Orthopedics

From the Author…A Clinical Commentary on the Nonarthritic Hip Joint Pain Practice Guidelines

By: Keelan R. Enseki, PT, MS, OCS, SCS, ATC, CSCS

The clinical diagnosis classified of nonarthritic hip pain has been a growing topic of interest in the orthopaedic literature. The relatively younger, more active population has been of particular interest when examining this population of patients. As part of the ongoing series, Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association, the Journal of Orthopaedic and Sports Physical Therapy recently published the guideline titled Nonarthritic Hip Joint Pain. The intention of the guideline is to review the risk factors, clinical findings, appropriate outcome measures, and intervention strategies associated with nonarthritic hip pain. The evidence for each category is graded and summary recommendations are made.

It is important to note that “nonarthritic hip join pain” can cover a range of conditions. Acetabular labral tears are the entity most clinicians will likely consider in this category. However, with the relatively rare exception of trauma, the underlying condition that provides a mechanism for development of a labral tear may be the more useful knowledge component that drives treatment.  In fact, these conditions should be considered risk factors.  The two most common mechanisms described in the literature are the osseouos abnormality of femoroacetabular impingement (FAI) or structural instability. Both conditions may result in labral compromise. However, treatment suggestions may vary depending on the specific underlying condition. FAI occurs when there is abnormal/premature contact between the acetabulum and femur. FAI can be the result of excessive femoral head or neck bone (cam impingement), excessive acetabular coverage (pincer impingement), or a mixture of both. It is suggested that FAI is correlated with tears of the acetabular labrum in some individuals and may contribute to the development of osteoarthritis of the hip joint.  Structural instability occurs when the boney elements of the joint do not provide appropriate support to allow normal function of the structure. The most common example for this category is dysplasia. Over time, it is suggested that structures that provided stability to the joint become excessively loaded and eventually may fail. This may include damage to the acetabular labrum.  FAI or features associated with structural instability may be confirmed with various imaging modalities. Other conditions that may be considered in the category of nonarthritic hip pain include: ligamentum teres tears, chondral lesions, and intra-articular loose bodies.

The clinical diagnosis for nonarthritic hip pain may be difficult to ascertain. This is due to a large number of potential differential diagnoses and clinical tests with relatively weak evidence as examined in the specific group of patients. Groin and/or lateral hip pain is the most common reported symptom. A patient’s type and level of activity should be considered as well. Patients who utilize repetitive or forceful end-range flexion and/or internal rotation positions may have a higher chance of becoming symptomatic if they have FAI characteristics. Patients who utilize repetitive movements that stress the capsule may be more likely to develop symptoms when structural instability is present. The flexion-adduction-internal rotation (FADIR) test may reproduce symptoms in individuals with FAI. The flexion-abduction-external rotation (FABER) test may reproduce symptoms in the unstable population. Assessment of impairments (strength, range-of-motion, flexibility) that may contribute to the underlying conditions becoming symptomatic is recommended.

At this time, the conservative clinical management of nonarthritic hip pain is highly variable. Addressing any basic impairment found during the initial examination is recommended. Patient education may be provided to the patient, so they are aware of specific activities to avoid or modify to decrease excessive loading of joint structures. Joint mobilization techniques may be utilized in cases of FAI where loss of capsular mobility is noted during examination. If a patient fails a full course of conservative care and there are no contraindications, surgery may be considered in select cases.

It is important to note that these guidelines serve to provide the best evidence available at the time of their publication. They are not intended to be the absolute standard of care, but hopefully contribute to a clinician’s decision-making process when they encounter patients with potential nonarthritic hip pain. Upon reviewing the guideline, it becomes very evident that there is a relatively small body of evidence available when examining and treating patients with nonarthritic hip pain. Many of the current suggestions are based on “expert opinion” or “weak evidence”.  Further research is essential as we attempt to develop a better understanding of how to treat these patients.

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Nonarthritic Hip Joint Pain Clinical Practice Guidelines Linked to the International Classifiation of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association.  J Orthop Sports Phys Ther. 2014;44(6):A1-A32.
         

Keelan completed his Bachelor of Science degree in Biobehavioral Health with a minor in Neuroscience in 1999 at the Pennsylvania State University. He attended the University of Pittsburgh completing a Master of Physical Therapy degree in 2001, and a Master of Science Degree in Health and Rehabilitation Sciences in 2003. He completed a sports physical therapy residency program through the University of Pittsburgh and Centers for Rehab Services/University of Pittsburgh Center for Sports Medicine in 2003. Keelan is also a certified athletic trainer, certified orthopaedic and sports physical therapy specialist, and NSCA strength and conditioning specialist. He is currently serving as the Orthopaedic Physical Therapy Residency Program director at the Centers for Rehab Services/UPMC Center for Sports Medicine Clinic as well as an adjunct and clinical instructor for the University of Pittsburgh Departments of Physical Therapy and Sports Medicine and Nutrition. His areas of interest include determinants of outcomes and treatment options available for active individuals with pathological conditions of the hip joint. He has presented nationally and internationally on these topics. Keelan has been an author and editor, including articles for the Journal of Orthopaedic and Sports Physical Therapy, Clinics in Sports Medicine, Current Reviews in Musculoskeletal Medicine, Operative Techniques in Orthopaedics, The Physician and Sportsmedicine,and Topics in Geriatric Rehabilitation. He has served as a content reviewer for the Journal of Orthopaedic and Sports Physical Therapy, PM&R and Physical Therapy in Sport. Additionally, he has co-authored several book chapters on the topics of rehabilitation of hip and knee injuries.

 

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