Posts tagged FAI
Only 1/3 Of Patients Are Satisfied With Activity Level Following Surgery For Hip Impingement

Hip impingement (FAI) is one of the fastest growing orthopedic surgeries, but much of this growth has outpaced our current understanding of this condition. A key question involves the additional bone development (cam and pincer lesions) found among athletes. Many of these athletes remain asymptomatic despite having positive findings of impingement on x ray and other imaging techniques. Other athletes with FAI who are symptomatic often return to sport and high function after undergoing Physical Therapy indicating some individuals are able to compensate and adapt for these structural changes or they may be a natural response to the sport itself.

Previous research has found equivocal long term outcomes between Physical Therapy and surgery for hip impingement. This data indicates a significant duration (8-12 weeks) of Physical Therapy should be attempted before surgical interventions. The majority of athletes undergoing hip impingement surgery will return to sport around 6-10 months post surgery, but many will be unable to return to their pre injury levels of activity. Prior studies have found only half are able to return to their previous sports and 1 in 5 will be able to return to the same sport with the same level of performance. A recent study sought to understand how these individuals function 6-10 months after surgery.

The Orthopedic Journal of Sports Medicine followed 33 patients who underwent hip arthroscopy for conditions involving hip impingement (Worner et al. 2019). On average, patients were reassessed at 8 months post op and their subjective history and objective testing were compared to their age matched peers. Authors reported decreased subjective function and ability to return to sport in the surgical group. Specifically, 46% and 18% were able to return the same sport at a lower or similar level, respectively. Consistent with prior research these individuals regained strength and range of motion after post operative Physical Therapy except continued to experience decreased hip flexion strength and range of motion compared to their peers.

This study adds to our existing knowledge on the recovery following hip arthroscopy for hip impingement. Despite being cleared to return to sport many athletes will require additional recovery time to regain participation in sporting activities.

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Majority of Patients With Hip Impingement Did Not Receive Physical Therapy Prior To Surgery

Hip impingement or femoroacetabular impingement (FAI) is common hip condition causing pain in the front of the hip and groin. This condition has received considerable attention in the medical research and our clinical practice because of the sky rocketing rates of advanced imaging including MRI and surgical procedures to “correct” the condition. Of greatest concern are the high rates of hip impingement and labral tears found on imaging in asymptomatic (pain free) individuals. Thus, are the structural changes associated with FAI natural adaptations to activity or do they require surgical intervention? The lack of a clear cause and effect between structural FAI and a patient’s symptoms supports the utilization of conservative interventions including Physical Therapy prior to any surgical intervention. Consistent with other musculoskeletal conditions, one of the main indications for surgery remains failure of conservative care, but a new research study reported the majority of patients with FAI did not receive Physical Therapy before surgical interventions.

In the Journal of Sports and Orthopedic Physical Therapy authors reported on health care utilization of patients undergoing hip arthroscopy between 2004 and 2013 (Young et al. 2019). They reviewed the charts of 1870 participants who underwent this procedure to determine what interventions they were offered prior to their surgery. Surprisingly, 60% (n=1106) did not receive any Physical Therapy prior to surgery and for those who did receive Physical Therapy they averaged only 2 visits, well below the standard of care for this condition. Further, only 12% of patients undergoing PT received 6 or more visits including exercise. Surgery is reserved for patients with persistent functional limitations (disability) not pathology (hip impingement on imaging), but without an evidence based course of Physical Therapy surgical decision making will be remain unclear.

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Pre Operative Expenses Linked To Post Operative Expenses After Hip Surgery

Arthroscopic hip surgery is one of the fastest growing orthopedic surgical procedures today. This procedure is commonly utilized to treat hip impingement and hip labral tears. The rapid growth of surgery for this condition is thought to result from both an increase in surgeons trained in hip arthroscopic surgery, as well as, the increased utilization of MRI scans. Experts have expressed concern over these increases in surgical rates due to the large numbers of pain free athletes and patients who show impingement and labral tears on MRI, but remain asymptomatic. One of the key indications for surgery remains failure of conservative treatments including high level, evidence based Physical Therapy. Patients who are unable to return to a desired level of activity or play may opt for the surgery after completion of this Physical Therapy program. A recent study reports on the pre and post operative costs associated with this procedure.

Clewley and colleagues performed a retrospective analysis of pre and post operative costs in 1850 patients who elected for hip arthroscopic surgery over a 12 year period (JOSPT. 2018). Authors found significant differences in costs and health care use between high and low health care utilization groups. In addition, authors found patients who utilized greater amounts of care before the procedure were more likely to use greater amounts of healthcare after the procedure. As expected, the higher utilization group spent significantly greater amounts of money for their associated care compared to their lower utilization peers. Future research is needed to determine the psychosocial and behavioral traits associated with higher health care expenditures.

Increased Medical Risks of Chronic Pain and Mental Health Disorders Found After Elective Hip Surgery

Inherent risks, such as infection and blood clots, are associated with orthopedic surgeries and should be considered in decision making between surgical and conservative treatments for musculoskeletal diagnoses. In addition to these inherent risks, patients should also consider other hidden or less common risks after surgery including increased healthcare costs (office visits, additional surgeries, hospitalization) and changes in disability after surgery. A recent study examined additional risks found in patients who elected for arthroscopic hip surgery.

Rhon and colleagues followed 1870 patients treated in the military health system up to 2 years after elective arthroscopic hip surgery to determine their subsequent healthcare utilization (Br J Sp Med. 2018). Specifically, the authors assessed for seven co morbidities (mental health, chronic pain, substance abuse, cardiovascular disoders, metabolic syndrome, systemic arthropathy, and sleep disorders) associated with poor outcomes in the management of musculoskeletal disorders. The incidence of these seven co morbidities at 1 and 2 year follow up was compared to each patient’s pre operative status. Authors reported a statistically significant increase in all seven co morbidities following the surgical procedure. Specifically, authors found significant increases in the following

Chronic Pain - 166%

Systemic Arthropathy - 132%

Sleep Disorders - 111%

Metabolic Syndrome - 86%

Mental Health Disorders - 84%

Cardiovascular Disorders - 71%

Authors concluded, “major clinical co morbidities increased substantially after elective hip surgery compared to preoperative status”.

Previous studies have not shown significant differences in outcomes between Physical Therapy and arthroscopic hip surgery. Thus, patient’s must consider surgical risks in their decision making.

Altered Functional Performance Found Among Patients With Hip Impingement

Hip impingement or Femoroacetabular Impingement is a common condition among athletes caused by abnormal contact within the hip joint.  Contributing factors include structural changes in the ball (Cam lesion) and/or socket (Pincer lesion), as well as, weakness in the hip musculature.  The powerful glut muscles act as both movers and stabilizers of the hip joint.  Many athletes with hip impingement remain asymptomatic if they maintain adequate glut strength and hip stability.  Conversely, hip impingement symptoms often worsen in the presence of glut weakness due decreased joint control and increased joint contact forces.  

A recent study in the Journal of Orthopedic and Sports Physical Therapy examined the biomechanical differences between patients with hip impingement (N=20) and their healthy peers (Lewis, C. et al. 2018).  Authors assessed biomechanical differences during a commonly used step down test.  Consistent with our Boulder Physical Therapy clinic's findings, patients with hip impingement demonstrated greater hip flexion and anterior pelvic tilt compared to their asymptomatic peers.  In addition, authors found decreased performance among females compared to male participants.  This study highlights the importance of regaining both glut strength and functional stability to restore function in patients with hip impingement.  

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No Difference Between Surgery or Physical Therapy for Hip Impingement

Hip impingement, or the compression of the soft tissue or bony structures of the hip joint, has become the flavor of the week in orthopedic surgery.  Surgical rates have risen 18 fold over the past ten years outpacing the available research on the condition.  Previous research has shown up 68% and 67% of asymptomatic hips will show labral tears and hip impingment, respectively.  The high rates of findings in asymptomatic patients, especially athletes, requires further research to determine if these changes are truly pathology or natural changes in athletic patient's hip joints.  Further, there has been no quality randomized trials between surgery and high quality Physical Therapy interventions until now.

Mansell and colleagues examined 80 patients with femoroacetabular impingement (FAI) syndrome over a 2 year period (Am J Sp Med. 2018).  Patients were randomized to receive either arthroscopic hip surgery with post operative Physical Therapy or Physical Therapy (twice per week x 12 weeks).  Both groups demonstrated improvements in pain and function, but no significant differences were found between groups were found at 2 year follow up.  Twenty patients from the Physical Therapy group eventually elected to have surgery but further analysis found this cross over did not alter the results.

This study highlights the importance of using Physical Therapy first for hip impingement.  To schedule your first appointment with the experts at MEND click here.