The hip muscles form a vital link in the lower extremity kinetic chain by transferring ground-reaction forces from the legs to the trunk during gait. These muscle groups supply coordinated propulsion and provide balanced stability for the pelvis and spine. However, through repetitive use patterns and after injuries, it is not unusual for some of these muscles to develop shortening and/or weakness. A comprehensive care program must include exercises to address these imbalances.
An appropriate and successful exercise program to rebalance the hip muscles does not require expensive, joint-specific equipment. The low-tech approach can be very effective for the treatment of most hip and pelvic conditions. With a few simple stretches (properly performed) and some home resistance exercises, the hip muscles can be easily strengthened and rebalanced.
The Hip Rotators and the Pelvis
The role of the hip rotator muscles is frequently overlooked when addressing prevention and rehabilitation of lumbar spine injuries. Deconditioned and/or shortened hip rotators contribute to abnormal lumbopelvic posture and cause compensatory motion in the lumbar spine during daily activities.1 This is particularly important during strenuous and competitive athletic efforts. The detrimental effects of inadequately conditioned and prepared hip rotators predisposes the athlete to lumbar spine injuries,2 many of which are eventually seen by the sports-oriented doctor of chiropractic.
Deficits of flexibility and strength in the hip rotators can add substantial stress to the pelvis and sacroiliac joint, as well as the lumbar and even thoracic spinal regions.3 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 will be necessary for a complete response to chiropractic care. The chiropractic correction of the flexed pelvis will help to 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 the range of motion of the hip internal rotators will be needed. This can be accomplished by stretching the shortened internal rotators and strengthening the antagonist external rotator muscles.
Stretching and Increasing Motion
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 the early stages of chiropractic treatment.
Piriformis syndrome and iliotibial band syndrome are two hip conditions that benefit from specific stretching exercises. In both of these, tight muscles contribute to an overuse condition that irritates sensitive tissues. Care must include inward rotation stretches for the piriformis muscle, corrections of subluxations and biomechanical faults of the pelvis, as well as predisposing factors such as an anatomically short leg and/or foot pronation.4 Correction of abnormal biomechanics such as leg length discrepancies must also be part of the care program.5
Weaker or injured muscles can be quickly strengthened with the use of isotonic resistance exercises. The resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body. Since the hip functions as part of a closed kinetic chain during most daily and sports activities, weight-bearing exercises, which require the co-contraction of accessory and stabilizing muscles, can be most effective. Open chain exercising (done with the foot and lower leg freely moving) is most helpful in the early stages of hip strengthening, to reduce the stress on the surrounding muscles after an injury. With athletes, exercise selection should also consider the sport-specific movement patterns. 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. Open chain exercising can be started very early with a symptomatic hip, since it doesn’t require the musculoskeletal structures to bear the weight of the body. 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, maybe, more useful than stretching for resolving the snapping.6 Rehab for patients with any 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 safely be supplied with heavier tubing.
Closed chain exercises. Weight-bearing strengthening exercises, with the foot on the floor, should be included when an athlete is preparing to return to sports activities. Examples of closed chain exercises for the hip rotators include partial squats, lunges (especially to the side), and single-leg body rotations. Initially, body weight is sufficient. Resistance can be gradually and progressively increased with the use of hand weights or elastic tubing. The particular benefit from closed chain exercises is their ability to re-train the co-contractions of accessory hip support muscles.
Functional Hip Alignment
A major underlying reason for developing an imbalance in the hip rotator muscles is an imbalance in weight-bearing alignment of the lower extremities. Alignment problems need to be addressed in order to prevent recurring hip muscle imbalances and 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. Osteoarthritis is much 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 use of custom-made orthotics and/or heel lifts is often necessary in order to establish long-term balance in the hip muscles.
Early in their treatment, patients with hip complaints and sports injuries should be started on appropriate and progressive rehabilitative programs that include muscle stretching and strengthening.8 These rehab techniques are easy and accessible, since they do not require expensive equipment or great time commitments. It isn’t difficult to select the best exercise approach for each patient’s hip problem. A home exercise program which is closely monitored allows the doctor of chiropractic to provide rehabilitative care which is cost efficient and effective.
Muscle alignment problems are frequently found in association with chronic and/or recurring hip imbalances. Therefore, patients must be screened for excessive leg length discrepancies and/or pronation. Proper alignment and support of the lower extremities will lead to muscles that are strengthened and lengthened, and hip joints that work smoothly.
Kim D. Christensen, DC, CCSP, CSCS, DACRB, founded the SportsMedicine & Rehab Clinics of Washington. He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs. Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the president of the American Chiropractic Association (ACA) Rehab Council. He is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association. Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition. He can be reached at Chiropractic Rehabilitation Assoc.,, 18604 NW 64th Avenue, Ridgefield, WA 98642 or by email at [email protected].
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