1
ITBS & PFPS:
Clinical Update in Conventional
and Integrative Rehabilitation
For Professional Yoga Therapist candidates:
This CE corresponds to Module 10, Part 4, Hour 1
Provider Disclaimer
• Allied Health Education and the presenter of this
webinar do not have any financial or other
associations with the manufacturers of any products or suppliers of commercial services that may be
discussed or displayed in this presentation.
• There was no commercial support for this
presentation.• The views expressed in this presentation are the
views and opinions of the presenter.
• Participants must use discretion when using the
information contained in this presentation.
Program Matriculation:
Recommended Module Progression
• Distance Modules: Prior to taking this course, complete Modules 1-7.
• Onsite Module: Complete and practice
final sequences in Module 8 and 14.
©2017. Ginger Garner. All rights reserved
2
Module 10 Series
• Part 1 – Nutrition & Orthopaedics: Focus on OA
Prevention and Management
• Part 2 – The Shoulder Complex and Spinal
Kinematics
• Part 3 – ACL, Foot, & Ankle Complex
• Part 4 – Hip Labral Injury, PFPS, and ITBS
©2017. Ginger Garner. All rights reserved
Integrated Clinical Guidelines
• Conventional + Integrative Medicine
• WHO ICF
• Medical Therapeutic
Yoga Biopsychosocial Model
©2017. Ginger Garner. All rights reserved
Course Outline – Hour 1
• Injury Epidemiology
• Biomechanics Update
• Prevention Update
• Management Update
• Case Study
©2017. Ginger Garner. All rights reserved
3
Problem
You have to inform your patient, an avid runner who depends on
running as her sole form of exercise for weight and stress
management, that she may need to consider a 6 week hiatus from
running because she has developed……
Think about how you will answer her questions
©2017. Ginger Garner. All rights reserved
Is this very common?
In order to answer her question, you must know:
Iliotibial band syndrome (ITBS)
• Leading cause of distal lateral thigh/knee pain in athletes
• 15% of all knee injuries
• High level athletes and general pop commonly suffer from both ITBS and PF syndrome
©2017. Ginger Garner. All rights reserved Baker & Fredericson 2016
Is this serious?
In order to answer her question, you
must know:
• ITB “anterolateral ligament of support.”
• Fascial relationships!
• Neuromotor function & torque
production
• Histologic and dissection studies
Baker & Fredericson 2016©2017. Ginger Garner. All rights reserved
4
Anatomical Theory 1
Fig. 3 Enthesopathy and compression model.
ITB, iliotibial band; LFE, lateral femoral epicondyle. Baker & Fredericson 2016
Anatomical Theory 2
Baker & Fredericson 2016
Fig. 4 Friction and impingement model.
ITB, iliotibial band; LFE, lateral femoral epicondyle.
How can you be sure the problem
is in my ITBS or PFPS?
In order to answer her question, you must know patients with ITBS might experience the following signs and symptoms:
• Lateral thigh or knee pain
• Hip or pelvic pain
• Ipsilateral knee pain at distal attachment point
• Increasing pain with activities such as cycling or running
• Patellar pain or tracking problems
• Medial knee pain
• Point tenderness over the ITB insertion
• Positive Ober Test (Low SN/SP in systematic reviews)
• Poor hip control/NM function
©2017. Ginger Garner. All rights reserved
5
How did this happen?
• Weak hip abductors (Fredericson et al 2000, MacMahon et al 2000, Noehren et al 2007).
• Angle of knee flexion between 20-30 degrees during stance phase of activity (Orchard et al 1996, Noble 1980, Miller et al 2007).
• Lower quarter malalignment (eversion or inversion)
• Increased forces on landing (Messier et al 1995, Devan et al 2004, Noehren et al 2007, Busseuil et al 1998).
• Increased tibial internal rotation (Messier et al 1995, Devanet al 2004, Noehren et al 2007, Busseuil et al 1998).
• Ipsilateral hamstring weakness (Messier et al 1995, Devan et al 2004, Noehren et al 2007, Busseuil et al 1998).
• Imbalance of agonist/antagonist (Messier et al 1995, Devanet al 2004, Noehren et al 2007, Busseuil et al 1998).
• Genu varus (Lavine et al 2010, Vasilevska et al 2009)
• Genu recurvatum (Messier et al 1995, Devan et al 2004, Noehren et al 2007, Busseuil et al 1998).
©2017. Ginger Garner. All rights reserved
Anatomical & Kinematic
Update
• 350 scopes, 35 TKA, 8 cadaver dissections, 21 ITBS surgical procedures, 3 MRI studies – No bursa under ITB insertion (lateral femoral condyle)
• Etiology of ITBS occurs in deceleration phase of stance—phase in running.
• Frontal and transverse plane risk factors identified
©2017. Ginger Garner. All rights reserved
Despite identifiable high risk populations, At
issues are considerably preventable. ITBS can fall into two broad categories:
1. Intrinsic Risk Factors
2. Extrinsic Risk Factors
Activities related to ITB injury include*:
• Running
• Rowing
• Soccer
• Field hockey
• Cycling
• Basketball
©2017. Ginger Garner. All rights reserved
6
What would happen if I kept
playing?
In order to answer her question, you must know that continued aggravation of her ITB could result in:
•Hip bursitis
•Pelvic pain
•Back pain
•Hip pain
•Proximal or distal ITBS
•Patellofemoral syndrome
•Poor patellar tracking and knee pain
•Greater trochanteric pain or bursitis
•ACL Injury
Baker & Fredericson 2016, Pelfort et al 2005©2017. Ginger Garner. All rights reserved
Objectives
1. Describe BPS model can improve orthopaedic management of ITBS and PFPS.
2. List evidence based methodology for incorporating medical yoga into current knee rehabilitation programs.
3. Identify five points for diagnosis and intervention in evidence based integrated
rehabilitation of ITBS and PFPS.©2017. Ginger Garner. All rights reserved
Objectives 2
4. Describe four critical factors for implementation of a BPS model of treatment for iliotibial band syndrome (ITBS) and patellofemoral (PF)
considerations.
5. List three postures to facilitate acute and
subacute ITBS healing.
6. Analyze postures and breath techniques in
a case study format.©2017. Ginger Garner. All rights reserved
7
Anatomy
• Iliac Tubercle Gluteals
• TFL
• Lateral patellar retinaculum
• Patella
©2017. Ginger Garner. All rights reserved
Injury Prevention
• Leg Length
• Large Q-
angle/pelvic
width
• Excessive foot
inversion or
eversion
Intrinsic Factors Extrinsic Factors
• Lower quarter deficiencies
• Ipsilateral vs. contralateral
• Poor training techniques
• Fatigue
• Poor footwear
• Environmental factors in sport and activity
• Surface condition where activity takes place
• Faulty equipment
(B&F 2016, A&L 2015, Paluska 2005; Khaund & Flynn 2005; Fredericson & Wolf 2005). ©2017. Ginger Garner. All rights reserved
WHO ICF Model
Case Study
World Health Organization (WHO) (2002). International Classification of Functioning, Disability and Health. Geneva, Switzerland.©2017. Ginger Garner. All rights reserved
8
Yogic Biopsychosocial Model
PHYSICAL
Anti-Inflammatory Lifestyle
Role of Nutrition & Exercise
Focus on Stability
ENERGETIC
Breath; Gut-Brain-Body Axis
PSYCHO-EMOTIONAL-SOCIAL
Meditation; Mindful Living
INTELLECTUAL
Patient Education
SPIRITUAL
Mind/body Homeostasis
Introspective Analysis
© 2014 Ginger Garner.
©2017. Ginger Garner. All rights reserved
Mindful Integrated Care:Physical Domain
1. Application of the BPS Model
2. Healing and prevention of reinjury depends on (2)
3. Massage or manual therapy techniques (Pedowitz 2006) combined with breathwork (3)
4. Breathwork facilitating safety & O2 nutritional exchange during
• Transitions between movementts/postures
• STM & MT work
• Giving breath priority
5. CKC posture sequencing
1. Hip abd/ER/extension strength (B & F 2016, A & L 2015, Reiman et al 2014, Prins and Van der Wurff 2009)
2. Contrast RSS issues with yoga program design
3. Use restoratives in acute phase
©2017. Ginger Garner. All rights reserved
Cautions
• Address the fasica
• Screen for:
• Primary Drivers such as
intra-articular hip injury or pelvic dysfunction
• Secondary Drivers such
as extra-articular hip
injury
AVOID:
•Running on uneven/sloped terrain
•Increased compression along the
origin or insertion point of the ITB,
especially during acute phase
•Overworking gluteus maximus in
presence of NM imbalance, in yoga
postures such as:
•Mountain
•Standing postures
•Backbends/spinal extension
postures
©2017. Ginger Garner. All rights reserved
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Injury Management - Acute
Acute Phase
• Activity Modification
• RICE
• NSAIDS
• Establish ITB freedom
• STM
• Friction massage (Lavine 2010)
• Trigger point therapy (Lavine2010)
• Facilitate proper patellar tracking in the femoral groove
• Flexibility
• Mobility
• Hip strength –abd/ER/ext (Prins and Van der Wurff 2009)
©2017. Ginger Garner. All rights reserved B&F 2016, A&L 2015
Tissue Response• Joint Mobilization
• Possible posterior glides to assist in reduction of anterior translation of femoral head and/or pain management
• Self MFR or STM deep front line:
• Diaphragm
• Transversalis/endothoracic fascia
• Infrahyoid/suprahyoid muscles
• Iliacus
• Psoas
• Rectus femoris
• Sartorius
• Obturator internus fascia
• Pelvic floor fascia
• Pectineus
• Adductor magnus
©2017. Ginger Garner. All rights reserved
The Yoga “Couch” –Three Tier Approach
http://www.gingergarner.com/2012/12/13/the-yoga-couch/
©2001-2015. Ginger Garner. All rights reserved.
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TATD Breath© Components
(TA-assisted thoraco-diaphragmatic breath)
LOOK | LISTEN | FEEL
1. Respiratory Diaphragm
2. Transversus Abdominis
3. Multifidus
4. PFM [Internal (PT only)]
© 2016. Ginger Garner. Medical Therapeutic Yoga. Handspring Ltd. Scotland, UK.
© 2016. Ginger Garner. Medical Therapeutic Yoga. Handspring Ltd. Scotland, UK.
TATD Breath©:
Optimal Arousal
© 2016. Ginger Garner. Medical Therapeutic Yoga. Handspring Ltd. Scotland, UK.
© 2016. Ginger Garner. Medical Therapeutic Yoga. Handspring Ltd. Scotland, UK.
TATD Breath
© 2016. Ginger Garner. Medical Therapeutic Yoga.
Handspring Ltd. Scotland, UK.
11
Mason et al., Evidence-Based Complementary and Alternative Medicine, vol. 2013
Victorious Breath - Ujyaii
Victorious breath “Ujyaii” (eww-jai-eeh)
•Replace pursed lip breathing
•Increase cardiac-vagal baroreflexsensitivity (BRS)
•Improve oxygen saturation
•Lower BP
•Reduce anxiety
•Improve relaxation response
•Vagal stimulation, Increased O2 absorption, Greater tidal volume
•Action
•Contraction of glottis creates “resistance breath”
•Equal inspiration/expiration showed greater clinical significance for improving baroreflex sensitivity in beginner yoga subjects.
©2017. Ginger Garner. All rights reserved
Hip Lock – Proximal Contrl
Chair (utkatasana) –single or double
• Deep Gluteal Sling/HIP RTC
• Control pelvic drop (add step down from elevated platform)
• Control trunk deviation
• Watch for fascial involvement (compression)
© 2016. Ginger Garner. Medical Therapeutic Yoga. Handspring Ltd. Scotland, UK.
Hip Rainbow RTC
GLUTEALS
PIRIFORMIS
GEMELLUS SUPERIOR
GEMELLUS INFERIOR
OBTURATOR EXTERNUS
OBTURATOR INTERNUS
QUADRATUS FEMORIS
© 2016. Ginger Garner. Medical Therapeutic Yoga. Handspring Ltd. Scotland, UK.©2017. Ginger Garner. All rights reserved
12
Neuromuscular Control -
GMAX
• GMAX1 - 80% of GMAX inserts
in ITB1
• Function1:
• hip extensor; lat. Rot.
• Accelerator in hip flexion
from 45-60 deg.
• Contralateral plant and cut maneuvers
• Avoid terminal hip ext. if psoas
compression is a concern
©2017. Ginger Garner. All rights reserved
Neuromuscular Control -
GMed
GMED
• GMED – train with good trunk and leg alignment, isometrics, and eccentrics, avoid compensatory actions
• Rationale – Avoid excessive lengthening of ITB on impact, abnormal compression, friction distally, reduce varus at knee, reduce femoral ER
Suggestions
• Sidelying Gmed – anterior and posterior fibers
• Standing pulley, hip hike, hip drop
• Functional markers: Work on active landing strategy (improve force attenuation through LE when TATD is not rigidly held) and sport specific training
©2017. Ginger Garner. All rights reserved
Pre-Asana Progression
Moon Salutation: 1. Downward Dog Prep (Pre-posture); 2. Caterpillar/Mod.
Dolphin dive; 3. Cobra; 4. Downward facing dog; 5. Three legged dog
©2017. Ginger Garner. All rights reserved
13
Subacute
Subacute Phase
• Continued facilitation of proper patellar tracking through strength & motor control
• Abductors, gluteus medius (Leninger 2009, Frederickson and Wolf 2005)
• Hamstrings
• Hamstring/quad balance
• Muscle Tone & Mobility (over flexibility alone) (Paluska 2005, Messier et al
1995).
• TFL
• Gluteus maximus
• Gait Training/Specificity of sport neuromuscular patterning (Frederickson and Wolf 2005)
B & F 2016, A & L 2015©2017. Ginger Garner. All rights reserved
Sub-Acute Program
Sequence: PYT Mountain Flow – 1. Mountain, 2. Chair, 3. Squat
1©2017. Ginger Garner. All rights reserved
Sub-Acute Progression
Sequence: Standing and supine hand to big toe
©2017. Ginger Garner. All rights reserved
14
Advanced Sub-Acute Progression
Postures: Revolved triangle; Pigeon; Half upward facing bow
©2014. Ginger Garner.
Facilitating Consciousness, Concentration, and Meditation
©2017. Ginger Garner. All rights reserved
Program Impact
Post-Test Results
6 months follow up
• TATD breath WNL
• No remaining point tenderness over distal insertion point of ITB
• Negative Ober
• TFL - WFL
• Hip IR/ER - 5/5, painfree
• Patellar mobility still an issue 2nd pt. resumed running (however on 2
year follow up patient had discontinued running and patellar
mobility returned to WNL)
©2017. Ginger Garner. All rights reserved
15
Now it’s your turn….
©2017. Ginger Garner. All rights reserved
Resources• Self-Massage for Lower Quarter,
including foot: http://gingergarner.com/Marma%20Massage%20Lower%20body.pdf
• FB – Hip Labrum Physical Therapy Network (closed)
• www.gingergarner.com - Yoga “Hip”py Blog
• www.medicaltherapeuticyoga.com- MTY Video & Book Chapter Access
• A-D breath
• Yoga Couch
• Foundational yoga postures
• TATD breath and more!
©2017. Ginger Garner. All rights reserved
The Hip Labrum:Clinical Update in
Conventional and
Integrative Rehabilitation
For Professional Yoga Therapist candidates:
This CE corresponds to Module 10, Part 4, Hour 2
16
Objectives
• Identify 2 categories for hip differential diagnosis and 5 evidence based risk factors for intra-articular hip labral injury in order to understand how intra-articular hip joint injury could be avoided.
• Describe the morphological classification system of labral tears in order to identify the most accepted provocative tests used in identification of intra-articular hip joint injury.
• Discuss current evidence based medical management, including surgical intervention, for labral tears and related secondary injuries of the hip.
• In a case study format, critically analyze indications and contraindications to follow a subacute through chronic phase functional intervention for hip joint preservation and rehabilitation in a multi-disciplinary team approach.
©2017. Ginger Garner. All rights reserved
Hour 2
• Anterior Hip Pain: Serious? Cause, Prevention, Differential Diagnosis
• Anatomy of the Hip Labrum
• Labral Tear Classification & Surgical Intervention
• Conservative Intervention & Case Study
• Chronic Progression Guidelines Video Lab Demonstrations
• Resources
©2017. Ginger Garner. All rights reserved
Problem
You have to inform your patient, a dancer, that she may not be able to perform with her company this year because she has developed anterior hip pain…..
Think about how you will answer her questions
Photo: Courtesy of Jennifer Miller Pearce
©2017. Ginger Garner. All rights reserved
17
Is this very common?
• Functional impairment
• Location of pain
• Groin 96-100% SN
• Buttocks
• Anterior thigh
• Mechanical symptoms
• Clicking, giving way, hip
pain SN 100%, SP 85%
• Labral tear scoped “+” in ___% of individuals with
mechanical hip symptoms.
©2017. Ginger Garner. All rights reserved
Clinical Standards of Care
Invasive Orthopaedic Clinical Standards of Care (2014)
1. Symptoms
2. History
3. Radiographs
4. Clinical Exam
5. Intra-articular Injection
6. MRI/MRA
7. Referral to PT
8. Arthroscopic or open surgery
Reiman MP, Mater RC, Has TW, et al. Examination of ALT: a continued
diagnostic challenge. Br J Sports Med 2014;48:311-319. ©2017. Ginger Garner. All rights reserved
Hip Bony Anatomy
• 6 degrees of freedom
• Multiaxial ball and socket
• Function: Load transfer of UE and LE
• Need ideal form and force closure to preserve hip (hip stability)
• Acetabulum = ischium, ilium, pubis
Retchford et al 2013©2017. Ginger Garner. All rights reserved
18
Fibrocartilaginous Anatomy
Fibrocartilaginous structure that outlines the acetabularsocket:
Attachment areas (3):
Vascular Supply: Outer 1/3
Inner 2/3
Obturator, superior gluteal, and inferior gluteal arteries
Reiman et al 2014, Kern-Scott et al 2011, Bharam 2006, Groh & Herrera 2009
Photo source: Primal Pictures.com
Image: http://www.londonhiparthroscopycentre.com/hip-and-groin-conditions-
labrum.asp
©2017. Ginger Garner. All rights reserved
Etiology of Tears
©2017. Ginger Garner. All rights reserved
Is this serious?
• Iliopsoas bursitis/tendinosis
• Neuralgia
• Lumbar radiculopathy
• Stress Fracture
• ALT
• Femoral-acetabular impingement (FAI)
• Pincer
• Cam
Reiman et al 2014, Margo et al 2003
Differential Dx must rule out:
• OA
• Inflammatory or infectious arthritis, osteomyelitis
• AVN, tumor, or fx
• Cancer
• Endometriosis, pelvic pain, ovarian cysts
• Difficulty related to previous surgeries
• PMH such as corticosteroid or alcohol abuse (risk for avascular necrosis)
• Fracture
©2017. Ginger Garner. All rights reserved
19
How can you be sure the problem is with my anterior hip?
(Kern-Scott et al 2011, Plante et al 2011, Groh and Herrera 2009, Lewis and Sahrmann 2006):
• Pain in groin (95-100% SN, Reiman et al 2014)
• Mechanical symptoms (SN 100%, SP 85%, Reiman et al 2014)
• Sharp pain, Clicking**, Locking or catching ***, Giving
way****
• Minor hip ROM limitations (in hip rotation, hip flexion,
adduction, abduction*****)
• Other: Night pain (Kern-Scott et al 2011)
*Lewis & Sahrmann 2006, McCarthy et al 2001, O’Leary et al 2001, Byrd 1996; Binningsley 2003, Hase & Ueo 1999, Klaue et al 1991
**Farjo et al 1999, Dorrell and Catterall 1986, Santori and Villar 2000, Byrd 1996, Neumann 2002
***Mason 2001, Farjo et al 1999, , Dorrell and Catterall 1986, Altenburg 1977, Hickman and Peters 2001)
****Farjo et al 1999, Altenburg 1977, Hickman and Peters 2001
*****Fitzgerald 1995, Nelson et al 1990, Byrd 1996, Binningsley 2003, Altenberg 1977, Hase & Ueo 1999
©2017. Ginger Garner. All rights reserved
In order to answer her question, you must know the following provocative tests may be positive:
High SN and SP:
• Thomas test (Reiman et al 2013)
• FADDIR (Reiman et al 2013, Plante et al 2011)
High SN and low SP:
• Scour test
• DIRI ( Plante et al 2011, Saw & Villar 2004)
• Positive FABER** (Mitchell et al 2003)
• Positive Stinchfield test/RLSR
• Posterior-inferior labrum test
How else can you tell the problem is
with my hip?
©2017. Ginger Garner. All rights reserved
Labral Pain Patterns
©2017. Ginger Garner. All rights reserved
20
How did this happen?
1. Dysplasia*
2. Direct Trauma**,***
3. Femoral acetabularimpingement
4. Degeneration***
5. Capsular laxity/Hip instability (Kelly et al 2005, Philliponet al 2005)
*(Kelly et al 2005, Phillipon et al 2005, Gorh and Herrara 2009, Lewis & Sahrmann
2006, Bache et al 2002, Robertson et al 1996, Li and Ganz 2003, Coleman 1978)
**(Gohr & Herrara 2009, Kelly et al 2005, Phillipon et al 2005, Lewis & Sahrmann 2006,
O’Leary et al 2001, Fitzgerald 1995, , Santori & Villar 2000, Byrd 1996, Ikeda et al
1988, Nelson et al 1990)
***Mason 2001, Fitzgerald 1995, Santori & Villar 2000, Saw & Villar 2004
©2017. Ginger Garner. All rights reserved
1. Intra-articular Injuries2. Extra-articular Injuries
In younger patients, sports injuries of the hip/pelvis most commonly include:
• Ballet Dancers (44%)
• Soccer players (13%)
• Runners (11%)
• Also:
• Golf
• Martial Arts
• Gymnastics
• Yoga
Reiman et al 2014, Kern-Scott et al 2011, Godinho 2007, Lewis and Sahrmann 2006, Farjo et al 1999
Despite identifiable high risk populations,
hip issues can be preventable. Hip injuries can fall into two broad categories: (Flannery et al
2001, Tibor and Sekiya 2008)
©2017. Ginger Garner. All rights reserved
Differential DiagnosisGeneral diagnoses for the hip are ordered under 2 categories:
Intra-articular• OA & RA
• Labral tears
• Loose bodies (& snapping hip 2nd to them) or Internal snapping hip (iliopsoassnapping over iliopectineal emminence or femoral head)
• Femoroacetabular impingement (FAI) – 88% of hips: “+” flexion impingement test (Clohisy et al 2009)
• Capsular laxity
• Tears of the ligamentum teres
• Chondral damage
• Flannery et al 2001, Tibor and Sekiya 2008
Extra-articular• Iliopsoas tendonitis and/or bursitis
• Snapping hip (2 types)
• Iliotibial band and greater
trochanteris bursitis
• Gluteal tendoninpathy
• Fractures (femoral neck)
• Piriformis syndrome
Related Dysfunction “hip mimickers” (4)
©2017. Ginger Garner. All rights reserved
21
What would happen if I kept
playing?
In order to answer her question, you must know that
continued aggravation of her hip could result in:
• Anterior hip injury
• Lateral hip injury
• Posterior hip injury
• Intra-articular hip joint damage
• Pelvic or sexual dysfunction
©2017. Ginger Garner. All rights reserved
Soft Tissue Pathophysiology
• Iliopsoas
• Gluteus Medius
• Hamstring
• Adductors
• Pelvic Floor
• External Rotators
©2017. Ginger Garner. All rights reserved
Anterior Hip Injury
Progression
Anterior hip injury
progression if a labral
tear is present:
• Increased
contact stresses (Ferguson et al 2000)
• Hip instability (Tan &
Seldes 2001)
• Iliopsoas bursitis,
tendonitis
©2017. Ginger Garner. All rights reserved
22
Lateral Hip Injury
Progression
Lateral hip injury
• ITBS
• Gluteal tendon tear
(positive Trendelenburg or
lateral SLR/MMT abductors)
• Trochanteric bursitis
©2017. Ginger Garner. All rights reserved
Posterior Hip Injury
ProgressionPosterior hip injury:
• Hamstring tendinosis or fraying from ischial tuberosity
• Intra-articular hip joint damage: (Gohr & Herrera 2009, McCarthy et al 2001, Phillippon 2003, Bharam et al 2002, Bharanet al 2003, Farjo et al 1999, Byrd 1996, Altenburg 1977)
• Chrondraldamage
• Osteoarthritis
©2017. Ginger Garner. All rights reserved
Posterior
Hip
©2017. Ginger Garner. All rights reserved
23
Acetabular Labral
Function
Reiman et al 2014, Retchford et al 2013, Groh & Herrera 2009
Zones of Labral Pathology
Ilizaliturri VM, Jr, Byrd JW, Sampson TG, Guanche CA, Philippon
MJ, Kelly BT, Dienst M, Mardones R, Shonnard P, Larson CM. A
geographic zone method to describe intra-articular pathology in hip
arthroscopy: cadaveric study and preliminary report. Arthroscopy.
2008;24:534–539. doi: 10.1016/j.arthro.2007.11.019.©2017. Ginger Garner. All rights reserved
Labral Tear Classifications
Four Labral Tear Morphological Types: (Thomas
et al 2013, Bharam 2006, Lage et al 1996)
I. Radial flap*,
II. Radial fibrillated,
III. Longitudinal peripheral,
IV. Unstable
Photo: Medscape.com
*Scope of labrum in watershed region
Labral Tear Locations: (Groh & Herrera
2009)• Anterior (86%) (McCarthy et al 2001, 2003) • Posterior (Robertson et al 2007)• Superior/lateral (Schmerl 2005, McCarthy et
al 2003)
©2017. Ginger Garner. All rights reserved
24
Can hip injuries be prevented?
In order to answer her question you must know prevention of
labral tears can be difficult secondary to the lack of sensitivity
and specificity of current clinical diagnostic measures.
©2014 Ginger Garner.
WHO ICF Model
• Common Language and nomenclature for functioning,
disability, and health
World Health Organization (WHO) (2002). International Classification of Functioning, Disability and Health. Geneva, Switzerland.
37 yo 3 mo. Postpartum female
with right hip joint pain and
external hip pain
Unable to participate
in activities,
especially FABER,
without clicking, hip
giving way, and pain
i.e. cannot carry newborn son
down stairs or appropriately
care for him because hip gives
way
Has no family nearby
but has supportive
husband with
excellent leave
situation
Well educated;
very healthy and
proactive; BMI
WNL for
postpartum
mother; motivated
Case Study –General Observations & Measures
• Objective Measures right hip:
• MMT hip flexion 4/5, painful ; abduction 2-
/5 and very painful; hamstrings 4-/5 and
painful; IR 5/5; ER 3/5 and painful; MMT
5/5 otherwise
• + Trendelenburg (for pain in GMED, not
function)
• Able to isolate TATD (includes PFM) and
maintain TATD breath during downward
dog prep (DDP), however DDP caused
deep hip pain; and pt. still working with
PP DRA (third child)
• Left hip WNL
and painfree
©2017. Ginger Garner. All rights reserved
25
Provocative Tests
• Diagnostic Tests:
• Xrays: Right hip dysplasia; shallow acetabulum; no FAI present
• MRA: Hamstring and gluteal tendon insertion degeneration
with marrow changes & fraying confirmed; “-” for labral tear
and FAI but positive for “minimal spurring”; marked OA at left SIJ; sig. hypertrophy of labrum
• Provocative Tests: Positive Ober (for proximal pain not ITB tightness); + FABER for pain in groin and c/o
instability; point tender over gluetus medius/minimus; +
DIRI; + FADDIR; + Stinchfield/RSLR tests; Right hypomobile
SIJ; + Thomas test for internal snapping hip (iliopsoas)
and groin pain
• Femoral Version: 30 degrees bilaterally?©2017. Ginger Garner. All rights reserved
CEA – A/P View
©2017. Ginger Garner. All rights reserved
©2016. Garner, G. Medical Therapeutic Yoga. Handspring Pub., Ltd. Scotland, UK.
26
Psychoemotional/Energeti
c
• Neuroendocrine Regulation – HPA Axis regulation,
especially cortisol (lack of sleep)
• Breathwork
• Meditaton through restorative yoga and breath
• Sleep positioning - Supine unweighted right hip; knee in open
packed
• Influence lumbopelvic stability and load transfer
• Contrast repetitive stress contributors with CAM
program design (5)
©2017. Ginger Garner. All rights reserved
Intellectual/Spiritual
Anti-Inflammatory Diet
Homeopathic and biochemical NSAIDS – team approach
with MD (arnica montana oral and topical; Advil 800 mg/TID)
Time Management for Rest/Exercise Balance:
From active fitness routine - yoga, Pilates 3-5x/week;
walking 2-3x/week
Daily restorative yoga and/or Pilates routine no more than
30’ and worked into childcare routine
Daily devotional time and prayer; music therapy
©2017. Ginger Garner. All rights reserved
IA Injection
• Patient had US-assisted
diagnostic injections
(6-8 weeks later)
• Iliopsoas
• Intraarticularsteroid injections
©2017. Ginger Garner. All rights reserved
27
Impression
• Impression: Right gluteus med/min
tendinopathy; internal snapping hip; right hamstring tendinopathy; excessive femoral
anteversion and shallow acetabulum
• What are your impressions?
©2017. Ginger Garner. All rights reserved
Contraindications
AVOID:
• End ranges in yoga, aquatic, and Pilates movements
• Domination of lower quarter stability via quadriceps and hamstrings
• Hip and knee hyperextension in walking/stance
• In acute phase – loading hip with/without torsion/rotation
CAM therapies that include movements which create: (2)
Yoga postures like:
Pilates Matwork and/or Reformer postures like:
Aquatic therapy:
Massage/manual therapy:
©2017. Ginger Garner. All rights reserved
Subacute to Chronic
Progression
Subacute Phase (8+ weeks)
Identification of root causes of injury
Unable to get 7-9 hours continuous sleep/night 2nd
nursing infant
From ADL and work task completion - Unable to modify ADL completion 2nd childcare responsibilities
Hormonal and cumulative effect of 3 pregnancies
Yoga posture alignment
Continued activity modification and rest
NSAIDS
Muscle energy
Lock/Bandha work
WB
Progression to Pilates matwork
Progression to yoga without lateral SLR or unilateral stance
Upright biking
©2017. Ginger Garner. All rights reserved
28
Gait • Faulty Patterns:
• Lack of knee flexion at heel strike
• Decreased hip abduction in stance/swing phase
• GMED1
• Stabilization of femur and pelvis during WB and stance phase
• 60% of total hip abduction cross-sectional area
• “Catwalk” • Prolonged foot flat and
knee hyperextension creating premature hip hyperextension (Lewis et al 2004)
Kennedy MJ, Lamontagne M, Beaule PE. Femoroacetabular impingement
alters hip and pelvic biomechanics during gait. Gait Posture. 30(2009) 41-44
1. Reiman MP, Bolgla LA, Loudon JK. A literature review of studies
evaluating gluteus maximus and gluteus medius activation during
rehabilitation exercises. Physiother Theory Pract. 2012;28(4):257-268. doi:
10.3109/09593985.2011.604981; 10.3109/09593985.2011.604981.
Ginger Garner.
©2017. Ginger Garner. All rights reserved
Gait continued…• Faulty patterns cont.
• Excessive hip extension (maximal end range hip extension)
• Mechanical or mobility impairments:
• Stiffness in subtalar joint
• Weakness or Ring/Thoracic shift
• Anterior gliding of femoral head – weakness of gluteals during hip extension and iliopsoasduring hip flexion (Lewis et al 2007)
• Self-limiting patterns in attempted stabilization
• Diminished hip extension during swing phase
Lewis CL, Sahrmann SA, Moran DW.. 2007 and 2010
©2014. Ginger Garner.
Program Impact – 9 mo.Post-Test Results (9 mo.)
• Able to perform Pilates advanced matwork routine 100%
• Except sidelying series performed at 50%
• Able to return to yoga 100%
• With elimination of FABER, With elimination of all end range of motion for hip
• Able to return to pool therapy with no further c/o instability or pain
• No remaining point tenderness
• Proximal ITB, TFL, Gluteus medius/minimus
• Able to sleep without interruption ~7-8/hrs. nightly
• Reduced night pain, Stopped nursing infant at 11 months©2017. Ginger Garner. All rights reserved
29
Acetabular labral tear MR arthrography
Sensitivity for anterior tear - 60% to 100% (Groh & Herrara
2009, Hunt et al 2007, Czerny et al 1999, Petersilge et al 1996, Czerny et al
1996, Byrd & Jones 2004, cote et al 2005, Plotz et al 2000, Studler et al 2008,
Chan et al 2005, Schmid et al 2003)
Specificity for anterior tear from 44% to 100% (Groh &
Herrera 2009, Hunt et al 2007, Keeney & Peelle 2004, Cote et al 2005,
Studler et al 2008, Toomayan et al 2006)
Sensitivity for posterior or lateral tear – 20 – 11%
respectively (McCarthy et al 2003)
> 2 tears before diagnosis of labral tear on average (Groh and Herrera
2009, Farjo et al 1999; O’Leary et al 2001; Fitzgerald 1995; McCarthy & Busconi
B. 1995; Byrd &, Jones 2000).
Clinical Impressions on
Hip Joint Preservation
©2017. Ginger Garner. All rights reserved
Review of “Red Flags”1. Breath is Paramount: TATD Breath
2. Functional Task Completion – Force & Form Closure
• SIJ position/Pelvic stability
• Femoral head articulation, positioning, and acetabular coverage
3. Recruitment Patterns – Load Transfer
• Over- and under-recruitment - gluteals, hamstrings, hip external rotators, and iliopsoas
• Neuromuscular coordination
4. Mask of face: Yogic lens©2017. Ginger Garner. All rights reserved
What can the average
patient with hip pain expect?
©2014 Ginger Garner.
30
Resources
• Full Hip Labrum Injury & Differential Diagnosis Course –www.hermanwallace.com -HLI
• www.gingergarner.com -Yoga Hip(py) Blog
• www.medicaltherapeuticyoga.com - MTY Videos & Book Access
• FB – Hip Labrum Physical Therapy Network (CLOSED)
©2017. Ginger Garner. All rights reserved