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EVIDENCE INFORMED PRACTICE
Figure 2: The Trendelenburg
test is often used in the clinic to assess control of the pelvis on the femur in single-leg standing, so is
perhaps the most relevant test to lateral hip pain. With a positive test, as body
weight is taken through one leg, the pelvis dips
downwards away from the weight- bearing leg.
Figure 3: A compensated positive result occurs if the body is tilted (side flexed) towards the weight-bearing leg.
begin building the endurance of the hip stabilising muscles (phase I). Next, general hip and lumbo-pelvic alignment is enhanced with an emphasis on controlling the weight shift especially during single-leg standing (phase II). Finally, more sport-specific actions are used to build control of the hip in functional sports actions (phase III). Clinically there is much overlap between each rehab stage and the order of exercise application will be dictated by your client’s symptoms. Rehabilitation can focus on pain relief, lengthening tight
tissues that restrict correct movement, re-training muscle which is underperforming (strength / endurance / power), and enhancing whole body and segmental alignment. Where pain is a dominant feature its relief is vital as it will have a significant effect on the quality of movement. In many cases trigger points within a tight muscle may be a dominant feature in the production of pain, and so tightness is targeted in this case. Overload of tissues and / or joints can lead to inflammation and pain making posture the lead feature.
Targeting the ITB
Often with lateral hip pain, the ITB becomes the focus of attention (17). Stretching the ITB is a subject of considerable debate. As the band attaches directly to the femur via the intermuscular septa, lengthening it would seem impossible (18). However, clinically, patients with ITBS do respond to stretching exercises showing increased range of motion, reduced pain and an alteration in tissue tension to palpation. It is suggested, therefore, that the superficial portion has some independence from the deeper portions. An effective ITB stretch must combine movement in three regions: the pelvis, hip, and knee. In order to stretch the ITB, hip adduction and extension on a fixed pelvis must be combined with knee extension. Justification for this joint positioning is that ITBS occurs when the gluteus medius shows poor endurance, and single-leg standing is supported by action of the TFL. This muscle is overworked and develops painful trigger points. To limit the pelvis tipping laterally, the muscle tone increases and the muscle ‘shortens’, or more
Figure 4: A further modification of the test is to ask the client to elevate the non-weight-bearing side of the pelvis.
accurately becomes overactive in its outer range. As the TFL is placed anteriorly, a position of hip extension will stretch it. The ITB passes over the knee to attach into the head of the fibula and lateral fascia covering the knee. This tissue is placed on stretch when the knee is extended and tension is taken from it as the knee is flexed. Combining hip adduction- extension with knee extension will, therefore, optimally stretch the ITB. However, stretch will be taken off the fascia if false hip adduction is performed. This can occur in the side lying position (Figure 5) if the pelvis tilts laterally allowing the anterior superior iliac spine (ASIS) to move caudally. To perform an effective ITB stretch the pelvis must remain fixed. The Ober test position (19) is chosen in the first instance, with the affected leg uppermost. Initially the leg is abducted (45° to the horizontal) and extended (10–15° behind the bodyline). The underside of the trunk is then pressed into the floor and kept in this position throughout the exercise. The upper leg is then lowered back towards the horizontal while maintaining the extended leg position. A useful visual cue is for the subject to look down towards their foot. If they can see their patella, the extension has been lost, if they cannot, the leg is extended and the view of the patella is blocked by the front of the pelvis. A tactile cue that may be used is to place a folded towel between the
True hip abduction Pelvis remains fixed and only femur moves
False hip abduction Femure remains fixed relative to pelvis. Pelvis has tipped laterally, forcing lumbar spine to sidebend
Figure 5: False hip abduction in side lying. [Figure taken from Norris 2004 (17)] 17