Hello, I'm Brett DeGoyer. I'm a primary care sports medicine specialist working for Samaritan Healthcare in Moses Lake, Washington. Now I'd like to demonstrate how to use manual treatment on a hip problem that's mostly with the hip capsule or along the front of the hip. These demonstrations aren't meant to be complete or exhaustive in any way, just as a means of demonstration to use some very elementary treatments to help a patient who comes into your office or you see on the sideline or in the training room. It's important to also note that manual treatments specifically use your hands. You have to touch the patient. You need to be very clear and direct with the patient of what you're doing so that they understand what you're trying to accomplish and that they feel very comfortable with the treatment that you're giving them. You also want to encourage the patient to give you any sort of feedback with positioning. Is something too painful? You need to know those things as a treating physician so that you can make accommodations or adjustments. It's also important to note any contraindications. Certainly, if there had been a surgical procedure, we'd want to be very careful with how we're approaching with manual treatments. Somebody who's very frail or has a lot of degenerative changes, again, you want to be very careful and anybody who has a fracture, you want to be very careful. These are all relative contraindications and not absolutes, but you need to be very deliberate about how you're approaching the problem that you're treating. This first approach is going to be using a technique that allows oscillatory motion or a little bouncing motion. This is going to treat the anterior hip capsule, and the goal is to relax that capsule so that the other muscles surrounding it can also then relax or be well treated. To do this, we're going to position the patient, again, making sure that they're very clear about what we're about to do and they're very comfortable with that. The knee is flexed to 90 degrees, and then I'm going to place this hand, the hand closest to the head, at the gluteal fold. That creates a little fulcrum so that as I lift up with my other hand under the knee, it allows a stretch to go along that anterior capsule. So I grasp under here, put pressure here, and I draw up until I feel tension. I want to add in a little bit of adduction as well. Once I find that area of tension, then I'm going to add in that oscillatory compression force through this hand that's at the gluteal fold. Again, that helps to add the stretch and hopefully relax that capsule. As I feel that tension relax, I'm going to add in more adduction without adding any more extension. So we don't add the extension. We want to keep it here. Just add in a adduction and repeat that oscillatory motion. Again, ask for patient feedback if there's any increased pain or discomfort, and then you can readjust to make sure to eliminate that. Additionally, we can treat the rectus femoris along the front using the same treatment approach, only the oscillatory motion is now through this hand and arm using the lower leg as that oscillatory motion is induced in this manner. And then reset and make sure that the patient feels comfortable. From the same position, we can use what's called a muscle energy treatment or a muscle energy technique. Again, the goal is to work with the the muscles and the connective tissues surrounding the hip joint to add relaxation not only at the muscles and tendons, but also the fascia where you have a lot of lymphatics and nerves and vasculature that are running. As we relax those areas, it allows those systems to also promote greater drainage, greater flow, and hopefully reduce the amount of pain that they're having as well, which would be the ultimate goal of doing this in the office. So once again, the setup. Bend the knee at 90 degrees, hand at the gluteal fold, only this time instead of oscillatory, we're going to stretch along that capsule and specifically along the iliopsoas muscle. The patient, you're going to ask to contract their muscle against your resistance, and in this case, the resistance is going to be on this hand with the patient's force down towards the table. So, go ahead and contract, and we don't want this to be a forceful contraction, but a very lightly gentle contraction for about two to five seconds. Once they relax, you take up the slack to the new tension area, and then have them repeat the contraction. This you want to repeat two to three times, go ahead and relax, until you feel like adequate motion has been achieved. The same can be done for the rectus femoris. Instead of having the patient push to the table, you're going to have the patient try to extend the knee and push the foot towards the end of the table. You can still stabilize at the gluteal fold just to help, and they are going to contract doing the same motion or the same approach. Not forceful, but a gentle contraction. Relax, and then you bring up the slack. If you want to add in a little bit more hip extension, that will also help give a better stretch to the rectus femoris and the quads. In this position, the other things that we can treat with muscle energy is the external rotators. This we're going to treat by inducing internal rotation at the acetabular joint. Again, the knee flexed to 90 degrees. The ankle is carried out laterally, and if we want to use a hand here to stabilize, to prevent any abduction and keep in adduction, that is also preferred. So, same approach as we find that area of tension. The contraction is to have the patient push their medial malleolus, their medial ankle, back towards the midline. In this case, back towards me as the treating physician. They relax after two to five seconds of contraction, and then as the physician, I take up that slack to find that new area of tension, and repeat that anywhere from two to three or four or five times, and then return everything back to normal, and then you can re-examine to make sure that you've made an improvement, and of course, ask the patient for their feedback as well on how they're feeling. Now, with the patient in a supine position, we're going to do a technique, or I will demonstrate a technique that targets the hip capsule a little bit more completely without much patient participation. This particular method is known as ligamentous articular strain, or LAS. The setup for this is to have the patient hip flexed, knee flexed to about 90 degrees. The hand that is furthest away from the joint is going to be placed at the greater trochanter, and for demonstration purposes for the camera, it's going to be, I'm going to demonstrate on this side. So here's the greater trochanter, and I want my thenar eminence to be right at that greater trochanter, and then my hand is going to cup around the posterior part of the joint, to cup the posterior part of the femoral head as much as possible. So I'm doing that, of course, on this treatment side, and grasping. The patient's knee is then going to be positioned into my axilla, for support, as well as I'm going to be adding compression through my shoulder down towards the acetabular joint. My other hand is going to come in and grasp the anterior portion of that femoral acetabular joint, or as much of the femoral head as possible. Again, because of the positioning and where hand placement needs to be, be very clear and deliberate with your patient, so that they understand what you're doing, and why you're doing it, what you're trying to accomplish. So this hand comes in, cupping with the webbing as much as possible, down deep into that anterior acetabular joint. The knee, at the axilla, I'm adding in compression, and then I'm going to compress through my two hands as well. As I remove my hands, I'm going to show you, compressing this direction, as well as compressing down into the joint. I'm going to balance those forces as much as possible. I can also add in a little bit of internal and external rotation, internal-external, as I'm compressing together to find that balance. I don't want one hand or one position overpowering the other. Once I find that area where I'm balancing all of those forces, I stay there until I feel tissues relax, or the hip capsule relax. Once I felt that relaxation, I can either tune again, meaning do micro movements to find another area of tension, balance those forces, and get those to relax. Once I've done that to my satisfaction, which is two to three times, then the treatment is done, and I bring the patient back into a neutral supine position. Now I'm going to demonstrate doing some muscle energy in the supine position. The advantage in this position is that often if you have an athlete or a patient who's much larger, holding on to the leg in the prone position can be a little difficult. So we use the supine position because we can allow gravity and other positioning to work to our advantage. So in this case, the patient is supine, and we're going to target the iliopsoas first. I'm going to have her slide towards the end of the table just to the point of those gluteal folds right at the ischial tuberosity. The treatment side, which will be this side, stays off the edge of the table. The opposite side, the contralateral side, is going to be brought up into hip and knee flexion, and she can either stabilize on her own, or as the physician, I can stabilize the knee that is the non-treatment side. The other hand is going to be placed over the knee on the side that's being treated, and I'm going to induce extension at the hip joint, putting a stretch on the iliopsoas and to a small degree on parts of the rectus femoris in order to get that capsule a good stretch and a good treatment anteriorly. I find that point of tightness, not to the point of an anatomic barrier. We're looking for tightness and restriction in that capsule and joint. Find that area of tightness, and then the treatment is, as we've described it before, the patient will push against my resistance for two to five seconds. Once they relax, I take and move the position into further extension to try and get at that tightness that's at that capsule and the iliopsoas muscle. So now I'm going to treat the internal and external rotators. As I bring the knee up and the hip up into 90 degrees of flexion, in order to treat the internal rotators, I'm going to bring the hip joint into external rotation in this way. So in external rotation, I'm putting a stretch on the internal rotating musculature. Once I find that area of tightness and I'm stabilizing at the knee, her mechanism of action, or the patient, is going to push her lateral malleolus against the resistance in this hand that's holding and supporting at the ankle. So she's going to go ahead and push, contract for two to five seconds, relax. As she relaxes, then I'm going to take up that slack and find the new area of tension. And again, repeating that two to five times and then rechecking. From there, I'll go into internal rotation to help treat those external rotators, which is the opposite motion of what we just demonstrated. The mechanism of support or contraction is the medial malleolus is going to be pushed towards the midline or back towards me or against the hand that's supporting at the ankle. So as she pushes, hold for two to five seconds, relax, and then after relaxation, finding that new area of tension. And then, once we're there, we could also do the rectus femoris by having her slide back down and taking up some of that slack through the tension that's created now with knee flexion. Go ahead and scoot back up. Again, the principle is same with all of the others for muscle energy treatment. Find the area of tension, add some isometric contraction for two to five seconds. After relaxation, you find that new place of tension and then repeat two to three times and then recheck. And that would be treatment for the hip capsule, especially the anterior.

2nd Edition, CASE 21

2nd Edition

Hip

hip treatment

manual therapy

muscle energy

patient comfort

contraindications