Sports Medicine Research: In the Lab & In the Field: Hip Special Tests Add Little Diagnostic Value (Sports Med Res)


Wednesday, January 21, 2015

Hip Special Tests Add Little Diagnostic Value

Diagnostics accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis

Reiman MP, Goode AP, Cook CE, Holmich P, & Thorborg K. Br J Sports Med.2014, 0:1-12. E pub ahead of print December 16, 2014

Take Home Message: There are many clinical special tests geared towards diagnosing labral tears and femoroacetabular impingement.  Unfortunately, these tests are largely not helpful in confirming the presence of the pathology in population that is likely to have either.

Hip surgery is becoming a common strategy to correct femoroacetabular impingement and labral pathologies.  Diagnosing these conditions can be challenging and there is interest around developing cost-effective and accurate clinical tests for diagnosis of these hip pathologies.  The authors of this systematic review aimed to evaluate the diagnostic accuracy of hip physical examination tests.  They identified 21 papers, which consisted of 1335 participants and 11 different clinical special tests.  There were a sufficient number of studies for a meta-analysis to investigate only two of the 11 tests: flexion adduction and internal rotation (FADDIR) as well as flexion internal rotation test. Eight of the included studies were retrospective, 9 were prospective, and the study design was unknown for 4 studies.  The reported FADDIR sensitivity averages ranged from 56 to 100% and specificity ranged from 6 to 83% for all of the studies.  For flexion-internal rotation tests the sensitivity averages ranged from 70 to 98% while the specificity ranged from 8 to 44% for all of the studies.  The pooled meta-analysis results indicated that FADDIR sensitivity was 94 to 99% while specificity ranged from 5 to 9%; and for the flexion-internal rotation test the sensitivity was 96% and specificity was 25%.  Most clinical special tests yielded at best a marginal increase in the probability of correctly diagnosing the pathology.    

The overall accuracy of clinical hip special tests is poor and this study highlights that their clinical helpfulness is minimal when there is a high suspicion of hip pathology.  The two clinical tests in the meta-analysis and many of the other tests could not correctly identify people without hip pathology when the test was negative. The “gold standard” in these studies was either surgery or MR-arthrogram.  This meta-analysis investigated the use of any one clinical special test in improving diagnostic accuracy.  It may be of value to try to determine what signs or symptoms in addition to a combination of special tests helps to accurately diagnose femoroacetabular impingement or labral pathology.  In conclusion, these clinical tests do not add much value to diagnosis and need to be interpreted carefully.  The clinical presentation and patient history may be more beneficial when trying to differentiate a diagnosis, but this needs to be further examined. 

Questions for Discussion:  What combination of clinical tests do you use to help to rule out or in femoroacetabular impingement or labral tear?  Are there any clinical findings that you anecdotally are finding to help with your diagnostic evaluation?

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

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Helpful Information:

Reiman, M., Goode, A., Cook, C., Holmich, P., & Thorborg, K. (2014). 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 DOI: 10.1136/bjsports-2014-094302


Alexander Dailey, ATC said...

Clinically, the combination of a good history and a couple of tests have been beneficial to help distinguish between FAI and labral tears.
Clinical tests that I have previously used includes range of motion, McMurray's, FABER, Trendelenburg gait and grind tests. FAI can present with elicited pain with flexion near end-range, abduction or internal rotation. Labral tears can present with pain provocation with flexion, adduction or internal rotation. Both of these ranges can be tested with McMurray's test. FABER could note differences between hip mobility, which could benefit the sensitivity for FAI. A Trendelenburg gait, especially with compensation over the affected hip in a labral tear. The grind test could help with the specificity of labral tears, due to the axial load placed on to the acetabulum. If pain is not elicited while moving within the available ranges of motion, then the suspicion of a labral tear can diminish.
Despite these tests, I still have a difficult time making a differential diagnosis between FAI and labral tears. In this case, x-rays that measure the retroversion angle of the femur could also help distinguish between FAI and labral tears.

Nicole Cattano said...

Thank you for your comment Alexander. I think you bring up a lot of really good points. I'm not certain that I have considered a Trendelenburg gait with a labral tear, I will certainly keep that in mind during my evalutions.

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