Common theme for management of musculoskeletal conditions is early detection and intervention equals optimal outcomes – this does not exclude anterior hip pain. Two most common anterior hip pathologies I see are labral tears and femoracetabular impingement (FAI). Differentiating between the two may prove a fools errand as clinical signs of FAI have been found to be present in up to 95% of patients with a labral tears.9 Therefore, one could speculate that FAI is a precursor to labral pathology, or we are not detecting the underlying larbal tear. Further down this diagnostic lineage possibly providing weight to management is speculation that labral tears may be a part of a continuum of joint degeneration leading to OA.1,3 Challenge with anterior hip pain is duration of symptoms tends to be longer than therapists like to see – being that of two years or greater.5 Consequently, on average, the patient that enters your office may be a chronic hip patient.
Thus begs the question why people are hurting for long durations, and why is the diagnostic utility for evaluating the hip relatively poor when comparing it to its cousin -the shoulder.5 Lewis et al, states the importance of this tissue to decrease compression loads at the hip as it is found that once removed contact stresses are 92% higher.5 Unfortunately, cadaveric studies demonstrate that 93% of subjects had at least one labral lesion.5Thus, this speculated high prevalence one would guess that most labral tears are asymptomatic. Especially as we see anterior hip pain presents in 22% of athletes and 55% of patients with mechanical hip pain with unknown etiologywere found to have a labral tear upon further evaluation.5
Even if labral tear is a suspect in your evaluation, identifying it and differentiating from its family member FAI is convoluted. Obvious subjective weight is location of symptoms being that of the groin (>90% of patients).5 Although, some labral pathologies provide posterior discomfort and even 22% of patients experienced pain distal to the knee, while foot pain was occasional, occurring in only 2% of patients.2,3 Thus an open minded evaluation is necessary.
For comparison sake, the shoulders anterior labrum is identified with Biceps Load 2 with a specificity of 96.9%, deeming this a valid test. Conversely, at the hip anterior labral testing has no adequate specific test, leaving the therapist tests to rule labral tears out with sensitive testing. Most commonly used by most therapists, including me, is FABER test. Again, sensitivity is adequate with 82% using the FABER, and subjective questioning of snapping provides us with more sensitive information (sn = 100%).7 Unfortunately, differential diagnosis of snapping is challenging as FAI and/or labral pathology can mirror hip flexor strains, iliopsoas bursitis, snapping hip syndrome, acetabular impingement, and femoral neck fracture.4 Thus the need for specific information to not only screen for a labral tear, but to isolate one. Challenge for testing is gold standard being surgical exploration, as even MRA’s are not flawless in our assistance giving us a sensitivity of 81% – thus good, but not unblemished.
Even if testing for anterior hip pain is complex – you still have the patient in your office who has had for 2 or more years, so what is adequate management?
Goals of my treatment parameters are consistent with literature as we are isolating to improve recruitment; activation, timing and strength of glut medius, maximus, transversus abdominis and multifidus. Along with increasing length at anterior hip musclature.9 Another vantage point is evaluating movement patterns, which is excellently described by Lewis et al as “ We believe that appropriate intervention should focus on reducing anteriorly directed forces on the hip by addressing the patterns of recruitment of muscles that control hip motion, by correcting the movement patterns during exercises such as hip extension and during gait, and by instruction in the avoidance of pivoting motions in which the acetabulum rotates on the femur, particularly under load.”5 Both approaches are important, personal flavor is addressing weakness and timing controlled in open kinetic chain (OCK) positions with progression to retraining in closed kinetic chain (CKC) positioning. If the shear forces of OCK proves aggravating, either manual techniques are administered, or progression earlier to standing positioning is chosen.
Personal struggle is strengthening of the iliopsoas, as this has been demonstrated to provide stabilization to this joint.9 I have a hard time thinking that this doesn’t receive over attention as patients tend to be in sedentary work shorten this muscle and provide it with activities throughout the day as while shortened it can disengage gluteus maximus from functional tasks as it can limit hip extension.
One personal caveat is trigger point to the hip flexors. Anecdotally this muscle group is challenging to obtain optimal stretch possibly due to guarding and some soft tissue techniques seem to improve extensibility quicker and frequently resolve my previously positive FABER. Personal speculation is that this enthusiastic muscle group may pull femur anteriorly with hip flexion. Thus even with the lack of evidence for this technique, test-re-test method proves extremely important to assist in diagnosis of anterior hip pain, and treatment efficacy.
A potential factor which may accelerate degenerative changes and pain at the hip joint is a tear of joint labrum.2 Therefore, stabilization of this joint may provide short term benefit as seen by this weeks literature, but possibly long term benefit. Hopefully seating the femur in the acetabulum, and encouraging patients to match their strength and stability to their activity may provide longer health the labrum, and possibly improving longevity of that joint. All speculative, but a possible sell for a skeptical population and hopefully with time, literature will reveal long term studies to demonstrate physical therapy’s place in anterior hip pain.
Original post: March 25, 2014
- Courtney C, Clark J, O’Hearn M. Clinical Presentation and Manual Therapy for Lower Quadrant Musculoskeletal Conditions. Journal of Manual and Manipulative Therapy. 2011; 19: 212-222.
- Arnold DR, Keene JS, Blankenbaker DG, Desmet AA. Hip pain referral patterns in patients with labral tears: analysis based on intra-articular anesthetic injections, hip arthroscopy, and a new pain ‘circle’ diagram. Phys Sportsmed 2011;39:29–35.
- Lesher JM, Dreyfuss P, Hager N, Kaplan M, Furman M. Hip joint pain referral patterns: a descriptive study. Pain Med 2008;9:22–5.
- Loudon J, Reiman M. Conservative Management of Femoralacetabular Impingement in the Long Distance Runner. Physical Therapy in Sport. 2014; 1-9.
- Lewis C, Sahrmann S. Acetabular Labral Tears. Physical Therapy Journal. 2006; 86: 110-121.
- Suttler R, Zubler V, Goffmann A, Mamisch-Saupe N, Dora C, Kalberer F, Zanetti M, Hodler J, Pfirmann CW. Hip MRI: how useful is intraarticular contrast material for evaluating surgically proven lesions of the labrum and articular cartilage? AJR Am J Roentgenol. 2014; 202: 160-9.
- Maslowski E, Sullivan W, Harwood F, Gonzalez P, Kaufman M, Vidal A, Aluthota V. The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.PM R. 2010 Mar;2(3):174-81. doi: 10.1016/
- Paul Mintken. Hip Soft Tissue Disorders: Bursitis, Tendinitis, Strains, Nerve Entrapements. Lecture Performed by EIM. Friday, March 21, 2014.
- Yazebek P, Ovanessian V, Martin R, Fudaka T. Nonsurgical Treatment of Acetabular Labrum Tears: A Case Series. JOSPT. 2011; 41: 346-354.