09 Aug The efficacy, validity and accuracy of osteopathic clinical skills in diagnosing acetabular labral tears: A systematic review By Dr. Mudathir Al-Sketty
Acetabular labral tears, case history, diagnosis, hip, osteopath, physical examination.
Objectives: To review current evidence on the diagnosis of acetabular labral tears to contribute to the formation of current best practices for the osteopath and to evaluate the efficacy of the use of Critical Analysis Skills Programme (CASP) tools in validating the research.
Data Sources: Electronic databases searched included; Medline, PubMed, Cochrane Library, Academic Search Complete, Wiley Online Library, Sage, Cinahl, Science Direct, Psych articles, Web of Knowledge and ASSIA combining terms; hip labral / labrum tear, acetabular labral/ labrum tear, diagnosis / diagnoses, osteopath, Osteopathy, osteopathic and Eyal Lederman.
Study Selection and Data Extraction: The evaluation of the hip arthroscopy and diagnostic imaging were investigated for a more complete evaluation of the current diagnostic tools in practice. The studies on the case history, patient symptoms and physical examination tests were also reviewed for a more osteopathic and physical therapy approach. The author reviewed the studies to be included and excluded, extracted and scored using the CASP tool. 25 studies were included for the purpose of this review.
Data Synthesis: Arthroscopic intervention and Magnetic Resonance Arthrography were the orthopaedic tools of choice. Symptoms prevalent amongst patients included groin pain in all cases. Clicking and locking may be present with no neurological symptoms reported in any of the cases. The studies that evaluated physical examination tests yielded contrasting research owing to the poor quality of some of the studies.
Conclusions: Anterior groin pain, Scour Test and the Anterior Impingement Test were the diagnostic identifiers and tools of choice for the osteopath and physical therapist.
Studies by McCarthy et al. (2001) and Narvani et al. (2003) reported the prevalence of acetabular labral tears (ALT) to be between 22% and 55%. There has been growing interest in the search for a suitable diagnostic tool in the determination of ALT (Narvani et al. 2003). Due to the number of differential diagnoses of hip conditions and the requirement for specialised diagnostic tools, ALT are frequently undiagnosed (Groh and Herrera, 2009). A study conducted by Bourn (2003) reported that 25% of referrals of suspected ALT made by general practitioners to orthopaedic surgeons were inappropriate. These figures increased from 6% to 10% of overall cases (Bourn, 2003), suggesting a potential niche for osteopathic intervention to aid in reducing the percentages of inappropriate referrals. In addition to this, the NHS spends on average £5000 (Bourn, 2003) on diagnostic hip surgeries. Consequently, it is important to find a non-invasive, accurate, cheap and time effective diagnostic tool to detect ALT. The potential benefits of osteopathic diagnosis may include the reduction in rehabilitation times following diagnostic surgery and the possible complications that may occur post – surgery such as infections. Therefore one could speculate that the decision to utilise patient case histories, symptomatic data and physical examination testing in the diagnosis of ALT may be increasing; however no evidence has suggested this. Osteopathy and consequently physical therapy should be at the forefront of such research, as these are the tools administered by these health professionals in order to formulate accurate diagnoses.
A systematic review was conducted to assess consistencies across all studies in the literature. The thorough searches minimises the risk of bias and therefore inaccuracies in the choice of studies. New research can therefore be revealed producing accurate and valid conclusions. The objective of this study was to amalgamate the current evidence on the diagnosis of ALT thereby contributing to the formation of current best practices for the osteopath and other physical therapists. A further reason was to evaluate the efficacy of the CASP tools in validating the research obtained. Evidence suggested that information from patient history and clinical examination is useful; however continued research is warranted to determine the diagnostic accuracy of the examination procedures implemented by physical therapists (Martin et al. 2006). With this in mind, recommendations to guide or change current practice protocols were compiled with a view to achieving a gold standard for osteopaths to follow for patients with hip pain.
For the purpose of this study the following terms must be defined:
Efficacy: “the maximum ability of a test to produce a result” (Anderson and Anderson, 1995, p.245).
Validity: “the extent to which a test measurement or other device measures what it is intended to measure” (Anderson and Anderson, 1995, p.749).
Accuracy: “the extent to which a measurement is close to the true value” (Anderson and Anderson, 1995, p.6).
Clinical diagnosis of ALT is complex Schmerl et al. (2005), Troelsen et al. (2009) ad Wang et al. (2011) due to the challenging nature of the structure and function of the hip and the variability of ALT amongst patients (Feeley et al. 2008). Hip conditions are progressively been identified as the source of hip and groin pain as cited by Kelly et al. (2005) in Burgess et al. (2011). The most occurring conditions of the hip presenting with groin pain were ALT. Age groups were unidentified in the study suggesting that other conditions may be more prevalent in different age groups, for example osteoarthritis in the elderly. However, numerous studies reported prevalence of patients being in their forties with diagnoses of ALT (Klaue, Durnin and Ganz, 1991, Fitzgerald, 1995, Petersilge et al. 1996, Leunig et al. 1997, 2004, Hase and Ueo, 1999, Santori and Villa 2000, Kloen, Leunig and Ganz, 2002, McCarthy and Lee, 2002), Suenaga et al. 2002, Narvani et al. 2003, Beck et al. 2004, Ito et al. 2004, Keeney et al. 2004, Beaule et al. 2005, Chan et al. 2005, Guanche and Sikka, 2005, Kassarjian et al. 2005 and Burnett et al. 2006). McCarthy et al. (2001) support the works of Kelly et al. (2005) stating that 55% of patients presenting with groin pain may be diagnosed with ALT.
Factors that predispose patients to ALT include Femoral Acetabular Impingement, Slipped Capital Femoral Epiphysis (SCFE) or trauma (Martin et al. 2006), particularly relevant for case history questioning. Peterson et al. (1992), cited in Burgess et al. (2011) stated that case history taking was found to be the most significant element of the diagnostic process in cases of hip pain revealing that examination improves the diagnostic ability by 12%. McCarthy and Busconi (1995) support this highlighting the importance of the osteopathic diagnostic process through case histories and physical examinations (DiGiovanna, Schiowitz and Dowling, 2005). If osteopaths are to use physical diagnostic tests, a high level of Sensitivity and Specificity must be present to establish diagnostic accuracy Deeks (2001) cited in Burgess et al. (2011). Deeks (2001) stated that high sensitivities are required to rule in a condition and high specificities to rule out a condition, thereby producing high diagnostic accuracies. Tests routinely used for the detection of ALT include the Modified Thomas Test (Narvani et al. 2003), Hip Impingement Test (Narvani et al. 2003, Burnett et al. 2006, Martin et al. 2008, Groh and Herrera 2009 and Troelsen et al. 2009), Scour Test (Martin et al. 2006, Martin et al. 2008 and Austin et al. 2008) and the Fitzgerald Provocative Test (Fitzgerald, 1995 and Springer et al. 2009) as the most common.
More conventional procedures include Magnetic Resonance Imaging (MRI), Magnetic Resonance Arthrography (MRA) (Czerny, Hoffman and Nuhold, 1996), Computerised Tomography (CT) (Yamamoto et al. 2007) and Ultrasound (US). Arthroscopic intervention appeared to be the most effective diagnostic tool for the diagnosis of ALT (Fitzgerald, 1995; McCarthy and Busconi, 1995 and Byrd and Jones, 2001). However whilst effective, Keeney et al. (2004) reported the procedure as being time consuming, costly and invasive hence the reliance on diagnoses using case histories and physical examination tests. Bourn (2003) revealed that patients waited on average four months to see a hip consultant, and then a further eight months before admission for surgery. These procedures represent orthopaedic practice within the biomedical model of health primarily due to their invasiveness. Therefore the primary focus is to determine diagnostic procedures that are just as accurate which are less time consuming, costly and invasive for both osteopaths and physical therapists.
A diagnostic test accuracy systematic review was conducted between May 2011 and April 2012 adhering to current methodological guidelines (Furlan et al. 2009).
An extensive search was conducted on electronic databases covering traditional and alternative medical literature. These included; Medline, PubMed, Cochrane Library, Academic Search Complete, Wiley Online Library, Sage, Cinahl, Science Direct, Psych articles, Web of Knowledge (WOK) and ASSIA combining terms; hip labral / labrum tear, acetabular labral/ labrum tear, diagnosis / diagnoses, osteopath, osteopathy, osteopathic and Eyal Lederman. Preliminary searches yielded limited results on the osteopathic diagnosis of ALT. Therefore broader search terms were added: “Eyal Lederman” and “Osteopathic Diagnosis”, yielding greater results. ”Eyal Lederman” was added to introduce the fundamentals of osteopathic diagnosis. His studies are highly regarded due to his extensive education and experience in the field manual therapy. This yielded 14 combinations of terms for each database (Appendix I). A manual search was also carried out involving scanning references cited in studies selected from the online search. Databases were searched with no date restrictions. Only English-language studies were included. The British School of Osteopathy (BSO) database of all previous literature from 2003 to 2011 was searched, osteopathic and medical texts were consulted and a general internet search of keywords was performed.
Inclusion and Exclusion Criteria
Titles and abstracts were screened to evaluate the eligibility of studies using inclusion and exclusion criteria. Suitable articles were retrieved and further screened for qualification for the review.
Table 1 – Inclusion criteria: Studies that fulfilled at least one of the following were included.
|Criteria Number||Inclusion criteria and reasoning|
|1||Written in the English language.|
|2||Any study design to allow for maximum yielding of results.|
|3||Population must be diagnosed with a labral tear in the hip.|
|4||Osteopathic diagnosis to ensure an osteopathic perspective to the study.|
|5||Sensitivity reporting to ensure validity.|
|6||Articles that included diagnosis or clinical tests used to assess ALT as relevant to osteopathy.|
|7||Articles that included diagnosis via case history taking as relevant to osteopathy.|
|8||Articles that included diagnosis via physical active or passive examination as relevant to osteopathy.|
|9||Diagnosis via manual therapy techniques and confirmed by diagnostic imaging or surgical intervention for a more complete review of articles.|
Table 2 – Exclusion criteria: Studies were eliminated from the study if at least one of the following was present:
|Criteria Number||Exclusion criteria and reasoning|
|1||Inconsistency with the inclusion criteria.|
|2||Articles in which experiments were conducted on animals.|
|3||Articles that only considered surgical intervention as a diagnostic tool because osteopaths do not use surgical intervention as a primary tool of diagnosis.|
|4||Articles that only included diagnostic imaging as a diagnostic tool because osteopaths have a lack of access to the technology.|
|5||Other pathologies at outset leading to hip pain due to irrelevance to the focus on ALT.|
|6||Articles which were speculative, retrospective or editorial in nature to ensure validity of sources.|
Risk and Quality Assessment
To minimise reviewer bias the included articles were shuffled and the studies evaluated at random. The included studies were assessed using the CASP tools (Appendix II), designed to evaluate the quality and applicability of studies of diagnostic reliability (Guyatt, G,H., Sackett, D.L., and Cook, D.J., 1993 and Guanche, C.A., and Sikka, R.S., 2005). The efficacy of using the tools was evaluated in the study with the view to test its reliability in validating studies. Its advantages include the variety of tools available enabling most studies to be allocated to a specific template. Every “yes” answer scored “1” and every “no” answer scored “0” (Appendix III). For assessing risk of bias, Furlan et al. (2009) suggested studies having no flaws and that meet 6 or more of the 12 assessment criteria are considered to have a low risk of bias, and those that meet less than 6 of the criteria to have a high risk of bias (Appendix IV and V). The articles that were neither included nor excluded were reassessed using the CASP tool.
A flow diagram of the search history is presented in Figure 1. 2214 articles were excluded from the study due to lack of consistency with the inclusion criteria or duplication of studies already obtained and 25 identified for inclusion in the review. For detailed calculations of studies refer to Appendix I.
Extraction, Tabulation and Interpretation from the included studies
Tables 3 to 6 amalgamate the key points from the included studies by diagnostic tool, CASP scoring and Risk Bias Analysis. This aims to provide authenticity and significance in the advancement of knowledge for osteopathic diagnostic criteria. For details of the studies refer to the corresponding numbers in Appendix III.
Table 3 – Extracted information to interpret the findings of Hip Arthroscopies.
|Study (Appendix III)||CASP / 11||Risk / 14||Key Findings|
|Arthroscopy useful and confirmed in 3/10 patients.|
|7||Arthroscopy – timely diagnosis of hip pain in 17 – 35 years.|
|7||ALT diagnosed in 56 hips in 55 patients. ALT identified in 88% of patients.|
|7||Arthroscopy- primary procedure in diagnosis of ALT.|
|4||49 patients referred for arthroscopy average ages 42.|
|23||6||6||60 hips arthroscoped identifying complete or incomplete detached ALT in one portion of the weight bearing region. High accuracy.|
|7||4||10||Arthroscopy- gold standard yet suggested only after thorough case histories, physical examination and radiographic studies.|
|13||6||3||102 hips – 93 were confirmed during arthroscopy. Of 94 arthroscoped patients 35 identified ALT.|
|21||4||6||Arthroscopy was the reference standard tool.|
|24||4||3||Arthroscopy used to diagnose ALT however its use as an initial diagnostic tool should be limited.|
|19||2||2||Arthroscopy is reserved for patients with hip pain without a diagnosis following case history, physical examination and radiography.|
|16||4||4||Surgery confirmed ALT – type of intervention unreported.|
|18||3||3||Hip arthroscopy allows for comprehensive evaluation of labrum.|
Table 4 – Extracted information to interpret the findings of X-Rays, MRI, MRA and US tools.
|Study (Appendix III)||CASP / 11||Risk / 14||Key Findings|
|10||7||7||MRA allows effective diagnosis of hip pain in adults aged 17 – 35.|
|20||8||7||MRI prior to arthroscopy revealed ALT.|
|14||4||4||MRI Arthrogram: 18 definite ALT, 29 possible ALT and 2 no ALT.|
|23||6||6||MRI with administration of contrast medium identified ALT although can be inaccurate.|
|7||4||10||Plain radiographs to assess for dysplasia and degeneration.MRI and CT scans unreliable – MRA is diagnostic test of choice. MRI alone unreliable – 30% Sensitivity and 36% accuracy producing false positives.MRA more effective – 80% Sensitivity and 70% Specificity on average. Diagnostic image guided intra articular hip injections useful in the diagnosis of ALT – 90% accuracy.|
|5||7||MRI using contrast agent more accurate than without.|
|17||3||3||4/18 patients (22%) identified ALT using MRA. MRI inaccurate.|
|5||MRA revealed 17/18 ALT. US visualised ALT in 17/18 hip joints. 16 confirmed by MRA – 1 was false positive and 1 false negative. MRA = gold standard. US = highly reliable with 95% Sensitivity.|
|3||CT inaccurate. MRA model of choice for diagnosing ALT in the young adult.|
|6||Radiographs of limited use. MRI has high incidence of false negatives. Sensitivity 80% and Specificity 65%. MRA: Sensitivity 95% and Specificity 65%.|
|2||Plain X- Rays and MRI inaccurate.MRI Sensitivity 30% and Specificity 36%.MRA Sensitivity 90% and Specificity 91%.|
|4||MRI identified abnormalities in acetabulums. CT scan revealed possible posterior ALT.|
|3||Radiographs and CT scans inaccurate in diagnosing ALT. MRI over last 20 years has become a major player in diagnosis of ALT. MRA needs further clarification.|
|4||MRA consistently outperformed MRI in the detection of ALT. CT was suggested as a useful procedure.|
|6||Imaging is useful after detailed case history and physical examination performed for higher accuracies.|
Table 5 – Extracted information to interpret the findings of symptoms by Case History taking.
|Study (Appendix III)||CASP / 11||Risk / 14||Key Findings|
|6||7||7||Hip pain after trauma = 10%. 38% of patients mentioned a limp.|
|14||4||4||Groin pain, clicking, pinching pain, lateral thigh pain and trochanteric tenderness not useful identifiers.|
|7||4||10||Anterior hip or groin pain in up to 55% of patients. 22% of athletes with groin pain and 55% of patients with mechanical hip pain had ALT. 66 patients with ALT reported 92% had groin pain, 52% anterior thigh pain,(anterior ALT) 59% lateral hip pain and 38% buttock pain (posterior ALT). Clicking, locking or catching or giving way with clicking being the most occurring. Dull ache with intermittent episodes of sharp pain worsening on activity. Walking, pivoting, running aggravates symptoms. Night pain in 71% of patients. Limping 89%, shorter walking distances 46% and sitting pain 25%.|
|3||Clicking 100% and 85% Sensitive and Specific respectively. Common cause of groin pain in athletes. 6/18 patients reported clicking. 4 patients reported clicking. Sensitivity and Specificity for clicking to predict ALT by MRA was 100% and 85% respectively.|
|6||In young active patients with groin pain with or without trauma suspect ALT. History may be non-specific. 71% of their patients had night pain and 89% of patients reported limping.|
|3||Most important part of diagnosing hip pain is history taking and clinical examinations. Symptoms include: pain, inguinal clicking, locking, catching, instability, giving way or stiffness. Locking or catching may not be sensitive for ALT. Pain location: groin 96%, anterior hip 34.5%, lateral hip 37.6%, buttock 16.8% and locking or clicking 58%. Tenderness to palpation and pain with stretching (stretches unreported). 100% of patients with ALT reported groin pain. Clicking had 100% Sensitivity, 85% Specificity and 67% possibility of ALT.|
|3||Antalgic gait indicates functional abnormalities in the hip – slight limp and pain. Snapping hip also a sign. Reduced ROM can indicate ALT.|
|2||Hip dysplasia correlated with ALT therefore important to ask about childhood hip problems such as Perthes disease and SFCE. Questions should include location, duration, frequency, distribution of pain, aggravating and relieving factors, history of repetitive rotational strains for example during sports or trauma. ALT causes pain in the anterior groin which may radiate into the buttocks and greater trochanter. Clicking or locking may also occur with pain. Dull ache and activity induced or positional pain not resolving with time.|
|3||4||4||Anterior groin pain and mechanical hip symptoms present in cases with ALT.|
Table 6 – Extracted information to interpret the findings of Clinical Physical Examination Tests.
|Study (Appendix III)||CASP / 11||Risk / 14||Key Findings|
|20||8||7||Inguinal pain. Positive Provocation Test (Hase and Ueo, 1999) and (Mason, 2001).|
|14||4||4||Flexion abduction External Rotation Test and Flexion Internal Rotation Adduction (FIRAD) Test were inaccurate diagnostically.|
|6||39% experienced pain during maximum Flexion Internal Rotation Test (FIRT). 27% showed positive result. A positive FIRT represented incomplete detaching tears in the postero-superior portion of the labrum. A negative maximum FIRT represented complete detaching tears in the postero-superior portion of the labrum. Sharp groin pain following passive flexion adduction internal rotation (FADIR). Apprehension and pain during passive hyperextension with external rotation (ER). Hip pain with or without clicking is characteristic of anterior ALT following a full FADIR immediately after full flexion abduction ER. Pain in Extension Abduction ER after FADIR indicates posterior ALT.|
|10||Positive Anterior Hip Impingement Test (AHIT) most effective. Less specific tests include FABER, Resisted Straight Leg Raise Test (RSLRT), Log Roll Test (LRT) and the Apprehension Test (AT). Physical exam findings yielded inaccuracies due to the variability of ALT locations. Reduced ROM in passive rotation, flexion, adduction and abduction.|
|7||Scour Test effective, valid and accurate. LRT reported reliability measures using Intraclass Correlation Coefficient (ICC) of 0.63 indicating moderate efficacy. Impingement Test accurate – Narvani et al. (2003) reported Sensitivity of 75% and 43% Specificity. Martin et al. ICC = 0.58. Faber Test cited by Martin et al. ICC = 0.61. The collection of positive test provides strong suspicion of ALT as valid diagnoses.|
|3||IR Flexion Axial Compression Test – 43% Specific and 75% Sensitive in 11 /18 patients. The test was positive in 3 /4 patients with ALT. Thomas Test inaccurate.|
|7||Evaluated ICC of the FABER test, FIRAD Test, LRT and palpation of the greater trochanter for tenderness. The measurement of agreement between the researchers using Kappa Coefficient for FABER, LRT and palpation was scored at 0.40 indicating a fair level of agreement at a 95% confidence level. FIRAD impingement test had a lower reliability.|
|3||Little research regarding Sensitivity and Specificity associated with a single clinical test or group of test in diagnosing ALT. FABER Test – pain not a positive sign for ALT however location of pain is. Limited ROM reported with ALT. FABER Test 88% Sensitive for intra articular hip pathology with no Specificity figures reported. Scour Test, FABER and RSLRT indicate ALT. Therefore the location of the pain in a positive test is essential. Groin pain and or clicking with Scour test. Narvani et al. (2003) cited: Hip pain with Impingement Test: Sensitivity 75% and Specificity 43%.|
|5||Impingement Test positive in 10/18 patients confirmed by MRA. 7 cases false negative and 1 true negative. Sensitivity of 59% and Specificity of 100%. FABER Test positive in 7/18 patients all true positives. 10 patients were false negative and 1 true negative. Sensitivity was 41% and 100% Specificity – more likely with groin pain. RSLRT positive in 1/18 cases confirmed by MRA, US and other clinical tests not disclosed. IR Flexion Axial Compression Test reported 75% Sensitivity and 43% Specificity using MRA as a reference.|
|6||ALT suspected with 80-85% accuracy with no significant difference between examiners and all demonstrating high diagnostic skills. Grind Test reported Sensitivity of 75% and 43% Specificity. Fitzgerald test was reported to be 100% specific. RSLRT produced anterior groin pain with ALT.
Positive clinical findings for Physical Therapists of 34 cases: Thomas Manoeuvre in ER = 83.8%, Thomas Manoeuvre in IR = 78.4%, full FIR Load / Grind Test = 89.4%, Fitzgerald into IR and adduction = 89.2%, Fitzgerald into ER and abduction = 86.5%, Eccentric Hip Flexion= 45.9%, RSLRT = 62.2% and RSLRT in ER = 86.5%.
Positive clinical findings for Orthopaedic Surgeon of 32 cases: Thomas Manoeuvre in ER = 75.7%, Thomas Manoeuvre in IR = 89.2%, full FIR Load / Grind Test = 97.3%, Fitzgerald into IR and adduction = 62.2%, Fitzgerald into ER and abduction = 37.8%, Eccentric Hip Flexion = 54.1%, RSLRT = 59.5% and RSLRT in ER = 73.0%.
Positive clinical findings for Orthopaedic residents of 30 cases: Thomas Manoeuvre in ER = 67.6%, Thomas Manoeuvre in IR= 83.8%, full FIR Load / Grind Test = 81.1%, Fitzgerald into IR and adduction = 75.7%, Fitzgerald into ER and abduction = 62.2%, Eccentric Hip Flexion= 54.1%, RSLRT = 62.2% and RSLRT in ER = 70.3%.
|6||Hip flexion, adduction and IR with or without compression provoke pain. 43 % Specificity, 75% Sensitivity reported.|
|2||Patients observed for any Trendelenberg gait or a shorter step length as soon as they walk into the clinic. FIRAD test can cause a sharp pain in the groin. McCarthy Sign with a painful click will occur in the presence of ALT. FIRT reported 70% positive cases out of 60 hips with ALT.|
|5||Reduced ROM is useful osteopathic diagnosis in particular the specific location, direction and degree of restriction. Palpation is useful in osteopathic diagnosis. Palpatory diagnosis represents a rapid non-invasive method of screening patients but should not be considered a replacement tool.|
|2||4||4||A thorough osteopathic structural examination after thorough case history taking and physical examination should be performed.|
|6||Palpatory diagnosis should involve tissue response and quality of ROM. Stiffness, end fell, crepitus and joint play are useful determinants.|
|3||ROM may not be limited but pain at end of ranges in symptomatic hips. FADIR produces groin pain indicating anterior superior ALT. Passive hyperextension, abduction and ER produces groin pain indicating posterior ALT. Flexion with ER and full abduction, followed by extension, abduction and IR causes groin pain indicating anterior ALT. Extension, abduction and ER, caused groin pain indicating posterior ALT. Clicking and locking maybe prevalent.|
|5||Postural and structural imbalances can result in pain. The Postural Structural Biomechanical Model (PSB) suggests that these imbalances and asymmetries can lead to injury or chronic conditions. Palpation incorporated into the PSB during assessments of patients leading to information obtained about tissue textures and muscle hypertonia, determining severities of tissue causing symptoms to formulate accurate diagnoses.|
|9||6||6||Pain at IR 90 degrees and pain at axial compression at 90 degrees with adduction in symptomatic hips.|
Discussion and Critical Analysis of Literature
Research highlights the understanding of ALT clinically despite limited osteopathic sources. The importance in considering all diagnostic tools establishes the current Osteopathic and its competitor’s climate of ALT diagnoses.
Critical Analysis of the Hip Arthroscopy
Arthroscopic intervention represents the main diagnostic procedure in the determination of ALT (Byrd and Jones, 2004) and (Schmerl et al. 2005).
“Arthroscopy currently represents the gold standard in both the diagnosis and treatment of labral tears” (Schmerl et al. 2005, pp. 632).
Overall findings of arthroscopic intervention in the diagnosis of ALT suggested efficacy of the procedure. Studies conducted by Fitzgerald (1995), Narvani et al. (2003), Martin et al. (2006) and Martin et al. (2008) to name a few, concur with the high diagnostic value of hip arthroscopies. Keeney et al. (2004) cited in Martin et al. (2006) reported the successful diagnosis of 93 out of 120 hips using hip arthroscopies. An older study by McCarthy and Busconi (1995) cited in Martin et al. (2006) showed that of 94 individuals who had arthroscopic surgery, 35 were diagnosed with ALT. Surprisingly dated studies (Fitzgerald, 1995) even reported high quality findings of this tool despite the high emphasis on the treatment of ALT therefore limiting the focus on the diagnostic efficacy of ALT. Troum and Crues (2004) suggested arthroscopy not to be used as initial diagnostic tools due to the high rates of negative studies reported; possibly suggesting its use as more of a confirmation tool following a suspected tear after osteopathic testing.
Critical Analysis of Diagnostic Imaging
Diagnostic imaging plays a large role in the diagnostic criteria of ALT. However, imaging should not replace the requirement for a thorough clinical examination.
“Such evaluation, coupled with knowledge of the relevant anatomy and an understanding of likely pathological conditions, remains the cornerstone of accurate diagnosis” (Orchard, Read and Anderson, 2005, pp. 482).
The use of imaging to evaluate the acetabular labrum is largely dependent on the position of the joint and hence misdiagnoses can be common (Emary, 2010). This further supports the requirement of accurate physical therapy testing.
MRA – Contrasting views on the efficacy of MRA in the diagnosis of ALT were revealed. The majority of studies confirmed that MRA is the current gold standard tool for imaging techniques; Hickman and Peters (2001), Hartog et al. (2003), Troum and Crues (2004), Schmerl et al. (2005), Martin et al. (2008), Groh and Herrera (2009), Troelsen et al. (2009), and Burgess et al. (2011). More precisely, Sensitivity scores of 95% and 90% and 80% were reported in the studies conducted by Hartog et al. (2003) and Schemer et al. (2005) and Groh and Herrera (2009) respectively. Specificity figures of 65%, 91% and70% were calculated for the respective studies. The only two studies that disagreed with these findings were those of Martin et al. (2008) and Narvani et al. (2003). They established that although MRA was useful in the diagnosis, it was difficult to determine a definite tear from possible ALT. The study showed 18 definitely had ALT and 29 were potential ALT, making the results arguable and contradictory to the above findings. Narvani et al. (2003) suggested the need for further clarification in the efficacy of MRA.
MRI – Interestingly Narvani et al. (2003), Fevziye et al. (2007) and more recent studies by Zlatkin et al. (2010) and Rakhra (2011) confirmed the superiority of MRI in the diagnosis of ALT. Berquist (1997) also stated that MRI provides superior soft tissue contrast however obese patients and patients with metallic implants cannot be examined, suggesting limitations in its diagnostic strength. The following studies propose the unreliability of MRI in comparison to MRA; (Suenaga et al. 2002, Sozen et al. 2005, Austin et al. 2008 and Morthland et al. (2010). Hartog et al. (2003) suggested the high false negative cases with the use of MRI scans further validating the use of MRI as a second class diagnostic tool. Further studies by Groh and Herrera (2009) and Schmerl et al. (2005) were the only 2 studies that report the total inaccuracy of the use of MRI with scores of 30% and 36% for both Sensitivity and Specificity of the procedures.
Studies evaluating the efficacy of radiographs, CT and US reported the unreliability of these tools. The studies also confirmed the limited use of them clinically in diagnosing ALT. Only two studies revealed the accurate use of US (Troelsen et al. 2009 and Morthland et al. 2011) but sample sizes were low, limiting their validity.
Critical Analysis of Case history and Symptomatic Data
Case history and patient symptoms are one of the key factors in the process of diagnostic evaluation for osteopaths, physical therapists and physicians.
Case history – It was suggested that the case history taking of the patient was the most important aspect of the diagnostic process (Martin et al.2006). Schmerl et al. (2005) agreed with Martin et al. (2006) who investigated aspects of case history taking which aided in the accurate diagnosis of ALT. Questions relating to the patient’s childhood were of significant importance due to the direct link between hip dysplasia and ALT. Leibold et al. (2008) stated that characteristic features to be considered for ruling out conditions that were not labral lesions depended on the age of the patient. Therefore, questions including the patient’s history of Perthes or SCFE should be asked. The location, pain distribution, aggravating and relieving factors, traumatic events, sporting history and rotation strains were also found to be key points of interest. However, Burnett et al. (2006) suggested that case history taking may be non- effective in the diagnostic process. Reasons for this were not disclosed however this may be due to vague answers that patients may provide or failure to reveal personal information.
Groin pain – The most common symptom of ALT is anterior groin pain. Several studies investigated the occurrence of anterior groin pain in patients with diagnosed ALT. Burnett et al. (2006) investigated 66 patients who were diagnosed with ALT arthroscopically revealing 92% had groin pain, 52% anterior thigh pain, 59% lateral thigh pain and 38% buttock pain. Martin et al. (2008) and Burgess et al. (2011) agreed with the presence of anterior groin pain in patients with confirmed ALT, although the study by Martin et al. (2008) only scored 4 on the CASP tool, suggesting a low validity. Research conducted by Groh and Herrera (2009) also with a CASP score of 4, confirmed that 55% of patients presented with anterior groin pain. Within this study, several citations by McCarthy and Busconi (1995), McCarthy et al. (2001) and Narvani et al. (2003) confirmed the presence of anterior groin pain in patients with ALT. McCarthy and Busconi (1995) claimed a 100% occurrence of anterior groin pain in patients with ALT. Keeney et al. (2004) cited in Martin et al. (2008) revealed 96% of patients complained of groin pain, 35 % anterior hip pain, 37% lateral hip pain and buttock pain 17% potentially indicating a posterior acetabular labral tear. Schmerl et al. (2005) revealed similar findings to those of Keeney et al. (2004) but with the potential of pain radiating to the knee. Further studies by Fitzgerald (1995), Pollard, Hoskins and Schmerl (2003), Fonstad and Hooper (2008), Clohisy, Hunt and Harris – Harris (2009) and Emary (2010) confirmed the occurrence of groin pain. These symptoms alone were suggested not to be used as single defining symptoms for ALT therefore other factors must be taken into account before a firm diagnosis reached.
Trauma – Fitzgerald (1995) reported the occurrence of clicking and pinching pain on sitting and lateral thigh pain after a history of trauma. With a CASP score of 7, this study could potentially be of high significance and reliability. However, a lower scored of study (8) by Martin et al. (2008) still concur with the works of Fitzgerald (1995) with the presence of lateral thigh pain too. However the dated source of Fitzgerald (1995) was a key limiting factor. Burnett et al. (2006) contradicted all research mentioned suggesting that patients with confirmed ALT with or without a history of trauma may occur.
Activity – Walking, prolonged sitting, running and pivoting produced sharp, catching pain or dull aches in patients with ALT. Groh and Herrera (2009) suggested the presence of a dull ache with intermittent sharp shooting pains in the hip were worsened with activity. The exact location of the pain was not reported. This was also agreed by Schmerl et al. (2005) reporting the lack of improvement of symptoms with time.
Clicking, locking and / or giving way – Clicking was found to be the most prevalent of mechanical symptoms in the hip with ALT (Narvani et al. 2003, Schmerl et al. 2005 and Groh and Herrera). Narvani et al. (2003) claimed that 6 out of 18 patients presented with clicking in the problematic hip; clicking having 100% Sensitivity and 85% Specificity. However Keeney et al. (2004) disagreed with the common presentation of clicking and reported Sensitivity and Specificity scores of 17% respectively, but agreed with the locking of the hip reporting a Sensitivity score of 58%. An interesting study by McCarthy and Lee (2002) reported 67% of subjects complained of clicking or locking of the hip of which 72% had ALT. However, Narvani et al. (2003) reported all 4 investigated reported clicking, although 2 patients without ALT also mentioned clicking – producing contradictory results. Research conducted by Leunig et al. (1997) found 6 of 23 patients with ALT presented with hip locking. Pain was not associated with locking and clicking of the hip except for one study found by Fitzgerald (1995) who reported that 34 of 64 patients had a click associated with hip pain – all confirmed as having ALT.
Studies evaluating the diagnostic efficacy of patients presenting with limps and night pain were of limited value with studies claiming variable percentages. Details of night pain were not thorough in investigating times during the night. Although some studies highly rank night pain (Burnett et al. 2001), the use of multiple tests should be incorporated for accurate diagnoses.
Critical Analysis of Physical Examination Testing
Osteopaths and physical therapists frequently use examination testing to confirm diagnoses. Overall results were poor due to the heavy reliance on surgical intervention (Byrd and Jones, 2004) who reported although physical examination can be reliable it may be poor at defining the true nature of a condition. A later study by Byrd (2007) revealed that examination processes should include observation, measurement through range of motion (ROM), symptom localisation and special testing:
Observation – Observation of the patient is important and should be noted from their entry to the immediate entry to the clinic observing any antalgic gait or a shorter step length (Schmerl et al. 2005). Posture should also be considered on sitting and standing. Any protective postures to alleviate stresses on the hip, any flexion of the symptomatic hip and any compensatory muscle groups may suggest ALT.
Palpation – Palpatory findings sensed by fingertips and ones proprioceptive mechanisms during the phase of motion testing are useful in osteopathic diagnosis (Chaitow, 2010). Palpatory diagnosis represents a rapid non-invasive method of screening patients but should not be considered a replacement for other diagnostic tools rather a supplement (Sucher, 1994). Palpatory diagnosis should involve tissue response and quality of motion analysis. Ease, stiffness, end fell, crepitus and joint play was used to determine tissue responses (Lesho, 1999).
ROM – A key aspect of osteopathic evaluation is determining the ROM of patient’s hip joints in assessing for any lesions of the capsule (Bickley and Szilagyi, 2007). Although this assessment tool is useful in osteopathically determining the nature of hip conditions and the presence of ALT it was reported that it may not be useful in specifically determining the exact location and degree of the tear due to the variability of tears that can occur (Sucher, 1994 and Groh and Herrera, 2009).
Scour Test – One of the more conclusive tests: Both studies that evaluated this test confirmed its high accuracy (Austin et al. 2008 and Martin et al. 2006). Martin et al. (2006) claimed that although the test has a high diagnostic accuracy, the location of the pain in the groin is the main factor that should not be dismissed to determine a positive labral tear. The presence of clicking may or may not be significant.
AHIT – This test was investigated by three studies. Groh and Herrera (2009) claimed the test to be the most consistent of all tests in the determination of ALT. The other two studies reported 75% Sensitivity in ruling in potential ALT (Narvani et al. 2003 and Martin et al. 2008) and a positive test producing hip pain. The exact location and description of the pain was not stipulated limiting the validity of the examination findings. Troelsen et al. (2009) performed a study using this test as a reference tool and of 18 patients, 10 were confirmed as having a labral tear by MRA. 7 false negatives and 1 true negative was obtained using the test, limiting the validity of this test as suggested by Troelsen et al. (2009) to a Sensitivity of 59%, however a Specificity of 100% in its ability to determine false readings.
The above elements were researched to be the most effective, valid and accurate diagnostic tools in diagnosing ALT. Other tests highlighted in Table 6, revealed the use of other special tests, namely Provocation Test, Eccentric FlexionTest, RSLRT, McCarthy Sign, FADIR, Grind Test, Fitzgerald Test, Passive Hyperextension Test, FIRT, Thomas Test, FABER, LRT and the AT. However these tests are rarely associated with labral tear diagnosis that they have very limited diagnostic value. In addition to this, limited numbers of studies evaluated these tools mostly with high risks of bias and CASP scores below 5, hence were not suggested for clinical use.
Algorithms for case history and physical examination tests were produced based on the findings of this study with a view to advance osteopathic practice. The algorithms highlight the key diagnostic criteria that could be implemented into current practice.
CASP Tool and Risk of Bias Evaluation
CASP tools were designed to develop an evidence based approach in health care. Due to the wide variety of study designs, the CASP scoring of the included articles proved to be difficult and occasionally non-specific for some of the articles. A more useful tool may have been more beneficial potentially better recognising the reliability and validity of the studies. The reduction of time with less questioning would be another reason for potentially choosing another tool. Whiting et al. (2005) found that diagnostic reviews failed to achieve high quality findings despite the use of available grading tools. The advantages of the CASP are the variety of tools available enabling most studies to be allocated to a specific template. However the specific scoring of the studies using “yes” and “no” answers although enabling structured analysis, forces studies into one category. This would suggest that all studies fall into a bracket of a certain type of study. This is not the case in research, and studies must not be disregarded or included based on them being one number away from inclusion or exclusion. There may still be valid elements not quite making the cut off point. This proved to be similar in the assessment of risk bias for the studies with the added complication of having an “unsure” answer therefore not validating the overall score if more than one “unsure” answer was provided. Furlan et al. (2009) suggested studies having no flaws and that meet 6 or more of the 12 assessment criteria are considered to have a low risk of bias and those that meet less than 6 of the criteria to have a high risk of bias; again forcing studies into categories. Another significant point to note is that most studies have elements of different types of studies within them which are what potentially highly validates them. Therefore to categorise them into a particular bracket would be inaccurate in some cases. In addition, some studies may be excluded on the basis of a poor section of part of the study for example an aspect of the methodology. This would not mean that the whole study should be invalidated because the overall study may have produced accurate results. Therefore many studies may have been excluded for the wrong reasons which would not provide a true reflection of the yielded results. A broader scoring tool would be a more beneficial tool to adopt, allowing for ease of validating studies and increased chances of categorising the studies effectively. Although CASP tools have their flaws, the included studies in this review were fortunately categorised efficiently thereby validating all the results obtained.
Limitations of the study
|Foreign studies excluded – potential bias.|
|One reviewer – limiting validity.|
|Inclusion and exclusion process – author bias.|
Recommendations for future research
|Identifying practitioner knowledge of Scour Test and AHIT.|
|Meta – analyses providing increased statistical diagnostic accuracy (Egger et al. 2001).|
|Larger populations reviewed.|
|Pilot studies of algorithms implemented into current practice – evaluation of the diagnostic processes.|
|Insufficient research on active resisted testing.|
This study has provided a diagnostic tool for the identification of ALT using non invasive techniques therefore can inform osteopaths, physical therapists and physicians. There were a variety of studies depicting a wide range of quality research. Although the study had its limitations the diagnostic algorithms are potentially major contributions to the differential diagnosis of hip pain. The main finding of this review was that hip arthroscopy and MRA are the leaders in diagnostic efficacy of ALT, consistently outperforming all the other diagnostic imaging tools. With this in mind, it is essential that osteopaths acknowledge this yet not rely on this as the only tools in suspected patients with ALT. The developed algorithm places the reliance on skills central to osteopathic practice namely case history taking and physical examination. Due to the numerous aetiologies of ALT, age although cited as a significant factor in many studies it should not be a significant diagnostic factor. The importance of a thorough case history due to the osteopathic subtlety in physical examination findings is therefore clearly highlighted. If further testing is required to confirm the presence of a labral tear, the physical examination algorithm is suggested. The research yielded varied results with little research obtained regarding Sensitivity and Specificity associated with a single clinical test or group of test in diagnosing ALT (Martin et al. 2006). While the accuracy is not optimal in these tests the collection of positives provides strong suspicion of ALT as a diagnosis. Although the literature frequently examines clinical tests in isolation, good practice and higher quality evidence strongly assert the need to use multiple tests in addition to other aspect of the consultation (General Osteopathic Council, 2012). From the evidence researched the tests of choice should be the Scour test and the AHIT. The palpation skills of Osteopaths should be incorporated into the postural-structural-biomechanical model during assessments of patients. Consequently obtaining feedback of tissue textures, muscle hypertonia, muscle bulks or landmarks (Lederman, 2010) and determining the severity of tissue causing symptoms in order to formulate an accurate diagnosis. Only if there is uncertainty in an ALT diagnoses should MRA and arthroscopies be considered. The osteopath would be aware of this if patient symptoms persist despite treatment then the possibility of an incorrect diagnosis may have been suggested. With the constant progression and development of research in physical therapy the potential of leadership in medical diagnostics field not only for ALT but for all musculoskeletal and systemic conditions may be possible.
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