WEEK 7 - hip and groin conditions

Question 1

common hip condtions:

Answer 1

> femoroacetabular impingement syndrome (FAI) ->
> acetabular dysplasia and/or hip instability -> misalignment between the femoral head and acetabulum secondary to changes in shape/ size/ orientation; instability and overload of the acetabular rim
> other conditions: labral tears/ chondral lesions/ ligamentum teres tears

Question 2

hip non-musculoskeletal conditions:

Answer 2

Ø Referral from lumbar spine/ sacroiliac joint
Ø Osteoarthritis
Ø Tumours
Ø Infections
Ø Stress fractures
Ø Slipped capital femoral epiphysis (SCFE)
Perthes disease

Question 3

what is FAI
- define
- symptoms
- signs and imaging

Answer 3

• a motion related clinical disorder of the hip with a triad of symptom, clinical signs and imaging findings. It represents symptomatic premature contact between the proximal femur and the acetabulum
  > Cam morphology
  > pincer morphology

symptoms: pain can be felt in back, buttock or thigh

signs and imaging: pain on hip impingement test (FADIR), limited ROM, imaging - x-ray confirmation of a cam/ pincer morphology

Question 4

subjective exam of FAI

Answer 4

• Body chart:
  > deep groing pain worse in FADIR functional positions
  > often present with generalised groin pain
  > may complain of chronic back/ gluteal pain
  
  • Common in athletes, cyclists, truck drivers (sustained hip joint flexion)
  • Kicking sports, martial arts, ballet dancers
  • May describe a ‘giving way’ sensation and acute pain
    May describe an audible click or clunk in IR and adduction of hip

Question 5

objective exam of FAI:

Answer 5

• Functional movements:
  > DL squat -> reduced squat depth
  > single leg balance e.g. star excursion balance test -> poor balance
  > single leg squat / step down -> poor control/ function
  
  • Measures of physical activity -> accelerometers/ FitBit
  • AROM + PROM -> IR may be restricted or imbalances between affected and non-affected hip
  • Muscle strength:
    > use a HHD, load cell or isokinetic device to have an objective measure
    > reduced strength on hip abduction, adduction, flexion, IR, ER
    > imbalanced between affected and non-affected hips
  • Special tests:
    > pain on anterior impingement test (FADIR)
    > IR at 90 degrees hip flexion less than 20 degrees -> FAI
    > pain and reproducible clunk/ catch on hip quadrant test (scour test_

Question 6

standardised measures of FAI

Answer 6

• Patient reported outcome measures
  
  • Hip and Groin Outcome Score (HAGOS)
  • International Hip Outcome Tool (iHOT) – long and shortened versions

Question 7

treatment/ management of FAI

Answer 7

• Physiotherapy-led interventions help with strength and function -> Evidence is unclear about pain and quality of life
  
  • Physiotherapy-led strengthening programs of at lease 3 months in duration have the best effect
    > However, unsure exactly what the best protocol is – strength training, movement pattern training, range of movement exercises, stretching?
    > Also unclear if including manual therapy provides a greater benefit.
  • Address the impairments in the problem list – “Treat what you find”
  • Strengthening around hips
    > Address strength impairments so the affected side is at least 90% strength of unaffected leg
    > Isometric strengthening with belt or band
    > Functional strength
  • Address limited ROM
    > Manual therapy to soft tissues if tight muscles are causing the restriction
    > Hip joint mobilisation if the joint capsule has become tight
    > Stretching

Question 8

surgical management of FAI

Answer 8

• Arthroscopic or open surgery
  
  • Improve morphology
  • Repair or debridement labrum
  • Prognosis good in men > women

Question 9

groin pain classification

Answer 9

1. Defined clinical entities for groin pain
   2. Adductor related groin pain -> Adductor tenderness on palpation and pain on resisted adduction testing
      i. Iliopsoas related groin pain -> iliopsoas tenderness/ pain on resisted hip flexion/ pain in stretching hip flexors
      ii. Inguinal related groin pain -> pain in the location of the inguinal canal and tenderness of the inguinal canal/ no palpable inguinal hernia/ pain on resisted testing of the abdominal muscles or Valsalva/ cough/ sneeze
      iii. Pubic related groin pain -> local tenderness on palpation of the pubic symphysis and immediately adjacent bone / no particular resistance test will provoke pubic related groin pain
   3. Hip-related groin pain
   3.Other causes of groin pain

Question 10

risk factors for groin pain

Answer 10

> Previous injury
> Pain and reduced strength on adductor squeeze test prior to onset of symptoms
Reduced hip internal rotation / bent knee fallout

Question 11

subjective exam fro groin pain:

Answer 11

• Pain area - can be generalised pain in the groin region
  
  • Aggs: kicking and change of direction / pain during and after exercise/ tight/ stiff during or after activity
  • 24hr pattern -> pain/stiffness am -> especially after training/ playing
  • Sport -> sports that involve kicking and multiple changes of direction at speed
    History -> may complain of loss of acceleration/ loss of maximal sprinting speed/ loss of distance with kick

Question 12

objective exam for groin pain

Answer 12

• Functional movements: single leg stance; single leg squat; kicking motion
  
  • AROM + PROM -> hip IR and ER at 90 degree hip flexion and in neutral (fall out test) -> will have limited IR or asymmetries between unaffected and affected leg
  • Muscle strength -> squeeze test with sphygmo or HHD and pain rating at 60 degree hip flexion (Odeg hip F) -> will be weak and have high pain score
  • Isometric strength around hip in all directions -> will have weakness and asymmetries between abduction and adduction, and between affected and unaffected leg
  • Assess lumbo-pelvic stability
  • Special tests: FADIR; FABER
    Palpation: identify painful structures

Question 13

standardised outcome measures for groin pain

Answer 13

• Hip and Groin Outcome Score (HAGOS)
  
  • Hip Outcome Score (HOS)
  • International Hip Outcome Score (iHOT) – short and long versions

Question 14

diagnosis of groin pain

Answer 14

• Pain in affected region that worsens on exercise
  
  • Pain on palpation, resistance testing (isometric pain provocation) and stretching
  • Pain resistance testing should be felt in the affected area structure and reproduce the patient’s familiar / recognisable pain
    Multiple diagnoses can co-exist -> Eg: can have FAI syndrome and adductor related pain

Question 15

treatment/ management of groin pain

Answer 15

• Education
  Ø Role of patient / role of patient
  Ø Explanation of cause
  Ø Load management
  
  • Physiotherapy specific
    Ø Address lumbo-pelvic stability impairments (motor control / Pilates)
    Ø Increase ROM – manual therapy (soft tissue massage) and stretching
    Ø Address strength deficits & asymmetries in strength
    Begin with pain free isometric contractions in mid-range → inner and outer range → low load isotonic contractions → increase load
    Begin 25%-30% MVC for 5-10 secs x 4 sets → 20-30 sec x 4 sets
  • Mechanical -> Taping pelvis / compression shorts
  • Contributing factors -> Address overtraining if an issue
    Interdisciplinary referral -> Exercise and sports physician -> Oral corticosteroids -> Collaboration with coaches / strength and conditioning coaches -> Graduated return to sport