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Case Study: Femoral Acetabular Impingement

Mike is a 32-year-old male law enforcement officer presenting with chief complaint of left hip pain upon transition in and out of his work vehicle and exercises involving hip flexion like squatting (loaded and unloaded). Patient was diagnosed with left Femoral Acetabular Impingement (FAI) with bony growths and a torn hip labrum. Mike was recommended to have surgery to fix his abnormal orthopedic findings after failed attempts at out-patient physical therapy. Patient’s goals are to return to a consistent and non-painful training program for health as well as preparation for occupational demands and selection testing for a specialized law enforcement team next year.

Examination Findings

  • Toe Touch = 2 inches from toes
  • Functional Squat (feet shoulder width, knees tracking over toes) = exacerbated painful symptoms one quarter of the way into decent
  • Hip Internal Rotation = 0° bilaterally – bony end feel – exacerbated painful symptoms
  • Adduction Drop Test = (+) bilaterally – bony end feel – 2 inches from table
  • Hip Flexion = 100° bilaterally exacerbates painful symptoms

Assessment
Mike demonstrates extreme limitations in passive and active range of motion contributing to his symptoms and likely to his medical diagnosis of FAI and labrum pathology. Bilateral hip internal rotation, adduction, and flexion limitations with bony end feels suggest a poorly positioned pelvis in relative anterior tilting, innominate out flaring, and/or pelvic outlet restriction.

Interventions & Re-Testing
1. 90-90 Alternating Crossover
– 2 sets of 5 breaths
Post Intervention Testing Changes:

  • Hip Internal Rotation = increased from 0° to 5° bilaterally – remained a bony end feel – continued exacerbation of painful symptoms
  • Hip Flexion = increased from 100° to 110° bilaterally – continued exacerbation of painful symptoms
  • Adduction Drop Test = (+) bilaterally – bony changed to soft end feel – from 2 inches to 1 inch from table

2. Bilateral Sidelying Adductor Pullback
– 2 sets of 5 breaths
Post Intervention Testing Changes:

  • Hip Internal Rotation = increased from 5° to 15° bilaterally – remained a bony end feel – continued exacerbation of painful symptoms
  • Hip Flexion = increased from 110° to 120° bilaterally – continued exacerbation of painful symptoms at end range
  • Adduction Drop Test = from (+) to (-) bilaterally

3. Modified Pigeon Posterior Capsule Stretch
– 2 minutes per side with active oscillations &
adduction movements
Post Intervention Testing Changes:

  • Hip Internal Rotation = increased from 15° to 25° bilaterally – bony changed to soft end feel – painful symptoms with movement resolved
  • Hip Flexion = increased from 120° to 135° bilaterally – painful symptoms with movement resolved
  • Adduction Drop Test = remained (-) bilaterally

4. Counterweight Squat
(5 lb plates, 6 inch ball between knees)
– 2 sets of 5 breaths with active adduction into the 6 inch ball
Post Intervention Testing Changes:

  • Hip Internal Rotation = increased from 25° to 30° bilaterally – continued soft end feel – non-painful
  • Hip Flexion = increased from 135° to 140° bilaterally – non-painful
  • Adduction Drop Test = remained (-) bilaterally
  • Toe Touch = fingers reaching to plantar surface of toes
  • Functional Squat (feet shoulder width, knees tracking over toes) = full deep squat non-painful

Conclusion

  • Toe Touch from 2 inches to fingers reaching the plantar surface of the toes.
  • Functional Squat from a painful quarter squat to a full squat with no pain.
  • Hip Internal Rotation from 0° bilaterally, bony end feel, and painful to 30° bilaterally, soft end feel, non painful.
  • Hip Flexion 100° bilaterally, painful to 140° bilaterally, non painful.
  • Adduction Drop (+) bilaterally, bony end feel, 2 inches from table to (-) bilaterally.

Mike was sent home with the four activities listed above to complete 1-3 times daily (or more) for 2-4 weeks before returning for a follow-up. At the follow-up the patient will then be prescribed a combined physical therapy and performance training program. The goal of Mike’s program will be to continue optimization of joint health and mobility while preparing him for occupational demands as well as selection testing in the Spring of 2017 for a specialized law enforcement team.