For Professional Yoga Therapist candidates: This CE ...€¦ · You have to inform your patient, an...

1

ITBS & PFPS:

Clinical Update in Conventional

and Integrative Rehabilitation

For Professional Yoga Therapist candidates:

This CE corresponds to Module 10, Part 4, Hour 1

Program Matriculation:

Recommended Module Progression

• Distance Modules: Prior to taking this

course, complete Modules 1-7.

• Onsite Module: Complete and practice

final sequences in Module 8 and 14.

©2014. Ginger Garner.

Module 10 Series

• Part 1 – Nutrition & Orthopaedics: Focus on OA

Prevention and Management

• Part 2 – The Shoulder Complex and Spinal

Kinematics

• Part 3 – ACL, Foot, & Ankle Complex

• Part 4 – Hip Labral Injury, PFPS, and ITBS


2

Integrated Clinical Guidelines

• Conventional + Integrative Medicine

• WHO ICF

• Medical Therapeutic

Yoga Biopsychosocial Model


Course Outline – Hour 1

• Injury Epidemiology

• Biomechanics Update

• Prevention Update

• Management Update

• Case Study


Problem

You have to inform your patient, an avid runner who depends on

running as her sole form of exercise for weight and stress

management, that she will have to take a 6 week hiatus from

running because she has developed……

Think about how you will answer her questions


3

Is this very common?

In order to answer her question, you must know:

• Iliotibial band syndrome (ITBS) is reported the leading cause of distal lateral thigh/knee pain in athletes with incidence between 1.6 – 12% (Falvey et al 2010, Lavine 2010, Leninger et al 2009, 1978; Taunton et al 2002, Frederiscon et al 2000, Messier et al 1995, McNicol et al 1981, Orava 1978).

• ITBS or friction syndrome has been found to comprise 15% of all knee injuries (Lavine 2010).

• High level athletes commonly suffer from both ITBS and PF syndrome (Leninger et al 1992).

• ITBS and PF syndrome can often occur together (Fairclough et al 2007).


Is this serious?

In order to answer her question, you

must know:

• Typically occurs secondary to

repetitive motion or stress (Lavine 2010).

• Because the ITB is capable of

medial/lateral movement, ITBS as a

“friction syndrome” has been

questioned. (Fairclough et al 2007)

• Popular theories on etiology include

(3) (Strauss et al 2011):


How can you be sure the problem

is in my ITBS or PFPS?

In order to answer her question, you must know patients with ITBS might experience the following signs and symptoms:

• Lateral thigh or knee pain

• Hip or pelvic pain

• Ipsilateral knee pain at distal attachment point

• Increasing pain with activities such as cycling or running

• Patellar pain or tracking problems

• Medial knee pain

• Point tenderness over the ITB insertion

• Positive Ober Test (Low SN/SP in systematic reviews)

• Poor hip control/NM function


4

How did this happen?

• Weak hip abductors (Fredericson et al 2000, MacMahon et al 2000, Noehren et al 2007).

• Angle of knee flexion between 20-30 degrees during stance phase of activity (Orchard et al 1996, Noble 1980, Miller et al 2007).

• Lower quarter malalignment (eversion or inversion)

• Increased forces on landing (Messier et al 1995, Devan et al 2004, Noehren et al 2007, Busseuil et al 1998).

• Increased tibial internal rotation (Messier et al 1995, Devan et al 2004, Noehren et al 2007, Busseuil et al 1998).

• Ipsilateral hamstring weakness (Messier et al 1995, Devan et al 2004, Noehren et al 2007, Busseuil et al 1998).

• Imbalance of agonist/antagonist (Messier et al 1995, Devan et al 2004, Noehren et al 2007, Busseuil et al 1998).

• Genu varus (Lavine et al 2010, Vasilevska et al 2009)

• Genu recurvatum (Messier et al 1995, Devan et al 2004, Noehren et al 2007, Busseuil et al 1998).


Despite identifiable high risk populations, At issues

are considerably preventable. ITBS can fall into two

broad categories:

1. Intrinsic Risk Factors2. Extrinsic Risk Factors

Activities related to ITB injury include*: • Running• Rowing• Soccer• Field hockey• Cycling• Basketball

*Lavine 2010, Devan et al 2004


What would happen if I kept

playing?

In order to answer her question, you must know that continued aggravation of her ITB could result in:

•Hip bursitis

•Pelvic pain

•Hip pain

•Proximal or distal ITBS

•Patellofemoral syndrome

•Poor patellar tracking and knee pain

•Greater trochanteric pain or bursitis

•ACL Injury (Pelfort et al 2005)


5

Objectives1. Describe how the biopsychosocial conceptual model can improve health care

and its delivery in the US through its holistic evaluative methodology.

2. List the evidence based methodology for incorporating the medical yoga model into current rehabilitation programs.

3. Identify five points for diagnosis and intervention in evidence based conventional rehabilitation of the ITB in order to understand the integrative model of medical therapeutic yoga in the PYT method.

4. Describe four critical factors for implementation of multi-faceted integrative therapeutic programming for iliotibial band syndrome (ITBS) and patellofemoral(PF) considerations using the pentagon of wellness conceptual model.

5. List the three postures necessary to facilitate completion of the acute and subacute ITBS programming in medical therapeutic yoga.

6. Critically analyze yoga postures and breathing techniques in a case study format in order to prescribe intervention for extrinsic risk factors in prevention or management of ITBS and PF considerations.


Anatomy

• Iliac Tubercle (Sher et al 2011)

• Gluteals

• TFL

• Lateral patellar retinaculum

• Patella

• Paluska 2005, Sher et al 2001


Injury Prevention

• Leg Length

• Large Q-

angle/pelvic

width

• Excessive foot

inversion or

eversion

Intrinsic Factors Extrinsic Factors

• Lower quarter deficiencies

• Ipsilateral vs. contralateral

• Poor training techniques

• Fatigue

• Poor footwear

• Environmental factors in sport and activity

• Surface condition where activity takes place

• Faulty equipment

©2014. Ginger Garner. (Paluska 2005; Khaund & Flynn 2005; Fredericson & Wolf 2005).

6

BPS: Self-Management Strategies

Change Stress

Response

Experiential

learning &

practice

Intuitive

Bio-energetic

methods

OR

©2014 Ginger Garner. All rights reserved.

WHO ICF Model

Case Study

World Health Organization (WHO) (2002). International Classification of Functioning, Disability and Health. Geneva, Switzerland.

Biopsychosocial Model:A Pentagon of Wellness

PHYSICAL Anti-Inflammatory LifestyleRole of Nutrition & Exercise

Focus on Stability

ENERGETICBreath; Gut-Brain-Body Axis

PSYCHO-EMOTIONAL-SOCIAL Meditation; Mindful Living

INTELLECTUALPatient Education

SPIRITUAL Mind/body Homeostasis Introspective Analysis

Empowering patients to take responsibility for their health depends on

focused, biopsychosocial assessment.

© 2014 Ginger Garner.

7

Mindful Integrated Care:

Physical Domain

1. Application of the BPS Model

2. Healing and prevention of reinjury depends on (2)

3. Massage or manual therapy techniques (Pedowitz 2006) combined with breathwork (3)

4. Breathwork facilitating safety & O2 nutritional exchange during

• Transitions between movementts/postures

• STM & MT work

• Giving breath priority

5. CKC posture sequencing

• Hip abd/ER/extension strength (Reiman et al 2014, Prins and Van der Wurff 2009)

• Contrast RSS issues with yoga program design

• Use restoratives in acute phase


Cautions

• Address MFR

• Superficial Front Line

• Deep Front Line

• Screen for:

• Primary Drivers such as

intra-articular hip injury or

pelvic dysfunction

• Secondary Drivers such

as extra-articular hip

injury

AVOID:

•Running on uneven/sloped terrain

•Increased compression along the origin

or insertion point of the ITB, especially

during acute phase

•Overworking gluteus maximus in

presence of NM imbalance, in yoga

postures such as:

•Mountain

•Standing postures

•Backbends/spinal extension postures


Fascial Lines: Myofascial

Meridians

• Deep Front Line “Myofascial Tracks” and “Bony Stations” –Myers 2009

• Lowest Common

• Lower Anterior

• Upper Posterior

• Upper Middle

• Upper Anterior

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Functional Fascial Line and

Contralateral Arm Line

Injury Management - Acute

Acute Phase

• Activity Modification

• RICE

• NSAIDS

• Establish ITB freedom

• STM

• Friction massage (Lavine

2010)

• Trigger point therapy (Lavine 2010)

• Facilitate proper patellar tracking in the femoral groove

• Flexibility

• Mobility

• Hip strength –abd/ER/ext (Prins and Van der Wurff 2009)


The Yoga “Couch” – Three

Tier Approach

http://www.gingergarner.com/2012/12/13/the-yoga-couch/

©2001-2014 Ginger Garner. All rights reserved.

http://www.gingergarner.com/2012/12/13/the-yoga-couch/

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Heather Mason, Matteo Vandoni, Giacomo deBarbieri, Erwan Codrons, Veena Ugargol, and Luciano

Bernardi, “Cardiovascular and Respiratory Effect of Yogic Slow Breathing in the Yoga Beginner:

What Is the Best Approach?,” Evidence-Based Complementary and Alternative Medicine, vol. 2013,

Article ID 743504, 7 pages, 2013. doi:10.1155/2013/743504

Science of Ujyaii

Victorious breath “Ujyaii” (ooh-jai-

ee)

• Pursed lip breathing; Increased

cardiac-vagal baroreflex sensitivity

(BRS); Improves oxygen saturation;

Lowers BP

• Reduces anxiety; Increases

parasympathetic activation correlated

with improved physical and mental

health

Action

•Contraction of glottis creates

“resistance breath”

•Equal inspiration/expiration showed

greater clinical significance for

improving baroreflex sensitivity in

beginner yoga subjects.


Supported child’s pose

Integrated Stability: TATD Breath & LQ Synergistic NM

Training

1. Anatomical Principle of MovementBiomechanical

1. PF Piston effect

2. Diaphragm/PF myofascial effect

3. Emotional factors

2. Science of Action Physiological

1. Coactivation for force closure

2. NM Patterning

3. SafetyClinical Efficacy1. Yoga evolution

2. Integrated PT care

(Streeter et al 2012, Renovato et al 2010, Hides et al 2011, Fraca et al 2012, Willson et al 2005, Richardson et al 1999, Hides et al 2006, Hodgest

and Richardson 1997, Cholewicki & McGill 1996, Cholewicki & Panjabi 1997, Cresswell and Thostensson 1994, Lee 2001, Hodgest and Gandevia

2000, Hodges et al 2003, McCandless 1975, Morris et al 1961, Critchley 2002, Lee 2005, Sapsford 2001)


Talasz et al 2010: “TATD” Description

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Hip Lock

• Hip external rotators

• Piriformis, gemellus superior and inferior, obturatorexternus and internus, quadratus femoris

• Isotonic and isometric initiation

• Dissociation of gluteals from pelvic floor from hip external rotators

• Neural patterning + force closure


Neuromuscular Control• GMAX1

• 80% of GMAX inserts in ITB1

• Function1:

• hip extensor; lat. Rot.

• Accelerator in hip flexion from 45-60 deg.

• Contralateral plant and cut maneuvers

• Avoid terminal hip extension if iliopsoascompression is a concern

• Increase gluteal recruitment as hip extender over hamstrings (Lewis et al 2005)

• Consider SIJ instability/dysfunction will complicate this issue

Reiman et al 2012



Acute Progression –

McConnell Taping in

Slow Posture Practice

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Pre-Asana ProgressionMoon Salutation: 1. Downward Dog Prep (Pre-posture); 2. Caterpillar/Mod.

Dolphin dive; 3. Cobra; 4. Downward facing dog; 5. Three legged dog


Subacute

Subacute Phase

• Continued facilitation of proper patellar tracking through strength & motor control

• Abductors, gluteus medius (Leninger 2009, Frederickson and Wolf 2005)

• Hamstrings

• Hamstring/quad balance

• Muscle Tone & Mobility (over flexibility alone) (Paluska 2005, Messier et al 1995).

• TFL

• Gluteus maximus

• Gait Training/Specificity of sport neuromuscular patterning (Frederickson

and Wolf 2005)


Sub-Acute Program

Sequence: PYT Mountain Flow – 1. Mountain, 2. Chair, 3. Squat


1

12

Sub-Acute Progression

Sequence: Standing and supine hand to big toe


Advanced Sub-Acute Progression

Postures: Revolved triangle; Pigeon; Half upward facing bow


Facilitating Consciousness,

Concentration, and Meditation

©2013 Ginger Garner. All rights reserved.

13

Program Impact

Post-Test Results

6 months follow up

• TATD breath WNL

• No remaining point tenderness over distal insertion point of ITB

• Negative Ober

• TFL - WFL

• Hip IR/ER - 5/5, painfree

• Patellar mobility still an issue 2nd pt. resumed running (however on 2 year

follow up patient had discontinued running and patellar mobility returned to

WNL)


Now it’s your turn….


Want More?Applying yoga in rehab:

• Promotes complete

healing through caring

patient connection

• Expand programming,

cash & insurance

based; grow referral

base

• Prevent practitioner

burnout


14

ResourcesShifting your practice paradigm touse yoga as medicine:

• Learning Lab for this module – Module 8 & 14 – www.professionalyogatherapy.org

• Self-Massage for Lower Quarter, including foot: http://gingergarner.com/Marma%20Massage%20Lower%20body.pdf

• Lower Extremity Review. Read Biomechanical Precepts Define 21st Century Yoga. LEW March 2011 Vol. 3/No. 3. http://www.lowerextremityreview.com/article/biomechanical-precepts-define-21st-century-yoga

• Taping Video: http://www.youtube.com/watch?v=sMJBHBiZjCs


http://www.professionalyogatherapy.org/

http://gingergarner.com/Marma Massage Lower body.pdf

http://www.lowerextremityreview.com/article/biomechanical-precepts-define-21st-century-yoga

http://www.lowerextremityreview.com/article/biomechanical-precepts-define-21st-century-yoga

http://www.youtube.com/watch?v=sMJBHBiZjCs

1

The Hip Labrum:

Clinical Update in Conventional

and Integrative Rehabilitation For Professional Yoga Therapist candidates:

This CE corresponds to Module 10, Part 4, Hour 2

Objectives

• Identify the 2 categories for differential diagnosis of the hip and the 5 evidence based risk factors for intra-articular hip labral injury in order to understand how intra-articular hip joint injury could be avoided.

• Describe the morphological classification system of labral tears in order to identify the most accepted provocative tests used in identification of intra-articular hip joint injury.

• Discuss current evidence based medical management, including surgical intervention, for labral tears and related secondary injuries of the hip.

• In a case study format, critically analyze indications and contraindications to follow a subacute through chronic phase functional intervention for hip joint preservation and rehabilitation in a multi-disciplinary team approach.


Hour 2

• Anterior Hip Pain: Serious? Cause, Prevention, Differential Diagnosis

• Anatomy of the Hip Labrum

• Labral Tear Classification & Surgical Intervention

• Conservative Intervention & Case Study

• Chronic Progression Guidelines Video Lab Demonstrations

• Resources

©2014 Ginger Garner.

2

Problem

You have to inform your patient, a dancer, that she may not be able to perform with her company this year because she has developed anterior hip pain…..

Think about how you will answer her questions

Photo: Courtesy of Jennifer Miller Pearce


Is this very common?

• Functional impairment

• Location of pain

• Groin 96-100% SN

• Buttocks

• Anterior thigh

• Mechanical symptoms

• Clicking, giving way, hip

pain SN 100%, SP 85%

• Labral tear scoped “+” in

___% of individuals with

mechanical hip

symptoms.


Clinical Standards of Care

Invasive Orthopaedic Clinical Standards of Care (2014)

1. Symptoms

2. History

3. Radiographs

4. Clinical Exam

5. Intra-articular Injection

6. MRI/MRA

7. Referral to PT

8. Arthroscopic or open surgery

Reiman MP, Mater RC, Has TW, et al. Examination of ALT: a continued

diagnostic challenge. Br J Sports Med 2014;48:311-319.

3

Hip Bony Anatomy

• 6 degrees of freedom

• Multiaxial ball and socket

• Function: Load transfer of UE and LE

• Need ideal form and force closure to preserve hip (hip stability)

• Acetabulum = ischium, ilium, pubis

©2014 Ginger Garner. Retchford et al 2013

Fibrocartilaginous Anatomy

Fibrocartilaginousstructure that outlines the acetabularsocket:

Attachment areas (3):

Vascular Supply:

Outer 1/3

Inner 2/3

Obturator, superior gluteal, and inferior gluteal arteries

Reiman et al 2014, Kern-Scott et al 2011, Bharam 2006, Groh & Herrera 2009

Photo source: Primal Pictures.com©2014 Ginger Garner.

Image: http://www.londonhiparthroscopycentre.com/hip-and-groin-conditions-labrum.asp

Etiology of Tears


4

Is this serious?

• Iliopsoas bursitis/tendinosis

• Neuralgia

• Lumbar radiculopathy

• Stress Fracture

• ALT

• Femoral-acetabularimpingement (FAI)

• Pincer

• Cam

Reiman et al 2014, Margo et al 2003

Differential Dx must rule out:

• OA

• Inflammatory or infectious arthritis, osteomyelitis

• AVN, tumor, or fx

• Cancer

• Endometriosis, pelvic pain, ovarian cysts

• Difficulty related to previous surgeries

• PMH such as corticosteroid or alcohol abuse (risk for avascular necrosis)

• Fracture


How can you be sure the problem is

with my anterior hip?

(Kern-Scott et al 2011, Plante et al 2011, Groh and Herrera 2009, Lewis and Sahrmann 2006):

• Pain in groin (95-100% SN, Reiman et al 2014)

• Mechanical symptoms (SN 100%, SP 85%, Reiman et al 2014)

• Sharp pain, Clicking**, Locking or catching ***, Giving

way****

• Minor hip ROM limitations (in hip rotation, hip flexion,

adduction, abduction*****)

• Other: Night pain (Kern-Scott et al 2011)

*Lewis & Sahrmann 2006, McCarthy et al 2001, O’Leary et al 2001, Byrd 1996; Binningsley 2003, Hase & Ueo 1999, Klaue et al 1991

**Farjo et al 1999, Dorrell and Catterall 1986, Santori and Villar 2000, Byrd 1996, Neumann 2002

***Mason 2001, Farjo et al 1999, , Dorrell and Catterall 1986, Altenburg 1977, Hickman and Peters 2001)

****Farjo et al 1999, Altenburg 1977, Hickman and Peters 2001

*****Fitzgerald 1995, Nelson et al 1990, Byrd 1996, Binningsley 2003, Altenberg 1977, Hase & Ueo 1999©2014 Ginger Garner.

In order to answer her question, you must know the following provocative tests may be positive:

High SN and SP:

• Thomas test (Reiman et al 2013)

• FADDIR (Reiman et al 2013, Plante et al 2011)

High SN and low SP:

• Scour test

• DIRI ( Plante et al 2011, Saw & Villar 2004)

• Positive FABER** (Mitchell et al 2003)

• Positive Stinchfield test/RLSR

• Posterior-inferior labrum test

How else can you tell the problem is with

my hip?


5

Labral Pain Patterns

How did this happen?

1. Dysplasia*

2. Direct Trauma**,***

3. Femoral acetabularimpingement

4. Degeneration***

5. Capsular laxity/Hip instability (Kelly et al 2005, Phillipon et al 2005)

*(Kelly et al 2005, Phillipon et al 2005, Gorh and Herrara 2009, Lewis & Sahrmann 2006, Bache

et al 2002, Robertson et al 1996, Li and Ganz 2003, Coleman 1978)

**(Gohr & Herrara 2009, Kelly et al 2005, Phillipon et al 2005, Lewis & Sahrmann 2006, O’Leary

et al 2001, Fitzgerald 1995, , Santori & Villar 2000, Byrd 1996, Ikeda et al 1988, Nelson et al

1990)

***Mason 2001, Fitzgerald 1995, Santori & Villar 2000, Saw & Villar 2004©2014 Ginger Garner.

1. Intra-articular Injuries2. Extra-articular Injuries

In younger patients, sports injuries of the hip/pelvis most commonly include:

• Ballet Dancers (44%)

• Soccer players (13%)

• Runners (11%)

• Also:

• Golf

• Martial Arts

• Gymnastics

• Yoga

Reiman et al 2014, Kern-Scott et al 2011, Godinho 2007, Lewis and Sahrmann 2006, Farjoet al 1999

Despite identifiable high risk populations, hip

issues can be preventable. Hip injuries can fall

into two broad categories: (Flannery et al 2001, Tibor and Sekiya 2008)


6

Differential DiagnosisGeneral diagnoses for the hip are ordered under 2 categories:

Intra-articular• OA & RA

• Labral tears

• Loose bodies (& snapping hip 2nd to them) or Internal snapping hip (iliopsoassnapping over iliopectineal emminence or femoral head)

• Femoroacetabular impingement (FAI) –88% of hips: “+” flexion impingement test (Clohisyet al 2009)

• Capsular laxity

• Tears of the ligamentum teres

• Chondral damage

• Flannery et al 2001, Tibor and Sekiya 2008

Extra-articular• Iliopsoas tendonitis and/or bursitis

• Snapping hip (2 types)

• Iliotibial band and greater trochanteris

bursitis

• Gluteal tendoninpathy

• Fractures (femoral neck)

• Piriformis syndrome

Related Dysfunction “hip

mimickers” (4)


What would happen if I kept playing?

In order to answer her question, you must know that

continued aggravation of her hip could result in:

• Anterior hip injury

• Lateral hip injury

• Posterior hip injury

• Intra-articular hip joint damage

• Pelvic or sexual dysfunction


Soft Tissue Pathophysiology

• Iliopsoas

• Gluteus Medius

• Hamstring

• Adductors

• Pelvic Floor

• External Rotators


7

Anterior Hip Injury

Progression

Anterior hip injury

progression if a labral

tear is present:

• Increased contact

stresses (Ferguson et al

2000)

• Hip instability (Tan &

Seldes 2001)

• Iliopsoas bursitis,

tendonitis


Lateral Hip Injury ProgressionLateral hip injury

• ITBS

• Gluteal tendon tear (positive

Trendelenburg or lateral

SLR/MMT abductors)

• Trochanteric bursitis


Posterior Hip Injury

ProgressionPosterior hip injury:

• Hamstring

tendinosis or

fraying from ischial

tuberosity

• Intra-articular hip

joint damage: (Gohr

& Herrera 2009, McCarthy et al 2001, Phillippon 2003,

Bharam et al 2002, Bharan et

al 2003, Farjo et al 1999, Byrd

1996, Altenburg 1977)

• Chrondral

damage

• Osteoarthritis


8

Posterior

Hip

Acetabular Labral Function

Reiman et al 2014, Retchford et al 2013, Groh & Herrera 2009

Zones of Labral Pathology

Ilizaliturri VM, Jr, Byrd JW, Sampson TG, Guanche CA,

Philippon MJ, Kelly BT, Dienst M, Mardones R, Shonnard

P, Larson CM. A geographic zone method to describe

intra-articular pathology in hip arthroscopy: cadaveric

study and preliminary report. Arthroscopy. 2008;24:534–

539. doi: 10.1016/j.arthro.2007.11.019.©2014 Ginger Garner.

9

Labral Tear Classifications

Four Labral Tear

Morphological Types: (Thomas et

al 2013, Bharam 2006, Lage et al 1996)

I. Radial flap*,

II. Radial fibrillated,

III. Longitudinal peripheral,

IV. Unstable

Photo: Medscape.com

*Scope of labrum in watershed region

Labral Tear Locations: (Groh & Herrera

2009)

• Anterior (86%) (McCarthy et al 2001, 2003)

• Posterior (Robertson et al 2007)

• Superior/lateral (Schmerl 2005, McCarthy et

al 2003)


Can hip injuries be prevented?

In order to answer her question you must know prevention of labral

tears can be difficult secondary to the lack of sensitivity and

specificity of current clinical diagnostic measures.


WHO ICF Model

• Common Language and nomenclature for functioning, disability, and

health

World Health Organization (WHO) (2002). International Classification of Functioning, Disability and Health. Geneva, Switzerland.

37 yo 3 mo. Postpartum female

with right hip joint pain and

external hip pain

Unable to participate

in activities,

especially FABER,

without clicking, hip

giving way, and pain

i.e. cannot carry newborn son

down stairs or appropriately

care for him because hip gives

way

Has no family nearby

but has supportive

husband with

excellent leave

situation

Well educated;

very healthy and

proactive; BMI

WNL for

postpartum

mother; motivated

10

Case Study –

General Observations & Measures

• Objective Measures right hip:

• MMT hip flexion 4/5, painful ; abduction 2-/5

and very painful; hamstrings 4-/5 and painful;

IR 5/5; ER 3/5 and painful; MMT 5/5

otherwise

• + Trendelenburg (for pain in GMED, not

function)

• Able to isolate TATD (includes PFM) and

maintain TATD breath during downward dog

prep (DDP), however DDP caused deep hip

pain; and pt. still working with PP DRA (third

child)

• Left hip WNL

and painfree


Provocative Tests

• Diagnostic Tests:

• Xrays: Right hip dysplasia; shallow acetabulum; no FAI present

• MRA: Hamstring and gluteal tendon insertion degeneration with marrow changes & fraying confirmed; “-” for labral tear and FAI but positive for “minimal spurring”; marked OA at left SIJ; sig. hypertrophy of labrum

• Provocative Tests: Positive Ober (for proximal pain not ITB tightness); + FABER for pain in groin and c/o instability; point tender over gluetus medius/minimus; + DIRI; + FADDIR; + Stinchfield/RSLR tests; Right hypomobile SIJ; + Thomas test for internal snapping hip (iliopsoas) and groin pain

• Femoral Version: 30 degrees bilaterally?©2014 Ginger Garner.

CEA – A/P View


11

Physical - Acute

Knowledge of activity modifications

Mindful movement

Slower pace

Awareness/consciousness

Correct faulty movement patterns – esp. gait

Integrated Therapies Chosen:

NWB (4) – Aquatics (a no go for this pt.), Pilates Reformer, Medical Therapeutic Yoga, Muscle Energy

WB (2) – Medical therapeutic yoga, Pilates matwork

STM - Lower Quarter Marma Massage points (none in anterior hip, however)

Homeopathy – through nutrition (anti-inflammatory diet)


Psychoemotional/Energetic

• Neuroendocrine Regulation – HPA Axis regulation,

especially cortisol (lack of sleep)

• Breathwork

• Meditaton through restorative yoga and breath

• Sleep positioning - Supine unweighted right hip; knee in open

packed

• Influence lumbopelvic stability and load transfer

• Contrast repetitive stress contributors with CAM program

design (5)


http://gingergarner.com/Marma Massage Lower body.pdf

12

Intellectual/Spiritual

Anti-Inflammatory Diet

Homeopathic and biochemical NSAIDS – team approach with MD

(arnica montana oral and topical; Advil 800 mg/TID)

Time Management for Rest/Exercise Balance:

From active fitness routine - yoga, Pilates 3-5x/week; walking 2-

3x/week

Daily restorative yoga and/or Pilates routine no more than 30’

and worked into childcare routine

Daily devotional time and prayer; music therapy


IA Injection

• Patient had US-assisted

diagnostic injections (6-8

weeks later)

• Iliopsoas

• Intraarticular

steroid injections


Impression

• Impression: Right gluteus med/min tendinopathy;

internal snapping hip; right hamstring

tendinopathy; excessive femoral anteversion and

shallow acetabulum

• What are your impressions?

13

Contraindications

AVOID:

• End ranges in yoga, aquatic, and Pilates movements

• Domination of lower quarter stability via quadriceps and hamstrings

• Hip and knee hyperextension in walking/stance

• In acute phase – loading hip with/without torsion/rotation

CAM therapies that include movements which create: (2)

Yoga postures like:

Pilates Matwork and/or Reformer postures like:

Aquatic therapy:

Massage/manual therapy:


Subacute to Chronic

Progression

Subacute Phase (8+ weeks)

Identification of root causes of injury

Unable to get 7-9 hours continuous

sleep/night 2nd nursing infant

From ADL and work task completion

- Unable to modify ADL completion

2nd childcare responsibilities

Hormonal and cumulative effect of

3 pregnancies

Yoga posture alignment

Continued activity modification and

rest

NSAIDS

Muscle energy

Lock/Bandha work

WB

Progression to Pilates matwork

Progression to yoga without

lateral SLR or unilateral stance

Upright biking


Gait • Faulty Patterns:

• Lack of knee flexion at heel strike

• Decreased hip abduction in stance/swing phase

• GMED1

• Stabilization of femur and pelvis during WB and stance phase

• 60% of total hip abduction cross-sectional area

• “Catwalk”

• Prolonged foot flat and knee hyperextension creating premature hip hyperextension (Lewis et al 2004)

Kennedy MJ, Lamontagne M, Beaule PE. Femoroacetabular impingement

alters hip and pelvic biomechanics during gait. Gait Posture. 30(2009) 41-44

1. Reiman MP, Bolgla LA, Loudon JK. A literature review of studies

evaluating gluteus maximus and gluteus medius activation during

rehabilitation exercises. Physiother Theory Pract. 2012;28(4):257-268. doi:

10.3109/09593985.2011.604981; 10.3109/09593985.2011.604981.


14

Gait continued…

• Faulty patterns cont.• Excessive hip extension (maximal end range

hip extension)

• Mechanical or mobility impairments: • Stiffness in subtalar joint

• Weakness or Ring/Thoracic shift

• Anterior gliding of femoral head – weakness of gluteals during hip extension and iliopsoasduring hip flexion (Lewis et al 2007)

• Self-limiting patterns in attempted stabilization• Diminished hip extension during swing phase

Lewis CL, Sahrmann SA, Moran DW.. 2007 and 2010 ©2014. Ginger Garner.

Program Impact – 9 mo.

Post-Test Results (9 mo.)

• Able to perform Pilates advanced matwork routine 100%

• Except sidelying series performed at 50%

• Able to return to yoga 100%

• With elimination of FABER, With elimination of all end range of motion for hip

• Able to return to pool therapy with no further c/o instability or pain

• No remaining point tenderness

• Proximal ITB, TFL, Gluteus medius/minimus

• Able to sleep without interruption ~7-8/hrs. nightly

• Reduced night pain, Stopped nursing infant at 11 months


Acetabular labral tear MR arthrography

Sensitivity for anterior tear - 60% to 100% (Groh & Herrara 2009,

Hunt et al 2007, Czerny et al 1999, Petersilge et al 1996, Czerny et al 1996, Byrd

& Jones 2004, cote et al 2005, Plotz et al 2000, Studler et al 2008, Chan et al

2005, Schmid et al 2003)

Specificity for anterior tear from 44% to 100% (Groh & Herrera

2009, Hunt et al 2007, Keeney & Peelle 2004, Cote et al 2005, Studler et al

2008, Toomayan et al 2006)

Sensitivity for posterior or lateral tear – 20 – 11%

respectively (McCarthy et al 2003)

> 2 tears before diagnosis of labral tear on average (Groh and Herrera 2009,

Farjo et al 1999; O’Leary et al 2001; Fitzgerald 1995; McCarthy & Busconi B. 1995;

Byrd &, Jones 2000).

Clinical Impressions on

Hip Joint Preservation


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Review of “Red Flags”

1. Breath is Paramount: TATD Breath

2. Functional Task Completion – Force & Form Closure

• SIJ position/Pelvic stability

• Femoral head articulation, positioning, and acetabular coverage

3. Recruitment Patterns – Load Transfer

• Over- and under-recruitment - gluteals, hamstrings, hip external rotators, and iliopsoas

• Neuromuscular coordination

4. Mask of face: Yogic lens©2014. Ginger Garner.

What can the average patient

with hip pain expect?


Resources

• Full Hip Labrum Injury &

Differential Diagnosis Course

– www.hermanwallace.com -

HLI

• www.gingergarner.com -

Patient Education Blogs on

HLI


http://www.hermanwallace.com

http://www.gingergarner.com

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