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Chiropractic Journal of Australia : CJA December 2012
Chiropractic Journal of Australia Volume 42 Number 4 December 2012 127 (medical) subluxation may in part be caused by compensatory stresses due to FAI.12 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.13 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.14 In cases of FAI where exacerbating activities can be modifed or removed, conservative management may provide improvement in function and symptoms.14,15 However, it must be emphasised that conservative management will not eliminate the underlying morphological abnormalities.15 FAI is now a well-documented cause of pain, dysfunction and premature degenerative changes of the hips in the athletic population.5,6,8,13,16-18 The chiropractic profession needs to increase their awareness of FAI, as they are often the primary contact for patients presenting with this disorder. Consequently, it is essential that chiropractic practitioners are familiar with the assessment, diagnosis and management of this condition. The purpose of this case series is to present the clinical diagnosis of FAI in three athletic patients, and to document the multi-modal chiropractic treatment approach to allow practitioners to adopt a similar process in the conservative management of FAI. CASE REPORTS Background Three patients, two male and one female aged from 31 to 42 years old (mean age, 35.3 years) were referred to the author from other health care professionals for further assessment and diagnosis, following unsuccessful conservative management of their hip and groin complaints. Previous diagnoses presented to the patients included “soft tissue injury”; back-related groin injury as a result of lumbopelvic pain referral; osteitis pubis; hip joint dysfunction (i.e. chiropractic subluxation / osteopathic manipulative lesion); lumbopelvic-hip myofascial pain syndrome; and early hip osteoarthritis. Case 1 A 33-year-old male, professional sprinter presented with left-sided groin pain of fve years duration. The onset was insidious, occurring after numerous training sessions focusing on starting blocks technique. He said the pain was always present on weight-bearing, having an “achy” quality. Additionally, he recalled feeling an intermittent “catching” pain whilst in the “set-position” on the starting blocks, or during activities that involved excessive hip fexion (e.g. some sprinting technique drills, putting on shoes). The patient had not been able to commence (preseason) training for the upcoming season due to a gradual worsening of his symptoms. He had been treated with chiropractic mechanically assisted adjusting techniques (MAT) to the left hip; high-velocity, low-amplitude (HVLA) spinal manipulative therapy (SMT) to the lumbopelvic, thoracic and cervical spine; acupuncture and laser to the left hip; as well as remedial massage and stretching to the lumbopelvic-hip complex. He had suffered from one episode of discogenic back pain four-years prior that was treated with rest, SMT and chiropractic fexion-distraction. There had been no previous history of hip injury. On physical examination, the patient had an apparent Trendelenburg gait on the left. The left pelvis was low compared to the right in standing posture. There was reduced range of motion of left hip flexion (~90°) and internal rotation (~5° with the hip in 90° of fexion) with both passive movements reproducing the patient's groin pain. There were tight (reduced range of motion) bilateral hip fexors (Thomas test was +10°) and hamstrings (70° straight leg raise [SLR]), as well as the left (25° hip abduction) and right (35° hip abduction) adductors. Tenderness and hypertonicity through the left gluteus medius, iliacus, psoas, tensor fascia latae (TFL), adductors and vastus lateralis musculature were noted. There was weakness of the bilateral gluteus maximus, and left gluteus medius, iliacus, psoas and TFL musculature on resisted muscle testing, graded 4/5. The anterior impingement, FABERE and Log Roll tests were all positive for the reproduction of the patient's groin pain. General motion restriction of the upper cervical, thoracic and lumbar spine, pubic symphysis, left SIJ and left hip was observed during dynamic (inter-segmental motion) palpation. The prone hip extension (PHE) test revealed decreased lumbopelvic-hip motor control with fndings of decreased left gluteus maximus contraction, as well as lumbar spine hyperextension and ipsilateral rotation when attempting to extend the left hip. Other physical examination fndings and testing procedures including Valsalva, neurological and orthopaedic examinations were unremarkable. Radiological examination revealed a combination of Cam-type and pincer- type FAI affecting the left hip, with some early degenerative changes to the acetabulum. Case 2 A 42-year-old male, personal trainer and professional middle-distance runner presented with right-sided hip pain of 10 years duration. The onset was insidious, occurring whilst employed in a gardening business, with no history of trauma. He reported the pain being located in the region of the “right iliopsoas.” He described that the right psoas “gets really tight,” and that around the right iliopsoas tendon “gets infamed.” He stated that performing squats and running training would aggravate his hip and would occasionally produce a “sharp pain.” The patient had experienced a gradual decline in running performance over the previous 12 months due to the worsening of his symptoms. He had been treated by a chiropractor, osteopath and myotherapist, expressing that “the massage helped most.” He also reported that the use of gravity boots (inversion training), self-stretching and self-massage could provide temporary relief sporadically. He had no previous history of hip injury but had suffered episodic low back pain over a 10-year period. On physical examination the patient was standing with an apparent anterior pelvic tilt and lumbar spine hyperlordosis. There was reduced range of motion of right hip fexion (110°) and internal rotation (15° with the hip in 90° of fexion), with tight bilateral hip fexors (+5° Thomas test). There was palpable hypertonicity through the right psoas, iliacus, lumbar and gluteal musculature, with weakness of the bilateral gluteus medius, as well as the right iliacus, psoas and erector spinae muscles graded 4/5. The anterior impingement and FABERE FEMOROACETABULAR IMPINGMENT JAROSZ
CJA September 2012
CJA March 2013