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Unlock the Hip: Using JointMobilizations to Improve Mobility
Great Lakes Athletic Trainers Association
45 st Annual Winter Meeting
Wheeling, ILMarch 16, 2013
Scott Lawrance, DHS, LAT, ATC, MSPT, CSCS
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Objectives
Lab Attendees will be able to perform static and dynamic
joint mobilizations for the hip in both weightbearingand non-weightbearing positions
Attendees will be able to demonstrate and instruct amobility exercise program to allow for maximal gain
following joint mobilization
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When did this become bad?
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and how does this become that?
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Neurodevelopment
As babys we have tremendousamount of joint mobility
We maintain this as childrenthrough play
As adults we start to loosemobility mostly due topositional and postural habits
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The Adult Hip
Generally has poormobility
Result of: Sitting posture Lack of squatting
Causes: Decreased length in hip
flexors
Reciprocal inhibition ofthe gluteal muscles
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The Athletic Hip
FMS administered to all incomingand transfer athletes at UIndy Fall2012 Average deep squat score: 2.04
Football: 2.14 Mens Soccer: 1.20
Volleyball: 1.42 Womens Soccer: 1.75
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Sequelae of Hip Hypomobility
Changes in functionalmovement Increased mobility needed
above and below Increased lumbar spine/SI
joint mobility and increasedlordosis
Increased mobility in the knee
and lower kinetic chain Increased muscular
activation in hamstrings,piriformis, erector spinae
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Sequelae of Hip Hypomobility
Changes in athletic performance Decreased strength Decreased power Decreased speed
Limits potential exercises that can be performed inthe weight room
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Assessment of Hip Mobility
History and Observation!
Deep Squat Movement Test Table Mobility Assessment
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Movement Assessment:Squat Test
Have your athlete stand withfeet shoulder width apart andarms overhead. Instruct themto squat and look to see if theycan maintain upright posture,hip/knee/ankle alignment and
feet flat on the floor
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Table Assessment:Pelvic Alignment/Hip Extension
Note: is the pelvis balanced? If not need to start there. Doesthe hip extend and is the resistance similar side-to-sideis thisfrom tight musculature or from joint tightness??? What are thearthrokinematics that link these?
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Table Assessment:Supine Mobility
After assessing pelvis/SI joint and hip extensionlook at passive: Hip flexion Hip flexion/adduction Hip flexion/abduction Hip internal rotation Hip external rotation
Note ROM, end-feel, quality of motion,restrictions present
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Treating Hip Mobility
Lots of options Stretching of hip flexor, hamstrings, adductors, IT
band, quadriceps
Foam roller Therapeutic exercise
(capsular)
But Do these really treat ALL of the problem?
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Treating Hip Mobility
Due to hip joint structure(deep articulating ball-and-socket) and musclebulk, mobilization of the
joint is needed to providea lasting change
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What is a Joint Mobilization?
AKA - Joint Mob
Manual therapy technique Used to modulate pain Used to increase ROM Used to treat joint dysfunctions that limit ROM by
specifically addressing altered joint mechanics
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History
Hippocrates (4 th century BC physician) may havebeen first recorded to perform jointmanipulations and spinal traction
English physicians in the 1700 and 1800sbelieved in strict rest after a joint injury, whilebonesetters would treat patients withmanipulations
Dr. Wharton Hood wrote the first medical bookon manipulation in the 1870s
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History
Kaltenborn - Scandinavian who merged what heconsidered the best of chiropractic, osteopathy,and physical medicine
Maitland - Australian PT who focused primarilyon mobilizations rather than manipulation, andhas meticulous examination skills that heavilyguide his treatments
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Movement Types
Physiologic movement: movements the patientcan perform voluntarily
Accessory movements: movement the patientcannot perform actively, but are necessary fornormal ROM
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Accessory Motion Arthrokinematics
5 types of arthrokinematics Roll, Slide (Glide), Spin, Compression, Distraction
3 components of joint mobilization Roll, Slide (Glide), Spin
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Roll
A series of points on one articulating surfacecome into contact with a series of points onanother surface Rocking chair analogy; ball rolling on ground Example: Femoral condyles rolling on tibial
plateau
Roll occurs in direction of movement
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Slide (Glide)
Characteristics of one bonesliding on another For a pure slide, the surfaces must be
completely congruent Car hitting brakes analogy Surfaces must be congruent for this to
occur
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Spin
Occurs when one bone rotates around astationary longitudinal mechanical axis Same point on the moving surface creates an arc of a circle as
the bone spins Car spinning its wheels analogy Example: Radial head during pronation/supination
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Convex/Concave Rule
Basic concept of correct mobilization application Is this the whole
picture?
Realize:1. This is only a tool
2. This is a helpful method to understand where tomobilize
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Convex moving on Concave
When convex is moving andconcave is stable: Glide and roll are OPPOSITE Joint surfaces slide in the
OPPOSITE direction of the bonemovement
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Concave moving on Convex
When concave is moving andconvex is stable: Roll and glide occurs in the
SAME direction Joint surfaces slide in the SAME
direction as the bone
movement
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Joint Mobilizations Grades
I
II
III
IV
V Available Joint
Play
Stretch
The oscillation grading systemwas developed by the AustralianPT Maitland.
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Indications
Grades I and II - primarily used for pain Pain must be treated prior to stiffness Painful conditions can be treated daily
Grades III and IV - primarily used to increasemotion Stiff or hypomobile joints should be treated 3-4 times
per week alternate with active motion exercises
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Effects of Joint Mobilization
Mechanical effects Improves mobility
Neurophysiological effects Stimulates mechanoreceptors to decrease pain
Nutritional effects Improved synovial fluid movement and nutrient
exchange in articular cartilage
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Contraindications for Mobilization
Contraindicated for: Inflammatory conditions or acute inflammatory
process
Malignancy Osteoporosis Ligamentous rupture
Herniated disks with nerve compression Bone disease
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Would you perform a Joint Mobon any of these athletes?
Beighton Index
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Before You Begin
Warm tissue prior to mobilization Muscle relaxation techniques may be needed
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Joint Mobilization Application
Patient should be relaxed Explain purpose of treatment & sensations to expect to
patient
Evaluate BEFORE & AFTER treatment (comparable sign) Use proper body mechanics Remove jewelry
Begin & end treatments with Grade I or II oscillations Stop the treatment if it is too painful for the patient
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Treatment Force and Direction ofMovement
Treatment force is applied as close to theopposing joint surface as possible The larger the contact surface is, the more
comfortable the procedure will be (use flat surface ofhand vs. thumb)
Direction of movement during treatment is either
PARALLEL or PERENDICULAR to the treatmentplane
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Treatment Direction
Treatment plane lies onthe concavearticulating surface,perpendicular to a linefrom the center of theconvex articulating
surface
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Speed, Rhythm, and Duration ofMovements Joint mobilization sessions
usually involve: 3-6 sets of oscillations Perform 2-3 oscillations
per second Lasting 20-60 seconds fortightness
Lasting 1-2 minutes forpain 2-3 oscillations per
second Apply smooth, regular
oscillations
For painful joints, applyintermittent distraction for7-10 seconds with a fewseconds of rest in betweencycles
For restricted joints, apply aminimum of a 6-secondstretch force, followed bypartial release then repeatwith slow, intermittentstretches at 3-4 secondintervals
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Patient Response
May cause soreness Perform joint mobilizations on alternate days to allow
soreness to decrease & tissue healing to occur
Patient should perform ROM techniques Patients joint & ROM should be reassessed after
treatment, & again before the next treatment
Pain is always the guide
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The Hip Joint
Concave acetabulum andconvex femoral head
Open packed position:
Hip flexion 30 degrees,abduction 30 degrees, slightexternal rotation
Close packed position: Hip extension, slight internal
rotation
Designed for stability
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Static Hip Mobilizations
Lateral Glide Technique for general mobility and/or pain control
Posterior Glide Used to increase hip flexion and internal rotation
Anterior Glide Used to increase hip extension and external rotation
Inferior Glide Used to increase hip flexion or rotation
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Mobilizations with Movement(MWM)
Mulligan concept of introducing dynamic motionas the mobilization is performed Advantage:
Can move into the restriction while performing mobilization Neural pathways activated when active motion is applied Athlete can get immediate positive feedback
comparable sign
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Mobilizations with Movement(MWM)
Principles Maintain joint mobilization through entire movement Move through as much of a full ROM as possible Force should remain constant Movement should be painfree
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How do you follow-up?
After mobilizing the joint, need to follow-up withmobility exercises Reinforce the new mobility gained and new
movement pattern Home program vs. in clinic/athletic training room
Correct underlying postural deficiencies
Rebalance the joint (if needed)
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Questions?
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Lab Set-up
Please find a partner(s) of similar build to workwith during lab
You will need a mobilization belt If you do not feel comfortable with any of the
mobilizations being performed on you, please donot do them!
If you need help or have a question, please ask us
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Lab
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Setting up the Belt
Know the type of beltyoure working with
Clinician body mechanics Set up belt to wrap around patients proximal thigh
and your hips/greater trochanter
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Hip Posterior Glide
Increase hip flexion orinternal rotation
Hip flexed, adducted,and slightly externallyrotated with foot ontable
Use hand across table toapply downward into hiptoward table
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Hip Anterior Glide
Increase hip extension orexternal rotation
Hip neutral position Can bias capsule by addition of
IR/ER
Apply force at gluteal fold
in anterior direction Beware of pain in the low back!
(may need to flex the hip)
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Hip Inferior Glide
Inferior glide with hip flexedplaces stress into posterior-inferior joint capsule
Helps to increase hip flexionand rotation
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Dynamic Hip Mobilizations
All performed using the belt Supine joint distraction with
Flexion Internal Rotation External Rotation
Standing lunge position with Forward lunge Lateral lunge
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Dynamic Hip Flexion Mobilization
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D i Hi I t l R t ti
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Dynamic Hip Internal RotationMobilization
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D n mic Hip E tern l Rot tion
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Dynamic Hip External RotationMobilization
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Dynamic Forward Lunge
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Dynamic Forward LungeMobilization
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Dynamic Lateral Lunge
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Dynamic Lateral LungeMobilization
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Hip Dynamic Mobility
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Hip Dynamic MobilityExercises
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Hip Dynamic Mobility
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Hip Dynamic MobilityExercises
Leg swings Front/back Lateral/across body
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Hip Dynamic Mobility
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Hip Dynamic MobilityExercises
Hurdle step over/under drills Forward Lateral
Backward Alternating Squatting
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Summary
Practice mobilization to refine technique Apply according to treatment parameters and
patient goals
Use good body mechanics to apply the mosteffective treatment and protect yourself
Follow up with mobility exercises to maximizebenefits
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Acknowledgements
Performance Rehab Products Mobilization Belts
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Dont Ever Mistake Activity for Achievement!- John Wooden
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Questions?
Thank you for attending our Learning Lab session!
Scott Lawrance, DHS, ATC, MSPT, CSCSUniversity of Indianapolis1400 East Hanna AvenueIndianapolis, IN 46227
(317) [email protected]
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