Hip and Core Rehabilitation - American Osteopathic Academy of

American Osteopathic Academy of Sports Medicine
James McCrossin MS ATC, CSCS
Philadelphia Flyers
April 23rd, 2015
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“Coming together is a beginning; keeping
together is progress; working together is
success.” ( Henry Ford)
A successful rehabilitation program occurs when
everyone is working on the same page.
The more knowledge we have of an individual’s
anatomy, function and pathology, prior to injury,
the more successful the outcome.
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Coxa vara: a deformity of the hip,
whereby the angle between the head
and the shaft of the femur (aka angle of
inclination) is reduced to less than 120
degrees.
This deformity results in decreased joint
load at the hip as forces are distributed
distally.
Results in genu varum at the knee –
MCL strain, lateral knee joint line
compression and pronation at the foot.
How many foot/ankle and knee issues
might be originating at the hip!
This deformity also causes increased
shearing forces that can lead to
pseudoathrosis of the femoral neck.
Femoral neck tends to be shorter
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Coxa valga: a deformity of the hip, whereby
the angle between the head and the shaft of
the femur (aka angle of inclination) is greater
than 130 degrees.
Coxa valga is considered to be one of the most
unfavorable structural configurations of the
hip because of increased joint compression.
Eccentric control of hip abduction is
diminished during landing (through the pelvis)
leading to increased forces through the joint.
Results in genu valga at the knee, inversion at
the ankle, compression stress along the medial
aspect of the knee
This position of the hip leads to loss of hip
abduction movement, which cause a force
imbalance and a prearthritic state, not the
deformity itself.
Femoral neck tends to be longer
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The femoral head and neck project anteriorly in relation to the
femoral condyles.
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This angle is known as the angle of declination.
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This angle is approximately 25-30 degrees at birth and 8-14
degrees in the adult.
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Increased angle is know as Anteversion
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Hip internal rotation will be increased, external rotation will be
decreased
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Anteversion may also induce genu-valgus and or ankle eversion,
as the femoral head points back towards the acetabulum for a
better fit.
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If the angle of declination is significantly decreased,
then retroversion results. This results in a greater
amount of external rotation (toe out), whether the hip
is positioned in 0 or 90 degrees of hip flexion.
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People who have acetabulum retroversion typically
have F.A.I.
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Craig’s Test is an excellent way of evaluating for hip
anteversion/retroversion.
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Retroverted individuals will have excessive external
rotation and limited internal rotation.
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Research has demonstrated that an isolated rehabilitation
approach after injury is not sufficient to normalize
performance that encompasses the entire body.
Data have also suggested that an isolated injury will
adversely affect regions away from the injury site.
“Regional Interdependence” why dysfunction in one body
region may be contributing to weakness, tightness, or pain
in another region.
Thus a valid and reliable measurement tool that assesses
multiple domains of function simultaneously is a very
effective source of knowledge to have, prior to your initial
evaluation.
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Fusionetics, Functional Movement Screen are just two
systems that many sport teams and physical therapy
centers are utilizing.
These programs will help you to develop a comprehensive
program of physical therapy, corrective exercise and
strength and conditioning programs.
It will assist the clinician in developing customized
programs for injury prevention and increased functional
movement, evaluating musculoskeletal inefficiencies in
order to provide corrective exercises and therapies.
Great liaison for expanding relationships between
physicians , physical therapist, athletic trainers and other
members of the sports medicine world.
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Developed to identify movement
impairments & underlying
causes
• Developed as kinesiopathological
assessment to direct treatment/
injury reduction programs
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Binary-scored checklist of
movement impairments (yes/no)
Double-leg Squat
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Single-leg Squat
Toe out
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Foot flattens
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Knee moves in
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Knee moves out
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Excessive trunk flexion •
Low back arches
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Arms fall forward
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Heels lift
Asymmetrical weight shift
Foot flattens
Knee moves in
Knee moves out
Hip hike
Hip drop
Trunk inward rotation
Trunk outward rotation
Identify underlying
muscle Imbalance
Hirth et al, 2007
Impacts recovery & durability
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Altered wheel / car alignment
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Greater tire wear & tear
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Poor steering & control
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Decreased efficiency
Increased steering and
suspension wear
Decreased durability
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Movement Compensation = Muscle Imbalance
Altered
lengthtension
Poor
muscle
control
Altered
joint
motion
Movement
impairment and
compensation
Tight or
Overactive
Weak or
Inhibited
Unequal force / tension → Mal-alignment
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The local muscle groups provide specific segmental spinal
stability through their attachment directly to the lumbar
vertebrae.
These muscles provide control of intersegmental motion
and position of the lumbar spine.
This group includes the following: transverse abdominis,
multifidus, and internal oblique ( fiber intersection into the
thoraco lumbar fascia.
Recent studies have also found that the pelvic floor
muscles, the diaphragm, and quadratus lumborum ( and
others) are also to be included in the local muscles.
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The transverse abdominis and internal
oblique muscles provide stability for the
lumbar spine through the thoracolumbar
fascia along with the control of the intraabdominal pressure.
Local muscles are capable of controlling
movement and intervertebral relationship of
the spinal segments and the posture of the
lumbar spine.
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Global muscle groups provide large trunk
movements and general trunk stability
through their attachments between the
thorax and pelvis and or pelvis and legs, with
no specific attachment to the lumbar spine.
The global muscle would include: longissimus
& Illiocostalis, pars thoracis and pars
lumborum, rectus abdominus, external and
internal obliques, hip abductors, extensors,
rotators.
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The global muscle group has also been described
as being divided into four slings between the
thorax, pelvis and lower extremity.
Posterior Oblique Sling: latissimus dorsi & glut
max via the thoracolumbar fascia
Anterior Oblique Sling: external oblique, anterior
abdominal fascia, contralateral internal oblique,
adductors of the lower extremity
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Longitudinal Sling: involves connections
between the peroneii, biceps femoris,
sacrotunerous ligament, deep lamina of
thoracolumbar fascia and erector spinae.
Lateral Sling: glute medius and minimus,
tensor fascia latae, lateral stabilizers of the
thoracopelvic region
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Posterior Fibers of the Glut Medius
The glut medius serves an integral component in
the kinetic chain of the athlete and is now
commonly described separately and having
several anatomic subdivions.
Posterior fibers have been described to function
as the primary segment in stabilizing the femoral
head in the acetabulum during weight transfer
and to contribute to external rotation of the
femur relative to the stable pelvis.
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It has been reported ( Neumann, 2002) that
importance of the posterior segment of the glut
medius in lunging and jumping by showing that
the glut maximus produced less external hip
rotation torque at hip flexion greater than 60
degrees.
Compromise of the glut medius has been linked
most commonly to ankle inversion and knee
injuries, including patella tendonitis, iliotibial
band syndrome, anterior cruciate ligament tears
and medial collateral ligament tears.
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Rob Donatelli PhD, PT has an excellent test know as
the Donatelli drop leg test
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The test is performed in the side lying position.
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The clinician passively abducts the leg to the end of
hip abduction range of motion and then extends the
hip to 20 degrees. While holding the leg in abduction
and extended position, the patient is asked to
maintain this leg position, while the clinician lets go.
A shortened lever arm with hip extension changes the
gluteus medius angle of pull, thus requiring the
abductor muscle to develop greater force, recruiting
more fibers to counter balance the effects of gravity.
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External oblique muscle is one of the largest
components of the human trunk. It is one of the
outermost of the abdominal muscles, extending
from the crest of the ilium to the pectorals.
It helps to rotate the trunk but also contributes
with a few vital functions. This muscle helps pull
the chest as a whole downwards, which
compresses the abdominal cavity.
The external oblique also is a contributor to
instability in the pelvis
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Shirley Sahramann PhD PT in her book and course
work provides us with an excellent ways to help test
and strengthen the external oblique muscle.
With the patient in the supine position with one hip
and knee flexed, have the patient slide the opposite
extremity into extension and then extends the other
lower extremity so both lower extremities are
extended.
With the patient in the standing position with the low
back flat against the wall and with the hips and knees
flexed, have them tighten their external oblique
muscles and straighten the hips and knee while
keeping their backs flat.
Is one of the smallest yet most “powerful” muscle that
gives support to the spine.
It helps to take pressure off the vertebral discs so that
our body weight can be well distributed along the
spine.
Superficial muscle group keeps our spine straight while
deep muscle group contributes significantly to the
stability of our spine.
Research has shown that the multifidus gets activated
before any action is carried out so to protect your spine
from injury.
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A little knowledge will only take you so far
Having access to a lot of knowledge and
information will certainly improve your
outcomes not just for the immediate future
but for years to come!
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Enjoy our City of Brotherly Love!