Hip Clinical Pearls: #4
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Clinical Pearl 4: Exercise Selection: Exercises Which Should Help But Don’t. Why?
In this next series of information related to the hip, peruse through the information to see if you can relate. Here is an example. Knee pain is present, and upon seeking an assessment, you are informed it is coming from weakness in your hip. Multiple studies show that knee pain is related to the outer hip muscle (your gluteus medius) being weak. Your Physical Therapist will give you clamshells, side leg lifts and side stepping with a band, for example, to address weakness in this area. You are informed these exercises will strengthen the hip, and help control your knee from excessively rolling inward, placing less abnormal stress on the knee itself, thus lessening your pain. Sometimes, exercises like these may be all you need to help rectify your painful issue. On occasion, these same exercises may increase pain or make an issue worse. The body should tell the individual to stop the exercises. If exercises feel like they worsen an issue, when they should be helping, why is that? Identifying not only the strength of muscles on the outside of your hip, but also muscle activation and flexibility of supporting musculature around the entire hip is important. Helping to identify insufficiencies in some key muscles at the hip helps in the overall game plan. And, if someone strengthens muscles in one plane or overloads a muscle with strengthening beyond its available capability, this could negatively affect an outcome.
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CONSIDERATIONS WITH EXERCISE CHOICE:
The choice of exercises is very important in treatment of the hip, and they are not a “one size fits all”. If you recall, we discussed the hip moving in three planes. Insufficient muscle function on one side of the joint will be related to overuse/tightness on the other side of the joint. Thus, stretching what feels tight and hoping this addresses an issue may do so for a short period of time. For example, it is common that persisting hip flexor tightness on the front of the hip, the muscles that move the thigh forward in space, will be related to insufficient gluteus maximus function on the back of the hip, muscles responsible for moving the thigh backward. Countering this tightness with improving the muscle function on the opposite side of the joint should be considered when treating this hip flexor tightness.
The choice of exercises is very important in treatment of the hip, and they are not a “one size fits all”. If you recall, we discussed the hip moving in three planes. Insufficient muscle function on one side of the joint will be related to overuse/tightness on the other side of the joint. Thus, stretching what feels tight and hoping this addresses an issue may do so for a short period of time. For example, it is common that persisting hip flexor tightness on the front of the hip, the muscles that move the thigh forward in space, will be related to insufficient gluteus maximus function on the back of the hip, muscles responsible for moving the thigh backward. Countering this tightness with improving the muscle function on the opposite side of the joint should be considered when treating this hip flexor tightness.
SUE'S VIEW ON FOUNDATION WORK:
I am known for not necessarily doing the same things as other Physical Therapists. I have seen numerous patients over the years who tell me that “I’ve done all the hip PT exercises, and they didn’t work.” Or, “I’ve done the clamshells and all the side steps I can do and they didn’t help.” Yes, I’ve heard it, and more. This information is helpful to know as I can potentially rule out some activities while I look toward other areas which haven’t been addressed to identify potentially contributing deficits. For example, someone may have a” functional assessment” by a physical therapist and demonstrate good strength in one plane but weakness in another plane. Then, rehab will be tailored to this “functional weakness”. Treating this perceived functional deficit on a larger scale may be too much for some patients. Due to persisting faulty movement patterns and persisting complaints, a more in depth assessment may be required to identify these deficits on a more rudimentary level.
If elementary level programming with muscle activation is lacking, a muscle will appear weak. If rehab focuses on higher level, gross motor function to address the weakness, this may be too high an intensity for certain muscles to adapt. This may contribute to unsuccessful rehab attempts. I believe this can be a major factor for perceived failure for rehab with individuals. In addition, anatomical issues such as a torn hip labrum or dysplasia can be a factor in one’s ability to address this elementary programming, especially if undiagnosed.
In summary, failure of your hip symptoms improving may be related to treating specific hip issues with generic exercises without proper monitoring of the efficacy of the exercises or performing too high a level of exercises for what your muscles can tolerate. These exercises may be prescribed by a physical therapist, personal trainer or chiropractor, to name a few. In addition, if you haven’t had an assessment of your hip, you may have underlying anatomical contributing factors to your unresolved pain. If progress isn’t achieved, don’t be afraid to seek another option or opinion. Remember, one size does not fit all!
One size does not fit all applies to symptom onset, which will be discussed in the Clinical Pearl #5
I am known for not necessarily doing the same things as other Physical Therapists. I have seen numerous patients over the years who tell me that “I’ve done all the hip PT exercises, and they didn’t work.” Or, “I’ve done the clamshells and all the side steps I can do and they didn’t help.” Yes, I’ve heard it, and more. This information is helpful to know as I can potentially rule out some activities while I look toward other areas which haven’t been addressed to identify potentially contributing deficits. For example, someone may have a” functional assessment” by a physical therapist and demonstrate good strength in one plane but weakness in another plane. Then, rehab will be tailored to this “functional weakness”. Treating this perceived functional deficit on a larger scale may be too much for some patients. Due to persisting faulty movement patterns and persisting complaints, a more in depth assessment may be required to identify these deficits on a more rudimentary level.
If elementary level programming with muscle activation is lacking, a muscle will appear weak. If rehab focuses on higher level, gross motor function to address the weakness, this may be too high an intensity for certain muscles to adapt. This may contribute to unsuccessful rehab attempts. I believe this can be a major factor for perceived failure for rehab with individuals. In addition, anatomical issues such as a torn hip labrum or dysplasia can be a factor in one’s ability to address this elementary programming, especially if undiagnosed.
In summary, failure of your hip symptoms improving may be related to treating specific hip issues with generic exercises without proper monitoring of the efficacy of the exercises or performing too high a level of exercises for what your muscles can tolerate. These exercises may be prescribed by a physical therapist, personal trainer or chiropractor, to name a few. In addition, if you haven’t had an assessment of your hip, you may have underlying anatomical contributing factors to your unresolved pain. If progress isn’t achieved, don’t be afraid to seek another option or opinion. Remember, one size does not fit all!
One size does not fit all applies to symptom onset, which will be discussed in the Clinical Pearl #5