2016 New Advances in Hip Rehabilitation
The last weekend in April, I went to Salmon Arm, for the course, New Advances in Hip Rehabilitation. The course was held at Lakeshore Physiotherapy and hosted by Julie and Jeff, owners of Lakeshore Physiotherapy. This was the first time in my life going to Salmon Arm. Even though I have been coming down to the Okanagan since the mid 1970’s, I had never been to Salmon Arm. When this course, which I had wanted to take for more than a few years was being held in Salmon Arm, I jumped at the chance!
The course is taught by two outstanding individuals, David Lindsay and Geoff Cuskelly. David works at the University of Calgary physiotherapy clinic. He works very closely with a number of orthopaedic surgeons and researchers. He is a little bit of a researcher himself, I believe he stated that he is the author of over 30 peer review papers. Impressive. I did not know that David was Australian, as he does not have an accent.
Geoff Cuskelly was the other gent teaching the course. He is the owner of Tower Physiotherapy in downtown Calgary. He is also Australian, easy to tell because he still has the accent. Geoff is a great businessman in the physiotherapy world and has done numerous things in his career. One of the interesting things that Geoff has done is become very knowledgeable about fascia and the fascial connections throughout the body. He taught us the soft tissue mobilization part of the course, getting the fascia to be less stuck.
Saturday morning was all lecture, the foundation for the course. David talked about hip anatomy. It was very interesting from a physiotherapist perspective. For example, the average hip angulation is 125°, that is the angle the shaft of the femur makes with the femoral neck. If the angle is greater than 130°, the hip is known as coxa valgum. If the hip angle is less than 120°, the hip is known as coxa varum. Interestingly enough, the hip and the knee seem to work in opposites in regard. For example, a coxa valgum at the hip has a predisposition to turn into a genu varum, bow legged, at the knee. As well as, coxa varum, at the hip, leads to genu valgum, knocked knees, at the knee. In addition we talked about the anteversion angle is normally 15°.
All of the above is for the femur, thigh bone. What about the pelvis where the femoral head attaches. The acetabulum is the name of the socket in the pelvis that is made up of the ischium, ilium and pubic bones. The acetabulum normally faces down about 60° from the horizontal and tilted 20° anteriorly. This is interesting to note that both the femoral neck and the acetabulum are both tilted about 20°. This is interesting for the physiotherapist in you. But if you are not a physiotherapist, you might find this lecture a little bit boring. I found it very interesting! If you understand the anatomy, then assessment and treatment seem to come from there.
An interesting fact, that in symmetrical standing, each hip joint takes about ⅓ of body weight. Why not half, you ask. Because about ⅓ of the body weight is below the hip joint, in the legs. The hip joint does not have to support the weight of the thighs, shins and feet. In addition, if you standing on one leg, the compressive forces increase to about 2.5 of body weight. This is caused by the muscular contractions around the joint to keep the hip in the same position.
One other thing that David liked to mention is that the head of the femur is about the size of a golf ball. That golf ball is covered in something more slippery than ice, the cartilage, on both sides of the joint. When we walk, while standing on one leg, we are essentially balancing our body weight and more, on a golf ball. Very good analogy.
Then we went onto the muscles. This is where it got really interesting. This is where us as physiotherapists and physiotherapy clients can cause changes! It is really, REALLY difficult to change the way a bone or part of a bone is facing. In reality, if you want to change the direction of a bone, you will have to have a surgeon break the bone, alter the position, then support the bone through the healing process so it does not move back to its original position. And you have to find a surgeon that is willing to do that to you.
The highlights of the muscles were that gluteus medius, glute med, is actually made up of three different muscles that are bound together into one. There are anterior, medial and posterior portions of the muscle. The anterior and medial portions help with hip abduction strength. The posterior portion muscle fibres are orientated nearly parallel to the shaft of the neck of the femur, at 120°. Interestingly enough, the fibres of gluteus minimus, glute min, are also oriented parallel, at 120°! There is one muscle in the front of the hip, pectineus, that is nearly identical orientation, except it is anterior to the hip joint, as the fibres of posterior glute med. The fibres of pectineus are 120°. Is anybody else seeing this pattern?
The thought is that when we walk, the fibres of glute med and min, along with pectineus, act to pull the hip of the femur into the acetabulum. This pull occurs along the line of the femoral neck. The cool thing is that as the femoral head gets pulled in, the synovial fluid gets pushed out slowly, around the head of the femur, slowed down by the labrum. This acts as a fluid shock absorber, so there is minimal impact from the femoral head getting slammed into the acetabulum.
If there are any muscle issues with either glute med, min or pectineus, this system breaks down. The femoral head does not piston in/out of the acetabulum along the axis of the femoral neck. It simply slides up and down in the acetabulum. Impacting the superior aspect of the hip joint. Co-incidentally, this is the area of the hip joint that almost always can be seen starting of compression at the OA. It is so neat when it comes together!
We talked about a couple of hip specific issues, labral tears and femoral-acetabular impingement.
Let’s quickly chat about both.
The hip labrum is not as deep as the labrum in the shoulder. It can be torn in a couple of different ways, either an acute tear, a traumatic event, or from chronic compression, femoral-acetabular impingement.
The labrum of the hip is made out of fibrocartilage and it has vascularization. If a structure in the body has blood flow to it, vascularized, then there is a possibility that it can heal itself! The function of the labrum does help to make the acetabulum deeper, up to 25%. The labrum is also thought, more recently, to limit the flow of synovial fluid from the central part of the capsule to the peripheral part. As mentioned above, when we step on one leg, for example walking, the leg we are standing, the femoral head gets pushed deeper into the acetabulum. As the femoral head gets pushed in, it displaces synovial fluid. The fluid is thought to be able to leave at a lesser rate when the labrum is intact. This would create a fluid hydraulic system that limits impact on the joint. If the labrum is torn, this slow leaking fluid is disrupted and possibly allowing more fluid to leave quicker and therefore having more impact on the joint.
MRI is not that great at diagnosing labral tears, about 36%. However, an MRA, when a contrast dye is injected into the joint and then an MRI takes place, is a much better test. MRA is > 90%.
Again, just like disc degeneration in the back, just because you see one on the MRI does not mean that that is the cause of the pain. In a cadaveric study, there were 55 hips studied and 95% of those hips had labral tears. That is much higher percentage than ‘normal’. What is normal? That is yet to be determined.
Femoral-acetabular impingement, FAI, sounds pretty scary, doesn’t it? It basically means pinching between the two parts of the hip joint, femur and acetabulum. There are two basic types of FAI, Cam and Pincer. The two differ on which part is enlarged. For example. Cam is when there is a larger piece of bone on the femur side. Whereas, the Pincer occurs when there is an extra large bone growth over the acetabular rim. This can lead to coxa profunda, a deeper pelvic socket. Another way in which the Pincer type can occur is when the acetabulum is retroverted, i.e. faces more posteriorly than normal.
About 57% of people diagnosed with FAI, have labral tears visible on MRI.
Normally pain caused by FAI comes on slowly and seems insidious. It does not come on with any specific traumatic event. It is thought that even though, FAI can be seen on x-ray, that it the pain can be controlled via good muscle control. It is known that many individuals have FAI bilaterally, on x-ray, but are only symptomatic on one side. There are many factors that could account for this and the one we, physiotherapists, can affect is the muscular control. If FAI is found to be severe on x-ray, then surgery might be an option.
So you have hip pain, where do you start to make it go away? The first thing is to find a practitioner that you trust to do a comprehensive assessment of your hip. If it is ‘true’ hip pain where does the pain show up? Most people that I see that complain about hip pain tell me about their pain in the buttock/gluteal region. That area is not the area for hip joint pain. Buttock pain can be from straining the hip musculature, pain from the low back, sacroiliac joint pain or referred pain from the low back zygapophyseal joints. Pain that comes from the hip joint, generally, is groin pain, anterior thigh or possibly pain going down to the knee.
Most of the time, it is a muscular imbalance that is causing the buttock/ gluteal pain. Muscular imbalance = muscles not working in the correct sequence to stabilize. There are many reasons for this, for example strained/pulled muscles. This is one question, I get from my clients. “If I strained/pulled my muscles a few months ago, why do they not heal”? The muscles do heal from the strain but something goes wrong with the nervous system and makes them much more sensitive. There are a lot of theories out there to why this occurs but nobody really knows the correct answer. People think that the pain will simply go away and it does not. Seeing the client 3-6 months after an incident/injury only makes the number of treatments greater. The sooner you see a physiotherapist after an injury, the less treatments you need. Yes, there is some evidence about this, it mainly has to do with people that suffer from whiplash.
The first step is actually finding a physiotherapist you like and trust. Second step, is to pick up the phone and call for an appointment. As mentioned above, this step can take several weeks/ months.
Once you want to fix the problem, a good assessment can diagnose the issue. Many times it is that the deep hip rotators and stabilizers are not functioning properly and are weak. In the same instance, the superficial buttock muscle, gluteus maximus, has got tight and is trying to do both the stabilizing and the mobility. Therefore, glute max is weak and sore. With glute max being weak, the hamstrings will try to help out to extend the hip. This can lead to the hamstrings cramping up because they are trying to do the work of the glutes at the hip. This is one possible reason why some people complain that their hamstrings are always tight, no matter how much they stretch them out.
The exercise program below should only be used if you have been assessed and the finding is that you have weak hip rotators, glute min and different fibres of glute med. Only do these if your physiotherapist or physician tells you it is a good thing to do. These exercises should be done as a progression over 8-12 weeks.
Personally, I really like the bridging exercise. It is a nice bilateral hip extension exercise that is weight bearing. I like to get my client’s doing this exercise in bare feet. My client’s are told to very gently grip the bed with their feet, NO foot cramps. Then they are told to think about ripping the bed in half, lengthwise, with their feet, using their hip muscles. Then lift their glutes off the bed. The gripping and ripping aspects are used to get the client to pre-tense the glutes and then lift by squeezing glutes even more. Bare feet help to ensure that the feet do not slip out as that would cause the hamstrings to become very active and cause some major cramping.
The other exercise I will start to give someone, after attending this course, is seated internal rotation. This exercise is one that I learned on this course. It is really makes a lot of sense to help strengthen the weak, deep hip rotators. Each leg, individually. I get the person sitting on the edge of the bed or counter top, basically dangling so their feet do not touch the floor. They can have a therapeutic elastic band, think Theraband, around their feet, if needed. To work the left leg, the left hand grabs the edge of the bed, immediately lateral to the left leg. The right hand grabs the edge of the bed in between the left and right legs. Basically you are sandwiching the left leg between the left and right hands. This stabilizes the leg. The client then rotates their thigh, with the foot going to the outside. If both legs were going at the same time, the client’s knees would be together and ankles/feet would be out to the side.
One more exercise that I like to give for people is balance. Simply standing on one leg. But not just simply standing on one foot. 🙂 I find that when people stand on one leg, they tend to shrink 1-2 inches. So I tell my client’s to stand tall. Pretend that there is a string attached to their head and someone gently pulls the string. When the client ‘grows’ back their 1-2 inches, they engage their glutes and their core musculature. I get my clients to gradually increase the length of time and number of times they practice their balancing.
There are many different variations on the different exercises. If you notice that I did not give how many sets and repetitions, reps. Those are variable, depending on the client. Sometimes I would start low, say 1 set of 5 reps and others 4 sets of 15 reps. Just depends where they the client is, are they simply weak, did they have hip surgery, do they have osteoarthritis in their hips? One thing that I think I do that is a little bit different is that I always give a progression with the number of reps. I believe that the body will adapt very quickly, so adding some reps to the exercises daily or every second day will give the body a little stimulus to change.
Okay, let me get back to the course, after my little tangent. Sunday morning we discussed David’s rehabilitation protocol for hip pain. We went through it step by step and it was really great! He has developed a progressive protocol that gradually introduces weight bearing and strengthening. David states that he has found that the strengthening and mobility of the hip should take about 3 months.
David was good to warn us, and he warns the clients, that for the first three weeks, there might be a little more pain. However, their strength and their ‘numbers’ will increase. Even at 6 weeks, Mr. Lindsay states that most people will notice a mild improvement. This ‘reprogramming’ is not a quick fix, it takes a lot of work from the client.
I am not going to give away David’s protocol, as it is not mine to give. However, his progression is slower than what I mentioned above. He usually sees people at 3 week intervals. His progression starts with seated internal rotation, clamshell, bridging, standing wall squats, lawnmower and airplanes. The last three get the client weight bearing while standing to engage their hip muscles.
One thing that I have not mentioned, was David’s thoughts on walking. The hip musculature should be engaged with every step walking. Therefore each step is a chance to activate the hip muscles. He does a very thorough gait analysis with everybody and gives them some gait correction if it is found that they are moving in a way that Dave does not approve. This gait correction should be used by the client for the rest of their lives. If the person can correct their gait, with conscious effect initially, they can put the correct nerve impulses to the hip joint/muscles 10 000 steps a day. That is pretty powerful stuff. Honestly, I never really thought of gait correction in that way. That is going to be something that I am going to incorporate into my practice as well.
Mid morning on Sunday, Geoff took over from David. Geoff talked about fascia. This has been one of my first introductions on fascia. Fascia is the stuff the surrounds muscles in the body. It is like the casing around our muscles, to use the analogy of casing around sausages. Just like the casing around sausages, the fascia joins one link to the next within the body. There is no area of the body that does not have fascial connections.
Geoff went through a list of different soft tissue mobilization techniques and the different instruments used. For example, Graston technique uses stainless steel instruments to ‘loosen up’ the muscles and fascia. He demonstrated the use of a Chinese soup spoon that could be used as well.
We went through progressions of soft tissue mobilization. These went from simply doing some soft tissue work, the last step was doing soft tissue mobilization with specific neural mobilizations.
In the hip region, we discussed fascia around the iliotibial band, ITB, and the connections to gluteus maximus and tensor fascia latae, TFL. We just did not do deep techniques but Geoff really tried to emphasize the superficial fascia and to work on that. We demonstrated on the lateral thigh, ITB area and vastus lateralis, most of the people on the course were more sensitive to deep pressure but there was one person that was more sensitive to skin rolling. My partner definitely was tight and there were spots that I could not grab the skin on the lateral thigh.
That is when I saw them. Geoff took them out and showed them around the room. They were silicon cups, for cupping. Cupping is used in acupuncture, usually glass cups are used. They will light moxibustion in the cup and stick the cup to the skin. The cup adheres via suction and creates negative pressure. The cups stay on for anywhere from 5-20 minutes. The client is then left with circular bruises. These silicone cups were a little bit different, they went on with suction. You use a little bit of oil on the skin area, squeeze the cup and attach it to the skin. The cup will create its negative pressure simply by suctioning onto the skin. Once the cup is on, it sticks very well. You can slide the cup up and down on the skin and it does not come off. We tried this on the lateral thigh and as long as there was massage lotion on the area, it worked wonderfully. It basically does skin rolling in a very effective manner. Cupping up/down my right lateral thigh was no issue, it glided smoothly. Gliding up/down on my left lateral thigh caused some crunching/popping, adhesions in the left lateral thigh fascia, more sensitive than the right as well.
Practical session included work on the lateral thigh and glutes. We did some practical examples using the progressions of soft tissue mobilization, mentioned above. For example, assessing/treating at resting length then check in the same muscles under tension. Doing some soft tissue work of the muscles/fascia while helping the client move their knee to about 30° of flexion and back to extension. Very similar to the range of motion where ITB friction syndrome is most commonly associated with. Ending with the client doing some active movement throughout their range of motion while the physiotherapist works on their musculature.
We did some test-retest of the seated internal rotation range and strength testing, before and after some soft tissue techniques on gluteus medius. Everybody seemed to gain a couple of cm’s in mobility and were slightly stronger with the retest. It is great that we can affect people that easily. Add neural input through the muscle to their nervous system increases the output back to the muscle immediately. This technique could be used with client’s that have gluteal amnesia, yes that is what we call the people that do not know how to activate their glutes.
I learned a lot from this course. David and Geoff were both dynamic presenters and kept the clinician engaged. Both have a wealth of practical experience and are extremely knowledgeable on the hip.
However was on the expensive side. It was the most expensive 2 day course, that I have taken to date. That was my only hesitation on taking this course. It would have liked a little more from Geoff. He taught the last third of the course, so we were a little fatigued, from our brains being full from David’s great insights of the hip.
I would recommend that if you want to learn more about this hip, how it functions and how to get it functioning ‘normally’ again. This is a great course to take.
Great course, great location and Jeff and Julie were wonderful hosts. I enjoyed my first visit to Salmon Arm. I will be back there this summer to spend some more time there.
If you have any questions or comments about this blog post or you would like to talk about your hip pain, simply click here to reach New Leaf Physiotherapy’s contact page.