Hip
Musculoskeletal Dynamics
Assessment (b proj)
- Observation
- Symptoms
- Subjective
Observation
- Assessing a client prior to the formal session, is an opportunity to gather the most candid movement and posture analysis.
Symptoms
Symptoms generally dictate a client’s chief complaint. Symptoms should be used as cues to the condition and are important to address in the plan of care, but should not be used to guide the plan of care.
For example, a client could be experiencing trunk pain as the source of their symptoms, but the cause and primary dysfunction is actually the hip. In this scenario, hyperfixating on the trunk would be a disservice to this patient, and would require constant symptom management until the primary dysfunction is addressed.
Subjective
Before you throw the patient on the table and go to town poking and prodding, take a moment to gather a complete subjective.
Take a moment to listen to:
The patient’s story
Their description of the
List the client’s activities and activities of daily living.
- Frequency
- Duration
- Intensity
Client’s will often exclude their favorite activities from their list of aggravating factors.
Table assessment
The table assessment should be guided based on a combination of your observations and their subjective account.
Initial setup
- Patient position: Prone with hips supported and feet supported.
- Clinician: Generally to the side of the patient
- Bend the knee so that you can use the distal lower leg as a lever to assess hip rotation
Palpation
To assess the hip here is how i usually start:
- Begin at the gluteal insertions around the rim of the ischium and iliac crests.
- move towards the center of the glutes and assess tone
- Move to the greater trochanter and assess hip IR
- assess the tendinous insertions of the Hip’s deep stabilizer muscles
- Assess/treat the muscle bellies of the deep stabilizers.
Adductor palpation
- Patient positioned in prone
- Start at ischial tuberosity and role infero-medially
- Note the difference in fiber direction and depth between the hamstring fibers and the adductor fibers
- At the ischial tuberosity, you should be able to palpate the origin of the adductor magnus
- Work your way down the femoral shaft, rolling medially to palpate the insertions of the adductors
- Proximal 1/4 of the femoral shaft
- The adductor magnus will be the most posteriorly superficial adductor muscle.
- After diving through the adductor magnus you will reach the posterior intermediate compartment, and you will palpate the adductor brevis.
- Lastly, the pectineus inserts most anteriorly and thus will be palpated last.
- Middle half of the femoral shaft
- You will first palpate the adductor magnus
- Diving deeper, you will be able to palpate adductor longus and adductor brevis.
- Both of these muscles are at the intermediate layer, and thus transition between these two muscles should be at the same depth.
- The adductor brevis muscle will be more superior
- The adductor longus inserts inferior to the adductor brevis.
- Distal 1/4
- The adductor longus’ insertion will end by the distal 1/4 of the femur.
- The adductor magnus’ insertion will also stop and then reinsert at the adductor tubercle.
- The space created is the adductor hiatus.
Sidelying palpation
- IT Band
- Follow it proximally as it moves anterolaterally to join the TFL
- Palpate it posterolaterally as it joins the gluteus maximus proximally
- Assess the IT band against the femur as moves distally
- It should feel fibrous, but the layers should be able to shear freely
- Feel how the IT band acts as a divider between the lateral quadriceps and the hamstrings.
- TFL
- Glute max
- Its transition in the IT Band
- Glute med and glute min
- Assess the lateral roll and inferomedial glide of the femoroacetabular joint.
- Press under the greater trochanter and into the femoral neck.
- Normal: Elastic feeling
- Abnormal: Premature and rigid end feel (no elastic bounce/give)
Rotation assessment
Hip rotation is a solid starting point for assessing the quality of the hip’s range of motion. This test can assess the quality of both internal rotation and extension.
Posterior hip muscle pathways
As you approach the hip in a practical/clinical sense, it will benefit you to group the muscles in terms of purpose rather than as individual muscles.
Setup:
- Use your treatment hand to palpate the posterior hip muscles.
- Bend the knee to 90° and keep the thigh supported against the treatment table.
- Your opposite hand is holding the individual’s distal lower leg.
- Using your opposite hand, rotate the hip from neutral (vertical lower leg) to internal rotation (away from midline)5.
Note:
- Hip end feel
- Muscle tension changes
A guarding end feel has no elasticity.
When a muscle is guarding, it will abruptly stop since it is protecting the body from a stretch. Muscle guard release begins at neutral. As the muscle release progresses, slowly progress the range of internal rotation.
Prone treatment Categories
- Gluteus maximus (Deep and superficial layers)
- Pelvitrochanteric muscles
- Gluteus medius and gluteus minimus
- Hamstrings, hip adductors, and IT band
Iliotibial tract and hip ROM in sidelying
Lateral stability is crucial to weight bearing and linear movements. The TFL and Glute max co-activate and tense the IT band to affect lateral stability5.
Stabilization (b proj)
The ligaments of the femoracetabular joint include the iliofemoral, pubofemoral, and ischiofemoral ligaments. All of these ligaments are tensioned in extension.
The posterior hip is supported by the deep stabilizers The anterior hip is supported by the long tendons of the hip flexors
Treatment Plan
Muscles
Maximal Torque Produced by the hip muscles
“Normative data on the maximaleffort torque production of the hip muscles may be useful for assessing progress and setting of goals for persons involved in rehabilitation and training programs. Fig. 12.48 depicts the average, maximal internal torque produced by a sample of healthy males.34 It is interesting to observe the ranking of the peak torques across the three planes of motion. The greatest torque is produced in the sagittal plane, with exten sion torque slightly exceeding flexion torque. The predominant strength of the hip extensors compared with all other muscle groups is not surprising: these muscles must lift or propel the body upward (and often forward) against gravity or control the descent of the body. The relatively high strength of the hip flexor muscles reflects the need to rapidly accelerate the lower limb during running, in addition to controlling the entire trunk and pelvis relative to fixed lower extremities. Consider in the latter case the physically powerful iliopsoas, for example—a muscle that likely accounts for a significant proportion of the flexion torque poten tial at the hip. The adductor and abductor muscles generate similar magni tudes of peak torque within the frontal plane, but of lower com bined magnitude than the flexor and extensor muscles.34,226 The internal and external rotator muscles produce the least magnitude of torque of all muscle groups of the hip. Such a ranking is likely due to the fact that, in the upright position, these muscles produce a rotary torque between the femur and pelvis in a plane that does not typically oppose the force of gravity.”6
Manual therapy
- Manual therapy should be prioritized around the primary dysfunction.
Abduction
Abduction refers to when the leg pivots directly laterally relative to the pelvis7.
ROM of this movement will depend on pelvic positioning and torso control7. When measuring ROM, the limit of abduction is when the pelvis begins to move with the leg in question7.
When reaching the abduction ROM limit of one hip, it will typically be followed by activation of the contralateral hip7. The passive limit of the ipsilateral hip and contralateral activation of the other results in lateral tilting of the pelvis towards the ipsilateral side7.
Sidelying Activation
- Patient sidelying and facing slightly towards the floor to promote hip abduction/extension
- Body position is the key to isolating the hip and preventing/minimizing compensatory counter movements7.
- Hold end position for 5 seeconds.
- This prevents the compensations that occur by bouncing between eccentric and concentric phases7.
Hip abduction + High knee
Adding a high knee component allows the linear movement to explore the full range, while holding the leg laterally against gravity7.
Keys to setup
Adduction
Adduction of the hips refers to when the leg pivots medially relative to the pelvis7.
“Due to opposite leg contact, there is no true adduction range”7
Hip adduction is a relative movement, only occurring when moving from abduction to neutral7.
Exercises include:
Dysfunction & Compensation
- Primary dysfunction:
- The epicenter of the manual therapy battle
- This is the region will not respond to treatment without the necessary time and effort5.
- Secondary dysfunction:
- Regions of the body that are adjusted their role and function due to the primary dysfunction
- Over time, the secondary dysfunctions will occur until tertiary compensations appear5.
The trunk’s muscle tolerance is generally much lower than the leg’s muscle guarding5. As a result, the legs will tend to disengage and rely on trunk mobility to achieve a movement.
Pain
Foundational Exercises
- Seated wall Hip adduction contract relax
- Adductor stretch
- Abduction ROM (not true abduction)
- Dead bugs
- Hip flexor activation
Hip Adduction / Wall Assist / Hand Resist
“Using a wall to assist in performing hand resistant hip adduction is not a true adduction movement. The adduction is coming from flexion + abduction + rotation position into flexion/adduction/rotation AROM. The goal is to activate hip adduction to release muscle guarding into greater pROM hip abduction range”7.
Setup
The setup is similar to the wall sit foundational exercise but instead of a “V” position of the lower extremity, we employ the “butterfly” position7.
- Sit at the crease of the wall and the floor
- Roll your hips forward (Anterior pelvic tilt) in order to push your glutes as far into the crease as possible
- Activate your abdominals by drawing your naval towards the wall without losing your hip position
- Retract and depress your shoulders
- Look forward (chin tuck) and bring your head backwards (retract) to hold it against the wall
- Bend both knees and externally rotate the hips so that the plantar feet are in contact with eachother at midline.
- Note the starting position of each leg, if they are symmetrical and how much range they hips have in this position.
- Place both hands on the medial surface of each knee
- Apply pressure to create tension on the hip adductors and feel for feedback
Elasticity is a sign of healthy adductor and hips7. Pain and rigidity is a sign of dysfunction7.
Osteology
Innominate
Femur
Acetabulum
Alignment
Acetabular alignment
Acetabular Labrum
Hip joint Capsule
Pack Position
Ligaments
Arthrokinematics
Hip Pathologies and selected therapeutic/surgical interventions
Hip Osteoarthritis (OA)
Treatment of Unstable hip
Lumbopelvic Movement
pelvic pronation
lumbopelvic hip complex during ground impact is a combination of 3-D shock-absorbing movements driving the pelvis into an anterior tilt, forward rotation, contralateral drop, and concomitant spinal extension/rotation and relative sacral nutation. Triplanar pelvic motion is analogous to pronation at the foot—an important mechanism for absorbing ground reaction forces6 and a key antecedent for effective propulsion during gaitdischiaviRethinkingDynamicKnee2019?
Biomechanics
Coxa Vara & Coxa Valga
“As previously described in this chapter, the average angle of inclination of the femoral neck is approximately 125 degrees (see Fig. 12.7A). The angle may be changed as a result of a surgical repair of a fractured hip or the specific design of a prosthetic hip. In addition, a surgical operation known as a coxa vara (or valga) osteotomy intentionally alters a preexisting angle of inclina tion. This operation involves cutting a wedge of bone from the proximal femur, thereby changing the orientation of the femoral head to the acetabulum. A goal of this operation is often to improve the congruency of the weightbearing surfaces of the hip.e”6
Kinematics
Flexion
Osteokinematics
- Active flexion < Passive flexion
- 120 ° flexion (when the knee is flexed)9
- 90 ° active flexion knee extendedkapandjiPhysiologyJointsVol2007?
- 120+ ° active flexion knee flexedkapandjiPhysiologyJointsVol2007?
Arthrokinematics
- Posterior/inferior glide/spin (According to class)
Extension
Osteokinematics
- 10-20 °
- “0 ° of hip extension when knee flexed”
Arthrokinematics
- Anterior slide & spin (According to class)
Limits
- anterior joint capsule, capsular ligaments (iliofemoral, ischiofemoral (if IR), pubofemoral)
- Rectus femoris will limit hip flexion more if the knee is extended since the RF crosses both the hip and knee
- Iliofemoral ligament is stressed during hip extension -> will limit hip extension
- Ischifemoral ligament comes from posterior side of capsule and wraps around to the front -> hip extension would pull the fibers down and cause stress -> limits hip extension when the hip is IR
Abduction
Adduction
External Rotation
Internal Rotation
MMT
Testing
Hip Tightness
Functional Tests
- Squat Analysis
- Deep Squat Test
Femoroacetabular Impingement & Labral Pathology Tests
- Flexion-Adduction-Internal Rotation (FADDIR)9
- Scour Test (Labral Stress Test)9
- Internal Rotation Over Pressure (IROP)9
- Posterior Impingement Test
- Flexion-Abduction-External Rotation (FABER/Patrick Sign)
Other/Extra-Articular Maneuvers
- Resisted Straight Leg Raise (Stinchfield Test)9
- Thomas Test9
- Gear Stick Sign9
Microinstability
Provocative maneuvers
In addition to astandardexamofthehip,thereareanumberofprovocative maneuvers that assess apprehension, range of motion, and joint stability