The layer concept: utilization in determining the pain generators, pathology and how structure determines treatment

Abstract

The level of understanding of pain in the nonarthritic hip has made significant strides in the last couple of decades beginning with the discoveries of Reinhold Ganz, MD. However, even with the detection of subtle bony abnormalities, including femoroacetabular impingement, a clinician's ability to differentiate pain generators in the hip has been ambiguous. Deciphering the etiology of the pathology versus the pain generator is essential in prescribing the proper treatment. The Layer Concept developed by Dr. Bryan Kelly, is a systematic means of determining which structures about the hip are the source of the pathology, which are the pain generators and how to then best implement treatment. Four layers will be discussed in this article. Layer I, the osseous layer, Layer II, the inert tissue layer, Layer III, the contractile layer and Layer IV, the neuromechanical layer.

The management of symptomatic femoroacetabular impingement: what is the rationale for non-surgical treatment?

“…Hip joint structures can be systematically evaluated for their involvement in the FAI pathomechanism 4. Osseous structures include the femur, pelvis and acetabulum, and provide hip joint congruence and structural guidance 4.…”

“…Osseous structures include the femur, pelvis and acetabulum, and provide hip joint congruence and structural guidance 4. The inert structures consist of the acetabular labrum, joint capsule and ligamentous complex, and provide static hip joint stability 4.…”

“…Osseous structures include the femur, pelvis and acetabulum, and provide hip joint congruence and structural guidance 4. The inert structures consist of the acetabular labrum, joint capsule and ligamentous complex, and provide static hip joint stability 4. Symptomatic patients with FAI consistently present with bony deformities at the proximal femur and/or acetabulum, and most demonstrate resultant acetabular labral and capsule-ligament complex injuries 1.…”

An Algorithmic Approach to Mechanical Hip Pain

“…During hip motion, dynamic factors may contribute to hip pain as abnormal stress and contact between the femoral head and acetabular rim occur. Different Table 2 Layered approach to clinical assessment of the hip joint (adapted from Draovitch et al [26]). Adapted with kind permission from Springer+Business Media: Curr Rev Musculoskelet Med, The layer concept: utilization in determining the pain generators, pathology, and how structure deterimines treatment, 2012, 1, pages 1-18, (Table 2).…”

“…Deciphering the etiology of the pathology versus the pain generator is essential in prescribing the proper treatment. The layer concept developed by the senior author (BTK) [26] is a systematic means of determining which structures about the hip are the source of the pathology, which are the pain generators and how to then best implement treatment. Consequently, an organized, structured, and reproducible physical examination, together with an understanding of the osseous, capsular, ligamentous, musculotendinous, and neuromechanical contribution to the underlying pathology, will guide the examiner to accurate treatment recommendations or further diagnostic studies.…”