The effect of pelvic tilt and cam on hip range of motion in young elite skiers and nonathletes

Acute Effects of Ice Hockey on Hip Range of Motion, Strength, and Pelvic Tilt in Competitive Male Players

BACKGROUND

Ice hockey players are at high risk for hip and groin injury. Several risk factors have been identified or proposed, including lower hip rotation range of motion (ROM), lower hip adductor strength, lower ratio of hip adductor to abductor strength, and lower pelvic tilt angle. It is not known how these risk factors change acutely with ice hockey participation.

HYPOTHESIS

Acute exposure to ice hockey will result in a reduction in ROM, strength, and pelvic tilt angle in competitive male players.

STUDY DESIGN

Controlled cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Risk factors for hip and groin injury, including isometric hip adductor strength at 0° of flexion, the ratio of hip adductor to abductor strength, total hip rotation passive ROM in supine, and the resting pelvic tilt angle, were assessed immediately before, immediately after, and 24 hours after an ice hockey exposure in 42 competitive male ice hockey players. Rating of perceived exertion (RPE) was collected to identify the intensity of the exposure.

RESULTS

There was a significant decrease in total hip rotation ROM (-7.32°, P < 0.01 (-3.91, -10.70)) and hip adductor strength (-4.41 kg, P < 0.01 (-2.81, -6.00) immediately after the exposure, and a significant decrease in total hip rotation ROM (-18.54°, P < 0.01 (-14.35, -22.73)), hip adductor strength (-6.56 kg, P < 0.01 (-4.58, -8.61)), and the ratio of hip adductor to abductor strength (-0.12, P < 0.01 (-0.21, -0.45)) 24 hours after. There was no significant change in pelvic tilt found in this study immediately after or 24 hours after. There was a moderate relationship between changes in hip adductor strength and changes in the ratio of hip adductor to abductor strength (r = 0.433, P < 0.01). RPE was not significantly correlated to any of the changes observed.

CONCLUSION

Risk factors for hip and groin injury in ice hockey players are modifiable after a single ice hockey exposure.

CLINICAL RELEVANCE

The identified fluctuation of injury risk factors for hip and groin injury in ice hockey players has implications for injury risk profiling, rehabilitation, and return-to-competition decision-making.

A New Clinical Examination Algorithm to Prescribe Conservative Treatment in People with Hip-Related Pain

Hip-related pain is a common issue in active adults affecting their quality of life, mobility, and overall function, and it can lead to persistent disability. However, diagnosing hip-related pain is challenging due to the many potential sources and causes, including intra-articular and extra-articular pathology, and referred pain from other areas (lumbar or groin related pain). To address this, there is a need for a clinical algorithm based on the best available evidence and expert consensus. This algorithm could guide healthcare professionals in assessing and managing patients with hip-related pain, during the diagnosis, test selection, intervention, monitoring, and promoting collaboration among various healthcare providers. This clinical algorithm for hip-related pain is a comprehensive, flexible, adaptable to different settings, and regularly updated to incorporate new research findings. This literature review aims to establish a clinical algorithm specifically for prescribing exercise treatment to patients with hip-related pain, addressing their individual needs and enhancing their overall care.

Editorial Commentary: Physical Therapy Alone May Not Successfully Treat Patients With Hip Pain and Large α Angles or Decreased Femoral Anteversion Combined With Femoroacetabular Impingement Syndrome

Understanding the relation between spinopelvic (lumbopelvic) tilt and femoracetabular impingement syndrome (FAIS) is complex, and determining the optimal patient parameters that lead to successful nonoperative management is vital. Physical therapy (PT) focusing on core and posterior chain strengthening is often successful. PT can change the posterior tilt of the pelvis by 5° to 10°, allowing increased range of motion (ROM) and decreased impingement of the hip. However, PT does not change cam anatomy. Thus, PT alone may not sufficiently increase ROM in patients with cam-type impingement and large α angles or limited femoral anteversion. Pelvic compensation may lead to successful nonoperative management of FAIS, but not in all patients. Large-cam, high-flexion athletes with chronic hip pain should try PT. Yet, while some patients with large cam lesions may improve without surgery if femoral version and/or pelvic tilt ROM can be increased, surgery should not be excessively delayed in patients with poor prognostic factors for nonoperative management.

Physical Therapy May Not Be Successful for Patients With Cam-Type Femoroacetabular Impingement Syndrome and May Result in Insufficient Hip Range of Motion When Femoral Anteversion Is Less Than 16° and α-Angle Is Greater Than 65°

PURPOSE

To identify factors associated with insufficient range of motion (ROM) improvement after the posterior pelvic tilt change in cam-type femoroacetabular impingement syndrome.

METHODS

Preoperative computed tomography images from 71 consecutive patients with femoroacetabular impingement syndrome treated with arthroscopic cam resection were evaluated. Using a dynamic computer simulation program, 3-dimensional models with a 10° posterior pelvic tilt from the supine functional pelvic plane (baseline) were created by computed tomography models. Patients were divided into 2 groups: those who experienced >10° (effective group) and ≤10° (ineffective group) improvements in internal rotation at 90° flexion after a 10° posterior pelvic tilt. Demographic characteristics; preoperative range of internal rotation at 90° flexion; and radiographic parameters, including Tönnis grade, lateral center-edge angle, acetabular roof obliquity angle, central acetabular anteversion, cranial acetabular anteversion, femoral anteversion, and α angle, were compared in the 2 groups. Univariate and multivariable logistic regression analyses were performed to evaluate factors associated with insufficient ROM improvement following a 10° posterior pelvic tilt.

RESULTS

The 71 patients included 58 men and 13 women, of mean age 41.4 ± 14.6 years. Posterior pelvic tilt was effective in 13 hips and ineffective in 58. Univariate analysis showed that preoperative range of internal rotation at 90°flexion, femoral anteversion, and α angle differed significantly in the 2 groups. Multivariable analysis showed that femoral anteversion <16° (odds ratio 7.4; 95% confidence interval 1.6-35; P = .012) and α angle >65° (odds ratio 6.7; 95% confidence interval 1.2-37; P = .027) were significant factors associated with insufficient ROM improvement after posterior pelvic tilt.

CONCLUSIONS

Physical therapy may not be successful for patients with cam-type femoroacetabular impingement syndrome and may result in insufficient hip ROM when femoral anteversion is less than 16° and α-angle is greater than 65°.

CLINICAL RELEVANCE

Patients with a prominent cam-type deformity and lower anterior femoral anteversion are at high risk of clinical failure following improvement in pelvic mobility by conservative treatment alone and are likely to benefit from surgery for cam deformity.

The Influence of Compensatory Pelvic Tilt on Patient-reported Outcome Measurements in FAI Patients Who Received Arthroscopic Treatment

OBJECTIVE

Pelvic compensation is common in femoroacetabular impingement (FAI) patients to reduce symptoms and increase range of motion. However, little attention was given to the postoperative clinical effect of pelvic compensation. Therefore, this study aims to compare the outcomes between pelvic compensation and normal pelvic position in femoroacetabular impingement (FAI) patients after hip arthroscopy.

METHODS

The retrospective study was conducted from January 2019 to June 2022, recruited consecutive patients who were diagnosed with FAI and received subsequent arthroscopic treatment. All patients completed an X-ray in the anterior-posterior standing position before and 4 weeks after surgery. Patients with pelvic compensation were compared with those who did not. Functional outcomes included hip disability and osteoarthritis outcome score (HOOS), modified Harris (mHHS) score, and lower-extremity activity scale (LEAS). Secondary outcomes included the EuroQol Five Dimensions Questionnaire (EQ-5D) and patient satisfaction. The intraclass correlation coefficient (ICC) was used to analyze interobserver and intraobserver reliability.

RESULTS

Ninety patients with a mean age of 39.40 years were included in the study. No significant compensation changes were noted within groups after the elimination of impingement. The functional scores showed no significant difference between groups (p(HOOS) = 0.352, p(mHHS) = 0.183, p(LEAS) = 0.865). The EQ-5D revealed statistically better performance in usual activities in the compensatory group (p = 0.044). There are no significant between-group differences in patients' satisfaction evaluations.

CONCLUSION

As assessed by Patient-Reported Outcome Measures (PROMs), patients with compensatory pelvic tilt demonstrated similar clinical outcomes without extra adverse events to patients with normal pelvic positioning in short-term follow-ups. Furthermore, compensatory pelvic tilt did not significantly enhance the range of motion or functional outcome at short-term follow-ups.

Effect of 3-Dimensional Versus Single-Plane Changes in Pelvic Dynamics on Range of Motion in Hips With Femoroacetabular Impingement: A Computer Simulation Analysis

Background

Femoroacetabular impingement (FAI) is primarily caused by bony impingement between the acetabulum and femoral neck during hip motion. Increasing posterior pelvic tilt improves hip range of motion in patients with FAI.

Purpose

To use computer simulation analysis to compare the effects of 3-dimensional (3D) changes in pelvic tilt (sagittal tilt [St], axial rotation, and coronal tilt) with changes in a single plane (St), with the aim of improving range of motion in patients with FAI.

Study Design

Controlled laboratory study.

Methods

We evaluated 43 patients with FAI treated by arthroscopic cam resection. A 3D simulation was used to construct the following pelvic models: a 5° and 10° increase posteriorly in St (St5° and St10°) and a combined 5° change in St, axial rotation, and coronal tilt (Complex5°) from the baseline of the anterior pelvic plane. Improvements in maximum internal rotation (MIR) at 45°, 70°, and 90° of hip flexion and improvements in maximum flexion with no internal rotation were compared among the St5°, St10°, and Complex5° models. The pelvic models of each single-plane change of 5° and 10° were evaluated in the same simulation.

Results

At 90° and 70°, there was a significant difference between the Complex5° and St10° models with respect to improvement in MIR (P = .004 at 90° of flexion; P = .017 at 70° of flexion). There was no significant difference in MIR at 45° of flexion (P = .71) or in maximum flexion (P = .42).

Conclusion

At 70° and 90° of hip flexion, a combined change in 3D pelvic alignment of 5° (ie, St, axial rotation, and coronal tilt) was more effective in improving hip MIR than a 10° change in St only.

Clinical Relevance

Effective physical therapy for FAI should address pelvic motion in all 3 planes rather than in a single plane.

Effect of Decreasing the Anterior Pelvic Tilt on Range of Motion in Femoroacetabular Impingement: A Computer-Simulation Study

Background:

The influence of pelvic tilt mobility, which can be reproduced in computer-simulation models, is an important subject to be addressed in the understanding of femoroacetabular impingement (FAI) pathophysiology.

Purpose:

To use computer-simulation models of FAI cases to evaluate the optimum improvement in hip range of motion (ROM) achieved by decreasing the anterior pelvic tilt and compare the results with the improvement in ROM achieved after cam resection surgery.

Study Design:

Controlled laboratory study.

Methods:

The pre- and postoperative computed tomography (CT) images from 28 patients with FAI treated with arthroscopic cam resection were evaluated. Using a dynamic computer-simulation program, 3-dimensional models with a 5° and a 10° decrease in anterior pelvic tilt from the supine functional pelvic plane (baseline) were created from the preoperative CT scans. Similar models were constructed for hips before (at baseline) and after cam resection. Improvements from baseline in maximum internal rotation at 45°, 70°, and 90° of flexion were assessed for the 5° change in pelvic tilt, 10° change in pelvic tilt, and cam resection models, and the results were compared for all conditions.

Results:

The combination of a 10° change in pelvic tilt and cam resection showed the largest ROM improvement from baseline (P < .001). Improvement in internal rotation in the cam resection model was significantly higher compared with the 5° pelvic tilt change model (P < .001), while there was no significant difference between the cam resection model and the 10° pelvic tilt change model.

Conclusion:

Decreasing anterior pelvic tilt by 10° in the preoperative computer simulation model resulted in an equivalent effect to cam resection, while a 5° change in pelvic tilt was inferior to cam resection in terms of ROM improvement.

Clinical Relevance:

Enough of a decrease in anterior pelvic tilt may contribute to ROM improvement that is as effective as that of cam resection surgery.

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.

Resolving anterior hip pain in a young male footballer following arthroscopic surgery for Femoroacetabular Impingement Syndrome: A case report

BACKGROUND

There appear to be limited studies available regarding the conservative management of patients following hip joint arthroscopic surgery, or investigating reasons for which patients still report hip and groin pain post surgery.

OBJECTIVES

Treatment was applied to restore spino-pelvic mechanics and to reduce soft tissue restrictions in hip joint motion. Neuromuscular movement control and work capacity exercises were encouraged to support the integrity of the hip joint and spino-pelvic complex.

CLINICAL FEATURES

A 22-year-old male footballer, (height 190cm and weight 82kg) presented reporting an eighteen-month history of hip and groin pain, having previously undergone bilateral arthroscopic surgery twelve months earlier for Femoroacetabular Impingement Syndrome. Strength measurements were recorded using the MicroFET 2 Wireless Digital Handheld Dynamometer. Trunk muscular endurance was evaluated with Sorenson test.

RESULTS

Five treatment consultations over a five-week period resulted in pain reduction, (Visual Analogue Scale 8/10 to 0/10). Improvement in range of motion, right hip flexion (70-100°) and left (80-100°), right internal rotation (30-45°) and left (40-45°). Improvement in strength, specifically right hip flexion (0.29-0.43Nm/kg, 48%) and right hip abduction (0.35-0.46Nm/kg, 31%). Improvement in trunk muscular endurance increased 41% from 170 seconds to 240 seconds.

CONCLUSION

This case report supports the rationale that the post arthroscopic management of Femoroacetabular Impingement Syndrome, should include both treatment to address spino-pelvic restrictions, if appropriate, combined with exercises that specifically target hip flexor strength. However, a larger randomized study would provide a clearer understanding for the management of this particular subset of patients.

The Biomechanics of Pregnancy: A Systematic Review

During pregnancy, a number of biomechanical and hormonal changes occur that can alter spinal curvature, balance, and gait patterns by affecting key areas of the human body. This can greatly impact quality of life (QOL) by increasing back pain and the risk of falls. These effects are likely to be the ultimate result of a number of hormonal and biomechanical changes that occur during pregnancy. Research Question and Methodology: Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, this systematic review sets out to analyse all available literature relating to the biomechanics factors caused by pregnancy and assess how this might reduce QOL. Fifty papers were deemed eligible for inclusion in this review based on the PUBMED and SCOPUS databases. Results: Angles of lordosis and kyphosis of the spine are significantly increased by pregnancy, but not consistently across all studies. Back pain is significantly increased in pregnant women, although this is not significantly correlated with spinal changes. Increased movements of centre of pressure (COP) and increased stability indexes indicate postural control is reduced in pregnancy. Trunk range of motion, hip flexion, and extension are reduced, as well as decreased stride length, decreased gait velocity, and increased step width; again, not consistently. It is likely that each woman adopts unique techniques to minimise the effects, for example increasing step width to improve balance. Further research should focus on how altered limb kinematics during gait might affect QOL by influencing the human body, as well as assessing parameters in all planes to develop a wider understanding of pregnant biomechanical alterations.