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