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iar institute for athlete regeneration

Hip Dysfunction in the Running Athlete

Marie Potter PT, DPT, OCS, SCS, FAAOMPT, ATC Christina Gomez PT, DPT, OCS

Introduction

Marie Potter, PT, DPT, OCS, SCS, FAAOMPT, ATC

Christina Gomez, PT, DPT, OCS

Understand the biomechanics of jogging versus sprinting

Recognize the risk factors for running-related injuries

Evaluate and diagnose hip pain in middle to long-distance runners

Implement appropriate manual therapy and therapeutic exercise interventions

Understand how to safely return this population to running

Understand how to design a return-to-running program for a recreational runner versus a competitive runner

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50% injury rate

3-11% of all LE injuries occur at the hip

Greater than 2.5x BW

Sex

Age

BMI

Biomechanical

Prior injury

Training

Running Surface

Footwear

Intrinsic Extrinsic

Risk Factors

Stance Phase

Absorption

Generation

Swing Phase

Generation

Absorption

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Biomechanics

Ground Reaction Forces Vertical A/P Medial/Lateral

Biomechanics

Frontal Plane

Sagittal Plane

Transverse Plane

Jogging vs. Sprinting

ROM increases

Duration of cycle decreases

Increase in velocity of joint motion

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Movement System Impairment Syndromes

“Maintaining or restoring precise movement of specific segments is the key to preventing or correcting musculoskeletal pain.”

- Shirley Sahrmann

Definition

Movement direction or alignment that most consistently causes or increases the patient’s symptoms

Correction of movement decreases or alleviates symptoms

Key Concepts

Repeated movements and/or prolonged postures (RMPP)

Directional susceptibility to movement (DSM)

Path of instantaneous center of rotation (PICR)

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RMPP

Precipitating factor

Alters the activation of muscles and available motion of joints

DSM

Path of least resistance

Affected by RMPP

Movement System Impairment Syndromes

• Anterior Glide Medial Rotation MSI

• Hip Adduction Medial Rotation MSI

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Femoral Anterior Glide with Medial Rotation

Hip anteversion

Genu Valgus

Swayback posture

Poor gluteal definition

Hip IR

Hip extension

Structural Variations

Acquired Impairments

PICR:

• Shape of joint surfaces

• Control by ligaments

• Force-couple action of muscular synergists

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Subjective Complaints

Pain in groin area

Pain with hip flexion

Common in runners and dancers

Functional Tests

• Posture • Gait

• Squat

• Lunge

Hip Flexion Strength

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Sitting Knee Extension

• Active knee extension with hip medial rotation

• Overactive medial hamstring

Hip Flexion ROM

• Decreased posterior glide

• Increase pain free hip motion with lateral rotation and posterior glide of femur

Active SLR

• Anterior movement of femoral head

• Reproduction of pain

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Prone Hip Extension

• Anterior movement of femoral head

• Hamstring vs gluteal dominance

• TFL tightness

Quadruped rock

• Affected hip does not flex as easily

• The pelvis on the affected side is higher

Femoral AGMR Summary

Primary Impairments: • Anterior joint capsule and soft tissue long • Decreased posterior glide of femoral head with

flexion

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Lab

See Lab Handout: Evaluation

Case Example

35-year-old female with right anterior hip/thigh pain

Novice runner training for a half marathon

Aggravating factors

Differential Diagnosis

Hip Flexor Tendonitis

Femoral Acetabular Impingement

Lumbar Radiculopathy (L2,3,4)

Hip Bursitis

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Gait

• Lumbar extension-rotation

• Hip extension ROM

• Femoral ADD/IR

• Foot/ankle mechanics

Running Analysis

• Decreased hip flexion

• Increased stance time

• Rearfoot strike

• Increased hip extension

• Poor trunk control

Functional Tests

• Overhead squat

• Single leg squat

• Single leg hop

Manual Muscle Tests

• Psoas

• Posterior Gluteus Medius

• Hamstring vs Gluteal activation

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OH squat:

• Decreased hip flex

• Increased lumbar lordosis

SL squat:

• Painful

• Femoral ADD/IR

• Decreased depth

Objective Summary

Tight posterior capsule

+ femoral anterior glide

Poor PICR

ICF Classification:

Non-arthritic hip joint pain with mobility deficits

MSI Diagnosis:

Femoral Anterior Glide with Medial Rotation

Pathoanatomical:

Femoral Acetabular Impingement

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Impairments

Hip always in extension

Tight posterior capsule

Weak gluteal muscles

Hip flexor STM

• Neurophysiologic effect

• Pain free

Hip mobilizations

• Improve femoral posterior glide

HEP

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Restoration of PICR

Single leg bridges

Clamshells

Fire hydrants

Resisted sidesteps

Strength

Overhead squat

Single leg squat progression

Neuromuscular Control

Single leg running balance progression

Single leg drop down progression

Exercise Cautions

Hip flexor stretching

KB swings

Lunges

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Lab

See Lab Handout: Manual Therapy & Ther Ex

Hip Adduction with Medial Rotation

Structural Variations

Broad pelvis

Genu valgus

Acquired Impairments

Apparent LLD

Hip IR

Pronated foot

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Subjective Complaints

Posterior lateral hip pain

Increased pain with weight-bearing

History of a fall or surgery

Single leg stance

• Hip adduction

• Hip IR

OR

• Trunk SB over the stance leg

Walking

• Trendelenburg gait

• Compensated Trendelenburg gait

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Functional Tests

• Gait • Sit to stand

• Stairs

• Single leg squat

Alternate Torsion Test

Posterior Gluteus Medius MMT

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Anterior Gluteus Medius MMT

HAMR Summary

Primary impairment:

• Hip adduction • Insufficient hip abductor muscles

Lab

See Lab Handout: Evaluation

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Case Example

45-year-old female c/o left lateral hip pain

Onset of symptoms

Aggravating factors

PMH includes several left ankle sprains

Lumbar Radiculopathy

SIJ dysfunction

ITB syndrome

Gluteus medius strain or tendinopathy

Trochanteric bursitis

Standing Alignment

Shifts weight onto L LE

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Single leg squat

Trunk alignment Squat depth

Hip/knee motion

Ankle motion

Running on TM

Arm swing Trunk alignment

Pelvic alignment

LE alignment

Cadence

Symmetry

PGM strength: 2/5

Decreased left ankle DF

Decreased great toe ext

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Objective Summary

Broad pelvis

Asymmetrical standing alignment

Hip Add/IR during functional activities

Pelvic drop

ICF Classification:

Non-arthritic joint pain with muscle power deficits

MSI Diagnosis:

Hip Adduction with Medial Rotation

Pathoanatomical:

ITB Syndrome

Impairments

Weak hip abd/ERs

Decreased ankle mobility

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Manual Therapy

HEP

Overhead lunges

Kettlebell/Dumbbell swings

Single leg deadlifts

Femoral AGMR

Anterior joint capsule and soft tissue loose/stretched

No posterior glide of femoral head with flexion

HAMR

Weak hip abductor muscles

Lengthened hip ERs

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Lab

See Lab Handout: Manual Therapy & Ther Ex

Return to Running

Evaluation of health

Evaluation of participation risk

Decision modification

Evaluation of Health

General guidelines

Functional outcome measures

Sports specific outcome measures

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Participation Risk

Intrinsic Factors

Extrinsic Factors

Decision Modification

Lab

See Lab Handout: Functional Testing

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Return to Running

Phase I

Phase II

Phase III

Phase IV

Phase I

Phase II

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Phase III

Phase IV

Phase V

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Decrease stride length and increase step rate

Increasing step rate by 10%

Decrease impact force

Decrease vertical excursion

Decrease heel strike

Decrease braking impulse

Increase gluteus medius & maximus firing

Increase hip flexor muscle activity throughout swing phase:

• Lower impact peak

• Decreased landing velocity

“Slide” into stance vs “dig” into the ground

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Running Program Design

VS

Aerobic Fitness

Neuromuscular Fitness

Specific Endurance

Variation

Technique Drills

Butt Kicks

High Knees

Bounding

Lateral Bounding

Grapevine

Bunny Hops

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Plyometrics

Switch Lunges

Single leg hops

Bench taps

Box jump

Rocket jump

Running Program Design

See Lab Handout: Technique Drills and Plyometrics

Novice Runners

Alternate shoes

Cross training

Run > 30km/week

Progress running distance < 30%/week

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References

See handout