Rebalancing the hip muscles provides stability for the pelvis and spine
While the value of establishing proper strength and balance in the trunk muscles—the core stabilizers—when treating or preventing spinal problems is obvious, the hip muscles are often overlooked. The hip joint is intrinsically stable due to its ball-in-a-deep-socket construction and a thick, joint capsule reinforced by strong spiral ligaments.1 The hip muscles form a vital link in the lower extremity kinetic chain transferring ground-reaction forces from the legs to the trunk during gait. These important muscle groups supply coordinated propulsion, and at the same time provide balanced stability for the pelvis and spine. Through repetitive-use patterns and postinjury, it is not unusual for some of these muscles to develop shortening and/or weakness. A comprehensive rehabilitation program must include exercises to address these imbalances.
An appropriate and effective exercise program does not require expensive, joint-specific equipment. With a few simple stretches and some home resistance exercises, the hip muscles can be easily strengthened and rebalanced.
From the Hip
Deconditioned and/or shortened hip rotators will contribute to abnormal lumbopelvic posture and cause compensatory motion in the lumbar spine during daily and athletic activities.2 The detrimental effects of inadequately conditioned and prepared hip rotators predisposes athletes to lumbar spine injuries.3
Flexibility and strength deficits in the hip rotators can add substantial stress to the pelvis and sacroiliac joint, as well as the lumbar and even thoracic spinal regions.4 For instance, there may be an anteverted (forward flexed) pelvis in conjunction with limited external hip rotation. In such cases, a combination of stretching and strengthening is necessary. The chiropractic correction of the flexed pelvis will help provide greater external hip rotation. On the other hand, if the flexed pelvis is secondary to shortened hip rotator muscles, then corrective exercises to increase range of motion of the hip internal rotators can be accomplished by stretching the shortened internal rotators and strengthening the antagonist external rotator muscles.
One-legged wall squats with a therapy ball. |
Standing illiotibial band stretch. |
Standing posterior lunges. |
Stationary step-ups. |
A Stretch in Time
Tightness of the external rotator muscles will limit internal rotation of the hip, while shortening of the internal rotators decreases external hip rotation. For some hip problems, improving the flexibility of short and tight muscles is necessary. Frequent, gentle, and sustained stretching of either the internal or external rotators should be demonstrated to the patient, who can usually start the stretching immediately, even in early stages of chiropractic treatment.
Piriformis syndrome and iliotibial band syndrome will benefit from specific stretching exercises. In both hip conditions, tight muscles contribute to overuse, which irritates sensitive tissues. Since the piriformis is an external rotator of the hip, treatment must include inward rotation stretches for the piriformis muscle.
Complete chiropractic care will also correct subluxations and biomechanical faults of the pelvis, as well as predisposing factors such as an anatomically short leg and/or foot pronation.5 Iliotibial band syndrome causes pain at the lateral aspect of the knee, whereas a tight iliotibial band rubs over the lateral aspect of the distal femur, causing a painful irritation, especially in runners. Correction of abnormal biomechanics such as leg length discrepancies must be part of the treatment, and orthotics may be needed.6
Hard to Resist
Weaker or injured muscles can be quickly strengthened with the use of isotonic resistance exercises using machines, weights, elastic tubing, or body weight. Weightbearing exercises, which require the cocontraction of accessory and stabilizing muscles, are the most effective because the hip functions as part of a closed kinetic chain. Open chain exercising (done with the foot and lower leg freely moving) is helpful in the early stages of hip strengthening to reduce stress on the surrounding muscles after an injury. For athletes, sport-specific movement patterns should be considered. Kickers—such as soccer players and martial artists—can concentrate on open chain strengthening, while runners and golfers will benefit more from closed chain exercises.
Open chain exercises: These can be prescribed very early with a symptomatic hip, which does not require musculoskeletal structures to bear body weight. The easiest method is to rotate the entire leg against the resistance of elastic tubing. Initial exercising should be done with a limited amount of movement—within a pain-free range of motion. These exercises are particularly useful for patients who have an injured rotator muscle or even a "snapping hip." Strengthening of the muscle and tendon involved in a snapping hip—such as the tensor fascia lata, iliopsoas, or biceps femoris muscles—is more useful than stretching for resolving the snapping.5
Rehab for patients with evidence of degenerative arthritis of the hip should also start with open chain exercising since the joint is more safely exercised when the damaged cartilage is not bearing weight directly. As the patient progresses, additional resistance can be safely supplied with heavier tubing.
Closed chain exercises: Weightbearing strengthening exercises with the foot on the floor are for athletes preparing to return to sports activities. Closed chain exercises for hip rotators include partial squats, lunges (especially to the side), and single-leg body rotations. Initially, body weight will be sufficient. Resistance can be gradually and progressively increased with the use of handweights or elastic tubing. The benefit of these exercises is the ability to re-train the cocontractions of accessory hip support muscles.
The Much Aligned Hip
An imbalance in weightbearing alignment of the lower extremities needs to be addressed to prevent eventual joint arthritis. Leg-length discrepancies and foot pronation problems are frequently found in association with symptomatic muscle imbalances, such as iliotibial band syndrome and piriformis syndrome.
A study by Ora Friberg, MD, has found that osteoarthritis is more common in the hip joint of a longer leg.7 Recurrent muscle strains,especially hamstring and groin pulls, can be an indicator of asymmetry in structural alignment.
The Final Outcome
To assess the effectiveness of a hip treatment plan, both objective and subjective data of patient results on outcomes must be collected and documented. Data should focus on the physical changes noted at the time of consultation and in subsequent visits. Ongoing outcome assessment data using the Hip Rating Questionnaire (available at www.outcomesassessment.org) with comparative graphs over treatment time documents the long-term results and effectiveness of rehab procedures. CP
About The Author
Kim D. Christensen, DC, CCSP, DACRB, is director of the Chiropractic Rehabilitation Association and current president of the American Chiropractic Association Rehab Council. He can be reached at Chiropractic Rehab Consulting Services, 18604 NW 64th Ave, Ridgefield, WA 98642 or via email: kimdchristensen@hotmail.com.
References
1. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. 2nd ed. Philadelphia: JB Lippincott; 1990:280.
2. Hruska R. Pelvic stability: influences of lower extremity kinematics. Biomechanics. 1998;5:23–29.
3. Regan DP. Implications of hip rotators in lumbar spine injuries. Strength Cond J. 2000;22(6):7–13.
4. Ninos J. A chain reaction: the hip rotators. Strength Cond J. 2001;23(2):26–27.
5. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg, Md: Aspen Publishers; 1998:134,265.
6. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone; 1989:312.
7. Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine. 1983;8:643–645.
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