- Hip = Ball and socket joint
- Closing Angle Impingement
- Using the elbow flexion as an example:
- Bicep is the closing angle side, triceps are the opening angle side
- We always want to feel the stretch/sensation in the opening angle side
- Dr. Andreo Spina always reinforced the fact that closing angle impingement is bad and is indicative of capsular limitation; where the deep connective tissue around the joint is tight.
- Think of capsular limitation as tightly wrapped saran wrap around the bone. This situation causes the bone to lose it’s ability to spin against another bone, increasing its glide and translation which causes closing angle impingement
- If a closing angle pinch is felt while flexing the hip, avoid flexing farther into the stretch because it will exacerbate the issue
- Usually, if individuals have hip/shoulder impingement - they aren’t able to move their extremities without moving their spine.
- Example: The inability to go through full ROM of hip flexion causes the lumbar spine to round in compensation. In this case, hip motion is not independent, rather it is interdependent on other regions of the body
- Strategies
- Isometric contraction using progressive and regressive angular isometric loads (functional range conditioning)
- Controlled Articular Rotation (CARs) for hips
- Isometrically pack air into gut, irradiate the contraction (Sherrington’s Law of Irradiation)
- Move joints one at a time: flex hip, ER hip, IR hip, extend hip and then reverse all movements
- Goal = have joint independence otherwise you will have jt interdependence
- Only go through pain free ROM if you experience closing angle pinch at any time during the exercise.
- Standing regression is to hold the wall for stability
- Floor regression is to perform CARs in a quadruped position (Avoid spinal flexion, bending in elbows. The only joint that should move is the hip)
- If there is a lot of spinal movement, regress to a prone position CARs (If individual is unable to lift the knee off the ground during hip extension, squeezing the glutes and pulling the knee back to the midline of the body will suffice). The pelvis (ASIS) and elbows should not lift off the ground; side bending of the torso should not occur.
- Teaching motion independence:
- In a quadruped position, place a ball on top of the sacrum and maintain the quadruped position
- Sit hips back (bring pelvis towards the ankles) without tipping the ball over
- Return back to start position
- Teaching motion independence:
- In a quadruped position, pull knees into hands and hands into knees (this isometrically engages the core musculature). Hold position for 4 seconds (this gives the individual enough time to hold the isometric contraction and breathe).
- Maintaining the isometric contraction above, sit hips back towards ankles. Hold for 4 seconds and then return back to start in 4 counts (still maintaining the isometric contraction and breathing throughout)
- Once the individual understands strategies 3 and 4, we can combine both exercises.
- For chronic impingement in particular, pain science has shown that representation of the painful region in the somatosensory cortex is lost. Isometric hip progressions are a good way to approach this situation as it is not inflammatory to the system, is a great way to introduce movement and improve nervous system engagement through from a less threatening place and builds somatosensory space in addition to strength.
- Depending on the level of impingement and strength, isometric hip progressions can be done with or without a band.
- Hold each isometric contraction for 1 min each side, 2-3 sets
- GROUND:
- Butterfly
- Straight leg raise
- Quadruped fire hydrant
- STANDING:
- Staggered stance (w/ reaches)
- Whatever your strategy, improving joint mobility has to be the number one step you take (release the capsule). Then, clear out the one joint muscles, followed by the two joint muscles.
- “The test is the exercise, and the exercise is the test” - Dr. Gary Gray
NOTE: The following decompression strategies are often performed prior to strengthening or mobility work, when it is appropriate for the patient
- If your patient responds well to traction or long axis distraction of a joint, decompression is for them.
- Decompression is not recommended for all patients
- If you distract a joint and the surrounding tissues become down-regulated, distraction is not an option
- If you distract a joint and the surrounding tissues become up-regulated, distraction is an option
- Use muscle testing to decide
- Strategies:
- Attach thick band to a stable object, double wrap the opposite side around one ankle. Move back and lie down so that there is tension in the band.
- Experiment with different angles to focus the distraction on different tissues as long as the decompression is still felt in the joint
- Hold until the foot goes numb
- Attach thick band to a stable object, pull band up to hip joint and get into a quadruped position. Sit the hips back towards the ankles.
KEY TAKEAWAY: Some individuals respond to compression better than distraction and some people respond better to distraction than compression. This directs my course of treatment.