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1

ITBS & PFPS:

Clinical Update in Conventional

and Integrative Rehabilitation

For Professional Yoga Therapist candidates:

This CE corresponds to Module 10, Part 4, Hour 1

Provider Disclaimer

• Allied Health Education and the presenter of this

webinar do not have any financial or other

associations with the manufacturers of any products or suppliers of commercial services that may be

discussed or displayed in this presentation.

• There was no commercial support for this

presentation.• The views expressed in this presentation are the

views and opinions of the presenter.

• Participants must use discretion when using the

information contained in this presentation.

Program Matriculation:

Recommended Module Progression

• Distance Modules: Prior to taking this course, complete Modules 1-7.

• Onsite Module: Complete and practice

final sequences in Module 8 and 14.

©2017. Ginger Garner. All rights reserved

2

Module 10 Series

• Part 1 – Nutrition & Orthopaedics: Focus on OA

Prevention and Management

• Part 2 – The Shoulder Complex and Spinal

Kinematics

• Part 3 – ACL, Foot, & Ankle Complex

• Part 4 – Hip Labral Injury, PFPS, and ITBS


Integrated Clinical Guidelines

• Conventional + Integrative Medicine

• WHO ICF

• Medical Therapeutic

Yoga Biopsychosocial Model


Course Outline – Hour 1

• Injury Epidemiology

• Biomechanics Update

• Prevention Update

• Management Update

• Case Study


3

Problem

You have to inform your patient, an avid runner who depends on

running as her sole form of exercise for weight and stress

management, that she may need to consider a 6 week hiatus from

running because she has developed……

Think about how you will answer her questions


Is this very common?

In order to answer her question, you must know:

Iliotibial band syndrome (ITBS)

• Leading cause of distal lateral thigh/knee pain in athletes

• 15% of all knee injuries

• High level athletes and general pop commonly suffer from both ITBS and PF syndrome

©2017. Ginger Garner. All rights reserved Baker & Fredericson 2016

Is this serious?

In order to answer her question, you

must know:

• ITB “anterolateral ligament of support.”

• Fascial relationships!

• Neuromotor function & torque

production

• Histologic and dissection studies

Baker & Fredericson 2016©2017. Ginger Garner. All rights reserved

4

Anatomical Theory 1

Fig. 3 Enthesopathy and compression model.

ITB, iliotibial band; LFE, lateral femoral epicondyle. Baker & Fredericson 2016

Anatomical Theory 2

Baker & Fredericson 2016

Fig. 4 Friction and impingement model.

ITB, iliotibial band; LFE, lateral femoral epicondyle.

How can you be sure the problem

is in my ITBS or PFPS?

In order to answer her question, you must know patients with ITBS might experience the following signs and symptoms:

• Lateral thigh or knee pain

• Hip or pelvic pain

• Ipsilateral knee pain at distal attachment point

• Increasing pain with activities such as cycling or running

• Patellar pain or tracking problems

• Medial knee pain

• Point tenderness over the ITB insertion

• Positive Ober Test (Low SN/SP in systematic reviews)

• Poor hip control/NM function


5

How did this happen?

• Weak hip abductors (Fredericson et al 2000, MacMahon et al 2000, Noehren et al 2007).

• Angle of knee flexion between 20-30 degrees during stance phase of activity (Orchard et al 1996, Noble 1980, Miller et al 2007).

• Lower quarter malalignment (eversion or inversion)

• Increased forces on landing (Messier et al 1995, Devan et al 2004, Noehren et al 2007, Busseuil et al 1998).

• Increased tibial internal rotation (Messier et al 1995, Devanet al 2004, Noehren et al 2007, Busseuil et al 1998).

• Ipsilateral hamstring weakness (Messier et al 1995, Devan et al 2004, Noehren et al 2007, Busseuil et al 1998).

• Imbalance of agonist/antagonist (Messier et al 1995, Devanet al 2004, Noehren et al 2007, Busseuil et al 1998).

• Genu varus (Lavine et al 2010, Vasilevska et al 2009)

• Genu recurvatum (Messier et al 1995, Devan et al 2004, Noehren et al 2007, Busseuil et al 1998).


Anatomical & Kinematic

Update

• 350 scopes, 35 TKA, 8 cadaver dissections, 21 ITBS surgical procedures, 3 MRI studies – No bursa under ITB insertion (lateral femoral condyle)

• Etiology of ITBS occurs in deceleration phase of stance—phase in running.

• Frontal and transverse plane risk factors identified


Despite identifiable high risk populations, At

issues are considerably preventable. ITBS can fall into two broad categories:

1. Intrinsic Risk Factors

2. Extrinsic Risk Factors

Activities related to ITB injury include*:

• Running

• Rowing

• Soccer

• Field hockey

• Cycling

• Basketball


6

What would happen if I kept

playing?

In order to answer her question, you must know that continued aggravation of her ITB could result in:

•Hip bursitis

•Pelvic pain

•Back pain

•Hip pain

•Proximal or distal ITBS

•Patellofemoral syndrome

•Poor patellar tracking and knee pain

•Greater trochanteric pain or bursitis

•ACL Injury

Baker & Fredericson 2016, Pelfort et al 2005©2017. Ginger Garner. All rights reserved

Objectives

1. Describe BPS model can improve orthopaedic management of ITBS and PFPS.

2. List evidence based methodology for incorporating medical yoga into current knee rehabilitation programs.

3. Identify five points for diagnosis and intervention in evidence based integrated

rehabilitation of ITBS and PFPS.©2017. Ginger Garner. All rights reserved

Objectives 2

4. Describe four critical factors for implementation of a BPS model of treatment for iliotibial band syndrome (ITBS) and patellofemoral (PF)

considerations.

5. List three postures to facilitate acute and

subacute ITBS healing.

6. Analyze postures and breath techniques in

a case study format.©2017. Ginger Garner. All rights reserved

7

Anatomy

• Iliac Tubercle Gluteals

• TFL

• Lateral patellar retinaculum

• Patella


Injury Prevention

• Leg Length

• Large Q-

angle/pelvic

width

• Excessive foot

inversion or

eversion

Intrinsic Factors Extrinsic Factors

• Lower quarter deficiencies

• Ipsilateral vs. contralateral

• Poor training techniques

• Fatigue

• Poor footwear

• Environmental factors in sport and activity

• Surface condition where activity takes place

• Faulty equipment

(B&F 2016, A&L 2015, Paluska 2005; Khaund & Flynn 2005; Fredericson & Wolf 2005). ©2017. Ginger Garner. All rights reserved

WHO ICF Model

Case Study

World Health Organization (WHO) (2002). International Classification of Functioning, Disability and Health. Geneva, Switzerland.©2017. Ginger Garner. All rights reserved

8

Yogic Biopsychosocial Model

PHYSICAL

Anti-Inflammatory Lifestyle

Role of Nutrition & Exercise

Focus on Stability

ENERGETIC

Breath; Gut-Brain-Body Axis

PSYCHO-EMOTIONAL-SOCIAL

Meditation; Mindful Living

INTELLECTUAL

Patient Education

SPIRITUAL

Mind/body Homeostasis

Introspective Analysis

© 2014 Ginger Garner.


Mindful Integrated Care:Physical Domain

1. Application of the BPS Model

2. Healing and prevention of reinjury depends on (2)

3. Massage or manual therapy techniques (Pedowitz 2006) combined with breathwork (3)

4. Breathwork facilitating safety & O2 nutritional exchange during

• Transitions between movementts/postures

• STM & MT work

• Giving breath priority

5. CKC posture sequencing

1. Hip abd/ER/extension strength (B & F 2016, A & L 2015, Reiman et al 2014, Prins and Van der Wurff 2009)

2. Contrast RSS issues with yoga program design

3. Use restoratives in acute phase


Cautions

• Address the fasica

• Screen for:

• Primary Drivers such as

intra-articular hip injury or pelvic dysfunction

• Secondary Drivers such

as extra-articular hip

injury

AVOID:

•Running on uneven/sloped terrain

•Increased compression along the

origin or insertion point of the ITB,

especially during acute phase

•Overworking gluteus maximus in

presence of NM imbalance, in yoga

postures such as:

•Mountain

•Standing postures

•Backbends/spinal extension

postures


9

Injury Management - Acute

Acute Phase

• Activity Modification

• RICE

• NSAIDS

• Establish ITB freedom

• STM

• Friction massage (Lavine 2010)

• Trigger point therapy (Lavine2010)

• Facilitate proper patellar tracking in the femoral groove

• Flexibility

• Mobility

• Hip strength –abd/ER/ext (Prins and Van der Wurff 2009)

©2017. Ginger Garner. All rights reserved B&F 2016, A&L 2015

Tissue Response• Joint Mobilization

• Possible posterior glides to assist in reduction of anterior translation of femoral head and/or pain management

• Self MFR or STM deep front line:

• Diaphragm

• Transversalis/endothoracic fascia

• Infrahyoid/suprahyoid muscles

• Iliacus

• Psoas

• Rectus femoris

• Sartorius

• Obturator internus fascia

• Pelvic floor fascia

• Pectineus

• Adductor magnus


The Yoga “Couch” –Three Tier Approach

http://www.gingergarner.com/2012/12/13/the-yoga-couch/

©2001-2015. Ginger Garner. All rights reserved.

http://www.gingergarner.com/2012/12/13/the-yoga-couch/

10

TATD Breath© Components

(TA-assisted thoraco-diaphragmatic breath)

LOOK | LISTEN | FEEL

1. Respiratory Diaphragm

2. Transversus Abdominis

3. Multifidus

4. PFM [Internal (PT only)]

© 2016. Ginger Garner. Medical Therapeutic Yoga. Handspring Ltd. Scotland, UK.


TATD Breath©:

Optimal Arousal



TATD Breath

© 2016. Ginger Garner. Medical Therapeutic Yoga.

Handspring Ltd. Scotland, UK.

11

Mason et al., Evidence-Based Complementary and Alternative Medicine, vol. 2013

Victorious Breath - Ujyaii

Victorious breath “Ujyaii” (eww-jai-eeh)

•Replace pursed lip breathing

•Increase cardiac-vagal baroreflexsensitivity (BRS)

•Improve oxygen saturation

•Lower BP

•Reduce anxiety

•Improve relaxation response

•Vagal stimulation, Increased O2 absorption, Greater tidal volume

•Action

•Contraction of glottis creates “resistance breath”

•Equal inspiration/expiration showed greater clinical significance for improving baroreflex sensitivity in beginner yoga subjects.


Hip Lock – Proximal Contrl

Chair (utkatasana) –single or double

• Deep Gluteal Sling/HIP RTC

• Control pelvic drop (add step down from elevated platform)

• Control trunk deviation

• Watch for fascial involvement (compression)


Hip Rainbow RTC

GLUTEALS

PIRIFORMIS

GEMELLUS SUPERIOR

GEMELLUS INFERIOR

OBTURATOR EXTERNUS

OBTURATOR INTERNUS

QUADRATUS FEMORIS

© 2016. Ginger Garner. Medical Therapeutic Yoga. Handspring Ltd. Scotland, UK.©2017. Ginger Garner. All rights reserved

12

Neuromuscular Control -

GMAX

• GMAX1 - 80% of GMAX inserts

in ITB1

• Function1:

• hip extensor; lat. Rot.

• Accelerator in hip flexion

from 45-60 deg.

• Contralateral plant and cut maneuvers

• Avoid terminal hip ext. if psoas

compression is a concern


Neuromuscular Control -

GMed

GMED

• GMED – train with good trunk and leg alignment, isometrics, and eccentrics, avoid compensatory actions

• Rationale – Avoid excessive lengthening of ITB on impact, abnormal compression, friction distally, reduce varus at knee, reduce femoral ER

Suggestions

• Sidelying Gmed – anterior and posterior fibers

• Standing pulley, hip hike, hip drop

• Functional markers: Work on active landing strategy (improve force attenuation through LE when TATD is not rigidly held) and sport specific training


Pre-Asana Progression

Moon Salutation: 1. Downward Dog Prep (Pre-posture); 2. Caterpillar/Mod.

Dolphin dive; 3. Cobra; 4. Downward facing dog; 5. Three legged dog


13

Subacute

Subacute Phase

• Continued facilitation of proper patellar tracking through strength & motor control

• Abductors, gluteus medius (Leninger 2009, Frederickson and Wolf 2005)

• Hamstrings

• Hamstring/quad balance

• Muscle Tone & Mobility (over flexibility alone) (Paluska 2005, Messier et al

1995).

• TFL

• Gluteus maximus

• Gait Training/Specificity of sport neuromuscular patterning (Frederickson and Wolf 2005)

B & F 2016, A & L 2015©2017. Ginger Garner. All rights reserved

Sub-Acute Program

Sequence: PYT Mountain Flow – 1. Mountain, 2. Chair, 3. Squat

1©2017. Ginger Garner. All rights reserved

Sub-Acute Progression

Sequence: Standing and supine hand to big toe


14

Advanced Sub-Acute Progression

Postures: Revolved triangle; Pigeon; Half upward facing bow

©2014. Ginger Garner.

Facilitating Consciousness, Concentration, and Meditation


Program Impact

Post-Test Results

6 months follow up

• TATD breath WNL

• No remaining point tenderness over distal insertion point of ITB

• Negative Ober

• TFL - WFL

• Hip IR/ER - 5/5, painfree

• Patellar mobility still an issue 2nd pt. resumed running (however on 2

year follow up patient had discontinued running and patellar

mobility returned to WNL)


15

Now it’s your turn….


Resources• Self-Massage for Lower Quarter,

including foot: http://gingergarner.com/Marma%20Massage%20Lower%20body.pdf

• FB – Hip Labrum Physical Therapy Network (closed)

• www.gingergarner.com - Yoga “Hip”py Blog

• www.medicaltherapeuticyoga.com- MTY Video & Book Chapter Access

• A-D breath

• Yoga Couch

• Foundational yoga postures

• TATD breath and more!


The Hip Labrum:Clinical Update in

Conventional and

Integrative Rehabilitation

For Professional Yoga Therapist candidates:

This CE corresponds to Module 10, Part 4, Hour 2

http://gingergarner.com/Marma Massage Lower body.pdf

http://www.gingergarner.com/

http://www.medicaltherapeuticyoga.com/

16

Objectives

• Identify 2 categories for hip differential diagnosis and 5 evidence based risk factors for intra-articular hip labral injury in order to understand how intra-articular hip joint injury could be avoided.

• Describe the morphological classification system of labral tears in order to identify the most accepted provocative tests used in identification of intra-articular hip joint injury.

• Discuss current evidence based medical management, including surgical intervention, for labral tears and related secondary injuries of the hip.

• In a case study format, critically analyze indications and contraindications to follow a subacute through chronic phase functional intervention for hip joint preservation and rehabilitation in a multi-disciplinary team approach.


Hour 2

• Anterior Hip Pain: Serious? Cause, Prevention, Differential Diagnosis

• Anatomy of the Hip Labrum

• Labral Tear Classification & Surgical Intervention

• Conservative Intervention & Case Study

• Chronic Progression Guidelines Video Lab Demonstrations

• Resources


Problem

You have to inform your patient, a dancer, that she may not be able to perform with her company this year because she has developed anterior hip pain…..

Think about how you will answer her questions

Photo: Courtesy of Jennifer Miller Pearce


17

Is this very common?

• Functional impairment

• Location of pain

• Groin 96-100% SN

• Buttocks

• Anterior thigh

• Mechanical symptoms

• Clicking, giving way, hip

pain SN 100%, SP 85%

• Labral tear scoped “+” in ___% of individuals with

mechanical hip symptoms.


Clinical Standards of Care

Invasive Orthopaedic Clinical Standards of Care (2014)

1. Symptoms

2. History

3. Radiographs

4. Clinical Exam

5. Intra-articular Injection

6. MRI/MRA

7. Referral to PT

8. Arthroscopic or open surgery

Reiman MP, Mater RC, Has TW, et al. Examination of ALT: a continued

diagnostic challenge. Br J Sports Med 2014;48:311-319. ©2017. Ginger Garner. All rights reserved

Hip Bony Anatomy

• 6 degrees of freedom

• Multiaxial ball and socket

• Function: Load transfer of UE and LE

• Need ideal form and force closure to preserve hip (hip stability)

• Acetabulum = ischium, ilium, pubis

Retchford et al 2013©2017. Ginger Garner. All rights reserved

18

Fibrocartilaginous Anatomy

Fibrocartilaginous structure that outlines the acetabularsocket:

Attachment areas (3):

Vascular Supply: Outer 1/3

Inner 2/3

Obturator, superior gluteal, and inferior gluteal arteries

Reiman et al 2014, Kern-Scott et al 2011, Bharam 2006, Groh & Herrera 2009

Photo source: Primal Pictures.com

Image: http://www.londonhiparthroscopycentre.com/hip-and-groin-conditions-

labrum.asp


Etiology of Tears


Is this serious?

• Iliopsoas bursitis/tendinosis

• Neuralgia

• Lumbar radiculopathy

• Stress Fracture

• ALT

• Femoral-acetabular impingement (FAI)

• Pincer

• Cam

Reiman et al 2014, Margo et al 2003

Differential Dx must rule out:

• OA

• Inflammatory or infectious arthritis, osteomyelitis

• AVN, tumor, or fx

• Cancer

• Endometriosis, pelvic pain, ovarian cysts

• Difficulty related to previous surgeries

• PMH such as corticosteroid or alcohol abuse (risk for avascular necrosis)

• Fracture


19

How can you be sure the problem is with my anterior hip?

(Kern-Scott et al 2011, Plante et al 2011, Groh and Herrera 2009, Lewis and Sahrmann 2006):

• Pain in groin (95-100% SN, Reiman et al 2014)

• Mechanical symptoms (SN 100%, SP 85%, Reiman et al 2014)

• Sharp pain, Clicking**, Locking or catching ***, Giving

way****

• Minor hip ROM limitations (in hip rotation, hip flexion,

adduction, abduction*****)

• Other: Night pain (Kern-Scott et al 2011)

*Lewis & Sahrmann 2006, McCarthy et al 2001, O’Leary et al 2001, Byrd 1996; Binningsley 2003, Hase & Ueo 1999, Klaue et al 1991

**Farjo et al 1999, Dorrell and Catterall 1986, Santori and Villar 2000, Byrd 1996, Neumann 2002

***Mason 2001, Farjo et al 1999, , Dorrell and Catterall 1986, Altenburg 1977, Hickman and Peters 2001)

****Farjo et al 1999, Altenburg 1977, Hickman and Peters 2001

*****Fitzgerald 1995, Nelson et al 1990, Byrd 1996, Binningsley 2003, Altenberg 1977, Hase & Ueo 1999


In order to answer her question, you must know the following provocative tests may be positive:

High SN and SP:

• Thomas test (Reiman et al 2013)

• FADDIR (Reiman et al 2013, Plante et al 2011)

High SN and low SP:

• Scour test

• DIRI ( Plante et al 2011, Saw & Villar 2004)

• Positive FABER** (Mitchell et al 2003)

• Positive Stinchfield test/RLSR

• Posterior-inferior labrum test

How else can you tell the problem is

with my hip?


Labral Pain Patterns


20

How did this happen?

1. Dysplasia*

2. Direct Trauma**,***

3. Femoral acetabularimpingement

4. Degeneration***

5. Capsular laxity/Hip instability (Kelly et al 2005, Philliponet al 2005)

*(Kelly et al 2005, Phillipon et al 2005, Gorh and Herrara 2009, Lewis & Sahrmann

2006, Bache et al 2002, Robertson et al 1996, Li and Ganz 2003, Coleman 1978)

**(Gohr & Herrara 2009, Kelly et al 2005, Phillipon et al 2005, Lewis & Sahrmann 2006,

O’Leary et al 2001, Fitzgerald 1995, , Santori & Villar 2000, Byrd 1996, Ikeda et al

1988, Nelson et al 1990)

***Mason 2001, Fitzgerald 1995, Santori & Villar 2000, Saw & Villar 2004


1. Intra-articular Injuries2. Extra-articular Injuries

In younger patients, sports injuries of the hip/pelvis most commonly include:

• Ballet Dancers (44%)

• Soccer players (13%)

• Runners (11%)

• Also:

• Golf

• Martial Arts

• Gymnastics

• Yoga

Reiman et al 2014, Kern-Scott et al 2011, Godinho 2007, Lewis and Sahrmann 2006, Farjo et al 1999

Despite identifiable high risk populations,

hip issues can be preventable. Hip injuries can fall into two broad categories: (Flannery et al

2001, Tibor and Sekiya 2008)


Differential DiagnosisGeneral diagnoses for the hip are ordered under 2 categories:

Intra-articular• OA & RA

• Labral tears

• Loose bodies (& snapping hip 2nd to them) or Internal snapping hip (iliopsoassnapping over iliopectineal emminence or femoral head)

• Femoroacetabular impingement (FAI) – 88% of hips: “+” flexion impingement test (Clohisy et al 2009)

• Capsular laxity

• Tears of the ligamentum teres

• Chondral damage

• Flannery et al 2001, Tibor and Sekiya 2008

Extra-articular• Iliopsoas tendonitis and/or bursitis

• Snapping hip (2 types)

• Iliotibial band and greater

trochanteris bursitis

• Gluteal tendoninpathy

• Fractures (femoral neck)

• Piriformis syndrome

Related Dysfunction “hip mimickers” (4)


21

What would happen if I kept

playing?

In order to answer her question, you must know that

continued aggravation of her hip could result in:

• Anterior hip injury

• Lateral hip injury

• Posterior hip injury

• Intra-articular hip joint damage

• Pelvic or sexual dysfunction


Soft Tissue Pathophysiology

• Iliopsoas

• Gluteus Medius

• Hamstring

• Adductors

• Pelvic Floor

• External Rotators


Anterior Hip Injury

Progression

Anterior hip injury

progression if a labral

tear is present:

• Increased

contact stresses (Ferguson et al 2000)

• Hip instability (Tan &

Seldes 2001)

• Iliopsoas bursitis,

tendonitis


22

Lateral Hip Injury

Progression

Lateral hip injury

• ITBS

• Gluteal tendon tear

(positive Trendelenburg or

lateral SLR/MMT abductors)

• Trochanteric bursitis


Posterior Hip Injury

ProgressionPosterior hip injury:

• Hamstring tendinosis or fraying from ischial tuberosity

• Intra-articular hip joint damage: (Gohr & Herrera 2009, McCarthy et al 2001, Phillippon 2003, Bharam et al 2002, Bharanet al 2003, Farjo et al 1999, Byrd 1996, Altenburg 1977)

• Chrondraldamage

• Osteoarthritis


Posterior

Hip


23

Acetabular Labral

Function

Reiman et al 2014, Retchford et al 2013, Groh & Herrera 2009

Zones of Labral Pathology

Ilizaliturri VM, Jr, Byrd JW, Sampson TG, Guanche CA, Philippon

MJ, Kelly BT, Dienst M, Mardones R, Shonnard P, Larson CM. A

geographic zone method to describe intra-articular pathology in hip

arthroscopy: cadaveric study and preliminary report. Arthroscopy.

2008;24:534–539. doi: 10.1016/j.arthro.2007.11.019.©2017. Ginger Garner. All rights reserved

Labral Tear Classifications

Four Labral Tear Morphological Types: (Thomas

et al 2013, Bharam 2006, Lage et al 1996)

I. Radial flap*,

II. Radial fibrillated,

III. Longitudinal peripheral,

IV. Unstable

Photo: Medscape.com

*Scope of labrum in watershed region

Labral Tear Locations: (Groh & Herrera

2009)• Anterior (86%) (McCarthy et al 2001, 2003) • Posterior (Robertson et al 2007)• Superior/lateral (Schmerl 2005, McCarthy et

al 2003)


24

Can hip injuries be prevented?

In order to answer her question you must know prevention of

labral tears can be difficult secondary to the lack of sensitivity

and specificity of current clinical diagnostic measures.

©2014 Ginger Garner.

WHO ICF Model

• Common Language and nomenclature for functioning,

disability, and health

World Health Organization (WHO) (2002). International Classification of Functioning, Disability and Health. Geneva, Switzerland.

37 yo 3 mo. Postpartum female

with right hip joint pain and

external hip pain

Unable to participate

in activities,

especially FABER,

without clicking, hip

giving way, and pain

i.e. cannot carry newborn son

down stairs or appropriately

care for him because hip gives

way

Has no family nearby

but has supportive

husband with

excellent leave

situation

Well educated;

very healthy and

proactive; BMI

WNL for

postpartum

mother; motivated

Case Study –General Observations & Measures

• Objective Measures right hip:

• MMT hip flexion 4/5, painful ; abduction 2-

/5 and very painful; hamstrings 4-/5 and

painful; IR 5/5; ER 3/5 and painful; MMT

5/5 otherwise

• + Trendelenburg (for pain in GMED, not

function)

• Able to isolate TATD (includes PFM) and

maintain TATD breath during downward

dog prep (DDP), however DDP caused

deep hip pain; and pt. still working with

PP DRA (third child)

• Left hip WNL

and painfree


25

Provocative Tests

• Diagnostic Tests:

• Xrays: Right hip dysplasia; shallow acetabulum; no FAI present

• MRA: Hamstring and gluteal tendon insertion degeneration

with marrow changes & fraying confirmed; “-” for labral tear

and FAI but positive for “minimal spurring”; marked OA at left SIJ; sig. hypertrophy of labrum

• Provocative Tests: Positive Ober (for proximal pain not ITB tightness); + FABER for pain in groin and c/o

instability; point tender over gluetus medius/minimus; +

DIRI; + FADDIR; + Stinchfield/RSLR tests; Right hypomobile

SIJ; + Thomas test for internal snapping hip (iliopsoas)

and groin pain

• Femoral Version: 30 degrees bilaterally?©2017. Ginger Garner. All rights reserved

CEA – A/P View


©2016. Garner, G. Medical Therapeutic Yoga. Handspring Pub., Ltd. Scotland, UK.

26

Psychoemotional/Energeti

c

• Neuroendocrine Regulation – HPA Axis regulation,

especially cortisol (lack of sleep)

• Breathwork

• Meditaton through restorative yoga and breath

• Sleep positioning - Supine unweighted right hip; knee in open

packed

• Influence lumbopelvic stability and load transfer

• Contrast repetitive stress contributors with CAM

program design (5)


Intellectual/Spiritual

Anti-Inflammatory Diet

Homeopathic and biochemical NSAIDS – team approach

with MD (arnica montana oral and topical; Advil 800 mg/TID)

Time Management for Rest/Exercise Balance:

From active fitness routine - yoga, Pilates 3-5x/week;

walking 2-3x/week

Daily restorative yoga and/or Pilates routine no more than

30’ and worked into childcare routine

Daily devotional time and prayer; music therapy


IA Injection

• Patient had US-assisted

diagnostic injections

(6-8 weeks later)

• Iliopsoas

• Intraarticularsteroid injections


27

Impression

• Impression: Right gluteus med/min

tendinopathy; internal snapping hip; right hamstring tendinopathy; excessive femoral

anteversion and shallow acetabulum

• What are your impressions?


Contraindications

AVOID:

• End ranges in yoga, aquatic, and Pilates movements

• Domination of lower quarter stability via quadriceps and hamstrings

• Hip and knee hyperextension in walking/stance

• In acute phase – loading hip with/without torsion/rotation

CAM therapies that include movements which create: (2)

Yoga postures like:

Pilates Matwork and/or Reformer postures like:

Aquatic therapy:

Massage/manual therapy:


Subacute to Chronic

Progression

Subacute Phase (8+ weeks)

Identification of root causes of injury

Unable to get 7-9 hours continuous sleep/night 2nd

nursing infant

From ADL and work task completion - Unable to modify ADL completion 2nd childcare responsibilities

Hormonal and cumulative effect of 3 pregnancies

Yoga posture alignment

Continued activity modification and rest

NSAIDS

Muscle energy

Lock/Bandha work

WB

Progression to Pilates matwork

Progression to yoga without lateral SLR or unilateral stance

Upright biking


28

Gait • Faulty Patterns:

• Lack of knee flexion at heel strike

• Decreased hip abduction in stance/swing phase

• GMED1

• Stabilization of femur and pelvis during WB and stance phase

• 60% of total hip abduction cross-sectional area

• “Catwalk” • Prolonged foot flat and

knee hyperextension creating premature hip hyperextension (Lewis et al 2004)

Kennedy MJ, Lamontagne M, Beaule PE. Femoroacetabular impingement

alters hip and pelvic biomechanics during gait. Gait Posture. 30(2009) 41-44

1. Reiman MP, Bolgla LA, Loudon JK. A literature review of studies

evaluating gluteus maximus and gluteus medius activation during

rehabilitation exercises. Physiother Theory Pract. 2012;28(4):257-268. doi:

10.3109/09593985.2011.604981; 10.3109/09593985.2011.604981.

Ginger Garner.


Gait continued…• Faulty patterns cont.

• Excessive hip extension (maximal end range hip extension)

• Mechanical or mobility impairments:

• Stiffness in subtalar joint

• Weakness or Ring/Thoracic shift

• Anterior gliding of femoral head – weakness of gluteals during hip extension and iliopsoasduring hip flexion (Lewis et al 2007)

• Self-limiting patterns in attempted stabilization

• Diminished hip extension during swing phase

Lewis CL, Sahrmann SA, Moran DW.. 2007 and 2010

©2014. Ginger Garner.

Program Impact – 9 mo.Post-Test Results (9 mo.)

• Able to perform Pilates advanced matwork routine 100%

• Except sidelying series performed at 50%

• Able to return to yoga 100%

• With elimination of FABER, With elimination of all end range of motion for hip

• Able to return to pool therapy with no further c/o instability or pain

• No remaining point tenderness

• Proximal ITB, TFL, Gluteus medius/minimus

• Able to sleep without interruption ~7-8/hrs. nightly

• Reduced night pain, Stopped nursing infant at 11 months©2017. Ginger Garner. All rights reserved

29

Acetabular labral tear MR arthrography

Sensitivity for anterior tear - 60% to 100% (Groh & Herrara

2009, Hunt et al 2007, Czerny et al 1999, Petersilge et al 1996, Czerny et al

1996, Byrd & Jones 2004, cote et al 2005, Plotz et al 2000, Studler et al 2008,

Chan et al 2005, Schmid et al 2003)

Specificity for anterior tear from 44% to 100% (Groh &

Herrera 2009, Hunt et al 2007, Keeney & Peelle 2004, Cote et al 2005,

Studler et al 2008, Toomayan et al 2006)

Sensitivity for posterior or lateral tear – 20 – 11%

respectively (McCarthy et al 2003)

> 2 tears before diagnosis of labral tear on average (Groh and Herrera

2009, Farjo et al 1999; O’Leary et al 2001; Fitzgerald 1995; McCarthy & Busconi

B. 1995; Byrd &, Jones 2000).

Clinical Impressions on

Hip Joint Preservation


Review of “Red Flags”1. Breath is Paramount: TATD Breath

2. Functional Task Completion – Force & Form Closure

• SIJ position/Pelvic stability

• Femoral head articulation, positioning, and acetabular coverage

3. Recruitment Patterns – Load Transfer

• Over- and under-recruitment - gluteals, hamstrings, hip external rotators, and iliopsoas

• Neuromuscular coordination

4. Mask of face: Yogic lens©2017. Ginger Garner. All rights reserved

What can the average

patient with hip pain expect?

©2014 Ginger Garner.

30

Resources

• Full Hip Labrum Injury & Differential Diagnosis Course –www.hermanwallace.com -HLI

• www.gingergarner.com -Yoga Hip(py) Blog

• www.medicaltherapeuticyoga.com - MTY Videos & Book Access

• FB – Hip Labrum Physical Therapy Network (CLOSED)


http://www.hermanwallace.com/

http://www.gingergarner.com/

http://www.medicaltherapeuticyoga.com/

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