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NONARTHRITIC HIP PAIN Causes or Effects Trends in Intervention How PT Impacts EMG Evidence and Biomechanics of Primary Hip Stabilizers
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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
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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
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Causes or Effects of Nonarthritic Hip Pain • Structural – Femoroacetabular Impingement (FAI)
• Morphology – Cam, Pincer Lesions
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“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
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“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.
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“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
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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.”
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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)
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“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.
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“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.
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“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.
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“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.
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“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.
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“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.
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Common Non-Weightbearing Exercises
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Common Weightbearing Exercises
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“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.
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Common Functional Exercises
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“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
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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).
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“An evidence-based review of hip-focused neuromuscular exercise interventions to address dynamic lower extremity valgus. ” 2015
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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