Young Adult Hip Pathology and FAI - c.ymcdn.com · Structures • Neurovascular ... – Under G....
Transcript of Young Adult Hip Pathology and FAI - c.ymcdn.com · Structures • Neurovascular ... – Under G....
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Young Adult Hip Pathology and FAI: Physical Therapy Management for
Non-Operative and Post-Operative Patients
Jill Monson, PT, OCS
Monson Orthopaedic Consulting, LLC
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BASICSCIENCE
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My “A-Ha” Moment • Closely observing dynamic squatting in
patients with primary c/o knee pain
• Knee squatters
• Cued to sit into hip flexionàCOULD NOT
• Put them on plinth for ROM and “A-Ha”
• Have you ever had groin pain or clicking at your hip?
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Poor, Lost Souls
• Young adult hip patients – Saw an average of 4.2± 2.9 health care
providers before a definitive diagnosis was made
– Experienced symptoms for a mean of 3.1 years prior to obtaining a definitive diagnosis
• Clohisy JC. Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement. Clin Orthop Relat Res 2009.
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Anatomy Exploration • Bony Construct
• Articular Surface
• Hip Capsule/Ligaments
• Musculotendinous Structures
• Neurovascular Structures
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Bony Anatomy of the Hip: Normal • Acetabulum:
– Ilium – Ischium – Pubis
• Femur: – Femoral head
• Fovea Capitus – Femoral Neck – Greater Trochanter – Lesser Trochanter
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Anatomy: Acetabulum
• Develops as early as 8 wks of gestation
• Fully formed by 11 weeks gestation – Watanabe R. Clin Orthop 1974
• Acetabular formation in response to presence of contact w/femoral head
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Acetabulum
• Triradiate cartilage at the confluence of ilium, ischium, pubis – Fuses fully by 16-18 y/o (**May be late)
• Ponseti J. Bone Joint Surg Am 1978
• VascularSupplytoAcetabulum:– InternalIliaca.
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FemoralHead&Neck
• VascularSupplyFemoralHead– Medialfemoralcircumflex
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AvascularNecrosis(AVN)
• TraumaHcAVNviadislocaHons– Medialcircumflexarteryistorn
• Non-traumaHcAVNAssociaHons– ETOH– Steroiduse– Chemotherapy
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Fibrocartilage: Acetabular Labrum
• Consists of both fibrocartilage and dense connective tissue
– Peterson W. Arch Orthop Trauma Surg 2003
• Creates a circumferential seal around the hip joint
• Nerve endings indicate nociceptive and proprioceptive capabilities @ labrum
• Kim YT. Clinic Orthop 1995 © Monson Orthopaedic Consulting, LLC
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Thickest@anterosuperiorrim(greatestloadshere)
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Acetabular Labrum Circumferential Seal of the Labrum
• Enhances joint stability through a suction effect and contributes to a fluid-enhanced force distribution
• Contributes to homeostasis at joint for lubrication, nutrition and load sharing with articular cartilage
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Labrum, Cont. • Blood supply via the obturator a., superior and inferior
gluteal aa., medial femoral circumflex a.
• Blood vessels only detected in the peripheral 1/3 of the labrum; internal portion avascular
– Peterson et al. immunostaining study; Arch Orthop Trauma Surg 2003
• Some capacity for labral healing has been observed in basic science and ovine experimental studies
– Seldes et al. Clin Orthop 2001 – Philippon Arthroscopy 2007 – Miozzari H Osteoarthritis and Cartilage 2004
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Capsular Anatomy
• Extends from acetabular rim to anterior intertrochanteric line at anterior aspect of proximal femur
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Capsular Anatomy: Ligamentous
3 Extra-articular ligaments
• All taut in extension • All lax in flexion
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Extra-capsular Ligaments • Iliofemoral (strongest, thickest)
– AIIS to anterior intertrochanteric line – Tight in ER and ADD
• Pubofemoral – Superior pubic ramus to inferior femoral neck – Tight in ER and ABD
• Ischiofemoral (weakest, thinnest) – Ischium to posterior inferior femoral neck – Tight in IR and ABD
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Extracapsular Ligaments
Anterior View Posterior View
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Intra-capsular: Ligamentum Teres
• Acetabular notch to fovus capitis (fovea) of femur – Tight in ADD, Flex, ER
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OtherLigamentousStructures• InguinalLigamant
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Bursae
• Trochanteric(“Gluteal”):– BetweentendonofG.Maxandgreatertrochanter
• Synoviallined,severallayersb/twtendonlayersofG.Med&Min
• Ischiogluteal:– UnderG.MaxjustposteriortoIschialTuberosity
• IliopecHneal:– BetweenPsoasMajortendonandIliopecHnealeminence
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Dermatomes
-HipJointisanL3structure
-Consider:Traveling/sweepingpain
vs.
Contained/localizedpain
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Hip Musculature • Tremendous functional cross-over at the hip
musculature
• Function contingent on: – Hip joint position – Trunk position – CKC/OKC function
• Tremendous interplay with proximal and distal segments – Pelvis, L-spine, Knee joint
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Musculature: Flexors • Psoas Major & Iliacus (Iliopsoas)
– Flex, ADD, ER
• Tensor Fascia Latae – Flex, ABD, IR
– Rectus Femoris
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Muscles:Extensors
• Gluteus Maximus – ABD, Ext, ER
• Hamstrings
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Musculature: Abductors – Gluteus Maximus
• ABD, Ext, ER
– Gluteus Medius • Anterior Fibers
– ABD, Flex, IR • Posterior Fibers
– ABD, Ext, ER
– Gluteus Minimus • ABD, IR
– TFL • ABD, Flex, IR
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Musculature: Adductors – Adductor Magnus – Adductor Longus
• ADD, Flex, ER
– Adductor Brevis • ADD, Flex, ER
– Gracilis • ADD, Ext, IR
– Pectineus • ADD, Flex, ER
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Musculature
• Adductor Magnus – Pubic ramusàLinea Aspera
• Flex, ADD, ER
– Isch TubàADD tubercle • Ext, ADD, IR
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Musculature: Deep External Rotators
• Obturator internus • Obturator externus • Superior gemellus • Inferior gemellus • Piriformis • Quadratus femoris
*All but Piriformis ADD hip *Think rotator cuff
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Musculature: Deep Internal Rotators
• Gluteus Medius – Anterior fibers
• Gluteus Minimus
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PalpaHon:AnteriorPelvis
• ASIS– TFLorigin– Sartoriusorigin– Inguinalligament
• AIIS– RectusFemorisorigin
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*Note*
• RectusFemoris– AppreciatetheproximityofitsoriginattheAIIStotheanterosuperioraspectoftheacetabulum
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PalpaHon:PosteriorPelvis
• Sacralborder– Gluteusmaximusorigin
• IliacWing– Gluteusmediusorigin– Gluteusminimusorigin
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GluteusMaximus• Origin
– Sacrum,dorsalsacroiliacligaments,smallareaofiliumnearPSIS,sacrotuberousligament
• InserHon– Upper½@lateralporHonofTFL,ITB– Lower½@dividedinserHonintoITBanddeeperfibersattheglutealtuberosity(lateralextensionoflineaaspera)
• BursabetweentendonandGT
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GluteusMedius
• Origin– Mostlyliesundertheglutmax,butanteriorfibersarenotcovered
– Upperlateralsurfaceoftheiliacwing(b/twA/Pgluteallines)&anteriorlyatthefascia
• InserHon– Greatertrochanter
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GluteusMinimus
• Origin– Lowerpartoflateralsurfaceofwingofilium(b/twanteriorandinferiorgluteallines)
• InserHon– GreaterTrochanter
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Piriformis
• Origin– Pelvicsurfaceofsacrum
• InserHon– InnersurfaceofupperpartofGT– FillsthesciaHcforamen
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PalpaHon:PosteriorPelvis
• IschialTuberosity– Semitendinosis
• Nearsacrotuberouslig.InserHon
– BicepsFemoris• Mostlateral
– AdductorMagnus• Mostmedial
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PalpaHon:PubicRegion• PubicTubercle(anterosuperiorsurfaceofpubicbody)
– Rectusabdominus(Superiorly)– Inguinalligament(Laterally)– Adductorlongus(Inferiorly)
• SuperiorPubicRamus– PecHneus
• InferiorPubicRamus– Gracilis– AdductorMagnus(atbonysegwaytoischialramus)
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PalpaHon:ProximalFemur
• Greatertrochanter(superior&posterioraspect)– GluteusmediusinserHon– GluteusminimusinserHon
• Justanteriortomedius
• GlutealTubercle(justdistaltogreatertrochanter)– GluteusmaximusinserHon
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PalpaHon:ProximalFemur
• Posteriortrochantericfacet– DeephiprotatorsinserHonpoint
• LesserTrochanter– Iliopsoas
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LAB:Palpa*on
• ASIS– Resistedhipflexion+IR(TFL)
• AIIS– Resistedhipflexion(RectusFemoris)
• PubicBone– ResistedhipADD(ADDlongus,PecHneus,Gracilis)
• IschialTuberosity– Resistedkneeflexion(Hamstring)
• GreaterTrochanter– ResistedhipABD
• Proximal:Gluteusmedius• Distal:Gluteusmaximus
• IliacCrest– ResistedhipABD(Gluteusmedius,minimus)
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Biomechanics vs. Kinematics
• Biomechanics – “I see dead people”/anesthetized
• Biomechanical laboratory studies – Dissected cadaver Hips: Hemi-pelvis, transected femurs
• Kinematics – “I see living people”
• Motion analysis laboratory kinematic studies – Real, moving humans with completely intact proximal and
distal anatomy and active musculoskeletal interactions
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Surgery vs. Rehabilitation • What can a surgeon change with their tool
set? – Bony anatomy – Ligamentous, Fibrocartilage fixation
• What can a physical therapist change? – Dynamic muscular control
• Strength, proprioception – Static Tissue quality:
• Stretching, joint/soft tissue mobilizations
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In Vivo Hip Joint Force Measurements Bergmann G, Deuretzbacher G, Heller M, et al. Hip contact forces and gait patterns from routine activities.
Journal of Biomechanics 2001.
• Implanted pressure transducers with THA components
• All forces acting on the hip accounted for • Muscle tension • Ligamentous tension • WB load
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Bergmann Study, cont. • In vivo hip joint force measurements
– 300% BW with slow walking – 350-400% BW with quick walking – Up to 500% with jogging – 800% during “stumbling”
– 2 legged stance = 80-100% BW • Attributed to persistent muscle tension at hips
during FWB stance
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Gait Kinematics: Stance • Initial Contact
– 30 deg hip flexion • Loading Response
– 30 deg hip flexion – 5-10 deg ADD, IR
• Mid-stance – 0 deg flex/ext
• Terminal Stance – 10 deg hip extension – Neutral ABD/ADD
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Stance, Cont. • 3-D Musculoskeletal Models
– Hip joint contact forces directed anteriorly during the last 20-30% of stance
• Stansfield and Nicol. Clinical Biomechanics 2002
– Important consideration for: • Injury location at labrum • Observing and progressing gait with non-op
and post-op rehabilitation
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Gait Kinematics: Swing
• Initial Swing – 20 deg hip flexion
• Midswing: – 20-30 deg hip flexion – 5 deg ABD
• Terminal swing – 30 deg hip flexion
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Warning:
We are now leaving the world of normal hips
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FAI FAI = Femoral Acetabular Impingement
• First described by Ganz in 1995 (Bern, Switzerland)
• Not published/presented in English literature until 1999
Myers SR, Eijer H, Ganz R. Anterior femoracetabular impingement after periacetabular osteotomy. Clinical Orthopaedics and related research
1999.
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Femur: Cam Deformity
• Pathology at the femoral head and/or head-neck junction
– Asphericity of the femoral head
– Decreased femoral head-neck offset
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CamDeformity• RadiologicDefiniHon:
– Crosstablelateral&Frogleglateralradiographs• Alphaangle• >50.5degreesconsidered(+)forcamdeformity
– NotzliHPetal.JBJSBr2002
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Radiology:AlphaAngle
• Perfectcirclearoundfemoralhead
• Drawlinealongthecenteroffemoralneck
• Otherlineatthecenterofthefemoralhead– Compareanglegeneratedb/twthoselines
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CamDeformityImpingement
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Acetabulum: Pathoanatomy • Acetabulum:
– Pincer Impingement (3 types) • Focal anterior overcoverage
– Associated with normal superior and posterior acetabular coverage
• Relative anterior overcoverage – Acetabular retroversion (normal=20-40° anteversion) – Decreased posterior coverage
• Global acetabular overcoverage – Coxa profunda – Protusio acetabuli
» Larson, C Sport Med Arthrosc Rev 2010
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Pincer Deformity • Acetabular overcoverage
of the femoral head
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AcetabularPathology
• Profunda(Deep)– Baseofthenotchispasttheilioischialline– Headisseateddeepintheacetabulum/pelvis
• Protrusio(Deeper)– Femoralheadispasttheilioischialline– Morepronouncedovercoverage– DeeperseaHngoffemoralheadwithinthepelvis/acetabulum
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Radiology:LateralCenterEdgeAngle
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PincerDeformityImpingement
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Other Bony Variables at the Femur • Anteversion:
– Rotation of the femoral neck relative to the shaft – Normal=10-15° anteversion – Abnormal is usually increased anteversion
(W-sitters) • Neumann DA. Mosby 2002
• Angle of Inclination: – Angle b/tw femoral neck and shaft of femur – Normal=125° – Dysfunction may be a higher or lower angle (Coxa Vara/Valga)
• Coleman SS. Mosby 1978
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OtherBonyHipPathology
• Slippedcapitalfemoralepiphysis
• AvascularNecrosis
• Legg-Calve-Perthesdisease
• “Dysplasia”
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FAI
• Most commonly presents as combined bony pathologies at both the femur and acetabulum
• Beck M et al. JBJS Br 2005 • Allen D et al. JBJS Br 2009
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Male:Female
• “Pure”camdeformitymorecommonlyobservedinmales
• “Pure”pincerdeformitymorecommonlyobservedinfemales
– BeckM,KalhorM,LeunigM,GanzR.JBJSBr2005
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EHology:CamDeformity
• Sub-clinicalslippedcapitalfemoralepiphysis(SCFE)
• FraitzlCRetal.JBJSBr2007• GoodmanDAetal.JBJSAm1997
• Growthabnormalityattheepiphysis
• SiebenrockKAetal.ClinOrthopRelatRes2004
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CamDeformity:Healthy,AsymptomaHcPopulaHon
Cam-TypeFAIbonyalignmentobservedinINDIVIDUALSWITHOUTHIPPAIN
• CopenhagenOsteoarthriHsStudy(N=3,202)– Cam-typeFAIresentin17%ofasymptomaHcmen– Cam-typeFAIpresentin4%ofasymptomaHcwomen
• GosvigKKetal.ActaRadiol2008
• HackKetal.JBJSAm2010(N=200)– Presentin25%ofasymptomaHcmen
• OfthepopulaHonfoundw/CamtypeFAI,79%weremale– Presentin5%asymptomaHcwomen
• Laborieetal.,Radiology2011(N=2081)– PrevalenceofCam-typemorphologyinhealthypopulaHon– 35%ofMales,10%ofFemales
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CamDeformity• Elitemaleandfemale
soccerplayers(N=95)– 67%prevalenceofFAI– Cam-typeFAI:68%Males,
50%Females– Meanalphaangle
Males=66°,Females=53°• Gerhardtetal.,AJSM2012
• Higherprevalence(89%)inbasketballplayersw/historyofhighintensityplayduringadolescence
• SibenrockKAetal.ClinOrthopRelatRes2011
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CamDeformity• Malecollegiatefootballplayers
(N=67)– 95%FAI– >70%cam-typeFAI
• Petersetal,JBJSAm2011
• NFLprospects(NFLCombine)(N=239)– 90%radiographicFAI– 75%Cam-typeFAI
• Larsonetal.,(SubmiOedArthroscopy2012)
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“FuncHonalHipImpingement”??
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EHology:PincerDeformity
• Pincerdeformitytheories– Retrotorsionofthehemipelvis– Congenital/developmental
• Hipdysplasia– Congenital– Males4.3%– Females3.6%
• (CopenhagenCohort)Gosvigetal.,JBJSAm2010
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PincerDeformity• Leunigetal.,CORR2009
– CohortofOAptswithprotrusio(globalovercoverage)
– 87%(27/31pts)ofprotrusioptswerefemale
• CopenhagenCohort(N=3620)
– Coxaprofunda&protrusio• 19.4%ofFemales• 15.2%ofMales
– Globalovercoverage=riskfactorforthedevelopmentofOA
– Gosvigetal.,JBJSAm2010
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DevelopmentalHipDysplasia• Morecommoninfemales:
– 78childrenwithDDH• 17.9%Males&82.1%Females
– Milasinovicetal.,ActaChirTraumatolCech2011
– 3613randomlyselectednewborns(USeval)• HigherproporHonofgirlsvsboyshadimmaturehips,minordysplasia(4.5%vs1.0%),&majordysplasia(1.2%vs0.2%)
– Rosendahletal.,PediatrRadiol1996
– 8145infants(clinicalexaminaHon)• FemalegendersignificantriskfactorforDDH
– Stein-ZamirCetal.,PediatrInt2008
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OAProgressionData
• Caucasions/EuropeanDescent
• Males>Females(slight)
• Obesityassociatedw/fasterprogressionofOAratherthanonset
• CibulkaMRetal.JOSPT2009
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ClinicalCriteriaforOADiagnosis
• HipIR<15degreesalongwith:– Hipflex≤115deg– Age>50y/o
OR• HipIR≥15degalongwith:
– Painw/hipIR– DuraHonofmorningsHffnessofhip≤60min– Age>50y/o
– AmericanCollegeofRheumatology– CibulkaMRetal.JOSPT2009
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OAProgression
• AcetabularlabralpathologysecondarytoFAIisaprecursortoearlyonsethipOA
• BeaulePEetal.JOrthopRes2005• BeckMetal.JBJSBr2005• KimKCetal.ClinOrthopRelatRes2007• McCarthyJetal.ClinOrthopRelatRes2003• McCarthyJCetal.ClinOrthopRelatRes2001• MurphySetal.ClinOrthopRelatRes2004• PfirrmanCWetal.Radiology2006• TanzerM,NoiseuxN.ClinOrthopRelatRes2004• TonnisD,HeineckeA.JBJSAm1999
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Synovial/CapsularCondiHons
• Osteochondromatosis
• PigmentedvillonodularsynoviHs
• SynoviHs
• CapsularInstability
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Capsular Pathology
• Atraumatic Capsular Laxity
– Global • Connective tissue disorders
– Focal Rotational • Results from excessive, forceful hip external
rotation • Can lead to iliofemoral ligament insufficiency • Can contribute to increased stress at the labrum
– Philippon MJ. Clin Sports Med 2001
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LabralPathology
• MostcommonbonyabnormaliHesassociatedw/labralpathology:– Acetabularretroversion
– Decreasedfemoralhead-neckoffset(Cam)
– CoxaValga • Wegneretal.ClinOrthopRelatRes2004
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Labral Tears
• Anterior Tears – More common in US and European countries
– May be due to poorer vascular supply at anterior labrum
• McCarthy et al. Clin Orthop 2001
– This region has the least bony constraint of femoral head anteriorly
• Rely on labrum, capsule and ligaments for stability
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LabralTears
• Posterior Tears
– More common in Japan
– Different lifestyle: more squatting, floor sitting
• Hase T. Arthroscopy 1999
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Articular Surface Pathology
• Labrum – Tearing – Detachment – Cystic changes
• Articular Cartilage – Localized lesions: Gr I-IV – Delamination
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Chondral Pathology
• 73% of patients with labral pathology have chondral damage
– McCarthy et al. Clin Orthop Relat Res 2001
• Presence of chondral lesions of the femur or acetabulum is associated with poorer prognosis following hip scope
– Byrd JW. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy. 2000
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Soft Tissue Pathoanatomy • Tendinopathy
• Snapping Hip Syndrome Iliopectineal Eminence
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ClinicalImaging
• RadiologyGoldStandards– A/PPelvis(standardized)– Falseprofileview
• Standingoblique• Showsanteriorcoverageofacetabulum
– Crosstablelateral– Frogleglateral
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ClinicalImaging
• MRIGoldStandards– Arthrogramw/gatolinium
– Highquality3TMRI