The following testimonial comes to us from Karen Dys, PTA. Karen recently attended the Care of the Pregnant Patient course, and she was inspired to send in the following review. Thanks for your contribution, Karen!

I have been working as a physical therapist assistant for 11 years and worked in a variety of settings. In the past two year I have become more focused on pelvic floor rehabilitation. During that time frame I have had a handful of pregnancy patient including being a pregnant woman myself. Since taking this course, my mind has been opened up of how I can treat my patients and educate them for their best future outcomes. I also can see now how I would have benefited myself if I knew some of these techniques that I’ve now learned. With knowing with my personal story and that my PT could have helped me more with avoiding bed rest and staying active longer with pregnancy, it has become my goal now to treat my pregnant patients differently. I am thankful for Herman and Wallace courses to gain these wonderful techniques to reach out and help so many people.

Within the first few moments of meeting the teacher at a continue education class I can tell if is going to be a good class or not. This course started out great with a very friendly and kind person. Sarah’s compassion and knowledge brightly shined throughout the weekend of teaching. It was very refreshing having a teacher who also has experienced some of the same problems are patients go through. It gave it a good personal perspective of how we can affect our patient outcomes.

One thing that I really appreciated at this course was the comfort level felt during the entire weekend. Right from the beginning Sarah made it clear that no question was stupid to ask. She explained that we are all at different learning stages in our career and that we are working together to gain this knowledge to be better therapists. I really appreciated hearing that and I know it made some of the new pelvic floor therapists feel more comfortable as well. I enjoyed having different labs throughout the weekend to practice these new techniques with new therapists of different educational levels. Sometimes I attend courses being more confused on techniques because the teacher, assistant or other course mates don’t have the time or knowledge to explain in further detail. At any of my Herman and Wallace courses I have attended, especially this one, I have not felt that way.

So I attended this wonderful class and now what? Well during the class I was thinking of my pregnant friends who are expecting multiples and how I can help them with their already felt extra swelling and low back pain. I also was thinking of some of my post-partum pelvic floor patients and how if I would have known some of this information sooner I could have impacted their pregnancy. Some things I would have changed were compression stock wear, abdominal binder/ brace wear, labor positioning techniques and strengthening more with education for post-partum phase. So now I have brought back to my company more knowledge of how to evaluate, assess more correctly and treat pregnancy patients. I have led a in-service for my coworkers who are primarily orthopedic based . They had a good take away of how to help patients with orthopedic complaints of pain who also happen to be pregnant.

I am thankful for this course I attended and look forward to making it a regular event I attend. Herman and Wallace courses never disappoint. Thank you.

Karen R Dys, PTA

Jennafer Vande Vegte, PT, BCB-PMD, PRPC is a H&W faculty member and one of the developers of the advanced Pelvic Floor Capstone course. In this guest post, she reflects on her own clinical and personal experience that informed her work on this advanced course, and her approach with patients.

Most days I feel like I am on a journey. Some days I make big strides forward, other days I might fall back. But I am always learning, and eventually I hope to grow. I think it is much the same for our patients. And also for ourselves.

My youngest daughter was diagnosed with eczema, allergies (food and others) and asthma at an early age. In my hubris I felt if I could learn all I could about what was going on in her body I could "fix" her. So began a journey that took me outside the realm of traditional medicine into holistic care. I learned so much! My daughter got a lot healthier. The rest of my family got a lot healthier. I got healthier too. And I began to recognize patients in my practice that needed more holistic care. Guess what, they got healthier too.

When she was in first grade she was diagnosed with ADHD. I retraced the steps of my previous journey that had helped her so much with her allergies, eczema and asthma. But ADHD proved to be resistant to diet , supplements, and homeopathy. We visited an OT and got some good suggestions. A family therapist helped us a ton as parents, but I'm not sure how much he helped my daughter. We tried Ritalin to no avail. Energy therapy and essential oils followed before I finally made an appointment with a ADHD child specialist MD. We will see where that step leads. Why

Why am I telling you all this you may ask? Because I realized that my journey with my daughter is very much like our journey walking next to our patients with chronic pain. They/we may try so many things trying to find the "fix" to make their pain go away. As we grow on our own life journeys and experiences and we add quality clinical tools to our toolboxes we very well may be able to help more people experience freedom from pain, improvements in function, and meeting their goals. But there will be always still be those that we feel like we didn't help. Don't despair dear friends. Every person we have come in contact with in the quest to better equip and understand my daughter's mental and physical health has been a wealth of information, inspiration, and resources. Some things I learned some years ago (essential oils for example) and only now am putting into practice. I wasn't ready before but I am now! I realized that there is a similar dynamic for our patients. We may help them take just one step forward. We may walk a whole journey to healing beside them, or we may never know what the impact of our treatment had on them. But in the end we both end up exactly where we needed to be.

Insignia Health developed the PAM (Patient Activation Measure) Survey (http://www.insigniahealth.com/products/pam-survey) to help heath care providers determine where along the pathway of activation of self care a patient falls. What is interesting about the tool is that a single point increase correlates to a 2% decrease in hospitalization and a 2% increase in medication adherence. The science behind the PAM shows that helping our patients to move forward just one step can have a profound influence on their health. The trick is meeting them where they are at.

Pelvic Floor Capstone was a joy to develop with Nari Clemons and Allison Arial. Our goal was to equip you to take one more step in your learning journey in pelvic health. We delve into intense topics like endocrine disorders, pelvic surgery, gynecological cancer, nutrition and pharmacology. Labs are focused on evaluating and treating myofascial restrictions utilizing a gentle, indirect three dimensional system that invites the brain to reconnect with connective tissue in a safe way for powerful change. We would love to see you at Capstone and hear your stories later on how our time together empowered you to help your patients take one more step.

The following is the first in a three-part blog series which chronicles the peripartum journey of Rachel Kilgore.

I. Pregnancy

In April, I had my first child, a sweet and healthy baby girl. Reflecting on the last year, what a ride! I have had many of my friends, family members, patients, and acquaintances discuss the journey and challenges of motherhood with me, however, experiencing it first hand was a memorable voyage. I thought I was very prepared and knew what I was getting into, but as usual, nothing compares to first-hand knowledge and experience. From an academic standpoint, I had done my research on everything from conception, what to expect each trimester of pregnancy, and reviewed the many options for labor and delivery. I even was lucky enough to assist in the Herman and Wallace Care for the Post-Partum Patient course with Holly Tanner while I was pregnant! As a practitioner, I love treating pregnant and post-partum patients, it is one of my favorite populations to treat. I love helping these strong, motivated women with pain relief and to teach them management skills to adapt to a new lifestyle and a changed body that has unique musculoskeletal needs.

First Trimester: Information, Nausea, and Fatigue

I had always had a preconceived notion that I would exercise diligently and eat super healthy through my pregnancy. After all, that was how my lifestyle was before pregnancy, why should it change? That lasted about 6 weeks, until 24-hour episodes of nausea and vomiting overwhelmed me, which continued until the start of the second trimester. I basically just tried to make it through the day without vomiting at work, and would go straight to bed whenever I had the chance. I even had to miss several days of work! I thought it was termed “morning sickness” implying that it went away after morning, but apparently it should be renamed to “forever nausea” as that is what it felt like at the time. Because of the nausea, I wanted nothing to do with food, which in turn lead to constant concern about the baby not getting enough nourishment. Of course, my regular activity levels plummeted. In addition to nausea was constant fear of miscarriage and whether my regular activities were somehow harmful to my baby. Instead of ice cream and pickles, I craved information. What should I be doing, and what should I not be doing?

Second Trimester: Return of Energy, Excitement, Planning and Doing!

When the first day of the second trimester hit, the nausea just went away. I was ecstatic! I got my energy back and was finally enjoying the pregnancy again! I was able to exercise regularly and eat healthy, two of my favorite things. Everything was going well, and it was time to start figuring out this whole baby thing. Luckily, most of my friends are mothers themselves, and they helped guide me. They directed me to great resources to satisfy my quest for knowledge about everything I needed to know for pregnancy, labor delivery, and the baby itself. They helped me decipher what all these baby products were, and what do you actually need. All the fun stuff was happening! We painted the baby’s room, ordered furniture, and planned a baby shower.

Third trimester: Waiting, Exhaustion, Heart Burn, and Reduced Mobility

Everything that happens to my patients happens to me. Third trimester was when I started to really “feel pregnant”. Daily mobility became challenging. I never realized how many times in a workday I show patients correct lifting mechanics or how often I set things on the ground or pick up weights. I started to dread every time I had to pick up something. At work, I would drop my pen on the ground so many times, and why had I never noticed that I did it so often? Luckily, I used my “physical therapy knowledge and skills” and did things I tell my pregnant patients to do; the results were minimal problems with musculoskeletal pain. Techniques such as: Using proper mechanics throughout my day, pulling in my core, and wearing a maternity support if my back was hurting a little. I never really developed severe back pain as is the case for many pregnant women. I completed hip and trunk exercises I usually give my pregnant patients and found they were easy to do and made me feel better... shocking right? Of course I was doing my kegels too! While my musculoskeletal system was doing well, my gastrointestinal system was not. I had never really had heart burn before, but now had it constantly, and found it to be very frustrating and depressing. I love cooking and eating but neither are enjoyable when you have heartburn. The heartburn was so bad it would wake me up every night coughing and chocking on my own acid reflux. Between lack of sleep, heartburn, and reduced mobility, I was getting pretty excited to be done with pregnancy and to finally meet “Baby K” as we had begun calling her. Overall, being pregnant was a very informative experience for me as a person and as a clinician. I often hear my patients tell me of their uncomfortable symptoms during pregnancy involving their musculoskeletal and gastrointestinal systems, however, now I empathize on another level.

Nancy Cullinane PT, MHS, WCS is today's guest blogger. Nancy has been practicing pelvic rehabilitation since 1994 and she is eager to share her knowledge with the medical community at large. Thank you, Nancy, for contributing this excellent article!

Clinically valid research on the efficacy and safety of therapeutic exercise and activities for individuals with osteoporosis or vertebral fractures is scarce, posing barriers for health care providers and patients seeking to utilize exercise as a means to improve function or reduce fracture risk^1,2. However, what evidence does exist strongly supports the use of exercise for the treatment of low Bone Mineral Density (BMD), thoracic kyphosis, and fall risk reduction, three themes that connect repeatedly in the body of literature addressing osteoporosis intervention.

Sinaki et al³ reported that osteoporotic women who participated in a prone back extensor strength exercise routine for 2 years experienced vertebral compression fracture at a 1% rate, while a control group experienced fracture rates of 4%. Back strength was significantly higher in the exercise group and at 10 years, the exercise group had lost 16% of their baseline strength, while the control group had lost 27%. In another study, Hongo correlated decreased back muscle strength with an increased thoracic kyphosis, which is associated with more fractures and less quality of life. Greater spine strength correlated to greater BMD⁴. Likewise, Mika reported that kyphosis deformity was more related to muscle weakness than to reduced BMD⁵. While strength is clearly a priority in choosing therapeutic exercise for this population, fall and fracture prevention is a critical component of treatment for them as well. Liu-Ambrose identified quadricep muscle weakness and balance deficit statistically more likely in an osteoporotic group versus non osteoporotics⁶. In a different study, Liu-Ambrose demonstrated exercise-induced reductions in fall risk that were maintained in older women following three different types of exercise over a six month timeframe. Fall risk was 43% lower in a resistance-exercise training group; 40% lower in a balance training exercise group, and 37% less in a general stretching exercise group⁷.

These studies allow us to unequivocally conclude that spinal extensor strengthening and therapeutic activities aimed at improving balance and decreasing fall risk are tantamount as therapeutic interventions for osteoporosis. But postural education/modification and weight bearing activities aimed at stimulating osteoblast production intended to improve BMD are a reasonable component of an osteoporosis treatment plan, despite the lack of concrete evidence for them. Nutrition and mineral supplementation with calcium and vitamin D have been shown to reduce morbidities, and hence we should incorporate this education into our treatment plans as well^{8, 9}. Studies on the efficacy of vibration platforms hold promise, but thus far, have not been substantiated as an evidence-based intervention to improve BMD.

Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures^1,2 is a multiple-part publication in the journal Osteoporosis International, based upon an international consensus process by expert researchers and clinicians in the osteoporosis field. These publications include exercise and physical activity recommendations for individuals with osteoporosis based upon a separation of patients into to three groups: osteoporosis based on BMD without fracture; osteoporosis with one vertebral fracture; and osteoporosis with multiple spine fractures, hyperkyphosis and pain. This group of experts emphasize the importance of teaching safe performance of ADLs with respect to bodymechanics as a priority to accompany strength, balance, fall & fracture prevention, nutrition and pharmacotherapy management. They promote establishment of an individualized program for each patient with adaptable variations of these concepts, with the most accommodation allotted for individuals with multiple vertebral compression fractures. An example of such an adaptation is altering prone back extensions such as those documented in the studies by Sinaki and Hongo, into supine shoulder presses, thus strengthening the back extensors in a less gravitationally demanding posture. Osteoporosis Canada has adapted the main concepts from these publications into a patient-friendly, instructional website with reproducible handouts at http://www.osteoporosis.ca/osteoporosis-and-you/too-fit-to-fracture/

A firm conclusion from the Too Fit to Fracture project is that higher quality outcomes studies are desperately needed to assist all healthcare providers in managing osteoporosis more effectively and comprehensively, and to do so prior to the onset of debilitating fractures that tend to produce serious comorbidities.

1. Giangregorio et al. Too Fit to Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporosis International. 2014; 25(3): 821-835
2. Giangregorio et al. Too Fit to Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fracture. Osteoporosis International. 2015; 26(3):891-910
3. Sinaki et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone. 2002; 30: 836-841 4. Hongo et al. Effect of low-intensity back exercise on quality of life and back extensor strength in patients with osteoporosis; a randomized controlled trial.Osteoporosis International. 2007; 10: 1389-1395
5. Mika et al. Differences in thoracic kyphosis and in back muscle strength in women with bone loss due to osteoporosis. Spine. 2005; 30(2): 241-246
6. Liu-Ambrose et al. Older women with osteoporosis have increased postural sway and weaker quadriceps strength than counterparts with normal bone mass: overlooked determinants of fracture risk? J Gerontology, Series A Biolog Sci Med Sci. 2003; 58(9): M862-866
7. Liu-Ambrose et al. The beneficial effects of group-based exercise on fall risk profile and physical activity persist 1 year post intervention in older women with low bone mass: follow-up after withdrawal of exercise. J Am Geriat Soc. 2005; 53 (10): 1767-1773
8. Ensrud et al. Weight change and fractures in older women: study of osteoporotic fractures research group. Archives Int Med. 1997; 157 (8): 857-863
9. Kemmler et al. Exercise effects on fitness and bone mineral density in early postmenopausal women: 1-year EFOPS results. Med and Sci in Sports Ex. 2002; 34 (12): 2115-2123

Today's blog is a contribution from Kristen Digwood, DPT, CLT, of the Elite Pelvic Rehab clinic in Wilkes-Barre, PA.

Urgency urinary incontinence (UUI), which is the involuntary loss of urine associated with urgency, is a common health problem in the female population. The effects of UUI result in limitations to daily activity and quality of life.

Current guidelines recommend conservative management as a first-line therapy in urinary incontinence, defined as "interventions that do not involve treatment with drugs or surgery targeted to the type of incontinence".

Electrical stimulation is commonly used as part of a treatment program for women with UUI. There are several methods and parameters that can be used to improve urge incontinence, however the magnitude of the alleged benefits and best parameters is not completely established. Studies have suggested that the use of electrical stimulation to inhibit an overactive bladder functions to modulate unwanted detrusor contractions by way of sensory afferent stimulation of S2 and S3. This causes parasympathetic inhibition.  In addition to this effect, contraction of the pelvic floor muscles results in inhibition and relaxation of the detrusor muscle which reduces urinary urgency.

Common methods of electrical stimulation include suprapubical, transvaginal, sacral and tibial nerves stimulation.

As with any medical treatment, practitioners seek the most effective methods and parameters to achieve the patient’s goals. A recent systematic review of electrical stimulation in the treatment of UUI included nine trials to treat UUI were included with total of 534 female patients. Most patients in the trials were close to 55 years of age. Five articles (total of nine) described a frequency of twice-weekly therapy and sessions of 20 minutes. Twelve weeks was the most common duration of therapy. All the studies applied an intensity of stimulation below 100 mA, with four of them (4/9) using 10 hz as the frequency. Intervaginal electrical stimulation showed the greatest subjective improvement and was the most effective.

The most frequent outcome measure was bladder diary, used in all papers; subjective satisfaction was used in 8; and quality-of-life questionnaires in 6, from a total of 9 papers.

The study noted that reports about electrical stimulation generally lack information on its cost-effectiveness. This is an important point, especially because in therapies with similar benefits cost may be one of the factors to indicate the most appropriate treatment. If we consider the relatively few adverse effects, low cost, and similar effectiveness when compared to medication, intravaginal electrical stimulation, according to available data, appears to be a good alternative treatment for UUI.

1. Thüroff JW, Abrams P, Andersson KE, Artibani W, Chapple CR, Drake MJ, et al.: EAU guidelines on urinary incontinence. Eur Urol. 2011; 59: 387-400.
2. Kralj B. The treatment of female urinary incontinence by functional electrical stimulation. In:Ostergard DR, Dent AD (eds). Urogenecology and Urodynamics. 3rd ed. Baltimore, MD: Williams and Wilkins; 1991.
3. Eriksen, BC. Electrical Stimulation. In: Benson JT editor. Female pelvic floor disorders: investigation and management. New York:Norton, 1992; 219-231.
4. Lucas Schreiner  , Thais Guimarães dos Santos  , Alessandra Borba Anton de Souza, et al. Int. braz j urol. vol.39 no.4 Rio de Janeiro July/Aug. 2013.

Today on the Pelvic Rehab Report, we hear from Dustienne Miller. Dustienne wrote and teaches the Yoga for Pelvic Pain course, which is available in Cleveland, OH on July 18-19, and in Boston, MA on September 12-13.

"It feels like my pelvic floor just sighed."

Grounding in Mountain Pose

As musculoskeletal professionals, we have a sharp eye for postural dysfunction. We explain to our patients that the ribcage is sheared posteriorly to the plumb line and how gravity magnifies forces at specific structures. Some physical therapists perform the Vertical Compression Test (VCT) to allow the patient to feel the difference between their typical habitual posture and a more optimally aligned posture. This works well to “sell” your patients on why their newly aligned posture allows for more efficient weight transfer through the base of support. In addition to the VCT, I utilize Tadasana, or Mountain Pose as an additional kinesthetic approach to postural retraining.

Last week in the clinic, I was teaching my client postural awareness using Tadasana. I asked her to close her eyes, or lower her gaze if she was not comfortable closing her eyes. Working from the ground up, we started bringing awareness to her base of support. She noted that she was standing with her weight mostly in her heels. When I encouraged her to bring her weight forward, hinging from the talocrural joint, she had an “aha moment.” She said, “It feels like my pelvic floor just sighed.” She was unaware that her habitual posture was to stand with her weight mostly posterior to plumb line, thus encouraging her posterior pelvic floor to remain in an overactive state. Once she balanced her body from the ground up, she felt a major release in her holding patterns.

At our follow-up session, the client remarked that her postural awareness increased dramatically. She was surprised at how often her pelvic floor was in a habitual pattern of over-firing. Additionally, she reported increased awareness while practicing standing yoga postures during class. She feels more in control of her body after experiencing embodied optimal alignment and has had success with carrying over postural awareness outside of the clinic setting. Self-awareness and empowerment are two major goals of my physical therapy practice, and using yoga to achieve these goals makes my clinical practice even more enjoyable.

For more info on the Vertical Compression Test, click here. For detailed instruction on Tadasana, click here.

This post was written by H&W instructor Peter Philip, PT, ScD, COMT, PRPC, who authored and instructs the Sacroiliac Joint Evaluation and Treatment course. The next SI Joint course will be taking place this January in Seattle.

Patient one:

55 year old female with complaints of pelvic pain. States that her pain is noted along the deep inguinal region, involving her pubis and labia majora. States that intercourse is difficult, and that she is quite anxious to initiate or participate. She denies trauma, only that she’d been increasing her fitness activities as she’s going to Florida for a winter get-away. She denies changes in her bowel and bladder function, other than intermittent SUI with ‘heavy exercise’.

Clinical testing:

ALROM is negative. During forward flexion there was no reversal of the lordosis.

Segmental myotomal and dermatomal testing is unremarkable.

ASLR and PSLR are negative.

Gillet’s and forward flexion are apparently negative.

There are palpable “marbles” to palpation along bilateral SIJ, and the sacrum is ~40? of nutation.

FABER, FAIR and McCarthy tests are negative. Iliac compression is modestly provocative for patient’s symptoms, while the sacral thigh thrust was provocative for ipsilateral symptom provocation.

While in prone, the patient demonstrated a positive Dead Butt Syndrome bilaterally and there were significant restrictions to fascial rolling throughout the lumbosacral region.

The clinical question is: What to do next? What would you do?

I chose to provide a local traction to each SIJ, followed by a mobilization with movement directed at S3 to promote counter nutation. After treatment, the patient arose from the plinth and remarked that her pain was significantly reduced. On follow up, her pain was 10% that of her initial pain at evaluation.

My questions to you are:

1. What caused her “pelvic pain”?
2. Why did her pain subside? 3. Would you have done an internal evaluation?

These and other questions will be addressed at Sacroiliac Joint and Pelvic Ring Evaluation & Treatment in Seattle, Washington January 25th to the 26th.

This post features an interview with Eric Dinkins, PT, MSPT, OCS, MCTA, CMP, Cert. MT, who will be instructing the brand new course, Manual Therapy for the Lumbo-Pelvic-Hip Complex: Mobilization with Movement including Laser-Guided Feedback for Core Stabilization. Pelvic Rehab Report sat down with Eric to learn a little bit more about his course and his clinical approach

Can you describe the clinical/treatment approach/techniques covered in this continuing education course?

During this two day lab based course, clinicians will learn anatomy, assessment techniques, and manual therapy techniques that are designed to minimize pain and restore function immediately. As a bonus, clinicians will be introduced to stabilization exercises utilizing the Motion Guidance visual feedback system for these areas. This system allows for immediate feedback for both the clinician and the patient on determining preferred or substituted movement patterns, and enhancing motor learning to quickly address these patterns if desired.

What inspired you to create this course?

Women's and Men's health patients often have concurrent orthopedic problems that contribute to the pain or dysfunction that they are experiencing in the lumbar spine, pelvis, hips and sexual organs. There are few manual therapy courses offered that are able to bridge a gap between these two topics. This makes for a unique opportunity to offer manual therapy techniques that can address these problems and help improve clinic outcomes.

What resources and research were used when writing this course?

The books and resources I pulled from include:

Mulligan Concept of Manual Therapy 2015

Travell and Simmons Volume 2. Myofascial Pain and Dysfunction: The Trigger Point Manual. The Lower Extremities

Principles of Manual Medicine 4th Edition

www.motionguidance.com

Why should a therapist take this course? How can these skill sets benefit his/ her practice?

PT's, PTA, DO's and DC's should take this course to give them knowledge and manual skills of pain free techniques to offer their Women's Health, Men's Health, and pregnancy patients with orthopedic conditions.

This post was written by H&W instructor Ginger Garner. Ginger will be presenting her Hip Labrum Injuries course in Houston in 2015!

There are two accepted forms of hip impingement currently documented in the literature. The two types are 1) CAM type FAI (femoracetabular impingement) and 2) Pincer type FAI. These two types are found inside the joint, meaning they are considered intra-articular bony anomalies.

FAI is a common comorbidity found with hip labral injury (HLI); and in fact, FAI is a risk factor for HLI. Specifically, FAI is a bony impingement that arises in the femoral head-neck function and the rim of the acetabulum (see photo at right). The two types of FAI also generally occur together more than they do in isolation. However, it is possible that, combined with other issues like acetabular undercoverage or hip instability, CAM or Pincer-type FAI can be found a singular diagnosis.

Surgical Intervention

However, the arena of impingement in the hip is now evolving to consider other locations. In the past 5 years there has been buzz about other types of FAI. They aren’t classically considered FAI issues since this new type of identified impingement occurs outside (extra-articular) the joint. One type newly identified is known as anterior inferior iliac spine/subspinal hip impingement (AIIS). In a 2011 study of 3 case reports, AIIS was found and treated with arthroscopic AIIS decompression with positive results. A more recent 2012 study found excellent results at short-term follow up for surgical decompression of AIIS.

Identification & Diagnosis of AIIS

Both personal and professional experience in the area of AIIS has shown that AIIS is not always discovered on an AP (anterior-posterior) radiograph. However, it is possible to see a larger AIIS on an AP film. Another helpful (but not always definitive) diagnostic test is a CT scan with MRI 3D reconstruction (and no contrast). Bony contrast is more reliable with CT scan than the typically preferred MRA (which is better for soft tissue contrast).

In addition, the rectus femoris (RF) could be implicated in AIIS pathology because the same area receives the proximal attachment of the RF. The same 2011 study reported that the morphology and role of the RF in extra-articular impingement is “not well reported at this time.”

Likewise, the identification of AIIS as a primary driver of pathology in intra-articular hip injury (FAI and/or HLI) is rare. Some cases of AIIS are being found during hip arthroscopy to correct identified existing deficits such as FAI and/or HLI. This means that AIIS may be missed and should be included as a potential mechanism of injury, especially for anterosuperior labral tears in the 2 to 3 o’clock region.

Patients who have AIIS may present like a typical HLI patient, which means they may have a positive Thomas test, FADDIR test, or mechanical symptoms such as popping, clicking, grinding or giving way. It is important to note these signs and symptoms and work in a team approach with surgeons and physical therapists who specialize in hip preservation and reconstruction.

To learn more about nonoperative and operative hip labral and FAI management, check out faculty member Ginger Garner's continuing education course on Extra-Articular Pelvic and Hip Labrum Injury: Differential Diagnosis and Integrative Management. The next opportunity to take the course is March of 2015 in Houston.

This post was written by H&W instructor Ginger Garner. Ginger will be presenting her Hip Labrum Injuries course in Houston in 2015!

One of the easiest ways to determine if someone is in pain is to watch the way they move. And perhaps the most commonly observed and universal movement pattern is gait. From a subtle loss of trunk rotation or pelvic translation to a gross loss of reciprocal gait, a dynamic assessment of walking is a very valuable tool in the physical therapist’s toolbox.

In evaluation of the hip, gait assessment is a critical element of the physical therapy exam. Pain-free ambulation is an essential part of measuring a person’s quality of life (QOL) and is a clinically significant functional outcome measure. Loss of hip extension and knee hyperextension prior to or at heel strike are part of several self-limiting patterns that arise from intra-articular hip injury. Dynamic gait assessment can give the therapist distinct clues as to hip pathophysiology etiology.

It was previously assumed that surgery to correct intra-articular pathology, such as in CAM-based femoracetabular impingement (FAI), would result in correction of deficiencies in gait patterning. CAM FAI limits and creates pain in the direction of hip osteokinematic flexion, adduction, and internal rotation range of motion and is caused by a lack of sphericity of the femoral head and neck, causing impingement of the labrum and/or chondral contact at the acetabulum.

A recent study published in 2013 in Gait and Posture, shows that previous assumptions about gait are incorrect. The study compared the gait of healthy controls to those with FAI and hypothesized that gait abnormalities would resolve status post surgery.

Gait measures were obtained both preoperatively and postoperatively. Researchers were surprised to find that gait abnormalities found presurgically did not automatically resolve postsurgically. Another pertinent finding is that the surgical patients not only retained their old faulty antalgic gait patterns and habits, they also adopted new abnormalities that resulted from surgical intervention, such as those arising from scar tissue, soft tissue pathology, neuromuscular patterning, or loss of arthrokinematic motion in the hip. These findings underscores the importance of early intervention via physical therapy for both operative and nonoperative patients if we want our patients to enjoy or return to a high quality of life.

Although the patients in the study who underwent FAI surgery did demonstrate decreased pain, nonoptimal preoperative gait patterns that persist postoperatively can put these patients at risk for reinjury (e.g. labral retears) or related cobmorbidities like pelvic pain, back pain, or sacroiliac joint dysfunction.

Further, a separate study published in 2009 established the presence of altered hip and pelvic biomechanics during gait, finding that those with hip FAI had decreased peak hip abduction, attenuated pelvic frontal ROM or translation, and less sagittal ROM than controls. Soft tissue restriction including scar tissue from previous or current surgeries, myofascial restriction, or neuromuscular patterning problems are, again, all important variables which must be differentially diagnosed for their possible contribution to the loss of ROM and function. Other considerations that can alter gait pattern and increase injury or reinjury risk assessment of capsular mobility, ligamentous integrity, and sacroiliac joint contributions to limited hip ROM and excursion.

To learn more about nonoperative and operative hip labral and FAI management, check out faculty member Ginger Garner's continuing education course on Extra-Articular Pelvic and Hip Labrum Injury: Differential Diagnosis and Integrative Management. The next opportunity to take the course is March of 2015 in Houston.