Download gluteus medius

OMM 16/17- Hip and Pelvis
Embryo
Limbs develop during 4th week due to myoblast aggregation
Femur
Longest and heaviest bone in body
Normal angle of inclination: 120-135 degrees
Formed by Anatomic (shaft) and longitudinal (neck) axes
• Coxa Valgus (to midline)
– Angle of Inclination: >135 degrees
• Coxa Varus (away from midline)
– Angle of Inclination: <120 degrees
3 bones make up acetabulum: pubis, ilium, ischium
Common dislocation: posterior and inferior
Ligaments
• Iliofemoral Ligament: Anterior aspect, Y-shaped, Tenses with full hip extension
– *Strongest ligament in the body
• Pubofemoral Ligament: Anterior aspect
• Ischiofemoral Ligament: Posterior aspect, Prevents hyperextension
OMM 16/17- Hip and Pelvis
When you externally rotate the hip, the foot actually comes toward the midline (knee flexed)
Internally: foot away from midline
Key points about muscles:
Gluteus maximus: strongest hip extensor
Iliopsoas: strongest hip flexor (don’t put heat on it, it gets larger)
Piriformis: abducts flexed thigh (sciatic nerve passes anterior)
There are no primary internal rotators: different muscles are secondary internal rotators
IT Band: location for viscerosomatic reflexes (Chapmans points for colon, prostate)
Sciatic: origins L4-S3
Sympathetic innervations to LE: T11-L2
No parasympathetic innervations to LE
Sciatica: hip and buttock pain that radiates down the back of the thigh (not past the knee)
Low back pain, lack of neurologic symptoms, decreased internal rotation of hip
Can be due to piriformis spasm (Piriformis innervated by S1-S2
Femoral triangle: NAVeL (lateral to medial)
Central line in here
Check femoral artery bilaterally to evaluate claudation sx
Physical exam
Get history of: Pain, numbness, weakness, trauma
Inspection
Bony palpation
TART changes
Soft tissue palpation
Range of motion*
OMM 16/17- Hip and Pelvis
Neurological exam/Muscular exam
DTRs
Invert foot
“Walk on heels”
“Walk on toes”
Sensation (dermatomes)
Muscle Strength (L4, L5, and S1)
Special tests
Straight leg raise test (Lasegue’s)
Assesses sciatic nerve compression/irritation
Keep knee extended, Dr flexes hip until patient reports pain (normal = 90 degrees)
Positive: back pain on the involved side that is accompanied by pain down the leg that reproduces sx.
Laseque’s Test
Tests for pain specific to sciatic nerve
Once pain is reported, Dr flexes knee and extends hip about 5 degrees, at new endpoint Dr extends knee
This removes hamstring pain while adding stress to sciatic n.
Considered abnormal if pt. reports return of pain (especially if radiates past knee)
Braggard’s test
Lower leg slightly and actively dorsiflexed foot
Positive: pain is accentuated in same leg distribution as SLR
If negative: pain from straight leg raise test may be secondary to tight hamstrings or due to
malingering (lying bastards…)
Heel walk/toe walk: test sensation (look at DTR pictures)
OMM 16/17- Hip and Pelvis
Special tests*
Thomas Test: assessment for contraleteral restricted or shortened iliopsoas muscle
Flex one thigh up to abdomen (active or passive)
Considered positive if opposite knee lifts off table
Treatment for Tight/Short Iliopsoas:
Have Pt Move Toward Edge of Table On Side of Positive Thomas Test
Treated Limb is Lowered off Table, Stabilize Contra lateral ASIS
Apply Gentle Posterior Traction to Treated Limb
Have Pt Attempt Flexion Against Your Resistance 3 Seconds, Rest 3 Seconds
Gently Increase Traction, Repeat 2 times
Optimal Extension: 30º(Kimberly), 35º (Foundations)
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Trendelenburg test: assessment of gluteus medius muscle strength
Patient stands on one foot while flexing opposite knee
Gluteus medius m. on opposite side of flexed knee should abduct leg, keeping pelvis level
Considered positive if pelvis tilts toward side of flexed knee
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Patricks/Fabere Test: Testing for hip and/or SI joint pathology
Patient supine, physician follows passive leg movements of flexion, abduction, ER, extension (in order from each
position)
Positive test recreates pain in SI joint (posteriorly) or in hip (more anteriorly in femoacetabular joint)
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OMM 16/17- Hip and Pelvis
Ober’s Test: Tests for contractures of IT tract
Patient on side with tested side up
Knee is flexed 90⁰, hip abducted 40⁰ and extended to its limit
While hip extension and knee flexion are maintained with pelvis stabilized, limb is gently adducted toward exam
table
Positive test: inability to adduct hip past midline
Supine Direct Myofascial Release for tight IT band
Find tightest point of IT band
Using pad of thumb, press medially and posteriorly on this point, maintain until release is felt
IT Band and Tensor Fascia Lata SD: Myofascial release
1. The patient lies supine or lateral recumbent with dysfunctional side up.
2. The physician palpates the IT band looking for the most restricted area.
3. The physician gently moves the palpating hands in a linear direction of choice with an appropriate amount of
pressure, noting symmetry and asymmetry in the tissues.
4. The physician slowly moves the myofascial tissues toward the appropriate barrier, holding the tissue at that
point without relieving pressure.
5. The physician follows the change in the tissues until no further evidence of creep occurs.
6. The physician reevaluates the tissues. The technique may be repeated.
Fascia Lata Kneading
• Stand side opposite extremity to be treated, Flex knee to 90 degrees
• Use fingers of cephalad hand to pull IT band towards you
• Simultaneously carry foot away from self, increasing tension on IT band
• Continue with kneading motion
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Diagnosis of Tight/Short extensors (Hamstrings) (flexion restriction= extension SD)
Pt. Supine, Test flexion by lifting leg off table while resting on dr shoulder, testing ROM
If extensors are tight, they decrease flexion of the hip
Treatment of Tight/Short extensors
Pt Supine, Distal Tibia on Docs Shoulder
Gently Take Extended Limb to Barrier
Have Pt Attempt Extension Against Resistance for 3 Seconds, Rest 3 Seconds
Gently Take up Slack to New Barrier, Repeat 2 More Times
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OMM 16/17- Hip and Pelvis
Diagnosis of Tight/short flexors (quadriceps): (extension restriction= flexion SD)
Pt. prone, test extension by pushing feet to butt
Testing knee flexion and extension of thigh (Flexors, mainly Quads)
If flexors are tight, they limit the ability to push the foot to butt
Treatment of Tight/Short Quadriceps
Pt Prone, Flex Leg at Knee
Distal Tibia Contacts Dr Shoulder, Dr. Applies Flexion Force To Resilient Barrier
Pt Attempts Extension of Leg 3 Seconds, Rest 3 Seconds
Increase Flexion Traction, Repeat 2 More Times
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Diagnosis of Tight/Short Abductors: (adduction restriction= abduction SD)
Pt supine, physician monitors ipsilateral ASIS
Grasp leg, extend lower limb, adduct limb to barrier
Testing abductors: gluteus medius, minimus
Optimal adduction: 35⁰
Treatment of Tight/Short Abductors
Maintain ADduction Tension, Have Pt Attempt ABduction Against Resistance for 3 Seconds, Rest 3 Seconds
Take up Slack into Further Adduction, Repeat 2 More Times
Optimal adduction: 20º-30º (kimberly), 35º (foundations)
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Diagnosis of Tight/Short Adductors: (abduction restriction=adduction SD)
Pt supine, physician monitors ipsilateral ASIS
Grasp leg, extend lower limb, abduct limb to barrier
Testing adductors (if adductors are tight/short= restriction in abduction)
Optimal abduction: 55⁰
Treatment of Tight/Short Adductors
Pt Supine, Grasp Lower Leg and Abduct, Stand Between Pt Leg and Table
Reinforce Knee against your thigh
Have Pt Attempt Adduction Against Operator Thigh 3 sec, Rest 3 Seconds, then Increase Abduction
Repeat 2 Times
OMM 16/17- Hip and Pelvis
Diagnosis of Tight/Short ER’s: (IR restriction= ER SD)
Supine
Physician on side of dysfunctional hip, hold distal tibia and stabilize knee
Internally rotate femur (move distal tibia laterally)
Prone
Physician at pt feet, pt knees flexed to 90⁰, grasp distal tibia and move laterally, internally rotating the
femur
Treatment of Tight/Short ERs (and Piriformis)
Post-Isometric Relaxation Muscle Energy
1. Pt prone, physician on side opposite dysfunction
2. Finger on piriformis muscle while holding ankle with other hand
3. Flex knee to 90⁰ and slowly move ankle away from midline (IR dysfunctional hip) until piriformis stretches
Engage edge of restrictive barrier
4. Pt pushed ankle toward midline against Dr’s counterforce
5.Hold 3-5 seconds, relax, reposition farther from midline, repeat until improved and RECHECK
Piriformis Counterstrain
Tender Point Location: approximately 7 to 10 cm medial to and slightly cephalad to the greater trochanter on the side of
dysfunction (midpoint between lower half of lateral aspect of sacrum and greater trochanter).
1. The patient lies prone, and the physician stands or sits on the side of the tender point.
2. The patient’s leg on the side of the tender point hangs off the edge of the table; the hip is flexed approx 135˚
and markedly abducted and externally rotated. The patient’s leg rests on the physician’s thigh or knee.
3. The physician fine-tunes and holds for 90 seconds.
4. The physician brings the patient back to neutral and rechecks the tender point.
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Diagnosis of Tight/Short IRs: (ER restriction= IR SD)
Supine
Physician on side of table, hold distal tibia and knee
Externally rotate femur (move distal tibia medially)
Prone
Physician at feet, pt knees flexed 90⁰, physician grasps distal tibia and moves medially, crossing legs,
externally rotating the femur
OMM 16/17- Hip and Pelvis
Internal or External Rotation SD: Combined muscle energy technique
Considered reciprocal inhibition (by activating the agonist muscles, we are relaxing the antagonists)
1. Indirect. Take hip away from the restrictive barrier, toward the direction of ease. Reciprocal Inhibition
• Internal S/D: Take into internal rotation
• External S/D: Take into external rotation
2. Flexion. Maintain internal or external rotation and go into flexion.
3. Direct. Take hip toward the restrictive barrier, away from the direction of ease. Post Isometric relaxation
• Internal S/D: Take into external rotation
• External S/D: Take into internal rotation
4. Extension. Maintain direct counterforce and allow leg to return to extended position.
5. Recheck.
Thus, for ER SD (for IR, switch steps 1 and 3)
Pt supine, physician on bad side, flex knee and hip less than 90
1. Lower limb into EXTERNAL ROTATION (ask pt to push outward and physician resists)
Ask pt to relax, go more into barrier, repeat steps 3-5 times
2. Maintain external rotation, take limb into flexion (Ask pt to push knee towards end of table, dr resists)
Ask pt to relax, go into new barrier, repeat 3-5 times
3. Maintain flexion, take limb into INTERNAL ROTATION (Ask pt to push ankle inward, dr resists)
Ask pt to relax, go into new barrier, repeat 3-5 times
4. Maintain internal rotation, gently allow knee to fall medially and then return to extended position
Chapmans Tender points:
OMM 16/17- Hip and Pelvis
Tender points
OMM 16/17- Hip and Pelvis
Muscle Energy
A direct technique, patient is positioned toward the restrictive barrier, pt voluntarily moves body against DO resist
Most useful in subacute to chronic conditions, where muscle shortening & fibrosis may be present.
Isometric muscle energy techniques primarily reduce the tone in hypertonic muscle & reestablish its normal resting
length. Shortened & hypertonic muscles are frequently identified as the major component of restricted motion
of an articulation or group of articulations.
Afferents from Golgi tendon receptors and gamma afferents from spindle receptors feed back to the cord; gamma
efferents return to the intrafusal fibers resetting their resting length, and this changes the resting length of the
extrafusal fibers of the muscle. There is a slight delay after the muscle isometric contraction before it can be
taken to a new resting length.
When an agonist muscle contracts & shortens, its antagonist must relax and lengthen. Contraction of agonist
reciprocally inhibits its antagonist allowing smooth motion.
OMM 16/17- Hip and Pelvis
Muscle Energy: Considerations
1. Physician positions bone, joint, or muscle to be treated at feather’s edge of restrictive barrier (point of initial
resistance) in all 3 planes of motion
2. Patient contracts muscle in specific direction against physician’s isometric counterforce for 3-5 seconds. D.O.
senses that contractile force is localized to the particular area being treated.
3. Physician asks pt to relax
4. Wait 1-5 seconds for pt to completely relax, reposition to new restrictive barrier
5. Repeat steps 1-4 three to seven times, depending on circumstances.
6. Physician rechecks
Don’t use too much or too little force, do not contact too long or too little, ALWAYS recheck
Use before HVLA to better engage the barrier
Patients may feel soreness within 12-36 hours because of increase in CO2, lactic acid, metabolic waste
Hip
Agonist
Abductors
Flexors
Interal Rotators
Antagonist
Adductors
Extensors
External Rotators
Hip can move in all planes of motion:
sagittal plane  transverse axis = flexion, extension
longitudinal (frontal or coronal) plane  AP axis = abduction, adduction
transverse (horizontal) plane  longitudinal (vertical) axis = internal & external rotation