hip musculature and its role in lower extremity kinetic chain function

Hip Musculature and Hip Musculature and its Role in Lower its Role in Lower Extremity Kinetic Extremity Kinetic Chain FunctionChain Function

Michael Krackow, Ph.D, ATC, PTA, CSCS, CEASMichael Krackow, Ph.D, ATC, PTA, CSCS, CEAS

Orthopedics: The kinetic chainOrthopedics: The kinetic chain

Most of force generated by the core Most of force generated by the core & transferred distally& transferred distallyTrunk and hips transfer momentum Trunk and hips transfer momentum to distal segmentsto distal segments

Orthopedics: Statistics of stressOrthopedics: Statistics of stress

3,000 foot strikes/mile 3,000 foot strikes/mile (Gambetta, 2005)(Gambetta, 2005)

450# of force each foot strike 450# of force each foot strike (Gambetta, (Gambetta, 2005)2005)

Each year between 30% and 70% of Each year between 30% and 70% of runners will have an injury that will runners will have an injury that will sideline him/her for @ least 1 week sideline him/her for @ least 1 week (Goss et at, 2005)(Goss et at, 2005)

Orthopedics: HipOrthopedics: Hip

Total hip replacements: Total hip replacements: ((ZicklerZickler, 2007), 2007)

•• 240,000 240,000 THRsTHRs/year/year•• 40,000 revisions/year40,000 revisions/year•• Avg. age 2004: 66Avg. age 2004: 66

Anatomical reviewAnatomical review

Largest weightLargest weight--bearing joint in the bearing joint in the bodybody


More than 20 muscles influence hip More than 20 muscles influence hip movementmovement•• Anterior:Anterior:

TFLTFLSatoriusSatoriusRectus Rectus femorisfemorisIliopsoasIliopsoas

Muscles that influence hip Muscles that influence hip movementmovement

Medially:Medially:•• PectineusPectineus•• GracilisGracilis•• Adductor:Adductor:

LongusLongusBrevisBrevisMagnusMagnus


Posterior:Posterior:•• Superficial:Superficial:

Gluteus Gluteus maximusmaximusBiceps Biceps femorisfemorisSemimembranosisSemimembranosisSemitendinosisSemitendinosis

•• Deep:Deep:Gluteus Gluteus mediusmediusGluteus Gluteus minimusminimus


Deep external rotators:Deep external rotators:•• PiriformisPiriformis•• Superior & inferior Superior & inferior gemelligemelli•• ObturatorObturator internusinternus & & externusexternus•• QuadratusQuadratus femorisfemoris


Others:Others:•• Erector Erector spinaespinae•• Rectus Rectus abdominisabdominis•• Internal & external Internal & external obliquesobliques•• Transverse Transverse abdominisabdominis

Musculature functionMusculature function

Gluteus Gluteus mediusmedius•• Key role in pelvic stability during gaitKey role in pelvic stability during gait•• Prevention of LBPPrevention of LBP

PsoasPsoas majormajor•• Hip flexionHip flexion•• Decelerate hip extensionDecelerate hip extension•• Stabilize lumbar spineStabilize lumbar spine


Gluteus Gluteus maximusmaximus::•• Significant role for posture Significant role for posture

and stability during normal and stability during normal gaitgait

Rectus Rectus FemorisFemoris: : (Snyder, et al, (Snyder, et al, 2007)2007)

•• Found greatest activity with Found greatest activity with resistive band walking resistive band walking lateral, forward, & backward lateral, forward, & backward when knee is flexed @ 30when knee is flexed @ 30ºº as compared to extendedas compared to extended


Hip adductor strengthening Hip adductor strengthening (Kerrigan, 2007)(Kerrigan, 2007)

•• hip adductor strength associated with hip adductor strength associated with OA progressionOA progression

•• Weak hip adductors associated with Weak hip adductors associated with weak hip abductorsweak hip abductors

TFL: TFL: (Snyder, et al, 2007)(Snyder, et al, 2007)

•• Resistive band walking demonstrated Resistive band walking demonstrated greatest activity with lateral movementgreatest activity with lateral movement


Hip extensors and rotators important Hip extensors and rotators important in efficient transmission of forces in efficient transmission of forces from the ground upfrom the ground upConsider sideConsider side--toto--side imbalancesside imbalancesLow back pain associated with Low back pain associated with impaired function of hip abductors & impaired function of hip abductors & extensorsextensors

Things to remember!!Things to remember!!

People will always sacrifice People will always sacrifice qualityqualityfor for quantityquantityLimited hip rotation ROM & strength Limited hip rotation ROM & strength can result in compensatory motion can result in compensatory motion @ thoracic & lumbar areas with @ thoracic & lumbar areas with rotation exercises rotation exercises (Regan, 2000)(Regan, 2000)

Tight hip flexorsTight hip flexors

Remember Remember the Corethe Core

You You MUSTMUST have proximal stability in have proximal stability in order to have distal mobilityorder to have distal mobility

Core stabilityCore stability

Core stability: Core stability: ““product of motor product of motor control and muscular control and muscular capacity of the capacity of the lumbolumbo--pelvicpelvic--hip complexhip complex””(Gamble, 2007)(Gamble, 2007)

““Think globally, act Think globally, act locallylocally””. . (Boone & Cook, 2006)(Boone & Cook, 2006)

Remember the CoreRemember the CoreNot just the abdominals & lumbar musculature:Not just the abdominals & lumbar musculature:•• HipsHips•• Shoulder stabilizersShoulder stabilizers•• Thoracic & cervical spinesThoracic & cervical spines

All motions start or run through the trunkAll motions start or run through the trunkStrong distal musculature and weak core results Strong distal musculature and weak core results in inability to produce efficient movementsin inability to produce efficient movementsActivation of the core initiates coordinated distal Activation of the core initiates coordinated distal actionsactions

Remember the CoreRemember the CoreShould be emphasized as much, if not more Should be emphasized as much, if not more than the extremitiesthan the extremitiesJoints are injured when exercised in the Joints are injured when exercised in the endend--ranges, which usually occurs during ranges, which usually occurs during muscle fatiguemuscle fatigue

Weak hip musculature can have Weak hip musculature can have implications throughout gait cycle.implications throughout gait cycle.Not only affects hip joint, but knee Not only affects hip joint, but knee and ankle as well.and ankle as well.



Weak hip abductors can Weak hip abductors can demonstrate pelvic instability demonstrate pelvic instability during single limb stanceduring single limb stance

Musculature dysfunctionMusculature dysfunction

Does not allow for smooth transfer of Does not allow for smooth transfer of force from lower extremity to trunkforce from lower extremity to trunkAssessment:Assessment:•• Perform singlePerform single--limb knee bendlimb knee bend•• Drop in pelvis with knee Drop in pelvis with knee valgusvalgus

indicates insufficient gluteus indicates insufficient gluteus mediusmedius•• Clinical example: insufficient ankle Clinical example: insufficient ankle

rehab after sprain, unable to keep feet rehab after sprain, unable to keep feet flat on floor during a full squatflat on floor during a full squat

Musculature dysfunctionMusculature dysfunction

Weak hip musculature can Weak hip musculature can be associated with be associated with impaired shoulder functionimpaired shoulder functionAssess single limb support Assess single limb support abilities:abilities:•• 11--leg stanceleg stance•• 11--leg squatleg squat•• Step upsStep ups•• TrendelburgTrendelburg testtest

Unilateral WeightUnilateral Weight--bearing exercise and hip bearing exercise and hip musculature in order of effectiveness: musculature in order of effectiveness:

((AyotteAyotte et al, 2007)et al, 2007)

Gluteus Gluteus maximusmaximus::•• Wall squatWall squat•• Forward stepForward step--upup•• Retro stepRetro step--upup•• MiniMini--squatsquat•• Lateral stepLateral step--upup

Gluteus Gluteus mediusmedius::•• Wall squatWall squat•• Forward stepForward step--upup•• Lateral stepLateral step--upup•• Retro stepRetro step--upup•• MiniMini--squatsquat

Unilateral WeightUnilateral Weight--bearing exercise and hip bearing exercise and hip musculature in order of effectiveness: musculature in order of effectiveness:

((AyotteAyotte et al, 2007)et al, 2007)

VMO:VMO:•• Wall squatWall squat•• Forward stepForward step--upup•• MiniMini--squatsquat•• Retro stepRetro step--upup•• Lateral stepLateral step--upup

Biceps Biceps femorisfemoris::•• Wall squatWall squat•• Forward stepForward step--upup•• MiniMini--squatsquat•• Lateral stepLateral step--upup•• Retro stepRetro step--upup

Orthopedics: AnkleOrthopedics: AnkleDeficit in postural control in subjects Deficit in postural control in subjects with chronic ankle instability and with chronic ankle instability and fatigue fatigue (Gribble et al, 2004)(Gribble et al, 2004)

Hip control important for controlling Hip control important for controlling ankle. Hip abductor weakness on ankle. Hip abductor weakness on same side of chronic ankle injuries same side of chronic ankle injuries ((FrielFriel et al, 2006)et al, 2006)

Patients with several ankle injuries Patients with several ankle injuries had delayed proximal hip muscle had delayed proximal hip muscle activationactivationUnable to counteract lateral sway Unable to counteract lateral sway from pelvisfrom pelvis

Remember the CoreRemember the Core

Stress gluteus Stress gluteus medius/minimusmedius/minimus strengthstrengthMost core exercises are OKCMost core exercises are OKCTry CKC:Try CKC:•• Hip weakness shows up with Hip weakness shows up with

CKC activitiesCKC activities•• Carry weight in left hand on Carry weight in left hand on

treadmilltreadmill

SingleSingle--limb support exerciseslimb support exercises

Crucial for Crucial for lumbolumbo--pelvic stabilitypelvic stabilityExercises:Exercises:•• Supine bridge with leg raiseSupine bridge with leg raise•• Stability ball bridgeStability ball bridge•• Stability ball bridge with leg raiseStability ball bridge with leg raise•• SideSide--lying raiselying raise--andand--holdhold•• Standing singleStanding single--leg hip leg hip flexion/extensionflexion/extension

KneeKnee

Weakness of hip abductors & ER Weakness of hip abductors & ER associated with lack of eccentric hip associated with lack of eccentric hip adduction control and IR of femur adduction control and IR of femur during WB, causing during WB, causing malalignmentmalalignment of of patella patella (Robinson & Nee, 2007)(Robinson & Nee, 2007)

KneeKnee

3030--00ºº of extension is when the quads of extension is when the quads are most active, but also when there are most active, but also when there is the MOST compressive forces is the MOST compressive forces b/tb/tthe patella & the the patella & the trochleartrochlear..Role of the hip abductors & external Role of the hip abductors & external rotators:rotators:•• Abductors: Very active @ heel strikeAbductors: Very active @ heel strike•• Ext Rotators: help decelerate hip IRExt Rotators: help decelerate hip IR

KneeKnee

13 female athletes with unilateral PF 13 female athletes with unilateral PF pain had significantly weaker hip pain had significantly weaker hip abductors and ERs on involved side abductors and ERs on involved side compared to noncompared to non--involved side. involved side. (Edwards, 2008)(Edwards, 2008)

KneeKneeFemale runners with PF pain had 13% Female runners with PF pain had 13% decreased hip external rotation and hip decreased hip external rotation and hip abduction strength than unabduction strength than un--injured runners.injured runners.U of WisconsinU of Wisconsin--Milwaukee study:Milwaukee study:•• 66--week program of hip strengthening week program of hip strengthening

significantly decreased peak knee abduction & significantly decreased peak knee abduction & rearrear--foot inversion during runningfoot inversion during running

U of Kentucky study:U of Kentucky study:•• 66--week program focusing on quad & gluteus week program focusing on quad & gluteus

mediusmedius strengthening along with neuromuscular strengthening along with neuromuscular control found decrease in PF pain & improved control found decrease in PF pain & improved timing of quadstiming of quads

KneeKnee

Strength of eccentric contraction of the Strength of eccentric contraction of the hip rotators are predictors of knee hip rotators are predictors of knee abductor angles in young males abductor angles in young males (Claiborne, (Claiborne, 2007)2007)

Hip extensor strength & PF pain Hip extensor strength & PF pain (Robinson & (Robinson & Nee, 2007)Nee, 2007)

•• Symptomatic side had 52% decreased hip Symptomatic side had 52% decreased hip extensor strength than nonextensor strength than non--symptomaticsymptomatic

•• Findings: weak gluteus Findings: weak gluteus maximusmaximus may cause may cause femoral IR during WB especially when hip is in femoral IR during WB especially when hip is in flexion flexion

KneeKneeACL injuries:ACL injuries:•• Hip abductors play a role Hip abductors play a role

in neuromuscular control in neuromuscular control of the kneeof the knee

KneeKnee

CKC exercises to aid the PF joint:CKC exercises to aid the PF joint:•• Lateral stepLateral step--up up •• Crab walkCrab walk•• Rotational stepRotational step--upup

hip musculature and its role in lower extremity kinetic chain function

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