Wednesday, March 11, 2015

Study Spotlight: The Layer Concept in Evaluating Hip Pain

The Layer Concept-Utilization in Determining the Pain Generators Pathology and How Structure Determines Treatment

Injuries occurring in the hip have become more prominent in the sports medicine world as of late.  The debate occurs on if injuries to this area are more common or if our sensitivity to these injuries has been enhanced.  While diagnosing hip injuries has increased it is still a difficult area to asses due to the phenomenal amount of structures that surround this hip allowing for is superior stability while also allowing for an equally impressive range of motion when free from restriction and injury.

This article was written by Peter Draovitch who is considered a leader in hip rehabilitation.  He discusses in this article the Four Layers he uses when assessing a hip and following up with their rehab protocol.  Four layers are discussed: Layer I, the osseus layer, Layer II, the inert tissue layer, Layer III, the contractile layer and Layer IV, the neuromechanical layer.

Diagnostic testing for identifying osseous, inert and soft tissue hip pathology has included x-ray, MRI, CT Scan, delayed gadolinium enhanced MRI of cartilage (dGERMIC) studies, diagnostic injection and clinical special tests.  While effective these diagnostic tests aren't always perfect alone and may need to be used in combination to reach final diagnosis.

The Layer Concept

Mr. Draovitch discusses the greater scope of mechanics that are involved in hip function and cautions to not focus on the hip solely.  Understanding any compensatory movement patterns that might affect the ability of the hip to function in its full capacity is vital to the evaluation process as you try and establish the root cause of the issue.

See more for how to assess below:

His recommendation therefore it to follow a functional movement exam and a spine screening (Layer IV) and then progress to the clinical exam of the hip beginning from Layer I and moving out toward Layer III.  A series of special tests may be used in examining the layers (See Table Below).  Draovitch then advises that treatment, however, begins from Layer IV and progresses in toward Layer I.  The kinematic chain must be addressed if a dysfunction is identified.  There is a need to look at if myofascial restrictions are present and if they are muscle tightness (adaptive shortening) versus tone (protective or myotomally driven) and how that will correspond to the correct treatment.  He suggests that muscle tightness may be differentiated from tone by noting if there is a palpable restriction at the end range of tissue length or if there is resistance to movement of the tissue throughout its length.

Along with these specific areas of focus we must remember to look at lumbo/pelvic motion and organization to rule out a great issue that is presenting its problem at the hip.  Assessing this more general area will allow for more global problems to be addressed and the greater motor control issues to be corrected.

Take Away:
A hip injury can be extremely frustrating to assess and eventually diagnose.  This study breaks it down to look at Layers within the hip to help specify which layer might be the problematic one.  This is a great guide to start with if you aren't able to get to the diagnostic imaging immediately.

Special Test for the Layer System

The Layer Concept utilization in determining the pain generators pathology and how structure determines treatment
Peter Draovitch
Curr Rev Musculoskelet Med (2012) 5: 1-8


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