A comparison of 6-month outcomes between periacetabular osteotomy with concomitant hip arthroscopy to isolated hip arthroscopy for femoroacetabular impingement.

PURPOSE: To compare early outcomes of periacetabular osteotomy (PAO) with concomitant hip arthroscopy to isolated hip arthroscopy for femoroacetabular impingement (FAI) and chondrolabral pathology using patient-reported outcomes measurement information system (PROMIS). MATERIALS AND METHODS: Consecutive patients scheduled for PAO with concomitant hip arthroscopy (PAO + HA) or isolated hip arthroscopy (HA) between the ages of 15 and 30 years old were prospectively included in the study. Based on power analysis, subjects were recruited until there were 22 subjects in the PAO + HA group. These subjects were then gender matched to the HA group. The PROMIS, with six subscales and two global health measures, were completed during preoperative and 6-month follow-up visits. One-way ANOVA was performed to compare intake information of age, symptom duration, body mass index, and Beighton scores as well as preoperative and 6-month postoperative PROMIS scores between the PAO + HA and HA. RESULTS: 22 consecutive subjects undergoing PAO + HA were all females (average age 20.0 years) and matched to 22 consecutive females (average age 22.6) in the HA group. ANOVA did not find a significant difference between the two groups when comparing intact information, with exception of age (p = 0.04). A significant difference was also not identified (p ≥ 0.05) between the two groups on preoperative or 6-month postoperative PROMIS scores. The largest difference in 6-month postoperative scores between the two groups was 4.4 points on physical function subscale. CONCLUSION: Outcomes at 6 months were not significantly different when comparing PAO + HA to HA for FAI and chondrolabral pathology in females under 30 years of age. The more extensive surgery with a prolonged protective period associated with PAO do not seem to negatively impact outcomes at 6 months when compared to HA. These finding support the use of PAO + HA, particularly if the patient and/or surgeon were concerned about prolonged disability, metal health issues, and/or higher pain levels that might be associated with the PAO procedure.

Postoperative Rehabilitation After Hip Arthroscopy: A Search for the Evidence.

CONTEXT: Hip arthroscopy has become an increasingly popular option for active individuals with recalcitrant hip pain. Conditions that may be addressed through hip arthroscopy include labral pathology, femoral acetabular impingement, capsular hyperlaxity, ligamentum teres tears, and the presence of intra-articular bodies. Although the body of literature examining operative procedures has grown, there is a paucity of evidence specifically on the efficacy of postoperative rehabilitation programs. To date, there are no systematic reviews that have evaluated the available evidence on postoperative rehabilitation. OBJECTIVE: To evaluate the available evidence on postoperative rehabilitation programs after arthroscopy of the hip joint. EVIDENCE ACQUISITION: A search of the PubMed, CINAHL, SPORTDiscus, ProQuest, and Google Scholar databases was conducted in January 2014 according the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting systematic reviews. EVIDENCE SYNTHESIS: Six studies met the inclusion criteria and were either case series or case reports (level 4 evidence) that described a 4- or 5-phase postoperative rehabilitation program. The available evidence supports a postoperative period of restricted weight bearing and mobility; however, the specific interventions in the postoperative phases are variable with no comparison trials. CONCLUSION: This review identified a paucity of evidence on postoperative rehabilitation after hip arthroscopy. Existing reports are descriptive in nature, so the superiority of a particular approach cannot be determined. One can surmise from existing studies that a 4- to 5-stage program with an initial period of weight-bearing and mobility precautions is efficacious in regard to function, patient satisfaction, and return to competitive-level athletics. Clinicians may consider such a program as a general guideline but should individualize treatment according to the surgical procedure and surgeon guidelines. Future research should focus on comparative trials to determine the effect of specific postoperative rehabilitation designs.

A review of femoroacetabular impingement and hip arthroscopy in the athlete.

Femoroacetabular impingement (FAI) is increasingly recognized as a pathological condition of the hip in athletes. Although it is not always symptomatic, the bone structure leading to FAI and its associated pathology can result in significant pain and performance decline in athletes. Recognition of athletes with symptomatic FAI is of the utmost importance, as prompt treatment is necessary in order to maintain desired sports activity levels and preserve joint function. This review explores the recent evidence on the evaluation, recognition, and treatment of femoroacetabular impingement, and discusses conservative management, postoperative rehabilitation, and treatment in the pediatric and master athlete populations.

Non-Operative Rehabilitation Principles for Use in Individuals with Acetabular Dysplasia: A North American Based Delphi Study.

Background: Acetabular dysplasia (AD) is defined as a structurally deficient acetabulum and is a well-recognized cause of hip pain in young adults. While treatment of severe AD with a periacetabular osteotomy has demonstrated good long-term outcomes, a trial of non-operative management is often recommended in this population. This may be especially true in patients with milder deformities. Currently, there is a paucity of research pertaining to non-operative management of individuals with AD. Purpose: To present expert-driven non-operative rehabilitation guidelines for use in individuals with AD. Study Design: Delphi study. Methods: A panel of 15 physiotherapists from North America who were identified as experts in non-operative rehabilitation of individuals with AD by a high-volume hip preservation surgeon participated in this Delphi study. Panelists were presented with 16 questions regarding evaluation and treatment principles of individuals with AD. A three-step Delphi method was utilized to establish consensus on non-operative rehabilitation principles for individuals presenting with AD. Results: Total (100%) participation was achieved for all three survey rounds. Consensus, defined a piori as > 75%, was reached for 16/16 questions regarding evaluation principles, activity modifications, appropriate therapeutic exercise progression, return to activity/sport criteria, and indications for physician referral. Conclusion: This North American based Delphi study presents expert-based consensus on non-operative rehabilitation principles for use in individuals with AD. Establishing guidelines for non-operative management in this population will help reduce practice variation and is the first step in stratifying individuals who would benefit from non-operative management. Future research should focus on patient-reported outcomes and rate of subsequent surgical intervention to determine the success of the guidelines reported in this study. Level of Evidence: Level V.

Hip Pain and Movement Dysfunction Associated With Nonarthritic Hip Joint Pain: A Revision.

The Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). This is an update to the 2014 Clinical Practice Guideline (CPG) for Hip Pain and Movement Dysfunction Associated with Nonarthritic Hip Joint Pain. The goals of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. This current CPG covers pathoanatomical features, clinical course, prognosis, diagnosis, examination, and physical therapy interventions in the management of nonarthritic hip joint pain. J Orthop Sports Phys Ther 2023;53(7):CPG1-CPG70. doi:10.2519/jospt.2023.0302.

Evaluating Functional Performance Tests in those with Non-arthritic Intra-articular Hip Pain: An International Consensus Statement.

Background: Non-arthritic intra-articular hip pain, caused by various pathologies, leads to impairments in range of motion, strength, balance, and neuromuscular control. Although functional performance tests offer valuable insights in evaluating these patients, no clear consensus exists regarding the optimal tests for this patient population. Purpose: This study aimed to establish expert consensus on the application and selection of functional performance tests in individuals presenting with non-arthritic intra-articular hip pain. Study Design: A modified Delphi technique was used with fourteen physical therapy experts, all members of the International Society for Hip Arthroscopy (ISHA). The panelists participated in three rounds of questions and related discussions to reach full consensus on the application and selection of functional performance tests. Results: The panel agreed that functional performance tests should be utilized at initial evaluation, re-evaluations, and discharge, as well as criterion for assessing readiness for returning to sports. Tests should be as part of a multimodal assessment of neuromuscular control, strength, range of motion, and balance, applied in a graded fashion depending on the patient's characteristics. Clinicians should select functional performance tests with objective scoring criteria and prioritize the use of tests with supporting psychometric evidence. A list of recommended functional performance tests with varying intensity levels is provided. Low-intensity functional performance tests encompass controlled speed in a single plane with no impact. Medium-intensity functional performance tests involve controlled speed in multiple planes with low impact. High-intensity functional performance tests include higher speeds in multiple planes with higher impact and agility requirements. Sport-specific movement tests should mimic the patient's particular activity or sport. Conclusion: This international consensus statement provides recommendations for clinicians regarding selection and utilization of functional performance tests for those with non-arthritic intra-articular hip pain. These recommendations will encourage greater consistency and standardization among clinicians during a physical therapy assessment.

The 2022 International Society for Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS): an international consensus statement.

The 2022 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS) was intended to present a physiotherapy consensus on the assessment and surgical and non-surgical physiotherapy management of patients with GTPS. The panel consisted of 15 physiotherapists and eight orthopaedic surgeons. Currently, there is a lack of high-quality literature supporting non-operative and operative physiotherapy management. Therefore, a group of physiotherapists who specialize in the treatment of non-arthritic hip pathology created this consensus statement regarding physiotherapy management of GTPS. The consensus was conducted using a modified Delphi technique to guide physiotherapy-related decisions according to the current knowledge and expertise regarding the following: (i) evaluation of GTPS, (ii) non-surgical physiotherapy management, (iii) use of corticosteroids and orthobiologics and (iv) surgical indications and post-operative physiotherapy management.

Rehabilitation Guidelines for Use Following a Periacetabular Osteotomy (PAO): A North American Based Delphi Consensus.

Background: Treatment of acetabular dysplasia with a periacetabular osteotomy (PAO) has been shown to improve long term outcomes and is considered the gold standard in the setting of symptomatic hip dysplasia in patients younger than 35 years of age. Post-operative rehabilitation following a PAO plays an important role in helping patients return to their prior level of function and reduce the impact of strength deficits that may persist. Currently, there is a paucity of research supporting post-operative rehabilitation guidelines. The purpose of this study is to present expert-driven rehabilitation guidelines to reduce practice variation following a PAO. Methods: A panel of 16 physiotherapists from across the United States and Canada who were identified as experts in PAO rehabilitation by high-volume hip preservation surgeons participated in this Delphi study. Panelists were presented with 11 questions pertaining to rehabilitation guidelines following a PAO. Three iterative survey rounds were presented to the panelists based on responses to these questions. This three-step Delphi method was utilized to establish consensus on post-operative rehabilitation guidelines following a PAO. Results: Total (100%) participation was achieved for all three survey rounds. Consensus (>75%) was reached for 11/11 questions pertaining to the following areas: 1) weight-bearing and range of motion (ROM) precautions, 2) therapeutic exercise prescription including neuromuscular control, cardiovascular exercise, and flexibility, and 3) objective measures for return to straight line running and return to full participation in sports. Conclusion: This Delphi study established expert-driven rehabilitation guidelines for use following a PAO. The standardization of rehabilitative care following PAO is essential for achieving optimal outcomes despite other factors such as geographical location and socioeconomic status. Further research on patient-reported outcomes is necessary to confirm successful rehabilitation following the guidelines outlined in this study.

Sensor-Based Evaluation of Physical Therapy Exercises.

Physical therapy is important for the treatment and prevention of musculoskeletal injuries, as well as recovery from surgery. In this paper, we explore techniques for automatically determining whether an exercise was performed correctly or not, based on camera images and wearable sensors. Classifiers were tested on data collected from 30 patients during normally-scheduled physical therapy appointments. We considered two lower limb exercises, and asked how well classifiers could generalize to the assessment of individuals for whom no prior data were available. We found that our classifiers performed well relative to several metrics (mean accuracy: 0.76, specificity: 0.90), but often returned low sensitivity (mean: 0.34). For one of the two exercises considered, these classifiers compared favorably with human performance.

Morphological Changes of the Hip Commonly Associated With Femoroacetabular Impingement Are Not Correlated With Rotational Range of Hip Motion in Elite Soccer Athletes.

BACKGROUND: Morphological changes characteristic of femoroacetabular impingement (FAI) are common in soccer players. However, the clinical relevance of such anatomical variations is still not well-defined. HYPOTHESIS: We hypothesized that high alpha angle values and/or acetabular retroversion index (ARI) are correlated with rotational range of motion (ROM) of the hip and that there are clinical-radiological diferences between the dominant lower limb (DLL) and nondominant lower limb (NDLL) in professional soccer players. STUDY DESIGN: Cross-sectional. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 59 male professional soccer players (average age 25.5 years, range 18-38 years) were evaluated in the preseason. As main outcome measures, we evaluated the alpha angle and the ARI and hip IR and ER ROM with radiographic analysis. RESULTS: The measurements taken on DLL and NDLL were compared and a significant difference was found between the sides in the ER (P = 0.027), where the DLL measures were 1.54° (95% CI, 0.18-2.89) greater than the NDLL. There were no significant differences between the sides in the measures of IR (P > 0.99), total ROM (P = 0.07), alpha angle (P = 0.250), and ARI (P = 0.079). The correlations between the rotation measurements and the alpha angle in each limb were evaluated and the coefficient values showed no correlation; so also between the ARI and rotation measures. CONCLUSION: Morphological changes of the femur or acetabulum are not correlated with hip IR and ER ROM in male professional soccer players. ER on the dominant side was greater than on the nondominant side. There was no significant difference in the other measurements between sides. CLINICAL RELEVANCE: In clinical practice, it is common to attribute loss of hip rotational movement to the presence of FAI. This study shows that anatomical FAI may not have a very strong influence on available hip rotational movement in professional soccer athletes.

The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of femoroacetabular impingement syndrome (FAIS): an international consensus statement.

The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on femoroacetabular impingement syndrome (FAIS) was intended to build an international physiotherapy consensus on the assessment, non-surgical physiotherapy treatment, pre-/post-operative management, and return to sport decisions for those patients with FAIS. The panel consisted of 11 physiotherapists and 8 orthopaedic surgeons. There is limited evidence regarding the use of physiotherapy in the overall management of those with FAIS. Therefore, a group of ISHA member physiotherapists, who treat large numbers of FAIS patients and have extensive experience in this area, constructed a consensus statement to guide physiotherapy-related decisions in the overall management of those with FAIS. The consensus was conducted using a modified Delphi technique. Six major topics were the focus of the consensus statement: (i) hip assessment, (ii) non-surgical physiotherapy management, (iii) pre-habilitation prior to hip arthroscopy, (iv) post-operative physiotherapy rehabilitation, (v) stages of post-operative rehabilitation and (vi) return to sports criteria/guidelines after surgery.

Erratum to: The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of femoroacetabular impingement syndrome (FAIS): an international consensus statement.

[This corrects the article DOI: 10.1093/jhps/hnaa043.].

LENGTH CHANGE OF THE ILIOFEMORAL LIGAMENT DURING TESTS FOR ANTERIOR MICROINSTABILITY OF THE HIP JOINT: A CADAVERIC VALIDITY STUDY.

PURPOSE/BACKGROUND: There is little information to support the use of clinical tests to assess for microinstability of the hip joint. The purpose of this study was to use a string model to describe and compare length changes of the iliofemoral ligament in the test positions commonly used to assess hip ligament laxity. METHODS: Twelve hip joints from nine cadavers (4 male; 5 female) with lifespans of 57-84 years of age were studied. A string model representing the medial and lateral arms of the iliofemoral ligament was secured to the proximal and distal attachment points. The amount of length change of the string model was compared in four test positions: 1) external rotation, 2) hyperextension-external rotation 3) abduction-extension-external rotation, and 4) adduction--extension-external rotation. RESULTS: For the medial arm, the greatest change occurred in the adduction-extension-external rotation position (12.7mm). This was significantly greater than the external rotation (5.1mm; p=0.002) and abduction-extension-external rotation position (1.9mm; p<0.001). The lateral arm also had the greatest excursion in the adduction-extension-external rotation position (16.6mm). This length change was significantly greater than the external rotation position (8.6mm; p=0.002), the hyperextension-external rotation (11.1mm; p=0.047), and the abduction-extension-external rotation position (5.6mm; p<0.001). CONCLUSIONS: Tests used for hip instability cause various levels of tension through the iliofemoral ligament. The combination of hip extension and external rotation increased the length change of string model and was maximized with hip adduction. The least amount of change occurred with the addition of hip abduction to extension and external rotation. CLINICAL RELEVANCE: Clinicians may use the information to help interpret tests for instability of the hip and may consider the combined position of hip extension, external rotation, and adduction to elucidate involvement of the iliofemoral femoral ligament. LEVEL OF EVIDENCE: 2b; Exploratory cohort study with good reference standards.

CLINICAL RELEVANCE of the LIGAMENTUM TERES: A LITERATURE REVIEW.

BACKGROUND: The ligamentum teres (LT) continues to be a structure of debate and interest. Previously thought of as a vestigial structure, an awareness of LT pathology and its potential importance has increased with the expansion of hip arthroscopy. PURPOSE: To provide a comprehensive literature synthesis on the LT and provide clinicians with the most current research regarding the LT and its anatomical features, functional relevance, prevalence of injury, risk factors for injury, clinical presentation, and treatment for pathology. METHODS: A systematic literature search was conducted using Medline/PubMed, CINAHL/EBSCO, and Cochrane/Wiley databases/platforms using the following search terms: ligament, ligament teres, hip, femur, femoral head, round ligament. RESULTS: This search yielded 1284 articles of which 44 met the inclusion/exclusion criteria and contributed to this manuscript. Information on the LT was summarized into the following areas: anatomy, function, injury prevalence, risk factors, mechanism of injury, duration of symptoms, clinical presentation (symptoms, range of motion, functional limitations, special testing), imaging, and treatment. CONCLUSIONS: The results of this review supported the following: 1) the LT has a function in restraining hip rotation range of motion; 2) the prevalence of LT pathology in any given population may be largely dependent on the severity of bony deformity (either femoroacetabular impingement(FAI) or dyplasia) and activity level; 3) older age and acetabular bony deformity (either FAI or dyplasia) are risk factors for generalized LT pathology; 4) unique signs and symptoms are difficult to identify because LT pathology rarely occurs in isolation and is likely the end-stage consequence of other hip pathology; 5) the presence of LT pathology may negatively affect an individual's ability to function; and 6) surgical debridement is recommend for pain relief of partial LT tears with reconstruction possible for complete LT tears when complaints of instability are noted. LEVEL OF EVIDENCE: 3.

Hip Pain and Mobility Deficits-Hip Osteoarthritis: Revision 2017.

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to hip pain and mobility deficits. J Orthop Sports Phys Ther. 2017;47(6):A1-A37. doi:10.2519/jospt.2017.0301.

Acetabular labral tears of the hip: examination and diagnostic challenges.

The purpose of this clinical commentary is to provide an evidence-based review of the examination process and diagnostic challenges associated with acetabular labral tears of the hip. Once considered an uncommon entity, labral tears have recently received wider recognition as a source of symptoms and functional limitation. Information regarding acetabular labral tears and their association to capsular laxity, femoral acetabular impingement (FAI), dysplasia of the acetabulum, and chondral lesions is emerging. Physical therapists should understand the anatomical structures of the hip and recognize how the clinical presentation of labral tears is difficult to view isolated from other hip articular pathologies. Clinical examination should consider lumbopelvic and extra-articular pathologies in addition to intra-articular pathologies when assessing for the source of symptoms and functional limitation. If a labral tear is suspected, further diagnostic testing may be indicated. Although up-and-coming evidence suggests that information obtained from patient history and clinical examination can be useful, continued research is warranted to determine the diagnostic accuracy of our examination techniques.

The hip joint: arthroscopic procedures and postoperative rehabilitation.

Recent technological improvements have resulted in a greater number of surgical options available for individuals with hip joint pathology. These options are particularly pertinent to the relatively younger and more active population. The diagnosis and treatment of acetabular labral tears have become topics of particular interest. Improvements in diagnostic capability and surgical technology have resulted in an increased number of arthroscopic procedures being performed to address acetabular labral tears and associated pathology. Associated conditions include capsular laxity, femoral-acetabular impingement, and chondral lesions. Arthroscopic techniques include labral tear resection, labral repair, capsular modification, osteoplasty, and microfracture procedures. Postoperative rehabilitation following arthroscopic procedures of the hip joint carries particular concerns regarding range of motion, weight-bearing precautions, and initiation of strength activities. Postoperative rehabilitation protocols that have been typically used for surgeries such as total hip arthroplasty are often not sufficient for the population of patients undergoing arthroscopic procedures of the hip joint. Postoperative rehabilitation should be based upon the principles of tissue healing as well as individual patient characteristics. As arthroscopic procedures to address acetabular labral tears and associated pathology evolve, physical therapists have the opportunity to play a significant role through the development of corresponding rehabilitation protocols.

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

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.

Rehabilitation following hip arthroscopy: an evolving process.

The utilization of hip arthroscopy to treat non-arthritic pain in athletes continues to grow in popularity. Though numerous protocols have been described in the literature, there is no current evidence-based consensus regarding the postoperative management of patients undergoing hip arthroscopy. Intraoperative findings determine the specific surgical procedure and subsequently play a role in postoperative rehabilitation. Current protocols are primarily based on tissue healing properties, patient tolerance, and clinician experience. General recommendations regarding range-of-motion initiation, weight bearing progression, and strength activities exist. Though relatively uncommon, postoperative complications have been described. Clinicians should be aware of factors, both surgical and rehabilitation-related, that may affect a patient's postoperative progression. In order to assess patients' postoperative improvement, clinicians must utilize outcome measures that effectively assess the functional status level of active individuals following hip arthroscopy. The development of criteria-based programs may improve the consistency of rehabilitation and potentially aid in providing patients a safe, efficient return to athletics.