Hip Exercises: Movement pathologies - A firm hold on the hips

Scott Smith explains the concept of a ‘rotator cuff’ of the hip and why the right degree of stability matters.

Hip problems are sometimes clear-cut, as in when, for instance, the client presents with local groin pain. But the hip joint can also be just one part of a bigger puzzle in a complex lower limb problem, as its functioning has such important consequences both for the lumbo-sacral region and for the knee and ankle.

The hip joint is usually very mobile, having to withstand both direct loading stresses and large rotational forces with weight-bearing activities. It is especially vulnerable to injury in sports that involve pivoting or twisting movements, such as soccer, Australian Rules football, tennis and golf.

In golf the hip is especially exposed to high-velocity internal rotation on the downswing, requiring a great deal of eccentric gluteal muscle control. Paradoxically, the increased risk of hip injury is a relatively recent hazard for golfers, arising from the greater rotation favoured by the modern golf swing – an adaptation to technique itself brought about to reduce the incidence of low-back injury among golfers.

In Australian Rules football the hip is subjected to repeated adduction and flexion/extension forces. This again requires great control throughout the gluteal muscles and the adductor muscle complex. It is these rotational and shear forces that cause injuries such as groin strains and osteitis pubis.

Tennis involves a combination of the above movement patterns, such as when performing ground strokes or when lunging forward and stretching for a drop shot.

The ‘rotator cuff’ muscles of the hip

Because the muscles around the hip joint attach directly on to the joint capsule, they have a large influence on the range of movement, as summarised in Tables 1 and 2 below.

Table 1: Muscles attaching on to the hip joint
Muscle	Capsular attachment
Rectus femoris and tensor fascia lata	Anterior capsule
Gluteus minimus	Superior capsule
Pectineus	Inferior capsule
Deep external rotators	Posterior capsule

Table 2: Movements at the hip and effect on the femoral head
Hip movement	Femoral head shift of position
External rotation/extension	Forwards
Internal rotation/flexion	Backwards
Abduction	Downwards
Adduction	Upwards

Rotational forces place tremendous strain on the ligamentous and muscular structures designed to protect the joint. The failure adequately to control these forces can lead to damage such as labral tears and femoral neck stress fractures ⁽¹⁾. Below, we consider two kinds of movement pathologies and self-help exercises to help correct them.

Figure 1: Lordotic-kyphotic posture, alignment characteristics

The first type of movement pathology – and the easier to treat – is when the hip joint has restricted motion. This can produce local hip pain or cause dysfunction in the lumbar spine/sacroiliac joint or the knee, as a result of these structures attempting to compensate for the lack of movement at the hip joint.

The second type of pathology is where the hip joint has an increased amount of movement arising from a lack of control of the femoral head in the hip socket. This patient often presents with clicking or clunking, or a feeling of weakness in the region. A failure to correct this lack of control can lead to joint damage and subsequent long-term restriction of movement.

If only it were so simple that clients only ever presented with one or other type of pathology. In reality they often have a combination of the two.

Pathology 1: restricted movement

The patient’s postural type can exert a significant influence on the length of the muscles around the pelvis and thus the degree of normal hip movement. There are two classic postural models that can cause restrictions to hip movement. So, for example, in the lordotic-kyphotic postural type (see fig 1, above), rectus femoris and the iliotibial band (ITB) will be shortened, reducing the range of hip extension. This is because these muscles attach directly on to the anterior capsule of the hip joint. The likely changes to muscle length are summarised in Table 3 below.

Table 3: Lordotic-kyphotic posture, predictable muscle length changes
Muscle group	Likely change
Abdominals obliques rectus abdominis	Long and inhibited Long
Back extensors longissimus and iliocostalis lumborum	Short and overactive
Hip flexors tensor fascia lata (and ITB) rectus femoris iliopsoas	Short and overactive Short and overactive ? Short / ? variable
Hip extensors gluteus hamstrings	Variable Variable

Table 4: Table 4: Swayback posture, predictable muscle length changes
Muscle group	Likely change
Abdominals obliques rectus abdominis	Long or inhibited Overactive or short
Back extensors superficial multifidus and spinalis	Long and inhibited
Hip flexors tensor fascia lata (and ITB) rectus femoris iliopsoas	Short and overactive Variable Long and inhibited
Hip extensors gluteus hamstrings	Inhibited Short and overactive

Source: Kendall FP, Mcreary EK, Province PG, 1993. Muscle Testing and Function, Williams & Wilkins

If the deep external rotators have restricted length, then you would expect reduced posterior movement of the femoral head and thus reduced internal rotation/flexion. The client who does not have adequate range of hip flexion/internal rotation would then have to compensate in other areas, such as the lumbar spine.

A common presentation is for the patient to have reduced posterior movement of the femur, thus reducing the range of flexion/ internal rotation. This often goes along with increased medial movement and range of hip abduction, which set the patient up for overstretching injuries in the groin. The groin muscles themselves are normally long and weak, and prone to spasm or appearing to shorten. This is a common presentation in conditions such as osteitis pubis.

Figure 2: Swayback posture, alignment characteristics

Figure 3: Femoral glide

The client can use the following two hip exercises to improve their hip flexion and adduction.

1. Femoral glide (see fig 3, above): Place feet against the wall, hips and knees at 90 degrees, and hold your hands around the top of the femur. Then apply a movement of the femur, pushing towards the wall, holding for 30 seconds and repeating four times. This should be performed twice daily.
2. Ball squeeze: Sit with legs flexed to 90 degrees and squeeze a small ball between the knees, holding for 30 secs. Repeat four times daily.

In addition, the therapist can use a seat-belt assisted technique to apply lateral glides with added hip flexion and/or internal rotation.

Pathology 2: lack of stability control

In the patient with poor hip stability, the hip demonstrates an increased amount of movement and thus lack of control of the gliding of the femoral head in the acetabulum (hip socket). This commonly occurs when the femoral head is sliding too far forward. For example, patients with a swayback posture (see figure 2, above) stand in posterior tilt/hip extension and then just hang on the ligaments and muscles anteriorly. As these muscles fatigue, there is increased strain on the underlying hip capsule.

Patients with this type of problem can present with a clicking/clunking hip, especially as they go from sitting to standing, or when (as in ballet turnout) they externally rotate the hip.

These patients need to improve their muscular control. If they also have a reduced range of hip movement in the opposing direction as a result of tight muscles, it will be helpful to try to increase this at the same time.

It is the local stability muscles that help control the shear forces produced by the forward movement of the femoral head. These are tonic or holding muscles which do not fatigue easily and which provide feedback to the nervous system regarding joint position and speed of movement.

Alison Grimaldi at the University of Queensland has proposed a new deep muscular system of hip control. Her research using magnetic resonance imaging of patients with hip pain has revealed wasting or decreased muscle mass in some of the deep rotators of the hip in these patients.

The new system targets the deep hip muscles that attach very close to the joint axis, which are predominately slow- twitch, endurance muscles, namely:

quadratus femoris
gluteus minimus
obturator internus and externus
the gemelli.

Grimaldi suggests that these muscles make up the ‘rotator cuff’ of the hip joint. She also states the importance of iliopsoas in controlling the anterior aspect of the joint. This is an area generally deficient in ligamentous control; yet animal studies have shown that iliopsoas comprises up to 73% slow-twitch fibres and thus has some form of stability role at the anterior hip.

The following two hip exercises are early stage rehab work to help the patient to recruit the deep stability muscles of the hip.

1. Hip suck (tonic psoas recruitment) Patient is in incline sitting or lying on their back. The patient palpates the anterior hip over the psoas insertion and attempts to draw the hip into the socket of the hip joint. A deep feeling is felt in the groin. The patient should not feel any activity in their rectus femoris or tensor fascia lata. Hold the position for 10 secs. Repeat for 10 contractions.

2. Heel squeeze (deep hip rotator activation) The patient lies prone with their knees bent and hips slightly spread apart. They gently push the heels together with minimal effort and no palpable gluteal contraction.

The key to progression is for the patient to be able to incorporate these deep muscular contractions into higher-level exercises. For example they can activate the psoas muscles as above when they perform a squat. They preset the psoas hip suck before they descend into the squat. This facilitation helps to achieve good hip flexion without a great deal of lumbar spine flexion.

Patients should also learn to incorporate these deep muscular feelings into everyday activities such as walking or sitting.

Grimaldi’s system should be incorporated at the earliest stage of rehab to bring about local joint control. The client can then work on good postural alignment and muscle length.

So, for instance, there is little point undertaking a lot of stretching of the groin muscles in circumstances where the underlying problem is one of instability of the pelvic joints. But on the other hand, it would be wasted work to improve deep muscle control without strengthening the larger hip muscles that promote improved postural control and resistance to large external forces in everyday sports.

The idea of the hip rotator cuff can be viewed as part of the deep muscle fibre systems that are aligned horizontally – namely pelvic floor, piriformis, internal oblique and transversus abdominis – thereby extending and complementing the concept of core stability.

Scott Smith is an Australian physiotherapist. He works at Albany Creek Sports Injury Clinic in Brisbane, specialising in running and golf injuries. He is currently working with Australian Rules football teams in Brisbane

Illustrations by Viv Mullett