Power of immediate symptoms change

Within the physiotherapy world, there are different views on short term interventions. The context, often can be a decider for the treatment approach in performance environments. Often in professional club environments, expertise within the medical team to identify changeable factors between condensed fixture periods becomes crucial in enhancing availability throughout the season. Equally, in private settings, if the patients’ expectation is for pain relief, having short term solutions up one’s sleeve is always handy (Bialosky et al, 2018).

So, how do we identify what is changeable? Traditional pathoanatomical diagnoses are limited by tests with poor diagnostic utilities with low specificities. These tests also point more towards treating the lesion rather than what we can improve functionally in front of us. Several researchers have suggested a movement based, kinesiopathological diagnostic model as a solution for the poor correlation between pathology and pain (Ludewig et al, 2022). Tools have been developed in the shoulder region to support a diagnostic approach to identify changeable drivers, contributing to the pain and pathology, to perhaps inform more specific treatment (Lewis et al, 2018; Ludewig et al 2022). As someone working in football, I am always curious if I can apply and create a similar framework for a lower limb joint.

 

Challenges manual therapy face

Targeted manipulative techniques often can provide effective immediate pain modulation through multimodal neurophysiological effects (Bialosky et al, 2018). The lack of single measurable, complex neurophysiological explanations of these techniques, propose barriers for a lot of practitioners when it comes to clinical reasoning. Effective manual therapy also requires accurate diagnosis, clinical reasoning and skill. Each of these components in their own right are often difficult to standardise and prone to inconsistencies (Brantingham et al, 2012). In this article, a simplified framework will be used to correlate the manipulative techniques with associated findings.

 

Hip as an example

In terms of diagnostic utility around the hip, tests for intra articular hip pathologies have been found to have low specificities, eg. FADIR 9%, FABER 18-75% and flexion internal rotation 25%, according to a systematic review by Reiman et al (2012). UEFA studies have shown that injury burden of hip related injuries remain a challenge for football clubs (Werner et al, 2019). When we send a symptomatic player with a positive hip cluster (Hip IR/FADIR/FABER) for an MRI, based on experience, typically we would expect an FAI presentation showing CAM morphology, some signs of labral tear, with or without acute oedema and iliopsoas pathology. In season, prioritising conservative approach will be the preferred option, with a view to avoid or delay the need going down the surgical pathway, which often comes with a lengthy period of time out. From a performance perspective, is the pain changeable and how can we manage it with minimal time loss on the pitch?

 

Proposed Hip Symptoms Modification Framework (HSMF)

Aim

1. To identify specific drivers contributing directly or indirectly towards the pain or pathology in injury management
2. To screen for changes in hip joint mechanics for injury prevention
3. To inform targeted treatment for pain modulation and functional restoration

 

Identifying Drivers

From years of personal experience, I believe there are four main movement drivers which contribute toward hip pain. These are deep anterior, rotational, lateral compression, and segmental. When applying this to treatment, I find it relatively easy to change the pain with the specified manipulative techniques and can have a long lasting effect when combined with specific motor control exercises. This can be a great treatment tool, but also a screening tool for ‘fit’ players to identify periodic changes in their joint function in correlation to training load and prescribe preventative interventions.

Changes in muscle synergy, muscle tension and capsule thickening can alter resultant hip vectors. Cumulative load over time accompanied with suboptimal hip orientation can result in progressive joint damage (Grimaldi et al, 2009). Similarly, acute episodes of hip joint damage can be caused by acute spikes in load which change hip biomechanics. Fortunately, when drawing from experience, can often be reversible with early detection and optimised treatment.

Deep anterior:

Tension in the iliofemoral ligament and thickening of anterior capsule have been shown to increase pain and reduce range in FAI patients. These features can contribute towards the development of CAM deformities (Shaw et al, 2022). Iliopsoas related pathology can present as anterior hip pain, commonly reported subjectively as sharp, pinching or catching.

Rotational:

Microtrauma overtime, caused by a combination of altered length tension relationship and functional instability, arise from changes in function of the deep hip muscles. These muscles are typically gluteus medius, piriformis, gemelli and the obturators which can all drive the development of intraarticular hip pathologies (Meinders et al, 2022).

Lateral compression:

The prime action of the TFL is abduction, it is also an internal rotator and under tension can increase innominate anterior tilt (Selkowitz et al, 2013). Overactivity of the TFL can narrow the anterior joint space of the hip. Studies have also shown that atrophy of the gluteus maximus in comparison to the TFL can cause hip degeneration (Grimaldi et al, 2009).

Segmental:

Biomechanically speaking, anterior tilt of the pelvis restricts hip flexion and rotation range. It has been shown that whilst symptomatic FAI individuals possess less posterior tilt, there are arguments for both sides whether that is a cause or a consequence (Azevedo et al, 2016). Treatments targeting posterior tilt often improve hip range and eases symptoms which have been shown to be effective for CAM morphology demographic (Aminoff et al, 2018).

Modification procedure

 *Compare to the asymptomatic side or the patient’s baseline data

Deep anterior:

1. Perform the passive hip flexion test, if range is reduced* or the test provokes symptoms, perform a hip anterior-posterior distraction manipulative technique

VIDEO 1 - Manipulative technique for deep anterior component

Improvement in range or symptoms suggests deep anterior contribution

Rotational:

1. Perform the passive hip internal rotation/external rotation test, if range is reduced* or the test provokes symptoms, perform a hip anterior-posterior compressive technique in hip flexion, adduction and external rotation

VIDEO 2 - Manipulative technique for rotational component

Improvement in range or symptoms suggests rotational contribution

Lateral compression:

1. Perform the Obers test, if the test shows positive or the adduction range is reduced*, perform TFL and upper fiber glute max release technique

VIDEO 3 – Tissue release technique for TFL

Improvement in range or symptoms guides suggests lateral compression contribution

Segmental:

1. Perform a passive hip flexion test and apply over pressure, if pelvic posterior tilt is restricting or contributing to hip flexion symptoms, perform an innominate posterior tilt manipulative technique

VIDEO 4 – Manipulative technique for segmental component

Improvement in range or symptoms guides suggests segmental contribution

 

Movement strategies

For each identified driver, prescription of targeted motor control exercises allow specific motor adaptation to happen. Studies on movement have highlighted the importance of both having movement variation and optimal movement strategies in sport (King et al, 2018; Blandford et al, 2018; Bramah et al, 2024). This can also apply in rehabilitation settings to provide a more holistic approach to optimise movement strategies upon return to sport.

Understanding the four aforementioned pain drivers, below are some examples of exercises for each driver. By selecting simple and familiar movements for the athlete, the aim is to reduce the demand of new motor skills so they can focus on the targeted motor control element we want them to train.

Summary

This simplified framework can hopefully provide an example of a stepwise approach for efficient pain modulation and functional restoration. The aim is to encourage discussion around different options of injury prevention and management when considering management of the pathological hip.

References

Swärd Aminoff, A., Agnvall, C., Todd, C., Jónasson, P., Sansone, M., Thoreson, O., Swärd, L., Karlsson, J. and Baranto, A., 2018. The effect of pelvic tilt and cam on hip range of motion in young elite skiers and nonathletes. Open Access Journal of Sports Medicine, pp.147-156.

Azevedo, D.C., Paiva, E.B., Lopes, A.M.A., Santos, H.D.O., Carneiro, R.L., Rodrigues, A.S., De Andrade, M.A.P., Novais, E.N. and Van Dillen, L.R., 2016. Pelvic rotation in femoroacetabular impingement is decreased compared to other symptomatic hip conditions. journal of orthopaedic & sports physical therapy, 46(11), pp.957-964.

Bialosky, J.E., Beneciuk, J.M., Bishop, M.D., Coronado, R.A., Penza, C.W., Simon, C.B. and George, S.Z., 2018. Unraveling the mechanisms of manual therapy: modeling an approach. Journal of orthopaedic & sports physical therapy, 48(1), pp.8-18.

Blandford, L., McNeill, W. and Charvet, I., 2018. Can we spread the risk? A demand-share perspective to sustained hamstring health. Journal of Bodywork and Movement Therapies, 22(3), pp.766-779.

Bramah, C., Mendiguchia, J., Dos’ Santos, T. and Morin, J.B., 2024. Exploring the role of sprint biomechanics in hamstring strain injuries: a current opinion on existing concepts and evidence. Sports Medicine, 54(4), pp.783-793.

Brantingham, J.W., Bonnefin, D., Perle, S.M., Cassa, T.K., Globe, G., Pribicevic, M., Hicks, M. and Korporaal, C., 2012. Manipulative therapy for lower extremity conditions: update of a literature review. Journal of manipulative and physiological therapeutics, 35(2), pp.127-166.

Grimaldi, A., Richardson, C., Durbridge, G., Donnelly, W., Darnell, R. and Hides, J., 2009. The association between degenerative hip joint pathology and size of the gluteus maximus and tensor fascia lata muscles. Manual therapy, 14(6), pp.611-617.

King, E., Franklyn-Miller, A., Richter, C., O’Reilly, E., Doolan, M., Moran, K., Strike, S. and Falvey, É., 2018. Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients. British journal of sports medicine, 52(16), pp.1054-1062.

Lewis, J.S., McCreesh, K., Barratt, E., Hegedus, E.J. and Sim, J., 2016. Inter-rater reliability of the Shoulder Symptom Modification Procedure in people with shoulder pain. BMJ Open Sport & Exercise Medicine, 2(1), p.e000181.

Locks, R., Utsunomiya, H., Briggs, K.K., McNamara, S., Chahla, J. and Philippon, M.J., 2018. Return to play after hip arthroscopic surgery for femoroacetabular impingement in professional soccer players. The American Journal of Sports Medicine, 46(2), pp.273-279.

Ludewig, P.M., Saini, G., Hellem, A., Kahnert, E.K., Rezvanifar, S.C., Braman, J.P., Staker, J.L. Changing our Diagnostic Paradigm Part II: Movement System Diagnostic Classification, 2022. Int J Sports Phys Ther. 17(1):7-17.

Reiman, M.P., Goode, A.P., Cook, C.E., Hølmich, P. and Thorborg, K., 2012. Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis. British journal of sports medicine, 49(12), pp.811-811.

Selkowitz, D.M., Beneck, G.J. and Powers, C.M., 2013. Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. journal of orthopaedic & sports physical therapy, 43(2), pp.54-64.