Hip interventions

What are the general goals for intervention?

1. unload, pt education, activity modification, AD training as needed

2. restore joint ROM

3. address contributing impairments, reduce risk for re-injury

4. movement retraining

5. strengthening, RTS

In general, what kind of exercises are appropriate for many acute injuries, post-op hip, or significant weakness &/or pain?

• A/AAROM

• isometrics

What exercise is best for EMG activation of glute med according to literature?

sidelying hip ABD

What exercises are best for EMG activation of glute max according to literature?

• SL squat

• SL DL

What mm can easily be confused with when trying to target glute med & min?

TFL

What exercise is best for EMG activation of the glutes compared to TFL?

clamshells

What are some pt education you can provide regarding FAIS?

• sitting: avoid excessive anterior pelvic tilt, crossing legs, knees higher than hips

• sleeping: pillow b/w legs if sidelying

• avoid extreme hip flex or rotation

What are some interventions you can do for FAIS?

• movement retraining

• hip, trunk, LE strengthening

• NM re-education to activate glutes (visual feedback, cuing)

• soft tissue mobs

• nonthrust & thrust mobs

What are some pt education you can provide regarding hip OA?

What should pt education be combined with?

• unload (activity modification)

• exercise

• lose weight if overweight

• pt education should be combined w/ exercise & manual therapy

What are some interventions you can do for hip OA?

• manual therapy for mild-moderate hip OA

  • lateral distractions

  • inferior glides

  • A-P mobs for hip flex & IR

  • P-A mobs for hip ext & ER

  • soft tissue mobs

• flexibility, strengthening, endurance for hip ext, ABD, ER

• functional, gait, balance training

• AD training if needed

• NSAIDs, corticosteroid injection

How does low-force nonthrust long axis distractions help hip OA?

High-force nonthrust?

• low force: improved pain tolerance

• high force: improved hip ROM & function

What are NOT recommended for treating hip OA?

• glucosamine sulfate

• hyaluronic acid injections

What are the general principles for treating extra-articular hip conditions?

• criterion based or time based

• pt education

• early tissue protection (activity modification, AD)

• minimize effects of immobilization

• progress from lower loads in tolerable ranges to increased loads at end ranges & sport specific positions

Tendon-specific:

• avoid aggressive stretching in acute phase, tendinopathies can have latent response (24 hrs)

• tendinopathies can have a longer rehab process

What is the normal range of ADD:ABD strength ratio for uninjured athletes?

109-121%

What is the rehab process for treating adductor-related pain?

Acute:

• gentle hip & knee ROM

• lumbopelvic stabilization

• AROM & isometrics of surrounding mms

• lateral walking

• soft tissue mobs

• criteria to pass:

  • not irritable

  • lower level ADLs w/ minimal pain

  • stable Sx’s

Intermediate:

• endurance (biking, swimming, elliptical)

• concentric hip ADD strengthening (standing cable ADD, standing ADD slides, seated ADD machine, BIL ADD on sliding board, sumo squats, lunges)

• balance training (SLS, BOSU, add in perturbations)

Advanced:

• intermediate exercises w/ resistance or speed progression

• eccentric hip ADD strengthening

• plyos or sport specific

• Copenhagen ADD, lateral skater jumps, cutting, pivoting, planks w/ ADD/ABD, hopping

What assessment can you administer to make a decision for RTS for pts w/ adductor-related pain?

Copenhagen 5 sec adductor squeeze test

What is the rehab process for treating iliopsoas-related pain?

Acute:

• deload hip flexors, hip flex in supine or quadruped, progress from lower loads (supine heel slides, active hip flex to 90°, standing hip flex to partial range)

• lumbopelvic stabilization

Intermediate:

• strengthen hip flex (TA activation, TA w/ hip flex in hooklying, planks, SLR)

• ensure proper lumbopelvic position during exercise

RTS:

• full strength, ROM

• tolerate all hip flexor, lumbopelvic exercises w/ proper form

What are the primary goals when treating GTPS?

• reduce compression

• strengthening to manage compression

• optimize movement patterns

What pt education can you provide for pts w/ GTPS?

• standing: avoid leaning to one side or crossing legs

• sitting: avoid crossing legs

• sleeping: pillow b/w legs if sidelying

• minimize stairs, hills, running on banked tracks, any aggravating activities

• maintain activity

What interventions can you do for GTPS?

• soft tissue mobs over hypertonic mms

• nonthrust or thrust mobs for joint stiffness

• reduce pain, load tendon to increase tendon capacity

  • acute: isometrics, limit hip ADD

  • strengthen deep hip rotators

  • lumbopelvic stabilization

  • progress to SLS exercises as tolerated

• movement training

  • control ADD during WB (repetition, cuing)

  • squats —> SLS —> SL squat

What should you do in the early phase of treating hamstring strains?

What are the criteria to advance to the next phase?

• control pain & swelling

• gait training

  • if crutches: foot flat, maintain normal gait as able

  • no crutches: temporarily reduce stride length

• ROM exercises up to minimal pain, avoid excessive hamstring stretching

• limit effect of immobilization

  • pain-free isometrics for hamstrings, TA

  • avoid PRE for hamstrings

  • low resistance stationary bike

To advance to the next phase:

• symmetrical A/PROM of hip & knee

• normal gait

• no pain w/ exercises

What should you do in the intermediate phase of treating hamstring strains?

What are the criteria to advance to the next phase?

• restore hamstring length

  • if weak: avoid aggressive stretching

  • if radiating Sx’s: neurodynamics

• LE strengthening

  • PRE for hamstrings towards end ranges

  • walking, jogging, biking, ellipticals

• lumbopelvic stabilization (reduce risk of re-injury)

• restore neuromuscular control

  • SL balance

  • others

• introduce eccentric exercises

  • before this, >50% hamstring strength compared to other leg

To advance to the next phase:

• tolerate all exercises in this phase

• >90% hamstring strength compared to other leg, 5/5 MMT

• good balance & neuromuscular control

• able to jog both directions at >50% effort w/o Sx’s

What should you do in the advanced phase of treating hamstring strains?

What are the criteria for RTS?

• maximize LE & hamstring strength, esp. eccentric

• advance lumbopelvic stability in all planes & speeds

• sports-specific endurance training

• running, agility, plyos

RTS criteria:

• normal, symmetrical, pain-free ROM

• full hamstring strength in all positions

• tolerance to all sports-specific activities

• no athlete apprehension (associated w/ reduced re-injury rates w/ H-test aka ballistic SLR w/ other leg secured)

What is one exercise that has high evidence for reducing risk of hamstring injuries?

nordic hamstring exercises

What are some considerations you should be aware of when taking pts w/ PHT through criterion-based progression?

• 0-3/10 pain acceptable during & after but should not be irritable

• Sx’s should settle within 24 hrs

What is the goal for PHT rehab?

Restore energy storage & energy release in mm group

How should pts w/ PHT unload?

• avoid direct hamstring stretching

• ischial tuberosity cutout

What is the prognosis for complete recovery for PHT?

3-6 months

What should you do in stage 1 of treating PHT?

What are the criteria to advance to the next stage?

• isometrics few times daily (SL bridge holds, straight leg pulldowns, trunk ext)

• reduce tendon compression

• monitor pain before & after exercise

To advance to the next stage:

• minimal to no pain (VAS 0-3) during exercises & within 24 hrs after

What should you do in stage 2 of treating PHT?

What are the criteria to advance to the next stage?

• isotonic hamstring exercises at neutral or midrange hip (<50°) (prone leg curls, supine leg curls, SL bridges)

• heavy slow resistance training to fatigue (3 sec concentric, 3 sec eccentric)

• SL exercises for asymmetries

• start w/ 15RM, progress to 8RM, 3-4 sets every other day

To advance to the next stage:

• minimal to no pain (VAS 0-3) on all stage 2 exercises and w/ higher-load functional tests (SL RDL, lunges, sport-specific postures)

What should you do in stage 3 of treating PHT?

What are the criteria to advance to the next stage?

• isotonic hamstring exercises at greater hip flex (still <90°) (RDL, SL RDL, lunges, step ups, hip thrusts)

• heavy slow resistance training to fatigue (3 sec concentric, 3 sec eccentric)

• progress double limb to SL for lumbopelvic stability & glute med activation

• progress hip flex for DL & lunges to load hamstrings

• start w/ 15RM, progress to 8RM, 3-4 sets every other day

To advance to the next stage:

• minimal pain w/ hamstring tendon loading through all ROM for functional & sports-specific activities

What should you do in stage 4 of treating PHT?

• energy storage loading

• progressive plyos (may be provocative, start conservatively)

• dynamic activities (avoid high hip flex to minimize tendon compression w/ elastic loading) every 3 days initially

• multiplanar, cutting, pivoting activities for sport

• 1 set of 15-20 reps, progress to 3 sets depending on pain

• be conservative w/ stairs, hills, speed training

• graded exposure to provocative activity before competition

What are some other treatment considerations for PHT besides tendon loading?

• nonthrust or thrust mobs for contributing impairments

• dry needling (little evidence)

• corticosteroids (little evidence)

What is the goal for piriformis syndrome rehab?

Reduce mm irritability and sciatic n. compression

What pt education can you provide for piriformis syndrome?

Unloading, reducing compression, avoid excessive piriformis lengthening

• avoid sitting on hard surfaces

• avoid sitting on wallet

• avoid sitting w/ legs crossed

• pillow b/w knees if sidelying

What are some interventions you can do for piriformis syndrome?

• soft tissue mobs to piriformis if low irritability

• piriformis stretching, avoid aggressive stretching

• neurodynamics if neural Sx’s

• glute & ER strengthening, isometric —> isotonic

• treat LBP if needed (lumbar unit)

• Botox or corticosteroid injections for challenging cases