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2/2/2016
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Managing the Athletic Hip
Jill Monson, PT, OCS
University Orthopaedics Therapy Center – Fairview
TRIA Conference
February 6th, 2016
Disclosures
• No disclosures
© Jill Monson | MOC, LLC 2016
Overview
• Key factors identified in individuals with hip
pain
• Screening and examination strategies for
athletes with hip pain
• Treatment strategies and progressions for
athletes with hip pain
© Jill Monson | MOC, LLC 2016
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3 Fair Statements
• Sparse literature investigating the relationship between hip dysfunction and measures of physical strength, movement & performance
• Lack of high level literature examining non-operative management of FAI-associated hip pain
• Post-operative outcomes (success/failure) largely associated with PRO’s (patient reported outcomes) and return to sport data, NOT objective measures of strength & performance
© Jill Monson | MOC, LLC 2016
Why We ALL Care…
Pain-free Athlete with FAI
Pain-free Athlete with FAI
Sport/Training Exposure
Sport/Training Exposure
Painful Athlete with FAI
Painful Athlete with FAI
InterventionIntervention
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Treatment Guiding Questions
Question 1:
• What are the physical performance
profiles of individuals with hip pain (FAI
or other) compared to those without?
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Treatment Guiding Questions
Question 2:
• Are we ACTUALLY changing anything
with our interventions?
– How are we measuring change?
• Patient reported (subjective)
• Clinical measures (objective)
© Jill Monson | MOC, LLC 2016
Treatment Guiding Questions
Question 3:
• If we change physical performance
variables (in measurable, clinically
significant ways), do patients get better?
(function, symptoms)
– Non-operatively?
– Post-operatively?
© Jill Monson | MOC, LLC 2016
Characteristics of the Painful Hip
Mosler et al. Which factors differentiate athletes with hip/groin pain from those without? A systematic review with
meta-analysis. BJSM 2015
• Hip/Groin Pain (not specifically FAI)
• 17 total studies; 10 high quality
Diamond et al. Physical impairments and activity limitations in people with femoroacetabular impingement: a systematic
review. BJSM 2014
• Symptomatic FAI: Asymptomatic FAI: Controls
• 16 moderate to high quality studies
© Jill Monson | MOC, LLC 2016
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Characteristics of the Painful Hip
ROM Muscle Function Pain, Symptoms
Mosler ����Hip IR, FABER ROM
• Hip ER ROM =
controls
����strength
w/Adductor squeeze
test
• Altered trunk
control (see box)
(+) Adductor
Squeeze test
• PRO’s
Diamond ����Hip ROM w/gait
(frontal & sagittal
plane)
���� Pelvic rotation @
max squat depth
• Hip Flex, IR ROM =
asymptomatic FAI
�ADD, ABD, ER, Flex
strength
�TFL activation
w/max HF effort
(no ∆ for rectus
femoris)• Thinner TA at ratiosrest
• Delayed onset of TA with SLR
• Altered trunk flexion/extension © Jill Monson | MOC, LLC 2016
Diamond et al. BJSM 2014
• Response to intervention
– Conservative:
• No significant changes in hip ROM after 25-28 month 4-stage
tx program in individuals w/radiographic, symptomatic FAI
– Ill-defined treatment protocol, exercise compliance not tracked
– Post-Arthroscopy Findings
• Increased max hip IR
• Improved ROM observed with gait & squatting
• No change in hip ROM w/stairs
• Some findings of NO change in ROM post-op
© Jill Monson | MOC, LLC 2016
Return to Sport
Casartelli et al. Return to sport after hip
surgery for femoroacetabular
impingement: a systematic review.
BJSM 2014
• 18 case series L4 evidence
• Moderate to high quality
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Casartelli et al: Return to Sport
Average 87% Return to sport post-op
82% at same level as prior to symptom onset
Higher rate for professional athletes compared to
recreational, college (level of play, resources)
Reduced RTP rates observed on longer term f/u 1-3 years (of
those who originally returned in the 1st year/season post-
op)
© Jill Monson | MOC, LLC 2016
Casartelli et al: Return to Sport
“Diffuse hip OA”
at time of surgery
interferes with
return to sport
outcomes
© Jill Monson | MOC, LLC 2016
Performance Testing the Hip
Kivlan BR, Martin RL Functional performance testing of the hip in athletes: a systematic review
for reliability and validity. IJSPT 2012
• 74 articles reviewed
• 4 categories:
– Movement (18), balance (24), hop/jump (26), agility (6)
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Kivlan et al. IJSPT 2012
Test
Validity,
Normative
Data
(+) Diagnostic
Association
(pain)
(+) Association
w/ ABD muscle
function
Single Leg
Stance
X G. Med
Tendonopathy
Single Limb
Squat
X X
Deep Squat X FAI
SEBT X X
Hop Tests
© Jill Monson | MOC, LLC 2016
Non-Operative Management
Austin AB, Souza RB, Meyer JL, Powers CM.
Identification of abnormal hip motion
associated with acetabular labral pathology.
JOSPT 2008;38:558-565.
• Single subject case study
• FAI patient
• Hip exam and motion analysis
© Jill Monson | MOC, LLC 2016
Austin AB, et al. JOSPT 2008
• Pt. demonstrated increased hip
IR, ADD & pain with:
– Single leg step down
– Running
– Drop Jump
• IR, ADD, and pain reduced in
single session with use of SERF
strap
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Non-Operative Management
Yazbek PM, Ovanessian V, Martin RL, Fukuda TY.
Nonsurgical treatment of acetabular labrum
tears: A case series. JOSPT 2011;41(5):346-353.
• Case series w/4 patients w/confirmed labral
pathology
• Hip exam, strength measures
© Jill Monson | MOC, LLC 2016
Yazbek PM, et al. JOSPT 2011
• 3 phase non-operative progression over
approx. 12 weeks
– Improved function
– Decreased pain
– Correction of muscular imbalance
– Increased muscle strength (hip flexors, ABD,
extensors)
© Jill Monson | MOC, LLC 2016
Yazbek PM, et al. JOSPT 2011
• Phase I:
– Pain control
– Basic trunk stabilization
– Correction of abnormal mvmt patterns
• Phase II:
– Muscle strengthening
– Restoration of ROM
– Sensory motor training
– Correction of muscular imbalance (LSI% 100%)
• Phase III:
– Advanced sensory motor training
– Sport-specific functional progressions
© Jill Monson | MOC, LLC 2016
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PT Problem Solving
Create your HypothesisCreate your Hypothesis
Confirm your
hypothesis
Confirm your
hypothesis
Apply Intervention
Apply Intervention
Did anything change??
© Jill Monson | MOC, LLC 2016
PT Problem Solving
Posture & Movement
Screen
Posture & Movement
Screen
Tabletop Exam
Tabletop Exam
Treat what you find
Treat what you find
Re-assess:
1) Did you improve any measurable objectives??
2) Do they function or feel better as a result??© Jill Monson | MOC, LLC 2016
Bryan Kelly, MD, HSS “Layer Model”
Layer 4
Layer 3
Layer 2
Layer 1
• “Neurokinetic”
• Lumbosacral plexus, lumbopelvic structures
• “Dynamic”
• Contractile structures
• Dynamic stability
• “Inert”
• Labrum, Ligament/Capsular complex
• “Osteochondral”
• Bony structures (true FAI)
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Bryan Kelly, MD | HSS Layer Model
• Determine to “driver”/layer of the pathology
per a combined appraisal of:
– Radiographic Findings
– Basic Clinical Exam
– Dynamic Mobility, Kinetic Chain Assessment
– Differential Diagnosis
– Patient response to intervention (or lack of)
© Jill Monson | MOC, LLC 2016
Contralateral Pelvic Collapse
• Hip weakness, activation deficit
• Lateral trunk weakness
• Poor postural stability
• Poor kinematic control, motor strategies
• Hip weakness, activation deficit
• Lateral trunk weakness
• Poor postural stability
• Poor kinematic control, motor strategies
• Restricted sagittal plane foot/ankle
mobility (DF) = transfer motion to frontal
plane (hip)
• Poor proprioceptive control
• Restricted sagittal plane foot/ankle
mobility (DF) = transfer motion to frontal
plane (hip)
• Poor proprioceptive control
• Quadriceps muscle weakness,
dysfunction
• Knee pain = not wanting to flex @ knee in
sagittal plane = transfer motion to frontal
plane (hip)
• Quadriceps muscle weakness,
dysfunction
• Knee pain = not wanting to flex @ knee in
sagittal plane = transfer motion to frontal
plane (hip)
© Jill Monson | MOC, LLC 2016
Contralateral Pelvic Hike
• Adductor, TFL tone/tightness
• Restricted hip mobility
• Hip weakness, activation deficit
• Hip pain
• Lateral trunk weakness
• Poor postural stability
• Poor kinematic control, motor strategies
• Adductor, TFL tone/tightness
• Restricted hip mobility
• Hip weakness, activation deficit
• Hip pain
• Lateral trunk weakness
• Poor postural stability
• Poor kinematic control, motor strategies
• Restricted/poor weight acceptance into
foot/ankle in frontal plane
• Poor proprioceptive control
• Restricted/poor weight acceptance into
foot/ankle in frontal plane
• Poor proprioceptive control
• Quadriceps muscle weakness,
dysfunction?
• Quadriceps muscle weakness,
dysfunction?
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Posture & Movement Screen
• Static posture (frontal & sagittal views)
• Dynamic movement (squat, lunge)
• Trunk rotation assessment
• Gait
• Athletic movement screen
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Static Posture Observations
© Jill Monson | MOC, LLC 2016
Rotational Movement Screen
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Dynamic Movement Screening
• This screening should be ONGOING
• Repeat throughout your rehab progressions
• Continue to look at all planes of motion
• Modify treatment per observations
Mobility/Flexibility Screen
© Jill Monson | MOC, LLC 2016
Assess Accessory Mobility:
T-spine Rotation
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Hip Special Testing
© Jill Monson | MOC, LLC 2016
Tabletop Exam• Palpate
– Zero in on painful structure
– Corroborate with other clinical exam findings
• Screen proximal distal joint mobility
– Foot/ankle, knee, spine
• Strength, Stability:
– Hip, trunk
• Differential screening prn:
– Neural
– Segmental mobility at spine
– SIJ© Jill Monson | MOC, LLC 2016
Key Treatment Progressions
Honor symptoms ALWAYS
Progress Motor Learning & Demand:
Load, repetition, complexity & speed
Normalize functional kinematics
Address fundamental impairments
Change the pain/Protect Joint
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Manipulate Symptoms
Change the pain/Protect joint
Activity (temporary) Modification
Movement Pattern Maximization
Manual interventions at relevant structures:
• Soft tissue work for tone
• Joint mobilizations for pain control (reduce impingement moments)
© Jill Monson | MOC, LLC 2016
Address Fundamental Impairments
Address fundamental impairments
Range of Motion
Full, pain-free, controlled, well-distributed:
Foot/Ankle � Hip � Spine
Muscular weakness, dysfunction:
360˚ Hip, Core
© Jill Monson | MOC, LLC 2016
Kinetic Chain Mobility Deficits
Ankle DF– Alters sagittal plane kinematics (squatting, stairs, gait)
Hip ABD, ER– Inability to pull out of valgus movement tendency
– Transfers rotational movement demand to other joints
Hip ADD, IR-Inability to load transfer effectively into the hip for single limb
tasks
-Alters hip functional hip arthrokinematics
Spine Rotation– Transfers rotational movement demand to other joints
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Address Fundamental Impairments
Address fundamental impairments
Range of Motion
Full, pain-free, controlled, well-distributed:
Foot/Ankle � Hip � Spine
Muscular weakness, dysfunction:
360˚ Hip, Core
© Jill Monson | MOC, LLC 2016
How do we work target muscles?
Distefano et al. JOSPT 2009• % of max volitional isometric
contraction achieved (MVIC)
• SL hip ABD
– 81% G. Med
– 39% G. Max
• SL hip ER
– 38-40% G. Med
– 34-39% G. Max
© Jill Monson | MOC, LLC 2016
Gluteus Maximus Strengthening
Ekstrom et al. JOSPT 2007
(% of MVIC with EMG)
– Quadruped Arm/Leg lift
• 56% G. Max
– Single Leg Bridge
• 40% G. Max
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Hip Strength and Core
Ekstrom et al. 2007(% of MVIC with EMG)
• Side Bridge:
– 74% G. Med
– 21% G. Max
– 69% External
Oblique
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CKC Glut Max and Glut Med
Distefano et al. JOSPT 2009(% of MVIC with EMG)
• Single limb squat:
– 64% G. Med
– 59% G. Max
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CKC Strength and Proprioception
Single Limb Dead Lift:59% MVIC at G. Max58% MVIC at G. Med
DiStefano, 2009
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Thoughtful Strength Progressions
Phillippon MJ, et al. Rehabilitation exercise
progression for the Gluteus Medius Muscle with
Consideration for Iliopsoas Tendinitis: An In Vivo
Electromyography Study. AJSM 2011. 39:1777.
© Jill Monson | MOC, LLC 2016
Recommendations per
Philippon AJSM 2011
• Phase I
(First 4-8 weeks):
– Prone resisted TKE
– Prone HS curl
– 2 leg bridge
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Recommendations per
Philippon AJSM 2011
• Phase II
(Next 4 weeks):
– Resisted hip extension
– Stool hip IR
– SL Hip ABD wall slides
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Recommendations per
Philippon AJSM 2011
• Phase III (Next 4 weeks):
– Prone heel squeeze
– SL Hip ABD w/femoral IR
– Single leg bridging
© Jill Monson | MOC, LLC 2016
Key Treatment Progressions
Honor symptoms ALWAYS
Progress Motor Learning & Demand:
Load, repetition, complexity & speed
Normalize functional kinematics
Address fundamental impairments
Change the pain/Protect Joint
© Jill Monson | MOC, LLC 2016
Key Treatment Progressions
Honor symptoms ALWAYS
Progress Motor Learning & Demand:
Load, repetition, complexity & speed
Normalize functional kinematics
Address fundamental impairments
Change the pain/Protect Joint
© Jill Monson | MOC, LLC 2016
2/2/2016
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Athletic Treatment Progressions
Mobility
• Get full, pain-free ROM
• Keep full, pain-free ROM
• Use full, pain-free ROM OKC�CKC
Strength, Power, Endurance
• Establish OKC base
• Progress OKC&CKC
• Increase Load
• Increase Speed
• Increase Reps
Motor Complexity
• Unisegmental�
Multi-segmental
• Uniplanar�
Multi-planar
• Planned�Reactive
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Triple Flexion<>Triple Extension
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Excursion
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Multi-Planar, Multi-Segment,
Rotational Control
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Sport-Specific Movements & Postures
© Jill Monson | MOC, LLC 2016
Athletics
���� External loads
���� External loads
���� Speed���� Speed
���� Excursion���� Excursion���� Duration���� Duration
���� Task Complexity, Reactivity
���� Task Complexity, Reactivity
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Athletic Progressions
Reproduce athletic
challenges with
therapy
progressions
© Jill Monson | MOC, LLC 2016
Key Treatment Progressions
Honor symptoms ALWAYS
Motor Learning Progressions & Demand:
Load, repetition, complexity & speed
Normalize functional kinematics
Address fundamental impairments
Change the pain/Protect Joint
© Jill Monson | MOC, LLC 2016
My hip still hurts…• When?
– During which motions, postures?
– For how long?
• Where/What?
– Anterior hip region: HF imbalance with rectus femoris, anterior hip
capsule hanging postures
– Lateral hip: G. Med overload (too short, too long), imbalance in hip mm.
actions (ABD<>ADD balance?)
– Groin: Lack of motion into ADD/IR still? (joint mobilizations, ADD STM)
• How?
– Sharp pinch, aching, tightness??
• Allows you to suspect the correct layer of involvement per symptom
nature
© Jill Monson | MOC, LLC 2016
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PT Problem Solving
Posture & Movement
Screen
Posture & Movement
Screen
Tabletop Exam
Tabletop Exam
Treat what you find
Treat what you find
Re-assess:
1) Did you improve any measurable objectives??
2) Do they function or feel better as a result??© Jill Monson | MOC, LLC 2016
In Summary…
• We do not yet fully understand the physical performance profiles of individuals with hip pain, FAI or not– Strength, movement patterns, etc.
• We have very preliminary evidence of the effectiveness of PT interventions for managing pain & returning athletes to play– More post-operative than non-operative evidence
• Effective examination & treatment of the hip require good working knowledge of the entire kinetic chain
© Jill Monson | MOC, LLC 2016
References• Austin AB, Souza RB, Meyer JL, Powers CM. Identification of abnormal hip motion
associated with acetabular labral pathology. J Orthop Sports Phys Ther. 2008;38:558-565. http:// dx.doi.org/10.2519/jospt.2008.2790
• Casartelli NC, Maffiuletti NA, Item-Glatthon JF, Staehli S, Bizzini M, Impellizzeri FM, Leunig M. Hip muscle weakness in patients with symptomatic femoracetabularimpingement. Osteoarthritis and Cartilage. 2011;19(7):816-821.
• Enseki KR, Martin RL, Draovitch P, Kelly BT, Philippon MJ, Schenker ML. The hip joint: arthroscopic procedures and postoperative rehabilitation. J Orthop Sports Phys Ther. 2006;36:516-525. http://dx.doi.org/10.2519/ jospt.2006.2138
• Casartelli, Nicola C., et al. "Return to sport after hip surgery for femoroacetabularimpingement: a systematic review." British journal of sports medicine (2015): bjsports-2014.
• Distefano L, Blackburn J, Marshall S, Padua D. Gluteal muscle activation during common therapeutic exercises. J. Ortho & Sports Phys Ther. 2009; 39(7): 532-540.
• Diamond, Laura E., et al. "Physical impairments and activity limitations in people with femoroacetabular impingement: a systematic review." British journal of sports medicine (2014): bjsports-2013.
© Jill Monson | MOC, LLC 2016
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References
• Ekstrom R, Donatelli R, Carp K. Electromyographic analysis of core trunk, hip and thigh muscles during 9 rehabilitation exercises. J. Ortho & Sports Phys Ther. 2007; 37(12): 754-762.
• Kivlan, Benjamin R., and RobRoy L. Martin. "Functional performance testing of the hip in athletes: a systematic review for reliability and validity." International journal of sports physical therapy 7.4 (2012): 402.
• Kapandji A. [Articulate Physiology. Volume 2: Lower Limb]. 5th ed. Sao Paulo, Brazil: Guanabara Koogan Guanabara Koogan; 2001.
• Kennedy MJ, Lamontagne M, Beaule PE. Femoroacetabular impingement alters hip and pelvic biomechanics during gait: Walking biomechanics of FAI. Gait & Posture 2009;30:41-44
• Kennedy MJ, Lamontagne M, Beaule´ PE. The effect of cam femoroacetabularimpingement on hip maximal dynamic range of motion. Journal of Orthopedics 2009;1(1):41–50.
• Lewis C, Sahrmann S. Acetabular Labral Tears. Physical Therapy. 2006;86(1):110-121.
• Lewis CL, Sahrmann SA, Moran DW. Anterior hip joint force increases with hip extension, decreased gluteal force, or decreased iliopsoas force. J Biomech. 2007;40:3725-3731. http:// dx.doi.org/10.1016/j.jbiomech.2007.06.024
© Jill Monson | MOC, LLC 2016
References• Mosler, Andrea B., et al. "Which factors differentiate athletes with hip/groin pain from those
without? A systematic review with meta-analysis." British journal of sports medicine 49.12
(2015): 810-810.
• Phillippon MJ, et al. Rehabilitation exercise progression for the Gluteus Medius Muscle with
Consideration for Iliopsoas Tendinitis: An In Vivo Electromyography Study. AJSM 2011.
39:1777.
• Philippon M, Schenker M, Briggs K, Kuppersmith D. Femoroacetabular impingement in 45
professional athletes: associated pathologies and return to sport following arthroscopic
decompression. KSSTA 2007;15:908-914. http://dx.doi.org/10.1007/ s00167-007-0332-x
• Stalzer S, Wahoff M, Scanlan M. Rehabilitation following hip arthroscopy. Clin Sports Med
2006;25:337–57.
• Wahoff M, Ryan M. Rehabilitation after hip femoracetabular impingement arthroscopy. Clin
Sports Med 2011;30:463-482.
• Wahoff MS, Briggs KK, Philippon MJ. Hip arthroscopy rehabilitation: evidence-based practice.
In: Kibler B, editor. Orthopedic knowledge update: sports medicine 4. Lexington (Kentucky):
AAOS; 2008. p. 273–81, 23.
• Yazbek PM, Ovanessian V, Martin RL, Fukuda TY. Nonsurgical treatment of acetabular labrum
tears: A case series. JOSPT 2011;41(5):346-353.
© Jill Monson | MOC, LLC 2016