Noush - TE2 - Hip

• This presentation covers Therapeutic Exercise II, specifically for the hip.
• Students should be able to identify hip structure and function, create exercise programs, understand postoperative programs, and demonstrate exercise progressions.

Bones and Joints: Hip & Pelvis

• The innominate bone consists of the ilium, ischium, and pubic bones.
• There is an anterior joint at the pubic symphysis.
• The posterior joints are the sacroiliac joints
• The femur transmits forces upward through the hips, pelvis, trunk, and supports weight.

Hip Joint

• A triaxial joint.
• Head of the femur and acetabulum of the pelvis are the components.
• The capsule is reinforced by iliofemoral (Y ligament of Bigelow, which is the strongest), pubofemoral, and ischiofemoral ligaments.

Ligaments Supporting the Hip

• Iliofemoral ligament (Y ligament) reinforces the anterior capsule and limits external rotation and extension.
• Pubofemoral ligament reinforces the inferior and anterior capsule, limiting extension and abduction.
• Ischiofemoral ligament reinforces the posterior capsule and limits extension; it also has accessory limitations for internal rotation, and adduction in flexion

Acetabulum Articular Surfaces

• Concave surfaces face laterally, anteriorly, and inferiorly.
• Reinforced by the acetabular labrum, which deepens the acetabulum providing more stability.
• The articular cartilage has a horseshoe shape and thicker in the lateral region for weight bearing.

Femur Articular Surfaces

• The spherical head of the femur is convex.
• Femoral head attaches to the femoral neck.
• It projects anteriorly, medially, and superiorly.

Femur Motion Arthrokinematics

• Open chain movements: convex femoral head slides in the direction opposite the physiological motion.
• Flexion and internal rotation cause posterior glide.
• Extension and external rotation leads to anterior glide.
• Abduction will cause an inferior glide.
• Adduction will cause a superior glide.

Pelvis Motion Arthrokinematics :

• Distal fixation of the lower extremity (CKC): concave acetabulum moves on the convex femoral head.
• The acetabulum glides in the same direction as the osteokinematic motion.
• The pelvis is a link in the kinetic chain; when the pelvis moves, motion also occurs at the hips and lumbar spine.

Functional Relationships in the Hip Region: Anterior Pelvic Tilt

• ASIS moves anterior and inferior, closer to the anterior aspect of the femur causing: -hip flexion -lumbar extension
• Muscles that move the pelvis into this position vary in open kinetic chain vs. closed kinetic chain.

Functional Relationships in the Hip Region: Posterior Pelvic Tilt

• PSIS moves posterior and inferior, closer to the posterior aspect of the femur, causing: -hip extension -lumbar flexion

Functional Relationships in the Hip Region: Lateral Pelvic Tilt

• Frontal plane motion defines pelvic motion by what happens on the weight bearing extremity side of the pelvis opposite.
• Hip hike: elevation of the pelvis.
• Hip drop/pelvic drop: lowering of the pelvis.
• In standing lateral pelvic tilt, the weight bearing side is on the side of the elevated pelvis, causing hip adduction as the lumbar spine laterally flexes to the side of elevation. The opposite side causes hip abduction.

Functional Relationships in the Hip Region: Pelvic Rotation During Gait

• Swing limb (unsupported side in TSw) of the pelvis moves forward causing forward rotation of the pelvis, counter rotation of the trunk, and femoral IR on the weight bearing/stabilizing side.
• Swing limb (unsupported side in ISw) of the pelvis moves backward causing posterior rotation of the pelvis, femoral ER on the WB side, and counter rotation of the trunk.

Muscles That Assist in Creating Pelvic Rotation

• Hip rotators
• Oblique muscles (external/internal abdominals)
• Transverse Abdominals
• Multifidus

Pelvic-Femoral Motion = Lumbopelvic Rhythm

• Combined movement between the lumbar spine and pelvis during maximum forward bending.
• In flexion a head/upper trunk initiates flexion shifting or translating, the pelvis posteriorly in order to maintain Center of Gravity over the Base of Support.
• Continued trunk flexion to ~45 degrees, controlled by spine extensors eccentrically.
• The posterior longitudinal ligament becomes taut and the superior facet joints slide upward and capsule becomes tight.
• Once the vertebral segments are at the end range, further movement shifts into the pelvis.
• Pelvis anteriorly tilts until full muscle length is reached in the gluteus maximus and hamstring muscles.

Functionally Called the Lower Extremity Closed Kinetic Chain (CKC)

• During weight bearing, hip, knee, and ankle postures and motions affect one another.

LE CKC Biomechanics during HIP FLEXION

• Controlled by the gluteus maximus and hamstrings eccentrically, leading to knee fexion (controlled by quadriceps) and ankle dorsiflexion (controlled by the gastrocnemius, soleus).

LE CKC biomechanics during HIP EXTENSION

• Knee extension occurs through the screw home mechanism. The IR of the femur occurs on a fixed tibia (CKC).

LE CKC Biomechanics Hip Rotation

• The internal rotation of the hip causes medial rotation of the femur on a fixed tibia as Force goes through tibia, causing eversion of the calcaneus/pronation of the foot.
• The external rotation of the hip causes lateral rotation of the femur on a fixed tibia, followed by ER of tibia, inversion of the calcaneus, and abduction/DF of TALUS (supination).

Hip and Gait: Muscle Activity

• Hip flexor activity: control hip extension at the end of stance phase eccentrically, then contract concentrically to initiate swing.
• Hip extensor activity: controls hip flexion in loading response eccentrically aiding in shock absorption. Gluteus maximus initiates hip extension.
• Hip abductor activity: control the lateral pelvic tilt, stabilizing and leveling the pelvis during Single Leg Stance.

Pathomechanics

• Lower extremity and pelvis positional relationships in pathomechanics can cause postural problems.
• Pathomechanics of the hip region include decreased flexibility, limited strength, muscle imbalance, and leg length discrepancies (LLDs), which can negatively affect the spine and entire lower kinetic chain.

Decreased Flexibility at the Hip

• Adaptive shortening of the hip flexors that leads to increased force transmission to the spine. It can also cause excessive lumbar extension as the hip extends and causes the knee to be unable to lock the hip is flexed unless excessive trunk flexion occurs.
• Adaptive shortening of hip adductors in weight bearing:
  • Contralateral (CL) hip drop
  • Ipsilateral (IL) side bending of the trunk Example: Tight left hip adductors cause right hip drop and left trunk side bend/lateral flexion.
• Adaptively shortened hip abductors in weight bearing: "Most commonly tight= TFL - CL hip hike - CL side bending of the trunk Example: tight left hip abductors cause right hip hike and right trunk side bend.

Dynamic Knee Valgus

• Limb collapse during weight bearing movements due to a Combination of hip adduction, hip internal rotation, and hip flexion.
• Decreased hip abductor, extensor, and external rotation strength causes increased hip adduction and IR as well as valgus collapse of the knee during closed chain loading.

LE CKC Biomechanics

• Unilateral weight bearing when weak gluteus medius causes contralateral hip drop, adduction of the femur then causing increased valgus of the knee. This increases the stress on the MCL, MPFL, and ACL.

Pathologies with Valgus Collapse of the Limb:

• Patellofemoral Joint dysfunction
• ACL and MCL strain
• Piriformis syndrome

Treatment To Prevent Valgus Collapse at the Limb

• Strengthen the opposite motions including hip ER, hip Abduction, and Hip Extension.

Muscle imbalances

• DOMINANCE is due to strength and muscle length deficits, along with altered proprioception and neuromuscular control
• Muscle imbalances lead to faulty movement patterns which causes overuse syndromes, soft tissue stress and joint pain.
• Should the Tensor Fascia Latae (TFL) and/or Gluteus Maximus shorten, and as they both insert into the IT Band decreased mobility of these structures can lead to the following overuse syndromes:
  • Greater trochanteric bursitis - Distal ITB syndrome
• Dominance of the TFL over the Gluteus Medius contributes increased tension on the ITB as well as valgus collapse at the knee ITB syndrome and PFJ pain.
• Dominance of the 2 joint hip flexors over the iliopsoas causes faulty hip mechanics or knee pain due to overuse of the muscles as they cross the knee.

Muscle Imbalances

• Limited gluteus maximus flexibility can cause increased tension on the ITB due to glute max attachment to the the ITB which causes PFJ pain or trochanteric bursitis.
• Dominance of the hamstrings over the gluteus maximus Disuse of the gluteus maximus leads to Dominance of the hamstrings as hip extensors, resulting in cramping in hamstrings, muscle imbalance at the knee, HS domination over the quadriceps causing excessive posterior glide on the tibia and overuse syndromes such as HS tendons, anterior knee pain from excessive knee flexion.

Muscle Imbalances

• Using lateral trunk muscles as hip abductors, which decreases strength of the hip abductors will cause excessive trunk motion/stress on the lumbar spine and can result in a + Trendelenburg sign or compensatory Trendelenburg Sign in gait.

Joints

• Hip joint degeneration can be due to OA, RA, Avascular necrosis (Legg Calvé Perthes, slipped capital femoral epiphyses. dislocations and/or fractures, and congenital deformities.
• Capsular patterns include stiffness after rest, antalgic gait ,impaired balance, postural control and includes pain in groin/referred pain along anterior thigh and knee. Internal rotation will become most limited.
• Functional limitations & disabilities include progressive pain with WB and repetitive activities, limitations with ADL's, difficulty moving from sit to stand, negotiating stairs, squatting, bathing, toileting, and dressing.

Joint Hypomobility: Management

• Correct faulty mechanics -Obesity, leg length discrepancy, muscle length and imbalances,SIJdysfunction leads to LLD -,injuries other joints in chain, postural education.
• Acute phase
• Education-rest pain control
• Grade 1-11 mobilization
• Corect LLD
• Aquatic therapy
• Chronic phases
• Grade 3 and IV mobilization
• Strengthining Stretching

Hip Fractures

• Extracapsular fractures-Intertrochanteric fracture, defined as are afrom lesser tronchanter to 5cm distilled shaft . Intracapsular Femoral neck and head.
• Intracapsular- may disturb blood supply to the femoral head. Greater risk with fam oral head fractures in elderly women can result in Nonunion and A vascular necrosis.
• Fracture dislocationsAcetabular-is most common in young and active individuals but can cause traumatic disruption of vascular due to osteonecrosis.

ORIF: Management

• Fractures with proximal femur- can be displaced and nondisplaced. Soft tissue has 6 weeks to recover while the bone has up to 16 weeks. Recognizing facture comes from soft tissue injuries. Glutes medius with GT , illiposas, Subtrochanteric with gluts Maximus.

Management

maximum protraction prevention of pulmonary issues and vascular. improves strength balance postural

• Stabilize to reestablish balance and stabilize to prevent inhibition.
• Moderate and management - Flexibility to shorting increase cardio.
• ORIF requires a incision and capsular of adhesions and excisions. Fracture may lead to changed mechanics from LLD table helps .
• Proximal femur, stable trunk for proximal for stable trunk/subtrochanteric distal to those.

Painful Hip Syndromes/Overuse Syndromes: Management

• Main causes of these are tendinopathies and muscle strains are the greatest offenders. (Gluteal). Other causes for painful the hip can be repetitive trauma, bursitis ( GT and Soas ) and impingment from femur.
• Gluteal tendinotomy is located on the lateral epicondyle and the greatest cause is from greatest medius and gluts is to assist body weight in all positions. High percentages in women 1 in 4 after 50 due lack estrogen from hormones. Other factors are from coxa , valrum, adduction, factors include long periods of high sitting with cross sitting legs for long periods of time- low chairs or uneven pressure.

DO NOT Recommendations:

• Compressive loads -no heavy stretching- Massage is not recemended in the acute - Foams rollers and acute injections are not recommend for tendinophathy. Acute should not be side-lying. Best ways to achieve this is to restore strengths
• Tendopathy: follow a scale of a sliding scale- slow progression. Isometricals and E centromere control are good alternatives. With acute isometrics again firms against a solid for stability in positions. Bridges are also good and slow elevation.

Rehab

• Femoroacetabular Impingement and post operatively management, start by refearing and following protocol as by MD.
• Protection phase starts at leg straight exercise that utilizes patient body wait but is not utilized until. patient has tolerance to FWB. Minimal flexors as of so. avoid extra and ER if surgery is preformed

Lab for hip interventions

• Dr. Chris Powers will make you lower quarter. Has eight stages to systematical to increase. Lower first 3- activation,4 to 6 to increase stranding and finally 7 increase. Lower extremity for balance is highly recommended.
  • -Non-weight bearing . – Increase trunk strength and isolation. –1 min static hold,
• Clams, sidelying all are good as it progress you move to the more challenging exercises.