MacDonald - AAOMPT Hip Labrum Poster 2010
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RETURN TO COMPETITION OF A COLLEGE HURDLER AFTER RESOLUTION OF LONG TERM HIP IMPAIRMENTS POST LABRAL REPAIR, USING HIP MOBILIZATION/MANIPULATION AND POSTERIOR HIP ECCENTRIC RETRAINING Cameron W. MacDonald PT DPT GCS OCS FAAOMPT Program Director/ Chief Fellow - Regis University Manual Physical Therapy Fellowship Program Owner Beinn Sonas Physical Therapy Services BACKGROUND & PURPOSE: There is growing interest in hip intra-articular impairments and pathologies. Hip surgery for hip labrum and intra-articular pathology is growing rapidly. Research though addressing rehabilitation post arthroscopic hip surgery is minimal, with no known research addressing prolonged mechanical impairments in this patient cohort. This case report demonstrates a successful impairment based approach to chronic right anterior hip/groin pain in a college level athlete, who had failed to return to participation in competitive events including long-jump and hurdling after hip labral and femoral head interventions. DESCRIPTION: A 20 year-old female presented 19 months post surgery for labral dysfunction plus femoral head delamination, with persistent anterior hip/groin pain and an inability to return to hurdling and long jump. Original trauma was due to a fall during cheerleading in her sophomore year of high-school, with delayed identification of right hip intra-articular pathology over three years. A hip labral tear was identified pre- operatively, and arthroscopic examination at the time noted that the right femoral head was delaminated 75%. Chrondroplasty and osteoplasty were completed to address this lesion in conjunction with the labral repair. Subsequent rehabilitation was completed at the University she attends, with an attempted return to sports participation at approximately 12 months. Due to persistent groin pain and irritation to the right iliotibial band outside referral was made to Physical Therapy. The initial examination noted impairments in anterior capsule mobility, restricted right hip flexor muscle length, hip external rotation (ER) restriction of 10 degrees and weakness in the posterior hip rotary muscles under eccentric and concentric loads. Weakness in the right hip posteriorly in the gluteus medius, gluteus minimus, adductors in extension and the medial hamstrings was graded at 4-/5. pain was rated at 9/10 with attempted participation in cross-country and athletic training. The patient also presented with local pain in response to unilateral lumbar PA’s from the thoraco-lumbar junction down to the L5 level. There was an altered firing pattern in the right sided lumbar multifidi with the multifidi firing prior to the gluteal musculature in hip extension. A compensation was noted with right sided lumbar extension excessive with diminished right hip extension. No neurological signs were present through the lumbo-sacral plexus and through either lower extremity. INTERVENTIONS: Specific interventions included traction manipulation of the right hip, belted mobilization with combined inferior and rotational glides of the right hip, prone hip internal rotation (IR) and ER mobilization and anterior glides of the hip joint with combined rectus femoris and iliospoas muscle stretching. Following the primary manual interventions, posterior neuro-motor retraining of the hip was completed. Eccentric retraining was emphasized, though concentric and proprioceptive neuro-muscular interventions were also utilized. A progression was made from neutral and at rest positions to more dynamic and unstable positions. OUTCOMES: Following nine sessions of physical therapy, the patient was able to return to full competition Manual Therapy Fellowship One Patient’s Hip Journey… A healthy hip, then a cheerleading fall. Three years of progressive dysfunction. Surgical repair with interventions to address femoral head delamination. Despite per protocol rehabilitation, unable to return to competitive sports at College level. Residual Impairments: noted 19 months post-operative. Right hip groin pain with attempted hurdling Right sided lumbar spine pain with training, especially running on uneven terrain Pain rates on numeric pain rating scale to 9/10 Restriction identified in manual examination of hip capsule anterior mobility Right hip posterior soft tissue mobility impairments with ER restriction of 10 degrees Only 4-/5 right hip muscle strength through the gluteal complex and deeper posterior hip musculature Restricted right hip flexor mobility Treatment Plan: impairment based interventions with functional re-assessments Prognosis – unclear, unique case presentation Timeline considerations – 19 months post surgical interventions, healing that could occur in the joint considered complete. Irritability – low, but pain high post activity, and occasionally very sharp (first attempt at return to hurdles) Manual Interventions – a selection. Exercise Interventions – a selection References: 1.Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007 Nov;37(11):658-60. 2.Garrison JC. Rehabilitation after arthroscopy of an acetabular labral tear. N Am J Sports PT. 2007. 2;4;241-250. 3.Fereidoon MJ. Hip pain in young adults. Femoroacetabular impingement. J Arthroplasty. 2007. 22;7:37-42 4.Kamath AF. Hip arthroscopy for labral tears. Am J Sports Med. 2009;37;9:1721-1726. 5.Cook KM. Conservative Management of a young hip with hip arthrosis. JOSPT. 2009;39;12:858-866. 6.Tonley JC. Treatment of an individual with piriformis syndrome focusing on hip muscle strengthening and movement re-education. A case report. JOSPT. 2010;40;2:103-111. 7.Wagner T. Strengthening and neuromuscular re-education of the gluteus maximus in a triathlete with exercise-associated cramping of the hamstrings. JOSPT. 2010;40;2:112-119. 8.Powers C. The influences of abnormal hip mechanics on knee injury: a biomechanical perspective. JOSPT. 2010;40;2:42-51 9.Ward SR. The architectural design of the gluteal muscle group: Implications for movement and rehabilitation. JOSPT. 2010;40;2:95-102. 10.Burnett SJ. Clinical presentation of patients with tears of the acetabular labrum. J Bone and Joint Surgery. 2006;88-A;7;1448-1457 11.Enseki KR. The hip joint: arthroscopic procedures and post-operative rehabilitation. JOSPT. 2006;36;7:516-525 12.Bharam S. Diagnosis and management of acetabular labral tears in the athlete. ISMJ. 2008;9;1:1-11 13.Philippon MJ. Rehabilitation after arthroscopic repair of intra-articular disorders of the hip in a professional football athlete. J Sport Rehab. 2009;18;118-134 14.Kuhlman GS. Hip impingement: identifying and treating a common cause of hip pain. American Family Physician. 2009;80;12:1429-1434. 15.Bharam S. Labral tears, extra-articular injuries, and hip arthroscopy in the athlete. Clin Sports Med. 2006;279-292. 16.Byrd JW. Hip arthroscopy in the athlete. Nth Am J Sport PT. 2007;2;4:217-230 17.Stalzer S. Rehabilitation following hip arthroscopy. Clin Sports Med. 2006;337-357. 18.Philippon MJ. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrrolabral dysfunction. J Bone Joint Surgery. 2009;91-B;16-23 Anterior right hip capsular mobilization with rectus femoris and iliospoas stretching. Shoulder block allows for contract-relax interventions. Anterior femoral head glide with 10-20 degrees abduction to avoid inferior acetabular loading. Addition of rectus manual stretch. Pillow to prevent excess lumbar extension in techniques. Hip IR mobilization through contralateral pelvic rocking once the end range barrier was established in IR of the right hip first. The Hip was taken into IIR firsts, medial knee stabilized then the pelvis rocked away from the right hip. Technique particular for this patient. posterior tissue stabilization of the femur with manual ER of the hip to lengthen the IR’s of the hip early in joint ROM. Combined inferior and posterior glides of the hip joint with belted mobilization with movement. The axilla catch of the knee allows for inferior glide whilst the belt allows for inferior translation as the femur is moved into progressive flexion. Long axis traction manipulation of the hip. In this patient extra care was taken to not let the femur ‘tap’ back on the acetabulum due to the delamination history. Eccentric IR, concentric ER with a moving Pilates reformer box set-up/. The Ball maintains hip spacing. Eccentric ER, concentric IR with a moving Pilates Reformer box set-up. Prone eccentric Hip ER, concentric IR on moving reformer box base. Prone eccentric hip IR, concentric ER on moving reformer box base. Bilateral strap hip circles.
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Poster presentation by Cameron MacDonald, Coordinator of the Regis University Fellowship in Manual Therapy program. This poster was presented at the 2010 American Academy of Orthopedic Manual Physical Therapy conference in San Antonio, TX.
Transcript of MacDonald - AAOMPT Hip Labrum Poster 2010
RETURN TO COMPETITION OF A COLLEGE HURDLER AFTER RESOLUTION OF LONG TERM HIP IMPAIRMENTS POST LABRAL REPAIR, USING HIP MOBILIZATION/MANIPULATION AND POSTERIOR HIP ECCENTRIC RETRAINING
Cameron W. MacDonald PT DPT GCS OCS FAAOMPT
Program Director/ Chief Fellow - Regis University Manual Physical Therapy Fellowship Program
Owner Beinn Sonas Physical Therapy Services
BACKGROUND & PURPOSE: There is growing interest in hip intra-articular impairments and pathologies. Hip surgery for hip labrum and intra-articular pathology is growing rapidly. Research though addressing rehabilitation post arthroscopic hip surgery is minimal, with no known research addressing prolonged mechanical impairments in this patient cohort. This case report demonstrates a successful impairment based approach to chronic right anterior hip/groin pain in a college level athlete, who had failed to return to participation in competitive events including long-jump and hurdling after hip labral and femoral head interventions.
DESCRIPTION: A 20 year-old female presented 19 months post surgery for labral dysfunction plus femoral head delamination, with persistent anterior hip/groin pain and an inability to return to hurdling and long jump. Original trauma was due to a fall during cheerleading in her sophomore year of high-school, with delayed identification of right hip intra-articular pathology over three years. A hip labral tear was identified pre-operatively, and arthroscopic examination at the time noted that the right femoral head was delaminated 75%. Chrondroplasty and osteoplasty were completed to address this lesion in conjunction with the labral repair. Subsequent rehabilitation was completed at the University she attends, with an attempted return to sports participation at approximately 12 months. Due to persistent groin pain and irritation to the right iliotibial band outside referral was made to Physical Therapy.
The initial examination noted impairments in anterior capsule mobility, restricted right hip flexor muscle length, hip external rotation (ER) restriction of 10 degrees and weakness in the posterior hip rotary muscles under eccentric and concentric loads. Weakness in the right hip posteriorly in the gluteus medius, gluteus minimus, adductors in extension and the medial hamstrings was graded at 4-/5. pain was rated at 9/10 with attempted participation in cross-country and athletic training.
The patient also presented with local pain in response to unilateral lumbar PA’s from the thoraco-lumbar junction down to the L5 level. There was an altered firing pattern in the right sided lumbar multifidi with the multifidi firing prior to the gluteal musculature in hip extension. A compensation was noted with right sided lumbar extension excessive with diminished right hip extension. No neurological signs were present through the lumbo-sacral plexus and through either lower extremity.
INTERVENTIONS: Specific interventions included traction manipulation of the right hip, belted mobilization with combined inferior and rotational glides of the right hip, prone hip internal rotation (IR) and ER mobilization and anterior glides of the hip joint with combined rectus femoris and iliospoas muscle stretching. Following the primary manual interventions, posterior neuro-motor retraining of the hip was completed. Eccentric retraining was emphasized, though concentric and proprioceptive neuro-muscular interventions were also utilized. A progression was made from neutral and at rest positions to more dynamic and unstable positions.
OUTCOMES: Following nine sessions of physical therapy, the patient was able to return to full competition without limitation, including all events in the heptathlon. Hip ER restriction was resolved and pain decreased in running from 9/10 to 1/10 with no limitations in a functional squat. Lumbar and the altered muscle recruitment resolved, with no ITB tenderness on firm palpation. The patient also returned to long jump, participation in the 400 meters and achieved personal best times and distances.
DISCUSSION-CONCLUSION: Rehabilitation post hip arthroscopy is currently focused on a four-step progression, with minimal consideration of delayed recovery. The current emphasis of hip labral rehabilitation is on assuring a smooth and stable intra-articular hip joint complex with optimal regional strength and range of motion. Manual interventions and posterior hip eccentric control is minimally addressed.
This case report identifies an impairment-based approach aimed at mobility restrictions and posterior hip rotary control deficits enabling a full return to athletic participation. Future research to further review the importance of these approaches in this patient cohort is warranted.
Manual Therapy Fellowship
One Patient’s Hip Journey…
A healthy hip, then a cheerleading fall.Three years of progressive dysfunction.
Surgical repair with interventions to address femoral head delamination.
Despite per protocol rehabilitation, unable to returnto competitive sports at College level.
Residual Impairments: noted 19 months post-operative.
Right hip groin pain with attempted hurdlingRight sided lumbar spine pain with training, especially running on uneven terrainPain rates on numeric pain rating scale to 9/10Restriction identified in manual examination of hip capsule anterior mobilityRight hip posterior soft tissue mobility impairments with ER restriction of 10 degreesOnly 4-/5 right hip muscle strength through the gluteal complex and deeper posterior hip musculatureRestricted right hip flexor mobility
Treatment Plan: impairment based interventions with functional re-assessments
Prognosis – unclear, unique case presentationTimeline considerations – 19 months post surgical interventions, healing that could occur in the joint considered complete. Irritability – low, but pain high post activity, and occasionally very sharp (first attempt at return to hurdles)Motivation – high, but very frustratedExternal factors – scholarship implications if unable to compete
Manual Interventions – a selection. Exercise Interventions – a selection
References:
1.Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007 Nov;37(11):658-60.2.Garrison JC. Rehabilitation after arthroscopy of an acetabular labral tear. N Am J Sports PT. 2007. 2;4;241-250.3.Fereidoon MJ. Hip pain in young adults. Femoroacetabular impingement. J Arthroplasty. 2007. 22;7:37-424.Kamath AF. Hip arthroscopy for labral tears. Am J Sports Med. 2009;37;9:1721-1726.5.Cook KM. Conservative Management of a young hip with hip arthrosis. JOSPT. 2009;39;12:858-866.6.Tonley JC. Treatment of an individual with piriformis syndrome focusing on hip muscle strengthening and movement re-education. A case report. JOSPT. 2010;40;2:103-111.7.Wagner T. Strengthening and neuromuscular re-education of the gluteus maximus in a triathlete with exercise-associated cramping of the hamstrings. JOSPT. 2010;40;2:112-119.8.Powers C. The influences of abnormal hip mechanics on knee injury: a biomechanical perspective. JOSPT. 2010;40;2:42-519.Ward SR. The architectural design of the gluteal muscle group: Implications for movement and rehabilitation. JOSPT. 2010;40;2:95-102.10.Burnett SJ. Clinical presentation of patients with tears of the acetabular labrum. J Bone and Joint Surgery. 2006;88-A;7;1448-145711.Enseki KR. The hip joint: arthroscopic procedures and post-operative rehabilitation. JOSPT. 2006;36;7:516-52512.Bharam S. Diagnosis and management of acetabular labral tears in the athlete. ISMJ. 2008;9;1:1-1113.Philippon MJ. Rehabilitation after arthroscopic repair of intra-articular disorders of the hip in a professional football athlete. J Sport Rehab. 2009;18;118-13414.Kuhlman GS. Hip impingement: identifying and treating a common cause of hip pain. American Family Physician. 2009;80;12:1429-1434.15.Bharam S. Labral tears, extra-articular injuries, and hip arthroscopy in the athlete. Clin Sports Med. 2006;279-292.16.Byrd JW. Hip arthroscopy in the athlete. Nth Am J Sport PT. 2007;2;4:217-23017.Stalzer S. Rehabilitation following hip arthroscopy. Clin Sports Med. 2006;337-357.18.Philippon MJ. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrrolabral dysfunction. J Bone Joint Surgery. 2009;91-B;16-23
Anterior right hip capsular mobilizationwith rectus femoris and iliospoas stretching. Shoulder block allows for contract-relax interventions.
Anterior femoral head glide with 10-20degrees abduction to avoid inferioracetabular loading. Addition of rectusmanual stretch. Pillow to prevent excesslumbar extension in techniques.
Hip IR mobilization through contralateralpelvic rocking once the end range barrierwas established in IR of the right hip first.The Hip was taken into IIR firsts, medial knee stabilized then the pelvis rocked awayfrom the right hip.
Technique particular for this patient. posterior tissue stabilization of the femurwith manual ER of the hip to lengthen theIR’s of the hip early in joint ROM.
Combined inferior and posterior glides ofthe hip joint with belted mobilization withmovement. The axilla catch of the knee allows for inferior glide whilst the belt allowsfor inferior translation as the femur is movedinto progressive flexion.
Long axis traction manipulation of the hip.In this patient extra care was taken to notlet the femur ‘tap’ back on the acetabulumdue to the delamination history.
Eccentric IR, concentricER with a moving Pilatesreformer box set-up/. The Ball maintains hip spacing.
Eccentric ER, concentricIR with a moving PilatesReformer box set-up.
Prone eccentric Hip ER,concentric IR on movingreformer box base.
Prone eccentric hip IR,concentric ER on moving reformer box base.
Bilateral strap hip circles.
