Physical examination tests for the diagnosis of femoroacetabular impingement. A systematic review

doi:10.1016/j.ptsp.2016.01.002

Physical Therapy in Sport

Volume 21, September 2016, Pages 87-93

https://doi.org/10.1016/j.ptsp.2016.01.002 Get rights and content

Highlights

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Clinicians are encouraged to use clinical examination to identify FAI.
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A comprehensive literature search about physical examination tests for FAI was done.
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Diagnostic accuracy of FAI clinical tests is limited due to its heterogenecity.
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More methodologically sound studies on this topic are needed.

Abstract

Numerous clinical tests have been proposed to diagnose FAI, but little is known about their diagnostic accuracy.

Objectives

To summarize and evaluate research on the accuracy of physical examination tests for diagnosis of FAI.

Methods

A search of the PubMed, SPORTDiscus and CINAHL databases was performed. Studies were considered eligible if they compared the results of physical examination tests to those of a reference standard. Methodological quality and internal validity assessment was performed by two independent reviewers using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool.

Results

The systematic search strategy revealed 298 potential articles, five of which articles met the inclusion criteria. After assessment using the QUADAS score, four of the five articles were of high quality. Clinical tests included were Impingement sign, IROP test (Internal Rotation Over Pressure), FABER test (Flexion–Abduction–External Rotation), Stinchfield/RSRL (Resisted Straight Leg Raise) test, Scour test, Maximal squat test, and the Anterior Impingement test. IROP test, impingement sign, and FABER test showed the most sensitive values to identify FAI.

Conclusions

The diagnostic accuracy of physical examination tests to assess FAI is limited due to its heterogenecity. There is a strong need for sound research of high methodological quality in this area.

Introduction

Femoroacetabular Impingement (FAI) is an abnormal anatomical relationship between the femoral head and/or femoral neck and the acetabulum. It produces a premature contact between both structures during coxofemoral joint movement which may lead to early degeneration of the labrum and adjacent cartilage. This continued damage over time may modify the lubrication and normal behavior of the hip joint and, consequently, may alter the function of the sealed joint. Initially introduced by Ganz, Parvizi, Beck, Leunig, Nötzli, and Siebenrock (2003), who classified the FAI into two groups: first type, called Cam, in which the presence of a bony prominence (hump) in the femoral head-neck alters the femoral head sphericity. It correlates directly with early osteoarthritis of the young-adult male. The second type known as Pincer, has a normal femoral neck junction but an over covered acetabular rim. It is more common in middle-aged active women (Banerjee & Mclean, 2011). There is also a combination of both types with a slight predominance of one of them (70% of the cases) (Marín, Ribas, Ledesma, Tey, Valles, & Vilarubias, 2008).

Interest on FAI has increased recently given that its existence was unknown until a few years ago (Ganz et al., 2003; Leunig, Beaulé, & Ganz, 2009). Recent studies have underlined FAI as one of the most important causes of labral tear and it is a recognized factor of hip early osteoarthritis, especially in young, adult active patients (Beck et al., 2005, Leunig et al., 2009). Besides, FAI has been recognized as a common cause of hip pain in this type of patients (Byrd, 2006), with 72% of men and 50% of women showing some evidence of radiographic hip abnormality consistent with FAI (Gerhardt, Romero, Silvers, Harris, Watanabe, & Mandelbaum, 2012), where a proper diagnosis is essential. According to Martin, Shears, and Palmer (2010) and Tibor and Sekiya (2008) patient history and a thorough physical examination play a very important role when identifying hip pain of intraarticular origin. In short, an early diagnosis is necessary for early and effective treatment and to avoid the need of a hip replacement implant in a young adult patient.

Accurate clinical testing should facilitate timely and appropriate intervention for patients suffering from hip pain and suspected FAI. Thus, a lack of consensus on diagnostic criteria and concordance in clinical assessment may difficult the choice of intervention. Many academic texts, narrative reviews, and on-line material exist to describe examination techniques, including special tests, specifically conceived for detecting hip pathology. Despite the acceptable number of clinical tests proposed to diagnose FAI, these tests have not been compared for their accuracy and, consequently, no single test have been identified as superior to another. Previous reviews have sought to assess the diagnostic test accuracy of hip physical examination tests as a whole (Rahman et al., 2013, Reiman et al., 2013), but no one has specifically focused on the diagnosis of FAI. The purpose of this systematic review was to determine the diagnostic accuracy of selected clinical tests for FAI and investigate the quality of the studies that have examined these values.

Section snippets

Study design

This systematic review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines during the search and reporting phase of the research process. The PRISMA statement includes a 27-item checklist designed to improve reporting of systematic reviews and meta-analyses (Liberati et al., 2009). The PRISMA guidelines were created for use in summarizing randomized controlled trials but can be used for multiple forms of research methodologies (Swartz, 2011).

Search strategy

Selection of studies

The systematic search through PubMed, SPORTDiscus and CINAHL netted 293 abstracts, and 5 additional papers were identified through an extensive hand search. In total, 298 titles were initially retained after duplicates were removed. Abstract and full-text review reduced the acceptable papers to five (Fig. 1).

Description of included studies

Details on study characteristics are provided in Table 1. Clinical tests investigated, participants, reference standard used, and diagnoses made by authors were included. A total of seven

Discussion

Systematic reviews of evaluation of tests are undertaken for the same reasons as the systematic reviews of treatment intervention to produce estimates of test performance and impact based on all available evidence, in order to evaluate the quality of published studies and to account for variation in the findings between studies (Deeks, 2001). This study investigated the diagnostic accuracy and quality of seven selected clinical tests for FAI. There were only five studies illustrating tests that

Conflicts of interest

None declared.

Funding

None declared.

Acknowledgments

The authors express their appreciation to Mrs. Maria A. Raya, Librarian, for her assistance in gathering background material and designing the searching method.

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Cited by (29)

Update on contribution of hip labral tears to hip pain: a narrative review
2023, Revue du Rhumatisme (Edition Francaise)
Des lésions du labrum sont retrouvées dans 22 % à 55 % des douleurs coxo-fémorales, mais elles n’en sont que rarement directement responsables, car ces douleurs proviennent surtout des structures adjacentes au labrum, soit intra-articulaires (lésions ostéochondrales), soit périarticulaires (capsule, sur laquelle s’insèrent rectus femoris, gluteus minimus, et iliopsoas). Bien que la suture précoce des déchirures labrales chez de jeunes sportifs puisse induire des soulagements rapides, et pourrait différer la survenue d’une coxarthrose, les micro-instabilités favorisées par les déchirures labrales paraissent bien moins importantes dans la pathogénie des lésions que les dysplasies/dysmorphies sous-jacentes. Les lésions labrales sont en effet presque toujours la conséquence de dysplasies, ou de dysmorphies responsables de conflits fémoro-acétabulaires. La présente revue aborde : (i) les sources des douleurs pouvant être amplifiées par les lésions labrales ; (ii) la difficulté à affirmer une micro-instabilité ; (iii) les moyens de détecter les lésions labrales, tant cliniquement (dont par le test IROP), que sur l’imagerie (IRM, arthroscanner, échographie). La mise en traction des coxo-fémorales ne semble pas majorer la sensibilité de l’échographie pour étudier le labrum. Par contre, l’échographie peut aider à guider le site des infiltrations périarticulaires, à envisager quand un soulagement n’est pas obtenu par une anesthésie intra-articulaire. Certaines douleurs paraissent en effet dues à des déchirures de la partie superficielle de l’épaisse capsule, dans les zones où s’insèrent sur elle le rectus femoris, le gluteus minimus et l’iliopsoas. Des travaux futurs pourraient mieux apprécier les efficacités respectives dans ces cas des réparations labrales, débridements tendineux, sutures capsulaires, ou dénervations focales.
Hip labral tears are found in 22‐55% of individuals with hip pain, but labral tears without cysts are usually not responsible for hip pain, which originates mostly from other structures than the torn labrum, like osteochondral, but also tendinous injuries (rectus femoris, gluteus minimus, iliopsoas) or capsulo-ligamentous tears (iliofemoral ligaments, ligament teres). Those lesions are mainly the consequences of underlying unrecognized functional acetabular dysplasia, and/or femoroacetabular impingements. Although the early repair of labral tears in young sportsmen induces a marked and lasting relief, and might delay the onset of osteoarthritis, the microinstability fostered by labral damages seems less important than underlying dysplasias/impingements. This narrative review details recent findings on: i) the various mechanisms of pain associated with labral tears; ii) few evidence for hip microinstability induced by isolated labral tears; iii) how to best detect labral tears, both clinically (including through IROP test) and on imaging (MRI, MRA, computed tomography arthrography, ultrasound). Some authors suggested to use pull-out tests during surgery, but pulling of hips do not seem to increase much diagnostic performances of ultrasounds. Ultrasound-guided intra-articular and peri-articular injections may tell how often hip pain is exclusively induced by peri-capsular injuries secondary to the acetabular dysplasia/femoro-acetabular impingements already responsible for labral tears. Further works could tell whether labral repair, tendinous debridement, plication of capsule, and/or focal denervation, may induce lasting reliefs of pain induced by the chronic contraction of surrounding muscles (rectus femoris, gluteus minimus, psoas), whose deep aponeuroses mix with the superficial fibres of the thick hip capsule.
Hip pain evaluation and treatment for athletes
2023, The Youth Athlete: A Practitioner's Guide to Providing Comprehensive Sports Medicine Care
Hip traumatic and overuse injuries are common in pediatric and adolescent athletes. Distinguishing pain that is related to intraarticular versus extraarticular conditions is key in devising appropriate treatment recommendations. With advancements in hip preservation surgery in the past 2 decades, understanding the role of hip deformity with or without a hip labral tear in the athlete's presentation is needed for careful evaluation and treatment plan. Though conservative care has not been defined, treatment should focus on relative rest, activity modification, improvement in muscle length, strength, and motor control across the lumbopelvic girdle and attention to sport-specific activities. Healthcare providers must also apply these principles to the care of extraarticular hip conditions whether they occur in isolation or cofounding with intraarticular hip conditions.
Update on contribution of hip labral tears to hip pain: A narrative review
2023, Joint Bone Spine
Citation Excerpt :
The Scour test is performed with the affected limb placed 90 degrees flexion and adduction, and a strong compression/axial force directed through the knee is then applied and maintained through a range of 65–140 degrees of hip flexion. It seems less sensitive [36]. Reproduction of pain through pulling out hip has not been assessed.
Hip labral tears are found in 22–55% of individuals with hip pain, but labral tears without cysts are usually not responsible for hip pain, which originates mostly from other structures than the torn labrum, like osteochondral, but also tendinous injuries (rectus femoris, gluteus minimus, iliopsoas) or capsulo-ligamentous tears (iliofemoral ligaments, ligament teres). Those lesions are mainly the consequences of underlying unrecognized functional acetabular dysplasia, and/or femoroacetabular impingements. Although the early repair of labral tears in young sportsmen induces a marked and lasting relief, and might delay the onset of osteoarthritis, the microinstability fostered by labral damages seems less important than underlying dysplasias/impingements. This narrative review details recent findings on: (i) the various mechanisms of pain associated with labral tears; (ii) few evidence for hip microinstability induced by isolated labral tears; (iii) how to best detect labral tears, both clinically (including through IROP test) and on imaging (MRI, MRA, computed tomography arthrography, ultrasound). Some authors suggested to use pull-out tests during surgery, but pulling of hips do not seem to increase much diagnostic performances of ultrasounds. Ultrasound-guided intra-articular and peri-articular injections may tell how often hip pain is exclusively induced by peri-capsular injuries secondary to the acetabular dysplasia/femoro-acetabular impingements already responsible for labral tears. Further works could tell whether labral repair, tendinous debridement, plication of capsule, and/or focal denervation, may induce lasting reliefs of pain induced by the chronic contraction of surrounding muscles (rectus femoris, gluteus minimus, psoas), whose deep aponeuroses mix with the superficial fibres of the thick hip capsule.
Femoroacetabular impingement, epidemiology and diagnostic: Review of the literature (part 1)
2022, Journal de Traumatologie du Sport
Les premières descriptions de conflits fémoro-acétabulaires (CFA) s’avèrent relativement récentes. Le nombre d’études sur ces pathologies a augmenté de manière exponentielle au cours des dernières années. L’objectif de cette revue narrative est de détailler les données épidémiologiques et les éléments diagnostiques les plus récents en se basant sur le meilleur niveau de preuve de la littérature scientifique.
Les recherches ont été effectuées dans la base de données « Pubmed ». La première étape a permis de mettre en évidence 202 revues systématiques et méta-analyses en lien avec les CFA. Au final, 14 d’entre elles ont été sélectionnées pour répondre à la problématique de cette revue narrative.
Les différentes publications ont permis d’avoir une meilleure idée de la prévalence de CFA présents chez des patients souffrant de douleurs au niveau de la hanche. Elles ont également servi à identifier les critères radiographiques et tests cliniques les plus adéquats afin de poser le diagnostic de conflit de hanche. Enfin, elles ont souligné le lien entre la pratique sportive et le développement secondaire de CFA.
De plus en plus d’auteurs scientifiques s’intéressent et publient des études portant sur les CFA. Ces travaux permettent de mieux comprendre les phénomènes liés à ces pathologies mais restent encore insuffisants. Il est essentiel que les scientifiques et experts s’accordent afin de créer des guidelines reposant sur les tests cliniques et l’imagerie adéquate pour poser le diagnostic d’un CFA.
The first descriptions of femoro-acetabular impingement (FAI) are quite recent. The number of studies on these pathologies has increased exponentially over the past few years. The aim of this narrative review is to detail the most recent epidemiological data and diagnostic elements based on the best level of evidence in the scientific literature.
Searches were conducted in the “Pubmed” database. The first stage identified 202 systematic reviews and meta-analyses related to FAI. In the end, 14 of them were selected to answer the problematic of this narrative review.
The various publications have provided insight into the prevalence of FAI in patients with hip pain. They were also used to identify the most appropriate radiographic criteria and clinical tests for the diagnosis of hip impingement. Finally, they highlighted the link between sports participation and the secondary development of FAI.
More and more scientific authors are interested in and publish studies on FAI. These studies allow a better understanding of the phenomena related to these pathologies but are still insufficient. It is essential that scientists and experts agree and create guidelines based on clinical tests and appropriate imaging to diagnose a FAI.
Increased range of motion but otherwise similar clinical outcome of arthroscopy over open osteoplasty for femoroacetabular impingement at midterm follow-up: A systematic review
2022, Surgeon
A systematic review was conducted comparing patient reported outcomes measures (PROMs), functional scores, and the rate of complications between arthroscopic and open treatment for femoroacetabular impingement (FAI) at mid-term follow-up.
This systematic review was performed according to the PRISMA guidelines. The literature search was performed in October 2020. All clinical trials treating FAI using open osteoplasty or arthroscopic surgery were considered for inclusion. Only articles reporting >12 months follow-up were included.
Data from 97 articles (9981 procedures) were collected. At a mean 19.2 months follow-up there was no difference between the two cohorts. At a mean follow-up of 38 months, the external rotation was increased in the arthroscopic group (P < 0.0001). The modified Harris Hip Score scored greater in favour of the open osteoplasty group (P = 0.04), as did the Hip Outcome Score - Activities of Daily Living subscale (P = 0.01). At a mean 45.1 months the arthroscopic group presented greater external rotation (P < 0.0001) and SF-12 Mental (P = 0.04). The modified Harris Hip Score was greater in favour of the open osteoplasty group (P = 0.03), as was the HOS-ADL (P = 0.01). Regarding complications, the arthroscopic group experienced lower rates of subsequent revisions (P < 0.0001).
Based on the significant reduction of revisions-rate and significant increase in range of motion, arthroscopy treatment for the management of FAI may be recommended.
Pre- and postoperative in silico biomechanics in individuals with cam morphology during stair tasks
2021, Clinical Biomechanics
Osteochondroplasty for cam femoroacetabular impingement is a common treatment to improve hip function and prevent joint degeneration. The purpose was to compare in-silico hip biomechanics during stair tasks in pre- and postoperative patients matched with healthy controls.
Ten symptomatic cam femoroacetabular impingement patients performed stair ascent and descent pre- and 2 years postoperatively. Patients were age, and body-mass-index matched to controls. Full-body kinematics and kinetics were computed and, muscle and hip contact forces were estimated using musculoskeletal modeling and static optimization. Stance-phases were time-normalized and compared using statistical non-parametric mapping.
Preoperatives showed lower hip abduction than controls during stairs ascent (76–100%, P = .007). Pre- and postoperative showed lower hip external rotation compared to controls on stair ascent (Pre-op vs controls: 71–100%, P = .005; Post-op vs controls: 72–100%, P = .01) and stair descent (Pre-op vs controls: 0–62%, P = .001; Post-op vs controls: 0–60%, P = .001). Postoperatives showed lower iliacus force compared to preoperative (1–3%, P = .012) and control (3–6%, P = .008), and higher gluteus maximus and piriformis forces compared to controls during stair descent. Lower postoperative anterior hip contact force (0–7%, P = .004) during descent, and superior (33–35%, P = .018) during ascent compared to controls were observed. Postoperative contact forces were medialized compared to preoperative (0–2%, P = .011) and controls (1–2%, P = .016).
Forcing participants to adhere to standardized step length/rise minimized sagittal kinematic differences between conditions and groups. Persistent reduced hip external rotation postoperatively and minor muscle force adaptations led to reduced superior hip contact force during stair ascent and reduced anterior and more medialized contact forces during stair descent.

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Literature reviewPhysical examination tests for the diagnosis of femoroacetabular impingement. A systematic review