Anterior hip pain is an increasingly frequent and relevant diagnosis seen in physical therapy practice in patients of all levels. While anterior hip pain is not always linked to femoroacetabular impingement and labral dysfunction, this review will focus on this medical diagnosis and assist clinicians in making informed decisions regarding conservative management, referral, and patient education.
As physical therapists, our biases indicate that patients will and should benefit from conservative management. However, there is not a wealth of high-quality evidence examining the effect of conservative care on anterior hip pain related to FAI/labral dysfunction.
There is a greater amount of evidence surrounding arthroscopic osteoplasty and labral repair. Although it should be noted that the majority of evidence is related to retrospective analysis rather than high quality, level I or II studies.
The goal of the following literature review is to address questions including whether conservative care or surgical interventions results in optimal patient outcomes, what are the long-term outcomes of hip arthroscopy, and how does research translate to clinical practice?
Do patients benefit from conservative management with confirmed evidence of FAI/hip labral dysfunction?
A study by Wright et al. in 2016 observed the effect of conservative management for patients with FAI.1
In this study patients were randomly allocated into two groups, one of which received manual therapy, supervised therapeutic exercise, advice, and HEP. The other group received only advice and a “hip handout” home exercise program. The study examined the results following a 6-week time period.
Following 6 weeks both groups demonstrated similar improvements in pain (statistically significant) indicating that at this time research is unable to support that clinically applied physical therapy is superior to a home program alone.
However, patients did show meaningful improvement with conservative management. It is encouraging that the data indicates physical therapy interventions (in the clinic or home setting) were able to have a positive effect on pain and performance. It should be noted, however, that this statistically significant improvement did not translate to patient satisfaction with treatment as 8 of the 15 participants elected to undergo arthroscopic surgery following physical therapy treatment (7 of the 8 indicated that they were unsatisfied with their physical therapy outcomes).
Additionally, there are published case series/studies detailing successful short-term outcomes in patients with FAI/hip labrum dysfunction.2 Seemingly these often include criterion-based rehabilitation programs focusing on symptom management, addressing of identified asymmetries and limitations, and a focus on the resumption of pre-morbid activities.
Does surgery or conservative management yield better outcomes for those patients with FAI/hip labrum dysfunction?
A study by Griffin et al.3 examined the outcomes of patients receiving conservative care compared to those receiving arthroscopic hip surgery to address FAI and labral dysfunction as needed.
This is a well-orchestrated study that addresses many questions that would play into a patient’s decision whether or not to pursue surgery when provided with all options and information.
The researchers examined the difference in clinical effect of hip arthroscopy compared to “personalized hip therapy”. Personalized hip therapy consisted of a package of 6-10 sessions of PT guided therapy (over 12-24 weeks) regarded as “best conservative care”. The program was taught in the clinic and repeated at home. Those patients who were randomly assigned to the surgical group underwent arthroscopic hip surgery to address FAI and labral repair as needed. Following surgery these patients underwent rehabilitation according to the surgeon’s preferred protocol.
The results of the study demonstrated that both conservative management and arthroscopic repair resulted in improved patient outcomes. However, all metrics demonstrated a stronger effect in the short-term for those undergoing arthroscopic repair compared to conservative care at the 12-month follow up.
Other findings of note included that even for a country with a national healthcare system, conservative care was more cost-effective compared to surgery. Additionally, correction of CAM type impingement was shown to have a greater therapeutic effect compared to pincer or mixed type morphological impingement.
This study determined that further research would be needed examining whether or not the difference in patient reported outcomes remained at long-term follow up. Additionally, further research would be needed to determine the likelihood and prevalence of progression to degenerative hip osteoarthritis in those undergoing arthroscopic repair.
Do the positive short-term outcomes remain at long-term follow up for those undergoing hip arthroscopy?
A study by Lee et al.4 in 2019 included follow-up review of outcomes at 2-5 years and 7-10 years of patients undergoing hip labrum repair (with femoroplasty and other indicated debridement).
The researchers found that improvements in both patient satisfaction and functional outcomes remained at long-term follow up. Additionally, results indicated that there was no progression in osteoarthritis from initial score to long-term follow up at a statistically significant level.
It is important to note that:
– There was no control group undergoing labral debridement or conservative care
– The inclusion criteria required that patients had no evidence of osteoarthritic changes at initial measure.
– Surgical procedures also included osteoplasty, synovectomy, and other debridement as indicated, meaning that one cannot attribute the clinical effects solely to the labral repair.
Does the length of symptoms prior to surgical intervention have an effect on long-term outcomes?
In a retrospective analysis of patients undergoing hip arthroscopy to address FAI related symptoms, Kunze et al.5 found an association between the length of pre-operative symptoms and post-operative outcomes including patient satisfaction, patient reported function, and pain.
Their results indicated that those patients undergoing arthroscopy with a duration of symptoms greater than 2 years were more likely to have unfavorable outcomes more often than those patients with shorter pre-operative symptoms.
What does all of this mean in practice?
To this point we have highlighted some key findings of a selection of articles, identified areas that require further research, and sufficiently muddied the waters for clinicians looking for answers regarding management of patients with anterior hip pain.
Now it is time to get to the point of this review and establish what matters in the management of these patients.
Evaluation:
When evaluating a patient with anterior hip pain, it is important to establish whether 1) the symptoms are musculoskeletal in nature and 2) you are dealing with a “muscle” or “joint” issue. Answering these two questions will shed light on whether or not you should refer for further evaluation and help to create a working “diagnosis”.
Examination:
The goal of your examination will be to 1) confirm/disconfirm your hypothesis, 2) establish an initial treatment plan based on the examination findings, and 3) conclude whether or not the patient will benefit from further examination and require referral.
Figure 1: Characteristics of joint and muscle/tendon dysfunction
Treatment:
While the goal of this review is not to perform a deep dive into interventions for anterior hip pain related to FAI/labral dysfunction, it would be beneficial to expand briefly on what a criterion-based rehabilitation program may look like. See figure 2.
Figure 2: Phase based rehabilitation for anterior hip pain
| Early-Stage Rehabilitation | Mid-Stage Rehabilitation | Late-Stage Rehabilitation |
| Goals: Homeostasis Restoration – Restore ROM – Reduce pain – Improve tolerance for daily life | Goals: Prepare for and reintegrate pre-morbid activities as tolerated | Goals: Build volume and initiate full return to activity progression – Tolerate repeated efforts of higher intensity activity – Increase complexity and intensity of activities to mimic demands of sport |
| Interventions: – Manual Therapy/Dry Needling – ModalitiesNon-provocative therapeutic exercises – Ambulatory activities | Interventions: – Reintroduction and loading of foundational movement patterns – Increase locomotive demands – Initiate graded impact progression – Strength and conditioning as tolerated | Interventions: – “Sport-like” drills – Gamification of conditioning and activities (i.e. role playing attacker/defender) – Higher level agility, change-of-direction, and plyometrics – Continuation of S&C |
| Exit Criteria: – Pain significantly reduced – Able to perform ADLs with manageable symptoms | Exit Criteria: – Local Tissue Endurance Restored – Multi-planar and body weight competency | Exit Criteria: – Completion of established RTS progression with acceptable symptom level – Passing of relevant RTS testing |
Anterior Hip Pain Clinical Decision-Making Tool
See figure 3 for a decision-making tool with recommendations based on the information summarized in this review to assist in management of patients with anterior hip pain.
Once red flags have been ruled out via subjective history, a thorough musculoskeletal exam consisting of A/PROM, palpation, muscle performance testing, special testing, and other relevant testing can be utilized to determine a plan of action.
For the sake of this review, we will focus on the joint-related dysfunction portion of figure 3.
Given that research suggests that patients with FAI/labral dysfunction will benefit from conservative management, it is reasonable that clinicians provide some form of treatment in those patients regardless of whether a referral is required.
The process of determining whether a patient with anterior hip pain suggesting FAI/labral dysfunction will require referral is a more nuanced subject. It is likely that a FADIR/FABER positioning of a hip may be sensitive for patients independent of labral dysfunction. A positive finding here does not necessarily require referral.
According to Thorborg et al.6, findings suggesting intra-articular joint related dysfunction require that further diagnostic examination is necessary. Subjective complaints including popping, clicking, shifting, catching, or stiffness following prolonged positioning may be suggestive of labral and intra-articular joint dysfunction.
Knowing that patients having symptoms <2 years in duration will likely experience improved outcomes following surgery, it is reasonable that patients having symptoms longer (>6 months) in duration would likely
benefit from an orthopedic consultation to ensure maximal outcomes in the case that they require surgical intervention.
The last piece of figure 3 to be addressed is the portion of joint-related dysfunction that indicates patients should be referred out. Patients demonstrating an unstable presentation, an inability to bear weight, or those sustaining injury of traumatic onset would most likely benefit from further diagnostic testing before initiating a physical therapy plan of care.
Figure 3: Anterior hip pain clinical decision-making tool
Summary:
Anterior hip pain is a common diagnosis seen in sports and orthopedic settings. Fortunately, research indicates that it is amenable to treatment (whether conservative or surgical). Additionally, research suggests that short-term outcomes are generally good with proper management. Recent research suggests that patients undergoing arthroscopic repair have favorable outcomes in the short- and long-term without evidence of progression of osteoarthritis in patients without pre-surgery osteoarthritis. It should be considered that the research and findings presented in this review are from studies mostly prospective or retrospective in nature and are of lower quality evidence. Future research should include randomized controlled trials, systematic reviews, and other studies of higher quality evidence that allow for stronger recommendations in the management of these patients. Other areas for further research also include investigation of long-term outcomes for conservative vs surgical management of anterior hip pain.
Sources:
[1] Wright AA, Hegedus EJ, Taylor JB, Dischiavi SL, Stubbs AJ. Non-operative management of femoroacetabular impingement: A prospective, randomized controlled clinical trial pilot study. J Sci Med Sport. 2016 Sep;19(9):716-21. doi: 10.1016/j.jsams.2015.11.008. Epub 2016 Jan 6. PMID: 26795448.
[2] Yazbek PM, Ovanessian V, Martin RL, Fukuda TY. Nonsurgical treatment of acetabular labrum tears: a case series. J Orthop Sports Phys Ther. 2011 May;41(5):346-53. doi: 10.2519/jospt.2011.3225. Epub 2011 Feb 18. PMID: 21335929.
[3] Griffin DR, Dickenson EJ, Wall PDH, Achana F, Donovan JL, Griffin J, Hobson R, Hutchinson CE, Jepson M, Parsons NR, Petrou S, Realpe A, Smith J, Foster NE; FASHIoN Study Group. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet. 2018 Jun 2;391(10136):2225-2235. doi: 10.1016/S0140-6736(18)31202-9. Epub 2018 Jun 1. PMID: 29893223; PMCID: PMC5988794.
[4] Lee JW, Hwang DS, Kang C, Hwang JM, Chung HJ. Arthroscopic Repair of Acetabular Labral Tears Associated with Femoroacetabular Impingement: 7-10 Years of Long-Term Follow-up Results. Clin Orthop Surg. 2019 Mar;11(1):28-35. doi: 10.4055/cios.2019.11.1.28. Epub 2019 Feb 18. PMID: 30838105; PMCID: PMC6389536.
[5] Kunze KN, Nwachukwu BU, Beck EC, Chahla J, Gowd AK, Rasio J, Nho SJ. Preoperative Duration of Symptoms Is Associated With Outcomes 5 Years After Hip Arthroscopy for Femoroacetabular Impingement Syndrome. Arthroscopy. 2020 Apr;36(4):1022-1029. doi: 10.1016/j.arthro.2019.08.032. Epub 2019 Dec 31. PMID: 31901396.
[6] Thorborg K, Reiman MP, Weir A, Kemp JL, Serner A, Mosler AB, HÖlmich P. Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management. J Orthop Sports Phys Ther. 2018 Apr;48(4):239-249. doi: 10.2519/jospt.2018.7850. Epub 2018 Mar 6. PMID: 29510653.
