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Clinical Tests for the Hip – Labral Tears, Hip Impingement, Intra-articular Hip Pathologies.

Further to my last post I thought we might start by looking at the clinical usefulness of tests we do for diagnosis of hip disorders. So todays question:

How useful are Clinical Tests for the Hip in diagnosing Labral Tears, Hip Impingement and/or Intra-artciular Hip Pathologies?

Evidence Regarding Orthopaedic Clinical/Special Tests

A systematic review by Reiman et al (2012) reviewed the following tests:

  • Impingement/Labral/Intra-articular Tests
    • FABER Test – Intra-Articular Patholoy
    • Internal Rotation with Overpressure
    • Scour test
    • Impingement (FADDIR) Test
    • Impingement Provocation Test (Postero-inferior Labrum Tear)
    • Flexion Internal Rotation Test
    • Internal Rotation Flexion Axial Compression Test
    • Thomas Test

The following conclusions were reached:

  • The meta-analysis demonstrated that most tests possess weak diagnostic properties.
  • In general, these tests demonstrated greater SN than SP.
  • Several studies have investigated pathology in the hip. Few of the current studies are of substantial quality to dictate clinical decision-making.

Tijssen et al (2012)

  • Systematic review to identify the diagnostic accuracy and validity of physical tests that are used to assess FAI (Femoroacetabular Impingement) and labral pathology of the hip joint.
  • The clinical diagnosis is currently based on MRI-A (magnetic resonance imaging-arthrogram) because the physical diagnostic tests available are diverse and information on diagnostic accuracy and validity is lacking.
  • 21 studies were included in which 18 different tests were described. For 11 of these tests, diagnostic accuracy figures were presented. Sensitivity was examined for all tests. Other diagnostic accuracy figures were often lacking, and when available, these were low.
  • Conclusions:
    • In previous studies a wide range of physical diagnostic tests have been described. Little is known about the diagnostic accuracy and validity of these tests, and if available, these figures were low.
    • The quality of the studies investigating these tests is too low to provide a conclusive recommendation for the clinician.
    • Thus, currently, no physical tests are available that can reliably confirm or discard the diagnoses of FAI and/or labral pathology of the hip in clinical practice.

The following article by Leibold et al (2008) was also of interest. Conclusions being:

  • Current best evidence indicates that a negative finding for the flexion-adduction-internal rotation test, the flexion-internal rotation test, the impingement provocation test, the flexion-adduction-axial compression test, the Fitzgerald test, or a combination of these tests provides the clinician with the greatest evidence-based confidence that a hip labral lesion is absent.
  • Currently, research has produced no tests with sufficient specificity to help confidently rule in a diagnosis of hip labral lesion.

The following youtube clip is quite a thorough one for those unfamiliar with orthopaedic screening of the hip.

My Conclusion:

So based on the above I think we can conclude that the current tests we use for diagnosis of labral tears, impingment and intra-articular pathologies at best provide us with “screening tools”, and are not “diagnostic tests”. Purely relying on these tests for clinical decision making is not sound Evidence Based Practice.

As a reminder from my previous post:

…….some tests are sensitive and have a low LR- only (they lack specificity and/or LR+) and hence are only useful as “screening” tests, others are specific or have high LR+ that are useful for “diagnosis”. Some tests lack both and hence are ineffective for “screening or diagnostics”.

Evidence Regarding Imaging

The general reported best imaging for suggested labral tears of the hip is a Magnetic Resonance Arthrogram (MRA). Burgess et al (2011) conducted a systematic review on this topic, results showing:

  • Magnetic Resonance Arthrography to consistently outperform Magnetic Resonance Imaging.
  • Computerised Tomography also showed high accuracy levels for the few studies identified.

But we need to be wary with imaging results not to purely base diagnosis on scan findings only. As Register et al (2012) reported in their prospective, double blinded study of asymptomatic (no history of hip pain, symptoms, injury, or surgery) patients:

  • Magnetic resonance images of asymptomatic participants revealed abnormalities in 73% of hips, with labral tears being identified in 69% of the joints.

So where are we at?

I feel that Reiman et al (2013) puts everything into perspective:

  • Although tremendous improvements in diagnostic utility for Acetabular Labral Tears (ALT) have occurred in the past 25 years, there are few patient history, clinical examination and special test findings that are unique to the condition. Imaging methods such as MRI, CT and ultrasonography have demonstrated reasonable accuracy, but not at a level that allows use as a stand-alone measure.
  • Outcomes measures that focus on functional limitation or that are used to measure recovery should envelop the complexities of the condition and be captured using both self-report and physical performance measures.
  • Only when patient history, objective testing, clinical examination special testing and imaging are combined can a clinician fully elucidate the multidimensional diagnosis of ALT.

I hope this post has been of some assistance.

References:

Burgess RM, Rushton A, Wright C, Daborn C. The validity and accuracy of clinical diagnostic tests used to detect labral pathology of the hip: a systematic review. Man Ther. 2011 Aug;16(4):318-26.

Leibold MR, Huijbregts PA, Jensen R. Concurrent criterion-related validity of physical examination tests for hip labral lesions: a systematic review. J Man Manip Ther. 2008;16(2):E24-41.

Register B, Pennock AT, Ho CP, Strickland CD, Lawand A, Philippon MJ. Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. Am J Sports Med. 2012 Dec;40(12):2720-4.

Reiman MP, Goode AP, Hegedus EJ, Cook CE, Wright AA. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. Br J Sports Med. 2012 Nov 7. [Epub ahead of print].

Reiman MP, Mather RC 3rd, Hash TW 2nd, Cook CE. Examination of acetabular labral tear: a continued diagnostic challenge. Br J Sports Med. 2013 Jul 31. doi: 10.1136/bjsports-2012-091994. [Epub ahead of print]

Tijssen M, van Cingel R, Willemsen L, de Visser E. Diagnostics of femoroacetabular impingement and labral pathology of the hip: a systematic review of the accuracy and validity of physical tests. Arthroscopy. 2012 Jun;28(6):860-71.

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Branch Councillor on the Western Australian Branch of the Australian Physiotherapy Association.

6 Comments on "Clinical Tests for the Hip – Labral Tears, Hip Impingement, Intra-articular Hip Pathologies."

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  1. Hip – (Falvey 2009) LAteral trochanteric triangle – patho-anatomical approach
    Hip – (Falvey 2009) The gluteal triangle – a patho-anatomical approach
    Hip – (Kang, 2009) Acetabular tears & FAI impingement.pdf
    HIP – (McCarthy 2003) Acetabular Labral Tears – Pathoanatomy and Rx.pdf
    Hip – (sims, 1999) Development of Hip OA – management

    Some other good sources.

  2. firstww says:

    Hip – (Falvey 2009) LAteral trochanteric triangle – patho-anatomical approach
    Hip – (Falvey 2009) The gluteal triangle – a patho-anatomical approach
    Hip – (Kang, 2009) Acetabular tears & FAI impingement.pdf
    HIP – (McCarthy 2003) Acetabular Labral Tears – Pathoanatomy and Rx.pdf
    Hip – (sims, 1999) Development of Hip OA – management
    Hip – knee (Powers, 2010) The influence of abnormal hip mechanics on knee injury
    HIP Keogh & Batt (2008) – FAI in athletes review.pdf

    Some other good resources.

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