Combining results from hip impingement and range of motion tests can increase diagnostic accuracy in patients with FAI syndrome

Clinical Presentation Differences Among Four Subtypes of Femoroacetabular Impingement: A Case-Control Study

OBJECTIVE

The aims of this study were to assess the psychological, functional, and physical differences between patients with femoroacetabular impingement (FAI) syndrome and individuals who were asymptomatic (controls) to analyze clinical differences among 4 subtypes of FAI (cam type, cam type with labral tear, pincer type, and pincer type with labral tear), to calculate the correlations among the variables described, and to identify risk factors contributing to the hip function variance.

METHODS

A case-control study was conducted at a hospital rehabilitation unit with a cohort of individuals who were asymptomatic (controls) and a cohort of patients with FAI. Sociodemographic characteristics, pain intensity, psychological health status, hip range of motion (RoM), hip isometric strength, and hip function were assessed.

RESULTS

A total of 69 controls and 69 patients with FAI were analyzed. Although sociodemographic characteristics were comparable between samples, poorer hip RoM, strength, and psychological health were found for the cases. FAI subtypes showed no significant pain intensity, psychological health, or RoM differences (except for hip adduction), but hip strength differed among FAI subtypes. Multiple significant correlations between psychological health, pain intensity, RoM, strength, and hip function were found. The variance values of the International Hip Outcome Tool, Hip Outcome Score (HOS) for daily living activities, and HOS for sports activities were partially explained (47.6%, 36.0%, and 21.6%, respectively) on the basis of kinesiophobia, hip strength, self-efficacy, and anxiety.

CONCLUSION

Patients with FAI showed poorer psychological health, hip RoM, and strength than individuals who were asymptomatic and had similar sociodemographic characteristics. FAI subtype influenced the patients' clinical presentations. Hip strength, kinesiophobia, anxiety, and self-efficacy should be targeted for improving hip function, as they have been demonstrated to be important contributors to hip disability.

IMPACT

This study demonstrated that pain catastrophizing, hip strength, and hip adduction differed among FAI subtypes. However, hip function and pain intensity were comparable between FAI subtypes.

Increased Duration and Intensity of Physical Activity Are Associated With Increased Pain in Individuals With Femoroacetabular Impingement Syndrome: An Ecological Momentary Assessment Study

OBJECTIVE

To investigate the relation between accelerometer-measured physical activity and real-time pain in individuals with femoroacetabular impingement syndrome (FAIS). We tested the hypothesis that increased duration of high intensity activity would contribute to momentary increases in pain.

DESIGN

Observational study.

SETTING

Participants' natural, day-to-day environment.

PARTICIPANTS

Population-based sample of 33 individuals with unilateral FAIS. Important eligibility criteria included no concomitant hip disorders or previous hip surgery. Key sociodemographic features include that all participants were required to have a smartphone.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Duration and intensity of physical activity as measured by a waist-worn accelerometer, and instantaneous pain reported in real-time smartphone-based ecological momentary assessment surveys. Physical activity variables included each person's average sedentary time, light physical activity (LPA), and moderate to vigorous physical activity (MVPA) in the 90 minutes proceeding all pain surveys as well as fluctuation in sedentary, LPA, and MVPA above or below average prior to each individual survey.

RESULTS

Linear mixed models revealed that the significant predictors of pain included fluctuation in sedentary time (B=-0.031, P<.001), average LPA (B=0.26, P=.035), and the interaction between fluctuation in LPA and fluctuation in MVPA (B=0.001, P<.001). Fluctuation in sedentary time above a person's average was associated with lower pain, while average LPA and fluctuations above average in both LPA and MVPA were associated with higher pain.

CONCLUSIONS

These results suggest that individuals with FAIS can engage in health-enhancing MVPA but should focus on avoiding concurrent increase above average in both high intensity and LPA in the same 90-minute period. Future work is warranted testing the efficacy of such an approach on pain. Additionally, given that high levels of LPA may arise from a host of socioeconomic factors, additional research is needed to disentangle the effect of LPA on pain in FAIS.

Unravelling the hip-spine dilemma from the CHECK-cohort: is sagittal pelvic morphology linked to radiographic signs of femoroacetabular impingement?

INTRODUCTION

To date the aetiology of femoroacetabular impingement (FAI) is still not completely understood. There are mechanical theories that suggest symptomatic FAI is linked to sagittal pelvic morphology and spinopelvic-femoral dynamics. The aim of this study is to evaluate the relation of sagittal pelvic morphology and orientation to radiographic signs of FAI. Additionally, we test whether the relation between FAI and spinopelvic parameters differs in osteoarthritic hips.

METHODS

From a prospective, observational cohort study, 1002 patients between 45 and 65 years old with a first episode of knee or hip pain were followed for 8 years. All patients who had lateral lumbar radiographs and clinical and radiographic follow-up of the hips were included in the present study. Range of internal rotation of the hip as well as radiographic signs of FAI (alpha and Wiberg angle) and presence of hip osteoarthritis (Kellgren and Lawrence) were systematically measured at baseline. Pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS)) were measured at 8-year follow-up. Associations between PI, PT, SS and FAI parameters were tested using generalised estimating equations.

RESULTS

421 subjects, 842 hips, were included. No significant relations between PI, PT or SS and alpha or Wiberg angle were found. Comparison of hips with and without radiological sign(s) of FAI showed no differences in PI, PT or SS. There was no relation between range of internal rotation of the hip and spinopelvic parameters.

CONCLUSION

Sagittal pelvic morphology and orientation are not related to the presence of radiological signs of FAI in this study population.

Validity and Reliability of Inertial Measurement Units in Active Range of Motion Assessment in the Hip Joint

Measuring joint range of motion has traditionally occurred with a universal goniometer, inclinometer, or expensive laboratory systems. The popularity of the inertial measurement unit (IMU) is growing, enabling the small and even single portable device to measure the range of motion. Until now, they were not used to assess hip joint range of motion. Our study aimed to check the validity of IMUs in assessing hip range of motion and compare them to other measurement devices-universal goniometer and inclinometer. Twenty participants completed three hip movements (flexion in standing and prone internal and external rotation) on both hips. Two testers independently assessed each movement with a goniometer, digital inclinometer, and IMU at different time points. To assess the agreement of active hip ROM between devices, Intraclass Correlation Coefficient (ICC) and Bland-Altman analysis were used. Furthermore, inter-rater and intra-rater reliability were also assessed by using ICC and Bland-Altman analysis. Limits of agreement (LOA) were calculated using Bland-Altman plots. The IMU demonstrated good to excellent validity (ICC: 0.87-0.99) compared to the goniometer and digital inclinometer, with LOAs < 9°, across all tested movements. Intra-rater reliability was excellent for all devices (ICC: 0.87-0.99) with LOAs < 7°. However, inter-rater reliability was moderate for flexion (ICC: 0.58-0.59, LOAs < 22.4) and poor for rotations (ICC: -0.33-0.04, LOAs < 7.8°). The present study shows that a single inertial measurement unit (RSQ Motion, RSQ Technologies, Poznan, Poland) could be successfully used to assess the active hip range of motion in healthy subjects, comparable to other methods accuracy.

Arthroscopy Confers Favorable Clinical Outcomes in Asian Patients with Borderline Developmental Dysplasia of the Hip

OBJECTIVE

Hip arthroscopy has recently appeared as a successful therapy in treating borderline developmental dysplasia of the hip (BDDH). This study aimed to describe the minimal 2-year follow-up after hip arthroscopy for patients with BDDH in the Asian population and use the combination of lateral center edge angle (LCEA) and alpha angles to detect the appearance of impingement in the BDDH population.

METHODS

This retrospective investigation was conducted utilizing information from arthroscopically treated BDDH patients in 2018 and 2019. The following patient-reported outcomes were reported: modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living, International Hip Outcome Tool 12-component form, and Visual Analog Scale. We also considered the clinical data regarding radiological measurements, intraoperative findings, interventions, complications, and subsequent surgical revisions, in the analysis of combination angles in detecting the occurrence of impingement. Patients with asymptomatic contralateral hips from traumatic hip injury (pelvic fracture) served as the control group. A 2:1 propensity score matching was based on age, sex, and BMI. A receiver operating characteristic curve (ROC) was used to identify the thresholds of combination angles and their accuracies.

RESULTS

A total of 77 hips met the inclusion and exclusion requirements. After the follow-up period, most patients showed a considerable improvement in patient-reported outcomes compared to their preoperative values (P < 0.001 for all). The overall rate of complications was 5.2%, whereas the rate of revisions was 3.9%. Increasing preoperative alpha angle age was significantly positively correlated with improving patient-reported outcomes. The combined angle cut-off was determined to be 80.5° (AUC, 0.858; 95% CI: 0.757-0.938; sensitivity (SE), 98.1%; specificity (SP), 74.1%; P < 0.001) for the occurrence of impingement in BDDH population.

CONCLUSION

Good patient-reported outcomes and low revision rates can be expected in the BDDH population with careful selection of patients in Asian populations. A combination angle >80.5° could be a reliable predictive factor of impingement in BDDH populations.

Does femoroacetabular impingement syndrome affect range of motion? A systematic review with meta-analysis

BACKGROUND

It is unclear whether femoroacetabular impingement syndrome (FAIS) affect hip range of motion (ROM).

SOURCES OF DATA

We performed a systematic review with meta-analysis searching six electronic databases from inception to March 21, 2022. We included studies assessing hip ROM in FAIS, FAI morphology without symptoms (FAIm), and healthy controls. Mean differences between groups were measured in ROM degrees with 95% confidence interval (CI).

AREAS OF AGREEMENT

A total of 17 studies (1702 hips) were included. Comparison of FAIS patients versus healthy controls showed that hip ROM was clinically and statistically reduced in FAIS for internal rotation (90° hip flexion, -8.01°, 95% CI: -11.21, -4.90; 0° hip flexion -6.38°, 95% CI: -9.79, -2.97); adduction (90° hip flexion, -4.74°, 95% CI: -8.13, -1.34); flexion (-5.41°, 95% CI: -7.05, -3.49), abduction (0° hip flexion, -5.76°, 95% CI: -8.38, -3.23), and external rotation (90° hip flexion, -3.5°, 95% CI: -5.32, -1.67) ranging from low to high certainty of evidence. Comparison of FAIm versus healthy controls showed no statistically significant differences in any direction of movement, albeit with uncertainty of evidence.

AREAS OF CONTROVERSY

The certainty of evidence was unclear, particularly for asymptomatic FAIm.

GROWING POINTS

Hip ROM may be reduced in all directions except extension in FAIS compared to controls. Hip ROM may not be restricted in asymptomatic FAIm.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further studies are needed to resolve the uncertainty of evidence about ROM restrictions in asymptomatic FAIm compared to healthy controls.

Hip muscle strength in male and female patients with femoroacetabular impingement syndrome: Comparison to healthy controls and athletes

OBJECTIVES

To examine hip muscle strength deficits in patients with femoroacetabular impingent syndrome (FAIS), with special emphasis on potential sex- and comparison-related (between-subject vs within-subject) differences.

DESIGN

Cross-sectional comparative study.

PARTICIPANTS

Forty FAIS patients (20 women), 40 healthy controls (20 women) and 40 athletes (20 women).

MAIN OUTCOME MEASURES

Hip abduction, adduction and flexion isometric strength was tested using a commercially-available dynamometer. Two between-subject comparisons (FAIS patients vs controls and FAIS patients vs athletes) and one within-subject comparison (inter-limb asymmetry) of strength deficits were conducted, based on the calculation of respective percent differences.

RESULTS

For all hip muscle groups, women were 14-18% weaker than men (p < 0.001), but no sex-related interactions were observed. For all hip muscle groups, FAIS patients were 16-19% weaker than controls (p = 0.001) and 24-30% weaker than athletes (p < 0.001). For FAIS patients, the involved hip abductors were 8.5% weaker than the uninvolved ones (p = 0.015), while no inter-limb asymmetry was observed for the other hip muscles.

CONCLUSION

Sex had no influence on hip muscle strength deficits in FAIS patients while a major impact of comparison method/group was observed. Hip abductors showed consistent deficits for all comparison methods, suggestive of a possible greater impairment compared to hip flexors and adductors.

Pain provocation tests and clinical entities in male football players with longstanding groin pain are associated with pain intensity and disability

BACKGROUND

Clinical examination of male football players with longstanding groin pain can be considered difficult. Pain provocation tests are used to examine and classify longstanding groin pain into clinical entities as adductor-, iliopsoas-, inguinal-, and pubic-related. It is unknown if pain provocation tests and clinical entities are associated with pain intensity and disability.

OBJECTIVES

To investigate if the number of positive pain provocation tests and clinical entities are associated with pain intensity and disability, measured by the Copenhagen 5-Second Squeeze Test (5SST) and the Copenhagen Hip and Groin Outcome Score (HAGOS), respectively.

DESIGN

Cross-sectional.

METHOD

Forty male football players (age: mean 24 years [SD: 3.2]; height: mean 182 cm [SD: 5.7]; weight: mean 78 Kg [SD: 6.6]) with longstanding groin pain for a median of 8.5 months (IQR: 4-36) were included. The players underwent a bilateral groin examination with 33 pain provocation tests and were classified with clinical entities (0-7) based on the test findings.

RESULTS

The number of positive pain provocation tests (median 10, range 2-23) correlated with pain intensity (5SST: rs = 0.70 [95% CI: 0.50, 0.83]) and disability (HAGOS subscales Sport: rs =-0.62 [95% CI: -0.81, -0.36], Pain: rs = -0.38 [95% CI: -0.69, -0.06], Symptoms: rs = 0.52 [95% CI: -0.73, -0.24], ADL: rs = -0.48 [95% CI: -0.71, -0.18]). The number of clinical entities (median 3, range: 1-7) showed similar but weaker correlations to pain intensity and disability.

CONCLUSIONS

In male football players with longstanding groin pain, the number of positive pain provocation tests and clinical entities shows weak to strong correlations with pain intensity and disability. Consequently, when pain intensity and disability are severe, a higher number of pain provocation tests may be positive, and more clinical entities may be present.

Diagnostic Accuracy of Clinical Tests and Imaging Exams for Femoroacetabular Impingement: An Umbrella Review of Systematic Reviews

OBJECTIVE

To synthesize available evidence about diagnostic accuracy of clinical tests and imaging examinations for femoroacetabular impingement (FAI) syndrome.

DESIGN

Umbrella review.

SETTING

N/A.

PARTICIPANTS

N/A.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Systematic reviews (SR) indexed in Embase, LIVIVO, PubMed, SCOPUS, the Cochrane Library, and Web of Science were searched in a 2-phase process. SR assessing diagnostic accuracy were considered eligible.

RESULTS

From 1520 studies, 6 SR were included, which evaluated 24 primary studies related to FAI syndrome. Of these, 5 SR assessed clinical tests, and a substantial heterogeneity was found concerning reference standards adopted across primary studies, which included arthroscopy, clinical examination (associated or not with imaging exams), intra-articular injections, and open surgery. Most clinical tests presented higher values of sensitivity compared with specificity, although evidence was considered limited because the same primary studies were often included across SR. Nonetheless, evidence around the flexion adduction internal rotation (FADIR) test was considered stronger and its use as a screening tool was consistently supported. Only one SR assessed the accuracy of imaging examinations, which adopted open surgery as the sole reference standard. Most imaging exams presented considerably high values of sensitivity, although specificity values were notably lower.

CONCLUSIONS

No robust recommendations can be provided for most clinical tests, although the FADIR test, in particular, was consistently supported as a screening tool. Moreover, although imaging examinations showed considerably high sensitivity values, evidence was considered sparse and further research is strongly recommended to validate its use as reference standards for diagnostic accuracy data.

Does Femoroacetabular Impingement Syndrome Affect Self-Reported Burden in Football Players With Hip and Groin Pain?

BACKGROUND

It is unknown if football players with femoroacetabular impingement (FAI) syndrome report worse burden than those with other causes of hip/groin pain, and to what extent this is mediated by cartilage defects and labral tears.

HYPOTHESIS

Football players with FAI syndrome would report worse burden than other symptomatic players, with the effect partially mediated by cartilage defects and/or labral tears.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

Football (soccer and Australian football) players (n = 165; 35 women) with hip/groin pain (≥6 months and positive flexion-adduction-internal rotation test) were recruited. Participants completed 2 patient-reported outcome measures (PROMs; the International Hip Outcome Tool-33 [iHOT-33] and Copenhagen Hip and Groin Outcome Score [HAGOS]) and underwent hip radiographs and magnetic resonance imaging (MRI). FAI syndrome was determined to be present when cam and/or pincer morphology were present. Cartilage defects and labral tears were graded as present or absent using MRI. Linear regression models investigated relationships between FAI syndrome (dichotomous independent variable) and PROM scores (dependent variables). Mediation analyses investigated the effect of cartilage defects and labral tears on these relationships.

RESULTS

FAI syndrome was not related to PROM scores (unadjusted b values ranged from -4.693 (P = 0.23) to 0.337 (P = 0.93)) and cartilage defects and/or labral tears did not mediate its effect (P = 0.22-0.97).

CONCLUSION

Football players with FAI syndrome did not report worse burden than those with other causes of hip/groin pain. Cartilage defects and/or labral tears did not explain the effect of FAI syndrome on reported burden.

CLINICAL RELEVANCE

FAI syndrome, cartilage defects, and labral tears were prevalent but unrelated to reported burden in symptomatic football players.

Characteristics of Biomechanical and Physical Function According to Symptomatic and Asymptomatic Acetabular Impingement Syndrome in Young Adults

Femoroacetabular impingement (FAI) is caused by hip joint anomalies. Although asymptomatic and symptomatic FAI have been reported in young adults, information on biomechanical and functional characteristics of FAI is rare. We compared the subjective hip score, range of motion (ROM), dynamic balance, and hip strength between symptomatic FAI (FAIsym) and asymptomatic FAI (FAIasym) groups and healthy controls. Participants (n = 307; men: 155, women: 152) were classified according to morphological abnormalities and hip joint symptoms, comprising symptomatic FAI, asymptomatic FAI, and healthy controls. The Copenhagen Hip and Groin Outcome Score (HAGOS), hip ROM, Y-balance test (YBT), and isokinetic hip strength were measured. The types of FAI were not significantly differenent in both men and women. FAIsym exhibited significantly reduced HAGOS, whereas FAIasym showed no significant difference compared to the healthy group (men: healthy 91.7 vs. FAIasym 87.2 vs. FAIsym 49.9, women: healthy 91.7 vs. FAIasym 86.2 vs. FAIsym 53.9). Hip flexion, adduction, and internal and external rotation ROMs were only significantly reduced in symptomatic FAI. Asymptomatic and symptomatic FAI groups displayed significantly lower YBT scores than healthy controls (men healthy: 84.9 vs. FAIasym: 69.0 vs. FAIsym 58.7, women healthy 79.2 vs. FAIasym 64.0 vs. FAIsym 55.5). Isokinetic hip flexion, adduction, and abduction strengths were significantly lower in FAIsym. In conclusion, FAIasym showed no decrease in muscle strength but displayed reduced dynamic balance. Subjective satisfaction, ROM, muscle strength, and dynamic balance were lower in FAIsym compared to FAIasym and healthy groups.

[Treatment strategies for the combination of hip dysplasia, femoroacetabular impingement and malrotation of the proximal femur : How much should be corrected?]

BACKGROUND

Hip dysplasia, FAI and femoral malrotation often occur together, resulting in mixed symptoms and severe biomechanical limitations of the hip.

OBJECTIVES

To report on the current recommendations for the best possible diagnosis and treatment strategies of combination pathologies in hip-preserving surgery.

METHODS

Review and discussion of the relevant literature with consideration of own experience in the treatment of complex combined pathomorphologies of the hip.

RESULTS

Patient history and a thorough clinical examination are key for determining the predominant pathomorphologies causing the symptoms. Standardized conventional ap pelvic and axial images of the hip are the basis for the radiological assessment of the hip, supplemented with MRI, CT and animations of the hip, depending on the case. As the pathologies influence each other functionally, a stepwise approach to treatment is recommended. The functionally most relevant pathology is treated first, followed by further corrections as needed. The primary goal is to achieve a stable hip with normal acetabular coverage, followed by an impingement-free range of motion and normalized musculoskeletal function. Care must be taken in the choice of surgical method to ensure that all pathologies can be adequately treated.

CONCLUSION

Complex, combined pathologies of the hip can be treated sufficiently with hip-preserving surgery. A thorough diagnosis is important in order to recognize the functional interaction of the different pathologies. The goal of the surgical therapy is a correctly covered, stable hip with a normal range of motion.

Association between femoroacetabular impingement syndrome and limited lateral hip rotation in young athletes: A case-control study

PURPOSE

Hip pain is very common in athletes. One of the main disorders causing hip pain is femoroacetabular impingement syndrome. This study aimed to identify a new etiological risk factor for femoroacetabular impingement in the hip.

METHODS

This case-control study included 88 young athletes, 34 with pains in the hip (supposedly with femoroacetabular impingement) and 54 controls. Femoroacetabular impingement was diagnosed with a flexion, adduction, internal, and rotation test and a particular type of hip pain during sports activities. The medial (internal) and lateral (external) hip ranges of rotation have been measured with an inclinometer. The data were analyzed using a t-test, the Wilcoxon test, the Mann-Whitney U test, and logistic regression.

RESULTS

There is a statistically significant difference in the external hip rotation range between the athletes with hip pain and controls. Logistic regression analysis showed that external hip range of motion is significantly associated with femoroacetabular impingement.

CONCLUSION

Limited external hip range of motion was found to be significantly associated with the diagnosis of femoroacetabular impingement in young athletes. A biomechanical explanation of the hypothesis that limited external hip rotation can predict femoroacetabular impingement is given. Based on our results, the hip's lateral range of motion screening can be advised within the regular screening of young athletes. Kinesiotherapeutic procedures for stretching the muscles of the medial hip rotors can be advised to prevent the lateral hip rotation restriction and lower the risk of femoroacetabular impingement in case the limited rotation is due to muscular restriction.

LEVEL OF EVIDENCE

level III-case-control study.

Five-Year Follow-up After Hip Arthroscopic Surgery in the Horsens-Aarhus Femoroacetabular Impingement (HAFAI) Cohort

Background:

Patients with femoroacetabular impingement syndrome (FAIS) are offered hip arthroscopic surgery to decrease hip pain, improve their function, and decrease development of hip osteoarthritis (OA). Nonetheless, long-term follow-up data are few.

Purpose:

To investigate patient-reported outcomes, clinical tests, reoperations, and radiographic status 5 years after primary hip arthroscopy in patients with FAIS.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 60 patients (age, 36 ± 9 years; 63% female) diagnosed with FAIS were included in the study and followed for 5 years after hip arthroscopy. Follow-up included Copenhagen Hip and Groin Outcome Score (HAGOS); Hip Sports Activity Scale; and clinical tests (flexion, adduction, internal rotation [FADIR]; flexion, abduction, external rotation [FABER]; and psoas muscle/tendon major pain provocation). Radiographic evaluation included lateral joint-space width (LJSW) and Tönnis classification for hip OA. Reoperations and conversion to total hip replacement (THR) were recorded. We calculated the proportion of patients who exceeded the minimal important change (MIC), achieved the Patient Acceptable Symptom State (PASS), and were within the 95% reference interval of age- and sex-matched persons with no hip problems. Changes were investigated using paired t tests.

Results:

Compared with preoperatively, all HAGOS subscales were improved substantially 5 years after surgery (mean, ≥21 points; P < .001), and 67% to 89% of patients reported improvements exceeding MIC. Between 56% and 80% achieved PASS, but only 7% to 24% reached the 95% reference interval for the HAGOS subscales. A total of 36% had a positive FADIR test and 25% had a positive FABER test, which were improvements compared with preoperatively (P < .001 for both). Patients with a positive FADIR test had significantly worse HAGOS subscales. Six patients (10%) had a THR since their primary hip arthroscopy. In the remaining patients, the mean LJSW was decreased (-0.4 mm; P = .043), and hip OA had worsened in 9 patients (23%; P = .003).

Conclusion:

Five years after surgery, the majority of patients experienced HAGOS improvements exceeding MIC while also showing an acceptable PASS. However, clinical tests, participation in physical activities, and quality of life indicated that many patients still experience hip problems.

Registration:

NCT04590924 (ClinicalTrials.gov identifier).

Physical Examination of the Hip: Assessment of Femoroacetabular Impingement, Labral Pathology, and Microinstability

Purpose of Review

Determining the correct diagnosis can be challenging in patients presenting with hip pain. The physical examination is an essential tool that can aid in diagnosis of hip pathology. The purpose of this review is to provide an updated summary of recent literature on the physical exam of the hip, particularly as it relates to diagnosis of femoroacetabular impingement (FAI) syndrome, labral injury, and hip microinstability.

Recent Findings

Physical exam findings consistent with the diagnosis of FAI include reduced supine hip internal rotation and positive flexion-adduction-internal rotation maneuvers. Labral tears can be detected on exam with the Scour test. Studies demonstrate altered hip biomechanics in patients with FAI during activities such as walking and squatting. Those with FAI have slower squat velocities, slower sit-to-stand tests, and increased hip flexion moments during ambulation. Hip microinstability is a dynamic process, which can occur after prior hip arthroscopy. For hip microinstability, the combination of the three following positive tests (anterior apprehension, abduction-extension-external rotation, and prone external rotation) is associated with a 95% likelihood of microinstability as confirmed by examination under anesthesia at the time of surgery.

Summary

A comprehensive hip physical exam involves evaluation of the hip in multiple positions and assessing hip range of motion, strength, as well as performing provocative testing. A combination of physical exam maneuvers is necessary to accurately diagnose FAI syndrome and labral pathology as individual tests vary in their sensitivity and specificity. While an elevated level of suspicion is needed to diagnose hip microinstability, the provocative tests for microinstability are highly specific.

Are cam morphology size and location associated with self‐reported burden in football players with FAI syndrome?

Cam morphology size and location might affect the severity of reported burden in people with femoroacetabular impingement (FAI) syndrome. We investigated the relationship between cam morphology size (i.e., alpha angle) and self‐reported hip/groin burden (i.e., scores for the International Hip Outcome Tool‐33 (iHOT‐33) and Copenhagen Hip and Groin Outcome Score (HAGOS)), examined separately for the anteroposterior pelvis (AP) and Dunn 45° radiographs in football players with FAI syndrome. In total, 118 (12 women) subelite football (soccer or Australian football) players with FAI syndrome with cam morphology (alpha angle ≥60°) participated. One blinded assessor quantified superior and anterosuperior cam morphology size by measuring alpha angles for the AP and Dunn 45° radiographs, respectively. Linear regression models investigated relationships between alpha angle (continuous independent variable, separately measured for the AP and Dunn 45° radiographs) and iHOT‐33 and HAGOS scores (dependent variables). Larger anterosuperior cam morphology (seen on the Dunn 45° radiograph) was associated with lower (i.e., worse) scores for the iHOT‐Total, iHOT‐Symptoms, iHOT‐Job, and iHOT‐Social subscales (unadjusted estimate range −0.553 to −0.319 [95% confidence interval −0.900 to −0.037], p = 0.002 to 0.027), but not the iHOT‐Sport (p = 0.459) nor any HAGOS scores (p = 0.110 to 0.802). Superior cam morphology size (measured using the AP radiograph) was not associated with any iHOT‐33 or HAGOS scores (p = 0.085 to 0.975). Larger anterosuperior cam morphology may be more relevant to pain and symptoms in football players with FAI syndrome than superior cam morphology, warranting investigation of its effects on reported burden and hip disease over time.

A proposed algorithm for the treatment of core muscle injuries

In recent years, there has been increased awareness and treatment of groin injuries in athletes. These injuries have been associated with various terminologies including sports hernia, core muscle injury (CMI), athletic pubalgia and inguinal disruption, among others. Treatment of these injuries has been performed by both orthopaedic and general surgeons and may include a variety of procedures such as rectus abdominis repair, adductor lengthening, abdominal wall repair with or without mesh, and hip arthroscopy for the treatment of concomitant femoroacetabular impingement. Despite our increased knowledge of these injuries, there is still no universal terminology, diagnostic methodology or treatment for a CMI. The purpose of this review is to present a detailed treatment algorithm for physicians treating patients with signs and symptoms of a CMI. In doing so, we aim to clarify the various pathologies involved in CMI, eliminate vague terminology, and present a clear, stepwise approach for both diagnosis and treatment of these injuries.

Review of Detection and Quantification of Rabies Virus Antibodies

Rabies is an almost invariably fatal disease. According to the World Health Organization (WHO), rabies virus neutralizing antibody (RVNA) titers of ≥0.5 IU/mL are considered adequate for rabies protection. Therefore, detection and quantification of RABV antibodies are important. Many methods have been developed for detecting RABV antibodies. In the present study, we reviewed several methods of detecting RABV antibodies in human and animal samples and evaluated and compared their performance. Of 34 methods, 5 demonstrated unsatisfactory sensitivity or specificity. The others exhibited sensitivity and specificity of ≥75%. The correlation coefficient for five of eight methods was >0.8. The Bland-Altman mean bias of five of five methods was <±2.0. The kappa values of 25 of 28 methods were higher than 0.4, demonstrating at least moderate agreement. Analysis of the performance of these methods emphasized that any new technology should be considered carefully and objectively before being used as an appropriate and applicable alternative.

Femoroacetabular impingement syndrome and labral injuries: grading the evidence on diagnosis and non-operative treatment-a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF)

This statement summarises and appraises the evidence on diagnostic tests and clinical information, and non-operative treatment of femoroacetabular impingement (FAI) syndrome and labral injuries. We included studies based on the highest available level of evidence as judged by study design. We evaluated the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation framework. We found 29 studies reporting 23 clinical tests and 14 different forms of clinical information, respectively. Restricted internal hip rotation in 0° hip flexion with or without pain was best to rule in FAI syndrome (low diagnostic effectiveness; low quality of evidence; interpretation of evidence: may increase post-test probability slightly), whereas no pain in Flexion Adduction Internal Rotation test or no restricted range of motion in Flexion Abduction External Rotation test compared with the unaffected side were best to rule out (very low to high diagnostic effectiveness; very low to moderate quality of evidence; interpretation of evidence: very uncertain, but may reduce post-test probability slightly). No forms of clinical information were found useful for diagnosis. For treatment of FAI syndrome, 14 randomised controlled trials were found. Prescribed physiotherapy, consisting of hip strengthening, hip joint manual therapy techniques, functional activity-specific retraining and education showed a small to medium effect size compared with a combination of passive modalities, stretching and advice (very low to low quality of evidence; interpretation of evidence: very uncertain, but may slightly improve outcomes). Prescribed physiotherapy was, however, inferior to hip arthroscopy (small effect size; moderate quality of evidence; interpretation of evidence: hip arthroscopy probably increases outcome slightly). For both domains, the overall quality of evidence ranged from very low to moderate indicating that future research on diagnosis and treatment may alter the conclusions from this review.

Benefits of a Specific and Supervised Rehabilitation Program in Femoroacetabular Impingement Patients Undergoing Hip Arthroscopy: A Randomized Control Trial

(1) To assess the efficacy of a specific rehabilitation protocol for femoroacetabular impingement syndrome (FAIS), patients who underwent hip arthroscopy (HA) were compared with a control group. (2) Patients with symptomatic FAIS who were scheduled for HA were randomized either to a control group (n = 45, 66.6% men, 41.8 ± 12.4 years) following a general post-surgical treatment protocol or to an experimental group (n = 45, 71.2% men, 40.9 ± 7.6 years) following a specific rehabilitation protocol supervised by a physiotherapist. Range of motion (ROM), orthopedic tests and pain were assessed immediately before surgery and at 4 and 14 weeks after surgery. The hip functional status was assessed by the modified Harris Hip Score (mHHS) before surgery and at the end of follow-up. (3) At 14 weeks after surgery and compared with the control group, the experimental group showed a lower percentage of positives for hip provocation tests (15.6% vs. 46.6% on Faber test; 15.6% vs. 77.8% on Fadir test; 2.2% vs. 20% on Ober test, experimental vs. control group, p < 0.001), a greater improvement in mHHS (27.2 vs. 10.7 points, p < 0.001) and higher ROM for all the movements evaluated: flexion (99.6 ± 12.2 vs. 89.6 ± 4.5, p < 0.001), extension (20.6 ± 5.8 vs. 13.3 ± 2.6, p < 0.001), adduction (30.6 ± 5.7 vs. 23.4 ± 8.4, p < 0.001), abduction (43.4 ± 10.7 vs. 32.8 ± 8.4, p < 0.001) and both internal (28.2 ± 8.5 vs. 18.7 ± 6.1, p < 0.001) and external hip rotation (36.8 ± 9.3 vs. 27.4 ± 5.6. p < 0.001). The pain decreased after surgery for both groups, although the reduction was greater in the experimental group at the end of intervention (13.8 ± 16.1 vs. 34.9 ± 16.3 mm, experimental vs. control group, p < 0.001). (4) The specific and supervised rehabilitation program in patients with FAIS undergoing HA showed better benefits at 14 weeks of treatment than the benefits achieved by a care protocol in terms of pain reduction and recovery of hip motion.

Association between severity of hip chondrolabral injuries, dynamic hip muscle strength and quality of life: A cross-sectional study in patients with femoroacetabular impingement syndrome scheduled for hip arthroscopy

BACKGROUND

We assessed the association between: the severity of hip chondral or labral pathology with dynamic hip muscle strength or quality of life in patients with femoroacetabular impingement syndrome scheduled for hip arthroscopy. We also assessed the association between dynamic hip muscle strength with quality of life.

METHODS

Eighty-three participants with femoroacetabular impingement syndrome scheduled for hip arthroscopy were included. We measured dynamic hip abduction and adduction muscle strength with an isokinetic dynamometer (Nm/kg), and quality of life with the iHoT-33 questionnaire. The severity of hip chondrolabral pathologies was scored using the modified Beck classification. Linear regression analyses were conducted to assess the association between severity of hip chondral or labral pathology with dynamic hip muscle strength and quality of life.

FINDINGS

The regression analyses showed no association between the (i) severity of hip chondral (adjusted r²: 0.14) or labral (adjusted r²: 0.08) pathology and quality of life (P > 0.05), (ii) between the severity of hip chondral or labral pathology and dynamic hip abduction and adduction muscle strength (P > 0.05). Significant correlation was observed for quality of life and hip abduction (adjusted r²:0.29; P < 0.001) or adduction (adjusted r²: 0.32; P < 0.001) muscle strength.

INTERPRETATION

The severity of hip chondral or labral pathologies were not associated with quality of life or dynamic hip muscle strength in participants with femoroacetabular impingement syndrome. Greater dynamic hip abduction and adduction muscle strength were associated with better quality of life in participants with femoroacetabular impingement syndrome scheduled for hip arthroscopy.

Less hip range of motion is associated with a greater alpha angle in people with longstanding hip and groin pain

PURPOSE

A higher alpha angle has been proposed to correlate with lower hip range of motion, but the association in people with longstanding hip and groin pain is currently unclear. The aims were to: (1) assess the association between range of motion and alpha angle in patients with longstanding hip and groin pain; (2) examine if a cut-off value in range of motion variables could identify patients with an alpha angle above or below 60°.

METHODS

Seventy-two participants were consecutively recruited from an orthopaedic department after referral for hip- and groin-related pain. Passive hip range of motion was measured in flexion, internal rotation with 90° hip flexion, internal rotation in neutral hip position, external rotation with 90° hip flexion, and abduction. The alpha angle was calculated from a frog-leg lateral radiograph. Linear regression examined the association between range of motion and alpha angle, and an ROC-curve analysis was performed to identify the sensitivity and specificity of range of motion cut-offs.

RESULTS

Lower range of motion in internal rotation in flexion, external rotation, and abduction were associated with higher alpha angle. Internal rotation of 27° or less displayed good sensitivity (81%) and specificity (85%) to detect an alpha angle above 60°, while a cut-off of 41° in external rotation and 27° in abduction showed a sensitivity of 72% and specificity of 50% and 60%, respectively.

CONCLUSION

Less internal rotation in flexion, external rotation, and abduction are associated with a greater alpha angle in a cohort of people with longstanding hip and groin pain. A cut-off of 27° in internal rotation has good sensitivity and specificity to identify people with an alpha angle above or below 60° and have the potential to be used in the clinical setting to identify patients that require further imaging, or that are unlikely to have cam morphology.

LEVEL OF EVIDENCE

II.