Resetting the hip
The purpose of the reset stage in the rehabilitation process, is to increase motor control or mobility of the joint structure through passive techniques like joint mobilizations, foam rolling, or stretches that positively impact the neuromuscular support around the joint (Cook, 2013). Joints that need mobility in the lower extremity include the ankle and hip. The hip becomes immobile when the prolonged inactivity causes the glutes to weaken, and the hip flexors to become dominant. This causes pain to the front of the hip and lower back. In this hypothetical case study, I’ll address how to treat a young woman with anterior hip pain, poor hip mobility, and lumbar back pain, by resetting the hip joint.
Janice is twenty-five-year-old office worker. She spends most of her time sitting at desk and working on computer. However, she ran in college, and continues to run around 50 miles a week. She complains of pains in the front of her hip and lower back. Janice would like to decrease hip pain and run a 10 k in the summer. Other than running, she has little exercise experience is unfamiliar with weight training. She does have experience with foam rolling and stretching . Based on a posture analysis, Janice has an anterior tilt of her pelvis, which indicates a shortness of the hip flexor. (Page, Frank, & Lardner, 2010). During a gait assessment there was poor amounts of hip hyper extension maybe due to joint stiffness (Page et al., 2010). A confirmatory modified Thomas test both her right and left hip flexors were short. In an overhead squat assessment, Janice arched her lower back, indicating tightness in the iliopsoases, buckled her knees, indicating a weak gluteals, and externally rotated her feet while coming down indicating a weak gluteus medius (Nickelston, 2011). Janice seems to have short hip flexors from prolonged sitting, as well as them being overactive and tight from distance running. To help restore Janice’s hip mobility, the hip flexors should be lengthened, and the gluteals should be strengthened. This should reduce the anterior pain in her hip, improve the pelvic positioning, reduce lordosis, and lessen her lower back pain.
To address Janice’s mobility issues in the hip the hip flexors, self-myofascial release techniques, stretching, and mobilizations are recommended. Foam rolling uses compression to help nerves in the muscles to relax, stimulate blood flow and aid in recovery (Verstegen & Williams, 2004). Foam rolling can reduce pain and increase flexibility of the hip flexors. Since the Thomas test confirmed tight hip flexors foam rolling is appropriate. foam roll out the hip flexors, Janice should lie face down with the roller slightly below one side of the hips. She should bent the opposite leg back at a 90°angle to get it out of her movement path. Her forearms should be placed in front of her to slightly in front of her and supporting her body weight. The leg that she has on the roller should then be extended back with the toes facing down and the foot flat. She should then roll slowly forward and back, with some side to side movement for 20-30 seconds and focus on the tight areas and trigger points. The movement is restricted to the hip flexors or the area of the pelvis and slightly to the top of the hip (SportsWebPT, 2014). To progress the movement, Janice should relax her thigh in the leg rolling. This increases the depth of the soft tissue massage. The second progression is slowing down rolling speed to increase the compression.
View foam rolling hip flexors here(https://www.youtube.com/watch?time_continue=39&v=AwIh_YjUt8g)
Stretching elongates the muscle to improve elasticity and restores comfortable muscle tone. Janice’s prolonged periods of inactivity coupled, with her running has shortened her hip flexors and made them overactive, specifically the illacus, and the psoas. The psoas stretches increases flexibility in both (McGill & Gray, 2014). To perform the stretch, Janice should be in a forward lunge position with her torso squared forward with the same arm raised straight up. Janice should then rotate her torso into the back leg. This exercise engages the psoas with the rotation, where most stretches ignore it. To progress the exercise, Janice can lower her lunge, or hold the stretch longer. The stretch should be held between about 45-60 seconds. The exercise can be viewed in Functional Training Handbook on pg.231
Hip joint mobilizations are appropriate tools to help improve capsule and potentially other connective tissue mobility limitations. Since Janice has issues with tight hip flexors, I would assist her perform an inferior glide. To perform the mobilization, Janice would be lying on the end of table or bench, with a belt or strap wrapped around her the top of her leg and my leg and my leg too (Buckingham, n.d.). To begin the exercise, I would be in a staggered stance applying a slight distraction force forward against the leg. While holding, Janice should resist into me for 3-5 seconds and then relax. While relaxing the leg she should move it into a more flexed position. Repeat several times. (View mobilization here: http://members.nata.org/quizcenter/courses/gettingfunctional/handouts/Functional-Mobilization-Techniques-for-the-Lower-Extremities-1.pdf).
To progress the mobilization Janice can perform an inferior glide be herself with a strap, a step, a towel and some weights. To begin Janice would place her foot on a low step, with a strap carrying light weights around the thigh as close to the hip joint as possible (Reimann & Matheson, 2013). Janice should lean forward, shift the knee over the ankle, keep the heel down. She should safely perform 10 repetitions slowly. To progress the exercise Janice could oscillate the weight underneath her, or lift the weights up and down beneath her (Reimann & Matheson, 2013). Janice can also step up and step back from the starting position, to help increase mobility around the joint capsule.
To strengthen and help improve activation of the gluteals, the glute bride is ideal. The exercise activates, develops and improves the recruitment patterns of the glute musculature (Verstegen & Williams, 2004). To perform the exercise Janice would lie flat on the ground with her knees bent at 90° with a towel between them. With the core tightened, she should lift the hips toward the ceiling, while keeping her core down tight. She should lower down slowly, but not hit her but to the ground (Verstegen & Williams, 2004). To progress the movement once she’s achieved mastery and control, she can lift one leg at a time. To further challenge herself Janice, could straighten the leg in the air and pull it in to work on some hip flexor flexibility at the same time (Verstegen & Williams, 2004). These exercise can be found on pg 64-65.
Janice has poor hip mobility due to tightness in her hip flexors and weakness in her gluteals. By foam rolling the hip flexor, doing the psoas stretch, and performing the inferior glide mobilization should reset the hip flexor group. Strengthening the gluteals will prevent, the lumbar spine from compensating in movement. These exercise series should help lessen Janice’s hip and back pain, restore her posture, improve her squat performance, and make her ready for more advanced exercises.
Buckingham, M. (n.d.). Functional mobilizations for the lower extremity. Retrieved from http://members.nata.org/quizcenter/courses/gettingfunctional/handouts/Functional-Mobilization-Techniques-for-
Cook, G. (2013, September 18). The three Rs. Retrieved from http://graycook.com/?p=1553
McGill, S., & Gray, J. (2014). Olympic weight lifting. In Functional training handbook (pp. 227-240). Philadelphia: Wolters Kluwer Health.
Nickelston, P. (2011). The overhead squat assessment. Dynamic Chiropractic, 29(2), 4-4.
Page, P., Frank, C. C., & Lardner, R. (2010). Assessment and treatment of muscle imbalance: The Janda approach. Leeds: Human Kinetics.
Reimann, M. P., & Matheson, J. W. (2013). Restricted hip mobility: Clinical suggestions for self‐mobilization and muscle re-education. International Journal of Sports Physical Therapy, 8(5), 729-740.
SportsWebPT. (2014, March 16). Hip flexors foam rolling. Retrieved from https://www.youtube.com/watch?time_continue=39&v=AwIh_YjUt8g
Verstegen, M., & Williams, P. (2004). Core performance: The revolutionary workout program to transform your body and your life. Emmaus, PA: Rodale.