I currently present an on demand and live webinar intended for physical therapists through Allied Health Education (www.alliedhealthed.com) on femoroacetabular impingement (FAI) regarding the recognition of this condition and current treatment principles.   Currently, I see on average 3-5 new patients per month with acetabular labral tears and/or those recovering from hip arthroscopy for this issue. As such, I am always staying abreast of the current literature on it.

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There is a new research design study that was just published in the August 2014 edition of the Journal of Orthopaedic & Sports Physical Therapy regarding hip pain as it relates to these patients. Specifically, the authors point out that some but not all of the hip pain may be attributed to intra-articular pathology. They suggest that extra-articular contributions from soft tissue (or myofascial pain) may account for hip pain thereby making the diagnosis and assessment of these patients even more complex.

The authors raise some interesting questions about lingering posterolateral hip pain that does not respond to injections or arthroscopy at all. Further, they assert that these patients may have more than one source of hip pain, as well as the possibility that the true source of the pain may not be related to the labrum at all. based on their experience they find that taut and tender gluteal, external rotator and tensor fascia latae (TFL) muscles are present in people with acetabular labral tears who also present with posterolateral hip pain. Previous research has identified myofascial taut bands or nodules as sources of such pain.

In this study, Cashman et al. wanted to investigate the effectiveness of soft tissue therapy, stretching and strengthening of the hip abductors/external rotators on treating patients with labral tears who also have posterior and lateral hip pain as well as evidence of abductor or external rotator myofascial pain syndrome.

Methods

  • Single subject research design chosen to assess efficacy in a small group in the absence of a control group
  • A-B-A design was used where A = no treatment phase and B = treatment phase targeting the posterolateral hip musculature
  • Pre-treatment phase was used to assess level and stability of outcome measures before intervention
  • Post-treatment phase was used to assess level and stability of any clinical progress after treatment was withdrawn

Subjects

  • Patients (4 females ranging 18-52 y/o) were selected if they had an anterior labral tear confirmed by MR arthrogram, 505 or greater of their reported pain was in the posterolateral hip and they had palpatory tenderness of ropy, dense or nodular tissues in the posterolateral hip muscles
  • Patients were excluded if they had hip OA graded greater than mild, signs of nerve impingement, lumbar or SI joint pain, bleeding disorders, connective tissue disease, active malignant neoplastic disease, infection or a history of previous arthroscopy on the involved hip
  • Patients were selected from a single university-based orthopaedic surgical center to which they had been seen for consultation to determine if surgical labral repair was necessary
  • Duration of symptoms ranged from 12 to 48 months

Intervention

  • Active release technique (ART) was performed by a DC with 7 years of experience doing ART for a minimum of 8 sessions at a frequency of 1-3x/week up to a maximum of 8 weeks unless the symptoms completely resolved or the patient had an adverse reaction
  • Treatment also included strengthening exercises (sidelying hip abduction to target both glute med.min and TFL as well as a clam exercise) to be performed 3-5x/week in a recumbent NWB position.  Subjects were instructed to do only one set of each exercise until they felt a muscle burn
  • Stretching exercises (supine figure 4 stretch, supine hip adduction with knee flexion across midline and half kneeling hip flexor stretch were performed 1-2x/day and held for 2 minutes each
  • Exercises were logged in a supplied calendar and taught the first 3 session in the clinic and then to be exclusively done at home thereafter
  • Patients were asked to refrain from using medication or any other treatment modalities

Results

  • Authors assessed progress using the ADL subscale of the Hip Outcome Score (HOS) and the pain visual analog scale (VAS)
  • The HSO ADL scale is 0-100 with 100 representing no disability performing ADLs and the minimally clinical important difference (MCID) has been shown to be 9 points on the subscale referenced
  • Pain VAS was used to assess anterior and medial hip as well as posterior and lateral hip
  • Differences between mean scores in pretreatment and posttreatment phases was clinically meaningful for all patients while improvements were statistically significant both phases in all patients
  • VAS scores revealed a reduction in posterolateral hip pain in all 4 patients after treatment began, while reductions in pain were statistically significant in both pretreatment and posttreatment phases in all patients
  • VAS scores revealed a reduction in anteromedial hip pain in 3 out of 4 patients
  • Adherence to the exercise log varied across the subjects

Summary

The authors conclude that myofascial treatment reduces pain and thereby increases function.  It is hard to definitively say what part of the treatment was most effective due to variable compliance with the exercises.  However, they feel that since patient #4 only performed 3 exercise sessions in the first month and still showed significant improvements in pain and function during this time that the soft tissue treatment played an integral role in initial improvements.  The authors also note that all 4 patients reported notable reductions in palpatory pain for the hip abductor, external rotator and TFL muscles at the conclusion of the study.

Some major restrictions and limitations to consider in this study include the short snapshot in time it captures compared to the long duration of symptoms which could impact results depending on the level of aggravation each subject is in.  While not the intent of the authors, all the subjects were women, so it is difficult to quantify how this approach would impact men.  Further, the small size limits the ability and accuracy of applying the results to a larger or more varied population.  Other limitations include a potential placebo effect given the self reporting and no blinding, as well as limited additional follow-up to determine the long term stability of the exercise intervention and whether surgical treatment could be avoided.

Nonetheless, I feel the study teaches us some important things about treating these patients.  I have often encountered patients who continue to struggle with posterior, lateral and anterior hip pain following the surgery.  Some key things to consider:

  1. Extra-articular pain responds well to soft tissue therapy and correctly identifying this and treating it with myofascial techniques (e.g. ART, STM, IASTM, dry needling, foam rolling) should be included in the treatment plan
  2. Patients with labral tears may have a significant amount of pain that may not in fact be caused by the labral tear itself, lending strength to giving non-operative treatment a chance prior to electing for surgery for those with less obvious FAI or frank labral tears
  3. Patients who fail to respond well to intra-articular injections during the MR arthrogram are excellent candidates for PT and caution should be used prior to considering diagnostic arthroscopy/repair until soft tissue work, stretching and strengthening exercises have been used for a set period of time (at least 6-8 weeks in my opinion)
  4. Multiple muscles create hip pain and correctly identifying trigger points and referred pain patterns is a must to selectively hone in on the areas most likely related to the pain
  5. This study did not address weightbearing strengthening and those involved in higher level activities will likely benefit from more functional rehab exercises (some examples include band walks, isometric split squats, Pallof press, single leg stance, etc) prior to electing to proceed with surgical intervention

In the end, we need more research on this area to guide our clinical decision making and treatment algorithms. I have seen many post-op patients who struggle with lingering adductor, hip external rotator and TFL tightness.  As we gather more long term outcome data on hip arthroscopy for FAI, we will begin to see how effective the procedure is on eliminating hip pain and restoring function.  It may also be very helpful to see some of these patients pre-operatively to work on strengthening and resolving myofascial pain on the front end to facilitate a smoother and more efficient post-op recovery.