Physical therapy intervention in early-stage femoral head osteonecrosis

Osteonecrosis of the femoral head (ONFH) is a debilitating disease with a multifactorial pathogenesis that ultimately leads to hip joint destruction. In the international scientific literature ONFH is also referred as avascular (AVNFH) or aseptic (ANFH) necrosis of the femoral head. The main feature of the disease is the reduction of vascular circulation, which results in the gradual destruction to the subchondral bone and then of the articular surface of the femoral head. On a yearly basis 20.000-30.000 of new incidents of ONFH are diagnosed.The majority of patients are men between 35 and 45 years of age and their quality of life and career are increasingly compromised. It is therefore of major interest for the health systems as well.The target of ONFH treatment aims to the prevention of further deterioration of the joint. Patients, who remain untreated, will experience severe pain and movement limitation during the development of the disease. The main therapeutic interventions of ONFH are distinguished in operative (surgical) and non-operative (conservative) treatment. Surgical methods include: core decompression (CD), osteotomy, bone transplantation and joint replacement. Conservative methods include: medication, weight bearing restriction and physical therapy. The main goals of nonoperative treatment are relief of symptoms, prevention of disease progression and improvement of functionality. This type of treatment can be selected under specific circumstances such as early stages and small lesions of ONFH or among patients for whom surgical management is contraindicated. However, the outcome depends on the stage, volume, classification of necrosis as well as the age of the patient and the etiology of the disease. This paper will review the current literature evidence of non-invasive methods in the early stages of ONFH with special focus on the effects of physiotherapeutic interventions. Abstract Osteonecrosis of the femoral head is a progressively destructive disease of multifactorial origin. The etiology and pathogenesis of osteonecrosis of the femoral head are not yet clear. Management alternatives for the treatment of osteonecrosis of the femoral head consist of non-operative and operative treatment. The efficacy of non-operative treatment alone is the subject of heated debate in the literature. The purpose of this article is to review, update and summarize the non-operative treatment, particularly physical therapy modalities in patients with avascular necrosis of the femoral head in early stages. According to current literature these methods mainly include restriction techniques, electromagnetic stimulation, shockwave, immobilization-traction and rehabilitation training. Despite the evidence that these modalities when applied alone improve motor-function, pain relief and delay disease progression mainly through angiogenesis, osteogenesis and tissue regeneration, there is need for more research to elucidate their role and duration in early stages of avascular necrosis of the femoral head.