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Editorial Commentary: When Gluteal Strengthening Fails, Hip Femoroacetabular Impingement Correction Is the Ultimate Physical Therapy

      Abstract

      Gluteal strength improvement is positively correlated with improved outcomes following hip arthroscopy femoroacetabular impingement correction. Arthroscopic femoroacetabular impingement surgery in itself also is correlated with postoperative improvement in gluteal strength. A trial of physical therapy or best conservative care can improve gluteal strength; however, oftentimes this is insufficient treatment. Hip arthroscopy can improve pain and function whilst also improving gluteal strength. When this is conveyed to patients, the additional knowledge can help them buy-in to their treatment regimen.
      What can I do to improve my hip FAI condition? I get this question from patients all the time. I commonly recommend core/gluteal strengthening through physical therapy, Pilates, or home exercises. While some patients embrace this approach, others are reticent. Will strengthening my hip muscles really help? The study by Yang, Mamtimin, Duan, Sun, Xu, Zhang, Zheng, Fan Huang, and Wang, “Volume of Gluteus Maximus and Minimus Increases After Hip Arthroscopy for Femoroacetabular Impingement Syndrome,” shows that hip arthroscopy femoroacetabular impingement (FAI) correction improves gluteal strength and that this improvement in gluteal strength (as measured by muscular volume) is positively correlated with improved function and decreased pain.
      • Yang F.
      • Mamtimin M.
      • Duan Y.
      • et al.
      Volume of gluteus maximus and minimus increases after hip arthroscopy for femoroacetabular impingement syndrome.
      Even though hip arthroscopy outcomes have definitively been shown to be superior to physical therapy,
      • Griffin D.R.
      • Dickenson E.J.
      • Wall P.D.H.
      • et al.
      Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): A multicenter randomized controlled trial.
      ,
      • Palmer A.J.R.
      • Gupta V.
      • Fernquest S.
      • et al.
      Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: Multicenter randomized controlled trial.
      I typically start treatment with physical therapy, since my assessment of the risk/benefit ratio of treatment usually favors physical therapy initially. My patients are smart (and if any of my patients are reading this, they are also charming, generous, and kind to small children). They want to know WHY physical therapy can help. Malloy et al.
      • Malloy P.
      • Stone A.V.
      • Kunze K.N.
      • et al.
      Patients with unilateral femoroacetabular impingement syndrome have asymmetrical hip muscle cross-sectional area and compensatory muscle changes associated with preoperative pain level.
      showed decreased cross-sectional area of gluteal musculature corresponds to symptoms of hip pain; conversely, Yang et al.’s study clearly demonstrates improvement in outcomes are correlated with improvement in gluteal strength. The answer to why physical therapy can help is that it is possible for some patients to “fake it till they make it,” ie, improve function and decrease pain enough by improving gluteal strength and skipping surgical FAI correction.
      We can consider hip arthroscopy as “the ultimate physical therapy aid” for patients who are unable to adequately improve gluteal strength and for whom compensation for their hip can improve as a result of hip arthroscopy FAI correction. Motivating our patients to work hard in physical therapy after surgery helps to improve their surgical outcomes, since increased exercise will increase their muscle mass and likely improve their end result.
      Draovitch et al.
      • Draovitch P.
      • Edelstein J.
      • Kelly B.T.
      The layer concept: Utilization in determining the pain generators, pathology and how structure determines treatment.
      eloquently described the different layers associated with hip pain, from the joint to the musculotendinous and neural layers. Looking at outcomes of hip arthroscopy in the context of the joint alone is incomplete; affecting one hip level also can positively affect other levels. Giving our patients a reasoned narrative on how treatment may help can encourage them to be a partner in their treatment regimen and ultimately help you help them.

      Supplementary Data

      References

        • Yang F.
        • Mamtimin M.
        • Duan Y.
        • et al.
        Volume of gluteus maximus and minimus increases after hip arthroscopy for femoroacetabular impingement syndrome.
        Arthroscopy. 2021; 37: 862-870
        • Griffin D.R.
        • Dickenson E.J.
        • Wall P.D.H.
        • et al.
        Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): A multicenter randomized controlled trial.
        Lancet. 2018; 391: 2225-2235
        • Palmer A.J.R.
        • Gupta V.
        • Fernquest S.
        • et al.
        Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: Multicenter randomized controlled trial.
        BMJ. 2019; 364: 1185
        • Malloy P.
        • Stone A.V.
        • Kunze K.N.
        • et al.
        Patients with unilateral femoroacetabular impingement syndrome have asymmetrical hip muscle cross-sectional area and compensatory muscle changes associated with preoperative pain level.
        Arthroscopy. 2019; 35: 1445-1453
        • Draovitch P.
        • Edelstein J.
        • Kelly B.T.
        The layer concept: Utilization in determining the pain generators, pathology and how structure determines treatment.
        Curr Rev Musculoskelet Med. 2012; 5: 1-8