(646) 355-8777

Herman & Wallace Blog

Extra-articular Hip Impingement: A New Discovery for Hip Preservation

This post was written by H&W instructor Ginger Garner. Ginger will be presenting her Hip Labrum Injuries course in Houston in 2015!

Ginger Garner

There are two accepted forms of hip impingement currently documented in the literature. The two types are 1) CAM type FAI (femoracetabular impingement) and 2) Pincer type FAI. These two types are found inside the joint, meaning they are considered intra-articular bony anomalies.

FAI is a common comorbidity found with hip labral injury (HLI); and in fact, FAI is a risk factor for HLI. Specifically, FAI is a bony impingement that arises in the femoral head-neck function and the rim of the acetabulum (see photo at right). The two types of FAI also generally occur together more than they do in isolation. However, it is possible that, combined with other issues like acetabular undercoverage or hip instability, CAM or Pincer-type FAI can be found a singular diagnosis.

Surgical Intervention

However, the arena of impingement in the hip is now evolving to consider other locations. In the past 5 years there has been buzz about other types of FAI. They aren’t classically considered FAI issues since this new type of identified impingement occurs outside (extra-articular) the joint. One type newly identified is known as anterior inferior iliac spine/subspinal hip impingement (AIIS). In a 2011 study of 3 case reports, AIIS was found and treated with arthroscopic AIIS decompression with positive results. A more recent 2012 study found excellent results at short-term follow up for surgical decompression of AIIS.

Identification & Diagnosis of AIIS

Both personal and professional experience in the area of AIIS has shown that AIIS is not always discovered on an AP (anterior-posterior) radiograph. However, it is possible to see a larger AIIS on an AP film. Another helpful (but not always definitive) diagnostic test is a CT scan with MRI 3D reconstruction (and no contrast). Bony contrast is more reliable with CT scan than the typically preferred MRA (which is better for soft tissue contrast).

In addition, the rectus femoris (RF) could be implicated in AIIS pathology because the same area receives the proximal attachment of the RF. The same 2011 study reported that the morphology and role of the RF in extra-articular impingement is “not well reported at this time.”

Likewise, the identification of AIIS as a primary driver of pathology in intra-articular hip injury (FAI and/or HLI) is rare. Some cases of AIIS are being found during hip arthroscopy to correct identified existing deficits such as FAI and/or HLI. This means that AIIS may be missed and should be included as a potential mechanism of injury, especially for anterosuperior labral tears in the 2 to 3 o’clock region.

Patients who have AIIS may present like a typical HLI patient, which means they may have a positive Thomas test, FADDIR test, or mechanical symptoms such as popping, clicking, grinding or giving way. It is important to note these signs and symptoms and work in a team approach with surgeons and physical therapists who specialize in hip preservation and reconstruction.

To learn more about nonoperative and operative hip labral and FAI management, check out faculty member Ginger Garner's continuing education course on Extra-Articular Pelvic and Hip Labrum Injury: Differential Diagnosis and Integrative Management. The next opportunity to take the course is March of 2015 in Houston.

Continue reading

Fatigue and Breast Cancer: More Common than Not

This post was written by H&W instructor Susannah Haarmann, PT, WCS, CLT, who authored and instructs the course, Rehabilitation for the Breast Oncology Patient.

Elizabeth Hampton

According to Schmitz et al, 94% of people experience fatigue as a side effect during breast cancer treatment, and, unfortunately, this condition commonly persists after treatment ends. Fatigue is often described as an unrelenting sense of tiredness that interferes with daily functioning. The symptoms of fatigue, such as generalized weakness, inability to concentrate and impaired short-term memory are often disproportionate to activity levels and unresponsive to sleep (Mitchell, 2010).

The causes of fatigue during cancer treatment are often multi-factorial and may be related to anemia, pain, deconditioning, hormonal and electrolyte imbalances or emotional distress, among other reasons. Physicians may attempt to alleviate the symptoms with pharmaceutical interventions such as pain and sleep medications or iron supplements, however, the only intervention that has been shown to have a significant effect in lowering fatigue levels is exercise. The NNCN states that exercise has been shown to lower fatigue levels by 40-50% (NCCN, 2008).

Radiation, chemotherapy and surgical intervention have been associated with fatigue, however, a Cochrane review by Markes, et al showed that exercise can improve physical function even during cancer treatment (Markes, Barckow & Resch, 2006). Patients who continue exercise within safe parameters during cancer treatment have been shown to reap the following benefits; improved energy, appetite, and psychological states, and even a greater functional capacity.

Furthermore, exercise during and after cancer treatment, has been shown to improve overall treatment outcomes and lower patient’s risk of cancer recurrence, as well as decrease the risk or limit other side effects of breast cancer treatment such as lymphedema, fatigue and osteoporosis. Susannah Haarmann’s course “Rehabilitation for the Breast Cancer Patient,” will explain safe parameters of exercise before and after cancer treatment to improve the health and overall quality of life of cancer patients.

References:

Markes, M., Borkcow, T., & Resch, K., Exercise for women receiving adjuvant therapy for breast cancer. Cochrane Database of Systematic Reviews (4). CD005001.
Mitchell, S., Caner-related fatigue; Clinical practice guidelines in oncolog. J. Natl. Comp. Canc Netw, 2010; 5 (10), 1054-1078.

Schmitz, K, Speck, R., Rye, S., DiSpio, T., Hayes, S., Prevalence of breast cancer treatment sequelae over 6 years of follow-up. Cancer, 2012; 118(8) 2217-2225.

Continue reading

Gait Patterns and Intra-articular Hip Injury

This post was written by H&W instructor Ginger Garner. Ginger will be presenting her Hip Labrum Injuries course in Houston in 2015!

Ginger Garner

One of the easiest ways to determine if someone is in pain is to watch the way they move. And perhaps the most commonly observed and universal movement pattern is gait. From a subtle loss of trunk rotation or pelvic translation to a gross loss of reciprocal gait, a dynamic assessment of walking is a very valuable tool in the physical therapist’s toolbox.

In evaluation of the hip, gait assessment is a critical element of the physical therapy exam. Pain-free ambulation is an essential part of measuring a person’s quality of life (QOL) and is a clinically significant functional outcome measure. Loss of hip extension and knee hyperextension prior to or at heel strike are part of several self-limiting patterns that arise from intra-articular hip injury. Dynamic gait assessment can give the therapist distinct clues as to hip pathophysiology etiology.

It was previously assumed that surgery to correct intra-articular pathology, such as in CAM-based femoracetabular impingement (FAI), would result in correction of deficiencies in gait patterning. CAM FAI limits and creates pain in the direction of hip osteokinematic flexion, adduction, and internal rotation range of motion and is caused by a lack of sphericity of the femoral head and neck, causing impingement of the labrum and/or chondral contact at the acetabulum.

A recent study published in 2013 in Gait and Posture, shows that previous assumptions about gait are incorrect. The study compared the gait of healthy controls to those with FAI and hypothesized that gait abnormalities would resolve status post surgery.

Gait measures were obtained both preoperatively and postoperatively. Researchers were surprised to find that gait abnormalities found presurgically did not automatically resolve postsurgically. Another pertinent finding is that the surgical patients not only retained their old faulty antalgic gait patterns and habits, they also adopted new abnormalities that resulted from surgical intervention, such as those arising from scar tissue, soft tissue pathology, neuromuscular patterning, or loss of arthrokinematic motion in the hip. These findings underscores the importance of early intervention via physical therapy for both operative and nonoperative patients if we want our patients to enjoy or return to a high quality of life.

Although the patients in the study who underwent FAI surgery did demonstrate decreased pain, nonoptimal preoperative gait patterns that persist postoperatively can put these patients at risk for reinjury (e.g. labral retears) or related cobmorbidities like pelvic pain, back pain, or sacroiliac joint dysfunction.

Further, a separate study published in 2009 established the presence of altered hip and pelvic biomechanics during gait, finding that those with hip FAI had decreased peak hip abduction, attenuated pelvic frontal ROM or translation, and less sagittal ROM than controls. Soft tissue restriction including scar tissue from previous or current surgeries, myofascial restriction, or neuromuscular patterning problems are, again, all important variables which must be differentially diagnosed for their possible contribution to the loss of ROM and function. Other considerations that can alter gait pattern and increase injury or reinjury risk assessment of capsular mobility, ligamentous integrity, and sacroiliac joint contributions to limited hip ROM and excursion.

To learn more about nonoperative and operative hip labral and FAI management, check out faculty member Ginger Garner's continuing education course on Extra-Articular Pelvic and Hip Labrum Injury: Differential Diagnosis and Integrative Management. The next opportunity to take the course is March of 2015 in Houston.

Continue reading

Upcoming Continuing Education Courses

Jan 10, 2020 - Jan 12, 2020
Location: Dominican Hospital - Physical Therapy

Jan 17, 2020 - Jan 19, 2020
Location: Spooner Physical Therapy

Jan 17, 2020 - Jan 19, 2020
Location: Banner Physical Therapy and Rehabilitation

Jan 17, 2020 - Jan 19, 2020
Location: Our Lady of the Lake Children's Hospital

Jan 24, 2020 - Jan 26, 2020
Location: Nova Southeastern University

Jan 24, 2020 - Jan 26, 2020
Location: UCLA Health

Feb 1, 2020 - Feb 2, 2020
Location: Evergreen Hospital Medical Center

Feb 1, 2020 - Feb 2, 2020
Location: Ochsner Health System

Feb 7, 2020 - Feb 9, 2020
Location: FunctionSmart Physical Therapy

Feb 22, 2020 - Feb 23, 2020
Location: Pacific Medical Centers

Feb 28, 2020 - Mar 1, 2020
Location: Inova Physical Therapy Center

Feb 28, 2020 - Mar 1, 2020
Location: University of North Texas Health Science Center

Feb 28, 2020 - Mar 1, 2020
Location: Novant Health

Feb 28, 2020 - Mar 1, 2020
Location: Rex Hospital

Feb 28, 2020 - Feb 29, 2020
Location: Rex Hospital

Mar 6, 2020 - Mar 8, 2020
Location: 360 Sports Medicine & Aquatic Rehabilitation Centers

Mar 6, 2020 - Mar 8, 2020
Location: Heart of the Rockies Regional Medical Center

Mar 6, 2020 - Mar 8, 2020
Location: University of Missouri-Smiley Lane Therapy Services

Mar 6, 2020 - Mar 8, 2020
Location: Princeton Healthcare System

Mar 6, 2020 - Mar 8, 2020
Location: Ochsner Health System

Mar 6, 2020 - Mar 8, 2020
Location: Spectrum Health System

Mar 7, 2020 - Mar 8, 2020
Location: Veterans Administration - Salt Lake City

Mar 7, 2020 - Mar 8, 2020
Location: GWUH Outpatient Rehabilitation Center

Mar 13, 2020 - Mar 15, 2020
Location: Sentara Therapy Center - Princess Anne

Mar 13, 2020 - Mar 15, 2020
Location: Thomas Jefferson University

Mar 13, 2020 - Mar 15, 2020
Location: Franklin Pierce University

Mar 14, 2020 - Mar 15, 2020
Location: Park Nicollet Clinic--St. Louis Park

Mar 20, 2020 - Mar 22, 2020
Location: Allina Hospitals and Clinics

Mar 20, 2020 - Mar 22, 2020
Location: Comprehensive Therapy Services

Mar 20, 2020 - Mar 22, 2020
Location: Shelby Baptist Medical Center