The irritable hip impingement – science and art

Over the past number of years, patients have travelled to our clinics from far afield on the recommendation of their surgeon for a clinical review. Their case history normally has involved surgery and aftercare physiotherapy, which appear to have failed to address their problem. Symptoms range from hip, groin, low back and leg pain, which are often worse when sitting, with great difficulty standing upright from a seated position. The following text is a short explanation of the current limited hip and groin research available and one proposed approach that has been used with great success in our clinics.

Maintaining and restoration of movement dysfunction is a key component of the physical therapy rehabilitation model. To correct movement function, special consideration of muscle strength and movement re-education is required in order to prevent and alleviate musculoskeletal pain. Knowledge and understanding of the interrelationship and interdependence between the kinetic chain segments of the spine-pelvis-hip complex is crucial for employing an integrated hip impingement rehabilitation protocol.

A surgical approach to management of FAI is by hip joint arthroscopy. Although this intervention appears to becoming more popular (Kemp et al 2012), post-surgical management of FAI patients following hip arthroscopy is variable. Several rehabilitation protocols have been documented, (Edelstein et al 2012; Jayasekera et al 2013; Pierce et al 2013;). These rehabilitation protocols include managing weight-bearing, hip joint range of motion and include different exercises and therapeutic treatment techniques. However, it appears that no one particular physical therapy protocol is more effective than any other or any more effective than no post-surgical rehabilitation.

A recent systematic review by Wall et al (2013) highlighted that conservative management of FAI is widely used. In this systematic review, conservative care consisted of activity modification, non-steroid anti-inflammatory drugs (NSAID’s) and physical therapy. Unfortunately, there are few studies that provide descriptions for physical therapy protocols and outcome scores.

It is important to comprehend that many causes of hip dysfunction may present simultaneously; i.e. coexisting alongside another pathology. Patients can present with either one or both a combination of soft tissue and articular movement restriction alongside neuromuscular control deficits. Often they have developed this pattern of substitution strategy to cope or manage themselves during movement and for pain avoidance. An example might be FAI being present alongside a local muscle issue. This local muscle issue may be related to over activity (hypertonic) or under activity (inhibition). This raises the question of which pathology is causing symptoms. Holmich et al (2014) demonstrated that patients who presented with adductor-related groin pain achieved good results with an exercise programme in spite of the coexistence of a bony morphology related to FAI and hip dysplasia. This suggests that an extra articular neuromuscular component to hip joint management should be considered prior to any surgical intervention. Holmich’s study (2014) also demonstrated that throughout the observation period of 8-12 years, patients with FAI in spite of not under going surgery, did not progress to having increased levels of joint degeneration and osteoarthritis.

Casartelli et al (2011) showed symptomatic FAI patients to have significant hip muscle weakness when compared to an asymptomatic group. It was further suggested by (Casartelli et al., 2011) that a conservative approach such as improving hip joint control, with strength and co-ordination training, might be worthwhile for improving clinical outcome measures. Holmich et al (1999) showed evidence of this in a randomized control trial of patients with long-standing groin pain. Those patients in this study who were treated with a strengthening and movement re-education programme responded much better than those patients treated with passive manual therapy and stretching programmes.

A reduction in hip flexor muscle strength has been found in patients with acetabular labral pathology (Mendis et al., 2014). In their study, isometric hip flexor strength was measured using a handheld dynamometer with patients in a supine lying with knee and hip at 90 degrees. It was proposed that such decreased levels of strength might have implications for physical function by contributing to altered movement, patterns in gait and functional tasks. There was however, no decrease shown on MRI in hip flexor size or the recruitment pattern. This might suggest that deficits in strength may be related to alteration of neuromuscular control rather than muscle atrophy. Perhaps in the presence of pain, neuromuscular control is altered as a result of reduced afferent input from damaged joint tissues and from modulating motor control output via spinal reflex pathways due to damaged joint receptors (Spencer et al., 1984; Stokes & Young, 1984; Rice & McNair, 2010).

For the patient with an irritable hip impingement it is often difficult to know where to seek the correct help advice. Ultimately our clinical goal is to reduce pain and improve function. Achieving this requires a level of patient co-operation and education. Much of our management approach for this condition involves empowering the patient with the correct advice, treatment and exercise to return to appropriate levels of activity of daily living. Examples are listed below.

Education (advice and avoidance)

  • Deep squatting, pivoting or twisting postoperative or during the inflammatory/irritable stage of injury
  • No hip joint flexion <90 degrees
  • Prolonged sitting with hip flexion <90 degrees i.e.: whist driving, workstation, etc

Medication (1-2 weeks)

  • Non steroid anti-inflammatory drugs (NSAID’s)

Manual therapy (2-12 weeks)

This should be semi-structured and guided by a combination of mandatory/non-mandatory components. Contact time with physical therapist should be one session every 2 weeks providing a total of 6 sessions. Treat the clinical symptoms as per assessment findings at time of presentation. Assess and record clinical findings at each treatment session. Progress from advice, to passive care to active care as quickly as the patient can cope within pain free parameters.

Initial goals after symptoms have become less acute is to improve:

  1. Hip mobility and strength (flexion and rotation to clear FAI)
  2. Thoracic spine mobility and strength (extension and rotation)
  3. Hip and spinal dissociation (move limbs independently of spine)

 

Use of manual release techniques for both soft tissue and articular restrictions and encourage neuromuscular control and control through a pain free range.

  • Trigger point inhibition techniques to tensor fascia latae, rectus femoris, adductors, superficial and deep fibres of gluteal muscles and obliques. To reduce soft tissue restriction and pain. To improve hip joint flexion and rotation ROM through relaxation of soft tissues and allowing posterior innominate rotation.
  • Lumbar and thoracic spine mobilisations, if indicated. To improve lumbo-pelvic mobility and pain-free ROM. To assist with hip function through relaxation of myofascial slings systems.
  • Strengthening of psoas muscle, four stages progressing from supine, hip suction, sitting and dynamic standing with and without resistance.
  • Strengthening of Gluteus Medius/Minimus/Maximus and deep hip rotators, seven stages progressing from supine, side lying, and dynamic standing with and without resistance. To optimise hip neuromuscular control and improve dynamic hip stability
  • Anterior and posterior hip stretch. To assist in regaining full hip ROM