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Diagnosis and Treatment of
Femoral Syndromes:
A Movement System
Impairment Approach
Who Am I?
Jill McVey, DPT, ATC
Physical Therapist at Movement Systems
Physical Therapy in Seattle
Athletic Trainer at University of Puget Sound in
Tacoma
Ex-softball player, aspiring roller derby athlete,
handbell ringer, Red Sox fanatic, LP collector...
Who Am I?
*Lead Author, The
Experience of Deep Brain
Stimulation for Individuals
with Parkinson's Disease
Submitted to JNPT 2010
*Lead Author, The Foot and
Ankle chapter of
Therapeutic Exercise:
Moving Toward Function 3
rd
Edition
*Teacher, Foundations in
Movement System Balance
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Who Am I Referencing?
Shirley Sahrmann, PhD, PT, FAPTA
Professor, Physical Therapy, Cell Biology & Physiology
Associate Professor, Neurology
Director, Program in Movement Science
Washington University School of Medicine
Author, Researcher, Teacher, Mentor, Comedienne
Reference Texts
The Movement System
Movement is the action of a physiologic
system that produces motion of the whole
body or of its component parts. It is the
functional interaction of structures that
contribute to the act of moving.
The movement system is in balance when the
elements interact appropriately, producing
variety in specific joint movements and
postures, which allows for movement to be
precise, which leads to good
musculoskeletal health.
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The Movement System
Component Parts
Base: Musculoskeletal elements. The foundation on
which movement is based
Modulator: Neurological. Regulates movement by
controlling the patterns and characteristics of muscle
activation
Biomechanical: Statics and dynamics
Support: Cardiopulmonary and metabolic systems
SO WHAT????
The Kinesiopathologic Model
One or more of the elements is dysfunctional
Impaired interaction of the structures
Movement is nonideal
...and the dysfunction is associated with pain.
As opposed to the pathokinesiologic model
-abnormality of movement is the result of
pathological conditions
MSI Paradigm Assumptions
Repeated movements and prolonged
postures induce tissue changes
contributing to...
-Development of relative flexibility:
the body takes the path of least
resistance for movements
-Development of a joint's directional
susceptibility to movement (DSM)
The direction susceptible to movement
(DSM) is associated with an
accessory motion hypermobility,
the cause of tissue injury and
degeneration.
Musculoskeletal pain is a progressive
condition, associated with
degenerative changes and is
affected by lifestyle.
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Key Concepts
It's all relative...stiffness/flexibility
You get what you train
The presence of a muscle does not mean that is
is being appropriately used.
There is no magic in an exercise except if the
desired motion is evident
The way everyday activities are performed is the
critical issue
Hypermobility is the loss of precise motion--the
loss of normal accessory motion. Hypermobility
leads to degeneration and pain.
Cause vs. Source
Cause: the mechanical factor (movement) that
results in tissue pathology (hip anterior glide
syndrome)
Source: the tissue/structure that is symptomatic
(labral tear). You can't treat a labral tear, but
you can fix the underlying mechanical CAUSE
of the labral tear.
Goals of the MSI Exam
Identify the primary dysfunction: the
compensatory movement that is associated with
the athlete's symptoms
...from history, signs, symptoms, examinations, and tests
Identify factors that are contributing to the
primary dysfunction
The syndrome is therefore named for the
principle impairmentthe movement direction
most consistently affecting the symptoms.
Correction of the dysfunction decreases or
eliminates the symptoms.
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Contributing Factors
**The WAY movement is performed**
The type of activity
Frequency
Duration/intensity
Tissue characteristics (collagen laxity),
anatomical variations
Body proportions (height, weight,
anthropometics)
Path of Instantaneous Center of
Rotation-- PICR
SO WHAT?
The majority of syndromes affecting the hip arise
from impairments in the muscles (recruitment,
length, performance) attaching close to the
proximal femur that control the alignment and
motion of the femur in the acetabulum. This results
in a deviation of the PICR.
The the point around which a
rigid body rotates at a given
instant of time...a critical
concept for assessing
aberrant femoral mechanics
Hip Articulation Anatomy
Acetabular Labrum:
fibrocartilaginous ring
that deepens boney
acetabulum.
Maintains negative intra-
articular pressure
*Free nerve endings
(nociception,
proprioception)
Highly vascularlized
Thinner anteriorly; absent
over inferior acetabulum
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Ligamentous Support
Anterior Posterior
Femoral Head, Structural
Variations
Angle of inclination:
angle between the
femoral shaft and
femoral neck (normal
= 125 degrees)
Coxa vara (seen with genu valgum): <125. Increases the
moment arm of hip abductors so one requires decreased mm
strength, but this increases the bending moment at the
femoral neck.
Coxa valga (seen with genu varum): >125. Increases the
subluxation risk; requires really strong abductors. The athlete
will want to accommodate their typically longer hip
abductors by standing in adduction.
Femoral Head, Structural
Variations
Angle of declination:
angle of femoral
head in the transverse
plane (normal = 12-
15 degrees)
Excessive anteversion directs the femoral head towards the
anterior aspect of the acetabulum when the femoral condyles
are aligned in their normal orientation. This allows for a
greater excursion of femoral MR relative to LR.
Be careful interpreting MR/LR ratio as indication of
anteversion or retroversion.
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Acetabular variations
Femoral head-neck proportions
Cam impingement:
abnormal femoral head-
neck junction is driven
into the acetabulum
during flexion/MR
Pincer impingement:
normal femoral neck
impinges against an
overhanging
anterosuperior
acetabulum
Muscular Control of the Hip
Flexors:
TFL
Sartorius
Rectus femoris
Iliopsoas**
Muscular Control of the Hip
Extensors:
Gluteus maximus, medius,
minimus
Piriformis (weak)
Hamstrings
Lateral rotators:
Gemilli, obturators,
piriformis, quadratus
femoris, portions of
gluteals (posterior
medius)
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Muscular Control of the Hip
Abductors:
Gluteus medius, minimus,
upper fibers of maximus
Adductors:
magnus, longus, brevis,
pectineus, gracilis
Lateral rotators:
gemilli, obturators,
piriformis, quadratus,
portions of gluteals
(posterior medius)
Medial rotators:
TFL, anterior gluteus
medius, minimus.
And your point is?
Femoral Syndromes
Femoral syndromes arise from pain directly related to
the hip joint, characterized by a movement
impairments of an accessory motion of the femur.
Anterior glide
Anterior glide with medial rotation
Anterior glide with lateral rotation
Posterior glide with medial rotation
Multidirectional Accessory Hypermobility (MAH)
MAH with knee movement
Hypomobility
While these syndromes typically produce
pain local to the hip joint, they may also
manifest as LBP or SIJ pain...
Cause vs. Source
Femoral anterior glide
Hypermobility
Posterior glide/anterior
glide with lateral
rotation
Iliopsoas
tendinopathy/bursitis
Adductor strain
Labral tear
Labral tear
Early degeneration
Piriformis syndrome
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Femoral Anterior Glide
Primary dysfunction: inadequate posterior glide
of the femoral head during hip flexion
Symptoms: Pain in the groin with hip flexion or
standing; may experience generalized hip pain
Source: Iliopsoas tendon/bursa/anterior
capsule/labrum
Cause: pressure of femoral head on the anterior
capsule
Primary contributing factor: postural hip
extension
Femoral Anterior Glide with
Medial Rotation
Primary dysfunction: inadequate posterior glide
and excessive medial rotation of femoral head
during hip flexion
Symptoms: groin pain during active hip flexion;
may progress to aching pain of whole hip
Cause/Source often the same as anterior glide
Primary contributing factor: failure of the hip
flexor/lateral rotators to counteract the hip
flexor/medial rotators
Femoral Anterior Glide with
Lateral Rotation
Primary dysfunction: inadequate posterior glide with
excessive lateral rotation of femoral head during hip
flexion
Symptoms: groin pain with hip extension and lateral
rotation, worse in weight bearing. Pain may be in the
more medial aspect of the joint. Can feel similar to a
groin strain.
Cause/Source often the same as with anterior glide
Primary contributing factor: sitting with involved limb's
foot resting on opposite thigh which increases
stiffness of hip extensors/lateral rotators
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Anterior Glide +/- Rotation Key
Examination Findings
POSTURE: hip extension (posterior pelvic tilt/knee
extension)
+MR: with MR / +LR: with LR
+ANTERIOR GLIDE SIGN: anterior PICR deviation (with
or without MR/LR) with SLR, hip flexion/knee flexed,
prone hip extension
ROM: limited hip flexion
+MR: increased MR or limited LR
+LR: increased hip LR or limited MR
STRENGTH: weak/painful iliopsoas
+MR: weak iliopsoas and LRs
Pelvis appears higher on involved side during quadruped
rocking
Anterior Glide Sign
Anterior Glide +/- Rotation
Focus of Treatment
Stop prolonged/excessive hip extension with
standing and walking
Restore precise hip flexion
Quad rocking, OP with hip flexion, stretch HS (seated knee
ext), strengthen iliopsoas*
+MR: same as anterior glide plus:
Correct MR during hip motion and strengthen hip LRs. NO
BACKWARD ROCKING
+LR: same as anterior glide plus:
Correct LR and strengthen Mrs. Backward rocking ok.
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Case Study
Collegiate football player with six month history of
pelvic girdle pain. Diagnosed with osteitis pubis
(visible on imaging studies)
Symptoms: pain with prolonged (>5') standing, sitting,
running, walking. Anterior hips often feel tight.
Exam findings (B): hip abduction and hyperextension in
standing, positionally weak/strained iliopsoas,
significant TFL hypertrophy and dominance, +anterior
glide sign with medial rotation with ASLR, knee to
chest.+ ant glide sign with PSLR, limited hip flexion
Treatment: corrected standing and walking (no
symptoms with corrections), quad rocking, heel slide
initiation without TFL. Instructed to NOT stretch hip
flexors.
Femoral Posterior Glide + MR
Primary dysfunction: imprecise spinning of the
femoral head during hip flexion with excessive
MR
Symptoms: deep hip pain, aching of whole joint,
piriformis pain
Source: posterior hip capsule/ligaments,
piriformis
Cause: pressure of femoral head on the posterior
capsule
Primary contributing factor: overstretching of
posterior hip structures
Femoral Posterior Glide +MR
Key Examination Findings
POSTURE: Excessive femoral MR; Head of
femur prominent in quadruped
- ANTERIOR GLIDE SIGN
Pelvis LOW on involved side or hip MRs during
quadruped rocking
ROM: Normal to increased hip flexion, increased
hip MR
STRENGTH: Weak LRs, gluteals
Rocking backward: greater trochanter medially
rotates, hip goes low
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Femoral Posterior Glide +MR
Focus of Treatment
Avoid end range hip flexion
Strengthen gluteals, LRs
Sitting: knee low relative to hip; towel roll just
anterior to ischial tuberosities; frequent
standing breaks
STOP STRETCHING!!!!
Case Study
33 yo female elite fitness competitor with 6 month
history of 8/10 posteromedial buttock pain and
sciatica secondary to rear-end MVA. Affected limb's
foot was resting on the dashboard
Symptoms: pain with prolonged sitting, esp. in car; pain
with running, splits, deadlifts.
Exam findings: Trendelenburg gait, femoral MR in
standing, posterior glide with quad rock, MR of femur
with forward bend, hamstring>gluteals with prone
SLR, very long and poorly recruited LRs
Treatment: No stretching, fill in well of car seat,
strengthen LRs and gluteals, corrected mechanics with
workout, core program; full resolution in 10 visits.
Multidirectional Accessory
Hypermobility (MAH)
Primary dysfunction: increased accessory
movement in a variety of directions
Symptoms: deep pain or groin pain with Wbing
activities or sitting (soft surfaces worst)
Source: any region of or adjacent to hip capsule
Cause: pressure of femoral head soft tissues
Primary contributing factor: postural hip
extension, overstretching
*Theory: hip joint hypermobile, passive stretch
of rectus femoris increases compression into
joint
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MAH Key Findings
+ ANTERIOR GLIDE
+ POSTERIOR GLIDE
MOVEMENT: posterior glide and/or MR with
knee extension. Prone active hip extension with
LR, LR with faulty arc of movement
ROM: usually excessive; hip rotation painful. LR
associated with PKB
STRENGTH: Weak iliopsoas, PGM, LRs, glut
max
Pelvis LOW on involved side or hip MRs with
quad rock
MAH Focus of Treatment
Avoid (all) end ranges
Attention to sitting posture (avoid MR), surface
Improve muscle performance of iliopsoas, PGM,
LRs, and glut max
In order to avoid excessive accessory motion during
exercise/basic activities
MAH with Knee Movement
Increased accessory movements associated with a
variety of hip movements AND knee movements.
History of athletics/ weight training
Same signs as MAH plus:
PKB and seated knee extension-symptoms
improve with distraction
Treatment: same as MAH plus:
Decrease use of thigh musculature to control
hip motion
Distraction
Modify weight training program
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Case Study
32 yo lawyer with 20 year hx/o dance and ballet with
lumbar disc herniation.
Symptoms: L perisacral/posterior buttock pain and
associated L thigh symptoms, pain 6/10. Unable to sit
<20', cannot exercise, wakes from sleep. Must stand
frequently in order to work a full day.
Exam: Significant Trendeleburg with lateral trunk shift
gait; impaired neurodynamic mobility, significantly
hypertrophied and dominant rectus abdominus and
TFL. Poor lumbar spine mobility, excessive hip
mobility with forward bend. Standing: affected leg's
knee in hyperextension and MR, trunk rotation to R,
poor inner core recruitment, R>L, positive ASLR,
PSLR, seated knee extension, intrapelvic torsion
Case Study
Goal of initial treatment: resolve impairments
related to lumbar disc pathology.
PPUs, seated L knee extension without lumbopelvic
rotation, lumbopelvic inner core isometrics--
>formal program, neurodynamic mobilizations.
Sitting tolerance 60' with significant decrease in
pain intensity and irritability in 2 visits.
Residual symptoms: return to yoga provokes
pelvic girdle/SIJ pain, needs increased Wbing
and sitting tolerance.
Case Study
Goals of second phase of treatment: stabilize
pelvis, stabilize femurs.
MET, advanced inner core stability training, deep hip
lateral rotators and iliopsoas strengthening; soft
tissue work to L>R glut wall (found to be very stiff,
hypertonic), education regarding hip
protection/positioning, postural education. Referral
to PT/yoga practitioner with MSI training to
modify yoga program. Progressed to balance
training, TFL downtraining, posterior hip muscle
strengthening.
Full symptom resolution with significantly improved
movement system balance in 18 visits.
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Hypomobility
Limited accessory motion in a variety of
directions especially flexion; occurs with OA
Symptoms: deep hip or groin pain and stiffness
Exam: loss of motion in capsular pattern; short
iliopsoas
Treatment: Improve ROM; increased muscle
performance of gluteals
Exam Demonstration
Summary / Key Points
Variety in movement strategies maintains movement
system balance and long term musculoskeletal
health
Hypermobility (loss of precise motion/normal
accessory motion) leads to degeneration and pain
Hip syndromes arise from impairments in muscles
attaching close to the proximal femur that control
alignment and motion.
Precise observation of movement strategies will
elucidate compensatory movements associated
with pain; correction decreases/resolves pain.
Examination findings dictate effective treatment
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Questions?
References
All material and pictures of anterior glide sign from:
1. Sahrmann SA. Diagnosis and Treatment of Movement
Impairment Syndromes. St. Louis, MO: Mosby; 2002.
2. Course Notes, Diagnosis and Treatment of Movement
Impairment Syndromes: Lower Quarter Advanced Application.
Presented by Shirley Sahrmann and faculty of Washington
University in St. Louis, October 1-4, 2011.
Picture References
1. Nolan Ryan Pitching: Accessed from http://www.totalprosports.com/wp-
content/uploads/2011/08/nolan-ryan.jpg on Februrary 1, 2012.
2. Knee PICR: Accessed from http://ars.sciencedirect.com/content/image/1-
s2.0-S0966636206000919-gr2.gif on February 1, 2012
3. Pelvis boney anatomy. Accessed from
http://etc.usf.edu/clipart/36800/36869/_36869_lg.gif on February 1,
2012.
4. Anterior hip ligaments. Accessed from
http://etc.usf.edu/clipart/36800/36869/_36869_lg.gif on February 12,
2012/
5. Posterior hip ligaments. Accessed from
http://etc.usf.edu/clipart/53500/53523/53523_hip_lg.gif on Febraury 5,
2012.
6. Angle of inclination. Accessed from
http://www.studydroid.com/imageCards/0b/gr/card-12087065-front.jpg
on February 5. 2012.
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Picture References
7. Angle of declination. Accessed from
http://www.pt.ntu.edu.tw/hmchai/kinesiology/KINlower/Hip.files/HipStruct
ure.htmon February 23, 2012.
8. Cam/pincer. Accessed from: http://www.kevinneeld.com/wp-
content/uploads/2011/07/Hockey-Training-Femoroacetabular-Impingement-
1024x798.jpg on Februrary 21, 2012.
9. Anterior hip musculature. Accessed from: http://www.coachr.org/tfl.jpg on
February 21, 2012
10. Posterior hip musculature. Accessed
from:http://etc.usf.edu/clipart/38800/38868/hip_joint_38868_lg.gif on
February 5, 2012.
11. Stop Stretching. Accessed from:
http://yoga.prevention.com/slideshows/uploads/1/7.3_pigeon_fold.jpg on
February 21, 2012.
12. Rat City Roller Girls. Accessed from:
http://www.westseattleherald.com/sites/robinsonpapers.com/files/imagecach
e/3col/images/wwwwestseattleheraldcom/2012/01/rat-roller-1.jpg on March
1, 2012.