Many joint surgeries are available to treat early- and late-stage joint disease of the hip and some fractures that compromise the vascular supply to the head of the femur. As a result of advances in arthroscopy of the hip over the past decade, small to medium-size full-thickness lesions of the articular cartilage of the acetabulum […]

As healing progresses and symptoms subside, the emphasis of management includes the following goals and interventions.
Progressively Increase Joint Play and Soft Tissue Mobility
Joint mobilization techniques. Progress joint mobilization to stretch grades (grade III sustained or grade III and IV oscillation) using the glides that stretch restricting capsular tissue at the end of the available ROM. […]

In conjunction with medical management of the disease for inflammation and pain, correction of faulty mechanics is an integral part of decreasing pain in the hip. Faulty hip mechanics may be caused by conditions such as obesity, leg-length differences, muscle length and strength imbalances, sacroiliac dysfunction, poor posture, or injury to other joints in the […]

To make sound clinical decisions when treating patients with hip disorders, it is necessary to understand the various pathologies, surgical procedures, and associated precautions and identify presenting impairments, functional limitations, and possible disabilities. Conservative and postoperative management of these conditions is also described in this section.
Joint Hypomobility: Nonoperative Management

Osteoarthritis (Degenerative Joint Disease)
Osteoarthritis is the most […]

The hip is innervated primarily from the L3 spinal level; hip joint irritation is usually felt along the L3 dermatome reference from the groin, down the front of the thigh to the knee.
Major Nerves Subject to Injury or Entrapment
Sciatic nerve. Entrapment may occur when the sciatic nerve passes deep to the piriformis muscle (occasionally it […]

During the normal gait cycle, the hip goes through a ROM of 40° of flexion and extension (10° extension at terminal stance to 30° flexion at midswing and initial contact). There is also some lateral pelvic tilt and hip abduction/adduction of 15° (10° adduction at initial contact, 5° abduction at initial swing); and hip internal/external […]

General Symptoms from Trauma

Often more than one tissue is injured as a result of trauma. The extent of the tissue involvement may not be detectable during the acute phase.
• There is pain, localized swelling, tenderness on palpation, and protective muscle guarding regardless of whether the injured tissue is inert or contractile. Muscle guarding serves the […]

Facet Joint Characteristics
Facet joints are synovial articulations that are enclosed in a capsule and supported by ligaments; they respond to trauma and arthritic changes similar to any peripheral joint.
Various types of meniscoid-like structures or invaginations of the facet capsules are present in the zygapophyseal joints of the spine. They are synovial reflections containing fat and […]

Anterior Pelvic Tilt Posture
• Short TFL and IT band
• General limitation of hip external rotation
• Weak, stretched posterior portion of the gluteus medius and piriformis
• Excessive medial rotation of the femur during the first half of stance phase of gait with increased stresses on the medial structures of the knee
• Associated lower extremity compensations including […]

Three-Joint Complex
The disk and facets make up a three-joint complex between two adjoining vertebrae and are biomechanically interrelated. Asymmetrical disk injury affects the kinematics of the entire unit plus the joints above and below, resulting in asymmetrical movements of the facets, abnormal stresses, and eventually cartilage degeneration. As the disk degenerates, there is a decrease […]

Muscles function through habit. Faulty mechanics from inadequate or excessive length and an imbalance in strength cause hip, knee, or back pain. Overuse syndromes, soft tissue stress, and joint pain develop in response to continued abnormal stresses.
Common muscle length-strength imbalances include the following.
• Shortened iliotibial (IT) band with shortened tensor fasciae latae (TFL) or […]

Etiology of Symptoms
The disk is largely aneural; therefore not all disk protrusions are symptomatic.
Pain. Symptoms of pain arise from pressure of a swollen disk or swollen tissues against pain-sensitive structures (ligaments, dura mater, blood vessels around nerve roots) or from the chemical irritants of inflammation if there is herniated disk material.
Neurological signs and symptoms. Neurological […]

Common impairments exhibited by patients during the acute and subacute stages of soft tissue healing and the initial phase of postoperative rehabilitation after THA are pain secondary to the surgical procedure, decreased ROM, muscle guarding and weakness, impaired postural stability and balance, and diminished functional mobility (transfers and ambulation activities). Depending on the type of […]

Injury and Degeneration of the Disk

Definitions
Various authors have defined the terms herniation, protrusion, prolapse, and extrusion differently. The following definitions are used in this text.
• Herniation: a general term used when there is any change in the shape of the annulus that causes it to bulge beyond its normal perimeter.
• Protrusion: nuclear material is contained […]

Abnormal structure or impaired function of the hip—such as a leg-length discrepancy, decreased flexibility, or muscle imbalances—can contribute to stress in the spine or other joints of the lower extremities.
Decreased Flexibility
Decreased flexibility in the structures around the hip joint cause weight-bearing forces and movement to be transmitted to the spine rather than absorbed in the […]

Disk herniation, tissue fluid stasis, diskogenic pain, and swelling from inflammation are conditions that may result from prolonged flexion postures, repetitive flexion microtrauma, or traumatic flexion injuries. Initially, symptoms may be exacerbated when attempting extension but then may be decreased when using carefully controlled extension motions. Several studies have documented that patients with a herniated […]

Pelvic Motions and Muscle Function
The pelvis is the connecting link between the spine and lower extremities. Movement of the pelvis causes motion at the hip joints and lumbar spine articulations. The hip musculature causes pelvic motion through reverse action. Hip flexors cause an anterior pelvic tilt; hip extensors, a posterior pelvic tilt; and abductors and […]

Motions of the Spinal Column
Motion of the spinal column is described both globally and at the functional unit or motion segment. The functional unit is comprised of two vertebrae and the joints in between (typically, two zygapophyseal facet joints and one intervertebral disk). Generally, the axis of motion for each unit is in the nucleus […]

The joint capsule is richly supplied with mechanoreceptors that respond to variations in position, stress, and movement for control of posture, balance, and movement. Reflex muscle contractions of the entire kinematic chain, known as balance strategies, occur in a predictable sequence when standing balance is disturbed and regained. Joint pathologies, restricted motion, or muscle weakness […]

Range of motion ( ROM / ROME ) is a basic technique used for the examination of movement and for initiating movement into a program of therapeutic intervention. Movement that is necessary to accomplish functional activities can be viewed, in its simplest form, as muscles or external forces moving bones in various patterns or ranges […]

Characteristics
The hip is a ball-and-socket (spheroidal) triaxial joint made up of the head of the femur and acetabulum of the pelvis. It is supported by a strong articular capsule that is reinforced by the iliofemoral, pubofemoral, and ischiofemoral ligaments. The two hip joints are linked to each other through the bony pelvis and to the […]

The hip is often compared with the shoulder in that it is a triaxial joint, able to function in all three planes, and that it is also the proximal link to its extremity. In contrast to the shoulder, which is designed for mobility, the hip is a stable joint, constructed for weight bearing. However, to […]

The head, neck, thorax, lumbar spine, and pelvis are all interrelated; and deviations in one region affect the other areas. In this section, the lumbopelvic and cervicothoracic regions and typical muscle length-strength impairments for each region are described separately for clarity of presentation.Pelvic and Lumbar Region
Lordotic Posture
Lordotic posture is characterized by an increase in the […]

In theory, treating impairments and functional limitations related to the tissues of the spinal column and trunk is the same as treating tissues of the extremities. The major complicating factor in the spine is the close proximity of key structures to the spinal cord and nerve roots. The challenge for the therapist is to recognize […]

Without adequate stabilization of the spine, contraction of the limb-girdle musculature transmits forces proximally and causes motions of the spine that place excessive stresses on spinal structures and the supporting soft tissue. For example, stabilization of the pelvis and lumbar spine by the abdominal muscles against the pull of the iliopsoas muscle is necessary during […]

Effect of Mechanical Stress
The ligaments, facet capsules, periosteum of the vertebrae, muscles, anterior dura mater, dural sleeves, epidural areolar adipose tissue, and walls of blood vessels are innervated and responsive to nociceptive stimuli. Mechanical stress to pain-sensitive structures, such as sustained stretch to ligaments or joint capsules or compression of blood vessels, causes distention or […]

The thoracolumbar fascia is an extensive fascial system in the back that consists of several layers. It surrounds the erector spinae, multifidi, and quadratus lumborum, thus providing support to these muscles when they contract. Increased bulk in these muscles increases tension in the fascia, perhaps contributing the stabilizing function of these muscles.
The aponeurosis of the […]

So long as the line of gravity from the center of mass falls within the base of support, a structure is stable. Stability is improved by lowering the center of gravity or increasing the base of support. In the upright position, the body is relatively unstable because it is a tall structure with a […]

Posture is a “position or attitude of the body, the relative arrangement of body parts for a specific activity, or a characteristic manner of bearing one’s body.” It is alignment of the body parts whether upright, sitting, or recumbent. It is described by the positions of the joints and body segments and also in terms […]

The clavicle articulates with the manubrium of the sternum to form the sternoclavicular joint (SC joint), the only direct skeletal connection between the upper extremity and the trunk. The sternal articulating surface is larger than the sternum, causing the clavicle to rise much higher than the sternum. A fibrocartilaginous disk is interposed between the two […]