Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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I currently present an on demand and live webinar intended for physical therapists through Allied Health Education (www.alliedhealthed.com) on femoroacetabular impingement (FAI) regarding the recognition of this condition and current treatment principles. Currently, I see on average 3-5 new patients per month with acetabular labral tears and/or those recovering from hip arthroscopy for this issue. As such, I am always staying abreast of the current literature on it.
There is a new research design study that was just published in the August 2014 edition of the Journal of Orthopaedic & Sports Physical Therapy regarding hip pain as it relates to these patients. Specifically, the authors point out that some but not all of the hip pain may be attributed to intra-articular pathology. They suggest that extra-articular contributions from soft tissue (or myofascial pain) may account for hip pain thereby making the diagnosis and assessment of these patients even more complex.
The authors raise some interesting questions about lingering posterolateral hip pain that does not respond to injections or arthroscopy at all. Further, they assert that these patients may have more than one source of hip pain, as well as the possibility that the true source of the pain may not be related to the labrum at all. based on their experience they find that taut and tender gluteal, external rotator and tensor fascia latae (TFL) muscles are present in people with acetabular labral tears who also present with posterolateral hip pain. Previous research has identified myofascial taut bands or nodules as sources of such pain.
Weakness in the gluteus maximus and gluteus medius is often cited in contributing to patellofemoral pain, IT band problems, hip pathology and even back pain. Furthermore, activating the glutes and minimizing tensor fascia lata (TFL) activation is preferential to avoid synergistic dominance with abduction exercises. This is a common finding on my clinical exams.
Photo from Myers
In the February 2013 issue of the Journal of Orthopaedic and Sports Physical Therapy (JOSPT), Selkowitz et al. examined several exercises to determine which ones had the highest gluteal-to-TFL muscle activation (GTA) index. The clam exercise proved to be the best with an index value of 115. The second highest exercise was a sidestep with elastic resistance with a value of 64.
The other three exercises to score a GTA index of 50 or higher were: Unilateral bridge (59), quadruped hip extension w/knee extended (50) and quadruped hip extension with knee flexed (50). Below is the clam executed against a wall as described in the study referenced.
Clam with resistance
Additional research done by Wilcox and Burden (published in the May issue of JOSPT) suggests that a neutral spine alignment and 60 degrees of hip flexion is the best position for gluteal activation during the clam. This study was done without resistance but offers additional insight to positioning. I try to mimic this hip flexion angle in the standing single and double leg versions I employ with mini-bands as part of my gluteal activation series in the clinic as well.
Single Leg ER (left)
In the Selkowitz study, participants performing the sidestep were instructed to step to the left replacing 50% of the distance between the feet in the start position and follow with the right leg also stepping at this 50% increment. This was then repeated to the right to return to the starting position for a total of 3 cycles.
This exercise has one of the lowest TFL activation and reinforces proper frontal plane mechanics and can be used with clients and athletes to reduce anterior knee pain and injury risk. To increase resistance and/or difficulty, bands can be moved to the ankles or a band can be applied above the knees and at the ankle. In my practice, I typically have clients sidestep for 10 yards in one direction (using the 50% rule) and then repeat moving back to the other side for 10 yards.
Sidestep
Another option is to perform the sidestep exercise with a staggered stance. For example, lead with the right leg forward moving to the right and vice versa. Again, small steps replacing 50% of the original stance is best to ensure quality work.
Staggered sidestep
For additional information on execution and application for these exercises, click on the links below for the online columns I wrote for Personal Fitness Professional Magazine:
Sidestep with elastic resistance
I utilize bridging as an assessment and exercise tool in my training and rehab programs. Posterior chain/hip stability is poor in many clients. The ability to maintain a neutral spine, engage the glutes and fight rotation is NOT an easy task by any means. So, coaching and cueing proper bridging is a great way to enhance pillar strength and reduce injury risk, while facilitating better movement patterns in sport.
I wrote a recent column for PFP magazine entitled iso bridge with alternate knee extension. Click here to read the column and the application, regression and progression of the exercise. In addition, I have included a short video below showing double leg and single leg bridge exercises that can be used to work on the hips and core. The second exercise is the dynamic version of the iso alternate knee extension bridge I write about. I show you some of the single leg progressions that come after mastering the iso bridge as well.
I hope this video and article is useful to you. I also want to take this opportunity to thank you for reading my blog and wish you a very Happy New Year!
I have been a bit behind on blogging as of late. I try to aim for one per week, but I also strive to deliver sound and relevant content. Additionally, I do not seek outside contributors so finding time to write can be tricky with work and family life too. So, forgive me for any apparent inconsistency in posting. Just know that I will always try to provide valuable content. Today’s post centers around an article in the July 2012 edition of AJSM.
My work at the Athletic Performance Center has provided me an increased opportunity to work with FAI and athletic hip injuries. This is an area of evolution and growth in our field, so I find it particularly interesting to see rationale and thought processes centering around the timing, contribution and selection of hip exercises for active patients/athletes.
This article comes from the Steadman Philippon Research Institute in Vail, CO. The purpose of the study was to measure the highest activation of the piriformis and pectineus muscle during various exercises. The hypothesis was that highest pectineus activation would occur with hip flexion and moderate activity with internal rotation, whereas the highest activation with the piriformis would be with external rotation and/or abduction.
Methods: 10 healthy volunteers completed the following 13 exercises:
- Standing stool hip rotation
- Supine double leg bridge
- Supine single leg bridge
- Supine hip flexion
- Side-lying hip ABD with external rotation
- Side-lying hip ABD with internal rotation
- Side-lying hip ABD against a wall
- Hip clam exercise with hips in 45 degrees of flexion
- Hip clam exercise with hips in neutral
- Prone heel squeeze
- Prone resisted terminal knee extension
- Prone resisted knee flexion
- Prone resisted hip extension
All of these exercises have been reported to be used in hip rehab following arthroscopy or recovery from injury. The exercises were executed slowly and methodically with a metronome to reduce EMG amplitude variations.
There seems to be consistent questions, debate and studies done with respect to stretching. As the thought of more closely analyzing the quality of movement (FMS, Y-Balance testing, SFMA for example) moves to the forefront in the PT and fitness world, many search for the right mix of exercise to maximize mobility.
I count myself as a supporter and follower of the work of Gray Cook and Stuart McGill. While I may not agree 100% with all of their ideas, I generally consider them to be brilliant minds and ahead of the curve. I have been using the FMS in my practice for some time now and have also begun to incorporate Y-Balance testing as well (see pic below courtesy of the IJSPT)
The Y-Balance test may not have significant relevance to hip mobility as much as it does limb symmetry, but I included it here to illustrate my point in observing kinetic chain movement to help determine where the weak link or faulty movement pattern may be. It gives us valuable information with respect to strength, balance and mobility.
With the revelation that FAI is more prevalent than we knew (click here for my post on FAI), I am always interested in hip mobility and how to increase movement in the hip joint. Limitations in hip mobility can spell serious trouble for the lumbosacral region as well as the knee.
I currently use foam rolling, manual techniques, dynamic warm-up maneuvers, bodyweight single leg and hip/core disassociation exercises and static stretching to increase hip mobility. However, I am often faced with the question of what works best? Is less more? How can I make the greatest change without adding extra work and unnecessary steps?
Well, Stuart McGill and Janice Moreside just published a study in the May 2012 Journal of Strength & Conditioning Research that sought to examine three different interventions and how they improve hip joint range of motion. Previous work has been focused on the hip joint alone, and they wanted to see how other interventions impacted the mobility of the hip. Click here for the abstract
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