Therapeutic Exercise II - PTA 1010: The Hip - PDF

Therapeutic Exercise II PTA 1010 The Hip  Road Map By the end of this presentation the student should be able to: Identify important aspects of the hip structure and function for review Implement a therapeutic exercise program to manage soft...

Therapeutic Exercise II PTA 1010 The Hip  Road Map By the end of this presentation the student should be able to: Identify important aspects of the hip structure and function for review Implement a therapeutic exercise program to manage soft tissue and joint lesions in the hip that are related to stages of recovery after an inflammatory insult to the tissues Demonstrate an understanding of postoperative programs for managing common surgical procedures of the hip. Demonstrate exercise progressions to develop and improve ROM, muscle performance, and functional use of the hip and lower extremity 2 © Stanbridge University 2023  Hip Functional Joint Anatomy and Relationships in Hypomobility Arthrokinematics the Hip Region and THA Hip Fractures Hip Syndromes 3 © Stanbridge University 2023  Bones & Joints: Hip & Pelvis Kinser & Colby Fig. 20.1 4 © Stanbridge University 2023  Structure and Function of the Hip Pelvis Innominate bone: ilium, ischium, pubic bones Anterior joint: pubic symphysis Posterior joints: sacroiliac joints Femur Transmits forces up through the hips, pelvis and trunk Supports the weight of the head, trunk, upper extremities 5 © Stanbridge University 2023  Hip Joint Ball and socket triaxial joint Components: -head of the femur -acetabulum of the pelvis Capsule reinforced by 3 ligaments: -Iliofemoral “Y ligament of Bigelow” *strongest* -Pubofemoral -Ischiofemoral 6 © Stanbridge University 2023  Ligaments supporting the Hip Iliofemoral ligament (Y ligament): reinforces anterior portion of capsule -Limits ER -Limits extension Kinser & Colby Fig. 20.2 Anterior view Posterior View 7 © Stanbridge University 2023  Ligaments supporting the Hip Anterior view Pubofemoral ligament: reinforces inferior & anterior portion of the capsule – Limits extension & abduction Kinser & Colby Fig. 20.2 8 © Stanbridge University 2023  Ligaments supporting the Hip Posterior View Ischiofemoral ligament: reinforces posterior capsule -Limits extension Accessory limitations: – IR – Adduction in flexion Kinser & Colby Fig. 20.2 9 © Stanbridge University 2023  Articular Surfaces: Acetabulum Concave Faces laterally, anteriorly, inferiorly Reinforced by acetabular labrum: fibrocartilage that deepens the acetabulum Articular cartilage: horse-shoe shape, thicker in lateral region (WB surface) 10 © Stanbridge University 2023  Articular Surfaces: Femur Spherical head of femur is convex Femoral head: attached to the femoral neck Projects anterior, medial, and superiorly 11 © Stanbridge University 2023  Review: Arthrokinematics of the Hip Joint: Femur Motion In open chain movements: Convex femoral head slides in the direction OPPOSITE the physiological motion of the femur: – Flexion, IR: posterior glide – Extension, ER: anterior glide – Abduction: inferior glide – Adduction: superior glide 12 © Stanbridge University 2023  Arthrokinematics of the Hip Joint: Pelvis Motion Distal Fixation of the Lower Extremity (CKC): concave acetabulum moves on the convex femoral head→ acetabulum glides in the SAME direction as the osteokinematic motion Pelvis is a LINK in the kinetic chain: When the pelvis moves, there is also motion at the hips and lumbar spine 13 © Stanbridge University 2023  Review What do each of the ligaments do in the pelvis and what are the motions that stress each of the ligaments? What are the arthrokinematics of the hip joint in closed vs open chain? 14 © Stanbridge University 2023  Hip Functional Joint Anatomy and Relationships in Hypomobility Arthrokinematics the Hip Region and THA Hip Fractures Hip Syndromes 15 © Stanbridge University 2023  Positions of the Pelvis Kinser & Colby Fig. 20.3 16 © Stanbridge University 2023  Functional Relationships in the Hip Region Anterior pelvic tilt ASIS moves anterior and inferior- closer to the anterior aspect of the femur Results in: -hip flexion -lumbar extension Muscles that move the pelvis into this position vary in OKC vs. CKC 17 © Stanbridge University 2023  Functional Relationships in the Hip Region Posterior pelvic tilt PSIS move posterior and inferior, closer to the posterior aspect of the femur Results in: -hip extension -lumbar flexion 18 © Stanbridge University 2023  Functional Relationships in the Hip Region Lateral pelvic tilt Frontal plane motion Pelvic motion defined by what is occurring on the side of the pelvis that is opposite the weight bearing extremity Hip hike: elevation of the pelvis Hip drop/pelvic drop: lowering of the pelvis 19 © Stanbridge University 2023  Functional Relationships in the Hip Region Lateral pelvic tilt in standing: Weight bearing side is the side of elevated pelvis Moves into hip adduction lumbar spine laterally flexes toward the side of elevation opposite side: hip abduction 20 © Stanbridge University 2023  Positions of the Pelvis Kinser & Colby Fig. 20.4 21 © Stanbridge University 2023  Functional Relationships in the Hip Pelvic rotation- walking Swing limb (unsupported side in TSw) of the pelvis moves forward: forward rotation of the pelvis -Counter rotation of the trunk -Femoral IR on the weight bearing/stabilizing side Swing limb (unsupported side in ISw) of the pelvis moves backwards: posterior rotation of the pelvis -Femoral ER on the WB side -Counter rotation of the trunk 22 © Stanbridge University 2023  Functional Relationships in the Hip Region Pelvic rotation Muscles that assist in creating pelvic rotation: -Hip rotators -Oblique muscles (external/internal abdominals) -Transverse Abdominals -Multifidus 23 © Stanbridge University 2023  Functional Relationships in the Hip Region Pelvic-femoral Motion = Lumbopelvic Rhythm Combined movement occurs b/w the lumbar spine and pelvis during maximum forward bending of the trunk Example 1: Head/upper trunk initiate flexion pelvis shifts or translates posteriorly to keep COG over BOS 24 © Stanbridge University 2023  Functional Relationships in the Hip Region Pelvic-femoral Motion = Lumbopelvic Rhythm Continued trunk flexion to ~ 45 degrees (controlled by spine extensors eccentrically) PLL becomes taut, superior facet joints slide upward and capsule becomes tight Once all the vertebral segments are at end range further movement shifts into the pelvis pelvis anteriorly tilts until full muscle length is reached in the gluteus maximus and hamstring muscles 25 © Stanbridge University 2023  During weight bearing hip, knee, and ankle postures and motions effect one another functionally called the Lower Extremity closed Kinetic Chain: LE CKC Biomechanics 26 © Stanbridge University 2023  LE CKC biomechanics HIP FLEXION controlled by gluteus maximus and HS eccentrically Knee flexion (controlled by quadriceps) Ankle DF (controlled by gastrocnemius, soleus) 27 © Stanbridge University 2023  LE CKC biomechanics HIP EXTENSION Knee extension- screw home mechanism IR of femur on fixed tibia (CKC) 28 © Stanbridge University 2023  LE CKC Biomechanics Hip Rotation IR the hip medial rotation of the femur on fixed tibia Force through tibia causes eversion of the calcaneus and pronation of the foot when weight bearing www.posturedirect.com © Stanbridge University 2023 29  LE CKC Biomechanics Hip Rotation ER of the hip lateral rotation of the femur on fixed tibia ER of tibia inversion of the calcaneus abduction and DF of TALUS (supination) www.posturedirect.com 30 © Stanbridge University 2023  The Hip and Gait: muscle activity Hip flexors activity: Control hip extension at the end of stance eccentrically & contract concentrically to initiate swing Hip extensor activity: Control the hip flexion in LR eccentrically (assist in shock absorption) Gluteus maximus initiates hip extension Hip abductor activity: Control the lateral pelvic tilt- stabilizes and levels the pelvis during SL stance 31 © Stanbridge University 2023  Pathomechanics: Lower extremity and Pelvis Positional Relationships www.cluchpoints.com 32 © Stanbridge University 2023  Pathomechanics of the Hip Region Box 20.2 pg 715 These things can negatively affect the spine and entire lower kinetic chain: – decreased flexibility – limited strength – muscle imbalance – leg length discrepancies (LLDs) 33 © Stanbridge University 2023  Decreased Flexibility at the Hip Leads to increased force transmission to the spine Adaptively shortened hip flexors: – Excessive LUMBAR extension as hip extends – Excessive load on the knee: unable to lock if hip is flexed unless compensation occurs with excessive trunk flexion builtwithscience.com 34 © Stanbridge University 2023 Therapeutic Exercise intervention Kinser & Colby Fig. 20.10 Hip Flexor Stretch In Thomas Test Position © Stanbridge University 2023 35  Decreased Flexibility at the Hip Adaptively shortened Hip Adductors in weight bearing Contralateral (CL) hip drop Ipsilateral (IL) side bending of the trunk i.e. tight left hip adductors: right hip drop and left trunk side bend/lateral flexion Trail Guides 36 © Stanbridge University 2023  Hip Adductor Stretch (To increase Abduction) Adductor Straddle Standing Lunge Stretch: Stretching left as he moves body to At 90 degrees of hip flexion against the wall the right Kinser & Colby Fig. 20.13 © Stanbridge University 2023 37  Decreased Flexibility at the Hip Adaptively shortened Hip Abductors in weight bearing ** most commonly tight= TFL** – CL hip hike – CL side bending of the trunk i.e. tight left hip abductors: right hip hike and right trunk side bend 38 © Stanbridge University 2023 Trail Guides  Stretches to Increase Hip Adduction Tensor Fascia Latae Stretches Kinser & Colby Fig. 20.20 & 20.21 39 © Stanbridge University 2023  Collapse in the limb during weight bearing movements is called Dynamic knee Valgus Combination of: Hip adduction Hip Internal rotation Hip flexion www.urbanrehab.uk.co 40 © Stanbridge University 2023  Decreased Strength Limited hip abductor, extensor and external rotation strength (GLUTEUS MAXIMUS WEAK) increased hip adduction and IR valgus collapse at the knee in closed chain loading 41 © Stanbridge University 2023  LE CKC Biomechanics Unilateral WB: weak gluteus medius causes contralateral hip drop Weak gluteus medius contralateral hip drop adduction of the femur increased valgus moment of the knee increased stress to: MCL, MPFL, ACL www.posturedirect.com 42 © Stanbridge University 2023  Pathologies with Valgus collapse of the Limb: Leads to (not inclusive list): 1. Patellofemoral Joint dysfunction 2. ACL and MCL strain 3. Piriformis syndrome 43 © Stanbridge University 2023  Treatment to prevent valgus collapse at the limb Strengthen the opposite motions Hip ER Hip Abduction Hip Extension 44 © Stanbridge University 2023  Gluteal Strengthening Hip ER’s Kinser & Colby Fig. 20.24 A. Hip Extensors B. Hip Abductors Kinser & Colby Fig. 20.26 45 © Stanbridge University 2023  One Exercise to address all 3 planes of motion 46 © Stanbridge University 2023  Muscle Imbalances Dominance of one muscle over another opposing muscle during functional activities can be due to: -Strength deficits -Muscle length deficits -Altered proprioception & neuromuscular control Leads to FAULTY MOVEMENT PATTERNS: overuse syndromes, soft tissue stress and joint pain 47 © Stanbridge University 2023  Muscle Imbalances Shortened Tensor Fascia Latae (TFL) &/or Gluteus Maximus Both insert into IT Band→ decreased mobility of these structures can lead to the following overuse syndromes: – Greater trochanteric bursitis – Distal ITB syndrome 48 © Stanbridge University 2023  Muscle Imbalances Dominance of the TFL over the Gluteus Medius: Leads to increased tension on the ITB -Valgus collapse at the knee -ITB syndrome -PFJ pain 49 © Stanbridge University 2023  Muscle Imbalances Dominance of the 2 joint hip flexors over the iliopsoas: 2 joint hip flexors: rectus femoris, TFL, Sartorius Lead to faulty hip mechanics or knee pain due to overuse of the muscles as they cross the knee 50 © Stanbridge University 2023  Muscle Imbalances limited gluteus maximus flexibility increased tension on the ITB (attachment of g. max) PFJ pain or trochanteric bursitis 51 © Stanbridge University 2023  Kinser & Colby Fig. 20.12 Gluteus Maximus Stretch Maintain lumbar extension; Shift weight posterior, moving into end range hip flexion; Hold © Stanbridge University 2023 52  Muscle Imbalances Dominance of hamstrings over the gluteus maximus: Disuse of the gluteus maximus leads to: Dominance of the hamstrings as hip extensors Leads to cramping in hamstrings with hip extensor exercises Can also create muscle imbalance at the knee: HS domination over the quadriceps → excessive posterior glide on the tibia Overuse syndromes: HS tendons, anterior knee pain from excessive knee flexion 53 © Stanbridge University 2023  Hamstrings Stretch Kinser & Colby Fig. 20.17 Kinser & Colby Fig. 20.18 Important to maintain L/S extension with hip flexion 54 © Stanbridge University 2023  Gluteus Maximus Strengthening Hip Extension with Knee Flexed Bridges Kinser & Colby Fig. 20.22 Kinser & Colby Fig. 20.28 55 © Stanbridge University 2023  Muscle Imbalances Use of lateral trunk muscles as hip abductors Decreased strength of the hip abductors = excessive trunk motion and stress on the lumbar spine + Trendelenburg sign or compensatory Trendelenburg Sign (with gait) 56 © Stanbridge University 2023  Gluteal Strengthening Hip ER and abductor Hip Abductor strengthening on WB side strengthening during a squat Kinser & Colby Fig. 20.28 Kinser & Colby Fig. 20.30 57 © Stanbridge University 2023  Hip strengthening: gluteus medius Clams with feet apart: Hip ER with Abduction Clams: Hip ER Sidelying hip abduction in slight extension 58 © Stanbridge University 2023  Gluteus Medius vs Maximus Distefano et al. JOSPT 2009 Gluteus Medius- most→ least Gluteus Maximus: most → Activation least activation Side lying hip abduction Single limb squat Single limb squat Single limb deadlift Lateral band walk Transverse lunge Single limb deadlift Forward lunge Sideways walk Sideways lunge Transverse hop Side lying hip abduction Transverse lunge Sideways hop Forwards hop Clams @ 600 hip flexion Forward lunge Transverse hop Clams @ 300 hip flexion Forward hop Sideways lunge Clams @ 300 hip flexion Clams @600 hip flexion Lateral band walk 59 © Stanbridge University 2023  More Recent Studies for EMG Activity of the Glutes Medius BOREN ET AL., 2011 Greatest Activation: Side-lying plank with hip abduction, dominant leg down Non-weight bearing side-lying hip abduction remains consistently high activation across all studies 60 © Stanbridge University 2023  Strengthening Hip abduction: 61 © Stanbridge University 2023  Kisner hip muscle EMG activity 62 © Stanbridge University 2023  Exercises used in the Kisner EMG activity presentation 63 © Stanbridge University 2023  Functional exercise progression Box 20.11 64 © Stanbridge University 2023  Review What are the functional relationships at the hip with tight hip flexors? Tight hip extensors? Tight adductors? Tight abductors? What must a pt maintain in order to isolate hip flexion with quadruped sit back? What occurs in the spine with a right hip hike? 65 © Stanbridge University 2023  Hip Functional Joint Anatomy and Relationships in Hypomobility Arthrokinematics the Hip Region and THA Hip Fractures Hip Syndromes 66 © Stanbridge University 2023  Joint Hypomobility: Related Pathologies Hip joint degeneration can be due to: OA RA Avascular necrosis (Legg Calvé Perthes) Slipped capital femoral epiphyses Dislocations and/or fractures Congenital deformities 67 © Stanbridge University 2023  Joint Hypomobility: Common Impairments Pain in groin Referred pain along anterior thigh and knee Stiffness after rest Capsular pattern: IR most limited Antalgic gait; with/without Trendelenburg sign Impaired balance, postural control 68 © Stanbridge University 2023  Joint Hypomobility: Functional Limitations & Disabilities Progressive pain with WB Progressive pain with repetitive activities Limitations with ADL’s: Standing to cook, clean house, shopping, etc. Difficulty moving from sit → stand, negotiating stairs, squatting Difficulty with bathing, toileting, dressing 69 © Stanbridge University 2023 Joint Hypomobility: Management Correct faulty mechanics: -Obesity: encourage pt to meet with a nutritionist -Leg length discrepancy (LLD) -Muscle length deficits -Muscle strength deficits -Muscle imbalances -SIJ dysfunction- leads to LLD -Postural education: sitting position, etc. -Injuries to other joints in the kinetic chain 70 © Stanbridge University 2023  Joint Hypomobility: Management Acute phase: Education: rest, activity modification, pain control Grade I or II joint mobilization in open pack postion Correct LLD: heel lift Assistive/adaptive devices- modify chairs: elevate, firm vs. soft, cane, crutches Cardio- aquatic therapy, nonimpact activities (bike, etc.) 71 © Stanbridge University 2023  Joint Hypomobility: Management Subacute & Chronic phases Grade III or IV joint mobilization; MWM Stretching Develop strength and control of hip muscles: focus on gluteus medius, maximus, hip ER’s Improve balance, postural awareness Progress to functional activities: progress WB activities to tolerance Low impact aerobic program 72 © Stanbridge University 2023  Hip Mobilization with Movement Kinser & Colby Fig. 20.5 73 © Stanbridge University 2023  Hip Stretches To Increase Abd, ER To Increase Add, IR Kinser & Colby Fig. 20.14 Kinser & Colby Fig. 20.15 74 © Stanbridge University 2023  Hip Strengthening Progressions Partial Lunge with assistance 75 © Stanbridge University 2023  Hip Strengthening Progressions Single Leg Deadlift: Maintain L/S extension 76 © Stanbridge University 2023  Hip Osteoarthritis Guidelines Cibulka et al, JOSPT 2009 B Patient education B Manual therapy B Flexibility, strengthening and endurance Exercises C Functional, gait and balance training 77 © Stanbridge University 2023  Joint Surgery and Postoperative Management Total Hip Arthroplasty (THA) Hemiarthroplasty of the hip: indications- fracture of proximal femur in the elderly with poor bone stock, failed ORIF, severe degeneration of femoral head with intact acetabulum 78 © Stanbridge University 2023  Total Hip Arthroplasty (THA) INDICATIONS Advanced arthritis of the hip -OA, RA, traumatic arthritis, AVN, ankylosing spondylitis Nonunion of a fracture Joint instability or deformity Bone tumors Failure of previous procedures -osteotomy, resurfacing arthroplasty, etc. 79 © Stanbridge University 2023  Radiographs Kinser & Colby Fig. 20.20 80 © Stanbridge University 2023  THA Types Cemented Immediate postoperative WB Complications: loosening of implant (more active patients) Un-cemented: Osseous ingrowth into textured surfaces, press fit techniques – Ingrowth occurs over 3-6-month period – WB restrictions: TTWB x 6 weeks, variable – Physically active, good bone quality Hybrid 81 © Stanbridge University 2023  THA: Traditional Techniques Posterior/Posterolateral approaches: most common Posterior: Gluteus maximus is split Post/lat: Split at interval b/w Gluteus max. and medius -Piriformis and ER tendons transected at insertion Capsule excised to expose joint 82 © Stanbridge University 2023  THA: Minimally Invasive Technique Smaller incisions Muscle – sparing techniques Accelerated recovery Improved cosmesis Reduced pain 83 © Stanbridge University 2023  THA: Procedure Open skin, split muscles, capsulotomy Dislocation of the joint Osteotomy of femoral neck, femoral head is removed Acetabulum reamed and remodeled Polyethylene cup is inserted into the acetabulum Femoral shaft inserted in intermedullary canal Capsule and muscles are repaired, muscles are balanced 84 © Stanbridge University 2023  THA: Complications Mal-positioning of prosthesis Fracture Insufficient equalization of leg lengths Nerve injury DVT Infection PNM Dislocation Implant loosening 85 © Stanbridge University 2023  THA: Motion Precautions Depends on the Approach: Kisner Box 20.6 page 734 Dislocations occur most often during first 2-3 months after surgery Posterior approach: Do not flex the hip past 90 degrees Do not IR the hip beyond neutral Do not adduct the leg beyond neutral Giles pg 118* Brotzman and Manske, Clinical Orthopedic Rehabilitation, 2011 86 © Stanbridge University 2023  THA: Motion Precautions Depends on the Approach: Kisner Box 20.6 page 734 Dislocations occur most often during first 2-3 months after surgery Anterior approach: Do not extend the hip beyond neutral No lying in prone Do not ER and adduct the hip Avoid flexion past 90 degrees flexion Giles pg 118* 87 © Stanbridge University 2023  Anterior approach: dislocation technique Int Orthop. 2007 Aug; 31(Suppl 1): 13–15. Hip replacement by a minimal anterior approach P. Paillard 88 © Stanbridge University 2023  THA: Post-operative Management Maximum Protection Phase: Prevent vascular and pulmonary complications Prevent dislocation (education on precautions, transfers, etc.) Achieve Independent functional mobility – Transfer training – Bed mobility – Gait training Prevent contracture of operated hip 89 © Stanbridge University 2023  THA: Post-operative Management Maximum Protection Phase (Cont) Maintain functional level of strength and endurance of non operative side and upper extremities Prevent reflex inhibition and atrophy of operated limb Regain active mobility and control of operated extremity 90 © Stanbridge University 2023  THA: Post-operative Management Criteria to progress to moderate Protection phase Well healed incision (I) level ground ambulation w/wo AD FWB on operated limb with full knee extension Functional ROM of hip 3/5 muscle strength of operated hip 91 © Stanbridge University 2023  THA: Post-operative Management Moderate Protection Phase:4-6 weeks → 12 weeks Restore ROM while adhering to post operative ROM restrictions Regain strength and endurance (primarily hip abductors, extensors) Improve cardiopulmonary endurance Improve postural stability and balance and gait 92 © Stanbridge University 2023  THA: Post-operative Management Criteria to progress to moderate protection phase Pain free ambulation w/wo AD Functional ROM and strength of operated hip (I) with ADLs 93 © Stanbridge University 2023  THA: Post-operative Management Minimum Protection Phase: 12 weeks post-op Improve muscle performance Improve cardiovascular endurance Reinforce patient’s knowledge of how to minimize excessive demands on the hip, which activities to avoid, etc. Return to Sport Activities: Box 20.5 page 733 94 © Stanbridge University 2023  Review What is the capsular pattern of the hip? Name one stretch to improve each of the motions lost by the capsular pattern. What are the top 3 exercises for glute max and glute med activation? 95 © Stanbridge University 2023  Hip Functional Joint Anatomy and Relationships in Hypomobility Arthrokinematics the Hip Region and THA Hip Fractures Hip Syndromes 96 © Stanbridge University 2023 Fractures of the Hip Kinser & Colby Fig. 20.7 © Stanbridge University 2023 97  Hip Fractures EXTRACAPSULAR INTRACAPSULAR Intertrochanteric ** Femoral head Subtrochanteric: defined as area Subcapital from lesser trochanter to 5cm distal Femoral neck shaft ** most common fracture type in the hip 98 © Stanbridge University 2023  Intracapsular Fractures May disturb blood supply to the femoral head – Occurs more with a displaced more than nondisplaced Fracture – Greatest risk with femoral head fractures – Most common in elderly women – Can result in: 1. Avascular Necrosis (AVN) 2. Non – union of the fracture 99 © Stanbridge University 2023  Hip Fractures Fracture dislocation/ acetabular trauma is most common in young, active individuals (posteriorly) With dislocation it can cause traumatic disruption of vascular supply and damage to joint cartilage Can result in: Osteonecrosis Posttraumatic arthritis 100 © Stanbridge University 2023  Open Reduction, Internal Fixation (ORIF) Femoral Neck Fracture Intertrochanteric Fracture Kinser & Colby Fig. 20.8 Kinser & Colby Fig. 20.9 101 © Stanbridge University 2023  Open Reduction, Internal Fixation (ORIF) Indications: Fractures of the proximal femur Displaced or non-displaced intra-capsular femoral neck fractures Fracture-dislocations of the head of the femur Stable or unstable intertrochanteric fractures Sub-trochanteric fractures 102 © Stanbridge University 2023  ORIF: Management Protection of tissue: – soft tissue- 6 weeks – bone- up to 16 weeks Recognize that with fracture comes soft tissue injury: – Greater trochanter fracture: gluteus medius – Lesser trochanter fracture: iliopsoas – Subtrochanteric region: gluteus maximus 103 © Stanbridge University 2023  Fracture site may interrupt muscle attachments depending on the location of the fracture: www.earthslab.com Greater Trochanter: Gluteus Medius attachment www.americanhipinstitute.org Lesser Trochanter: Subtrochanteric area: Iliopsoas attachment Gluteus Maxiums attachment 104 © Stanbridge University 2023  ORIF: Management Intracapsular fractures: ORIF requires excision of capsule and may lead to capsular adhesions Fracture may lead to LLD and change in mechanical advantage of a muscle →weakness Table 20.6 Exercise Progression: pgs 741-742 105 © Stanbridge University 2023  ORIF Management Maximum Protection Phase Prevent vascular and pulmonary complications Improve strength of the upper and sound lower extremities Re-establish balance, postural stability and safe and functional mobility within weight bearing restrictions Prevent postoperative reflex inhibition of hip and knee musculature Restore mobility and control of the operated hip and adjacent joints 106 © Stanbridge University 2023  ORIF Management Moderate and Minimum Protection Phase Increase the flexibility of chronically shortened muscles Improve strength and muscular endurance in the lower extremities for functional activities Increase postural stability, neuromuscular responses, standing balance and functional mobility Increase aerobic capacity/ cardiopulmonary endurance 107 © Stanbridge University 2023  Review List the 3 different types of common hip fractures. Name the associated soft tissue traumatized with each of the hip fractures you listed. What is an associated structural change that can occur with a hip fracture? What stretches and strengthening may be associated with those changes? 108 © Stanbridge University 2023  Hip Functional Joint Anatomy and Relationships in Hypomobility Arthrokinematics the Hip Region and THA Hip Fractures Hip Syndromes 109 © Stanbridge University 2023  Painful Hip Syndromes/Overuse Syndromes: Non-Operative Management Tendinopathies and muscle strains – Gluteal tendinopathy Repetitive trauma Bursitis: -Trochanteric bursitis -Psoas bursitis -Ischiogluteal bursitis Femoral acetabular impingement 110 © Stanbridge University 2023  Gluteal Tendinopathy Typically pain in the lateral hip traveling down to the knee (not below) Localized Lacks neurologic symptoms Most common: gluteus medius tendon- largest and thickest in the body (size of your palm). Role- holding your body weight up 1 in 4 women over 50 have the condition (Segal et al 2007) More common in women (40-60 years of age) with loss of estrogen 111 © Stanbridge University 2023  Gluteal Tendinopathy Women are predisposed with increased coxa varu (widens the hips or femur) Often in women that start a new exercise or walking program Overload injury with compression IT band compresses over the tendon in adduction and flexion past 90 degrees Aggravating factors Sitting low seats with legs crossed Lying on one side (either) Pelvic obliquity (unstable pelvis I walking) Standing on one leg more than the other Stairs (going up with slight adduction in the hip flexed posture) 112 © Stanbridge University 2023  Gluteal Tendinopathy Clinical Presentation Night pain, pain with sit to stand, pain carrying children on hip, pain with sitting low with legs crossed Sharp pain transitioning out of sitting Very TTP over the lateral hip (proximal to greater trochanter) Pain with FADDIR, FABER, pain with resisted abduction, pain with SL stance, hopping Poor balance Observation: poor pelvic stability in gait and “flat buttock” 113 © Stanbridge University 2023  Gluteal Tendinopathy Treatment DO NOT: Stretch (compressive loads) Massage (compressive) Foam roll (major compression) Cortisone injection (in the presence of tear) Early phases- avoid side lying positions 114 © Stanbridge University 2023  Gluteal Tendinopathy Treatment Restore strength and coordination the deep hip “RTC” muscles Follow tendinopathy research: ✓Do not rest, follow a sliding scale of activity modification ✓Load the tissue progressively- slow progression ✓Consider (depending on stage of healing)- isometrics, heavy slow loading, eccentric exercises, neuromuscular control exercises 115 © Stanbridge University 2023  Gluteal Tendinopathy Treatment During Acute and early sub-acute phases: Isometrics against a firm belt (neutral hips) – Supine with legs extended, hook-lying, or sitting (preferred) Bridge progressions – Start on elevated box, add ER, progress to SL Squat with abduction – Use band or resistance at feet, start with UE supported, progress to loading Progress to a standing resisted hip thrust 116 © Stanbridge University 2023  Gluteal Tendinopathy Treatment Chronic or advanced exercises Goal of returning to SL loading (monitor for symptoms) Dead lifts (protect back) and add abduction loads See Dr. Chris Powers Program later in PowerPoint 117 © Stanbridge University 2023  Trochanteric Bursitis Pain over lateral hip, and possibly down the lateral thigh to knee Aggravated by walking, stairs Look for: postural imbalances, flexibility and strength imbalances, etc. Usually, a secondary condition to gluteal tendinopathy*** 118 © Stanbridge University 2023  Psoas Bursitis Pain in groin or anterior thigh and possibly to patellar area Aggravated by: repetitive hip flexion 119 © Stanbridge University 2023  Ischiogluteal bursitis Pain at ischial tuberosity Aggravated by: sitting, weak gluteus maximus, etc. Sciatica symptoms present if nerve is irritated from the swelling in region 120 © Stanbridge University 2023  Femoroacetabular Impingement (FAI)- Two types CAM: Enlargement of bone on the femoral head and/or neck www.orthoinfo.aaos.org 121 © Stanbridge University 2023  Femoroacetabular Impingement (FAI)- Two types Pincer: Overgrowth of the acetabulum www.orthoinfo.aaos.org 122 © Stanbridge University 2023  FAI www.jointpain.md 123 © Stanbridge University 2023  Femoroacetabular Impingement (FAI) Acetabular Labral Impingement: Causes: capsular laxity, hip dysplasia, trauma, joint degeneration, poor neuro-motor control Groin or anterior hip pain with anterior tears Pain in buttock with posterior tears Pain, clicking, locking, catching, giving way + FADIR and FABER tests + Log roll and hip scour tests 124 © Stanbridge University 2023  Femoroacetabular Impingement Post operative management Rehab per Protocol by referring MD Protection phase: Straight leg exercise: Applies a force of 1.5-1.8 times body weight and should be utilized only when a patient is allowed WBAT and FWB status and with patient tolerance Minimal activation of hip flexors in this phase due to increased compression on the joint Avoid hip extension and ER if capsule has been surgically modified 125 © Stanbridge University 2023  Femoracetabular Impingement Post-op: arthroscopy 0-2 weeks: PROM→AAROM→ AROM as tolerated 0-4 wks: Limit hip flexor activity (usually using crutches for weight bearing) 0-12 wks: No impact activities(ie. running) WBAT Brotzman and Manske 126 © Stanbridge University 2023  127 © Stanbridge University 2023 Exercise Interventions Lab for hip interventions  Lower Quarter Strengthening Program Developed by Dr. Chris Powers, PhD, PT, FACSM, FAPTA  Systematic Progression Levels 1. Non-weight bearing 2. Weight bearing Double limb support: static 3. Weight bearing Single limb support: static 4. Weight bearing Double Limb support: dynamic 5. Weight bearing Single limb support: dynamic 6. Weight bearing Double limb support: ballistic 7. Weight bearing Single limp support: ballistic 8. Sports Specific training 130 © Stanbridge University 2023  Systematic Progression Levels Levels 1-3 are for Activation Levels 4-6 are for strengthening Levels 7-8 are for movement retraining 131 © Stanbridge University 2023  Non weight bearing activation (level 1): Goals: – hip and trunk isolation – increase ability to activate – endurance training To progress to level 2: perform 1 min static hold of each exercise 132 © Stanbridge University 2023  Level 1 exercises: 1. Clam (biplanar) 2. Clam with trunk activation 3. Fire hydrant (triplanar) 4. Sidelying hip abduction 5. Sidelying hip abduction with trunk activation 6. Planks 133 © Stanbridge University 2023  Clam (biplanar) 134 © Stanbridge University 2023  Clam with trunk activation 135 © Stanbridge University 2023  Fire hydrant (triplanar) 136 © Stanbridge University 2023  Side lying hip abduction 137 © Stanbridge University 2023  Sidelying hip abduction with trunk activation 138 © Stanbridge University 2023  Level 2 exercises: 1. Squats with Theraband 2. Squats with trunk activation 3. Surfer squat with theraband 139 © Stanbridge University 2023  Squats with Theraband 140 © Stanbridge University 2023  Squats with trunk activation 141 © Stanbridge University 2023  Surfer Squats with Theraband 142 © Stanbridge University 2023  Level 3 exercises: 1.Unilateral Glute Med wall push 2.Unilateral Glute Med wall push with trunk activation 3.Simulated wall push in standing 4.Standing fire hydrant 5.Kneeling bosu work with CL hip AROM 143 © Stanbridge University 2023  Unilateral Gluteus Medius wall push 144 © Stanbridge University 2023  Unilateral Glute Med wall push with trunk activation 145 © Stanbridge University 2023  Simulated wall Push 146 © Stanbridge University 2023  Standing fire hydrant 147 © Stanbridge University 2023  Kneeling bosu work with CL hip AROM 148 © Stanbridge University 2023  Level 4 exercises: 1. Resisted squat with trunk activation 2. Kettlebell squat with TheraBand 3. Crab walks 4. Hip Abduction walks 5. Crab walk with trunk activation 6. Forward lunge with hip bias 149 © Stanbridge University 2023  Resisted squat with trunk activation 150 © Stanbridge University 2023  Resisted Squat 151 © Stanbridge University 2023  Kettlebell squat with TheraBand 152 © Stanbridge University 2023  Crab walks 153 © Stanbridge University 2023  Crab walk with trunk activation Move laterally while maintaining the correct posture with hips abducted, leading with femur rather than foot/tibia 154 © Stanbridge University 2023  Hip Abduction Walks 155 © Stanbridge University 2023  Forward lunge with hip bias 156 © Stanbridge University 2023  Level 5 exercises: 1. Single leg squat with bench assist 2. Single leg squat 3. Romanian dead lift 4. Low cable pull 5. Dynamic standing fire hydrants 6. Step up with hip bias 7. Standing hip dip 8. Step down with hip strategy 157 © Stanbridge University 2023  Single leg squat with bench assist 158 © Stanbridge University 2023  Single leg squat 159 © Stanbridge University 2023  Romanian dead lift 160 © Stanbridge University 2023  Low Cable Pull 161 © Stanbridge University 2023  Dynamic Standing Fire Hydrant Performed just as the fire hydrant hold but moving in repetitions from start and end of the ROM 162 © Stanbridge University 2023  Step up with hip bias 163 © Stanbridge University 2023  Standing Hip Dip 164 © Stanbridge University 2023  Step down with hip strategy 165 © Stanbridge University 2023  Review Be able to describe the common soft tissue pathologies described in this power point? Be able to describe aggravating and relieving positions in for each of these pathologies. Why is the SLR an aggravating activity in the acute phase of tissue healing or in a patient who is NWB? 166 © Stanbridge University 2023  Road Map At this point the student should be able to: Identify important aspects of the hip structure and function for review Implement a therapeutic exercise program to manage soft tissue and joint lesions in the hip that are related to stages of recovery after an inflammatory insult to the tissues Demonstrate an understanding of postoperative programs for managing common surgical procedures of the hip Demonstrate exercise progressions to develop and improve ROM, muscle performance, and functional use of the hip and lower extremity 167 © Stanbridge University 2023