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?

• avoid excessive anterior pelvic tilt while sitting

• don’t sit cross legged

• don’t sit w/ knees higher than hips

• put pillow b/w legs if sleeping on side

• avoid extreme hip flex or rotation

What are some interventions you can do for FAIS?

• soft tissue mobs

• nonthrust & thrust mobs

• movement retraining

• hip trunk, LE strengthening

• visual feedback, cuing

• NM re-education to activate glutes

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

• activity modification

• exercise

• lose weight if overweight

• unload to protect joint

What are some interventions you can do for hip OA?

• manual therapy for mild-moderate hip OA

  • lateral distractions

  • A-P mobs for hip flex & IR

  • caudal glides

  • 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, use AD To unload/deload)

• 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

• concentric hip ADD strengthening

• balance training

Advanced:

• progress resistance or speed

• eccentric hip ADD strengthening

• plyometrics or sport specific

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, initiate hip flex in supine or quadruped

• lumbopelvic stabilization

• progress AROM from lower loads

Intermediate:

• strengthen hip flex

RTS:

• full strength, ROM

• tolerate all hip flexor resistance training

• proper form w/ resistance training

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 running on banked tracks

• minimize any aggravating activities

• minimize stairs or hills

• maintain activity

What interventions can you do for GTPS?

• soft tissue mobs over hypertonic mms

• nonthrust or thrust mobs for joint stiffness

• reduce pain, progress tensile stress to increase tendon capacity

  • limit hip ADD early on

  • strengthen deep hip rotators

  • isometrics in acute cases

  • progress to SLS exercises as tolerated

  • address weak lumbopelvic

• 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 stretching of hamstrings

• limit effect of immobilization

  • submax pain free isometric exercises for hamstrings, TA

  • low resistance stationary bike

  • avoid PRE for hamstrings

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?

• LE strengthening

  • progress towards end ranges

  • PRE for hamstrings

  • walking, jogging, biking, ellipticals

• restore mm length

  • if weak: avoid aggressive stretching

  • neurodynamics if radiating Sx’s

• improve lumbopelvic stability

  • weak lumbopelvic = risk factor for re-injury

• restore neuromuscular control

  • SL balance

  • other neuromuscular control exercises

• introduce eccentric exercises

  • should demonstrate >50% hamstring strength compared to healthy leg and tolerate program well before adding eccentrics

To advance to the next phase:

• tolerate all exercises in this phase

• near-symmetrical hamstring strength: >90% compared to healthy 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