Week 5: Management of Hip Conditions Flashcards by Caitlin O'Farrell

What is a CAM morphology? What degree is indicative of CAM morphology?

Alpha angle indicates the angle at which the femoral head departs from its normal spherical outline.

> 55 degrees indicative of CAM morphology

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How is the alpha angle determined?

A circle of best fit is drawn over the femoral head. The alpha angle is formed by the axis of the femoral neck (1) and a line (2) drawn from the femoral head centre to the point where the head extends beyond the margin of the best-fit circle (arrow).

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True or false: A patient can have CAM morphology without having an FAI

TRUE - must have symptoms to have an FAI

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What might a hip x-ray of <2mm (or 2.5mm) in the joint space indicative of?

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What are the three locations that joint space should be measured?

Medial point: measure joint space of acetabulum to femoral head at a 90° angle to the most medial aspect of the acetabular sourcil line.

Central point: measure joint space of acetabulum to femoral head at a 90° angle to the center of the superior articular surface.

Lateral point: measure joint space of the acetabulum to femoral head at a 90° angle to the most lateral weight-bearing aspect of the femoral head

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What does the lateral central edge angle measure?

Under or over coverage of the hip

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Lateral central edge angle of < 20 deg is indicative of…

Dysplastic (undercoverage)

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Lateral central edge angle of 21- 25 deg is indicative of…

Borderline dysplastic

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Lateral central edge angle of 26-40 deg is indicative of…

Normal

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Lateral central edge angle of >40 eg is indicative of…

Overcovered

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FAI describes …..

Abnormal contact between the femoral head and acetabulum

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What are the two main types of FAI?

CAM and Pincer

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True or False it is possible to have mix of CAM and PINCER morphology

TRUE

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What type of FAI is associated with OA?

CAM lesions

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Previous studies have shown that larger cam lesions (alpha angle > ….. ) are associated with ….-fold increased risk of hip osteoarthritis (OA) and progression to hip arthroplasty within 5 years.

> 83
10-fold increase

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True or False: None of our physiotherapy management options can actually change the underlying skeletal morphology of a patient

True

When does CAM morphology develop? Why? How can it be corrected?

Youth

The forces going through the hip lead to changes in the underlying bony morphology

Surgery is the only option if we are looking at changing the underlying bony morphology)

Intrinsic factors for FAI

Strength/ROM
Biomechanics
Morphology

Extrinsic factors for FAI

Type of activity
Total work load
Weight

Hip Arthroscopy vs best conservative care for FAI?
* 6 to 10 face-to-face contacts with the physiotherapist over 12–24 weeks
* Surgery: Shape abnormalities & consequent labral and cartilage pathology were treated.

Note: Both groups started around the same point in terms of hip related disability and quality of life (iHot-33). Higher score = less your hip impacts you in day to day activities

At 6mths results looked very similar but at 1 year the hip arthroscopy group are significantly better than the personalised exercise group

HOWEVER neither option brings patients anywhere near back to normal

Note: the non-surgical group was described as best care but only consisted of 6-10 sessions, inadequately progressed exercises, largely stability based, etc.

How did the adverse affects occur comparing the hip arthroscopy and conservative care?

More severe adverse effects occurred only in the arthroscopy group eg wounds, infection, etc
Hip therapy any adverse effects were more minor eg soreness

Cross-sectional studies (Kemp) - What was associated with better quality of life for FAI patients?

Note: the study Measured patient strength on a single day and asked them to fill out outcome measures related to quality of life – seen what physical impairments eg hip flexion range, adduction strength, etc are associated with better quality of life

Better hip flexion range
Better adduction strength

Cross-sectional studies (Kemp) - What was associated with better functional performance for FAI patients?

Greater strength in hip abduction and adduction

**Better functional performance = less pain and QOL

What position in FAI rehab should you start away from?

Starting in positions away from hip flexion

eg performing exercises in a deep squat or deadlift (quite provocative) instead starting with bridging based exercise in a more neutral hip position, lying and standing hip abduction, etc

Kemp standard dosage exercises

* Load magnitude: 20-repetition maximum * Repetitions: 20 * Sets: 3 * Rest between sets: 90 seconds * Number of exercise interven: 2 to 4 per week * Recovery time: 48 hours

Kemp exercise focus

Hip abduction Hip extension Hip adduction Hip ER Trunk muscle Functional progressions Plyometrics **Arguably this is a more demanding program than used in the arthroscopy vs surgery study

Gluteal tendinopathy - general info - Affects up to ... in 4 post-menopausal women - Severe impacts on ..... - Average age of .... (ranges from low to mid ... – .... odd) - Lateral hip pain that can be felt down the lateral .... and around the .... (even at times into the shin!)

1 in 4 QoL, physical function & sleep 50 (30-70s) Thigh and around the buttock

Main area of pain upon palpation is...

The greater trochanter (very tender on palpation)

Primary pathology of GT

Insertional tendinopathy of the gluteus medius and minimus tendons (both attach at greater trochanter)

Common impairments in GT?

- Difficulty lying on affected side (significantly impacts sleep quality) - Affects ability to ambulate (particularly walking up hills and activities that involve high levels of hip abductor function ie walking/running)

GT: When the hip is moved into positions of adduction, the ...... band compresses the ..... and ..... and that can be ...... for patients (understanding the impact of compression and trying to minimise that both in day to day activities is a really important component of managing gluteal tendinopathy

ITB band compresses the bursa and tendons and that can be provocative for patients

What positions compress and aggravate pain in GT?

Sitting (esp cross-legged) Sitting with knees together & feet out Stretching eg figure 4 Standing slouched on one leg

How can we differentiate GT and OA?

one key way to differentiate between hip OA and gluteal tendinopathy is to ask if they have trouble putting their shoes and socks on – hip OA will – requires a lot of ROM!)

What strength is impaired in GT?

Hip Abductor Strength

What did the LEAP trial for GT find? * 204 patients entered with glute tendinopathy * 3 treatments: education + exercise, corticosteroid injection or wait and see approach

* At 8 weeks the global rating of change scale (GROC) had the greatest benefit in the education & exercise group (77% reported they were moderately better, 58% from the corticosteroid and 29% from the wait and see group) --> Similar results at 52 weeks

In the LEAP trial what education was provided? What exercises were prescribed?

- Managing compression ie avoid positions that compress glute med and min tendons (avoid hip adduction) - Avoid hip flexion > 90 degrees --> any exercises avoid these too eg clams! (Also compresses) - Exercise: glute bridges, squat, single leg stance, abductor loading