC 2012 18
OtherLigamentousStructures• InguinalLigamant
© Monson Orthopaedic Consulting, LLC 2012 19
Bursae
• Trochanteric(“Gluteal”):– BetweentendonofG.Maxandgreatertrochanter
• Synoviallined,severallayersb/twtendonlayersofG.Med&Min
• Ischiogluteal:– UnderG.MaxjustposteriortoIschialTuberosity
• IliopecHneal:– BetweenPsoasMajortendonandIliopecHnealeminence
© Monson Orthopaedic Consulting, LLC 2012 20
Dermatomes
-HipJointisanL3structure
-Consider:Traveling/sweepingpain
vs.
Contained/localizedpain
© Monson Orthopaedic Consulting, LLC 2012 21
Hip Musculature • Tremendous functional cross-over at the hip
musculature
• Function contingent on: – Hip joint position – Trunk position – CKC/OKC function
• Tremendous interplay with proximal and distal segments – Pelvis, L-spine, Knee joint
© Monson Orthopaedic Consulting, LLC 2012 22
Musculature: Flexors • Psoas Major & Iliacus (Iliopsoas)
– Flex, ADD, ER
• Tensor Fascia Latae – Flex, ABD, IR
– Rectus Femoris
© Monson Orthopaedic Consulting, LLC 2012 23
Muscles:Extensors
• Gluteus Maximus – ABD, Ext, ER
• Hamstrings
Musculature: Abductors – Gluteus Maximus
• ABD, Ext, ER
– Gluteus Medius • Anterior Fibers
– ABD, Flex, IR • Posterior Fibers
– ABD, Ext, ER
– Gluteus Minimus • ABD, IR
– TFL • ABD, Flex, IR
© Monson Orthopaedic Consulting, LLC 2012 25
Musculature: Adductors – Adductor Magnus – Adductor Longus
• ADD, Flex, ER
– Adductor Brevis • ADD, Flex, ER
– Gracilis • ADD, Ext, IR
– Pectineus • ADD, Flex, ER
© Monson Orthopaedic Consulting, LLC 2012 26
Musculature
• Adductor Magnus – Pubic ramusàLinea Aspera
• Flex, ADD, ER
– Isch TubàADD tubercle • Ext, ADD, IR
Musculature: Deep External Rotators
• Obturator internus • Obturator externus • Superior gemellus • Inferior gemellus • Piriformis • Quadratus femoris
*All but Piriformis ADD hip *Think rotator cuff
© Monson Orthopaedic Consulting, LLC 2012 28
Musculature: Deep Internal Rotators
• Gluteus Medius – Anterior fibers
• Gluteus Minimus
© Monson Orthopaedic Consulting, LLC 2012 29
PalpaHon:AnteriorPelvis
• ASIS– TFLorigin– Sartoriusorigin– Inguinalligament
• AIIS– RectusFemorisorigin
*Note*
• RectusFemoris– AppreciatetheproximityofitsoriginattheAIIStotheanterosuperioraspectoftheacetabulum
PalpaHon:PosteriorPelvis
• Sacralborder– Gluteusmaximusorigin
• IliacWing– Gluteusmediusorigin– Gluteusminimusorigin
© Monson Orthopaedic Consulting, LLC 2012 32
GluteusMaximus• Origin
– Sacrum,dorsalsacroiliacligaments,smallareaofiliumnearPSIS,sacrotuberousligament
• InserHon– Upper½@lateralporHonofTFL,ITB– Lower½@dividedinserHonintoITBanddeeperfibersattheglutealtuberosity(lateralextensionoflineaaspera)
• BursabetweentendonandGT
© Monson Orthopaedic Consulting, LLC 2012 33
GluteusMedius
• Origin– Mostlyliesundertheglutmax,butanteriorfibersarenotcovered
– Upperlateralsurfaceoftheiliacwing(b/twA/Pgluteallines)&anteriorlyatthefascia
• InserHon– Greatertrochanter
© Monson Orthopaedic Consulting, LLC 2012 34
GluteusMinimus
• Origin– Lowerpartoflateralsurfaceofwingofilium(b/twanteriorandinferiorgluteallines)
• InserHon– GreaterTrochanter
© Monson Orthopaedic Consulting, LLC 2012 35
Piriformis
• Origin– Pelvicsurfaceofsacrum
• InserHon– InnersurfaceofupperpartofGT– FillsthesciaHcforamen
© Monson Orthopaedic Consulting, LLC 2012 36
PalpaHon:PosteriorPelvis
• IschialTuberosity– Semitendinosis
• Nearsacrotuberouslig.InserHon
– BicepsFemoris• Mostlateral
– AdductorMagnus• Mostmedial
PalpaHon:PubicRegion• PubicTubercle(anterosuperiorsurfaceofpubicbody)
– Rectusabdominus(Superiorly)– Inguinalligament(Laterally)– Adductorlongus(Inferiorly)
• SuperiorPubicRamus– PecHneus
• InferiorPubicRamus– Gracilis– AdductorMagnus(atbonysegwaytoischialramus)
© Monson Orthopaedic Consulting, LLC 2012 38
PalpaHon:ProximalFemur
• Greatertrochanter(superior&posterioraspect)– GluteusmediusinserHon– GluteusminimusinserHon
• Justanteriortomedius
• GlutealTubercle(justdistaltogreatertrochanter)– GluteusmaximusinserHon
PalpaHon:ProximalFemur
• Posteriortrochantericfacet– DeephiprotatorsinserHonpoint
• LesserTrochanter– Iliopsoas
LAB:Palpa*on
• ASIS– Resistedhipflexion+IR(TFL)
• AIIS– Resistedhipflexion(RectusFemoris)
• PubicBone– ResistedhipADD(ADDlongus,PecHneus,Gracilis)
• IschialTuberosity– Resistedkneeflexion(Hamstring)
• GreaterTrochanter– ResistedhipABD
• Proximal:Gluteusmedius• Distal:Gluteusmaximus
• IliacCrest– ResistedhipABD(Gluteusmedius,minimus)
© Monson Orthopaedic Consulting, LLC 2012 41
Biomechanics vs. Kinematics
• Biomechanics – “I see dead people”/anesthetized
• Biomechanical laboratory studies – Dissected cadaver Hips: Hemi-pelvis, transected femurs
• Kinematics – “I see living people”
• Motion analysis laboratory kinematic studies – Real, moving humans with completely intact proximal and
distal anatomy and active musculoskeletal interactions
© Monson Orthopaedic Consulting, LLC 2012 42
Surgery vs. Rehabilitation • What can a surgeon change with their tool
set? – Bony anatomy – Ligamentous, Fibrocartilage fixation
• What can a physical therapist change? – Dynamic muscular control
• Strength, proprioception – Static Tissue quality:
• Stretching, joint/soft tissue mobilizations
© Monson Orthopaedic Consulting, LLC 2012 43
In Vivo Hip Joint Force Measurements Bergmann G, Deuretzbacher G, Heller M, et al. Hip contact forces and gait patterns from routine activities.
Journal of Biomechanics 2001.
• Implanted pressure transducers with THA components
• All forces acting on the hip accounted for • Muscle tension • Ligamentous tension • WB load
© Monson Orthopaedic Consulting, LLC 2012 44
Bergmann Study, cont. • In vivo hip joint force measurements
– 300% BW with slow walking – 350-400% BW with quick walking – Up to 500% with jogging – 800% during “stumbling”
– 2 legged stance = 80-100% BW • Attributed to persistent muscle tension at hips
during FWB stance
© Monson Orthopaedic Consulting, LLC 2012 45
Gait Kinematics: Stance • Initial Contact
– 30 deg hip flexion • Loading Response
– 30 deg hip flexion – 5-10 deg ADD, IR
• Mid-stance – 0 deg flex/ext
• Terminal Stance – 10 deg hip extension – Neutral ABD/ADD
© Monson Orthopaedic Consulting, LLC 2012 46
Stance, Cont. • 3-D Musculoskeletal Models
– Hip joint contact forces directed anteriorly during the last 20-30% of stance
• Stansfield and Nicol. Clinical Biomechanics 2002
– Important consideration for: • Injury location at labrum • Observing and progressing gait with non-op
and post-op rehabilitation
© Monson Orthopaedic Consulting, LLC 2012 47
Gait Kinematics: Swing
• Initial Swing – 20 deg hip flexion
• Midswing: – 20-30 deg hip flexion – 5 deg ABD
• Terminal swing – 30 deg hip flexion
© Monson Orthopaedic Consulting, LLC 2012 48
Warning:
We are now leaving the world of normal hips
© Monson Orthopaedic Consulting, LLC 2012 49
FAI FAI = Femoral Acetabular Impingement
• First described by Ganz in 1995 (Bern, Switzerland)
• Not published/presented in English literature until 1999
Myers SR, Eijer H, Ganz R. Anterior femoracetabular impingement after periacetabular osteotomy. Clinical Orthopaedics and related research
1999.
© Monson Orthopaedic Consulting, LLC 2012 50
Femur: Cam Deformity
• Pathology at the femoral head and/or head-neck junction
– Asphericity of the femoral head
– Decreased femoral head-neck offset
© Monson Orthopaedic Consulting, LLC 2012 51
CamDeformity• RadiologicDefiniHon:
– Crosstablelateral&Frogleglateralradiographs• Alphaangle• >50.5degreesconsidered(+)forcamdeformity
– NotzliHPetal.JBJSBr2002
© Monson Orthopaedic Consulting, LLC 2012 52
Radiology:AlphaAngle
• Perfectcirclearoundfemoralhead
• Drawlinealongthecenteroffemoralneck
• Otherlineatthecenterofthefemoralhead– Compareanglegeneratedb/twthoselines
© Monson Orthopaedic Consulting, LLC 2012 53
CamDeformityImpingement
© Monson Orthopaedic Consulting, LLC 2012 54
Acetabulum: Pathoanatomy • Acetabulum:
– Pincer Impingement (3 types) • Focal anterior overcoverage
– Associated with normal superior and posterior acetabular coverage
• Relative anterior overcoverage – Acetabular retroversion (normal=20-40° anteversion) – Decreased posterior coverage
• Global acetabular overcoverage – Coxa profunda – Protusio acetabuli
» Larson, C Sport Med Arthrosc Rev 2010
© Monson Orthopaedic Consulting, LLC 2012 55
Pincer Deformity • Acetabular overcoverage
of the femoral head
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AcetabularPathology
• Profunda(Deep)– Baseofthenotchispasttheilioischialline– Headisseateddeepintheacetabulum/pelvis
• Protrusio(Deeper)– Femoralheadispasttheilioischialline– Morepronouncedovercoverage– DeeperseaHngoffemoralheadwithinthepelvis/acetabulum
© Monson Orthopaedic Consulting, LLC 2012 57
Radiology:LateralCenterEdgeAngle
PincerDeformityImpingement
© Monson Orthopaedic Consulting, LLC 2012 59
Other Bony Variables at the Femur • Anteversion:
– Rotation of the femoral neck relative to the shaft – Normal=10-15° anteversion – Abnormal is usually increased anteversion
(W-sitters) • Neumann DA. Mosby 2002
• Angle of Inclination: – Angle b/tw femoral neck and shaft of femur – Normal=125° – Dysfunction may be a higher or lower angle (Coxa Vara/Valga)
• Coleman SS. Mosby 1978
© Monson Orthopaedic Consulting, LLC 2012 60
OtherBonyHipPathology
• Slippedcapitalfemoralepiphysis
• AvascularNecrosis
• Legg-Calve-Perthesdisease
• “Dysplasia”
© Monson Orthopaedic Consulting, LLC 2012 61
FAI
• Most commonly presents as combined bony pathologies at both the femur and acetabulum
• Beck M et al. JBJS Br 2005 • Allen D et al. JBJS Br 2009
© Monson Orthopaedic Consulting, LLC 2012 62
Male:Female
• “Pure”camdeformitymorecommonlyobservedinmales
• “Pure”pincerdeformitymorecommonlyobservedinfemales
– BeckM,KalhorM,LeunigM,GanzR.JBJSBr2005
© Monson Orthopaedic Consulting, LLC 2012 63
EHology:CamDeformity
• Sub-clinicalslippedcapitalfemoralepiphysis(SCFE)
• FraitzlCRetal.JBJSBr2007• GoodmanDAetal.JBJSAm1997
• Growthabnormalityattheepiphysis
• SiebenrockKAetal.ClinOrthopRelatRes2004
© Monson Orthopaedic Consulting, LLC 2012 64
CamDeformity:Healthy,AsymptomaHcPopulaHon
Cam-TypeFAIbonyalignmentobservedinINDIVIDUALSWITHOUTHIPPAIN
• CopenhagenOsteoarthriHsStudy(N=3,202)– Cam-typeFAIresentin17%ofasymptomaHcmen– Cam-typeFAIpresentin4%ofasymptomaHcwomen
• GosvigKKetal.ActaRadiol2008
• HackKetal.JBJSAm2010(N=200)– Presentin25%ofasymptomaHcmen
• OfthepopulaHonfoundw/CamtypeFAI,79%weremale– Presentin5%asymptomaHcwomen
• Laborieetal.,Radiology2011(N=2081)– PrevalenceofCam-typemorphologyinhealthypopulaHon– 35%ofMales,10%ofFemales
© Monson Orthopaedic Consulting, LLC 2012 65
CamDeformity• Elitemaleandfemale
soccerplayers(N=95)– 67%prevalenceofFAI– Cam-typeFAI:68%Males,
50%Females– Meanalphaangle
Males=66°,Females=53°• Gerhardtetal.,AJSM2012
• Higherprevalence(89%)inbasketballplayersw/historyofhighintensityplayduringadolescence
• SibenrockKAetal.ClinOrthopRelatRes2011
© Monson Orthopaedic Consulting, LLC 2012 66
CamDeformity• Malecollegiatefootballplayers
(N=67)– 95%FAI– >70%cam-typeFAI
• Petersetal,JBJSAm2011
• NFLprospects(NFLCombine)(N=239)– 90%radiographicFAI– 75%Cam-typeFAI
• Larsonetal.,(SubmiOedArthroscopy2012)
“FuncHonalHipImpingement”??
© Monson Orthopaedic Consulting, LLC 2012 68
EHology:PincerDeformity
• Pincerdeformitytheories– Retrotorsionofthehemipelvis– Congenital/developmental
• Hipdysplasia– Congenital– Males4.3%– Females3.6%
• (CopenhagenCohort)Gosvigetal.,JBJSAm2010
© Monson Orthopaedic Consulting, LLC 2012 69
PincerDeformity• Leunigetal.,CORR2009
– CohortofOAptswithprotrusio(globalovercoverage)
– 87%(27/31pts)ofprotrusioptswerefemale
• CopenhagenCohort(N=3620)
– Coxaprofunda&protrusio• 19.4%ofFemales• 15.2%ofMales
– Globalovercoverage=riskfactorforthedevelopmentofOA
– Gosvigetal.,JBJSAm2010
DevelopmentalHipDysplasia• Morecommoninfemales:
– 78childrenwithDDH• 17.9%Males&82.1%Females
– Milasinovicetal.,ActaChirTraumatolCech2011
– 3613randomlyselectednewborns(USeval)• HigherproporHonofgirlsvsboyshadimmaturehips,minordysplasia(4.5%vs1.0%),&majordysplasia(1.2%vs0.2%)
– Rosendahletal.,PediatrRadiol1996
– 8145infants(clinicalexaminaHon)• FemalegendersignificantriskfactorforDDH
– Stein-ZamirCetal.,PediatrInt2008
OAProgressionData
• Caucasions/EuropeanDescent
• Males>Females(slight)
• Obesityassociatedw/fasterprogressionofOAratherthanonset
• CibulkaMRetal.JOSPT2009
© Monson Orthopaedic Consulting, LLC 2012 72
ClinicalCriteriaforOADiagnosis
• HipIR<15degreesalongwith:– Hipflex≤115deg– Age>50y/o
OR• HipIR≥15degalongwith:
– Painw/hipIR– DuraHonofmorningsHffnessofhip≤60min– Age>50y/o
– AmericanCollegeofRheumatology– CibulkaMRetal.JOSPT2009
© Monson Orthopaedic Consulting, LLC 2012 73
OAProgression
• AcetabularlabralpathologysecondarytoFAIisaprecursortoearlyonsethipOA
• BeaulePEetal.JOrthopRes2005• BeckMetal.JBJSBr2005• KimKCetal.ClinOrthopRelatRes2007• McCarthyJetal.ClinOrthopRelatRes2003• McCarthyJCetal.ClinOrthopRelatRes2001• MurphySetal.ClinOrthopRelatRes2004• PfirrmanCWetal.Radiology2006• TanzerM,NoiseuxN.ClinOrthopRelatRes2004• TonnisD,HeineckeA.JBJSAm1999
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Synovial/CapsularCondiHons
• Osteochondromatosis
• PigmentedvillonodularsynoviHs
• SynoviHs
• CapsularInstability
© Monson Orthopaedic Consulting, LLC 2012 75
Capsular Pathology
• Atraumatic Capsular Laxity
– Global • Connective tissue disorders
– Focal Rotational • Results from excessive, forceful hip external
rotation • Can lead to iliofemoral ligament insufficiency • Can contribute to increased stress at the labrum
– Philippon MJ. Clin Sports Med 2001
© Monson Orthopaedic Consulting, LLC 2012 76
LabralPathology
• MostcommonbonyabnormaliHesassociatedw/labralpathology:– Acetabularretroversion
– Decreasedfemoralhead-neckoffset(Cam)
– CoxaValga • Wegneretal.ClinOrthopRelatRes2004
© Monson Orthopaedic Consulting, LLC 2012 77
Labral Tears
• Anterior Tears – More common in US and European countries
– May be due to poorer vascular supply at anterior labrum
• McCarthy et al. Clin Orthop 2001
– This region has the least bony constraint of femoral head anteriorly
• Rely on labrum, capsule and ligaments for stability
© Monson Orthopaedic Consulting, LLC 2012 78
LabralTears
• Posterior Tears
– More common in Japan
– Different lifestyle: more squatting, floor sitting
• Hase T. Arthroscopy 1999
Articular Surface Pathology
• Labrum – Tearing – Detachment – Cystic changes
• Articular Cartilage – Localized lesions: Gr I-IV – Delamination
© Monson Orthopaedic Consulting, LLC 2012 80
Chondral Pathology
• 73% of patients with labral pathology have chondral damage
– McCarthy et al. Clin Orthop Relat Res 2001
• Presence of chondral lesions of the femur or acetabulum is associated with poorer prognosis following hip scope
– Byrd JW. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy. 2000
© Monson Orthopaedic Consulting, LLC 2012 81
Soft Tissue Pathoanatomy • Tendinopathy
• Snapping Hip Syndrome Iliopectineal Eminence
Head of femur © Monson Orthopaedic Consulting, LLC
2012 82
ClinicalImaging
• RadiologyGoldStandards– A/PPelvis(standardized)– Falseprofileview
• Standingoblique• Showsanteriorcoverageofacetabulum
– Crosstablelateral– Frogleglateral
© Monson Orthopaedic Consulting, LLC 2012 83
ClinicalImaging
• MRIGoldStandards– Arthrogramw/gatolinium
– Highquality3TMRI