Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip PDF

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WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice  EHR520 – Week 6 Functional Anatomy and Rehabilitation of the Pelvis and Hip Tim Miller (ESSAM AES AEP) E: [email protected] Ph: (02) 6338 4442 Functional Anatomy and Rehabilitation of the Pelvis and Hip FUNCTIONAL ANATOMY AND REHABILITATION OF THE SACROILIUM AND PELVIS Functional Anatomy and General Considerations Pelvis: Left & right hemipelvis joined at pubic symphysis & SIJ’s Ilium, pubis and ischium Lumbopelvic‐hip complex: Spine, pelvis, hips Direct attachments means each segment influences the other (alignment & function) Anteriorly tilted pelvis = hips in flexion Lumbar hyperlordosis = anterior pelvic tilt Posterior pelvic tilt = hips in extension Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 4 Functional Anatomy and General Considerations SIJ’s only have limited movement – A total of 4 – 6 degrees (2 – 3 degrees in each nutation and counternutation) Can become both hypo‐ and hyper‐ mobile Lumbopelvic‐hip stability is important for the transmission of forces through the kinetic chain (efficient movement) and prevention of back and pelvic pain (pain-free movement) Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 5 Sacroiliac Stabilisation 1. Form closure: Anatomical stability of pelvic ring Reduced with ligament or bone injury/changes 2. Force closure: Muscles provide stability through their strength & function Reduced with muscle (core) injury 3. Neuromotor control: Proper activation and sequential recruitment of muscles Dysfunctional recruitment following injury Ligament sprain compromises form closure Focus is on improving force closure with appropriate strengthening and activation exercises to re‐establish lumbopelvic‐hip stability Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 6 The Core Inner (deep) core: Transverse abdominis, diaphragm, multifidus and the pelvic floor Outer core: Erector spinae, rectus abdominis, external oblique, gluteal muscles, thoracolumbar fascia (through latissimus dorsi & quadratus lumborum) Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 7 The Core Core instability also linked to: Knee injuries including ACL sprains, ankle sprains & PFP syndrome Hip muscles not only provide hip motion but also influence pelvis & trunk motion Hip extensors, abductors & rotators Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 8 Pelvic Neutral Stable pelvis serves as a platform for lumbopelvic‐hip stability and extremity performance Pelvis is stable when it is in pelvic neutral Minimises injury risk & optimises load transfer Head, arms & trunk are all balanced on the pelvis Maintain pelvic neutral in all activities Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 9 Combining Local and Global Core Muscles Abdominal hollowing Abdomen drawn in to facilitate transverse abdominis & multifidus Does not activate outer core muscles Abdominal bracing Abdominal & back muscles co‐contract Activates outer core muscles Progress to functional activities Sit to stand, walking, picking up objects Running & dynamic movements Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 10 Pathological Sacral Alignment – Movement Tests Investigation of the sacroiliac region should include posture, alignment and lumbar spine ROM Standing Forward‐Bend Test Thumbs on L & R PSIS Thumbs should move inferiorly as client bends forward (nutation) Seated Forward‐Bend Test As for standing test Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 11 Pathological Sacral Alignment – Movement Tests Kinetic Test (Gillet Test) To test left SIJ: Left thumb on left PSIS Right thumb on sacrum at same level Pt. lifts L knee to chest, L thumb should move inferiorly while R thumb stays still (nutation – WB on opposite leg) If L SIJ is injured & movement restricted, L thumb will stay at same level as R thumb Pt. lifts R knee to chest, R thumb should move inferiorly while L thumb stays still (counternutation – non WB on opposite leg) If L SIJ is injured & movement restricted, R thumb will stay at same level as L thumb Therapist then repeats the tests for the right SIJ Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 12 Pathological Sacral Alignment – Movement Tests Kinetic Test (Gillet Test) Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 13 Pathological Sacral Alignment – Provocation Tests Distraction Pt supine. Examiner applies posterolateral directed pressure to bilateral ASIS. (Reproduction of pain) Compression Pt sidelying. Examiner compresses pelvis with pressure applied over the iliac crest directed at the opposite iliac crest. (Reproduction of symptoms) Thigh Thrust (Femoral Shear) Pt supine. Examiner places hip in 90 deg flexion and adduction. Examiner then applies posteriorly directed force through the femur at varying angles of abduction/adduction. (Reproduction of buttock pain) Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 14 Pathological Sacral Alignment – Provocation Tests Sacral Thrust Pt prone. Examiner delivers an anteriorly directed thrust over the sacrum. (Reproduction of pain) Gaenslan’s Test Pt supine with both legs extended. The test leg is passively brought into full knee flexion, while the opposite hip remains in extension. Overpressure is then applied to the flexed extremity. (Reproduction of pain) Collectively known as the Cluster of van der Wurff https://www.youtube.com/watch?v=0fQYI5CVjvk Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 15 Exercise Program Considerations Postures or activities that increase SIJ stresses increase risk of SIJ injuries Excessive lumbar lordosis & anterior pelvic tilt Leg‐length discrepancy Fall & landing on one hip Misjudging step/gutter while walking or running Combined bending & twisting motions of the lumbar spine Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 16 Exercise Program Considerations Treatment should include: Stretches/mobility exercises (e.g. lumbar spine / hip flexibility) Core activation/strengthening Specific global/outer core muscle strengthening Functional activities while maintaining pelvic neutral Performance‐specific/work‐related activities while maintaining pelvic neutral Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 17 Functional Anatomy and Rehabilitation of the Pelvis and Hip FUNCTIONAL ANATOMY AND REHABILITATION OF THE HIP The Hip Joint The hip is a stable joint (deep socket with strong surrounding ligaments & muscles) Microtraumatic injuries > macrotraumatic injuries Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 19 The Hip Joint Common injuries: Muscle imbalance syndromes, acute soft‐tissue injuries, inflammatory conditions, fractures & dislocation Balance of muscle flexibility, strength & coordinated movement required for optimal function Hip injuries can alter kinetic chain loading patterns (e.g. compensatory movements) Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 20 Stabilisation Hip muscles contribute to core stability (lumbopelvic‐hip complex) Especially hip extensors, abductors & ER’s during single leg activities Hip strength important for force transfer between lower & upper body (kinetic chain) Lower extremities & trunk contribute 50‐55% of total force required for overhead activities Hip weakness = less force generation & greater stress on compensatory structures Hip ROM & strength testing important for not only hip pathology but also back, shoulder, knee and ankle injuries Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 21 Joint Mechanics Pelvic tilt & hip position Anterior pelvic tilt places hips in slight flexion Posterior pelvic tilt places hips in slight extension Single leg stance Gluteus medius (hip abductor) on stance leg must work harder to prevent pelvic drop on non‐WB side, keep the hips level, trunk vertical & head & shoulders level Weakness of gluteus medius will result in a Trendelenburg gait or leaning of the torso over the WB leg Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 22 General Rehabilitation Principles It can be difficult to interpret hip pain because several referring sources are possible Knee, thigh & groin pain can refer into the hip joint Spinal pain can refer into the ant. hip, buttock or thigh Sacral pain can refer into the buttock, posterior/lateral thigh Internal organs & abdomen pain can refer into the groin (particularly hernias) Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 23 General Rehabilitation Principles You should attempt to produce a comparable sign during hip testing to rule out referring pain from another region Reduce pain & control inflammation (may require de‐loading with use of assistive device) Progress through flexibility, strength, proprioception & functional activities Include pelvic neutral & core stability exercises & kinetic chain activities Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 24 Flexibility Exercises Several hip muscles cross more than one joint Also cross knee, pelvis & spine which must therefore be stabilised during stretching Agonist muscle should be relaxed during stretch however antagonist may contract to promote relaxation of agonist Stretches should be held 30 seconds or more & repeated throughout day, however prolonged stretching may be required for altering tissue length in scar tissue or ITB 2‐joint muscles need to be stretched over both joints For example, rectus femoris and hamstrings Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 25 Strengthening Exercises Can be progressed through isometric, bodyweight, resistance band, machine, free weight and swissball exercises Weight‐cuffs can be placed at the ankle & if less resistance is indicated, applied more proximally towards the hip Technique needs to be correct to avoid using the wrong muscles Smooth, controlled movements through full ROM Strength & control deficiencies in the trunk, knee & ankle need to be addressed (kinetic chain) Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 26 Proprioception, Functional and Performance-Specific Exercises Proprioception/balance exercises begin early in the rehab program Progress from static balance activities to distracting balance activities to agility to plyometrics Functional & performance‐specific ex’s according to sport or work demands For example, squats, lunges, steps, lateral lunges, cariocas Return to full participation/normal duties Once pt. can demonstrate normal strength, flexibility & agility bilaterally Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 27 Special Tests of the Hip Thomas Test Measures flexibility of the hip flexors https://www.youtube.com/watch?v=NMDd-4NspHs FABER Test (Patrick’s Test) Non-specific provocation test of the hip and SIJ Quantifies limitation of hip ROM https://www.youtube.com/watch?v=89Qiht82zmg FADDIR Test Provocation test for femoroacetabular impingement or labral tear https://www.youtube.com/watch?v=xyJUIhsL4lg OBER Test To identify tightness in the ITB and TFL https://www.youtube.com/watch?v=Amjv6FzDeLE Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 28 Muscle Imbalance Syndromes Muscle imbalances cause soft tissue injuries and pain around the pelvis, hip & thigh Characterised by tightness of a muscle group & weakness of the antagonist muscle group Hip flexor tightness – typically observed with lumbar lordosis Tight hip flexors (iliopsoas, iliacus, rectus femoris) & weak hip/lumbar extensors Pt. presents with anteriorly tilted pelvis & hypertonic lumbar ES, QL & lat. Dorsi Risk for Lx pain, disc degeneration, spondylosis, spondylolysis & spondylolisthesis +ve Thomas test & underactive glutes in prone hip extension mechanism test Tx as for lower crossed syndrome Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 29 Acute Soft-Tissue Injuries Groin strains can involve any of the hip adductors Usually from high‐speed activities with rapid changes of direction (overstretch and/or overload) Risk factors: Muscle tightness, weakness and imbalances Antalgic gait favouring injured side, shortened step length, uneven cadence, reduced hip & knee motion (may require crutches) Aquatic‐based exercise rehab – warmer temperatures relax muscles & increase blood flow Progress through ROM, strength, balance, plyometric & functional ex’s Sprains Usually from high‐impact accidents or falls May require crutches Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 30 Femoroacetabular Conditions Pincer Impingement: Acetabulum covers more of femoral head than it should Cam (Acetabular) Impingement: Anterior–superior femoral head–neck junction is aspherical Common to have both types of impingement Causes articular damage & damage to the labrum Early onset hip OA Painful hip flexion/medial rotation, squatting, kicking sports Exercise rehab following surgery – avoid end‐range hip flexion, hip extension, abduction & lateral rotation movements esp. in WB Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 31 Hip Osteoarthritis 9% of Australians (~2.1 million people) have OA 2/3 are female; 26% of people with OA report fair to poor health vs. 13% of people without OA 31% increase in hip joint replacement due to OA from 2005‐06 to 2014‐15 Risk factors for hip OA: Age, developmental disorders, previous injuries, overweight/obesity, sports participation, leg‐length discrepancy Pain: Deep dull ache in groin, lateral hip, medial knee and/or buttock Typically, movement provokes pain, rest relieves pain Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 32 Hip Osteoarthritis If 4 of 5 of the following variables are present there’s a 90% probability that the pt. has hip OA 1. Self‐reported squatting is an aggravating factor 2. Active hip flexion causes lateral hip pain 3. Scour test with adduction (similar to the FADIR test) causes lateral hip or groin pain 4. Active hip extension causes pain 5. Passive internal rotation of less than or equal to 25 degrees when it should be 45 degrees Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 33 Hip Osteoarthritis - Management Manage pain & inflammation Modify activities – may require use of assistive devices, proper body mechanics & posture education; switch WB to non‐WB activities if required Alter biomechanical loading & forces through the hip joint Often a result of muscle imbalances which affect posture & gait Restore ROM particularly through hip extension, flexion, medial rotation & abduction Strengthen hip abductors, lateral rotators, extensor Above all, encourage an increase in physical activity levels and a reduction in body mass if overweight or obese Evidence clearly shows that these two parameters (physical activity levels and body mass are the two most influential factors in improving hip OA pain) Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 34 Hip Osteoarthritis – Total Hip Replacement The treatment of choice for unrelenting, severe hip OA pain or hip OA that is resulting in ‘giving way’ Can be performed using a variety of surgical approaches, the two most common are the posterior and anterior approaches Posterior approach - https://www.youtube.com/watch?v=1lTeY2gZ4xY Anterior approach - https://www.youtube.com/watch?v=MTJK9tdSsQY Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 35 Hip Osteoarthritis – Total Hip Replacement Each Surgeon will provide a post-operative rehabilitation protocol following THR (these will vary depending on the Surgeon and the surgical approach used to perform the procedure) You need to exercise great care in rehabilitation following a posterior approach THR Posterior approach THR precautions (first 3 months post-operatively) No hip flexion past 90 degrees No adduction past the midline of the body No weight bearing pivots or twists Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 36 Hip Dislocation Rare but serious injury with long‐term rehab Caused by MVA / MBA & high‐impacts e.g. crash during downhill skiing Weeks 0 ‐ 6: non‐WB ambulation; isometric hip strength ex’s, isotonic knee & ankle ex’s (e.g. resistance bands & ankle weights) Avoid hip adduction, flexion & trunk flexion – i.e. crossing legs, sitting in 90° hip flexion, bending forward from waist for 12 ‐ 16 weeks post‐injury Crutches for 6 ‐ 8 weeks post‐injury until normal ambulation Aquatic ex’s 2 ‐ 3 weeks post‐injury Partial WB – heel slides for AROM of the hip Full WB – partial squats, step‐ups & calf raises Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 37 Hip Dislocation Weeks 6 ‐ 8: Stationary cycling Week 10: Treadmill walking Week 12: Incline walking Week 14‐16: Jogging Weeks 20 ‐ 30: Running & performance‐specific activities Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 38 Other Hip Conditions Overuse injuries are common: Bursitis and tendinopathies Caused by faulty biomechanics through repetitive motion Normalise ROM, normalise biomechanics, ensure strength is equal and address muscle imbalances One common example is ITB syndrome, which is usually caused by endurance running (or cycling) with adduction of the stance leg during the WB phase Due to excessive foot pronation, medial tibial & femoral rotation & pelvic drop Typically pt. has weak hip abductors, extensors & lateral rotators & presents with lower crossed syndrome Pain felt at lateral hip or knee Injury stems from poor lumbopelvic‐hip stability & altered biomechanics Week 6 - Functional Anatomy and Rehabilitation of the Pelvis and Hip 39