Nonsurgical Management of Femoroacetabular Impingement/Acetabular Labral Tears

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At Canyon Park Physical Therapy we strive to utilize an Evidence Based Medicine (EGM) approach in order to best serve out patients, fellow clinicians and third party payers. In order to keep our colleagues and referral sources updated on our efforts, we issue a quarterly newsletter that will review research as it relates to conditions treated in our clinic. Each newsletter focuses on a particular condition and examines several pieces of literature that may directly or indirectly affect our treatment approach for that condition. This newsletter examines the effectiveness of conservative management of Femoroacetabular Impingement and acetabular labral tears.

Conservative Treatment for Mild Femoroacetabular Impingement

Emara K, Samir W, Motasem E, Ghafar K. Journal Of Orthopaedic Surgery (Hong Kong) [serial online]. April 2011;19(1):41-45.

Results: Patients were followed up at 25 to 28 months. Of the 37 patients, 4 underwent surgical procedures due to failure of conservative measures. The remaining 33 showed improvements consisting of: Harris Hip Score improved convincingly from 72 prior to treatment to 91 at the 24 month follow up, the mean non arthritic hip scores improved for 72 to 91, and the mean visual analog scale improved from 6 to 2. Of the remaining 33 patients, 6 experienced recurrent hip pain and discomfort though not severe enough for surgical management.

Conclusions: The results, despite the improvement in function and pain, showed no improvement in range of motion due to modifications. This study showed very good improvements and promise for conservative management of FAI without loss of normal recreational activities and activities of daily living as long as necessary modifications are taken to adapt to the hip condition.

Nonsurgical Treatment of Acetabular Labrum Tears: A Case Series.

Yazbek P, Ovanessian V, Martin R, Fukuda T. The Journal Of Orthopaedic And Sports Physical Therapy [serial online]. May 2011;41(5):346-353.

Objective: The purpose of this case series was to describe a nonsurgical program for those with clinical evidence of an acetabular labrum tear, that emphasized hip and lumbopelvic stabilization, correction of hip muscle imbalance, biomechanical control, and sport-specific functional progression.

Results: All four patients in this study exhibited decreased pain, functional improvement, and correction of muscular imbalance. Increased strength in hip flexors, abductors, and extensors was noted as well.

Conclusion: All the patients in this study responded well to the physical therapy program. This case series suggests that patients with clinical evidence of an acetabular labral tear confirmed with MRI can show meaningful improvement with nonsurgical intervention.

Anterior Hip Joint Force Increases With Hip Extension, Decreased Gluteal Force, or Decreased Iliopsoas Force

Lewis C, Sahrmann S, Moran D. Journal Of Biomechanics [serial online]. 2007;40(16):3725-3731.

Objective: Excessive, abnormal force on the anterior hip joint and labrum may be a cause of hip pain, instability and resulting labral pathology. The purpose of this study was to determine the effect of hip joint position and of weakness of the gluteal and iliopsoas muscles on anterior hip joint force.

Results: This study found that decreased force contribution from the gluteal muscles during hip extension and the iliopsoas muscle during hip flexion resulted in an increase in the anterior hip joint force.

Conclusion: This study suggests the use of hip strengthening of gluteal hip extensors and iliopsoas may decrease force on anterior hip. Further studies are needed to determine if increased utilization of the gluteal muscles during hip extension and of the iliopsoas muscle during hip flexion, and avoidance of hip extension beyond neutral would be beneficial for people with anterior hip pain, subtle hip instability, or an anterior acetabular labral tear.

Implications for Physical Therapy Practice

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Individuals with FAI or acetabular labral tears often present with pain with combined hip flexion and IR as well as impaired activation of hip musculature. Weakness in the gluteus medius, gluteus maximus, and hip flexor musculature has been shown to produce increased stress on the anterior labrum. Without the proper activation patterns of gluteal and core musculature, the patient is allowed to attain positions detrimental to the structures involved. Therefore, physical therapy focusing on global hip strength, correction of muscle imbalance, and neuromuscular re-education will allow the patient to avoid positions placing stress on the injury. At TAI Canyon Park, we strive to evaluate and correct muscle imbalances and biomechanical abnormalities decreasing and eventually eliminating acetabular labral irritation. This evidence-based approach allows us to apply current research to our practices and produce the most effective results.