Microinstability of the hip_Clinical pattern
The clinical presentation of microinstability of the hip is like the presentation of instability in other joints (eg shoulder instability, lumbar instability)
Main problem: hip pain in the groin, buttock, thigh, or in the “C sign” distribution, sometimes the patient is complaining about apprehension, sense of giving way or clicking and locking (also signs for a labral tear)
Aggravating activities: activities with repetitive hip rotation and axial loading, such as seen in certain sports activities (see previous Blog); uncontrolled hip movements; sustained end of range positions; symptoms through range.
Symptom reduction with: rest, avoidance of aggravating activities; slow, controlled hip movements
History: idiopathic microinstability has often an insidious onset and the symptoms are gradually worsening.
Predisposing factors: repetitive hip movements during sport activities, hip dysplasia, generalized ligamentous laxity, previous trauma, hip operations, FAI (Femoroacetabular impingement), labral and ligamentum teres tears.
Possible observational findings during standing and during hip activities (walking, standing on one leg, rotation on one leg, hip squat, single leg squat, split stance …)
- muscular dysbalances of the hip, pelvis, leg and trunk muscles;
- sway back with increased passive hip extension;
- increased hip external or internal rotation (be aware of altered torsion of the femur and/or the acetabulum – see IMTA Blog Maria Brugner);
- decreased hip abduction stabilization
- increased translation of the femoral head (eg. during active SLR, see IMTA Blog Di Addison)
Possible findings during passive hip movements:
- hypermobility of the hip joint; sometimes generalized hypermobility (Breighton Score)
- altered behavior of resistance (R1 and R2) during physiological movements and accessory movements (reduced R especially during distraction)
- spasm (S) /apprehension eg. anterior apprehension, posterior apprehension, in the direction of rotation
- positive relocation test
- locking (especially if the instability is in combination with labral tears or FAI)
In the literature the following 5 special tests are described as hip instability tests (3):
Leg roll test or hip dial test
Anterior apprehension test
Posterior apprehension test
Prone external rotation test
Abduction-extension-external rotation test
The soft tissues palpation and length, muscular activity pattern and strength should also be assessed.
- Patient education
- Activity modification
- Treatment of muscular dysbalances (hip, lower extremity, pelvis, trunk) and neuromuscular reeducation
- Manual therapy to reduce pain and AMI (arthromyogenic inhibition); to treat stiff adjacent joints or stiff movement directions
Surgical Treatment: if extensive conservative management fails eg. capsular repair and/or plication dependent on the underlying pathology (3)
References (Happy easter quiz_Part 2 and Microinstability of the hip_Clinical pattern):
1. Shu B, Safran M. Hip instability: anatomic and clinical considerations
of traumatic and atraumatic instability. Clin Sports Med
2011; 30: 349–67.
2. Boykin R, Anz A, Bushnell B et al. Hip instability. J Am Acad
Orthop Surg 2011; 19: 340–9.
3. Kalisvaart MM, Safran MR. Microinstability of the hip-it does
exist: etiology, diagnosis and treatment. J Hip Preserv Surg.
1. Berkes, MB, Cross MB, Shindle MK, et al. Traumatic posterior hip instability and
femoroacetabular impingement in athletes. Am J Orthop (Belle Mead NJ). 2012;
2. Canham, CD, Yen YM, and Giordano BD. Does femoroacetabular impingement
cause hip instability? A systematic review. Arthroscopy. 2016; 32: 203-8.
3. Cerezal L, Arnaiz J, Canga A, Piedra T, et al . Emerging topics on the hip: Ligamentum teres and hip microinstabiltiy. European Journal of Radiology 2012; 81: 3745-3754 4. Chandrasekaran, S, Vemula SP, Martin TJ, et al. Arthroscopic technique of
capsular plication for the treatment of hip instability. Arthrosc Tech. 2015; 4:
5. Harris, JD, Gerrie BJ, Lintner DM, et al. Microinstability of the hip and the splits
radiograph. Orthopedics. 2016; 39: e169-75.
6. Harris, JD. Capsular Managment in hip arthroscopy. Clin Sports Med 2016; 35:373-389.
7. Levy, DM, Grzybowski J, Salata MJ, et al. Capsular plication for treatment of
iatrogenic hip instability. Arthrosc Tech. 2015; 4: e625-30.