Diagnostics of Femoroacetabular Impingement and Labral Pathology of the Hip: A Systematic Review of the Accuracy and Validity of Physical Tests

doi:10.1016/j.arthro.2011.12.004

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 28, Issue 6, June 2012, Pages 860-871

https://doi.org/10.1016/j.arthro.2011.12.004 Get rights and content

Purpose

Femoroacetabular impingement (FAI) and labral pathology have been recognized as causative factors for hip pain. The clinical diagnosis is now 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. The purpose of this systematic review was to identify the diagnostic accuracy and validity of physical tests that are used to assess FAI and labral pathology of the hip joint.

Methods

We performed a computerized literature search using PubMed, Medline, Web of Science, PEDro, the Cochrane Library, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) (through EBSCO). Studies describing tests and diagnostic accuracy studies were included. All included studies were assessed by the Levels of Evidence for Primary Research Questions list. All diagnostic accuracy studies were assessed by the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) score.

Results

We included 21 studies 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. All articles describing tests had Level IV or V evidence. All diagnostic accuracy studies, except 1, had Level II or III evidence. Three articles had a good QUADAS score.

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.

Level of Evidence

Level III, systematic review of Level III studies.

Section snippets

Methods

The objective of this study was to identify (1) which physical diagnostic tests are used to assess intra-articular hip pathology, especially FAI and labral pathology; (2) the diagnostic accuracy and validity of these tests; and (3) the quality of the diagnostic accuracy studies describing these tests.

Results

The search identified a total of 307 studies. Based on the title and abstract, 245 studies were excluded. There were 16 doubles, and 25 studies were excluded based on full-text assessment, which left a total of 21 studies to be included (Fig 1). Of these studies, 7 described tests for diagnosing FAI and/or labral pathology and 14 focused on diagnostic accuracy. There were minor disagreements between reviewers regarding inclusion of studies, but consensus was reached in all cases.

Discussion

This review identified 21 studies describing 18 physical diagnostic tests for the assessment of FAI and/or labral pathology of the hip joint. Of the studies, 7 gave a description of these tests and 14 were diagnostic accuracy studies. Many physical tests were the objective of previous studies, but results show that there was a lack of diagnostic accuracy parameters or these parameters had poor values. This was supported by our finding that based on the QUADAS score, only 3 of 14 diagnostic

Conclusions

There exists a wide range of physical diagnostic tests for FAI and/or labral pathology and little information on the diagnostic accuracy and validity. The methodologic quality of the diagnostic accuracy studies is moderate to poor. Uniformity in test executions is warranted, and these should be thoroughly investigated for diagnostic accuracy and validity. For now, no (combination of) physical diagnostic tests are available that can reliably confirm or discard the diagnoses of FAI and/or labral

References (41)

R.L. Martin et al.
The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates
Arthroscopy
(2008)
L.M. Tibor et al.
Differential diagnosis of pain around the hip joint
Arthroscopy
(2008)
B.A. Levy et al.
Screening for femoroacetabular impingement in asymptomatic adolescent athletes
Arthroscopy
(2011)
P.J. Singh et al.
The outcome of hip arthroscopy in Australian football league players: A review of 27 hips
Arthroscopy
(2010)
J.W.T. Byrd et al.
Hip arthroscopy for labral pathology: Prospective analysis with 10-year follow-up
Arthroscopy
(2009)
J.W.T. Byrd et al.
Arthroscopic management of femoroacetabular impingement: Minimum 2-year follow-up
Arthroscopy
(2011)
J.W.T. Byrd
Hip arthroscopy: Surgical indications
Arthroscopy
(2006)
C.M. Larson et al.
Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement
Arthroscopy
(2009)
I.B. Botser et al.
Open surgical dislocation versus arthroscopy for femoroacetabular impingement: A comparison of clinical outcomes
Arthroscopy
(2011)
N. Awan et al.
Role of hip arthroscopy in the diagnosis and treatment of hip joint pathology
Arthroscopy
(2006)

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A Layered Approach to the History and Physical Exam of the Athlete's Hip
2024, Operative Techniques in Sports Medicine
Hip pathology is a common source of pain and dysfunction in athletes. Taking a layered approach to the history and physical examination of the athlete's hip is imperative to deciphering the vast differential diagnoses for an athlete's hip pain. Systematic evaluation of the (1) osteochondral, (2) capsulolabral, (3) musculotendinous, (4) neurovascular, and (5) kinematic chain layers of the hip allow for the comprehensive consideration of hip pain etiologies, including femoroacetabular impingement syndrome, labral tears, osteoarthritis, Coxa Saltans, hamstring and gluteal tendinopathy, and sacroiliac joint dysfunction, among numerous other conditions. A thorough history, including the location, acuity, quality, radiation, and sport-specific limitations of the hip pain, followed by a methodologic physical examination, with ordered inspection, gait, palpation, range of motion, strength testing, and provocative maneuvers, allows clinicians to arrive at an early and accurate diagnosis of hip pain. Only after a thorough history and physical examination can more specific diagnostic and therapeutic modalities be applied.
Cam-Type Impingement: Ensuring an Ideal Femoroplasty
2024, Operative Techniques in Sports Medicine
When conservative measures have failed, arthroscopic femoroplasty has proven highly efficacious in treating femoroacetabular impingement (FAI) and improving hip joint mechanics. It is best to approach this in a systematic manner with preoperative planning and intraoperative confirmation. Plain radiographs, MRI and/or CT are helpful in the preoperative assessment in identifying the location and shape of the cam deformity. Understanding the extent of the cam lesion prior to surgical intervention will aid in the resection process. The resection can then be confirmed by an intra-operative fluoroscopic exam and arthroscopic dynamic motion evaluation under direct visualization. Using the trough technique, the resection can be marked using the cortical-cancellous border as a depth landmark. When performing the resection, a smooth contour should be performed, with an understanding that both over and under-resection can be problematic. Adequate resection should be ensured by testing range of motion, with fluoroscopic imaging, to obtain a circumferential view of the resected area. It is essential to understand how to position the lower extremity to obtain different fluoroscopic views of the femoral head-neck junction clock-face. Once complete, a thorough irrigation of the joint should be performed to remove bony debris. An ensuing capsular closure should be performed to minimize the risk of iatrogenic hip instability.
Ilio-femoral ligament strains during the flexion-abduction-external rotation test: A cadaveric study
2023, Clinical Biomechanics
Flexion-abduction-external-rotation (FABER) test is one of the most used tests during the clinical assessment of the hip joint. The limited range of motions reached could be due to iliofemoral ligament tightness, but no study has assessed capsular ligament strain during this test. The main objective of this study is to report strains within the iliofemoral ligament during the FABER test using a segmental approach.
9 hips were harvested, and all muscles were removed. Hemispherical markers (∅ 2.6 mm) were glued on the lateral and medial borders of both the medial and lateral iliofemoral bands, separating each border into proximal, mid, and distal portions. The lower limb was placed in a FABER test position. A laser scanner allowed to digitize the 3D surface of the capsule. A Kruskal-Wallis test was performed to assess the effect of ligaments, borders, and portions.
The lateral band of the iliofemoral ligament showed greater strains (14.6 ± 11.4%) compared to the medial band (−8.7 ± 14.2%) (p < 0.001). The greatest strains were observed in the distal portion of the lateral border of the lateral band (51.1 ± 21.5%). A decrease in strain was observed in the mid-portion of the medial border of the medial iliofemoral ligament (−27.9 ± 8.9%).
The FABER test is used to assess pain at the hip. Our results show that the limited range of motion at the hip during this test might be caused by increased strains in the lateral band. These results demonstrate that a limitation of joint range of motion during the FABER could be due to an excessive tension of the lateral band of the iliofemoral ligament.
Intracapsular pressures in the flexion-abduction-external rotation and flexion-adduction-internal rotation tests and their comparison with classic hip range of motion: A cadaveric assessment
2022, Clinical Biomechanics
Background
Flexion-Abduction-External-Rotation and Flexion-Adduction-Internal-Rotation tests are used to reproduce pain at the hip during clinical assessment. As pain can be elicited by high intracapsular pressure, no information has been provided regarding intracapsular pressure during these pain provocative tests.
Methods
Eight hip joints from four cadaveric specimens (78.5 ± 7.9 years) were assessed using intra-osseous tunnels reaching the lateral and acetabular compartments. To simulate synovial liquid, 2.7 ml of liquid were inserted in both compartments using adaptor injectors. Optic pressure transducers were used to measure pressure variations. Pressures were compared between compartments in each test and between tests for each compartment. Both tests were compared with uniplanar movements.
Findings
The Flexion-Adduction-Internal-Rotation test showed a significant difference between pressure measured in the lateral (27.17 ± 42.63 mmHg) and acetabular compartment (−26.80 ± 29.26 mmHg) (P < 0.006). The pressure measured in the lateral compartment during the Flexion-Adduction-Internal-Rotation test (27.17 ± 42.63 mmHg) was significantly higher than in the Flexion-Abduction-External-Rotation test (−8.09 ± 15.09 mmHg) (P < 0.010). The pressure measured in the lateral compartment in the Flexion-Abduction-External-Rotation test was significantly lower than during internal rotation (P = 0.011) and extension (P = 0.006).
Interpretation
High intracapsular pressure is correlated with greater pain at the hip. Clinicians should assess pain with caution during the Flexion-Adduction-Internal-Rotation test as this test showed high intracapsular pressures in the lateral compartment. The Flexion-Abduction-External-Rotation is not influenced by high intra-capsular pressures.
Influence of Standardized Procedures on the Reliability of Hip Clinical Assessment
2021, Journal of Manipulative and Physiological Therapeutics
Citation Excerpt :
The internal rotation between the starting and ending positions was termed IRROM. For the C condition, the FADIR test procedure was slightly adapted from previous studies.2,18 Usually, the FADIR test is performed in 1 movement.
This study evaluated a standardized and personalized approach to verify the effects of conditions on intrarater and interrater reliability, standard error of measurement, and minimal detectable difference for provocative tests and range-of-motion (ROM) tests used in hip pain assessment: flexion-adduction-internal rotation (FADIR), flexion-abduction-external rotation-extension (FABER), and hip internal rotation with 90° of hip flexion (hip IR).
Nineteen participants (mean [± SD] age = 24 ± 2 years; 10 women and 9 men) without lower limb or back pain were recruited. Three raters evaluated each participant during 2 testing sessions, 1 day apart. Raters performed the 3 tests in 4 conditions: classic (C), controlled pressure duration (CPD), subject-specific position (SSP), and mixed (M = CPD + SSP).
For intrarater reliability, the CPD condition showed the highest intraclass correlation coefficients (ICCs; mean and 95% confidence interval [CI]) for hip IR_ROM (0.83; 95% CI, 0.53-0.94) and FADIR_ROM (0.75; 95% CI, 0.60-0.89). The SSP condition showed the highest ICCs for FABER_height (0.71; 95% CI, 0.42-0.87) and FABER_ROM (0.62; 95% CI, 0.27-0.83). Concerning interrater reliability, the classic condition presented the highest ICCs for FABER variables (height: 0.54; 95% CI, 0.28-0.76; ROM: 0.58; 95% CI, 0.32-0.79) and hip IR ROM (0.72; 95% CI, 0.51-0.87). The CPD condition showed the highest ICC for FADIR_ROM (0.57; 95% CI, 0.32-0.78).
In the conditions of this study, CPD showed the highest ICCs for hip IR_ROM and FADIR_ROM, and SSP showed the highest ICCs for FABER_height and FABER_ROM.
Quantification and Reliability of Hip Internal Rotation and the FADIR Test in Supine Position Using a Smartphone Application in an Asymptomatic Population
2020, Journal of Manipulative and Physiological Therapeutics
Citation Excerpt :
In a clinical setting, the assessor can easily retain the starting position and write it down after the testing procedure. Execution of the FADIR test was slightly adapted from a previous study.13,14 Usually performed in 1 movement, the FADIR was sequenced in 3 successive steps in order to standardize the testing protocol.
The purpose of this study was to quantify and report the intrarater and interrater reliability of hip internal rotation (IR) range of motion supine with the hip and knee at 90° of flexion and for the flexion-adduction-internal rotation (FADIR) test. Hip internal rotation measured in a lying supine position with the hip and knee at 90° of flexion revealed information on hip impairments. To date no simple quantification approach has been presented in this position; therefore, the FADIR test has not been quantified yet.
Twenty participants (mean ± standard deviation [SD] age, 24.0 ± 2.1 years; 10 women and 10 men) without lower-limb or back pain were recruited. Three raters evaluated each participant during 2 testing sessions, 1 day apart. A built-in smartphone compass application was used to obtain the hip IR range of motion in both procedures.
Mean (± SD) supine IR was 51.7° (± 9.7°) and 62.6° (± 11.4°) for men and women, respectively. Concerning the FADIR test, mean values were 41.8° (± 9.64°) and 50.1° (± 8.0°) for men and women, respectively. The mean intrarater and interrater reliability coefficients were 0.80 and 0.72 for hip IR and 0.75 and 0.40 for the FADIR test. The standard error of the mean ranged from 4.8° to 8.3° (minimal detectable difference [MDD], 13.3° to 22.9°) for hip IR and from 4.6° to 10.3° (MDD, 12.8° to 28.6°) for the FADIR test.
Overall, the smartphone compass application is adequate to quantify hip IR in a lying supine position. However, the poor to moderate interrater reliability in the FADIR test and the size of the MDD values suggest that the FADIR test should be standardized.

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: The authors report that they have no conflicts of interest in the authorship and publication of this article.

Note: To access the video accompanying this report, visit the June issue of Arthroscopy at www.arthroscopyjournal.org.

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Systematic Review With Video IllustrationDiagnostics of Femoroacetabular Impingement and Labral Pathology of the Hip: A Systematic Review of the Accuracy and Validity of Physical Tests

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Methods

Results

Discussion

Conclusions

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Man Ther

Arthroscopy

Arthroscopy

Arthroscopy

Clin Sports Med

Clin Sports Med

Clin Sports Med

Arthroscopy

PM R

Systematic Review With Video Illustration
Diagnostics of Femoroacetabular Impingement and Labral Pathology of the Hip: A Systematic Review of the Accuracy and Validity of Physical Tests