1 Anatomy of the Core Anatomy of the Core Lower Limb Injures in the Athlete Lower Limb Injures in the Athlete Complex Rotational Movement Patterns in the Complex Rotational Movement Patterns in the Athlete Athlete ‐ Axial Twisting Axial Twisting Lumbar Lumbar‐Pelvic Pelvic‐Hip Complex Hip Complex ‐ Torque Conversion Torque Conversion 6 Movement Patterns of all Athlete Movement 6 Movement Patterns of all Athlete Movement Spinal Stabilization What is it? Spinal Stabilization What is it? Anatomy of the CORE Anatomy of the CORE ‐ Trunk Trunk‐Pelvis Pelvis‐Hip Hip Over Use Injures Over Use Injures Gait Gait Treatment Returning the Injured Athlete to Sports Treatment Returning the Injured Athlete to Sports Lumbar Lumbar‐ Pelvic Pelvic – Hip Complex Hip Complex Complex Movement Patterns Complex Movement Patterns Situational demands of the sporting activity will Situational demands of the sporting activity will stimulate the Central Nervous System to stimulate the Central Nervous System to selects selects specific programs for the motor solution to the specific programs for the motor solution to the problem problem The motor program then recruits the specific motor The motor program then recruits the specific motor The motor program then recruits the specific motor The motor program then recruits the specific motor units to execute a coordinated motor response. units to execute a coordinated motor response. The muscle must be set on a higher state of The muscle must be set on a higher state of readiness to prevent injury by protecting joints from readiness to prevent injury by protecting joints from perturbation forces and be able to execute perturbation forces and be able to execute exceptionally skilled activities performed at high exceptionally skilled activities performed at high velocities. velocities. Axial Twisting Axial Twisting – Protection = Co Protection = Co‐contraction contraction Axial twist moments, Axial twist moments, results in a complex results in a complex pattern of muscle pattern of muscle activity involving activity involving substantial co substantial co‐ i f i f contraction of rectus contraction of rectus abdomens and erector abdomens and erector spinae muscles, despite spinae muscles, despite their limited potential to their limited potential to generate twisting generate twisting moments. moments. Athletic activities the power Athletic activities the power is generated by the hips is generated by the hips with a stable trunk. with a stable trunk.
Transcript
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Anatomy of the Core Anatomy of the Core Lower Limb Injures in the AthleteLower Limb Injures in the Athlete
Complex Rotational Movement Patterns in the Complex Rotational Movement Patterns in the Athlete Athlete ‐‐ Axial TwistingAxial Twisting
LumbarLumbar‐‐PelvicPelvic‐‐Hip Complex Hip Complex ‐‐ Torque ConversionTorque Conversion
6 Movement Patterns of all Athlete Movement6 Movement Patterns of all Athlete Movement
Spinal Stabilization What is it?Spinal Stabilization What is it?
Anatomy of the CORE Anatomy of the CORE ‐‐ TrunkTrunk‐‐PelvisPelvis‐‐Hip Hip
Over Use InjuresOver Use Injures
Gait Gait
Treatment Returning the Injured Athlete to SportsTreatment Returning the Injured Athlete to Sports
LumbarLumbar‐‐ PelvicPelvic –– Hip ComplexHip ComplexComplex Movement PatternsComplex Movement Patterns
Situational demands of the sporting activity will Situational demands of the sporting activity will stimulate the Central Nervous System to stimulate the Central Nervous System to selects selects specific programs for the motor solution to the specific programs for the motor solution to the problemproblem
The motor program then recruits the specific motorThe motor program then recruits the specific motor The motor program then recruits the specific motor The motor program then recruits the specific motor units to execute a coordinated motor response. units to execute a coordinated motor response.
The muscle must be set on a higher state of The muscle must be set on a higher state of readiness to prevent injury by protecting joints from readiness to prevent injury by protecting joints from perturbation forces and be able to execute perturbation forces and be able to execute exceptionally skilled activities performed at high exceptionally skilled activities performed at high velocities. velocities.
results in a complex results in a complex pattern of muscle pattern of muscle activity involving activity involving substantial cosubstantial co‐‐
i fi fcontraction of rectus contraction of rectus abdomens and erector abdomens and erector spinae muscles, despite spinae muscles, despite their limited potential to their limited potential to generate twisting generate twisting moments.moments.
Athletic activities the power Athletic activities the power is generated by the hips is generated by the hips with a stable trunk. with a stable trunk.
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Anatomy and Movement of the COREAnatomy and Movement of the CORELower Limb Injures in the AthleteLower Limb Injures in the Athlete
Complex Rotational Movement Patterns in the Complex Rotational Movement Patterns in the Athlete Athlete ‐‐ Axial TwistingAxial Twisting
6 Movement Patterns of all Athlete Movement6 Movement Patterns of all Athlete Movement
Spinal Stabilization What is it?Spinal Stabilization What is it?
Anatomy of the CORE Anatomy of the CORE ‐‐ TrunkTrunk‐‐PelvisPelvis‐‐HipHip
Over Use InjuresOver Use Injures
GaitGait
Returning the Injured Athlete to SportsReturning the Injured Athlete to Sports
TrunkTrunk‐‐PelvicPelvic‐‐Hip Reduced to Triplanar Hip Reduced to Triplanar
Movement PatternsMovement Patterns Torque ConversionTorque Conversion
Trunk Trunk –– Important to stabilization and Important to stabilization and coupling movementscoupling movements
Pelvis Pelvis –– Important to power and high velocity Important to power and high velocity rotational movementsrotational movements
Hip Hip –– Important to power and rotational Important to power and rotational movements movements ‐‐ controls the femur and patella controls the femur and patella alignmentalignment
Subtalar joint is the Lower Limb Torque Subtalar joint is the Lower Limb Torque ConvertorConvertor
Pivotal movement of cuboid and calcaneusPivotal movement of cuboid and calcaneus FF supinationFF supination--dorsi flexion 1dorsi flexion 1stst metatarsalmetatarsal
Supination= ext rotn tibia Supination= ext rotn tibia Talus dorsiflexes Talus dorsiflexes Locking of the MTJ Locking of the MTJ
ScrewScrew--like action of navicular and cuboid along like action of navicular and cuboid along longitudinal axis longitudinal axis
Forefoot pronates Forefoot pronates ––plantar flexion of the first ray for plantar flexion of the first ray for pushpush--offoff
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Torque ConversionTorque Conversion
Subtalar joint torque conversion of :Subtalar joint torque conversion of : Transverse Plane Rotations Transverse Plane Rotations ––from from
thoracic spine thoracic spine –– L/S, pelvis, hip, femur L/S, pelvis, hip, femur and tibia are transferred INTO sagittal and tibia are transferred INTO sagittal and transverse plane motions of the talusand transverse plane motions of the talus
T i l t f P tiT i l t f P ti
STJ Pronation STJ SupTib int rotn Tib ext rotn
Triplanar movements of Pronation Triplanar movements of Pronation Supination Are the torque conversion Supination Are the torque conversion movementsmovements
Can customCan custom--made biomechanical shoe made biomechanical shoe orthoses prevent problems in the back and orthoses prevent problems in the back and
lower extremitieslower extremities??
A randomized, controlled A randomized, controlled intervention trial of 146 military intervention trial of 146 military conscripts.conscripts.
Boots and FormthoticsBoots and Formthotics
Larsen K, Weidich F, Leboeuf‐Yde C. J Manipulative Physiol Ther 2002 Jun;25(5):326‐31The Medical Research UnitBoots and FormthoticsBoots and Formthotics
Reduced Back and LE injuries.Reduced Back and LE injuries.
Comparative trial of the foot pressure patterns between Comparative trial of the foot pressure patterns between corrective orthotics, Formthotics, bone spur pads and corrective orthotics, Formthotics, bone spur pads and
flat insoles in patients with chronic plantar fasciitis.flat insoles in patients with chronic plantar fasciitis.
Formthotics and Custom FOs.Formthotics and Custom FOs.
6 Movement Patterns of all Athlete Movement6 Movement Patterns of all Athlete Movement
Spinal Stabilization What is it?Spinal Stabilization What is it?
Anatomy of the CORE Anatomy of the CORE ‐‐ TrunkTrunk‐‐PelvisPelvis‐‐HipHip
Over Use InjuresOver Use Injures
GaitGait
Returning the Injured Athlete to SportsReturning the Injured Athlete to Sports
Six Movement Patterns Part of all Athlete Trunk, Six Movement Patterns Part of all Athlete Trunk, Pelvic, Hip and Lower Limb MovementsPelvic, Hip and Lower Limb Movements
McGill movement can be broken down into 6 McGill movement can be broken down into 6 patterns: patterns:
1) squat/lift 1) squat/lift
2)push/pull2)push/pull 2)push/pull 2)push/pull
3) twist 3) twist
4) balance 4) balance
5)lunge 5)lunge
6) gait6) gait
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Six Patterns of MovementSix Patterns of Movement
Majority of athletic Majority of athletic movement patterns are movement patterns are focused aroundfocused around axial rotations such as axial rotations such as
twisting and lateral bending twisting and lateral bending in a swing or throwing anin a swing or throwing an
6 Movement Patterns of all Athlete Movement6 Movement Patterns of all Athlete Movement
Spinal Stabilization What is it?Spinal Stabilization What is it?
Anatomy of the CORE Anatomy of the CORE ‐‐ TrunkTrunk‐‐PelvisPelvis‐‐Hip Anatomy Hip Anatomy
Over Use InjuresOver Use Injures
GaitGait
Returning the Injured Athlete to SportsReturning the Injured Athlete to Sports
What is Spinal StabilizationWhat is Spinal Stabilization
Muscle “dysfunction” destabilized the spine, reduces Muscle “dysfunction” destabilized the spine, reduces the role of facet joints in transmitting load, and shifts the role of facet joints in transmitting load, and shifts loads to the discs and ligaments. loads to the discs and ligaments.
D i bili i i ll i f dD i bili i i ll i f d Dynamic stabilization is usually is referred to as coDynamic stabilization is usually is referred to as co‐‐contraction of musclescontraction of muscles
In addition to augmenting stability and joint In addition to augmenting stability and joint stiffness, costiffness, co‐‐contraction also can serve to regulate contraction also can serve to regulate the stress distributions during joint contact. the stress distributions during joint contact.
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Hip Muscles Protect and Improve PerformanceHip Muscles Protect and Improve Performance
Low back pain, pelvic, hip and lower extremity Low back pain, pelvic, hip and lower extremity injuries injuries ‐‐ demonstrate tightness of the hip flexors demonstrate tightness of the hip flexors and weakness of the gluteal maximus, posterior and weakness of the gluteal maximus, posterior fibers of gluteus medius and the deep six external fibers of gluteus medius and the deep six external rotatorsrotators
Watkins et al. demonstrated the importance of Watkins et al. demonstrated the importance of trunk and hip muscles in stabilizing and controlling trunk and hip muscles in stabilizing and controlling the loading response for max power and accuracy in the loading response for max power and accuracy in golfer’s.golfer’s.
Anatomy of the COREAnatomy of the CORELower Limb Injures in the AthleteLower Limb Injures in the Athlete
Complex Rotational Movement Patterns in the Complex Rotational Movement Patterns in the Athlete Athlete ‐‐ Axial TwistingAxial Twisting
LumbarLumbar‐‐PelvicPelvic‐‐Hip Complex Hip Complex
6 Movement Patterns of all Athlete Movement6 Movement Patterns of all Athlete Movement
Spinal Stabilization What is it?Spinal Stabilization What is it?
Anatomy of the CORE Anatomy of the CORE ‐‐ TrunkTrunk‐‐PelvisPelvis‐‐HipHip
Over Use InjuresOver Use Injures
GaitGait
Returning the Injured Athlete to Sports Returning the Injured Athlete to Sports
Local musclesLocal muscles IntertransversariiIntertransversarii
InterspinalisInterspinalis
Lumbar Longissimus Lumbar Longissimus
Iliocostalis lumborumIliocostalis lumborum
Global musclesGlobal muscles Longissimus & Iliocostalis pars Longissimus & Iliocostalis pars
thoracis pars lumborum thoracis pars lumborum
Rectus abdominusRectus abdominus
Obliquus externus and internusObliquus externus and internus Iliocostalis lumborumIliocostalis lumborum
MultifidusMultifidus
Quadratus lumborumQuadratus lumborum
Transverse AbdominisTransverse Abdominis
Obliquus externus and internusObliquus externus and internus
Hip Abductors/ Extensors/ Hip Abductors/ Extensors/ RotatorsRotators
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Local and Global MusclesLocal and Global Muscles
Local muscles are capable of Local muscles are capable of controlling movement andcontrolling movement andintervertebral relationship of the intervertebral relationship of the spinal segments and the spinal segments and the posture of the lumbar spine.posture of the lumbar spine.
Global muscles are involved in Global muscles are involved in moving the spine and moving the spine and transferring load directly transferring load directly between the thoracic cage and between the thoracic cage and the pelvis.the pelvis.
Balance external loads applied Balance external loads applied to the trunk so that the residual to the trunk so that the residual forces can be handled by the forces can be handled by the local muscleslocal muscles
Multifidus Multifidus Thickest at L4, L5 Thickest at L4, L5 –– S1 where anterior shear forces are greatest.S1 where anterior shear forces are greatest.
L4L4‐‐5 contributes 67% of segmental stiffness generated by lumbar muscles5 contributes 67% of segmental stiffness generated by lumbar muscles(Porterfield & DeRosa, 1991)(Porterfield & DeRosa, 1991)
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Abdominal Muscles Abdominal Muscles Transverse Abd. & Rectus Transverse Abd. & Rectus Local and GlobalLocal and Global
Top relaxed abdominal musclesTop relaxed abdominal muscles
GlobalGlobal‐‐Back extensors and AbdominalsBack extensors and Abdominals
BieringBiering‐‐Sorensen 1984 demonstrated that a decreased torso extensor Sorensen 1984 demonstrated that a decreased torso extensor
endurance predicts greater risk of back problemsendurance predicts greater risk of back problems. . Balance of three muscle groups are involved in spine stability during any Balance of three muscle groups are involved in spine stability during any
task and critical for the athletetask and critical for the athlete
T tT t Abd i l B iAbd i l B i itit t ith b k tt ith b k t Test one Test one –– Abdominal BracingAbdominal Bracing –– sitsit‐‐up posture with back rest up posture with back rest at 60E angle at 60E angle –– back rest removed & HOLDback rest removed & HOLD
Test two Test two –– Lateral MusclesLateral Muscles ––Full side bridge position legs Full side bridge position legs extended and top foot in front extended and top foot in front –– non wt. arm to opposite non wt. arm to opposite shoulder. HOLDshoulder. HOLD
Test threeTest three‐‐Back ExtensorsBack Extensors ––upper body over table feet are fix upper body over table feet are fix hands resting on opposite shoulders hands resting on opposite shoulders ‐‐ HOLDHOLD
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Mean Endurance Times(sec) and Ratios Mean Endurance Times(sec) and Ratios Normalized to ExtensorsNormalized to Extensors
Mean age 21 92M 137F Times: Ext 161 M 185 F Flex 136 M 134 F RSB 95 M 99 F LSB 99 M 78 F LSB 99 M 78 F Ratios: Flex/Ext .84M .72F RSB/LSB .96M .96F RSB/Ext .58M .40F LSB/Ext .61M .42F
Assessment of Quadratus LumborumAssessment of Quadratus LumborumLocal Core MuscleLocal Core Muscle
95% of muscle activation is an Isometric Contraction95% of muscle activation is an Isometric ContractionSide bridge Side bridge –– McGill Optimal ExerciseMcGill Optimal Exercise
In addition High EMG activity of: In addition High EMG activity of:
EMG Activity of Longissimus Thoracis, Lumbar Multifidus, EMG Activity of Longissimus Thoracis, Lumbar Multifidus, External Obliques and Rectus AbdExternal Obliques and Rectus Abd
Experience With “Sports Hernia” Spanning Two Decades
Meyers, McKechnie, Philippon, Ann Surg 2008
1. Adductor longus, adductorbrevis, or pectineus – are involved in most of adductor injuries 2. gracilis, adductor magnus, and obturator externus, which are,sometimes involvedIn addition, there are clear female variants of these problems that involve lateral compensatorypelvic structures after medial pelvic injury3. 18+ distinct syndromes
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Adductor enthesopathy is a potentialsource of adductor‐related groin pain in competitive
athletes ‐
MRI appearance of osteitis pubis: (B) shows the bone marrow edema (arrow), plus osseous musculoskeletal pelvis protocol (A) shows bright bone marrow edema (arrows) symmetrically across the pubic symphysis indicating an inflammatory process.
Top Six Sports (Total 8490 Athletes) 76% athletes% of Entire Series % of Last 2 YearsSoccer 44.6 27.2Football 22.3 32.7Hockey 8.1 10.2Baseball 6.3 6.1Basketball 6.2 5.3Distance running 1.2 4.2
The Hip: Is It StableThe Hip: Is It Stable??
14% of all athletic injuries 14% of all athletic injuries ((Milan, JOSPT, 1994Milan, JOSPT, 1994))
Contributes to the Contributes to the generation and generation and transference of Forcestransference of ForcesC l t f lC l t f l Complex set of muscles Complex set of muscles to create motion and to create motion and dynamic stabilitydynamic stability
30% of hip pain remains 30% of hip pain remains devoid of predevoid of pre--op dx op dx ((Baber, JBJS, 1999Baber, JBJS, 1999))
Impingement: New Impingement: New ConceptsConcepts
Hip Impingement Hip Impingement –– Labral TearsLabral Tears
1.1.TraumaticTraumatic based on a clear history based on a clear history of injuryof injury. .
2.Congenital Hip Dysplasia = 2.Congenital Hip Dysplasia = Slipped Slipped Capital Fem EpiphysisCapital Fem Epiphysis
3. Degenerative 3. Degenerative –– FAI cause of early FAI cause of early degenerative joint changesdegenerative joint changes
4. 4. Idiopathic Idiopathic –– overuse overuse & & microtrauma in Sportsmicrotrauma in Sports
Injury to the anterior part of Injury to the anterior part of the labrum may occur from the labrum may occur from recurrent twisting or recurrent twisting or
Besaule et JBJS 2009 Acetabular labral TearsBesaule et JBJS 2009 Acetabular labral TearsSpencer S J Ped Orthopedics 2006 Early results Spencer S J Ped Orthopedics 2006 Early results
of Rx of hip impingement syndrome in of Rx of hip impingement syndrome in slipped capital femoral epiphysis and pistol slipped capital femoral epiphysis and pistol grip deformity….grip deformity….
92% Anterior92% Anterior = External = External rotn in hyperextension and rotn in hyperextension and minimal flexionminimal flexion-- Golf, Golf, Hockey, FootballHockey, Football
96% Posterior/Superiorly:96% Posterior/Superiorly:Axial loading on Flexed hipAxial loading on Flexed hip
LateralLateral-- RareRareSelders et al. Clin Orth Rel Selders et al. Clin Orth Rel
Research 2001Research 2001Fitzgerald, Clin Ortho and Fitzgerald, Clin Ortho and
Demonstrating a crushed anterior labrum secondary to th t i h d kthe anterior head-neck junction impinging on the acetabulum as the femoral head levers out of the socket posterior.
Abutment of acetabular rim and femoral neck in association Abutment of acetabular rim and femoral neck in association with abnormalities of proximal femur and acetabulumwith abnormalities of proximal femur and acetabulum
Aspherical junction between head and neckAspherical junction between head and neck Pistol grip Pistol grip –– broad head and neck junction reduced anterior broad head and neck junction reduced anterior
offoff--set of femoral headset of femoral head Femoral head is too large causingFemoral head is too large causing camcam--type impingementtype impingement Femoral head is too large causing Femoral head is too large causing camcam--type impingementtype impingement
abnormal junction is driven into the acetabulum produce abnormal junction is driven into the acetabulum produce damage to the cartilage anteriordamage to the cartilage anterior--superior rimsuperior rim
Pincer Impingement Injury patternPincer Impingement Injury pattern Acetab Acetab Retroversion, Coxa ProfundaRetroversion, Coxa ProfundaTanzer M Clin Orthop Related Research 2004 Osseous Abnormalities & Tanzer M Clin Orthop Related Research 2004 Osseous Abnormalities &
Early OA: Role of Hip ImpingmentEarly OA: Role of Hip Impingment
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Hip ImpingementHip ImpingementPistol Grip DeformityPistol Grip Deformity
Normal Hip ANormal Hip A
Pistol grip deformity B’Pistol grip deformity B’
MRI pistol gripMRI pistol grip
Arrow showing Arrow showing
anterior superior anterior superior impingementimpingement
Hip Labral Tears Biomechanics of Hip Labral Tears Biomechanics of ImpingementImpingement
A: A normal hip. B: Reduced femoral headA: A normal hip. B: Reduced femoral head--neck offset (neck offset (camcam--type type impingementimpingement). C: Excessive over coverage of the femoral head ). C: Excessive over coverage of the femoral head ((pincerpincer--type impingementtype impingement). D: Combination of cam and pincer types ). D: Combination of cam and pincer types of impingement.of impingement.
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Acetabular Acetabular Retroversion Retroversion -- The crossover signThe crossover sign
red arrow the anterior wall & the yellow arrow pointing posterior wallred arrow the anterior wall & the yellow arrow pointing posterior wall
Crossover sign in the left hip and a normal (anteverted) acetabulum in the right hip.
Normal R hip, the edge of the posterior wall (dotted line) may be at, or lateral to, the center of the femoral head.
Retroverted L hip, the anterior wall (bold line) is lateral to the posterior wall at the most proximal aspect of the acetabulum (crossover sign) and the posterior wall is medial to the center of the femoral head
Groin Pain, usually Groin Pain, usually intermittent, often activity intermittent, often activity dependentdependent
Forced external rotation with Forced external rotation with hip extensionhip extension
Secondary Signs:Secondary Signs:-- Limp & Trendenlenburg Limp & Trendenlenburg
Temporary relief from Temporary relief from pain pain –– + for intra+ for intra--articular articular hip pathologyhip pathology
FAI TreatmentFAI Treatment
Hip Muscle weakness in patients with symptomatic FAIHip Muscle weakness in patients with symptomatic FAI
Casartelli et al Osteoarthritis and Cartilage 2011Casartelli et al Osteoarthritis and Cartilage 2011
Hip abd, add, flexors and external rotatorsHip abd, add, flexors and external rotators
Powers et al Powers et al –– collapse of hip internal rotation, adduction, collapse of hip internal rotation, adduction, and flexion secondary to weak posterior lateral muscle unable and flexion secondary to weak posterior lateral muscle unable to control femur leading to increased stress to PFJ to control femur leading to increased stress to PFJ ‐‐TibiofemTibiofem
Proposal Donatelli et al Proposal Donatelli et al –– weakness of posterior fibers GM, weakness of posterior fibers GM, Extensors, and external rotators related to symptomatic FAIExtensors, and external rotators related to symptomatic FAI
NWB to PWB for up to 3 months (some vascularization NWB to PWB for up to 3 months (some vascularization seen acutely)seen acutely)
CKC, Perturbation and Balance training when pain freeCKC, Perturbation and Balance training when pain free
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Tendinitis : An In Vivo Electromyography Study Rehabilitation Exercise Progression for the Gluteus Medius Muscle With Consideration for Iliopsoas
Philippon, Decker et al Am J Sports Med 2011 39: 1777 May 12, 2011
Tendonitis of the Iliopsoas – avoid supine hip flexion
Hip clam exerciseswere pidentified to also activate the iliopsoas muscle considerably and should be avoided in the face of concurrent hip flexor irritation.
Anterior fibers contribute to hip flexion and hip Anterior fibers contribute to hip flexion and hip internal rotation, internal rotation,
Posterior fibers to hip extension and hip Posterior fibers to hip extension and hip external rotation. external rotation.
Gottschalk et al. through EMG testing described Gottschalk et al. through EMG testing described the posterior fibers as functioning as the the posterior fibers as functioning as the primary segment in stabilizing the femoral primary segment in stabilizing the femoral head in the acetabulum during weighthead in the acetabulum during weighthead in the acetabulum during weight head in the acetabulum during weight transfer transfer
Preventing the opposite side of the pelvis from Preventing the opposite side of the pelvis from dropping during the stance phase of gait dropping during the stance phase of gait ‐‐major role in providing frontal stability for major role in providing frontal stability for the pelvis during walking the pelvis during walking
Assists in PFJ alignmentAssists in PFJ alignmentImproved use of GM in the sagittal plane may Improved use of GM in the sagittal plane may
serve to unload the Quads by decrease serve to unload the Quads by decrease compensatory action to absorb impact compensatory action to absorb impact forceforce
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Leg Drop Test Leg Drop Test TestTest‐‐Posterior fiber of Gluteus MediusPosterior fiber of Gluteus Medius
Positive leg drop test Positive leg drop test –– unable to holdunable to hold
Electromyographic Analysis of HipRehabilitation Exercises in a Group of Healthy Subjects
Lori A. Bolgla, PT, MS, ATC Timothy L. Uhl, PT, PhD, ATC
J Orthop Sports Phys Ther • Volume 35 • Number 8 • August 2005
The vertical solid line in each figure shows the force of gravity equal to approximately 19% body mass
The horizontal, broken line represents the length of the external moment arm for each exercise. The arrows depict the rotary motion produced by the hip abductors to lift the right lower extremity. .
NWB standing hip abduction exercises required the least activation, benefit patients who cannot safely perform the WB or sidelying hip abd.
Weight BearingWeight Bearing
The vertical, solid line shows the force of gravity equal to approximately 84% body mass (mass of the head, trunk, arms, and left lower extremity).
The horizontal, broken linet th t lrepresents the external
moment arm for that mass. The arrow depicts the rotary motion produced by the hip abductors to maintain a level pelvis, which required greater EMG activity than non–weight-bearing exercise
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Changes in the length of the external moment arm based on the magnitude of right trunk lean.
Right trunk lean maintain balance on the right lower extremity when abducting the left leg
Trunk lean may reduce the external torque applied to the right hip. The vertical lines represent the force of gravity; the horizontalthe force of gravity; the horizontal lines represent the external moment arm.
length of the external moment arm has shortened with exaggerated right trunk lean, decreased demands for the right hip abductors to maintain a level pelvis
(A) With the pelvis level, the resultant ground reaction force vector passes medial to the knee joint center, thereby creating a varus moment at the knee.
(B) Hip abductor weakness t l t l
The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective Powers C. JOSPT Feb/2010
can cause a contra-lateral pelvic drop and a shift in the center of mass away from the stance limb. This increases the varus moment at the knee
(C) Shifting the center of mass over the stance limb to compensate for hip abductor weakness can create a knee valgus moment
The ground reaction force vector passes lateral with respect to the knee joint center.
Structural Deformity of the Lower LimbStructural Deformity of the Lower Limb
Craig’s TestCraig’s Test ProneProne Knee flex at 90EKnee flex at 90E Palpation of GreaterPalpation of Greater Palpation of Greater Palpation of Greater
TrochTroch Hip IR/ERHip IR/ER Measure where Measure where
Greater Troch most Greater Troch most prominentprominent
Excessive Anteversion shown to Excessive Anteversion shown to reduce functionreduce function of LE mm (glut of LE mm (glut max, glut med post, soleus) to max, glut med post, soleus) to extend hip and knee in gait extend hip and knee in gait reduced by at least 10%. reduced by at least 10%. Hicks J., Arnold A., et al. Hicks J., Arnold A., et al. Gait & PostureGait & Posture, ,
26:4, pp.54626:4, pp.546‐‐552, October 2007552, October 2007
REDUCED dynamic frontal/trans plane femoral control in those with Excessive Anteversion
Nyland J, Kuzemchek, et al. J of Nyland J, Kuzemchek, et al. J of Electromyography and Kinesiology. 14, Electromyography and Kinesiology. 14, 255255‐‐261, 2004261, 2004
Femoral AnteversionFemoral Anteversion
Direct influence on patellar alignment and Direct influence on patellar alignment and tracking tracking Creates increased patellofemoral contact Creates increased patellofemoral contact
pressure with increasing anteversionpressure with increasing anteversion Nyland J, et al. J of Electormyography and Nyland J, et al. J of Electormyography and
Result: Result: Inc Fem Anteversion reduced Inc Fem Anteversion reduced MVC of Glut Med and hip abd MVC of Glut Med and hip abd moment by 34%. moment by 34%.
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Hip/Pelvis and GaitHip/Pelvis and Gait Morris, 1971 Biomechanics of RunningMorris, 1971 Biomechanics of Running
22 22 muscles cross the hip joint for force muscles cross the hip joint for force production and control production and control
1.6 x BW across hip during slow walking1.6 x BW across hip during slow walking
RunningRunning 5X BW in stance5X BW in stance
3X BW in swing3X BW in swing
8X BW can occur on a slip/stumble 8X BW can occur on a slip/stumble ((Bergman, 1993, J of BiomechanicsBergman, 1993, J of Biomechanics))
Anatomy of Dysfunction of the CORE Anatomy of Dysfunction of the CORE Lower Limb Injures in the AthleteLower Limb Injures in the Athlete
Complex Rotational Movement Patterns in the Complex Rotational Movement Patterns in the Athlete Athlete ‐‐ Axial TwistingAxial Twisting
LumbarLumbar‐‐PelvicPelvic‐‐Hip Complex Hip Complex
6 Movement Patterns of all Athlete Movement6 Movement Patterns of all Athlete Movement
Spinal Stabilization What is it?Spinal Stabilization What is it?
Anatomy of the CORE Anatomy of the CORE ‐‐ TrunkTrunk‐‐PelvisPelvis‐‐Hip Hip
Over Use Injures Over Use Injures –– Mechanics Mechanics
Gait Understand Muscle Function & Kinematics
Returning the Injured Athlete to Sports Returning the Injured Athlete to Sports
Hip/Pelvis and GaitHip/Pelvis and Gait
Importance of Importance of CONTROLCONTROL of Trans/Frontal plane of Trans/Frontal plane motions and transfer of Forces motions and transfer of Forces
Clinical note:Clinical note:Fi t 10% f it l ft f t t t th i l diFi t 10% f it l ft f t t t th i l di First 10% of gait cycle after foot contact there is a loading First 10% of gait cycle after foot contact there is a loading response. response.
A triplanar of hip flexion, adduction, and internal rotation A triplanar of hip flexion, adduction, and internal rotation caused by caused by
External forcesExternal forces-- controlled by extension, abduction, ext rotation. controlled by extension, abduction, ext rotation. Hip flexion is minimal 2E Hip flexion is minimal 2E –– add/int rotn (10add/int rotn (10--15E) 15E)
Excessive add/int rotn = knee valgus Excessive add/int rotn = knee valgus –– tibia to abd and foot tibia to abd and foot pronationpronation
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Pelvic Kinematics in GaitPelvic Kinematics in Gait
Three Determinants of Gait From the PelvisThree Determinants of Gait From the Pelvis
Lateral Pelvic Tilt +/Lateral Pelvic Tilt +/‐‐ 4E 4E
Pelvic Rotation +/Pelvic Rotation +/ 4E4E Pelvic Rotation +/Pelvic Rotation +/‐‐ 4E 4E
Pelvis has minimal movement to Pelvis has minimal movement to Conserve EnergyConserve Energy
Hip KinematicsHip Kinematics
SAGITTAL PLANESAGITTAL PLANE Extension is the greatest from heelExtension is the greatest from heel‐‐off to toe off to toe off maximum of 5off maximum of 5‐‐10 deg.10 deg.‐‐
C t ib ti t hC t ib ti t h ff i i i lff i i i l Contribution to pushContribution to push‐‐off is minimaloff is minimal. .
Flexion is the greatest from toeFlexion is the greatest from toe‐‐off to swing off to swing 3535‐‐40 degrees 40 degrees ––
Driving force in runningDriving force in running
Hip FlexorsHip FlexorsProvides forward propulsionProvides forward propulsion
Iliopsoas with minor role in internal rotation, but can , but can contribute indirectly through its contribute indirectly through its MA (moment arm) in Flexion MA (moment arm) in Flexion Tight iliopsoas contributes To
excessive internal rotation 2ºexcessive internal rotation 2º hip flex
Works with erector spinae, Works with erector spinae, multifidus & deep abdominal multifidus & deep abdominal wallwall Works to balance anterior Works to balance anterior shear forces of lumbar shear forces of lumbar spinespine
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Psoas MajorPsoas Major PsoasPsoas
Can reciprocally inhibit Can reciprocally inhibit gluteus maximus, gluteus maximus, multifidus, deep erector multifidus, deep erector spinae, internal oblique spinae, internal oblique & transverse abdominus & transverse abdominus when tightwhen tight
Extensor mechanism Extensor mechanism d f tid f tidysfunctiondysfunction
Synergistic dominance Synergistic dominance during hip extensionduring hip extension
May alter gluteus May alter gluteus maximus function, maximus function, altering hip rotation, gait altering hip rotation, gait cyclecycle
Gluteus MaximusGluteus MaximusEccentricallyEccentrically‐‐ Decelerate the thighDecelerate the thigh
Gluteus maximusGluteus maximus and Eand External xternal rotatorsrotatorsmay be may be MOREMORE critical in critical in controlling hip and tibiofemoral controlling hip and tibiofemoral joint kinematics compared to the joint kinematics compared to the glut medius. glut medius.
GLUT MAX found to have great GLUT MAX found to have great f gf gcapacity for ERcapacity for ER
The glut max plays a significant role The glut max plays a significant role in controlling the rate of hip in controlling the rate of hip flexion and internal rotation AND, flexion and internal rotation AND, therefore, knee valgustherefore, knee valgus
Inhibited by a tight PsoasInhibited by a tight Psoas
rotation and internal rotation Max 5rotation and internal rotation Max 5--7 7 degrees throughdegrees through--out stance phaseout stance phase Internal rotation greaterInternal rotation greater Internal rotation greaterInternal rotation greater
Frontal Plane movements adduction and Frontal Plane movements adduction and abduction 7abduction 7--5 degrees 5 degrees Adduction greaterAdduction greaterClinical note: Females exhibit a biomechanical Clinical note: Females exhibit a biomechanical profile of increased add and internal rotation profile of increased add and internal rotation increased increased valgus strain at knee = ACL tearsstrain at knee = ACL tears
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Gluteus Medius (Gluteus Medius (Post FibersPost Fibers‐‐ R DonatelliR Donatelli)) plays a vital role in plays a vital role in controlling multicontrolling multi‐‐planar hip joint kinematicsplanar hip joint kinematics
Glut Max along with Glut Max along with glut med are important glut med are important in the control of frontal in the control of frontal plane stability of the plane stability of the
hip on the pelvis. They hip on the pelvis. They degree degree
diagonal).diagonal).CKC CKC
exercise: exercise: ECCENTRIC ECCENTRIC control of control of ADD/IRADD/IR
p p yp p ywork synergisticallywork synergistically
Conneely M, et al. Conneely M, et al. Physical Therapy in Sport. Physical Therapy in Sport. 2006 “Dissection of the 2006 “Dissection of the glut med & max with glut med & max with
respect to their suggested respect to their suggested roleds in pelvic and hip roleds in pelvic and hip
stabilitystability
Research Based Clinical ApplicationResearch Based Clinical Application
Ireland M. J of Athletic Training. 1999 “ACL Injury in Ireland M. J of Athletic Training. 1999 “ACL Injury in female athletes: Epidemiology”female athletes: Epidemiology”
Powers C. JOSPT, 2003 “The Influence of Altered LE Powers C. JOSPT, 2003 “The Influence of Altered LE
Kinematics on PFJ DysfcnKinematics on PFJ Dysfcn…”…”
Ab l ti f th tibi d fAb l ti f th tibi d fAbnormal motion of the tibia and femur Abnormal motion of the tibia and femur in the transverse and frontal planes in the transverse and frontal planes have an effect on patellofemoral joint have an effect on patellofemoral joint mechanics through closed kinetic mechanics through closed kinetic chain function.chain function.
Hip External RotatorsHip External Rotators
Lawrence, et al. Clinical Lawrence, et al. Clinical Biomechanics. 2008 Biomechanics. 2008
“Influences of hip ER strength “Influences of hip ER strength on knee mechanics during on knee mechanics during singlesingle‐‐leg drop landings in leg drop landings in
females.”females.”N=72 Females. Tested Single Leg N=72 Females. Tested Single Leg Drop Landings Drop Landings ‐‐grt hip and quad grt hip and quad
Hip AdductorsHip AdductorsContinuous ActivityContinuous Activity during running to maintain foot during running to maintain foot
posture to midlineposture to midline
Over powering adductors at Over powering adductors at foot contact foot contact –– valgus knee valgus knee ––medialmedial knee strainknee strain
O hi fl i b d 40O hi fl i b d 40Once hip flexion beyond 40Once hip flexion beyond 40‐‐70E Line of force of 70E Line of force of adductor muscles crosses adductor muscles crosses the extensor side medial the extensor side medial lateral axis of rotation,lateral axis of rotation,Gains leverage to become Gains leverage to become hip extensorship extensorsAdductor MagnusAdductor Magnus (post (post fibers) Extends Hip fibers) Extends Hip
Tensor Fascia LataeTensor Fascia Latae
Int Rot of PL fibers of Int Rot of PL fibers of TFL helps to offset ER TFL helps to offset ER of Glut Med and to of Glut Med and to assist with stabilizationassist with stabilization
Clinical Note:Clinical Note:
Excessive adduction Excessive adduction and internal rotation and internal rotation may be the etiology of may be the etiology of Iliotibial band Iliotibial band SyndromeSyndrome
Injuries of LE SummaryInjuries of LE Summary
Be mindful of the anatomy and biomechanicsBe mindful of the anatomy and biomechanics Understand Understand CKC functionCKC function Know the Know the mechanical implicationsmechanical implications of weak mm of weak mm
in gait and in gait and CKC functionCKC function Understand the Understand the normal mechanicsnormal mechanics of gaitof gait Remember: Often times hip dysfcns go Remember: Often times hip dysfcns go
undiagnosedundiagnosed Understand Understand “True” Hip Pain“True” Hip Pain and and Differential Differential
DiagnosesDiagnoses FOCUS ON ECCENTRIC STRENGTH AND FOCUS ON ECCENTRIC STRENGTH AND
CONTROL OF EXCESSIVE FEMORAL CONTROL OF EXCESSIVE FEMORAL MOTIONMOTION
