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Rehabilitation Concepts of Hip & Core Muscle Injuries

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Rehabilitation Concepts of Hip & Core Muscle Injuries American Osteopathic Academy of Sports Medicine James McCrossin MS ATC, CSCS Philadelphia Flyers April 23rd, 2015 “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. 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 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 The femoral head and neck project anteriorly in relation to the femoral condyles. This angle is known as the angle of declination. This angle is approximately 25-30 degrees at birth and 8-14 degrees in the adult. Increased angle is know as Anteversion Hip internal rotation will be increased, external rotation will be decreased Anteversion may also induce genu-valgus and or ankle eversion, as the femoral head points back towards the acetabulum for a better fit. 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. People who have acetabulum retroversion typically have F.A.I. Craig’s Test is an excellent way of evaluating for hip anteversion/retroversion. Retroverted individuals will have excessive external rotation and limited internal rotation. 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. 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. Developed to identify movement impairments & underlying causes • Developed as kinesiopathological assessment to direct treatment/ injury reduction programs Binary-scored checklist of movement impairments (yes/no) Double-leg Squat Single-leg Squat • Toe out • Foot flattens • Foot flattens • Knee moves in • Knee moves in • Knee moves out • Knee moves out • Hip hike Identify underlying • Excessive trunk flexion • Hip drop muscle Imbalance • Low back arches • Trunk inward rotation • Arms fall forward • Trunk outward rotation • Heels lift • Asymmetrical weight shift Hirth et al, 2007 Impacts recovery & durability • Altered wheel / car alignment • Greater tire wear & tear • Poor steering & control • Decreased efficiency • Increased steering and suspension wear • Decreased durability Movement Compensation = Muscle Imbalance Poor Altered muscle length- control tension Altered joint motion Tight or Weak or Overactive Inhibited Movement impairment and Unequal force / tension → Mal-alignment compensation 16 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. The transverse abdominis and internal oblique muscles provide stability for the lumbar spine through the thoracolumbar fascia along with the control of the intra- abdominal pressure. Local muscles are capable of controlling movement and intervertebral relationship of the spinal segments and the posture of the lumbar spine. 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. 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 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 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. 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. Rob Donatelli PhD, PT has an excellent test know as the Donatelli drop leg test The test is performed in the side lying position. 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. 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 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. 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! Enjoy our City of Brotherly Love!.
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