T Kevin Robinson And Karen M Griffin

Unlock Your Hip Flexors

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FIGURE 17.8. With the patient positioned prone' the hip is maximally extended 30 degrees.

rily by the symptoms. For this patient, a primarily home-based rehabilitation program may suffice. It relies on patient compliance, however. After initial exercise instruction about frequency and duration, the program can often be accomplished with the simplest

FIGURE 17.9. (A' B) Abduction and adduction are measured. Care is taken to avoid accessory movement by keeping the pelvis stable.
FIGURE 17.10. (A, B) With the hip flexed 90 degrees, maximal internal and external rotation are recorded.
FIGURE 17.11. A quick test of abduction is performed by asking the patient to stand and spread his or her legs as far apart as possible.

FIGURE 17.12. Adduction is checked by asking the patient to al- FIGURE 17.14. Combined flexion and adduction are checked by alternately cross his or her legs. ternately crossing one thigh over the other in a seated position.

FIGURE 17.13. Flexion can be estimated by having the patient draw the knee toward the chest as far as possible without bending the FIGURE 17.15. Extension is checked by having the patient rise back. from a seated position with arms folded across the chest.

FIGURE 17.16. The Thomas test allows more accurate quantification of hip flexion. Accessory movement via pelvic tilt is eliminated by maintaining the contralateral hip in maximal extension. Flexion of the examined hip is then recorded.
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FIGURE 17.18. The Ober test assesses tightness of the iliotibial band. With the patient positioned on his or her side, the hip is extended and the knee flexed. Limitation of passive adduction is then indicative of a tight iliotibial band.

home equipment. For a patient undergoing abrasion arthroplasty, the rehabilitation process is much more deliberate, with a prolonged interval of protected weight bearing. During this time, the intensity of rehabilitation is conservative and often may be accomplished easily with an independent program and only occasional supervision. Conversely, an athlete with a labral tear and otherwise healthy joint may be expected to progress much more aggressively through the protocol phases with the anticipation of regaining full function and return to sports. In this case, the clinical environment, or at least access to a well-equipped workout facility, is preferred. More clinical attention is necessary to gauge the patient's response and ensure safe progression.

Postoperative recovery actually begins with the preoperative educational process. This may be a struc-

FIGURE 17.17. Conversely, the Thomas test can be used to check for a flexion contracture. The contralateral extremity is drawn maximally toward the chest. The examined hip is then extended. Inability to lay the leg flat on the table reflects a hip flexion contracture.

tured prehabilitation program that addresses impairments such as pain, swelling, postural deviations, compensated mobility, muscle length and muscle strength, decreased proprioception, and muscular and cardiovascular endurance. Hip pain may alter lum-bopelvic hip movement patterns that lead to impairments of muscular balances and faulty mechanics. In other cases, a single comprehensive preoperative visit for instruction, explanation, and demonstration of the expected postoperative rehabilitation protocol is all that is needed. The patient should be aware that the rehabilitation responsibilities begin even before leaving the outpatient area. Many of the initial exercises can be performed independently, but the patient should understand the importance of beginning isometric contractions at the hip and ankle plantarflexion and dorsiflexion pumps to facilitate lower extremity circulation (Appendix A).

The patient's weight-bearing status can vary depending on the surgeon's findings and procedure performed. Typically, weight bearing is allowed as tolerated, and crutches are discontinued within the first week. Although the discomfort associated with ar-throscopy might be surprisingly little, there can still be a significant amount of reflex inhibition and poor muscle firing as a result of the combination of penetration with the arthroscopic portals and the traction applied during the procedure. The gluteus medius muscle is a prime example of this. In a typical ar-throscopic procedure the anterolateral and posterolat-eral portals pass through this muscle. Clinically, it is common for the patient to have a difficult time regaining muscle tone and appropriate firing of this muscle after surgery. This problem is analogous to the effects of an arthroscopic knee surgery on the vastus medialis muscle. Functionally, this muscle is needed to maintain a level pelvis during ambulation. Addi tionally, due to the short moment arm of the gluteus medius, this muscle causes a large joint compression force when it contracts during the single limb stance phase of gait.5 In a patient with hip articular pathology it is common to find inhibition of the gluteus medius muscle as a result of pain. Consequently, as-sistive devices are helpful to reestablish a normal gait pattern and synchronous muscle activity. The most effective method of neutralizing compressive forces across the hip is to allow the patient to apply the equivalent weight of the leg on the ground (Figure 17.19). Maintaining a true nonweight-bearing status requires significant muscle force to suspend the extremity off the ground, thus generating considerable dynamic compression across the joint as a result of muscle contraction. Resting the weight of the leg on the ground neutralizes this dynamic compressive effect of the muscles. Additionally, simple devices such as insoles may help to relieve compressive stress for some patients.

Muscle-toning exercises are performed within the first week after surgery. These exercises require progression dependent on the patient's tolerance but should not be overly aggressive. Isometric exercises are the simplest and least likely to aggravate underlying joint symptoms: these include isometric sets for the gluteals, quadriceps, hamstrings, adductor and abductor muscle groups, and lower abdominals. Addi-

FIGURE 17.19. Protected weight bearing allows gradual transference of weight to the affected extremity.

FIGURE 17.20. Gluteal isometrics may decrease overactivity of the iliopsoas and provide a decrease in anterior hip pain.

tionally, isometric contraction of the antagonistic muscle group may inhibit spasms and promote pain relief. Gluteal isometrics may decrease overactivity of the iliopsoas and provide a decrease in anterior hip pain (Figure 17.20) (Appendix B).

An aquatic program is often beneficial for allowing early return to exercise and can begin as soon as the portal sites have healed and the sutures have been removed. A pool program allows for earlier joint mobilization and gentle strengthening in a reduced-weight environment. The water buoyancy can provide assistance to movement in all planes as safer resistance with increased active exercises (Figure 17.21). Gait activities can be progressed in waist-deep water with minimized compression of the surgical site (Appendix C).

Active assisted range-of-motion exercises are begun early. These are then progressed to active range of motion, gravity-assisted, and then to gravity-resisted exercises during the postoperative recovery. Exercises

FIGURE 17.21. A water program allows for the progression of many exercises in a reduced-weight environment.

FIGURE 17.19. Protected weight bearing allows gradual transference of weight to the affected extremity.

FIGURE 17.21. A water program allows for the progression of many exercises in a reduced-weight environment.

are directed in all planes of hip motion, and the end ranges of motion are determined by the patient's level of discomfort (Appendix D). Stretching is typically pushed only to tolerance, and the patient is educated as to these parameters. Pushing the extremes of range of motion does little to enhance function and may exacerbate discomfort. An exception to this is after excision of large bony osteophytes that had created a prominent bony block to motion. Aggressive early stretching under these circumstances can regain the previously blocked motion and might indeed improve function when there was a significant mechanical block. Manual mobilization techniques can assist in the reduction of compressive forces across the articular surfaces. This reduction may lessen discomfort, and over time enhance cartilage healing.30 Small accessory oscillation movements stimulate joint mechanorecep-tors, assisting in pain modulation. Graded mobilization with flexion and adduction movement or internal rotation is gently implemented with the moderately painful joint.21

Distraction techniques (longitudinal movement) are most useful when hip movements are painful. Oscillatory longitudinal movements are produced by pulling gently on the femur (Figure 17.22). This technique can be assisted by a rolling or sliding motion by the clinician with support under the patient's thigh in the direction of the treatment movement and can be performed in varying degrees of hip flexion (Figure 17.23). Oscillatory movements in a compression mode, stopping short of the pain position, can be helpful, especially for patients with pain on weight bearing.

Very little posteroanterior movement of the femoral head takes place within the acetabulum, but anterior and posterior glides can also be beneficial for the painful hip joint (Figure 17.24). It can also be used as an accessory movement at the limit of physiologic range when a goal of treatment is to increase the range of motion of the joint.21 The pres-

Inferior Glides Hip
FIGURE 17.23. To perform inferior glides, the patient's lower leg rests on the therapist's shoulder. The therapist then manually applies a distraction force on the anterior proximal thigh.

ence of a capsular pattern of the hip as described by Cyriax is often found secondary to the postoperative effusion. Characteristic of that pattern is a gross limitation of flexion, abduction, and internal rotation, with minimal loss of extension and external rotation.31

Joint range of motion is normalized by restoring capsular extensibility. Limitation of hip flexion and internal rotation commonly occurs because of posterior capsular restrictions. In cases with painful restricted motion, the clinician must assess carefully whether mobilization techniques are a viable treatment option, depending on the physical status of the hip joint and the psychologic status of the patient. Because of apprehension or other psychomotor factors, some patients may not be good candidates for application of these techniques.

Posterior Femur Glide

FIGURE 17.24. For posterior glides, the therapist applies pressure downward on the knee, creating posterior translation of the femoral head relative to the acetabulum.

FIGURE 17.22. Straight plane distraction is demonstrated by applying an axial traction force on the extremity.

FIGURE 17.24. For posterior glides, the therapist applies pressure downward on the knee, creating posterior translation of the femoral head relative to the acetabulum.

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Essentials of Human Physiology

Essentials of Human Physiology

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