Young Adult Hip Pathology and FAI: Physical Therapy Management for Non-Operative and Post-Operative Patients

Jill Monson, PT, OCS

Monson Orthopaedic Consulting, LLC

BASIC SCIENCE 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?

• 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.

• Bony Construct

• Articular Surface

• Hip Capsule/Ligaments

• Musculotendinous Structures

• Neurovascular Structures

• Femur: – Femoral head • Fovea Capitus – Femoral Neck – Greater Trochanter – Lesser Trochanter

• 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

• 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

• Vascular Supply to Acetabulum: – Internal Iliac a.

• Vascular Supply Femoral Head – Medial femoral circumﬂex

• Traumac AVN via dislocaons – Medial circumﬂex artery is torn

• Non-traumac AVN Associaons – ETOH – Steroid use – Chemotherapy

• Consists of both Thickest @ anterosuperior rim fibrocartilage and dense (greatest loads here) 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

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

• 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

• Extends from acetabular rim to anterior intertrochanteric line at anterior aspect of proximal femur

3 Extra-articular ligaments

• All taut in extension • All lax in flexion

• 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

Anterior View Posterior View

• Acetabular notch to fovus capitis (fovea) of femur – Tight in ADD, Flex, ER

• Inguinal Ligamant

• Trochanteric (“Gluteal”): – Between tendon of G. Max and greater trochanter • Synovial lined, several layers b/tw tendon layers of G. Med & Min

• Ischiogluteal: – Under G. Max just posterior to Ischial Tuberosity

• Iliopecneal: – Between Psoas Major tendon and Iliopecneal eminence

-Hip Joint is an L3 structure

-Consider: Traveling/sweeping pain vs. Contained/localized pain

• Function contingent on: – Hip joint position – Trunk position – CKC/OKC function

• Tremendous interplay with proximal and distal segments – Pelvis, L-spine, Knee joint

• Psoas Major & Iliacus (Iliopsoas) – Flex, ADD, ER

• Tensor Fascia Latae – Flex, ABD, IR

– Rectus Femoris

• 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

– Adductor Magnus – Adductor Longus • ADD, Flex, ER – Adductor Brevis • ADD, Flex, ER – Gracilis • ADD, Ext, IR – Pectineus • ADD, Flex, ER

• 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

• Gluteus Medius – Anterior fibers

• Gluteus Minimus

• ASIS – TFL origin – Sartorius origin – Inguinal ligament

• AIIS – Rectus Femoris origin

*Note*

• Rectus Femoris – Appreciate the proximity of its origin at the AIIS to the anterosuperior aspect of the acetabulum Palpaon: Posterior Pelvis

• Sacral border – Gluteus maximus origin

• Iliac Wing – Gluteus medius origin – Gluteus minimus origin

• Inseron – Upper ½ @ lateral poron of TFL, ITB – Lower ½ @ divided inseron into ITB and deeper ﬁbers at the gluteal tuberosity (lateral extension of linea aspera) • Bursa between tendon and GT

• Origin – Mostly lies under the glut max, but anterior ﬁbers are not covered – Upper lateral surface of the iliac wing (b/tw A/P gluteal lines) & anteriorly at the fascia

• Inseron – Greater trochanter

• Origin – Lower part of lateral surface of wing of ilium (b/tw anterior and inferior gluteal lines)

• Inseron – Greater Trochanter

• Origin – Pelvic surface of sacrum

• Inseron – Inner surface of upper part of GT – Fills the sciac foramen

• Ischial Tuberosity – Semitendinosis • Near sacrotuberous lig. Inseron

– Biceps Femoris • Most lateral

– Adductor Magnus • Most medial Palpaon: Pubic Region

• Pubic Tubercle (anterosuperior surface of pubic body) – Rectus abdominus (Superiorly) – Inguinal ligament (Laterally) – Adductor longus (Inferiorly)

• Superior Pubic Ramus – Pecneus

• Inferior Pubic Ramus – Gracilis – Adductor Magnus (at bony segway to ischial ramus)

• Greater trochanter (superior & posterior aspect) – Gluteus medius inseron – Gluteus minimus inseron • Just anterior to medius

• Gluteal Tubercle (just distal to greater trochanter) – Gluteus maximus inseron Palpaon: Proximal Femur

• Posterior trochanteric facet – Deep hip rotators inseron point

• Lesser Trochanter – Iliopsoas LAB: Palpaon

• ASIS • Ischial Tuberosity – Resisted hip flexion + IR – Resisted knee flexion (TFL) (Hamstring) • AIIS • Greater Trochanter – Resisted hip flexion – Resisted hip ABD (Rectus Femoris) • Proximal:Gluteus medius • Pubic Bone • Distal: Gluteus maximus – Resisted hip ADD (ADD • Iliac Crest longus, Pecneus, – Resisted hip ABD Gracilis) (Gluteus medius, minimus)

• 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

• What can a physical therapist change? – Dynamic muscular control • Strength, proprioception – Static Tissue quality: • Stretching, joint/soft tissue mobilizations

© Monson Orthopaedic Consulting, LLC 43 2012 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 44 2012 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 45 2012 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

– 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

• Initial Swing – 20 deg hip flexion

• Midswing: – 20-30 deg hip flexion – 5 deg ABD

• Terminal swing – 30 deg hip flexion

We are now leaving the world of normal hips

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.

• Pathology at the femoral head and/or head-neck junction

– Asphericity of the femoral head

– Decreased femoral head-neck offset

© Monson Orthopaedic Consulting, LLC 51 2012 Cam Deformity • Radiologic Deﬁnion: – Cross table lateral & Frog leg lateral radiographs • Alpha angle • >50.5 degrees considered (+) for cam deformity – Notzli HP et al. JBJS Br 2002

• Perfect circle around femoral head • Draw line along the center of femoral neck • Other line at the center of the femoral head – Compare angle generated b/tw those lines

© Monson Orthopaedic Consulting, LLC 54 2012 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

• Profunda (Deep) – Base of the notch is past the ilioischial line – Head is seated deep in the acetabulum/pelvis • Protrusio (Deeper) – Femoral head is past the ilioischial line – More pronounced overcoverage – Deeper seang of femoral head within the pelvis/ acetabulum

© Monson Orthopaedic Consulting, LLC 59 2012 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

• Slipped capital femoral epiphysis

• Avascular Necrosis

• Legg-Calve-Perthes disease

• “Dysplasia”

• 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

• “Pure” cam deformity more commonly observed in males

• “Pure” pincer deformity more commonly observed in females

– Beck M, Kalhor M, Leunig M, Ganz R. JBJS Br 2005

• Sub-clinical slipped capital femoral epiphysis (SCFE) • Fraitzl CR et al. JBJS Br 2007 • Goodman DA et al. JBJS Am 1997

• Growth abnormality at the epiphysis • Siebenrock KA et al. Clin Orthop Relat Res 2004

• Copenhagen Osteoarthris Study (N=3,202) – Cam-type FAI resent in 17% of asymptomac men – Cam-type FAI present in 4% of asymptomac women • Gosvig KK et al. Acta Radiol 2008

• Hack K et al. JBJS Am 2010 (N=200) – Present in 25% of asymptomac men • Of the populaon found w/Cam type FAI, 79% were male – Present in 5% asymptomac women

• Laborie et al., Radiology 2011 (N=2081) – Prevalence of Cam-type morphology in healthy populaon – 35% of Males, 10% of Females

• Elite male and female soccer players (N=95) – 67% prevalence of FAI – Cam-type FAI: 68% Males, 50% Females – Mean alpha angle Males = 66° , Females = 53° • Gerhardt et al., AJSM 2012

• Higher prevalence (89%) in basketball players w/history of high intensity play during adolescence • Sibenrock KA et al. Clin Orthop Relat Res 2011

• Male collegiate football players (N= 67) – 95% FAI – > 70% cam-type FAI • Peters et al, JBJS Am 2011

• NFL prospects (NFL Combine) (N=239) – 90% radiographic FAI – 75% Cam-type FAI • Larson et al., (Submied Arthroscopy 2012) “Funconal Hip Impingement”??

• Pincer deformity theories – Retrotorsion of the hemipelvis – Congenital/developmental

• Hip dysplasia – Congenital – Males 4.3% – Females 3.6% • (Copenhagen Cohort) Gosvig et al., JBJS Am 2010

• Leunig et al., CORR 2009

– Cohort of OA pts with protrusio (global overcoverage)

– 87% (27/31 pts) of protrusio pts were female

• Copenhagen Cohort (N=3620)

– Coxa profunda & protrusio • 19.4% of Females • 15.2% of Males

– Global overcoverage = risk factor for the development of OA – Gosvig et al., JBJS Am 2010 Developmental Hip Dysplasia

• More common in females:

– 78 children with DDH • 17.9% Males & 82.1% Females – Milasinovic et al., Acta Chir Traumatol Cech 2011

– 3613 randomly selected newborns (US eval) • Higher proporon of girls vs boys had immature hips, minor dysplasia (4.5% vs 1.0%), & major dysplasia (1.2% vs 0.2%) – Rosendahl et al., Pediatr Radiol 1996

– 8145 infants (clinical examinaon) • Female gender signiﬁcant risk factor for DDH – Stein-Zamir C et al., Pediatr Int 2008 OA Progression Data

• Caucasions/European Descent

• Males>Females (slight)

• Obesity associated w/faster progression of OA rather than onset

• Cibulka MR et al. JOSPT 2009

• Hip IR <15 degrees along with: – Hip ﬂex ≤115 deg – Age >50 y/o OR • Hip IR ≥15 deg along with: – Pain w/hip IR – Duraon of morning sﬀness of hip ≤60 min – Age >50 y/o – American College of Rheumatology – Cibulka MR et al. JOSPT 2009

• Acetabular labral pathology secondary to FAI is a precursor to early onset hip OA • Beaule PE et al. J Orthop Res 2005 • Beck M et al. JBJS Br 2005 • Kim KC et al. Clin Orthop Relat Res 2007 • McCarthy J et al. Clin Orthop Relat Res 2003 • McCarthy JC et al. Clin Orthop Relat Res 2001 • Murphy S et al. Clin Orthop Relat Res 2004 • Pﬁrrman CW et al. Radiology 2006 • Tanzer M, Noiseux N. Clin Orthop Relat Res 2004 • Tonnis D, Heinecke A. JBJS Am 1999

• Osteochondromatosis

• Pigmented villonodular synovis

• Synovis

• Capsular Instability

• 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

• Most common bony abnormalies associated w/labral pathology: – Acetabular retroversion

– Decreased femoral head-neck oﬀset (Cam)

– Coxa Valga • Wegner et al. Clin Orthop Relat Res 2004

• 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

• 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

• 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

• Tendinopathy Iliopectineal Eminence • Snapping Hip Syndrome

• Radiology Gold Standards – A/P Pelvis (standardized) – False proﬁle view • Standing oblique • Shows anterior coverage of acetabulum – Cross table lateral – Frog leg lateral

• MRI Gold Standards – Arthrogram w/ gatolinium – High quality 3T MRI