Hip Dysfunction in the Running Athlete - IAR · Hip Dysfunction in the Running Athlete Marie Potter...

iar INSTITUTE FOR ATHLETE REGENERATION

Hip Dysfunction in the Running Athlete

Marie Potter PT, DPT, OCS, SCS, FAAOMPT, ATC Christina Gomez PT, DPT, OCS

Evaluation

Hip flexion ROM

The hip is passively flexed. Assess for mobility, end feel, and symptom recreation. Flexion in sagittal plane: 120 degrees with knee flexed Flexion with 30-40 degrees abduction: 150 degrees

Iliopsoas strength

With patient in sitting, therapist flexes the patient’s hip to end range while maintaining neutral spine position. The clinician must note any immediate loss of hip flexion once they release the patient’s leg. If this occurs, the iliopsoas strength is considered below 3/5 on the MMT scale. If the patient is able to maintain end range hip flexion, the clinician can place an inferior force to the patient’s LE and grade strength accordingly.

Alternate torsion test

Internal and external rotation is passively tested in supine and prone. Must be tested in both positions. Positive test: If internal rotation is more than external rotation in both positions, we assume anteversion. If external rotation is more than internal rotation in both positions, we assume retroversion.


Craig’s test This test is used to assess the presence of torsion. Performed in prone by rotating the hip through the full ranges into internal and external rotation while palpating the greater trochanter and determining the position in the range where the greater trochanter sits most lateral or parallel to the table. This position is where the femur sits most optimal in the acetabulum. Measure the angle of a vertical line to the tibia with the axis through the femur. Positive test: If the angle is greater than 15 degrees in the direction of internal rotation, the femur is considered to be in anteversion.

Active SLR

Patient in supine. Palpate the greater trochanter. As the patient performs a straight leg raise, assess the movement of the greater trochanter. Positive test: The greater trochanter glides anteriorly instead of maintaining its initial position.

Prone hip extension Patient prone. Therapist lightly places one finger on both the gluteal muscles and the hamstring muscles of one leg. The patient is then asked to extend hip while maintaining knee extension so that the leg lifts off the plinth. Therapist is assessing pattern of muscle activation during motion. Positive test: Hamstrings engage before gluteal muscles. Indicates hamstring dominance over the glutes or decreased gluteal activation.


Quadruped rock

Patient in quadruped position with feet hanging off plinth. The patient then lowers buttocks so that they are sitting on their heels. The therapist then compares height of ischial tuberosities to each other. Positive test: Asymmetrical height of ischial tuberosities (one side higher than other or lateral shift of pelvis observed). Indicates posterior hip capsule tightness.

Sitting knee extension

Patient in sitting with legs hanging off plinth. The patient then extends knee fully. The therapist assesses alignment of lower leg in this position, specifically if internal rotation noted at end range or if patient unable to extend knee fully. Positive test: Decreased knee extension or internal rotation noted at end range. Indicates medial hamstring dominance or hamstring tightness.

Posterior gluteus medius strength

Patient in sidelying. Abduct the leg, flex the hip, and externally rotate the foot. They must independently maintain this externally rotated position. If they cannot do this, the test is over. If they can, push the leg down and forward, while the patient resists. Do not allow the pelvic girdle to roll backwards.


Anterior gluteus medius strength Patient in sidelying. Abduct the leg, extend the hip, and externally rotate the foot. They must independently maintain this externally rotated position. If they cannot do this, the test is over. If they can, push the leg down and forward, while the patient resists. Do not allow the pelvic girdle to roll backwards.

Functional Tests

Star Excursion Balance Test (SEBT) The patient stands on 1 leg in center of a grid/star with the most distal aspect of the great toe at the starting line. While maintaining single-leg stance, the patient reaches with the free limb in the anterior, posteromedial, and posterolateral directions in relation to the stance foot. The maximal reach distance is measured by marking the tape measure where the most distal part of the foot reached. Trials are discarded and repeated if the patient: fails to maintain unilateral stance; lifts or moves the stance foot from the grid; touches down with the reach foot; fails to return the reach foot to the starting position. The process is repeated while standing on the other leg. The greatest of three trials for each reach direction is used for analysis of the reach distance in each direction. Also, the greatest reach distance from each direction is summed to yield a composite reach distance for analysis of the overall performance on the test. Limb length was measured from the inferior aspect of the ASIS to the most distal aspect of the medial malleolus with the patient lying supine. Indicates decreased hip strength and potential risk of injury. A composite reach distance < 94% of the patient’s leg length is at higher risk for injury (Kivlan, 2012).


Deep Squat

Decreased squat depth and pain indicates FAI or gluteal tendinopathy (Kivlan, 2012).

Single Leg Stance

Provocation of pain during the 30-second single-leg stance indicates tendinopathy of the gluteal muscles (Kivlan, 2012).

Triple Hop for Distance

The triple hop for distance is performed by standing on 1 leg and performing 3 consecutive hops as far as possible, landing on the same leg. The total distance for 3 consecutive hops is recorded.

Single Leg Squat Subjects stands on dominant leg on a 20-cm step. Patients were instructed to fold their arms across their chest and to squat down as far as possible 5 times consecutively. Each repetition must be performed at a rate of approximately 1 squat per 2 seconds in a slow and controlled manner while maintaining their balance. Indicates decreased hip abductor strength (Kivlan, 2012).


Manual Intervention

Hip Distraction- Short axis

Patient is supine. Therapist at side of patient with fixation belt around hips (not on lumbar spine). Hand over hand under fixation belt, close to the hip joint. Hip in resting position (30 degrees flexion, 30 degrees abduction, 20 degrees external rotation). Distract by leaning away from patient and gliding femoral head in lateral, inferior and posterior direction. Can be performed without a belt.

Hip Distraction- Long axis

Patient is supine with a banana belt around the groin and anchored at head of table. The therapist is standing at the end of the table. Grasp the patient’s ankle, with both hands located just proximal to the malleoli. Distract by leaning back. This same positioning can be used as a manipulation by adding a high velocity, short amplitude at end range.

Posterior hip mobilization

Therapist stands at opposite side of table. Their proximal hand is hooked under the posterolateral iliac crest and their distal hand on the patient’s flexed knee. The therapist pushes down on the knee to glide the head of the femur posteriorly.

Iliopsoas soft tissue mobilization

With the patient in supine, the therapist places their fingers just medial to the iliac crest. Gently, the therapist applies an A-P force to the iliopsoas muscle. The force must be spread out through both hands due to this area generally being highly sensitive to manual intervention.


Exercises

Core Activation

Gluteal Activation I

Gluteal Activation II

Quadruped Hip Extension

Fire Hydrant

Single Leg Bridge


Side Plank

Plank

Single Leg Deadlift

Overhead Lunge

Dumbbell Swing

Side Steps

Single Leg Fall

Running Progression (with step)


World’s Greatest Stretch

Posterior Hip Capsule Self-mob

Plyometrics Technique Drills Switch lunges

Single leg hops Bench taps Box jumps

Rocket jumps

Butt kicks High knees Bounding

Lateral bounding Grapevine

Bunny Hops


Return to Running Program

(adapted from Brigham and Women’s Hospital, 2007) PHASE I: WALKING

Progression Criteria x Walk aggressively (4.2-5.2 mph) in a controlled environment x Follow general soreness rules x Be able to complete this program without setbacks x Remain pain free

PHASE II: PLYOMETRICS

Program Progression Criteria Exercise Sets Foot Contacts Per

Set Total

Contacts x Follow general

soreness rules x Be able to

complete this program without setbacks

x Remain pain free

Two leg hops in place 3 30 90 Two leg hops forward/backward

3 30 90

Two leg hops side to side 3 30 90 Single leg hops in place 3 20 60 Single leg hops forward/backward

3 20 60

Single leg hops side to side 3 20 60 Single leg broad jump 4 5 20 One mile typically consists of 1500 foot contacts (750 per foot) Rest Intervals: x Between sets: 90 seconds x Between exercises: 3 minutes

PHASE III: WALK/JOG PROGRESSION

Program Progression Criteria Walk Jog Reps Total Time x Follow general

soreness rules x Be able to

complete this program without setbacks

x Remain pain free

Stage I 5 mins 1 min 5 x 30 mins Stage II 4 mins 2 mins 5 x 30 mins Stage III 3 mins 3 mins 5 x 30 mins

Stage IV

2 mins 4 mins 5 x 30 mins

Stage V

Jog every other day with a goal of reaching 30 consecutive minutes of walking, gradually increasing the pace. End with 5 minutes of walking, gradually decreasing the pace to a comfortable walk


PHASE IV: TIMED RUNNING SCHEDULE

x Rules to follow: o Begin running program on a flat, giving surface before different terrain o Increase the intensity (how fast) you run before increasing the duration (how

long) of a run o When you increase the frequency of workouts, decrease the duration o In the first few weeks if you make increases, make them after a day of rest o 10% rule: only increase the weekly mileage by 10% of previous week

Intermediate Program Progression

Criteria Designed for runners whom are restarting a training program or recovering from an injury or illness that has significantly limited their weight bearing activity for 4+ weeks.

Sun Mon Tues Wed Thurs Fri Sat x Follow general soreness rules

x Be able to complete this program without setbacks

x Remain pain free

Week 1 30 min 30 min 30 min 35 min Week 2 30 min 30 min 35 min Week 3 35 min 30 min 35 min 35 min Week 4 35 min 40 min 35 min Week 5 35 min 40 min 40 min 35 min Week 6 40 min 40 min 40 min Week 7 45 min 40 min 40 min 45 min Week 8 45 min 40 min 45 min 30 min

Run multiple days in a row after 8 weeks Week 9 45 min 35 min 45 min 40 min Week

10 45 min 45 min 45 min 45 min 30 min

Week 11

45 min 45 min 35 min 45 min 45 min 40 min

Week 12

45 min 45 min 45 min 45 min 45 min

On days off, use them for total rest or active rest by cross training * These times are based on a pace between 8-9 minutes per mile


Advanced Program Progression

Criteria Designed for runners who are recovering from a soft tissue injury, which has forced them to cross train for 4+ weeks

Sun Mon Tues Wed Thurs Fri Sat x Follow general soreness rules

x Be able to complete this program without setbacks

x Remain pain free

Week 1 30 min 30 min 30 min 30 min Week 2 35 min 35 min 40 min 35 min Week 3 40 min 40 min 45 min 40 min 45 min Week 4 45 min 45 min 40 min 30 min 45 min Week 5 40 min 35 min 45 min 40 min 40 min Week 6 45 min 45 min 40 min 45 min 45 min 45 min Week 7 50 min 45 min 40 min 50 min 45 min Week 8 45 min 50 min 50 min 45 min 50 min Week 9 50 min 50 min 55 min 50 min 50 min Week

10 55 min 55 min 50 min 55 min 55 min 55 min

Week 11


Week 12


On days off, use them for total rest or active rest by cross training * These times are based on a pace between 7:30-8 minutes per mile

Soreness Rules* Criterion Action

Soreness during warm up that continues 2 days off, drop down 1 activity level Soreness during warm up that goes away Stay at level that led to soreness Soreness during warm up that goes away, but redevelops during the session

2 days off, drop down 1 activity level

Soreness the day after, but not muscle soreness

1 day off, do not advance to next activity level

No soreness Advance 1 activity level per week When

After Activity x Continue to progress program is discomfort appears to be

muscle soreness x If joint pain/swelling develops, increase rest between exercise

During Activity at Beginning and

Dissipates

x Maintain same activity level x Low intensity x Don’t progress until symptoms subside

Gradually Developing During Activity and

Worsens

x Decrease intensity of exercise x Stop activity if symptoms are not relieved with a rest break during

the activity x Maintain activity level, but if symptoms continue then decrease

activity to previous level

Wakes You Up x You’re doing too much x Total rest until symptom free x Decrease activity to previous level and keep intensity low


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Hip Dysfunction in the Running Athlete - IAR · Hip Dysfunction in the Running Athlete Marie Potter...

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