Physical Therapy Management of Femoroacetabular Impingement

Physical Therapy Management of Femoroacetabular Impingement
Femoroacetabular Impingement is a classified by an abutment of the femor and the acetabular rim. With this disorder, there is often repeated stress being put on the acetabular labrum or the adjacent cartilage. The positions where soft tissue is at the greatest risk involves hip flexion, adduction, and internal rotation. For more information on characteristics of this disorder see the main morphopedics page for FAI. Common patient symptoms for diagnosis include [1] - Pain experienced in the anterior groin area - The C sign - Described as dull and aching - Pain is worse with prolonged sitting - Occasional sharp catching pain with activity - Increase symptoms with hip flexion, adduction, and internal rotation. The following are limitations that Patients with a FAI may experience • Pain • Decreased ROM • Decreased muscle strength • Posture dysfunction • Impaired muscle performance • Limited function • Knowledge deficit regarding condition, self-management, home program, prevention Pattern 4D Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with connective Tissue Dysfunction. (Approximate range of number of visits per episode of care: 3 to 36) The following are Physical Therapy goals associated with FAI from the Guide to Physical Therapy Independent self-management of pain, posture, joint protection. Decrease pain Increase ROM Increase strength Improve gait efficiency and quality Maximize function and return to active lifestyle Independence with home exercise program Under this practice pattern the following are proposed interventions Aerobic capacity Balance, coordination, and agility training* Body mechanics and postural stabilization* Flexibility exercises* Gait and locomotion training* Relaxation Strength, power, and endurance training* These are interventions that should be considered for the specific diagnosis of FAI. See information below for more information. The following modalities are suggested by the Guide to Physical Therapy for this practice pattern. Cryotherapy Hydrotherapy Infrared Lazer Ultrasound Thermotherapy Compression Traction - For most severe impingements, surgery is the best option. To learn more about about the surgery check out the following sites. http://www.patrickbirminghammd.com/femoroacetabular-impingement.html. - Analgesics are also used to help address the pain associated with FAI. - TENS along with appropriate conservative treatment which is listed below maybe helpful in decreasing pain. Surgical treatment of AFI has been extremely effective. Research shows that the majority of athletes are able to return to their designated sport at a competitive level within 1.6 years. [2]It is important to recognize that the surgery should be followed by a rehabilitation treatment. The following guidelines should be implemented. PWB up to 20 lbs or toe touch WB status within the first 4 weeks to prevent the possibility of stress fracture to the femoral neck [3] [2] A hip brace to limit hip abduction and rotation for 10 days post op [2] CPM 0-90 degrees for 8 hours a day for up to 4 weeks [2] Physical Therapy exercises should be implemented within 4 hours of surgery (important to reduce the risk of adhesions) Active hip flexion exercises should be limited within the first 4 to 6 weeks of treatment to reduce the possibility of hip flexor tendonitis [3] [2] Abductor strengthening should be implemented immediately and continued in a HEP Impact activities such as running are not encouraged within the first 6 months [3] Post operative rehabilitation is extremely important for increased function outcomes. The general progression should be restoring passive ROM, followed by active ROM, and then strengthening. [4] For more information on post surgical treatment see the following site. Hip Flexors Hip internal rotators Hip adductors The goal of stretching should be to increase the area between the neck of the femor and the acetabular rim.[2] Structures to consider strengthening (approximately 30 minutes 3 times a week) Core musculature specifically the transverse abdominis Gluteal muscles Hamstrings The goal of strengthening should be to help posteriorly tilt the pelvis to increase the area between the femor and the acetabular rim. The following activities have been reported as being difficult for patients with FAI (ranked from more common complaints to less common) [3] - Heavy work (push/pull, climbing, carrying - Twisting - Squatting - Heavy-duty housework (moving furniture) - Walking for 15 min or more - Rise from a sitting position - Walking up steep hills - Light to moderate work (including standing/walking) - Getting into and out of an average car - Putting on shoes and socks - Low-duty housework (including cooking, dusting, vacuuming, and laundry) - Standing or sitting for 15 min - Getting into or out of bathtub - Going down a flight of stairs - Walking down steep hills These activities should be addressed in patient education on how to help avoid positions of pain. Activities that patients with FAI should avoid include [2] - end range stretching into flexion, adduction, and internal rotation. - Running on a treadmill or narrow straight trail (this prevents internal rotation of the lower extremity) - Upright cycling (this involves flexion combined with internal rotation of the hip) - Sitting with hips flexed and a neutral spine for long periods of time Activities a patients with FAI may consider include [2] - Zigzag and wide running courses (encouraging abduction and eternal rotation with turns) - Use of a recumbent bike (decreases flexion at the hip) - Lean back every 5 to 7 minutes when sitting for any length of time There is no real research on what modalities to use but the constant insult to the soft tissue leads to general inflammation, strains, and possibly sprains. The AAFP suggests that these conditions should be treated with rest, ice, and compression. [5] One thing to take into account is that compression is a suggested mechanism of injury for labral tears. Compressive force is not as significant on the labrum in non weight bearing situations, which implies that those are the situations where the compression should be applied to the soft tissue. [7] Pain for people with FAI is a result of insult to the soft tissue. It has been shown that transcutaneous electrical nerve stimulation is effective in relieving mild to moderate pain. [6] Education is one of the most important aspects of treatment when for patients who have an FAI. They must be aware of what activities and actions make their condition worse especially if they are not going to have it surgically repaired. There is no evidence that says Physical Therapy can reverse effects of FAI. There is some research that says PT can be used in combination with anti-inflammatory drugs to reduce hip pain and to avoid further cartilage damage. It is important that the patient is made aware that this issue can only be solved with surgery. Not all patients are a candidate for the surgery. Those, who have a mild impingement or are not a candidate for the surgery, should be taught to modify their activities of daily living to avoid further damage to the soft tissue. 1. Emara K, Samir W, Motasem E, & Gharfar K. Conservative treatment for mild femoroacetabular impingement. J of Ortho Surg. 2011; 19(1): 41-45. 2. Philippon M, Schenker M, Briggs K, & Kuppersmith D. Femoroacetabular impingement in 45 athletes: associated pathologies and return to sport following arthroscopic decompression. Knee Surg Sports Traumatol Arthrosc. 2007; 15(7): 908-914. 3. Clohisy J, & McClure J. Treatment of anterior femoroacetabular impingement with combined hip arthroscopy and limited anterior decompression.Iowa Orthop J. 2005; 25:164-171. 4. Philippon M, Briggs K, Yen Y, & Kuppersmith D. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: A minimum 2 year follow up. J Bone Joint Surg. 2009; 91(B):16-23. 5. O'Kane J. Anterior hip pain. Am Fam Physician. 1999; 60(6):1687-1696. 6. Jones I, & Johnson M. Transcutaneous electrical nerve stimulation. Contin Educ Anaesth Crit Care Pain. 2009; 9(4): 130-135. 7. Beck M, Kalhor M, & Leunig M. Hip morphology influences the pattern of damage to the acetabular cartilage. J Bone Joint Surg. 2005; 87:1012-18. Original article and pictures take http://morphopedics.wikidot.com/physical-therapy-management-of-femoroacetabular-impingement site