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Chiropractic Journal of Australia : CJA September 2012
96 Chiropractic Journal of Australia Volume 42 Number 3 September 2012 baseline to 119.9° postoperatively, and internal rotation (in 90° hip fexion) from 11.5° to 23.9°.30 Early to mid-term results from surgical procedures demonstrate good to excellent clinical outcomes in 75- 80% of patients.31 Factors associated with a good outcome include minimal radiographic DJD, limited cartilage damage at surgery, young age and labral repair (rather than debridement).29 The three main causes of treatment failure were marked DJD, extensive chondropathy, and age older than 35 years at the time of surgery.32 These fndings underscore the importance of early diagnosis and timely treatment for symptomatic hips.15 Role of Chiropractic An important goal is to improve awareness of FAI among chiropractors, who are often the primary contact for patients presenting with this disorder. However, the majority of publications regarding FAI have been documented within the orthopaedic literature. Therefore, it is reasonable to presume that the greater part of the chiropractic profession is not familiar with FAI. The majority of conditions treated by chiropractors are of a neuromusculoskeletal nature.33 It has been suggested that the prevalence of FAI is as high as 14% within the general population.14 It is logical to deduce that patients with FAI (and its associated symptomatology) are presenting to chiropractors relatively frequently. An insuffcient awareness of FAI has been shown to lead to diagnostic delays of approximately two to four years.3,15 As such, the chiropractic profession is an important position to appropriately assess and diagnose these patients early, and offer evidence- based clinical recommendations in order to improve the management of FAI. Based upon the current evidence, surgical intervention has been demonstrated to be the most successful treatment approach for FAI in the absence of advanced degenerative changes to the hip.8 However, whilst surgical procedures demonstrate good to excellent clinical outcomes (if performed prior to secondary degenerative changes), there is a lack of evidence to support or refute the use of conservative treatment interventions.25 In cases of FAI where exacerbating activities can be modifed or removed, conservative management may provide improvement in function and symptoms.25,27 However, it must be emphasised that conservative management will not eliminate the underlying morphological abnormalities, and therefore, will not improve hip range of motion.27 For a chiropractor to serve as the conservative management alternative, it is the opinion of the author that an individualised multi-modal approach to management should be used. Multi-modal chiropractic management incorporates a combination of therapies and techniques including adjusting (manipulation) and mobilisation, soft tissue and stretching techniques, rehabilitation and corrective exercises, taping, physiological therapeutics, nutrition and training (activity) advice/programs in order to address both the acute (pain) phase and the chronic (rehabilitation) phase.34,35 Chiropractic manipulation and mobilisation should address the entire kinetic chain (lumbar spine, sacroiliac, knee, ankle and foot joints).36 Caution should be applied with manipulation/mobilisation of the hip joint, as attempts FEMOROACETABULAR IMPINGMENT JAROSZ to passively improve hip range of motion may exacerbate FAI symptoms.7,12,19,28 However, hip manipulation/ mobilisation techniques involving long-axis traction may be benefcial.36 The author utilises active release (ART) and myofascial release (MFR) soft tissue techniques; post- isometric relaxation (PIR), proprioceptive neuromuscular facilitation contract-relax-antagonist-contract (PNF-CRAC) and active isolated stretching (AIS) techniques to address both neuromuscular and connective tissue factors, and promote hip abduction, external rotation and extension.25,27 Exercise therapy focusing on hip extension, abduction and external rotation may provide an improvement in function and pain symptoms, and allow independent patient management through a home exercise program.25,27 Patient education concerning activity modifcation (e.g. avoiding activities involving repetitive, forceful or hyper-hip fexion), as well as the potential need for MRI-arthrography, and orthopaedic referral, must be emphasised. In cases of FAI where patients are unable to remove or modify their activities (as occurs with semi-elite and elite athletes), or when patients fail to respond to conservative management, referral for MRI-arthrography is warranted. The presence of articular cartilage or labral pathology necessitates referral and evaluation by an orthopaedic surgeon who specialises in hip joint preservation procedures.7 For FAI that requires co-management, chiropractors serve an important role in the diagnosis, prehabilitation (multi-modal treatment approaches utilised prior to surgical intervention) and post-surgical rehabilitation. For further information regarding clinical presentation and multi-modal chiropractic management of FAI, please refer to the article “Femoroacetabular impingement and its relevance to chiropractors. Part II: a case series”. (Forthcoming) CONCLUSION FAI has been increasingly recognised over the past fve to six years as a major cause of pain and premature degenerative changes in the hips of young adults. Early diagnosis is crucial in order to improve the management of this condition and avert the pathological progression from impingement to end- stage DJD. FAI typically presents as insidious onset groin pain in physically active adults aged 20 to 50 years, often in association with sporting activities. On examination, internal rotation in fexion is markedly limited in comparison to the other side. A positive impingement test is possibly the most important clinical fnding indicative of FAI. The plain flm radiographic signs of the Cam and pincer morphological abnormality are often overlooked because they are not looked for routinely. When detected, these radiographic signs provide the diagnosis of FAI, provided they are consistent with the clinical fndings. MRI-arthrography to evaluate acetabular chondropathy and labral pathology is considered the gold standard. The diagnosis is based on the synthesis of the clinical pain presentation, a positive impingement sign, and imaging studies demonstrating morphological abnormalities associated with FAI. Chiropractors are in an important position to appropriately assess and diagnose patients with FAI, and offer evidence-based clinical recommendations in order to improve the management of this disorder.
CJA June 2012
CJA December 2012