Therapy Exercises for the Hip

Exercise Techniques

Therapy exercises for specific disorders

Iliopsoas bursitis

A rehabilitation program for the iliopsoas syndrome with hip rotation (to increase mobility), strengthening ( of the hip muscles) and stretching exercises is aiming to improve pain and functioning of patients with this syndrome.[1] (Level of evidence: 2b)

First two weeks of the program

1. The internal rotation hip strengthening exercise

The patient needs to be in a sitting position. An elastic resistance strap is used to do this exercise. The patient is sitting on the table. The elastic resistance strap is attached to the table leg 10 cm above the ground. The other side of the resistance strap is attached around the foot of the patient’s affected hip. The patient performs an internal rotation. The patient should perform three sets of 20 repetitions on both the affected and unaffected side. When the strength test reveals that the affected side is weaker than the unaffected side, then the number of sets on the unaffected side needs to be reduced to two sets of 20 repetitions instead of three sets. Patients can experience fatigue in the posterolateral hip region when they are performing the internal hip rotation exercise. The internal rotation strengthening exercise needs to be performed daily and only on the affected side for two weeks. After two weeks the exercises will change to incorporate a more functional position for the hip joint.

Internal rotation .jpg


2. The external rotation hip strengthening exercise.

Same position as internal rotation but now the patient performs an external rotation. The strap is used to stabilize the thigh to prevent sagittal and frontal plane hip motion. This exercise can be used for the patellofemoral pain syndrome( See PFP).[2](Level of evidence: 2b). The patient should perform three sets of 20 repetitions on both the affected and unaffected side. When the strength test reveals that the affected side is weaker than the unaffected side, then the number of sets of the unaffected side needs to be reduced to two sets of 20 repetitions instead of three sets. Patients can experience fatigue in the anteromedial hip region when they are performing the external hip rotation. After two weeks of the strengthening program we do another exercise for two weeks.
External 2.png

3. The side-lying abduction/external rotation exercise

The patient lies on the table on his/her side with the hip in approximately 45 degrees of flexion (the elastic resistance strap surrounds the knees).The patient performs an abduction with his upper leg. He slowly lowers his leg: at this point the hip abductors contract eccentrically. [3] The patient should perform this exercise three sets of 20 repetitions on the affected side and two sets of 20 repetitions on the unaffected side. The side-lying abduction exercise should be performed daily for 2 weeks. The initial internal and external exercises in sitting positions should be continued during this stage at a frequency of two or three times a week. At the one month stage: the final progression of the strengthening program

Abductie.jpg
4. Weightbearing hip strengthening exercise

The patient is standing against the wall on one leg. The patient bears his weight on the affected side en he/she performs a series of mini-squats. The patient should maintain the external rotation of the affected hip so that the hip remains over the lateral portion of the foot/leg which is bearing the weight. This exercise should be performed two or three times a week with three sets of 20 repetitions on the affected side and two sets of 20 repetitions on the unaffected side.

Mini squat.jpg

5. Stretching program

The patients need to stretch daily. The main stretches are: stretching of the hip flexor, the quadriceps, the lateral hip/piriformis and the hamstring muscles. The patients should perform more stretches on the affected side than on the unaffected side. They have to repeat them as often as they can throughout the day. They should keep stretching their muscles as long as they’re in pain.

Hip flexor stretch.jpgQuadricepsstretch.jpgHamstring stretch.png Piriformis syndrome

Hip muscle Strengthening exercises and movement re-education(4) In its case report, Tonley et al. describes an alternative treatment approach for piriformis syndrome. The intervention focused on functional exercises aimed at strengthening the hip extensors, abductors and external rotators, as well as the correction of faulty movement patterns. Despite positive outcomes (full resolution of low back pain, cessation of buttock and thigh pain) in this case report, care must be taken in establishing cause and effect based on a single patient. Further investigation is needed to extrapolate the outcomes to other patients with piriformis syndrome. The patient in this article followed physical therapy 8 times over a 3-month period. The exercises are divided over 3 phases. 9


1. Phase 1 (week 0-4): non-weight-bearing exercises to accentuate isolated muscle recruitment

1) Bridge with Thera-band resistance

  • Wrap Thera- band around the thighs just proximal to the knee.
  • Supine position + flexion of the knees and hip
  • Elevate the pelvis, with in the meantime abduction and external rotation of the hips.
  • It’s important to avoid adduction and internal rotation while lowering the hip.
  • 3 sets of 15 repetitions

2) Clamshells with thera-band resistance

  • Sidelying, flexion of hip and knee in 45°, holding feet together
  • Raise knees up and back + hip abduction and external rotation
  • Use theraband as resistance if patient is able to perform 3 sets of 15 repetitions without resistance.
  • 3 sets of 15 repetitions

2. Phase 2 (week 4-9): Weight-bearing strengthening exercises

1) Squat with Thera-band resistance

  • Wrap Thera-band around the thighs just proximal to the knee.
  • Execute a squat maneuver to a dept of 45° (later 75°) with back s
  • 3 sets of 15 repetitions

2) Side-step with Thera-band resistance

  • Wrap Thera-band around the thighs just proximal to the knee
  • Squat position, 45° hip and knee flexion
  • Take steps to the right and the left along a 10-m walk-away, abduct and external rotate the hips
  • Keep trunk erect during the exercise
  • Avoid knees over toes
  • 3 sets of 15 repetitions

3) Single-limb sit to stand

  • Sit on a treatment table (start at 70 cm)
  • Squat position
  • Stand up and control hip motions and keep alignment of lower extremity in frontal and transverse planes during the exercise
  • Progress by lowering the surface in 4 cm increments., double-limbed to single-limbed
  • 3 sets of 15 repetitions

4) Step Down

  • Stand on a 20 cm high step stool
  • Touch the heel to the ground and return slowly to the start position over a 3-second period
  • Control hip motions and keep alignment of lower extremity in frontal and transverse planes during the descending and ascending
  • Perform with contralateral upper extremity support first, later without support (if patient is able to execute 3 sets of 15 repetitions with control of hip motions)

3. Phase 3 (week 9-14): Functional Training, namely dynamic and ballistic training

1) Forward lunge

  • The lead knee is flexed to a dept of 75°
  • Don’t pass the knee beyond the foot
  • Keep alignment femur in frontal and transverse planes during the exercise
  • 3 sets of 15 repetitions

2) Lateral Lunge at 45°

  • The lead knee is flexed to a dept of 75°
  • Don’t pass the knee beyond the foot
  • Keep alignment femur in frontal and transverse planes during the exercise
  • 3 sets of 15 repetitions

3) Double limb take-off jumps with double-limb landings

  • Perform maximal effort double-limb take –off jumps to double-limb landings to a deep squat, with flexion of the knee (90°) , without hip adduction or internal rotation
  • Control hip motions and keep alignment of lower extremity in frontal and transverse planes
  • 3 sets of 15 repetitions

4) Double limb take-off jumps with single-limb landings

  • Perform maximal effort double-limb take –off jumps to single limb landings, with flexion of the knee (90°) , without hip adduction or internal rotation
  • Control hip motions and keep alignment of lower extremity in frontal and transverse planes
  • 3 sets of 15 repetitions

Therapy exercises to improve several functions

Strength

  1. Pelvicdrop[4][5](Level of evidence: 2c )

This is a simple exercise to improve the strength in the gluteal muscles. By training these muscles, you will be able to prevent not only hip problems, but also back or knee problems. Moreover, you can maintain appropriate functional mobility. [6]

Stand on a step stool. Hang one leg off the step and keep your abdominals tight and your pelvis horizontal. Let this leg slowly fall towards the ground by allowing your pelvis to slowly drop down. Drop your pelvis down as far as possible (your foot may not touch the ground) and hold this position for two seconds. After these two seconds, raise your pelvis up by using the hip muscles in your support leg. Repeat this exercise a few times (10-15). If it becomes easy to perform, you can hold a dumbbell to add resistance. During the execution of this exercise it’s important to hold you’re back straight and your abdominals tight. Your support leg should also remain straight.

Pelvic drop.png

Agility

1. Hamstrings

This exercise is to stretch the hamstrings. You can use this with shortened or stiff hamstrings.

Straight leg raise test: The patient lays on his back in front of a wall. The hip is in neutral position (the hip angle can vary).
Then he/she places his heel against the wall. The passive tension is applied by gradually increasing the hip flexion angle [7](Level of evidence: 1b) The patient holds his leg, without moving, during 10 seconds in the air against the wall. After the 10 seconds, the patient needs to bring his leg slowly to the floor. The patient repeats this exercise 4 x 10 seconds. Remark! The patient needs to stop raising the leg when his pelvic rotates. It’s a kind of compensation.The value can be measured with three instruments: Goniometer, flexometer and tape measure. [8](Level of evidence: 4) This exercise can also be performed as a passive exercise. The patient needs to lay on a table. The hip needs to be extended 180°. Now it’s the therapist who raises the leg from the patient, as high as he can. (without compensation! Without pain!) Duration: The therapist holds the leg in the air for 10 seconds and repeats this 4 times.

Slr.png

Tonley JC et al [9], who had an alternate theory about the cause of piriformis syndrome (see etiology piriformis syndrome), described an alternative treatment approach for piriformis syndrome. The patient in this article followed physical therapy 8 times over a 3-month period. The program was concentrated on strengthening the hip extensors, abductors and external rotators, as well as movement reeducation. The exercises were divided over 3 phases. [9]

The first phase (week 0-4) contained non-weight-bearing exercises to accentuate isolated muscle recruitment. This phase included two exercises, namely ‘bridge with Thera–band resistance’ and ‘clam with thera–band resistance’. The bilateral bridge (figure 4A) was executed with the Thera- band, that was wrapped around his thighs just proximal to the knee. The patient must elevate his pelvis, with in the meantime abduction and external rotation of his hips. It’s important to avoid adduction and internal rotation while lowering the hip. The clam exercise (figure 4B) was performed in sidelying, first without resistance. The point of departure contains flexion of hip and knee in 45° with holding his feet together. Then the patient raises his knee up and back, which was accomplished by hip abduction and external rotation. After a while , the Thera-Band was used as resistance during exercise. On one condition, that the patient must be able to perform 3 sets of 15 repetitions of the exercise without resistance. [9]

Phase 2 (week 4-9) contains weight – Bearing strengthening exercises. The patient started initially with double-limb weight-bearing exercises. Afterwards the patient performed single-limb movements to multiply the demands on the hip musculature. This phase included four exercises. The first exercise was a squat maneuver (figure 5A) performed with the thera–band resistance, which was applied around the thighs just proximal to the knees. The squat was first executed to a depth of 45° and later on to 75 °. During the second exercise the patient performed a sidestepping exercise with Thera-Band (figure 5B). The patient began the exercise in a squat position of 45° of hip and knee flexion. Subsequently he took steps to the right and the left along a 10-m walk-way by abducting and externally rotating his hips. It is important to keep the trunk erect during exercise and to avoid knees over toes. The next exercise, named single – limb sit to stand, was executed in a manner similar to the squat (figure 5C). The patient performed the exercise first from a 70-cm (measured from the floor to the top of a treatment table) high surface and finally when he could execute 3 sets of 15 repetitions, the height was each time reduced with 4 cm, to a final height of 58 cm. The last exercise called the step-up/step-down exercise (figure 5D). The patient used a 20-cm-high step stool. The exercise was performed by touching his heel to the ground and returning slowly to the start position over a 3- second period. First the patient had contralateral upper extremity support. This support was removed when the patient was able to control his hip motions and to perform 3 sets of 15 repetitions.[9]

Phase 3 (week 9-14) consisted of Functional Training, namely dynamic and ballistic training. This phase includes 4 exercises. The progression in this phase was achieved by increasing the rate of speed during exercises. Initially the patient performed forward lunges (figure 6A) and later he progressed to lateral lunges (figure 6B), to the left and the right at a 45° angle. The lead knee is flexed to a depth of 75 °. It’s not permitted to pass the knee beyond the foot. When the patient was capable to demonstrate 3 sets of 15 repetitions, he progressed to the lateral lunges. The third exercise were double-limb take –off jumps with double-limb landings to a deep squat, with flexion of the knee (90°) , without hip adduction or internal rotation(figure 6C). The fourth and last exercise included also the double-limb take-off jumps, but now right and left single-limb landings. (figure 6D) Excessive hip adduction or internal rotation are still not allowed. [9]

In this document you can find some photos for every phase : File:Images exercises hip phase 1,2,3.doc

References

  1. 1. C. A. M. johnston, D. M. (1999). Treatment of lliopsoas Syndrome with a Hip Rotation Strengthening Program: A Retrospective Case Series. Journal of Orthopaedic & Sports Physical Therapy , pp. 218-224. Level of evidence: 2b
  2. 2. KHALIL KHAYAMBASHI, Z. M. (2012, January). The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial. journal of orthopaedic & sports physical therapy , pp. 22-29. Level of evidence: 2b
  3. 3. Nugteren, K. v. (2007). Addendum: tendinose van heupabductoren als oorzaak van het trochanter major pijnsyndroom. In D. W. Koos van Nugteren, Onderzoek en behandeling van de heup (p. 82). Houten: Bohn Stafleu van Loghum.
  4. 4. Kristen Boren, C. C. (2011, September). ELECTROMYOGRAPHIC ANALYSIS OF GLUTEUS MEDIUS AND GLUTEUS MAXIMUS DURING REHABILITATION EXERCISES. The International Journal of Sports Physical Therapy , pp. 206-223. Level of evidence: 2c
  5. 5. Kieran O'Sullivan, S. M. (2010). Electromyographic analysis of the three subdivisions of gluteus medius during weight-bearing exercises. Sports medicine arthroscopy, rehabilitation therapy technology . Level of evidence: 2c
  6. 6. Sears, B. (2012, Juli 2). www.physicaltherapyabout.com. Opgeroepen op November 2012, van www.about.com: http://physicaltherapy.about.com/od/strengtheningexercises/ss/Pelvic-drop_3.htm
  7. 7. JO M. FASEN, A. M. (2009, Maart). A RANDOMIZED CONTROLLED TRIAL OF HAMSTRING fckLRSTRETCHING: COMPARISON OF FOUR TECHNIQUES. the Journal of Strength and Conditioning fckLRResearch , pp. 660-667. Level of evidence: 1b
  8. 8. Chang-Yu Hsieh, J. M. (1983). Straight-Leg-Raising Test : Comparison of Three Instruments. Journal of the American Physical Therapy Association , pp. 1429-1433. Level of evidence: 4
  9. 9.0 9.1 9.2 9.3 9.4 Tonley JC, Yun SM et al. Treatment of an Individual With Piriformis syndrome Focusing on Hip Muscle Strengthening and Movement Reeducation : A case report. Journal of Orthopaedic Sports Physical Therapy 2010; 40(2): 103-111.