Download ISHA Hip Gender PT FINAL (KE_9-1-2016).pptx

9/2/16 Disclosures
Hip Rehabilitation for Men and Women: Strategic Treatment Recommendations • 
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No personal disclosures/conflicts
No institutional disclosures/conflicts
ISHA 2016 – Advanced Hip Rehabilitation Symposium
Keelan R. Enseki, MS,PT,OCS,SCS,ATC,CSCS
Hip Rehabilitation Strategies for Men and Women
Hip Rehabilitation Strategies for Men and Women
•  Majority of research pertains to hip kinematics and
recruitment as it pertains to sex-differences for
rehabilitation in the knee injury population
•  Minimal data available for sex-differences specific
to the pathological hip population
•  Trends that have been observed in the non-arthritic
hip pain population (Harris-Hayes et al., 2014) have not
been well-delineated between males and females
•  Concern for conditions that have higher incidence
in one sex
•  Factors to consider
o  Anatomical variation
•  Bony
o  Pelvis
o  Femur
•  Pelvic musculature
o  Kinematic differences
o  Muscle recruitment differences
o  Pelvic floor conditions
•  Male/Female
o  Urinary & bowel
o  Sexual dysfunction
•  Postpartum
o  Dysplasia (F>M)
o  Pelvic floor dysfunction (different underlying causes in women vs. men)
o  Birth related/post-partum
Kinematic Differences
Anatomical Variations
•  Adult pelvic structure variation to accommodate
delivery for females
o  Relatively wider
o  Structurally more round
•  Morphological differences(Köhnlein W et al., 2009;
Nakahara et al., 2011)
o  Acetabular surface area
•  Women < Men
o  Acetabular anteversion
•  Women > Men
o  Femoral anteversion
•  Women > Men
o  Q Angle
•  Women > Men
•  Rehabilitation implications
•  Although anatomical trends have been described, the observed
differences currently have minimal impact on specific rehabilitation
considerations when considered in isolation
•  Overall, female athletes moved into greater hip
internal rotation and used less sagittal plane hip
motion during the early deceleration phase of a
cutting maneuver (Pollard et al., 2007)
•  Women had larger peak extension angles across
numerous single leg exercises and smaller peak hip
flexion angles with single leg squat tasks (Dwyer et al.,
2010)
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Rehabilitation implications
o  Males and females appear to have different hip kinematics with various
exercise tasks
o  The utility of available information is limited due to testing of uninjured
subjects and/or original intention to apply majority of data to knee
population
o  Expansion of testing to subjects with hip injuries is necessary
1 9/2/16 Strength and EMG Data
•  Mean root-mean-square amplitudes for gluteus
maximus and rectus femoris muscles in both the
concentric and eccentric phases of 3 exercises
were greater for women than for men (Dwyer et al.,
2010)
•  “Trunk and hip electromyographic activity during
single leg squat exercises do sex differences
exist?”(Bolgla et al., IJSPT, 2014)
o  Females generated moderate (39% greater MVIC vs.
males) EMG activity (neuromuscular education/
endurance)
o  Males generated low EMG activity (likely no therapeutic
effect)
•  Rehabilitation implications
o  Healthy females and males appear to recruit differently
o  Injured population?
o  External resistance may be necessary for progressive gluteus medius
strengthening, particularly in males
Pelvic Floor Concerns
•  Male or females
o  Female cases better and more
frequently described in the
literature
•  Unique conditions/events
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Pregnancy/delivery
Urinary & bowel issues
Sexual dysfunction
Organ prolapse
Hypertonicity
•  Pelvic floor rehabilitation
specialists
•  Rehabilitation implications
o  Concurrent or primary pelvic floor
rehabilitation can play an
important role in treating
individuals with hip pain
o  Screening is integral
•  Internal examination?
Summary of Rehabilitation Recommendations
Interaction of Hip Strength and Joint Kinematics
•  Men demonstrated greater
hip abductor peak torque
when landing from a jump
(Jacobs et al., 2007)
•  Correlations between hip
abductor strength and
landing kinematics were
generally larger for women
than for men (Jacobs et al. 2007)
•  Rehabilitation implications
o  Consider the potential effect of
decreased hip abductor
strength on single leg landing
tasks
o  Consider strength testing as
part of advancement criteria
Postpartum Considerations
•  Points of Consideration
o  Hormonal changes
•  Increased joint laxity
•  Breastfeeding may extend this period of induced mobility
o  Anthropometric changes that occurred during and after pregnancy
o  Deconditioning
o  Compromise of lumbopelvic muscle integrity through delivery or c-section
•  Clinical Recommendations
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Focus on proximal strength
Lumbopelvic/core stabilization
Neuromuscular re-education
General endurance
Pelvic floor specialty consultation if indicated
•  Rehabilitation implications
o  The presence of joint pathology (labral,capsular,etc.) and physiological/
structural changes associated with childbirth create a unique
rehabilitation challenge
o  Integrated treatment approach should be considered
Thank You
•  The general approach to strengthening and other
rehabilitation activities (volume, frequency, etc.) should
not be prescribed differently based upon sex
•  Specific recommendations (exercise selection) may be
made based upon limited movement and recruitment
data
•  Kinematic data may indicate sex-specific usefulness of
specific exercises
o  Consider incorporating single-leg squat, lunge, and step-up-and-over exercises in
rehabilitation program to enhance pelvic control
o  Hip abductor strength is important for men and women; however, deficits may
result in more significant kinematic differences for females
•  Other associated factors may be considered: specific
pathology/conditions, pre-injury physical status, patientgoals, etc.
•  Further study and clarification required
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Bolgla L, Cook N, Hogarth K, Scott J, West C. Trunk and hip electromyographic
activity during single leg squat exercises do sex differences exist? Int J Sports Phys
Ther. 2014 Nov;9(6):756-764.
Dwyer MK, Boudreau SN, Mattacola CG, Uhl TL, Lattermann C. Comparison of
Lower Extremity Kinematics and Hip Muscle Activation During Rehabilitation Tasks
Between Sexes. Journal of Athletic Training. 2010;45(2):181-190.
Harris-Hayes M, Mueller MJ, Sahrmann SA, et al. Persons with Chronic Hip Joint Pain
Exhibit Reduced Hip Muscle Strength. The Journal of Orthopaedic and Sports
Physical Therapy. 2014;44(11):890-898.
Howard JS, Fazio MA, Mattacola CG, Uhl TL, Jacobs CA. Structure, Sex, and
Strength and Knee and Hip Kinematics During Landing. Journal of Athletic Training.
2011;46(4):376-385.
Jacobs CA, Uhl TL, Mattacola CG, Shapiro R, Rayens WS. Hip Abductor Function
and Lower Extremity Landing Kinematics: Sex Differences. Journal of Athletic
Training. 2007;42(1):76-83.
Köhnlein W, Ganz R, Impellizzeri FM, Leunig M. Acetabular Morphology: Implications
for Joint-preserving Surgery. Clinical Orthopaedics and Related Research.
2009;467(3):682-691.
Nakahara I, Takao M, Sakai T, Nishii T, Yoshikawa H, Sugano N. Gender differences in
3D morphology and bony impingement of human hips. J Orthop Res. 2011 Mar;
29(3):333-339.
Pollard CD, Sigward SM, Powers CM. Gender differences in hip joint kinematics and
kinetics during side-step cutting maneuver. Clin J Sport Med. 2007 Jan;17(1):38-42.
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