the hip

THE HIP

Therapeutic exercise 2

Lino Linford Bangayan

Hip Anatomy

• articulation between the hemispherical head of the femur and the cup-shaped acetabulum of the hip bone

• It is a ball-and-socket joint.• Has a wide range of movement: flexion,

extension, adduction, abduction, external rotation, and internal rotation.

Open-pack resting position: 30° abd, 30° flex, and slight lat rot

Close-pack position: Ext, med rot, and abdCapsular Pattern: Flex, Ext, and Med Rot (order may vary)

Degree of movement• Flexion (110° to 120°)• Extension (10° to 15°)• Abduction (30° to 50°)• Adduction (30°)• Lateral rotation (40° to 60°)• Medial rotation (30° to 40°)

Arthrokinematics of the hip jointPhysiologic motions of the femur

roll slide

Flex Ant Post

Ext Post Ant

Abd Lat Inf

Add Med Sup

Int rot Med Post

Ext rot lat Ant

Legg-Calve-Perthes Disease

• Definition: Legg-Calve-Perthes disease is a idiopathic osteonecrosis of the femoral head in children. AKA coxa plana

• Incidence: Frequently in boys (80%) ages of 3-12 years old, mostly 7 yrs old. Unilateral involvement is 85%, more common than bilateral.

• Etiology: cause is not been established• Pathophysiology: necrosis of the epiphysis of

the femoral head bone and marrow. The femoral head collapses and necrotic bone is reabsorbed. Regeneration of the head (2-3yrs) occurs, rarely to its original shape.

Sign and Symptoms:• Limping w/ or w/out pain (progressive)• Muscle spasm• Slight limitation of motion• Shortening of the leg

• Med management: bilateral long leg casts w/ braces to maintain abd. And slightly int. Rot. Or surgery (osteonomy) only for Pts w/ poor prognosis.

Osteonomy• Surgical cutting and realignment of bone• Postop: cast to maintain bone-bone

apposition for 8-12 wksPT Management• Before med management: traction• Braces: stretching, resistance exercises, ROM

Osteonomy postop: • ROM on unaffectd joints • when motion is allowed AAROM to AROM to

resistance exercise(2-3wks after immobilization)

• joint mobilization (grade 3 or 4) • Stretching• Scar tissue mobilization

Chondrolysis

• Definition: or cartilage necrosis of the hip is a disorder of unknown cause. Characterized by progressive narrowing of the joint space due to the loss of cartilage from both acetabular and femoral surfaces. It its most frequently seen complicates slipped capital femoral epiphysis but also in other hip disorders after hip surgery.

• Incidence: occurs in teenagers, particularly common w/ black patients w/ slipped epiphysis

• Pathophysiology• Matrix loss and articular cartilage

degeneration

• Signs and symptoms• Hip pain w/ progressive loss of mobility• Hip flexion and adduction contractures

• Med management• Anti inflammatory drugs

• PT management• Gentle active exercises to prevent

deformity(isometrics)

Hip Fracture

• Definition: it its the fracture of the most proximal part of the femur in the hip joint area.

• Incidence: 70% are >70 years old, women > men, 2-3% < 50 years old

• Pathoohysiology: high-impact trauma or repetitive microtrauma to the proximal femur, patients w/ osteoporosis increases the chance of a pathologic fracture

• Signs and symptoms: pain in the hip or groin region, pain w/ active or passive motion of the hip, pain w/ lower extremity weight bearing, lower extremity appears shorter and in a external rotation position.

• Types of hip fracture: • Intracapsular: femoral head, subcapital, and

femoral neck (transcervical)• May disturb blood flow and cause avascular

necrosis or nonunion

• Extracapsular: intertrochanteric, and stable or unstable (comminuted)

• Does not disturb blood flow but nonunion can occur as a result to fixation failure

• Medical Management:• Surgical intervention (open reduction)

• Signs and symptoms of possible failure of the internal fixation mechanism:

• Severe persistent pain @ the groin, thigh or knee

• Progressive limb length inequality• Persistent ext. Rot. On operated limb• (+) trendelenburg sign

• Trendelenburg sign

Weight-bearing considerations

• The surgeon decides how much allowable weight-bearing each individual Pt

• Factors involved: age, bone quality, fracture location and pattern, type of fixation, and intraoperative stability

• PT ManagementPostoperative managment (start moving as early

as possible)Goals for maximum protection phase• Prevent vascular or pulmonary complications• Improve strength of upper and lower x• Prevent postoperative reflex inhibition of hip

and knee musculature• Restore active mobility and dynamic control of

the involved hip and adjacent joints

• Maximum protection phasePROM, resistance exercises for unaffected

extremitiesAround 2-4 wks postop expect 80° - 90° hip flex

w/ knee flexDelay resistance exercise for hip to 4-6 wks

postop

• Moderate and minimum protection phasesGoals:• Increase flexibility of any chronically

shortened ms• Improve strength and muscular endurance in

the lower x for functional activities• Improve postural stability and standing

balance• Increase cardiopulmonary endurance

• Moderate and minimum protection phases6 wks soft tissues healed, partial weight bearing

only as tolerated8-12 wks some degree of bone healing, wean

from the use of assistive ambulatory devices8-16 wks or up to 6 mons in some patients bone

healing durationfocus on strengthening and increase in

functional control

Total Hip Arthroplasty

• Definiton: is a surgical procedure in which the acetabulum and the femur is rescted and replaced with prosthetics.

• Incidence: Pts 60-65 yrs old

• Pathophysiology: advanced stage of Osteoarthritis (has deteriolated the joint)

Indications to THA

• Joint deterioration and loss of articular cartilage associated with OA, RA, ankylosing spondylitis, or osteonecrosis

• Nonunion fracture, instability or deformity of the hip

• Bone tumors• Failure of conservative management or

previous joint reconstruction procedures

Contraindications for THA

Asolute• Active joint infection• Systemic infection• Chronic osteomyelitis• Significant loss of bone

after resection of a malignant tumor

• Neuropathic hip joint• Severe paralysis of the

muscles surrounding joint

Relative• Localized infection• Insufficient function of

the gluteus med• Progressive neurologic

disorder• Progressive bone dse

(compromised bone or not enough stock)

• Dental surgery>arthroplasty

• High-demand activities

Preoperative Management

• Examination and evaluation of pain, ROM, muscle strength, balance, ambulatory, status, leg lengths, gait characteristics, use of assistive devices, general level of function, perceived level of disability

• Patient and family education• Post operative precautions• Functional training for early days of postop• Early postop exercises• Criteria for discharge

Types of THA surgical procedures• Standard: substantial trauma to soft tissue

contributes to lengthy postop and less complications involved

• Posterolateral approach• Direct lateral approach• Anterolateral approach

• Minimally invasive: less soft tissue trauma but more technically challenging surgery and more complications

Complications

Can occur during ealry part of recovery (6 wks-2-3 mons)

• Malpostioning of prosthetic components

• Femoral fracture• Nerve injury• Infection• DVT• Pneumonia• Wound healing problems

• Dislocation• Disruption of bone graft

site • And leg length

discrepancyLate complications• Dislocation• Loosening of bone

implant• Polyethylene wear• Heterotopic ossification

Risk factors for joint dislocation in THA

Pts related factors• >80-85 yrs old• THA for femoral neck

fracture• RA>OA• Poor quality soft tissue from

chronic inflammatory dse• History of past hip surgery• Pre and postop muscle

contracture• Cognitive dysfunction

Surgery/prosthesis factors• Surgical approach:

post>ant• Malpositioning of the

acetabular component• Inadequate soft tissue

balancing during surgery of poor quality soft tissue repair

• Experience of the sugeon

Postop management

Early postop precautionsPost/postlat approach• Avoid >80-90° hip flex (6

wks), add, and int rot beyond neutral

• Transfers and pivot only in sound side

• No cross leg• Knees slightly lower than

hips• no sidelying

Ant/antlat and lat approaches w/ or w/out trochanteric osteonomy

• No >90° hip flex (6 wks), ext, add, and ext rot (>45°)

• If the gluteus med is incised and repaired or a trochanteric osteonomy was done, no active antigravity abd for 6-8 wks or approved by the sugeon

Maximum protection phase (day1-4to6wks)

• Exercises are done 1st day right after surgery• Prevent vascular and pulmonary complications• Prevent dislocation and subluxation• Achieve independent functional mobility prior to

discharge• Resistive and ROM for unoperated joints• Isometric exercises for operated limb (precaution if

there is trochanteric osteonomy)• Regain active mobility and control

Moderate and Minimum protection phases

• Regain strength and muscular endurance• Improve cardiopulmonary endurance• Reduce contractures while adhering to motion

precautions • Improve gait, postural stability, and balance• Prepare for full level of functional activities

Accelerated rehab of minimal invasive THA (9 days)

• Eligible for this program: 40-75 yrs old w/ BMI <35, no previous hip surgery, no history of vascular, cardiac, or pulmonary disorders

• Preoperative activities: Pts Ed• Postop therapy: can start 5-6hrs after surgery: bed

transfers, ambulation w/ crutches progressing to cane as tolerated, up and down stairs

• Home-based and outpatient therapy: progress to cane ASAP until able to ambulate symmetrically and no limping. Have patient maintain an activity log

Hemiarthroplasty of the hip

Indications• Acute displaced

intracapsular fracture of proximal femur on an old Pt

• Failed internal fixation of intracapsular fractures associated w/ osteonecrosis

• Severe degeneration of the head of femur (acetabulum intact)

Postop management• same in THA• Precaution: avoid

compressing or shearing forces on the hip, threatens to erode the acetabulum cartilage

Hip Dislocation

• The displacement of the head of the femur. It is mostly displaced upwards or posteriorly.

• PathophysiologyPathologic dislocation of the hip may result in 2ways: erosion of bone about the acetabulum,the femoral head, or both or paralysis of themuscles and relaxation of other soft tissuesaround the hip joint.

• Signs and symptoms:• Flex and add w/ pain and spasm• In paralytic disorders: weak extensors and

abductors w/ overpull of flex and add can result to dislocation.

• Med management• surgery

• PT Mangaement• Prevention, the possibility of a dislocation

should be anticipated• Prevent flex and add• In infections: the leg must be kept in traction

and in abd• In paralytic disorders: lengthening of the

iliopsoas tendon

Overuse Syndromes

• Tendinitis/muscle pull• definition: inflammation of a tendon in the hip

muscle• Incidence: Poor flexibility and fatigue may

predispose anybody to strain and injury during an activity or sporting events.

• Pathophysiology: overuse or trauma to any muscle of the hip region can result from excessive strain while the muscle is contracting or repetitive use w/ no time to give time for the muscle to heal. repetitive use w/out letting the muscle rest to heal, sudden falls

• Trochanteric Bursitis• Definition: inflammation of the trochanteric

bursa causing pain to the lat. Hip and thigh and knee.

• Pathophysiology: standing asymmetrically for long periods of time. Muscle flexibility and strength imbalance may occur = faulty pelvis posture. The leg is usually held in a abd and ext rot position to relieve the gluteus max and the bursa. Any leg motion makes pain

• Iliopsoas bursitis• Definition: inflammation of the iliopsoas bursa

• Pathophysiology: pain is caused by the pressure of the femoral nerve. Radiate down to the front of the leg.

• Ischiogluteal bursitis (tailor’s or weaver’s button)

• Definition: the inflammation of the ischiogluteal bursa.

• Incidence: develops in tailors, boatmen, and other people whos occupation requires sitting in hard surfaces in a prolonged period.

• Pathophysiology: tenderness over the tuberosity of the ischium. Radiating pain down to the back of the thigh along of the course of the hamstrings

• Common sign and symptoms• Pain• Gait deviations• Imbalance in muscle flexibility and strength• Decreased muscular endurance

• Med management:• If infected (bursa): antibiotics and drainage• Procaine and hydrocortisone

• PT management:Protection phase• Control inflammation and promote healing• Develop support in related areasControlled motion phase• Develop a strong mobile scar and regain flexibility• Develop a balance in length and strength of hip

muscles • Develop stability and closed-chain function• Develop muscle and cardiopulmonary endurance• Patient education

Return to function phase• Progress strength and functional control• Return to function

Exercise Intervention for the hip region

Techniques to stretch range-limiting hip structures

To increase hip extension• Prone press-up in prone position w/hands on table, raisethe thorax while thepevis sags.

• Thomas testSupine while hips on theedge of the treatmenttable, both hips and kneesflexed, and the thighopposite to the tight hip isheld against the hip. Havethe patient lower theaffected leg and allow theknee to extend.

• Modified fencerStanding in a fencer’sLunge-like position, w/back leg in the same paneas the front leg and thefoot pointing forward. Doa posterior pelvic tilt thenshift body weight onto theanterior leg.

• To increase hip flexion• Bilateral knee to chestSupine. Have patient bring

both knees to chest and grasp the thigh firmly. The pelvis should not rise or else it would be a lumbar stretch

• Unilateral knee to chestJust like in bilateral kneeto chest but only theother extremity is. Onlykept extended on the mat.To emphasize stretch onthe gluteus med, have the Patient pull the knee to the opposite shoulder.

• Quadruped stretchOn hands and knees, havethe patient rock the pelvis to an anterior tilt. Then shift buttocks back in an attempt to sit on the Heels.

• chair stretch• Sitting in a chair w/ hip

ant rot and back extended. Hold the chair and lean forward while keeping the back arched.

• To increase hip abduction

• Supine w/ both hips flexed 90°, knees ext, and legs and buttocks against the wall. Have the patient abd both hips as far as possible.

• To increase hip abd and ext rot simultaneously

• Sitting or supine w/ soles of feet together and hands on the inner surface of knees. Have the patient push down.

• Standing in fencer’s position but w/ hind leg ext rot and shift weight to the front leg.

• Techniques to stretch range-limiting 2-joint muscles

• Thomas test stretch: the difference here is the knee is flexed

• Prone stretch: prone w/ knee flexed on the side to be stretched

• Standing stretch: standing w/ the hip ext and knee flexed and grasping the ankle.

• Hamstring stretches• Straight leg raising:

supine w/ towel under thigh. Have the patient perform SLR(straight leg rising) w/ 1 extremity and apply stretch force by pulling on the towel to move the hip into more flexion.

• Doorway stretch:• Supine on the floor w/ 1

leg propped up against the door frame. The pelvis and opposite leg must remain on the floor and knee extended.

• Chair stretch• Sitting w/ the leg to be

stretched extended across to another chair, or sitting at the edge of the treatment table, with the leg to be stretched on the table and the opposite foot on the floor. Lean forward and back ext to stretch.

• Bilateral toe touching• Standing and w/ hands

on the side. Ant pelvic tilt and back ext, bend only the hips.

• To stretch the TFL• Standing stretch• Standing w/ the side to

be stretched at the wall, w/ hand of that side placed on the wall. have the patient add and ext rot the extremity to be stretched and cross it w/ the on other extremity. To stretch, shift weight to the wall and let the other leg knee bend.

• Side-lying stretch• Side-lying w/ the leg to

be stretched at the upper portion. Bottom part is flexed for support, the stretched leg is outstretched and laterally rotated, then slowly adduct. Flex knee for additional stretched.

Exercises to develop and improve muscle performance and functional control

• To develop control of and strengthen hip abd

• Supine abduction: used in very weak Pts

• Side-lying abduction: if Pt has difficulty in control let the Pt practice w/ ext rot 1st.

• Standing abduction• If TFL is tight, stretch it out

1st

• To develop control and strengthen hip extension

• Gluteal muscle setting• Forward-bending leg lift:

standing at the edge of the treatment table and the trunk flexed and supported on the table, alternately ext hip knee flexed

• Note: if the hamstring cramps, let the Pt learn how to relax before progressing

• Quadruped leg lifts: alternately ext hip and knee flexed

• To develop control of and strengthen hip external rotation

• Prone: knees flexed and 10in apart and press heels together

• Side-lying: legs flexed and aligned, lift knee while heels are together

• To progress: ext top hip till same plane w/ body cont. Roll leg outward

• Standing: feet parallel 4in apart, flex knees pointing laterally (you squat :\)

• Sitting: w/ knees flexed at the edge of treatment table w/ an elastic material secured on the ankle and to the leg of the same side. Move foot to the opposite side

• To develop control of and strengthen hip adduction

• Side-lying: w/ the bottom leg aligned w/ the body and the upper leg flexed forward and foot resting on the floor/ table. Have the bottom leg do add. A harder position is to abd the upper leg and the lower leg adds to reach it.

• Standing: have the leg add in front of the weight-bearing leg

Closed-chain weight-bearing exercises

• Hip hiking/pelvic drop• Standing on one leg on

a 2-4in block and lower and elevate the unsupported pelvis

• Bridging: hook-lying position, elevate pelvis and ext hips

• Progression: add a weight belt or bridging on a gym ball

• Single-leg stance against resistance

• Stand on uninvolved leg. Place elastic resistance on the other leg(thigh) and secure it to a stable upright structure.

• This exercise is open chain for the moving extremity and closed for the weight-bearing

• Step-ups• Begin w/ low steps 2-

3in high progress if Pt is able. Have the Pt step forward, backward, and sidewards.

• Lunges• Have the Pt stride forward

and flex the hip and knee of the forward extremity and return upright. Progress till 90° knee flexion.

• Use cane for balance control.

• Progression: weights on hands, longer strides, can progress to functional activity: lunge to pick objects

Note: ACL deficiency or a surgically repaired ACL should not flex knee forward the toes. To protect ACL, knee flex 0-60°, to protect a patellofemoral compression squat only in pain free ranges and no deep knee bends

• Wall slides• Have Pt rest the back

against the wall feet forward and shoulder-width apart. Pt slides down by flexing hips, knees, and dorsiflexing ankles then slide up by ext of hips and knees and plantarflexing ankles.

• Progression:• A large exercise ball on

the back, add arm motions or weights to add coordination or resistance. To develop isometric strength, hold flexed position and superimpose arm postions w/ weights

• Partial squats/mini squats

• Have Pt lower trunk by flex the hips and knees like sitting on a chair. Add weights on hands or use elastic resistance secured under the feet. Progress to safe lifting technique.

• Postural control and balance activities

• Weight-bearing control and balance training begins as soon as the Pt can tolerate Partial weight-bearing.

• Weight shifting• Pt cannot bear the full

weight: use parallel bars• Shift ant, post, side, and

obliquely• Add pressure for

resistance

• Balance activities w/ arm movements

• Bilateral to uilateral• progression: Simple

arm movements, moving arms, moving arms w/ following movement w/ the eye and head, moving the entire trunk w/ arm movement

• Marching and resisted walking

• March in place• Moving forward and

backward• Walking w/ resistance: elastic

resistance or pulley tied to pelvis

• Alternating isometrics and rhythmic stabilization

• Apply resistance against the pelvis in alternating directions ask patient to hold.

• Vary the force and progress from pelvis, shoulders, and finally out stretched arms

• React to cues then w/out warning. Progress to unilateral

• Teach Pt self-applied stabilization tech: single-leg stance against resistance

• Balance training on unstable surfaces

• Have Pt stand (with bilateral support) on foam, rocker board, wobble board, or BAPS board, begin w/ single plane weight-shifting

• Progress: placing extremities on a diagonal plane and shift weight from one extremity to another

• Progress to unilateral activities on uneven surface

• Advance stability and balance activities• While standing on a rocker board balance

w/out touching ground while tossing a weighted ball to partner on different angles

• Pt holds on 2 ends of elastic resistance bands while someone pulls it different directions and various speeds

Functional training

• Increase challenges for ambulation: supervised then unassisted

1. Walk on uneven surfaces2. Turn3. Walk backwards4. Up and down ramps• As Pt is available practice: rising up, sitting

down on chairs of various heights, up and down the stairs

• add Resistance exercises that would strengthen muscles used for proper body mechanics

• Use agility drills (incorporate running, jumping, hopping, skipping, and side-shuffling)

• If Pt is returning to functional activities requires strength and power give the Pt plyometric drills

• Use maximum eccentric loading. These exercises the Pt cannot do alone.

Are you all sleepy? >:)

THE END