Comprehensive Guide to Hip Alignment and Rehabilitation

1. chapter24 Hip

2. Hip • A common site for pain referral • Lumbar disc • Organ disease • Myofascial pain • SI dysfunction • Knee • Force transmitter for upper and lower extremities • Stability for upper- and lower-extremity activities • experiences repetitive, microtraumatic injuries more often than acute, macrotraumatic injuries Reassess if no change after 2 weeks of treatment

3. Hip Alignment Coxa valga (see figure 24.1b) • Angle between neck and shaft = >125° •  Femoral head load,  femoral neck stress • Lengthens the limb •  Hip abductor effectiveness Coxa vara (see figure 24.1c) • Angle between neck and shaft = <125° •  Femoral neck stress,  femoral head load • Shortens the limb •  Hip abductor effectiveness

4. Figure 24.1b

5. Figure 24.1c

6. Transverse Plane Hip Alignment Retroversion (see figure 24.2b) • Femoral neck is rotated in relation to femoral shaft at an angle <12° • External rotation (ER), toe-out gait • Supinated foot, frog-eyed patellae,  Q-angle,  lumbar lordosis (continued)

7. Transverse Plane Hip Alignment (continued) Anteversion (see figure 24.2c) • Femoral neck rotated in relation to femoral shaft at an angle >15° • Internal rotation (IR), toe-in gait • Pronated foot, squinting patellae,  Q-angle,  lumbar lordosis

8. Figure 24.2b

9. Figure 24.2c

10. Figure 24.3a

11. Figure 24.3b

12. Neural Considerations • Sciatic nerve • Can run through piriformis • Impingement: posterior leg, calf symptoms • Lateral femoral cutaneous nerve • Goes through psoas major and under inguinal ligament • Impingement: tensor fascia latae, anterolateral thigh ache/burn • Obturator nerve • Enters thigh to provide sensory and motor innervation to medial thigh • Impingement: medial thigh sensory, adductor strength changes

13. Joint Mobility • Convex on concave rule • Resting position: 30° flexion, 30° abduction, slight lateral rotation • Close-packed position: full extension, abduction, and internal rotation • Capsular pattern: • ER = normal • IR = most restricted • Loss of motion: IR > flexion and abduction > extension

14. Influence of Pelvis • Pelvis movement influences hip movement • Anterior pelvic tilt • Moves anterior pelvis closer to anterior femur •  Hip flexion • Posterior pelvic tilt • Moves posterior pelvis closer to posterior femur •  Hip extension

15. Unilateral Weight Bearing • In one-leg stance: • Rotation stress on hip • Hip abductors prevent contralateral pelvic drop • Necessary abductor force • >BW 2° LAL (lever-arm length) • If weak, hip will drop or patient must lean to  BW LAL

16. Figure 24.4

17. Assistive Devices in Ambulation • Assistive devices used to assist weak hip abductors • Cane on opposite side  upward counterbalance force • Force through cane is small (~15%): cane LAL = >CoG LAL

18. Figure 24.5

19. Leg-Length Discrepancies • Can be caused by true length or soft-tissue differences • Pelvis drops on shorter side; trunk bends away from the short leg in weight bearing • Uneven shoe wear most obvious indication • Can lead to osteoarthritis of longer leg

20. Reducing Hip Stress in AcuteLower-Extremity Injuries • Goal post-injury: normal gait • Antalgic gait: requires assistive devices until normal ambulation is possible •  Stride length during walking or running • Smaller stride reduces the force and motion demands • Spica wrap

21. Rehabilitation Considerations • Hip pain can be difficult to interpret since there are several referring sources of pain • Hip: to groin, medial anterior thigh • Spine: to anterior hip, buttock, thigh • Sacrum: buttock, posterior thigh, lateral thigh • Organs and abdomen: to groin • Differential diagnosis may be needed (continued)

22. Rehabilitation Considerations (continued) • Some hip injuries are self-limiting. • Predisposing factors must be corrected to reduce recurrence. • Inclusion exercises: • Hip stabilization • Knee and ankle weakness • Trunk stabilization

23. Soft-Tissue Mobilization • If Rx is not effective, reassess: • Soft-tissue techniques • Deep-tissue massage • Scar-tissue massage • Cross-friction mobilization • Myofascial release (i.e., trigger point and ice-and-stretch) • End with active stretches • Home exercise program: Stretches, self-mobilization

24. Figure 24.6a1

25. Figure 24.6a2

26. Figure 24.6b

27. Figure 24.6c

28. Figure 24.8a1

29. Figure 24.8a2

30. Figure 24.8a3

31. Figure 24.8b

32. Figure 24.8c

33. Figure 24.9a

34. Figure 24.9b

35. Figure 24.9c

36. Figure 24.10a

37. Figure 24.10b

38. Figure 24.10c

39. Joint Mobilization • Capsular pattern: grades III, IV • Techniques • I and II: oscillating • III and IV: sustained or oscillating • Little need to stabilize hip joint before mobilization; pelvis is sufficient anchor • Self-mobilization: with strap or on step

40. Figure 24.12a

41. Figure 24.12b

42. Figure 24.13a

43. Figure 24.13b

44. Figure 24.13c

45. Figure 24.14a

46. Figure 24.14b

47. Figure 24.15

48. Figure 24.16a

49. Figure 24.16b

50. Figure 24.17