The clinical presentation of individuals with femoral acetabular impingement and labral tears: A narrative review of the evidence

Accepted Manuscript The Clinical Presentation of Individuals with Femoral Acetabular Impingement and Labral Tears: A Narrative Review of the Evidence Scott Cheatham, PT, DPT, OCS, ATC, Assistant Professor, Director Pre-Physical Therapy Program, Keelan R. Enseki, MS, PT, SCS, ATC, Physical Therapy Orthopaedic Residency Program Director, Adjunct Instructor, Morey J. Kolber, PT, PhD, OCS, Cert. MDT, Associate Professor, Director of Physical Therapy PII:

S1360-8592(15)00263-6

DOI:

10.1016/j.jbmt.2015.10.006

Reference:

YJBMT 1273

To appear in:

Journal of Bodywork & Movement Therapies

Received Date: 28 July 2015 Revised Date:

3 October 2015

Accepted Date: 15 October 2015

Please cite this article as: Cheatham, S., Enseki, K.R., Kolber, M.J., The Clinical Presentation of Individuals with Femoral Acetabular Impingement and Labral Tears: A Narrative Review of the Evidence, Journal of Bodywork & Movement Therapies (2015), doi: 10.1016/j.jbmt.2015.10.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT

1 2

Title: The Clinical Presentation of Individuals with Femoral Acetabular Impingement and Labral Tears: A Narrative Review of the Evidence

3

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

1. Scott Cheatham PT, DPT, OCS, ATC Assistant Professor Director Pre-Physical Therapy Program Division of Kinesiology and Recreation, SAC 1138 California State University Dominguez Hills 1000 E. Victoria St. Carson, CA 90747 Office # (310) 243-3794 email: [email protected]

41

manuscript.

RI PT

Corresponding Author: Scott W. Cheatham

SC

4

TE D

M AN U

2. Keelan R. Enseki, MS, PT, SCS, ATC Physical Therapy Orthopaedic Residency Program Director Centers for Rehab Services/UPMC Center for Sports Medicine Adjunct Instructor - University of Pittsburgh School of Health and Rehabilitation Sciences Department of Physical Therapy Department of Sports Medicine and Nutrition 3200 South Water Street Pittsburgh, PA 15203 412-432-3700 [email protected]

AC C

EP

3. Morey J. Kolber, PT, PhD, OCS, Cert. MDT Associate Professor Nova Southeastern University Department of Physical Therapy 3200 South University Drive Ft. Lauderdale, FL 33328 (954) 262-1615 Fax (954) 262-1783 [email protected] Director of Physical Therapy Boca Raton Orthopaedic Group 561.391.0366 [email protected]

Conflicts of Interest and Source of Funding: Scott Cheatham (Author) declares that there is no conflict of interest or source funding for this

1

ACCEPTED MANUSCRIPT

Abstract:

43 44 45 46 47 48 49

Femoral acetabular impingement (FAI) has emerged as one of the more commonly recognized intraarticular hip pathologies and is often accompanied with a labral tear. The understanding of the clinical characteristics of individuals with symptomatic FAI has evolved over the past several years due to emerging research. As research progresses, there is often a gap in translating the current evidence to clinical practice. This manuscript presents the latest evidence underpinning the clinical presentation of FAI and labral tears. Evidence is presented within the context of bridging the latest research and clinical practice.

RI PT

42

50

Key Words: Anterior; Hip; Pain

SC

51 52

M AN U

53 54 55 56

60

61

62

63

EP

59

AC C

58

TE D

57

64

65

66 2

ACCEPTED MANUSCRIPT

67

68

Introduction The hip joint has become an emerging area of study due to the improved recognition and diagnosis of pathologies such as femoral acetabular impingement (FAI) and acetabular labral

70

tears. The examination process can be very complex due to competing pathologies that have

71

similar clinical presentations making it difficult to make a clear diagnosis. In fact, as much as

72

60% of hip arthroscopic patients are initially misdiagnosed (Domb, Brooks, & Byrd, 2009).

73

Misdiagnosis may lead to a delay of appropriate care as well as utilization of unnecessary

74

healthcare resources.

SC

M AN U

75

RI PT

69

Among the intra-articular pathologies of the hip, FAI has emerged as a one of the more commonly recognized pathologies and often is accompanied with a labral tear (Clohisy et al.,

77

2013). There are three common types of FAI: cam-type, pincer-type, and mixed cam-pincer type.

78

There is a higher predilection for mixed and cam-type FAI in younger adult males and pincer-

79

type FAI in younger adult females (Clohisy et al., 2013; Nepple et al., 2015). Several

80

investigations have found a correlation between FAI and osteitis pubis (Matsuda, 2010; Verrall

81

et al., 2005), athletic pubalgia (Larson, Pierce, & Giveans, 2011), and lumbosacral issues

82

(Hammoud, Bedi, Voos, Mauro, & Kelly, 2014; Voos, Mauro, & Kelly). Due to the growing

83

recognition of FAI, clinicians should have a comprehensive understanding of the condition in

84

order to provide effective management strategies.

EP

AC C

85

TE D

76

The examination process for evaluating individuals with symptomatic FAI has evolved

86

over the past several years providing both researchers and clinicians more insight into the clinical

87

presentation of these patients. As the research progresses, there is often a gap in translating the

88

current evidence to clinical practice. The lack of translational research may slow the growth of

3

ACCEPTED MANUSCRIPT

best practice rehabilitation strategies for patients with suspected or diagnosed FAI. In this

90

review, the latest evidence regarding the clinical presentation of individuals with FAI and labral

91

tears will be discussed with a focus on key examination findings. To enhance the translational

92

process from research to clinical management, a series of charts will be presented to assist the

93

clinician in examination and determining a working diagnosis.

95

SC

94

RI PT

89

Patient History

Patients with suspected hip FAI or labral tears often describe a deep “anterior groin

97

related pain” and may point or cup their hand around the anterior hip region which is often called

98

the “C-sign” and is most indicative of intraarticular pathology (Figure 1) (Byrd, 2007; Cheatham

99

& Kolber, 2012; H. D. Martin, Shears, & Palmer, 2010). Anterior “groin pain” that worsens with

M AN U

96

prolong standing, sitting, and walking is often related to FAI and acetabular labral tears

101

(sensitivity 96% to 100%) (Reiman, Mather, Hash, & Cook, 2014). If the patient’s pain is related

102

to specific hip positions (e.g. flexion, adduction, and internal rotation) and sports activity (e.g.

103

rotation and pivoting) then femoral acetabular impingement (FAI), acetabular labral tear, or other

104

intraarticular pathology should be suspected (Sink, Gralla, Ryba, & Dayton, 2008). The majority

105

of anterior hip pain may be from articular structures since the hip is primarily innervated by the

106

femoral and obturator nerve which innervate the anterior and medial hip joint (Frank et al.,

107

2010). These symptoms may be accompanied by lateral or posterior hip discomfort and

108

mechanical symptoms (Byrd, 2007). More specifically, sharp pain with clicking and giving way

109

may be related to an intraarticular pathology such as FAI, acetabular labral tear, or cartilage

110

defect (sensitivity 100%, specificity 85%) (Reiman, Mather, et al., 2014). Clinicians should be

AC C

EP

TE D

100

4

ACCEPTED MANUSCRIPT

111

aware of the key signs and symptoms revealed during the patient’s history in order to develop a

112

working hypothesis to test during the objective portion of the examination.

114

RI PT

113

Differential Diagnosis

A thorough patient history will most often help the clinician determine what test and

116

measures are needed in order to formulate a diagnosis. During the differential diagnosis, it is

117

important to determine if the suspected impingement is intra-articular or extra-articular as many

118

of these pathologies have similar clinical presentations. There is a growing body of literature

119

reporting external causes of hip impingement in younger non-arthritic patients which may

120

include: iliopsoas impingement, subspine impingement, and ischiofemoral impingement.

121

Iliopsoas impingement is an emerging diagnosis of anterior hip pain and has been linked to

122

acetabular labral tears and is often treated with a surgical release of the tendon (Domb et al.,

123

2011). It’s postulated that the impingement may be caused by two mechanisms: (1) a repetitive

124

traction injury by the iliopsoas tendon that is scarred on adherent to the capsule-labrum complex

125

of the hip or (2) a tight or inflamed iliopsoas tendon that causes impingement during hip

126

extension (Sutter & Pfirrmann, 2013). Subspine impingement is caused by a prominent anterior

127

inferior iliac spine (AIIS) abnormally contacting the distal femoral neck during hip flexion (de

128

Sa et al., 2014). This may be caused by excessive muscular activity of the rectus femoris during

129

repetitive knee flexion with hip extension resulting in an avulsion injury of the AIIS. This

130

repetitive traction injury is common in running sports and sports involving rapid high energy

131

kicking such as soccer (de Sa et al., 2014). Upon healing, this often results in an enlarged bony

132

protrusion at the AIIS that abnormally abuts the femoral neck (Sutter & Pfirrmann, 2013).

AC C

EP

TE D

M AN U

SC

115

5

ACCEPTED MANUSCRIPT

Subspine impingement has been related to CAM-type FAI and may be surgically corrected with

134

surgery (Sutter & Pfirrmann, 2013). Ischiofemoral impingement is characterized by a narrowed

135

space between the ischial tuberosity and the lesser trochanter resulting in repetitive pinching of

136

the quadratus femoris muscle (de Sa et al., 2014; Lee, Kim, Lee, & Lee, 2013; Stafford & Villar,

137

2011). The impingement has been reported to be mainly congenital but may also be acquired

138

from a hip fracture or superior medial migration of the hip joint with osteoarthritis (Sutter &

139

Pfirrmann, 2013). Other forms of atypical hip impingement include greater trochanteric/pelvic

140

impingement, abnormal femoral antetorsion, abnormal pelvic and acetabular tilt, and extreme hip

141

motions (de Sa et al., 2014; Sutter & Pfirrmann, 2013). Table 1. Provides a summary of the

142

external impingement pathologies.

143

145

Pelvic Position

TE D

144

M AN U

SC

RI PT

133

Recent evidence has observed a pattern of static pelvic positions in patients diagnosed with FAI. Ida et al (2014) retrospectively reviewed the cases of 94 patients (100 hips) with

147

symptomatic hip dysplasia. All patients went through radiographic and pelvic computed

148

tomography (CT) examinations. The authors found that 38 patients (40%) had both cam-type

149

FAI and acetabular dysplasia and assumed a greater standing anterior pelvic tilt. The authors

150

concluded that these morphological issues may induce secondary symptoms in these patients

151

(Ida, Nakamura, Hagio, & Naito, 2014). Ross et al (2014) also examined preoperative pelvic CT

152

scans in 48 patients (50 hips) who underwent surgery for FAI. The authors created three-

153

dimensional computer models and analyzed various pelvic tilt and hip positions. The authors

154

found that an anterior pelvic tilt resulted in significant acetabular retroversion (5.8°, P<0.001), a

155

decrease in femoral internal rotation (5.9°, P<0.001) in 90° of flexion and 15° of adduction (8.5°,

AC C

EP

146

6

ACCEPTED MANUSCRIPT

P<0.001). A posterior pelvic tilt resulted in an increase in femoral internal rotation (5.1°,

157

P<0.001) in 90° of flexion and 15° of adduction (7.4°, P<0.001). The authors concluded that

158

dynamic anterior tilting is a predictor for earlier occurrences of FAI, whereas a posterior pelvic

159

tilt will result in a later occurrence of FAI which may have implications for non-surgical

160

treatment (Ross et al., 2014). These findings are also supported by Lewis et al (2010, 2015) that

161

found that individuals with anterior hip pain walk in a sway back posture (posterior pelvic tilt)

162

which may increase the anterior hip joint forces during gait due to the hip being in more

163

extension. Clinician’s should be aware of the assumed pelvic positions in a symptomatic patient

164

with FAI due to the possible implications it may have on the patient’s symptoms and risk for

165

future pathology (Table 2).

166

168

Soft-Tissue and Joint Restrictions

TE D

167

M AN U

SC

RI PT

156

To date, there is no consensus as to whether joint hypomobility, soft tissue restriction, or muscle length deficits are risk factors or contributors to the symptoms of FAI and labral tears.

170

However, several investigations have observed a connection between these issues and FAI. Domb et al (2011) were the first to report the association between the iliopsoas tendon

AC C

171

EP

169

172

and anterior hip labral tears. The authors found that impingement of the iliopsoas tendon resulted

173

in an anterior hip labral tear in 25 patients with no radiographic finding or bony morphology

174

consistent with acetabular labral tears. Other authors (Cascio, King, & Yen, 2013; Nelson &

175

Keene, 2014) have found a connection between psoas impingement and anterior labral tears. The

176

common treatment for iliopsoas impingement includes surgical tenotomy of the iliopsoas tendon

177

and labral repair or debridement (Domb et al., 2011; Nelson & Keene, 2014). Currently, there are 7

ACCEPTED MANUSCRIPT

no clinical trials that have measured the effects of non-surgical treatment (e.g. manual therapy)

179

for this pathology. The paucity of evidence seems to be the result of this being a more recent

180

diagnosis.

181

RI PT

178

Kennedy et al (2009) observed gait difference in hip abduction, sagittal and frontal plane hip ROM in subjects (N=17) with unilateral cam-type FAI when compared to a control group

183

(N=14). The authors found lower peak hip abduction (p=0.009), frontal range of motion (ROM)

184

(p=0.003) and pelvic frontal ROM (pelvic roll) (p=0.004) in the FAI group when compared to

185

controls. The authors concluded that these differences may be caused by soft-tissue restriction in

186

the hip and limited lumbosacral mobility (Kennedy, Lamontagne, & Beaule, 2009). Other case

187

reports (Cashman, Mortenson, & Gilbart, 2014; Cheatham & Kolber, 2012, 2015; Wright &

188

Hegedus, 2012; Yazbek, Ovanessian, Martin, & Fukuda, 2011) have reported muscle length

189

deficits, soft-tissue, and joint restrictions around the hip and lumbopelvis in subjects diagnosed

190

with FAI and labral tears. The correlation between soft-tissue restriction and FAI and labral tears

191

is still under investigation. Whether these findings are a sequela or a causative factor of an intra-

192

articular pathology is still to be determined. Clinicians should consider these factors when

193

examining patients suspected of having an intra-articular pathology (Table 2).

194

Muscle Weakness

M AN U

TE D

EP

AC C

195

SC

182

Several investigations have found weakness in the hip musculature in individuals with

196

symptomatic hip FAI. Casartelli et al (2011) investigated hip strength in patients (N=22) with

197

FAI when compared to a matched control group (N=22). The outcome measures included

198

isometric maximal voluntary contraction (MVC) strength of all hip muscle groups using hand-

199

held and isokinetic dynamometry and electromyographic (EMG) activity of the rectus femoris

8

ACCEPTED MANUSCRIPT

(RF) and tensor fasciae latae (TFL) during active hip flexion. The authors found patients with

201

FAI to have significantly lower strength than controls for hip flexion (26%), abduction (11%),

202

adduction (28%), and external rotation (18%). The TFL EMG activity was also significantly

203

lower in patients with FAI than controls (P=0.048). There was no significant difference found in

204

hip extension and internal rotation MVC strength and rectus femoris EMG activity (Casartelli et

205

al., 2011). Nepple et al (2015) also measured preoperative MVC isometric strength in all hip

206

muscle groups using a dynamometer in patients (N=50) with unilateral FAI and labral tears. The

207

authors found hip abduction weakness in 46% of the patients and hip flexor weakness in 42% of

208

patients. There was an 8% decrease in hip flexion and an 8.7% decrease in hip abduction of the

209

involved hip when compared to the uninvolved (Nepple et al., 2015). Lewis et al (2007) also

210

found that patients with intra-articular pathology demonstrated decrease force of the gluteal

211

muscles during hip extension and the iliopsoas during hip flexion which increased the forces

212

across the anterior hip. This research suggests that patients with symptomatic FAI may present

213

with global hip weakness that may affect their function. The most common muscle weakness

214

seems to be in the hip flexors and abductors which should be considered during the examination

215

process (Table 2).

216

Function and Gait

SC

M AN U

TE D

EP

AC C

217

RI PT

200

Patient with intra-articular pathology such as FAI and labral tears tend to limit their

218

motion during function and gait due to pain and fear. Mannion et al (2013) found that the top 2

219

pre-operative reasons for patients electing to have surgery for FAI included: “alleviation of pain”

220

and “fear of worsening.” Lamontagne et al (2009) observed limited pelvic ROM in patients

221

(N=15) with cam-type FAI in comparison to a matched control group (N=11) (14.7 +/- 8.4°

222

versus 24.2 +/- 6.8°) during a bilateral maximum squat. No differences were found in hip motion 9

ACCEPTED MANUSCRIPT

between groups during the squat. Diamond et al (2015) conducted a systematic review looking at

224

the physical impairments and activity limitations in individuals with FAI. The authors found that

225

the most commonly reported physical impairment was decreased ROM in the direction of hip

226

impingement (e.g. flexion, adduction) (Diamond et al., 2015). Rylander et al (2013) observed

227

decreased hip internal rotation and sagittal plane range of motion during walking (p = 0.01, p <

228

0.001) and stair ambulation (p = 0.03, p < 0.001) in patients with FAI (N=17) when compared to

229

matched controls (N=17).

SC

RI PT

223

Individuals with FAI and labral tears may demonstrate a compensatory gait pattern. Hunt

231

et al (2013) observed kinematic and kinetic differences in patients (N=30) with symptomatic FAI

232

and a matched control group (N=30). Patients with FAI exhibited a significantly slower cadence,

233

kinematically less peak hip extension, adduction, and internal rotation during stance. FAI

234

patients also exhibited less peak hip flexion (ES=0.52) and external rotation (ES=0.85) moments

235

when compared to the control group (Hunt, Guenther, & Gilbart, 2013). Similar findings have

236

been observed in other investigations (Diamond et al., 2015; Kennedy et al., 2009; Rylander,

237

Shu, Andriacchi, & Safran, 2011). Clinicians should consider integrating gait observation and

238

functional tests such as squats and stair ambulation into the examination process to have a better

239

understanding of the patient’s functional abilities (Table 2). The presence of pain and fear should

240

also be considered as factors that could influence the patient’s performance.

241

Joint Mobility

242

AC C

EP

TE D

M AN U

230

As mentioned above, hip ROM deficits may be present in these individual during gait and

243

function activity. ROM deficits may also be present with direct measurement of hip joint ROM

244

(Reiman & Thorborg, 2014). Yuan et al (2013) also observed decreased hip internal ROM in

10

ACCEPTED MANUSCRIPT

asymptomatic adolescents (N=19) with radiographic finding of FAI. Audenaert et al (2012) also

246

found decrease hip internal ROM in symptomatic and asymptomatic patients with FAI (N=20)

247

when compared to a control group (N=10). Other investigations have found a correlation

248

between hip internal rotation deficits and radiographic evidence of FAI (Kapron et al., 2012;

249

Ross et al., 2015; Whiteside, Deneweth, Bedi, Zernicke, & Goulet, 2015).

The clinical measurement of hip ROM should be conducted with caution in patients with

SC

250

RI PT

245

FAI due to possible discomfort. Research measuring the accuracy of goniometric measurement

252

in patients with FAI has produced mixed results. Kapron et al (2012) measured the effectiveness

253

of the physical examination using the FADIR test and ROM measures to detect bony

254

abnormalities in 65 male athletes. Two orthopedic surgeons conducted the examination in all

255

athletes, which was compared to radiographic findings. Maximum hip flexion (supine) and

256

internal and external rotation (supine, sitting, and prone) were measured with a standard

257

goniometer. The authors found that decreased hip internal rotation significantly correlated (p<

258

0.01) with radiographic findings of CAM impingement. Naussbaumer et al (2010) measured the

259

validity and reliability of standard goniometry to an electromagnetic tracking system. Measures

260

were taken simultaneously for hip flexion, abduction, adduction, internal, and external rotation of

261

15 patients with FAI and 15 controls. The authors found that goniometry provided greater hip

262

ROM values compared to digital measures (range 2.0-18.9 degrees; P < 0.001). Concurrent

263

validity was good between the goniometer and digital measures for hip abduction (ICC= 0.94)

264

and internal rotation (ICC =0.88). Test-retest reliability was good (ICC= 0.90) between devices

265

except for hip adduction (ICC= 0.82-84). The authors concluded that standard goniometry

266

considerably overestimate hip ROM in patients with hip FAI when compared to digital measures.

AC C

EP

TE D

M AN U

251

11

ACCEPTED MANUSCRIPT

267

This may be due to difficulty in goniometer placement and controlling pelvic motion during

268

testing (Nussbaumer et al., 2010). Electronic devices such as a digital inclinometer or goniometer may be better clinical

RI PT

269

tools due to their enhanced accuracy when compared to standard goniometry (Bierma-Zeinstra et

271

al., 1998; Charlton, Mentiplay, Pua, & Clark, 2015). Overall, the research suggests that a

272

clinical measure of decreased hip internal rotation may be indicative of an intra-articular

273

pathology such as CAM-type FAI.

SC

270

275

276

M AN U

274

Special Testing

Several special tests are used during the clinical examination of a suspected intra-articular hip pathology. Among the tests, the flexion-adduction-internal rotation (FADIR) and flexion-

278

abduction-external rotation (FABER) test are commonly used tests (Table 3) (Reiman, Goode,

279

Cook, Holmich, & Thorborg, 2014). Kapron et al (2015) conducted an exploratory study

280

visualizing hip arthrokinematics via fluoroscopy during the supine clinical examination using the

281

FADIR and FABER tests in patients with FAI and a control group. The authors found that

282

patients with FAI had significantly less hip internal rotation and adduction during the FADIR

283

exam and less abduction and external rotation during the FABER exam when compared to

284

controls. The authors did observe substantial pelvic motion in all participants during the FADIR

285

and FABER exams which should be considered when choosing to use these tests during the

286

clinical examination (Kapron, Aoki, Peters, & Anderson, 2015).

287 288

AC C

EP

TE D

277

Other special tests include the flexion-internal-rotation test, Thomas test, resisted straight leg raise test, log roll test, and the impingement provocation test (Reiman, Goode, et al., 2014; 12

ACCEPTED MANUSCRIPT

Reiman, Mather, & Cook, 2015; Reiman, Mather, et al., 2014). Table 3 provides a description of

290

these tests along with their statistical properties. The statistic strength of these special tests is still

291

being investigated. Laborie et al (2013) found that a positive anterior hip impingement test is not

292

uncommon in health young adults primarily males. The authors recommend combining the

293

clinical test with diagnostic imaging for active patients presenting with anterior hip pain

294

(Laborie, Lehmann, Engesaeter, Engesaeter, & Rosendahl, 2013). The authors conclusion

295

supports the idea that impingement testing should be part of a comprehensive examination that

296

includea a comprehensive history, evidence based test and measures, and appropriate imaging. A

297

requisite skill set for the individual with clinical acumen would seem dependent upon

298

recognizing the wide-ranging of intra-articular and extra-articular causes of impingement.

299

Diagnostic Imaging

SC

M AN U

Diagnostic imaging may be used to confirm the clinical diagnosis of FAI or labral tear.

TE D

300

RI PT

289

Several types of imaging are used to diagnose FAI and labral tears and include: radiographs,

302

computer tomography (CT) scans, diagnostic ultrasound (US), magnetic resonance imaging

303

(MRI), and magnetic resonance arthrography (MRA). Radiographs are commonly utilized to

304

assess the bony architecture of the coxa femoral joint to assess for bony abnormalities such as

305

positional changes, abnormal density, joint space, as well as changes in the cortical outline and

306

shape of the bone. Some of the common criteria for diagnosing pincer-type FAI include a lateral

307

center edge angle >40° (sensitivity 81%, specificity 100%) and acetabular index (Tönnis angle)

308

of less than 0° (Diaz-Ledezma, Novack, Marin-Pena, & Parvizi, 2013; Kutty et al., 2012). For

309

cam-type FAI, an alpha angle >50.5° (sensitivity 91%, specificity 88%) and head-neck offset

310

less than 8mm are considered key finding for this type of impingement (Barton, Salineros,

311

Rakhra, & Beaule, 2011; Kim, Choi, Lee, & Lee, 2015; Yamasaki et al., 2015). Other

AC C

EP

301

13

ACCEPTED MANUSCRIPT

radiographic finding for diagnosing FAI include pistol-grip deformity, acetabular crossover sign,

313

and prominent posterior wall sign (Chakraverty, Sullivan, Gan, Narayanaswamy, & Kamath,

314

2013). CT scans have shown good diagnostic accuracy for FAI and acetabular labral tears

315

(sensitivity 92% to 97%, specificity 87% to 100%) and articular cartilage lesions (sensitivity

316

88%, specificity 82%) (Nishii et al., 2007; Reiman, Mather, et al., 2014; Yamamoto, Tonotsuka,

317

Ueda, & Hamada, 2007). Diagnostic US is an emerging test often used for soft-tissue

318

pathologies such as muscle, tendon, and cartilage pathology. The diagnostic utility of US for the

319

hip region is still emerging. The available studies have shown sensitivity of 82% and specificity

320

of 60% for diagnosing acetabular labral tears (Fearon, Scarvell, Cook, & Smith, 2010; Kong,

321

Van der Vliet, & Zadow, 2007). MRI and MRA are the preferred techniques for diagnosing intra-

322

articular hip pathologies. MRI has a pooled sensitivity of 66% and specificity of 79% for

323

diagnosing FAI while MRA has a sensitivity of 91% and specificity of 80% (Reiman &

324

Thorborg, 2014; Smith, Hilton, Toms, Donell, & Hing, 2011). MRI and MRA have both shown

325

moderate sensitivity (66%, 87%) and specificity (79%, 64%) for diagnosing acetabular labral

326

tears (Smith et al., 2011). For hip joint articular cartilage lesions, MRI has a pooled sensitivity of

327

59% and specificity of 94% while MRA has a sensitivity of 62% and specificity of 86% (Smith,

328

Simpson, Ejindu, & Hing, 2013). Diagnostic imaging is often prescribed to confirm the finding

329

from the clinical examination and determine what structures are involved in order to develop a

330

definitive diagnosis (Table 2).

331

Patient Related Outcome Measures (PRO’s)

332

AC C

EP

TE D

M AN U

SC

RI PT

312

Patient related outcome measures or PRO’s should also be included with the examination

333

and treatment in order to obtain a more objective, repeatable measure of the patient’s progress.

334

For non-arthritic hip and groin pathology in young to middle age adults, the Copenhagen Hip and 14

ACCEPTED MANUSCRIPT

Groin Outcome Score (HAGOS), Hip Outcome Score (HOS), International Hip Outcome Tool-

336

33 (IHOT-33) and IHOT-12 (Short version) are recommended (Table 4) (Thorborg et al., 2015).

337

All questionnaires contain good clinometric properties including: content validity (except HOS),

338

test–retest reliability, responsiveness, construct validity, and interpretability (Thorborg et al.,

339

2015). The HAGOS contains 6 separate subscales that assess pain, symptoms, physical function

340

in daily living, physical function in sports and recreational activity, participation in physical

341

activity, and hip and/or groin quality of life (Thorborg, Holmich, Christensen, Petersen, & Roos,

342

2011). The HOS contains 24 questions that measure both activities of daily living and physical

343

function during sports activity (Reiman & Thorborg, 2014; Thorborg et al., 2015). The IHOT-33

344

contains 33 questions and IHOT-12 (Short version) contains 12 questions. Both tools measure

345

hip related symptoms, function, sports, function with occupational activities, and quality of life

346

(Griffin, Parsons, Mohtadi, & Safran, 2012; Mohtadi et al., 2012).

347

Conclusion

SC

M AN U

TE D

348

RI PT

335

A definitive understanding of the clinical presentation expected among individuals with FAI and labral tears is still emerging and expected to grow with developing research and

350

advances in imaging technology (e.g. Tesla 3 MRI). The differential diagnose is often wide-

351

ranging at first owing to the proximity of anatomical structures. This proximity, similar to other

352

joints, can make it difficult to accurately identify FAI as a definitive source of symptoms based

353

on the clinical presentation alone. Clinicians should have a comprehensive understanding of the

354

key clinical markers related to symptomatic FAI. These clinical markers may be recognized as

355

part of the history and clinical test and measures. This review provided current evidence

356

underpinning the clinical presentation of patients suspected of having hip FAI. Future research is

357

necessary to help guide clinical practice and better recognize this emerging pathology.

AC C

EP

349

15

ACCEPTED MANUSCRIPT

References

359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407

Barton, C., Salineros, M. J., Rakhra, K. S., & Beaule, P. E. (2011). Validity of the alpha angle measurement on plain radiographs in the evaluation of cam-type femoroacetabular impingement. Clin Orthop Relat Res, 469(2), 464-469. Bierma-Zeinstra, S. M., Bohnen, A. M., Ramlal, R., Ridderikhoff, J., Verhaar, J. A., & Prins, A. (1998). Comparison between two devices for measuring hip joint motions. Clin Rehabil, 12(6), 497-505. Byrd, J. W. (2007). Evaluation of the hip: history and physical examination. N Am J Sports Phys Ther, 2(4), 231-240. Casartelli, N. C., Maffiuletti, N. A., Item-Glatthorn, J. F., Staehli, S., Bizzini, M., Impellizzeri, F. M., & Leunig, M. (2011). Hip muscle weakness in patients with symptomatic femoroacetabular impingement. Osteoarthritis Cartilage, 19(7), 816-821. Cascio, B. M., King, D., & Yen, Y. M. (2013). Psoas impingement causing labrum tear: a series from three tertiary hip arthroscopy centers. J La State Med Soc, 165(2), 88-93. Cashman, G. E., Mortenson, W. B., & Gilbart, M. K. (2014). Myofascial treatment for patients with acetabular labral tears: a single-subject research design study. J Orthop Sports Phys Ther, 44(8), 604-614. Chakraverty, J. K., Sullivan, C., Gan, C., Narayanaswamy, S., & Kamath, S. (2013). Cam and pincer femoroacetabular impingement: CT findings of features resembling femoroacetabular impingement in a young population without symptoms. AJR Am J Roentgenol, 200(2), 389-395. Charlton, P. C., Mentiplay, B. F., Pua, Y. H., & Clark, R. A. (2015). Reliability and concurrent validity of a Smartphone, bubble inclinometer and motion analysis system for measurement of hip joint range of motion. J Sci Med Sport, 18(3), 262-267. Cheatham, S. W., & Kolber, M. J. (2012). Rehabilitation after hip arthroscopy and labral repair in a high school football athlete. Int J Sports Phys Ther, 7(2), 173-184. Cheatham, S. W., & Kolber, M. J. (2015). Rehabilitation after hip arthroscopy and labral repair in a high school football athlete: a 3.6 year follow-up with insight into potential risk factors. Int J Sports Phys Ther, 10(4), 530-539. Clohisy, J. C., Baca, G., Beaule, P. E., Kim, Y. J., Larson, C. M., Millis, M. B., Zaltz, I. (2013). Descriptive epidemiology of femoroacetabular impingement: a North American cohort of patients undergoing surgery. Am J Sports Med, 41(6), 1348-1356. de Sa, D., Alradwan, H., Cargnelli, S., Thawer, Z., Simunovic, N., Cadet, E., Ayeni, O. R. (2014). Extraarticular hip impingement: a systematic review examining operative treatment of psoas, subspine, ischiofemoral, and greater trochanteric/pelvic impingement. Arthroscopy, 30(8), 1026-1041. Diamond, L. E., Dobson, F. L., Bennell, K. L., Wrigley, T. V., Hodges, P. W., & Hinman, R. S. (2015). Physical impairments and activity limitations in people with femoroacetabular impingement: a systematic review. Br J Sports Med, 49(4), 230-242. Diaz-Ledezma, C., Novack, T., Marin-Pena, O., & Parvizi, J. (2013). The relevance of the radiological signs of acetabular retroversion among patients with femoroacetabular impingement. Bone Joint J, 95-B(7), 893-899. Domb, B. G., Brooks, A. G., & Byrd, J. W. (2009). Clinical examination of the hip joint in athletes. J Sport Rehabil, 18(1), 3-23. Domb, B. G., Shindle, M. K., McArthur, B., Voos, J. E., Magennis, E. M., & Kelly, B. T. (2011). Iliopsoas impingement: a newly identified cause of labral pathology in the hip. HSS J, 7(2), 145150. Fearon, A. M., Scarvell, J. M., Cook, J. L., & Smith, P. N. (2010). Does ultrasound correlate with surgical or histologic findings in greater trochanteric pain syndrome? A pilot study. Clin Orthop Relat Res, 468(7), 1838-1844. Frank, R. M., Slabaugh, M. A., Grumet, R. C., Virkus, W. W., Bush-Joseph, C. A., & Nho, S. J. (2010). Posterior hip pain in an athletic population: differential diagnosis and treatment options. Sports Health, 2(3), 237-246.

AC C

EP

TE D

M AN U

SC

RI PT

358

16

ACCEPTED MANUSCRIPT

Griffin, D. R., Parsons, N., Mohtadi, N. G., & Safran, M. R. (2012). A short version of the International Hip Outcome Tool (iHOT-12) for use in routine clinical practice. Arthroscopy, 28(5), 611-616; quiz 616-618. Hammoud, S., Bedi, A., Voos, J. E., Mauro, C. S., & Kelly, B. T. (2014). The recognition and evaluation of patterns of compensatory injury in patients with mechanical hip pain. Sports Health, 6(2), 108118. Hunt, M. A., Guenther, J. R., & Gilbart, M. K. (2013). Kinematic and kinetic differences during walking in patients with and without symptomatic femoroacetabular impingement. Clin Biomech (Bristol, Avon), 28(5), 519-523. Ida, T., Nakamura, Y., Hagio, T., & Naito, M. (2014). Prevalence and characteristics of cam-type femoroacetabular deformity in 100 hips with symptomatic acetabular dysplasia: a case control study. J Orthop Surg Res, 9, 93. Kapron, A. L., Anderson, A. E., Peters, C. L., Phillips, L. G., Stoddard, G. J., Petron, D. J., Aoki, S. K. (2012). Hip internal rotation is correlated to radiographic findings of cam femoroacetabular impingement in collegiate football players. Arthroscopy, 28(11), 1661-1670. Kapron, A. L., Aoki, S. K., Peters, C. L., & Anderson, A. E. (2015). In-vivo hip arthrokinematics during supine clinical exams: Application to the study of femoroacetabular impingement. J Biomech. [Epub ahead of print] Kennedy, M. J., Lamontagne, M., & Beaule, P. E. (2009). Femoroacetabular impingement alters hip and pelvic biomechanics during gait Walking biomechanics of FAI. Gait Posture, 30(1), 41-44. Kim, J., Choi, J. A., Lee, E., & Lee, K. R. (2015). Prevalence of imaging features on CT thought to be associated with femoroacetabular impingement: a retrospective analysis of 473 asymptomatic adult hip joints. AJR Am J Roentgenol, 205(1), W100-105. Kong, A., Van der Vliet, A., & Zadow, S. (2007). MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome. Eur Radiol, 17(7), 1772-1783. Kutty, S., Schneider, P., Faris, P., Kiefer, G., Frizzell, B., Park, R., & Powell, J. N. (2012). Reliability and predictability of the centre-edge angle in the assessment of pincer femoroacetabular impingement. Int Orthop, 36(3), 505-510. Laborie, L. B., Lehmann, T. G., Engesaeter, I. O., Engesaeter, L. B., & Rosendahl, K. (2013). Is a positive femoroacetabular impingement test a common finding in healthy young adults? Clin Orthop Relat Res, 471(7), 2267-2277. Larson, C. M., Pierce, B. R., & Giveans, M. R. (2011). Treatment of athletes with symptomatic intraarticular hip pathology and athletic pubalgia/sports hernia: a case series. Arthroscopy, 27(6), 768775. Lee, S., Kim, I., Lee, S. M., & Lee, J. (2013). Ischiofemoral impingement syndrome. Ann Rehabil Med, 37(1), 143-146. Leibold, M. R., Huijbregts, P. A., & Jensen, R. (2008). Concurrent criterion-related validity of physical examination tests for hip labral lesions: a systematic review. J Man Manip Ther, 16(2), E24-41. Martin, H. D., Shears, S. A., & Palmer, I. J. (2010). Evaluation of the hip. Sports Med Arthrosc, 18(2), 63-75. Martin, R. L., & Sekiya, J. K. (2008). The interrater reliability of 4 clinical tests used to assess individuals with musculoskeletal hip pain. J Orthop Sports Phys Ther, 38(2), 71-77.

450 451 452 453 454 455 456 457

Maslowski, E., Sullivan, W., Forster Harwood, J., Gonzalez, P., Kaufman, M., Vidal, A., & Akuthota, V. (2010). The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology. Pm r, 2(3), 174-181. Matsuda, D. K. (2010). Endoscopic pubic symphysectomy for reclacitrant osteitis pubis associated with bilateral femoroacetabular impingement. Orthopedics, 33(3). Mitchell, B., McCrory, P., Brukner, P., O'Donnell, J., Colson, E., & Howells, R. (2003). Hip joint pathology: clinical presentation and correlation between magnetic resonance arthrography, ultrasound, and arthroscopic findings in 25 consecutive cases. Clin J Sport Med, 13(3), 152-156.

AC C

EP

TE D

M AN U

SC

RI PT

408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449

17

ACCEPTED MANUSCRIPT

EP

TE D

M AN U

SC

RI PT

Mohtadi, N. G., Griffin, D. R., Pedersen, M. E., Chan, D., Safran, M. R., Parsons, N., Larson, C. M. (2012). The Development and validation of a self-administered quality-of-life outcome measure for young, active patients with symptomatic hip disease: the International Hip Outcome Tool (iHOT-33). Arthroscopy, 28(5), 595-605; quiz 606-510 e591. Nelson, I. R., & Keene, J. S. (2014). Results of labral-level arthroscopic iliopsoas tenotomies for the treatment of labral impingement. Arthroscopy, 30(6), 688-694. Nepple, J. J., Goljan, P., Briggs, K. K., Garvey, S. E., Ryan, M., & Philippon, M. J. (2015). Hip Strength Deficits in Patients With Symptomatic Femoroacetabular Impingement and Labral Tears. Arthroscopy. Nishii, T., Tanaka, H., Sugano, N., Miki, H., Takao, M., & Yoshikawa, H. (2007). Disorders of acetabular labrum and articular cartilage in hip dysplasia: evaluation using isotropic high-resolutional CT arthrography with sequential radial reformation. Osteoarthritis Cartilage, 15(3), 251-257. Nussbaumer, S., Leunig, M., Glatthorn, J. F., Stauffacher, S., Gerber, H., & Maffiuletti, N. A. (2010). Validity and test-retest reliability of manual goniometers for measuring passive hip range of motion in femoroacetabular impingement patients. BMC Musculoskelet Disord, 11, 194. Reiman, M. P., Goode, A. P., Cook, C. E., Holmich, P., & Thorborg, K. (2014). Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis. Br J Sports Med. [Epub ahead of print] Reiman, M. P., Mather, R. C., 3rd, & Cook, C. E. (2015). Physical examination tests for hip dysfunction and injury. Br J Sports Med, 49(6), 357-361. Reiman, M. P., Mather, R. C., 3rd, Hash, T. W., 2nd, & Cook, C. E. (2014). Examination of acetabular labral tear: a continued diagnostic challenge. Br J Sports Med, 48(4), 311-319. Reiman, M. P., & Thorborg, K. (2014). Clinical examination and physical assessment of hip joint-related pain in athletes. Int J Sports Phys Ther, 9(6), 737-755. Ross, J. R., Bedi, A., Stone, R. M., Sibilsky Enselman, E., Kelly, B. T., & Larson, C. M. (2015). Characterization of symptomatic hip impingement in butterfly ice hockey goalies. Arthroscopy, 31(4), 635-642. Ross, J. R., Nepple, J. J., Philippon, M. J., Kelly, B. T., Larson, C. M., & Bedi, A. (2014). Effect of changes in pelvic tilt on range of motion to impingement and radiographic parameters of acetabular morphologic characteristics. Am J Sports Med, 42(10), 2402-2409. Rylander, J. H., Shu, B., Andriacchi, T. P., & Safran, M. R. (2011). Preoperative and postoperative sagittal plane hip kinematics in patients with femoroacetabular impingement during level walking. Am J Sports Med, 39 Suppl, 36S-42S. Santori, N., & Villar, R. N. (2000). Acetabular labral tears: result of arthroscopic partial limbectomy. Arthroscopy, 16(1), 11-15. Sink, E. L., Gralla, J., Ryba, A., & Dayton, M. (2008). Clinical presentation of femoroacetabular impingement in adolescents. J Pediatr Orthop, 28(8), 806-811. Smith, T. O., Hilton, G., Toms, A. P., Donell, S. T., & Hing, C. B. (2011). The diagnostic accuracy of acetabular labral tears using magnetic resonance imaging and magnetic resonance arthrography: a meta-analysis. Eur Radiol, 21(4), 863-874. Smith, T. O., Simpson, M., Ejindu, V., & Hing, C. B. (2013). The diagnostic test accuracy of magnetic resonance imaging, magnetic resonance arthrography and computer tomography in the detection of chondral lesions of the hip. Eur J Orthop Surg Traumatol, 23(3), 335-344. Stafford, G. H., & Villar, R. N. (2011). Ischiofemoral impingement. J Bone Joint Surg Br, 93(10), 13001302. Sutter, R., & Pfirrmann, C. W. A. (2013). Atypical hip impingement. American Journal of Roentgenology, 201(3), W437-W442. Thorborg, K., Holmich, P., Christensen, R., Petersen, J., & Roos, E. M. (2011). The copenhagen hip and groin outcome score (HAGOS): development and validation according to the COSMIN checklist. Br J Sports Med, 45(6), 478-491.

AC C

458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507

18

ACCEPTED MANUSCRIPT

M AN U

SC

RI PT

Thorborg, K., Tijssen, M., Habets, B., Bartels, E. M., Roos, E. M., Kemp, J., Holmich, P. (2015). PatientReported Outcome (PRO) questionnaires for young to middle-aged adults with hip and groin disability: a systematic review of the clinimetric evidence. Br J Sports Med. Tijssen, M., van Cingel, R., Willemsen, L., & de Visser, E. (2012). Diagnostics of femoroacetabular impingement and labral pathology of the hip: a systematic review of the accuracy and validity of physical tests. Arthroscopy, 28(6), 860-871. Troelsen, A., Mechlenburg, I., Gelineck, J., Bolvig, L., Jacobsen, S., & Soballe, K. (2009). What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics? Acta Orthop, 80(3), 314318. Verrall, G. M., Hamilton, I. A., Slavotinek, J. P., Oakeshott, R. D., Spriggins, A. J., Barnes, P. G., & Fon, G. T. (2005). Hip joint range of motion reduction in sports-related chronic groin injury diagnosed as pubic bone stress injury. J Sci Med Sport, 8(1), 77-84. Voos, J. E., Mauro, C. S., & Kelly, B. T. Femoroacetabular impingement in the athlete: compensatory injury patterns. Operative Techniques in Orthopaedics, 20(4), 231-236. Whiteside, D., Deneweth, J. M., Bedi, A., Zernicke, R. F., & Goulet, G. C. (2015). Femoroacetabular impingement in elite ice hockey goaltenders: etiological implications of on-ice hip mechanics. Am J Sports Med, 43(7), 1689-1697. doi:10.1177/0363546515578251 Wright, A. A., & Hegedus, E. J. (2012). Augmented home exercise program for a 37-year-old female with a clinical presentation of femoroacetabular impingement. Man Ther, 17(4), 358-363. Yamamoto, Y., Tonotsuka, H., Ueda, T., & Hamada, Y. (2007). Usefulness of radial contrast-enhanced computed tomography for the diagnosis of acetabular labrum injury. Arthroscopy, 23(12), 12901294. Yamasaki, T., Yasunaga, Y., Shoji, T., Izumi, S., Hachisuka, S., & Ochi, M. (2015). Inclusion and exclusion criteria in the diagnosis of femoroacetabular impingement. Arthroscopy. [Epub ahead of print] Yazbek, P. M., Ovanessian, V., Martin, R. L., & Fukuda, T. Y. (2011). Nonsurgical treatment of acetabular labrum tears: a case series. J Orthop Sports Phys Ther, 41(5), 346-353.

TE D

508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537

EP

538

540 541 542 543 544 545 546

AC C

539

Figures and Tables 1) 2) 3) 4) 5)

Figure 1. “C” sign Table 1. Common Types of Extraarticular Hip Impingement Table 2. Clinical Characteristics of Patients with FAI Table 3. Tests for Intraarticular Pathology Table 4. Patient Related Outcome Measures

547 548

19

SC

RI PT

ACCEPTED MANUSCRIPT

552 553 554 555 556 557

Figure 1. C-Sign (B & W) & (Color)

EP

551

AC C

550

TE D

M AN U

549

558 559 560

20

ACCEPTED MANUSCRIPT

Table 1. Common Types of Extra-Articular Hip Impingement Pathological Characteristics

Average age: 25–35 years (range, 15–57 years)

Patients are typically active individuals with reports of “anterior hip pain”. Clinical findings include a positive hip impingement test.

The pathology may be caused by: (1) a tight or inflamed iliopsoas tendon that causes impingement during hip extension, (2) a repetitive traction injury by the iliopsoas tendon that is scarred on adherent to the capsulelabrum complex of the hip

Patients are typically active individuals with reports of “anterior hip or groin pain”. Clinical findings include limited hip flexion and palpable tenderness over the AIIS.

The pathology is caused by a prominent anterior inferior iliac spine (AIIS) abnormally contacting the distal femoral neck during hip flexion. This may be due to an avulsion injury to the AIIS due to excessive muscular activity of the rectus femoris during repetitive knee flexion and hip extension.

Subspine Impingements

Average age: 14–30 years Gender: Males more than females

Average age: 51–53 years (range, 14–77 years)

Patients typically Report nonspecific pain in the hip, groin, buttock, or lower extremity. There are no specific clinical tests. Diagnosis is typically done with MRI.

TE D

Ischiofemoral impingement

561 562 563

AC C

EP

Gender: Females more than males

SC

Gender: Females more than males

RI PT

Clinical Presentation

M AN U

Iliopsoas impingement

Patient Demographics

564 565 566 567 21

The pathology is caused by a narrowed space between the ischial tuberosity and the lesser trochanter resulting in repetitive pinching of the quadratus femoris muscle.

ACCEPTED MANUSCRIPT

Table 2. Clinical Characteristics of Patients with FAI

571 572 573 574 575

Soft-tissue and joint restriction

Tight iliopsoas, hip joint and lumbosacral mobility restrictions may be present

Joint ROM

Decreased hip flexion and internal rotation.

Muscle weakness

Weakness in hip flexors, extensors, abductors, adductors, and external rotators

Function

Limited motion with bilateral squats, stair ambulation, decreased motion with motion that cause hip flexion and adduction

Gait

Slower cadence, kinematically less peak hip extension, adduction, and internal rotation during stance phase. Less peak hip flexion and external rotation moments may be present.

Special testing

Positive impingement tests

Diagnostic imaging

Radiographs: Pincer-type FAI include a lateral center edge angle >40° and acetabular index (Tönnis angle) of less than 0°. Cam-type FAI includes an alpha angle >50.5° and head-neck offset less than 8mm.

M AN U

SC

RI PT

Greater static standing anterior pelvic tilt or posterior pelvic tilt

TE D

570

Pelvic position

EP

569

Pt reports “anterior groin related pain”, demonstrates “C” sign, “pain” reported with different positions such as flexion and adduction, mechanical pain such a “clicking” or “giving way” may be present.

AC C

568

Patient history

576 577 578 579 22

ACCEPTED MANUSCRIPT

Table 3. Tests for Intraarticular Pathology FAI and labral Tear

Patient Position: Supine with legs extended onto table Examiner Position: Standing on the side of the test leg

Accuracy (64-95%), sensitivity (75% to 100%), specificity (10% to 100%), positive predictive value (0.64-1.0), negative predictive value (0), positive likelihood ratio (0.86 to 2.4), negative likelihood ratio (0.04 to 2.2)(R. L. Martin & Sekiya, 2008; Reiman, Goode, et al., 2014; Reiman et al., 2015)

RI PT

Flexion-AdductionInternal Rotation Test (FADIR)

SC

Procedure: Passively move the test hip into 90 degrees of hip and knee flexion, the hip is passively adducted with internal rotation and overpressure in both directions.(Leibold, Huijbregts, & Jensen, 2008; Reiman et al., 2015)

Flexion Internal Rotation Test

M AN U

Interpretation: A positive test is reproduction of the patients reported pain and/or mechanical symptoms FAI and labral pathology

Patient Position: Supine with legs extended onto table Examiner Position: Standing on the side of the test leg

TE D

Procedure: Passively move the test hip into 90 degrees of hip and knee flexion, the hip is passively internally rotated with overpressure.(Reiman et al., 2015)

Accuracy (70-100%), sensitivity (100%), specificity (0%), positive predictive value (0.83-1.0), negative predictive value (NC), positive likelihood ration (1.0) (Leibold et al., 2008; Santori & Villar, 2000)

Intraarticular hip pathology

AC C

Thomas Test

EP

Interpretation: A positive test is reproduction of the patients reported pain and/or mechanical symptoms. Patient Position: Supine at end of table with both knees to chest. Lumbar spine and pelvis are flat on table. Examiner Position: Standing on the side of the test leg. Procedure: The examiner passively lowers test legs while stabilizing ipsilateral side of pelvis. The patient holds the non-test leg to their chest with both arms.(Reiman et al., 2015) Interpretation: a positive test is reproduction of the patients reported pain and/or mechanical symptoms such as a painful

23

Sensitivity (89%), specificity (92%), positive likelihood ratio (11.1), negative likelihood ratio (0.12) (Reiman et al., 2015)

ACCEPTED MANUSCRIPT

“click”.

Flexion-AbductionExternal Rotation (FABER)

Intraarticular hip pathology, OA, or sacroiliac joint pathology

Rationale: Assess for intraarticular hip pathology or sacroiliac joint pathology Patient Position: Supine with legs extended onto table

Sensitivity (44% to 100%), specificity (57% to 100%), positive predictive value (46% to 100%), negative predictive value (9 %), positive likelihood ratio (0.73), negative likelihood ratio (2.2) (R. L. Martin & Sekiya, 2008; Maslowski et al., 2010; Mitchell et al., 2003; Tijssen, van Cingel, Willemsen, & de Visser, 2012; Troelsen et al., 2009)

SC

Examiner Position: Standing on the side of the test leg

RI PT

Note: This is a modified version from the standard test that measures muscle length. (Reiman et al., 2015)

M AN U

Procedure: Passively move the test hip into hip flexion, abduction, and external rotation followed by overpressure (downward). The opposite hand applied pressure to the contralateral iliac crest to stabilize pelvis during testing.

Impingement Provocation Test

Posterior labral tear

TE D

Interpretation: A positive test is reproduction of the patients reported pain and/or mechanical symptoms (Troelsen et al., 2009)

Patient Position: Supine at end of table with both legs extended.

Log Roll Test

AC C

EP

Examiner Position: Standing on the side of the test leg

Anterior capsularligamentous laxity of the hip joint

Procedure: The examiner passively lowers the test leg into hyperextension, abduction, and external rotation with overpressure.

Accuracy (82%), sensitivity (100%), specificity (0%), positive predictive value (0.82), negative predictive value (NC), positive likelihood ratio (1.0), negative likelihood ratio (NC)(Leibold et al., 2008)

Interpretation: A positive test is reproduction of the patients reported pain

Patient Position: Supine on table with both legs extended. Examiner Position: Standing on the side of the test leg Procedure: The examiner grasps the patient’s

24

No diagnostics have been calculated only interrater reliability (kappa 0.61) (R. L. Martin & Sekiya, 2008)

ACCEPTED MANUSCRIPT

thigh and moves into passive internal and external rotation. This maneuver is done several times.

Anterior capsule and/or acetabular labrum

Patient Position: Supine on table with both legs extended. Examiner Position: Standing on the side of the test leg

M AN U

Procedure: The patients actively flexes the straight leg to approximately 30 degrees. The patient is told maintain the position while the examiner applies a downward force into extension.

583 584 585 586 587 588

EP

582

AC C

581

TE D

Interpretation: A positive test is reproduction of the patient anterior hip or groin pain.

580

Sensitivity (59%), specificity (32%), positive likelihood ratio (0.87), negative likelihood ratio (1.28) (Maslowski et al., 2010)

SC

Resisted Straight Leg Raise

RI PT

Interpretation: A positive test is a notable increase of external ROM in the test hip. Pain or mechanical symptoms in the groin or anterior hip may be indicative on an intraarticular pathology.

589 590

Table 4. Patient Related Outcome Measures 25

ACCEPTED MANUSCRIPT

Content

Score Interpretation

Hip and Groin Outcome Score (HAGOS)

6 subscales that measure pain, symptoms, physical function in daily living, physical function in sports and recreational activity, participation in physical activity, and hip and/or groin quality of life

Each subscale is scored separately, subscales scores are calculated and raw scores are transformed to a 0100 scales. This is interpreted as: (0) extreme hip/groin problems to (100) no hip/groin problems.

Hip Outcome Score (HOS)

24 questions measuring activities of daily living and physical function during sports activity

Each subscale score separately, The highest potential score for the ADL scale is 68 and 38 for the sports subscale. The scores are converted to a percentage. A higher score represents a higher level of physical function.

International Hip Outcome Tool-33 (IHOT-33) and IHOT-12 (Short version)

IHOT has 33 questions that measure hip related symptoms, function, sports, function with occupational activities, and quality of life. IHOT-12 is a modified version with 12 questions.

Each question uses a VAS grading format. Scores are calculated transformed to a 0-100 scale This is interpreted as: (0) worst to (100) best.

Hip Disability and Osteoarthritis Outcome Score (HOOS)

5 subscales that measure pain, symptoms, function in activity of daily living, and function in sport and recreation, and hip quality of life

Each subscale is scored separately, subscales scores are transformed to a 0-100 scales. This is interpreted as: (0) worst to (100) best.

24 items with 3 subscales: pain, stiffness and disability

Each subscale is scored separately. A higher score represents worse pain and a lower score represents less pain.

SC

M AN U

TE D

EP

Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC®)

591

AC C

Harris Hip Score (HHS)

RI PT

Scale

10 Items. The domains covered are pain, function, absence of deformity, and range of motion.

592

26

Each item has a unique numerical scale. There are 100 total points. The scores are interpreted as <70 is considered a poor result; 70–80 is considered fair, 80–90 is good, and 90–100 is an excellent result.