chapter 24 Hip

A common site for pain referral –Lumbar disc –Organ disease –Myofascial pain –SI dysfunction –Knee Force transmitter for upper and lower extremities Stability for upper- and lower-extremity activities experiences repetitive, microtraumatic injuries more often than acute, macrotraumatic injuries Reassess if no change after 2 weeks of treatment

Hip Alignment Coxa valga (see figure 24.1b) –Angle between neck and shaft = >125° –  Femoral head load,  femoral neck stress –Lengthens the limb –  Hip abductor effectiveness Coxa vara (see figure 24.1c) –Angle between neck and shaft = <125° –  Femoral neck stress,  femoral head load –Shortens the limb –  Hip abductor effectiveness

Figure 24.1b

Figure 24.1c

Transverse Plane Hip Alignment Retroversion (see figure 24.2b) –Femoral neck is rotated in relation to femoral shaft at an angle <12° –External rotation (ER), toe-out gait –Supinated foot, frog-eyed patellae,  Q-angle,  lumbar lordosis (continued)

Transverse Plane Hip Alignment (continued) Anteversion (see figure 24.2c) –Femoral neck rotated in relation to femoral shaft at an angle >15° –Internal rotation (IR), toe-in gait –Pronated foot, squinting patellae,  Q-angle,  lumbar lordosis

Figure 24.2b

Figure 24.2c

Figure 24.3a

Figure 24.3b

Neural Considerations Sciatic nerve –Can run through piriformis –Impingement: posterior leg, calf symptoms Lateral femoral cutaneous nerve –Goes through psoas major and under inguinal ligament –Impingement: tensor fascia latae, anterolateral thigh ache/burn Obturator nerve –Enters thigh to provide sensory and motor innervation to medial thigh –Impingement: medial thigh sensory, adductor strength changes

Joint Mobility Convex on concave rule Resting position: 30° flexion, 30° abduction, slight lateral rotation Close-packed position: full extension, abduction, and internal rotation Capsular pattern: –ER = normal –IR = most restricted –Loss of motion: IR > flexion and abduction > extension

Influence of Pelvis Pelvis movement influences hip movement Anterior pelvic tilt –Moves anterior pelvis closer to anterior femur –  Hip flexion Posterior pelvic tilt –Moves posterior pelvis closer to posterior femur –  Hip extension

Unilateral Weight Bearing In one-leg stance: –Rotation stress on hip –Hip abductors prevent contralateral pelvic drop Necessary abductor force –>BW 2° LAL (lever-arm length) –If weak, hip will drop or patient must lean to  BW LAL

Figure 24.4

Assistive Devices in Ambulation Assistive devices used to assist weak hip abductors Cane on opposite side  upward counterbalance force Force through cane is small (~15%): cane LAL = >CoG LAL

Figure 24.5

Leg-Length Discrepancies Can be caused by true length or soft-tissue differences Pelvis drops on shorter side; trunk bends away from the short leg in weight bearing Uneven shoe wear most obvious indication Can lead to osteoarthritis of longer leg

Reducing Hip Stress in Acute Lower-Extremity Injuries Goal post-injury: normal gait Antalgic gait: requires assistive devices until normal ambulation is possible  Stride length during walking or running –Smaller stride reduces the force and motion demands –Spica wrap

Rehabilitation Considerations Hip pain can be difficult to interpret since there are several referring sources of pain –Hip: to groin, medial anterior thigh –Spine: to anterior hip, buttock, thigh –Sacrum: buttock, posterior thigh, lateral thigh –Organs and abdomen: to groin Differential diagnosis may be needed (continued)

Rehabilitation Considerations (continued) Some hip injuries are self-limiting. Predisposing factors must be corrected to reduce recurrence. Inclusion exercises: –Hip stabilization –Knee and ankle weakness –Trunk stabilization

Soft-Tissue Mobilization If Rx is not effective, reassess: Soft-tissue techniques –Deep-tissue massage –Scar-tissue massage –Cross-friction mobilization –Myofascial release (i.e., trigger point and ice-and- stretch) End with active stretches Home exercise program: Stretches, self- mobilization

Figure 24.6a1

Figure 24.6a2

Figure 24.6b

Figure 24.6c

Figure 24.8a1

Figure 24.8a2

Figure 24.8a3

Figure 24.8b

Figure 24.8c

Figure 24.9a

Figure 24.9b

Figure 24.9c

Figure 24.10a

Figure 24.10b

Figure 24.10c

Joint Mobilization Capsular pattern: grades III, IV Techniques –I and II: oscillating –III and IV: sustained or oscillating Little need to stabilize hip joint before mobilization; pelvis is sufficient anchor Self-mobilization: with strap or on step

Figure 24.12a

Figure 24.12b

Figure 24.13a

Figure 24.13b

Figure 24.13c

Figure 24.14a

Figure 24.14b

Figure 24.15

Figure 24.16a

Figure 24.16b

Figure 24.17

Flexibility Exercises Knee, back, and pelvis must be positioned appropriately. Active contraction of opposing muscles leads to improved results. Prolonged stretches are most effective for aged scar tissue or thick collagen tissue structures.

Figure 24.18

Figure 24.19a

Figure 24.19b

Figure 24.19c

Figure 24.20a

Figure 24.20b

Figure 24.20c

Figure 24.20d

Figure 24.21a

Figure 24.21b

Figure 24.22a

Figure 24.22b

Figure 24.23a

Strengthening Exercises Substitutions of other muscles occur easily in the hip and must be corrected. Include exercises to strengthen trunk, knee, and ankle Manual resistance and weight cuff resistance: applied anywhere along extremity

Proprioceptive and Functional Activities Progression: static to distracting and dynamic balance activities Agility exercises such as rapid box exercises Plyometrics Functional exercises: based on patient’s specific sport and position

Figure 24.26a

Figure 24.26b

Figure 24.27a

Figure 24.27b

Figure 24.27c

Figure 24.28

Figure 24.30a

Figure 24.30b

Figure 24.33a

Figure 24.33b

Figure 24.35a

Figure 24.35b

Figure 24.36

Figure 24.37

Muscle Imbalance Syndromes Characterized by tightness of a muscle group, weakness of antagonist, compensatory muscle firing patterns Symptoms: pain, reduced function Possible results: structural adaptations, changes in myofascial tissue (continued)

Muscle Imbalance Syndromes (continued) Hip flexor tightness syndrome can lead to other pathology Normal muscle firing sequence in hip extension: 1.hamstrings, 2.gluteus maximus, 3.contralateral lumbar spine, 4.ipsilateral lumbar spine, 5.contralateral thoracic spine, 6.ipsilateral thoracic spine (not scapular muscles) (continued)

Muscle Imbalance Syndromes (continued) Piriformis syndrome can occur from sacroilium dysfunction, leg-length discrepancies, other muscle imbalances, running on canted surface What do you recommend for rehabilitation of this condition?

Acute Soft-Tissue Injuries Contusions –Hip pointer = iliac crest –No rehab unless weakness is disabling –Injury is self-limiting Groin strain: adductors, flexors—rehab may take a week to several weeks Sprains: rare in sports—occur in extremes of ROM What are your rehabilitation recommendations?

Chronic Conditions Bursitis: can occur in several bursae –Trochanteric, ischiogluteal, iliopectineal –Rule out disc, facet, fracture, nerve, organs, hip joint disease, tumors if Rx is unsuccessful Tendinopathy –Most often affects adductor longus, iliopsoas, rectus femoris –Causes: leg-length discrepancy, tightness, canted surfaces, poor mechanics, muscle imbalance, too much too soon (continued)

Chronic Conditions (continued) Are self-limiting Clicking: torn labrum Correction of underlying causes must be included in treatment program What would you do for rehabilitation?

Fractures and Dislocations Dislocations rare in sport; seen in high-energy sports: medical emergency Traumatic fractures: rare in sports Stress fractures: more common Slipped capital femoral epiphysis –= Growth plate fracture in adolescents – Limited IR, rests in ER –Groin pain Pool activities = beneficial What would you include in your rehabilitation?