Clinical Consult

I have a 45 year old male patient who sits in lotus (FABER) position for prayers.  In November he began having left hip and low back pain and took Naprosyn for 2 months which alleviated the pain.  In January after he stopped the Naprosyn the pain returned specifically when sitting in a chair, sitting for prayers, and with the first few steps after standing.  The pain begins within 5 minutes and becomes severe after 10 minutes, radiating to the knee.  He reports no clicking in the hip.

The first few treatments were directed at the lumbar spine with manipulation of the lumbar spine and SIJ's with cavitation.  Within 3 treatments, he reports no back pain.  His chief complaint now is severe anterior hip pain (over the iliopsoas) when sitting for prayers and with coming to standing and the intial first few steps. I have tried hip mobilizations and long axis thrust manip to the hip with relatively little change for 3 treatments.
Other treatment includes stretching and hip abductor and extensor strengthening.  He has had a total of 5 treatments.

ROM measured yesterday:

Flexion painful at 95 degrees, extension 20 degrees not painful, external rotation 60 degrees with pain at endrange (capsular), and internal rotation 20 degrees (capsular).  Abduction 45 degrees with no pain, adduction 35 degrees with no pain.  Long axis traction relieves the hip pain as does seated hip rotation using foot supported on a ball.

Special tests: He has pain with Flexion internal rotation compression grind test but no clicking.  Positive Thomas test left > right, Negative FAIR test in sidelying, and negative Ober's test.

The MRI of the spine was negative for significant findings, as were the MRI of the hip and a/p and med/lat x-rays of the hip.  X-rays showed mild OA changes.  When looking in the literature, I found an article by Tanzer
(2004) on hip labral tears with a "pistol grip" deformity of the femoral neck leading to labral tear in 38 of 38 patients undergoing arthroscopic surgery.  This was discovered with the x-rays: a/p, med/lat, and "frog leg"
position.  Even though I would love to believe something with this high specificity, I am of course skeptical.

Questions for the group:

1.  What testing would you suggest to differentially diagnose labral tear?

2.  Is a click necessary to confidently diagnose a labral tear?

3.  Have you found any treatment that has worked for you in anterior hip impingement patients?

4.  Do you have any literature on the false negative rate of labral tear with MRI?

He is returning to the doctor next week....

Any ideas or comments would be greatly appreciated.

Thanks,

Carina Lowry, MPT

Tanzer, M. Osseous abnormalites and early osteoarthritis: the role of hip impingement. Clin Orth Rel Res. 2004. 429;170-177.
Download Tanzer-ClinOrthopRelRes-2004-HipPainLabralTearOA.pdf

Comments

[Sean Deardorff]

Carina:
This article discusses the anatomy, etiology, diagnosis, and treatment (including surgery) of acetabular labral tears. Hopefully you will find it helpful.

Acetabular Labral Tears
Cara L Lewis and Shirley A Sahrmann
Physical Therapy Volume 86 · Number 1 · January 2006
http://www.ptjournal.org/PTJournal/Jan2006/v86n1p110.cfm

Sean Deardorff, PT

[Jason Silvernail]

Hip impingement is difficult to treat, in my opinion. I don't have any literature to cite (primarily because there's not much out there), but a suggestion based on theoretical biomechanics and some anecdotal evidence. Not a promising intro, huh?

Check his other hip. Look for asymmetry.
Anterior hip impingement is tough, but I have had some limited success in taking a Sahrmann type approach to this. I'm willing to bet that he has a lot more ER on his symptomatic hip than his other side. He needs to cease the external rotation positioning (any type of it), try mobilizing his hip into IR (it will probably be limited) and do some posterior hip capsule mobs and self stretching, and iliopsoas stretch/femoral nerve mobs.
I think that Sahrmann makes a pretty good case biomechanically about what to do here, but my limited success in treating it makes me cautious.
Keep us posted.
J

[John Ware]

Sahrmann would probably classsify this pt as hip ER w/ anterior glide syndrome. (Her book is a "must read" if for no other reason than it's very practical review of biomechanics of the hip from a very clinical perspective). I agree with the approach proposed by Jason. The key, in my experience with these anterior impingements, is avoiding any position that places the hip in external rotation or that encourages anterior glide of the femoral head-especially walking. If the pt hyperextends his hip during gait, this must be corrected. Avoidance of the "tailor" sitting position is also a must.
I recently attended a presentation by a local orthopod on hip arthroscopy. He cited some data on false negatives on MRI for labral tear better than 80%. MRI with contrast reduces the error to around 15%, which is still pretty high. He suggested that provocation tests for the hip are kind of like McMurry's for the knee. Highly valid when you get the "click," you just rarely get one.
John

[Selena Horner]

I don't believe any of our manual tests are sensitive or specific enough to indicate a labral tear in the hip. Sometimes there are also cysts in the joint that cause the pain symptoms. I've even had a patient that basically had his bony surfaces just slowly erroding secondary to high prednisone use because of cancer (MRI, X-ray, CT were all negative).

I believe from working with and talking to a few orthopods that the diagnostic tests are not very good in revealing labral tears. From their perspective, a hip arthroscopy is the gold standard in diagnosing a labral tear. And, in talking to them, it doesn't appear that the procedure is easy. Supposedly there are 3 surgeons in my area that will do a hip arthroscopy, but apparently only one of the surgeons is highly skilled in the procedure.

[Adam Rufa]

Thanks to Dr. Cleland's wonderful book I can tell you that hip joint clicking has a sens of 1.0 and a spec of .85 when it comes to labral tears. The scour test has sens of .75 and spec of .43.

Narvani et al "a preliminary report on prevalence of acetabular labral tears in sports patients with groin pain." Knee surg Sports Traumatol Arthrosc. 2003

[Sarah Case]

Hi all,
I would agree with everything above except that Sahrmann cautions against stretching the hip flexors, as the anterior hip capsule is already overstretched and it would promote more anterior gliding. I personally have been diagnosed with a partial labral tear through arthrogram and I have not had success with PT approaches I've tried over the last 5 years. I am seeking a second opinion for surgery currently. Good luck!

[Kim Schoensee]

I read your blog and am presently working with an orthopedic surgeon who has performed over 55 hip arthoscopic surgeries. He gave us a talk and has some publicatins pending on this topic. Your patient, by history sounds like a labral tear. The best diagnostic test is MRI with contrast and even then you need a surgeon who can read it and find it. My surgeon can see them on plain MRI's but the diagnostic center radiologists cannot. They even have a hard time with contrast dye as well. There is a web site, Hipscope.com. That can give you some information. Most people are difficult to diagnosis but labral tears do NOT heal with conservative care, and according to my friend, the preferred surgery is to REPAIR the labrum and not just debridement. Hope this information helps. My surgeon's website is www.centralcoastsportsmedicine.com. (I think) S Austin Yeargan III. He studied with Marc Phillipon MD, at Vail, Colorado whose entire practice is hip scopes. It is a tedious procedure and they use bendable tools that work in a joint that is heavily distracted. Good luck with your patient.

[John Ware]

All:
Before we relinquish all of our anterior hip impingment pt's to the orthopods, I think we should take a step back and consider Dr. Sahrmann's kinesiopathological model. According to Dr. Sahrmann's theory, it is faulty movements and postures that lead to imbalances in the movement system that adversely alters the "precise instaneous center of rotation" (PICR) of the joint resulting in soft tissue strain, irritation, inflammation, and so on (last month's PT journal has a reseach article on the shoulder that supports a posture-impairment relationship). If this is the case, then shouldn't all of these pt's-if not pre-operatively, then at least post-op- be under the care of a PT in order to learn how to move correctly-to help restore the PICR? As a manual therapist, I add joint and ST mobilizations in to the mix, which in my experience helps move things along-pun intended.
John

[Carina Lowry]

Sean,

Yes, I did read that article when it came out in January. It's always good to go back and review it. Dr. Sahrmann did report the false negative rate of the MRI, which doesn't really surprise me much. I agree with the posted idea that arthroscopy is the best way to visualize the labral tear. Yes, I have "the book" by Dr. Cleland and I use it quite often to ground me in tests and measures.

Yet, surgery is the answer? I'd have to question the rush to surgery since surgery isn't always the answer either, according to the Sahrmann article in PT. I have definitely been mobilizing this pt's hip, avoiding increasing the pain intensity (have to modify some of them or not take it as far into some of the ranges).

So as for conservative management, I would like to explore some of Sahrmann's ideas. Do you have the reference to the text you mentioned John or Jason? Not that I need more complication by looking at it from the biomechanical model, but I do think the low back/SIJ has a factor in his hip pain.

Sarah, with the iliopsoas tightness it seems that I should address this. I have been stretching them without taking the hip into hyperextension in the modified Thomas test position. Does anyone have any other ideas about this?

Thank you so much to everyone for their comments and ideas.

Carina

[Craig O'Neil]

The insidious onset of anterior hip pain and the symptoms described seem to point toward an anterior hip capsule entrapment, likely due to altered mechanics. The altered mechanics can be from joint hypo or hypermobility, soft tissue restrictions or poor neuro-muscular control. I have had success with soft tissue mobilization to the proximal rectus femoris and occasionally to the iliopsoas. Frequently, mobilizing the anterior hip capsule clears the impingement. Either approach is followed by re-education of the hip flexors and to restore motion around a physiologic axis. When this works, it works well within 2-3 visits. I have no evidence to back this up, other than clinical experience. However, it has worked consistently on several patients with a very similiar history.

[Cara Lewis]

To provide more answers to a few of the questions that have come up along the way:
The Lewis / Sahrmann article gives a pretty thorough review of the literature on diagnosis of labral tears. Basically there isn't a great test, and a lot of the tests are dependent on the level of experience of those conducting the tests. That being said, I don't think that it is very important (unless there is catching / clicking / locking) to know if there is a labral tear, nor to correct it. Despite what some articles / posts might say, one can get very good results with physical therapy even in the presence of a labral tear. True, the tear does not "heal", but the patient can be asymptomatic and return to sports activities. Neither approach (surgery or therapy) have enough long-term result to determine if one is better than the other.

Hip ER ROM: The increased ER makes me think that the femoral head is sliding / translating forward. The forward translation may be stressing the labrum too much (and could have caused a labral tear, vs. one caused by impingement).

Easy tests: I would check the ER with your hand over the anterior aspect of the hip (groin line) to see if the ROM is then reduced, or if you feel more anterior pressure. If you are tentative about hand placement for this, have the patient lie prone, put a rolled towel at the anterior groin line, and measure ER with and without the towel roll.

Alternative positions: I'm assuming that your patient will stop listening to you the moment you tell him that he can't pray anymore. True, minimizing the amount of ER would be good. But if you can't do that, could he place something under the lateral knee when in the lotus position so that it isn't passively hanging into ER, but is instead supported by resting on the support. The other option is to see if varying the amount of hip flexion (by changing the anterior / posterior angle of the pelvis). Adding more anterior pelvic tilt will move the anterior aspect of the acetabulum over the femoral head. If this is done after the femoral head has slid forward, too late... it will result in increased impingement / pain. If done before, it will add to the stability and could reduce the anterior translation of the femoral head.

Things to avoid: anything which increases anterior glide of the femur relative to the acetabulum.

Sahrmann's book is: Diagnosis and Treatment of Movement Impairment Syndromes.

As for stretching hip flexors without going into hyperextension, I applaud you for being careful about this. You may also want to check the anterior glide even with this limitation (again, had on the anterior groin line). Sometimes adding some posterior force at the anterior hip during stretching will help make the stretch more effective.

I think that is a long enough post for my first one.

-- Cara

[Erica Meloe]

Carina-
You have gotten very good advice. I have had a good deal of success with the Sahrmann approach for hip impingements. The quadruped intp sitback on heels, which promotes a posterior femoral glide has been helpful for patients. (it's in her book) I would also avoid stretching the hip flexors-what I have done in the past (as Cara mentioned above) is apply a posterior force to the hip while in a modified Thomas Test position and this seems helpful. You can also try some soft tissue to the psoas. Try some inferior/lateral glides with a mobilizing belt which also helps. Re-ed of the hip flexors is important-I find that starting in the supine position is more tolerable than the sitting position. I also have a hip impingment and the soft tissue approach to the psoas/rectus, belt mobs, exercises ala Sahrmann have really helped me as well. Good luck! Keep us posted. Regards,
Erica

[Carina Lowry]

Hi all,

I am still thoroughly impressed by the clinical expertise that has been shared in this post. The pt came back in today, and yes indeed the femoral head is translating forward excessively. I palpated over the anterior joint capsule with ROM and also did the prone with towel under hip to measure ER/IR. Much less pain and improved ER with the towel. We also discussed the need for him to sit with anterior pelvic tilt instead of posterior pelvic tilt, and I did some soft tissue work to the iliopsoas and rectus.

I am most pumped about the towel under the knee in the tailor sitting position. We did this without pain and he sat for at least 10 minutes in this position with little pain. It was beautiful! His guru is coming from India (THE MAN in his religion) so he will be spending a lot of time with his towel roll.

So I will continue on the same track with the mobs, STM, and working with the iliopsoas to control the hip. I started with just a heel slide. I'm just wondering what the progression is of this?

I will also try the modified child's pose aka prayer position as well to see if we can be more aggressive with the posterior mobilization of the femur.

Thank you all so much for all your insight.

Carina

[Sean Deardorff]

Hello Carina:
This is a brief synopsis of the “femoral anterior glide with lateral rotation” classification from Dr. Sahrmann’s book with several of her suggested exercises and functional recommendations. I have added in my own comments for some of these exercises and postural modifications.

Femoral Anterior Glide with Lateral Rotation

Goals:
Improve participation of hip internal rotators and iliopsoas.
Improve IR and flexion ROM.
Increase femoral posterior glide.
Improve flexibility of external rotators.

Exercises:
Quadruped Rocking backwards. Limit motion to hip flexion and try to avoid ER. Often the patient’s preferred position includes lumbar flexion and ER of the hip. When rocking backward I use tactile cueing and/or taping to prevent lumbar flexion as a compensation for decreased posterior glide.

Prone Hip IR. Avoid lumbo-pelvic rotation. I may add some isometrics at end-range to improve IR strength and motor control. I may also try passive stretching as well to increase ROM.

Supine Hip Adduction and IR. Avoid lumbo-pelvic rotation if patient is doing the stretch. This is a stretch of the external rotators and improves control of the adductors. I may add overpressure making sure to stabilize the pelvis if I am doing the stretch. Also, some soft-tissue work to the external rotators such as the pirifirmis can increase flexibility.

Sidely Abduction with hip in IR and flexion. I haven’t tried this exercise too often although in this classification abduction may be weaker in this position (vs. abduction with hip extended and in ER)

Sitting. Lift thigh to maximum flexion and hold to improve psoas strength. If the weight of their leg is too painful (or if they can not hold at end-range) they may need their hands for support or try supine as Erica mentioned.

Functional Modifications:
As needed to avoid excessive hip extension and external rotation during movements or sustained postures.

Common functional recommendations for this classification include:
Sleeping. Avoid sleeping prone in FABER position.
Sitting. Do not sit with legs crossed (i.e. ankle on opposite knee),
Sitting. Avoid excessive ER of hip.
Driving. Avoid excessive abd/ER of hip when swinging leg in/out of car.
Standing/Walking. Avoid hyperextension of hip.
Bending. When bending forward try to bend at the hips rather than the back.
Cycling. The patient may have a tendency to slightly abduct and ER the hip at the top of the upstroke and may need cueing or seat height adjustment to avoid (or minimize) this.

Good luck,
Sean

[Cara Lewis]

Carina,

I keep thinking about your patient, and have a few more ideas…

If your patient has pain after sitting in the prayer position, it might be helpful for him to move into quadruped before he stands up. This will help to reposition the femur posteriorly in the acetabulum.

You mentioned that he has pain when walking after standing up… I would look at his sit to stand posture. If he is going into hip extension as he stands up, correct this. I try to remind my patients to keep their head over / in front of their toes so that they push them selves up using their legs. I also emphasize NOT rotating on the leg once standing. I try to break it into two moves… 1. standing, and 2. turning by lifting the leg, not pivoting on it.

Walking… sometimes I’ve seen patients who extend the hip beyond its tolerance when walking and get an anterior glide of the femoral head during late stance on the involved leg. I’ve also seen ones who rotate on the femur. I’ve been known to try to palpate the femur while walking (it works for me if I can put my fingers in the anterior groin line, and my thumb posterior to be able to hold on). Usually the modification (if there is anterior glide) is to reduce stride length (so he goes into less hyperextension) and increase knee flexion during terminal stance (knee hyperextension at terminal stance results in greater hip extension) and increase ankle push off (which will help drive hip and knee flexion.)

The other “home treatment” that I’ve used before (especially if long axis traction is helpful) is letting the leg hang with an ankle weight. I usually do this at the stairs… uninvolved leg up a step and the involved leg with the ankle weight hanging. I would be a little concerned about doing this with your patient because of the history of back pain… he might rotate too much while standing there. But if he has someone who could assist him and do a little traction, it might help him on the bad days.

Hope all that helps.

-- Cara

[Dr.David Black]

Anterior hip pain together with a weak iliopsoas can occur through anterior pelvic rotation.The leg length is often longer on the affected side.
We frequently treat these patients with success.