hip mobility

8/10/2019 Hip Mobility

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Unlock the Hip: Using JointMobilizations to Improve Mobility

Great Lakes Athletic Trainers Association

45 st Annual Winter Meeting

Wheeling, ILMarch 16, 2013

Scott Lawrance, DHS, LAT, ATC, MSPT, CSCS


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Objectives

Lab Attendees will be able to perform static and dynamic

joint mobilizations for the hip in both weightbearingand non-weightbearing positions

Attendees will be able to demonstrate and instruct amobility exercise program to allow for maximal gain

following joint mobilization

GLATA 2013 W HEELING , IL


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When did this become bad?



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and how does this become that?



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Neurodevelopment

As babys we have tremendousamount of joint mobility

We maintain this as childrenthrough play

As adults we start to loosemobility mostly due topositional and postural habits



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The Adult Hip

Generally has poormobility

Result of: Sitting posture Lack of squatting

Causes: Decreased length in hip

flexors

Reciprocal inhibition ofthe gluteal muscles



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The Athletic Hip

FMS administered to all incomingand transfer athletes at UIndy Fall2012 Average deep squat score: 2.04

Football: 2.14 Mens Soccer: 1.20

Volleyball: 1.42 Womens Soccer: 1.75



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Sequelae of Hip Hypomobility

Changes in functionalmovement Increased mobility needed

above and below Increased lumbar spine/SI

joint mobility and increasedlordosis

Increased mobility in the knee

and lower kinetic chain Increased muscular

activation in hamstrings,piriformis, erector spinae



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Sequelae of Hip Hypomobility

Changes in athletic performance Decreased strength Decreased power Decreased speed

Limits potential exercises that can be performed inthe weight room



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Assessment of Hip Mobility

History and Observation!

Deep Squat Movement Test Table Mobility Assessment

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Movement Assessment:Squat Test

Have your athlete stand withfeet shoulder width apart andarms overhead. Instruct themto squat and look to see if theycan maintain upright posture,hip/knee/ankle alignment and

feet flat on the floor



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Table Assessment:Pelvic Alignment/Hip Extension

Note: is the pelvis balanced? If not need to start there. Doesthe hip extend and is the resistance similar side-to-sideis thisfrom tight musculature or from joint tightness??? What are thearthrokinematics that link these?



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Table Assessment:Supine Mobility

After assessing pelvis/SI joint and hip extensionlook at passive: Hip flexion Hip flexion/adduction Hip flexion/abduction Hip internal rotation Hip external rotation

Note ROM, end-feel, quality of motion,restrictions present



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Treating Hip Mobility

Lots of options Stretching of hip flexor, hamstrings, adductors, IT

band, quadriceps

Foam roller Therapeutic exercise

(capsular)

But Do these really treat ALL of the problem?



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Treating Hip Mobility

Due to hip joint structure(deep articulating ball-and-socket) and musclebulk, mobilization of the

joint is needed to providea lasting change



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What is a Joint Mobilization?

AKA - Joint Mob

Manual therapy technique Used to modulate pain Used to increase ROM Used to treat joint dysfunctions that limit ROM by

specifically addressing altered joint mechanics



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History

Hippocrates (4 th century BC physician) may havebeen first recorded to perform jointmanipulations and spinal traction

English physicians in the 1700 and 1800sbelieved in strict rest after a joint injury, whilebonesetters would treat patients withmanipulations

Dr. Wharton Hood wrote the first medical bookon manipulation in the 1870s



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History

Kaltenborn - Scandinavian who merged what heconsidered the best of chiropractic, osteopathy,and physical medicine

Maitland - Australian PT who focused primarilyon mobilizations rather than manipulation, andhas meticulous examination skills that heavilyguide his treatments



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Movement Types

Physiologic movement: movements the patientcan perform voluntarily

Accessory movements: movement the patientcannot perform actively, but are necessary fornormal ROM



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Accessory Motion Arthrokinematics

5 types of arthrokinematics Roll, Slide (Glide), Spin, Compression, Distraction

3 components of joint mobilization Roll, Slide (Glide), Spin



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Roll

A series of points on one articulating surfacecome into contact with a series of points onanother surface Rocking chair analogy; ball rolling on ground Example: Femoral condyles rolling on tibial

plateau

Roll occurs in direction of movement



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Slide (Glide)

Characteristics of one bonesliding on another For a pure slide, the surfaces must be

completely congruent Car hitting brakes analogy Surfaces must be congruent for this to

occur



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Spin

Occurs when one bone rotates around astationary longitudinal mechanical axis Same point on the moving surface creates an arc of a circle as

the bone spins Car spinning its wheels analogy Example: Radial head during pronation/supination



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Convex/Concave Rule

Basic concept of correct mobilization application Is this the whole

picture?

Realize:1. This is only a tool

2. This is a helpful method to understand where tomobilize

3. This does not take into account dynamic forcesGLATA 2013 W HEELING , IL


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Convex moving on Concave

When convex is moving andconcave is stable: Glide and roll are OPPOSITE Joint surfaces slide in the

OPPOSITE direction of the bonemovement



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Concave moving on Convex

When concave is moving andconvex is stable: Roll and glide occurs in the

SAME direction Joint surfaces slide in the SAME

direction as the bone

movement



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Joint Mobilizations Grades

I

II

III

IV

V Available Joint

Play

Stretch

The oscillation grading systemwas developed by the AustralianPT Maitland.



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Indications

Grades I and II - primarily used for pain Pain must be treated prior to stiffness Painful conditions can be treated daily

Grades III and IV - primarily used to increasemotion Stiff or hypomobile joints should be treated 3-4 times

per week alternate with active motion exercises



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Effects of Joint Mobilization

Mechanical effects Improves mobility

Neurophysiological effects Stimulates mechanoreceptors to decrease pain

Nutritional effects Improved synovial fluid movement and nutrient

exchange in articular cartilage



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Contraindications for Mobilization

Contraindicated for: Inflammatory conditions or acute inflammatory

process

Malignancy Osteoporosis Ligamentous rupture

Herniated disks with nerve compression Bone disease



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Would you perform a Joint Mobon any of these athletes?

Beighton Index

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Before You Begin

Warm tissue prior to mobilization Muscle relaxation techniques may be needed



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Joint Mobilization Application

Patient should be relaxed Explain purpose of treatment & sensations to expect to

patient

Evaluate BEFORE & AFTER treatment (comparable sign) Use proper body mechanics Remove jewelry

Begin & end treatments with Grade I or II oscillations Stop the treatment if it is too painful for the patient



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Treatment Force and Direction ofMovement

Treatment force is applied as close to theopposing joint surface as possible The larger the contact surface is, the more

comfortable the procedure will be (use flat surface ofhand vs. thumb)

Direction of movement during treatment is either

PARALLEL or PERENDICULAR to the treatmentplane



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Treatment Direction

Treatment plane lies onthe concavearticulating surface,perpendicular to a linefrom the center of theconvex articulating

surface



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Speed, Rhythm, and Duration ofMovements Joint mobilization sessions

usually involve: 3-6 sets of oscillations Perform 2-3 oscillations

per second Lasting 20-60 seconds fortightness

Lasting 1-2 minutes forpain 2-3 oscillations per

second Apply smooth, regular

oscillations

For painful joints, applyintermittent distraction for7-10 seconds with a fewseconds of rest in betweencycles

For restricted joints, apply aminimum of a 6-secondstretch force, followed bypartial release then repeatwith slow, intermittentstretches at 3-4 secondintervals



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Patient Response

May cause soreness Perform joint mobilizations on alternate days to allow

soreness to decrease & tissue healing to occur

Patient should perform ROM techniques Patients joint & ROM should be reassessed after

treatment, & again before the next treatment

Pain is always the guide



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The Hip Joint

Concave acetabulum andconvex femoral head

Open packed position:

Hip flexion 30 degrees,abduction 30 degrees, slightexternal rotation

Close packed position: Hip extension, slight internal

rotation

Designed for stability



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Static Hip Mobilizations

Lateral Glide Technique for general mobility and/or pain control

Posterior Glide Used to increase hip flexion and internal rotation

Anterior Glide Used to increase hip extension and external rotation

Inferior Glide Used to increase hip flexion or rotation



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Mobilizations with Movement(MWM)

Mulligan concept of introducing dynamic motionas the mobilization is performed Advantage:

Can move into the restriction while performing mobilization Neural pathways activated when active motion is applied Athlete can get immediate positive feedback

comparable sign



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Mobilizations with Movement(MWM)

Principles Maintain joint mobilization through entire movement Move through as much of a full ROM as possible Force should remain constant Movement should be painfree



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How do you follow-up?

After mobilizing the joint, need to follow-up withmobility exercises Reinforce the new mobility gained and new

movement pattern Home program vs. in clinic/athletic training room

Correct underlying postural deficiencies

Rebalance the joint (if needed)



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Questions?

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Lab Set-up

Please find a partner(s) of similar build to workwith during lab

You will need a mobilization belt If you do not feel comfortable with any of the

mobilizations being performed on you, please donot do them!

If you need help or have a question, please ask us



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Lab



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Setting up the Belt

Know the type of beltyoure working with

Clinician body mechanics Set up belt to wrap around patients proximal thigh

and your hips/greater trochanter



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Hip Posterior Glide

Increase hip flexion orinternal rotation

Hip flexed, adducted,and slightly externallyrotated with foot ontable

Use hand across table toapply downward into hiptoward table



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Hip Anterior Glide

Increase hip extension orexternal rotation

Hip neutral position Can bias capsule by addition of

IR/ER

Apply force at gluteal fold

in anterior direction Beware of pain in the low back!

(may need to flex the hip)



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Hip Inferior Glide

Inferior glide with hip flexedplaces stress into posterior-inferior joint capsule

Helps to increase hip flexionand rotation



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Dynamic Hip Mobilizations

All performed using the belt Supine joint distraction with

Flexion Internal Rotation External Rotation

Standing lunge position with Forward lunge Lateral lunge



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Dynamic Hip Flexion Mobilization


D i Hi I t l R t ti


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Dynamic Hip Internal RotationMobilization


D n mic Hip E tern l Rot tion


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Dynamic Hip External RotationMobilization


Dynamic Forward Lunge


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Dynamic Forward LungeMobilization


Dynamic Lateral Lunge


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Dynamic Lateral LungeMobilization


Hip Dynamic Mobility


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Hip Dynamic MobilityExercises




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Leg swings Front/back Lateral/across body




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Hurdle step over/under drills Forward Lateral

Backward Alternating Squatting



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Summary

Practice mobilization to refine technique Apply according to treatment parameters and

patient goals

Use good body mechanics to apply the mosteffective treatment and protect yourself

Follow up with mobility exercises to maximizebenefits



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Acknowledgements

Performance Rehab Products Mobilization Belts



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Dont Ever Mistake Activity for Achievement!- John Wooden



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Questions?

Thank you for attending our Learning Lab session!

Scott Lawrance, DHS, ATC, MSPT, CSCSUniversity of Indianapolis1400 East Hanna AvenueIndianapolis, IN 46227

(317) [email protected]

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