Hip To The Literature
The British Journal of Sports Medicine recently released an excellent issue with some great insight on current concepts regarding femoral acetabular impingement (FAI). Of note, is the open access consensus statement regarding current best practice in regards to diagnostics and treatment and the promotion of individualized care for individuals with FAI syndrome.
Yes, the consensus’ addition of the word syndrome to FAI is important, as we have learned that there is more to this topic than just hip joint morphology. Symptoms of hip pain, clinical signs of decreased range of motion, painful hip flexion-adduction-internal rotation (FADIR/Impingement Test), hip strength and motor impairments combined with diagnostic injections and pathoanatomical findings via diagnostic imaging are required to make the correct diagnosis. This is the easy part.
The expert panel recommended that the patient should then be exposed to all treatment options and requires individualized care. The literature offers us no clear path on choosing that course of care. The debate of conservative or surgical care remains challenging. With physiotherapy-led rehabilitation, the goal is to regain hip strength, stability, and motor control while improving (and protecting) appropriate mobility and movement impairments. The surgical goal is eliminate a potential pain generator and restore impingement-free motion. Then the individual will undergo a course of rehabilitation, tackling the same goals previously mentioned. Ultimately, all paths eventually lead to physical therapy.
The FaSHioN randomized controlled trial (Wall) offers suggestions on current best practice of a conservative course of care. Of importance for success includes proper patient subgroup selection and intervention selection. Freke’s review of symptomatic FAI revealed consistent impairments of hip mobility, hip strength, motor control, and single leg deficits. It makes sense that that the FaSHioN group attempts to take on these functional limitations. However, what those terms mean to each physical therapist is different, and falls in line with a lack of consistency of care in the literature. (All Open Access! Go Read Now!)
When clinically reasoning through these cases, it makes sense to be careful about pushing mobility, considering morphological blocks and irritants. Without irritating the key lesion, assessing and treating lumbopelvic and soft tissue mobility, along with pragmatic inferior and posterior glides of the hip joint, may create increased pain-free mobility and movement. This serves as a gateway to the desired avenue of exercise. Loudon & Reiman (PT in Sport 2014) provide an excellent review on potential pathomechanics and provide clues on mechanisms that could be assessed and treated conservatively. After appropriate assessment, exercise intervention may benefit by paying attention to tiny details provided in the research of Selkowitz, (JOSPT September 2016, February 2013) and Khuu (IJSPT April 2016), in that subtle technique variations to bias motor recruitment and biomechanical function has the potential to feed or attack potential impairments. How we choose to gain mobility, stability, dose exercise and achieve motor recruitment and control matters.
So what did we really learn from this influx of new evidence? The consensus is that there is no consensus beyond diagnostics and complexity remains in treating this syndrome. The picture is less clear than ever, as we spin our wheels slowly moving forward and awaiting clinical trials to comparing conservative and surgical care. At the minimum, a patient-centered and individualized plan of care is a must. Regardless of the course of care, similar impairments will be present and targeting regional mobility, hip strength, single leg stability and motor control of the hip and pelvis are necessary. If you are still with me, check out a few of our current ways of addressing these through exercises on the video posted below!
Disclaimer: This is not medical advice and these opinions are independent of any entity. These thoughts were likely fueled by consumption of too much coffee and great music.
Griffin DR, Dickenson EJ, O'Donnell J, Awan T, Beck M, Clohisy JC, Dijkstra HP, Falvey E, Gimpel M, Hinman RS, Hölmich P. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. British Journal of Sports Medicine. 2016 Oct 1;50(19):1169-76.
Freke MD, Kemp J, Svege I, Risberg MA, Semciw A, Crossley KM. Physical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidence. British Journal of Sports Medicine. 2016 Oct 1;50(19):1180-.
Wall PD, Dickenson EJ, Robinson D, Hughes I, Realpe A, Hobson R, Griffin DR, Foster NE. Personalised Hip Therapy: development of a non-operative protocol to treat femoroacetabular impingement syndrome in the FASHIoN randomised controlled trial. British Journal of Sports Medicine. 2016 Oct 1;50(19):1217-23.
Loudon JK, Reiman MP. Conservative management of femoroacetabular impingement (FAI) in the long distance runner. Physical Therapy in Sport. 2014 May 31;15(2):82-90.
Selkowitz DM, Beneck GJ, Powers CM. Comparison of Electromyographic Activity of the Superior and Inferior Portions of the Gluteus Maximus Muscle During Common Therapeutic Exercises. journal of orthopaedic & sports physical therapy. 2016 Sep;46(9):794-9.
Selkowitz DM, Beneck GJ, Powers CM. Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. journal of orthopaedic & sports physical therapy. 2013 Feb;43(2):54-64.
Khuu A, Foch E, Lewis CL. NOT ALL SINGLE LEG SQUATS ARE EQUAL: A BIOMECHANICAL COMPARISON OF THREE VARIATIONS. International journal of sports physical therapy. 2016 Apr;11(2):201.