Hip Mobility Exercises to Prevent Pathologies

Restricted Hip Mobility: Clinical Suggestions for self-mobilization and muscle re-ediucation – free full-text PMC3811738 – 2013 Oct;

Restricted hip mobility has shown strong correlation with various pathologies of the hip, lumbar spine and lower extremity.

Restricted mobility can consequently have deleterious effects not only at the involved joint but throughout the entire kinetic chain.

Promising findings are suggesting benefit with skilled joint mobilization intervention for clients with various hip pathologies.

Supervised home program intervention, while lacking specifically for the hip joint, are demonstrating promising results in other regions of the body.  

Application of an accompanying home program for the purpose of complementing skilled, in clinic intervention is advisable for those clients that respond favorably to such methodology.

Problem:

Hip mobility limitations have been suggested to be present in some conditions of the lumbar spine14 as well as in more distal lower extremity pathologies.57

Directly relevant to the hip itself these mobility limitations have been found in clients with osteoarthritis,810 sports related groin pain,11,12 and femoroacetabular impingement (FAI) and/or hip labral tear.10,13

Lower extremity range‐of‐motion (ROM) deficits are often noticed in clients with various hip joint pathologies. Clients with FAI and labral tear tend to exhibit reduced hip ROM for flexion, internal rotation, and/or adduction.1418

Athletes with groin pain were also found to have limited hip ROM.11,12

Strong predictor variables for the presence of hip osteoarthritis include squatting as an aggravating factor,19 as well as limited hip internal rotation ROM.8,9,19

Additionally, decreased ROM of hip abduction has been suggested to predict the occurrence of future lower extremity injuries.20

Therefore, it is important to minimize the deleterious effects of limited ROM if possible.

Limitations in flexion and internal rotation ROM have been implicated as characteristic of hip pathology.1418

Any sport that requires squatting, pivoting, plant and cut, and similar movements will approximate these positions. Other sport‐related activities do not frequently require this combination of movement.

Upright running, for example, is such an example and is a particularly important skill requirement of most sports.

Limited hip extension flexibility has been proposed as one possible cause of increased anterior pelvic tilt and lumbar lordosis during running.21,22Currently, there are few published investigations regarding limited hip extension in running athletes.

Additionally, the literature that is available does not clearly elucidate the reason for this limited hip extension, although it appears that the deficit in extension cannot be explained by muscle tightness alone.23

Therefore, careful assessment of the lumbar spine, pelvis, and hip should be undertaken in the running athlete lacking this motion in order to most appropriately intervene regarding their limitation(s).

When joint mobility restrictions limiting hip motions are discovered, an appropriate intervention to address these limitations is joint mobilization of the appropriate portions of the joint capsule, most likely the posterior, inferior and lateral portions.24,25

Achieving optimal client outcomes can be augmented with self‐mobilizations26 and muscle re‐education exercises in order to maintain treatment benefit.

Furthermore, mobilization and muscle re‐education exercises have been suggested as part of a multi‐modal approach for hip pathology.2730

Recent findings are suggestive of abnormal hip joint morphology in young athletes contributing to limited ROM, even those without pathology.3134

The extent that these limitations in ROM are due to radiographic changes is not fully elucidated. Additionally, the extent to which joint ROM and mobility can be improved in a client with radiographic changes is not currently understood.

The individual anatomical geometry of the proximal femur and acetabulum only partly influences restricted mobility and function.  A hip with an abnormal radiographically illustrated morphology may not be destined for arthritic degeneration.35,36

The clinician must consider though whether joint mobilization is an appropriate component of the treatment plan. For the client with bony morphologic changes, mobilizations may be inappropriate.

As with all employed interventions, client tolerance and re‐assessment to a trial of joint mobilization and muscle re‐education intervention is necessary (if it is even appropriate at all).

The utilization of skilled joint mobilization interventions supplemented with an appropriately implemented self‐mobilization program may be of benefit for the client with mobility deficits.

Solution:

There are various methods to self‐mobilize and/or re‐educate hip musculature for the client with either hip intra‐ or extra‐articular pathology

The goals of the combined techniques (self‐mobilization and muscle re‐education) are also to improve capsule and connective tissue mobility, as well as improve muscle re‐education.

Additionally, often with these techniques the recruited muscles can assist with optimizing hip joint movement. In some cases, this improved joint movement may significantly alleviate the athlete or client’s symptoms.

All of the techniques described in this clinical suggestion may be carried out in a clinical setting as clinician directed multi‐modal treatment including both therapeutic exercise and manual therapy interventions.

With proper in‐clinic instructions selected clients may be able to enhance their treatment plan by performing a series of selected self‐mobilization techniques and end range exercises as part of a home rehabilitation program

These techniques are not, and should not, be employed as an alternative to a skilled intervention applied by a properly trained clinician. They are simply adjuncts to achieving the treatment goals of the clinician and client.

The CDC recommends these INSTEAD of “real medicine” while this therapist acknowledges they are only an adjuvant to other therapy.

The authors have selected a variety of self‐hip mobilization techniques for possible integration into a home program

Hip Inferior‐Posterior Glide
with/without Muscle Re‐Education in Hip Flexion

This self‐mobilization technique is likely most appropriate for the client with restricted hip flexion and adduction such as those with FAI and requires the use of a towel, some version of weight, a rope/strap, and a stable step close to a stable surface that the client can hold onto for balance.

The client places their involved foot onto the step. The weight(s) are tied to the jump rope (in this case). The jump rope is then tied to the towel and the towel is wrapped around the client’s thigh and placed as close to the hip joint as possible. The client grasps both handles of jump rope in order to control weight and decrease/increase the load on the hip as tolerated (Figure 1).

The amount of weight applied is dependent on the client tolerance, safety, goal of the exercise, and weight availability. Once the proper weight is established according to therapist‐determined guidelines, the client is instructed to perform a step‐up (Figure 2) or step‐back (Figure 3).

  • Figure 1.Inferior‐posterior glide with towel‐jump rope set‐up – start position.
  • Figure 2.Inferior‐posterior glide with towel‐jump rope set‐up – finish position.
  • Figure 3.Inferior‐posterior glide with towel‐jump rope set‐up – step‐back finish position.

Hip Inferior and Lateral Glides
with Hip Flexion Movement

Research outcomes have demonstrated that clients with FAI have limited squatting motion compared to controls due to limited pelvic sagittal plane motion.

The depth of squat has also been improved in clients with FAI post‐surgically, and theorized as a result of reduced acetabular coverage and an improved pelvic posterior inclination angle.

this technique is likely most beneficial for the client with limited hip flexion motion in a loaded position.

With the same set‐up as in the technique described in Figure 1, the client is asked to further flex their hip via moving their trunk/upper body down toward the floor (e.g. pelvic on femoral hip flexion).

This same technique can be performed with a self‐lateral distraction mobilization in place of the inferior glide

Instead of weights (unless the client has access to a weighted pulley system and weight belt), a rope/jump rope or belt/strap can be tied to the end of the sheet or a weightlifting belt (Figure 4). A large knot (or the handles of the jump rope) is placed on the other side of a solid, closed door that is not currently being used or, as in Figure 4,

Three sets of 30 repetitions twice a day is suggested.

  • Figure 4.Pelvic on femoral flexion movement with laterally directed femur glide.
  • Figure 5.Pelvic on femoral flexion movement with laterally directed femur glide during squat.
  • Figure 6.Pelvic on femoral flexion movement with laterally directed femur glide and muscle re‐education during squat.

Hip Posterior Glide
with/without Movement

This technique best selected for a client with posterior and lateral capsular restrictions and requires a solid bench or chair and good upper body strength to perform.

This can be padded if necessary for comfort. The client grasps each side of the surface (flexing their hip to approximately 90°) and attempts to pull their trunk toward the surface, imparting a posterior glide to the hip joint (

The client places the involved knee on the solid supporting surface.

  • Figure 7.Unilateral weight‐bearing posterior glide.
  • Figure 8.Unilateral weight‐bearing posterior‐lateral glide.
  • Figure 9.Kneeling lateral hip distraction weight shift a) start position, b) finish position.
  • Figure 10.Kneeling lateral hip distraction with active internal rotation movement.

Hip Lateral Glide
with/without Muscle Re‐Education

  • Figure 11.Standing lateral hip distraction – a) start position, b) finish position.
  • Figure 12.Standing lateral hip distraction with muscle re‐education – a) start position, b) finish position.
  • Figure 13.Standing lateral hip distraction with overpressure.

Hip Anterior Glide
with Muscle Re‐Education

  • Figure 14.Standing anterior glide with active movement: a) start position, b) finish position.

Hip Long‐Axis Distraction

For the client with multi‐planar restricted capsular mobility, or the client requiring sustained overall capsular stretch, the supine long‐axis distraction (Figure 15) can be a particularly effective technique.

Clients with osteoarthritis, for example, have demonstrated multi‐planar restrictions of ROM.8,9 The clinician should consider that, due to the geometry of the hip joint, this technique is essentially an inferior glide.

DISCUSSION

The authors’ endorsement of these self‐selected hip mobilizations is based on anecdotal observations and a shared opinion of benefit that exists in the absence of evidence

Therefore clinicians are strongly encouraged to utilize these techniques as adjunct to other treatment techniques and not in absence of interventions supported by higher‐level evidence (e.g. in clinical manual therapy techniques)

Finally, although it remains unknown if self‐mobilization for the hip is of significant benefit to the client with hip mobility deficits, it does allow for some carry over of manual techniques outside of the clinic setting.

This may improve home program adherence, functional outcomes, and client independence in the management of their hip joint mobility deficits.

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