30 Aug Optimizing Hip Mobility: Clinical Pearl
The natural design of the hip allows it to serve as the key to foundational movement! It is a ball and socket joint, similar to the shoulder which allows it to be extremely mobile. However, in addition to its exceptional mobility, the hips are responsible for giving us a base of weight bearing capabilities to perform complex movements such as walking, swinging a golf club, squatting to pick up objects, dancing, etc., as it also serves as a key stabilizer. If the hips become stiff our movement options become limited! The purpose of this [P]Rehab Clinical Pearl is to enhance your understanding of how to facilitate long-term improvements in hip mobility either for yourself, or for your patients. There will be a series of exercises from our exercise library that you can visualize as we discuss hip mobility throughout this post. You won’t want to miss this hip mobility clinical pearl.
“This blog is one of our ‘clinical pearls’, which is designed to assist clinicians in understanding exercise progressions for various clinical conditions. Throughout each of these clinical pearls, you will learn multiple ways to attack similar issues we all see when treating our patients. We also highlight many of our personal exercise library videos throughout these pearls, all of which you can gain access to as an exercise library member!”
It’s All In The Hips!
Being a ball and socket joint, the hip is allowed 3 degrees of freedom meaning it has mobility in all available planes of motion! Sadly humans nowadays move less, and because of this our hips move less! As technological advances have made our living and work environments easier, the sacrifice of exploring our full hip mobility in all planes of motion has been made. If we are only taking our hips through flexion/extension (sitting/standing) day after day we are missing out on significant movement potential and actually increase our risk for injury! Hip mobility limitations have been correlated with a variety of musculoskeletal conditions, including low back pain, femoral acetabular impingement (FAI), hip osteoarthritis, and labral pathologies.
To really optimize hip mobility, we need a multi-centered approach. There is a ton going on at the hip from an anatomical, physiological, and biomechanics perspective. The hip joint itself, all of the muscular and soft tissue attachments, its proximity to the pelvis, there is a lot to consider when working on mobility. To give you some perspective, there are 27 muscles that cross the hip joint and there are many other muscle groups above and below the hip joint that affect overall hip function! We have to attack the hip from all angles, not only figuratively, but literally as well!
We breakdown this pearl into the following sections:
- Patient Education: Movement-based work environments as well as modifying risk factors for mobility restrictions of the hip.
- Joint Mobilizations: Mostly focused on self-mobilizations, as with [P]Rehab, one of our core values is giving society the key to the ignition and allowing them to start their own movement engines towards success. Taking ownership of your own health is what we want to continue promoting!
- Dynamic Mobility Exercises: We talk about dynamic stretching and how it also helps improve hip mobility.
- Muscle Activity/Strengthening/Re-Education: A key component that is often forgotten when optimizing hip mobility.
Step 1: Educate, Educate, Educate!!!
It all starts with education when improving hip mobility for our clients. What we want to help individuals understand is that improving mobility at the hips is not just performing exercises, but changing your lifestyle. Modifying risk factors such as work environment, sedentary habits, and so forth is crucial. Is there an ideal sitting posture…The answer is No! We are bound to fall into “faulty postures”, such as slouching in a chair, shifting to one side, etc. What we can do is educate our patients on creating a movement-based work environment. For instance, we know that a lot of people are now sitting a lot for their jobs. With that being said, how can we educate our patients to create a movement-based environment within what they can control?
Education For Sitting Environment
- Invest in a standing desk if able: This allows individuals to transition between different body positions frequently throughout the day, rather than staying in one position for a large portion of the day
- Set reminders: If you are not able to have a standing desk, set reminders on your phone or computer to get up and move around at least every 20-30 minutes
Sitting Positions To Avoid With FAI
What about patients with hip impingement (FAI)? We know that hip flexion, adduction, and internal rotation (FAIR position) is painful for patients with hip impingement. Simply put, educate patients to avoid this if they have FAI! This includes:
- Avoid allowing the knees to come together, which creates femoral adduction and internal rotation, often provocative for individuals with FAI
- Avoid overcompensating in attempts to sit upright for long periods of time as this creates more hip flexion
- A slight slouch in posture is NOT bad!
A summary of the key points mentioned above are discussed below in this video.
Step 2: Consistency Is Key – Don’t Overstretch!
We all get questions from individuals about, how much should we stretch? The key takeaway for improving hip mobility is to work on dynamic stretching exercises, but to not overstretch. When we say overstretch, we mean pushing past your body’s end range. What may happen over time if you constantly push past a limited motion is that your body may compensate and try to gain motion from somewhere else, which develops bad movement patterns. In addition, if someone continues to push past an end range of motion, discomfort/injury may result, which will hinder recovery! It is important to educate your patients on this concept from the first encounter of treatment, to ensure they understand their body’s limits as well as what sensations to feel when stretching.
Patients often become eager to gain mobility quickly, and we know significant gains in mobility do not happen overnight. We must set realistic expectations for our patients and educate them to understand it is a slow process that will happen overtime. Let’s tap into some great dynamic stretching exercises for the hip.
This 90-90 position is great to work on hip mobility, as you are not only working on improving hip external rotation of one hip, but you are simultaneously attacking hip internal rotation on the opposite side!
If an individual is unable to get into a perfect 90-90 position, do NOT force it! Sometimes, if people are lacking hip external rotation mobility, they try to compensate at their tibiofemoral joint (knee joint), by attempting to externally rotate at the knee, which can lead to knee pain. As we harped on earlier, stay consistent, find where your limit is, and don’t push beyond that! Overtime with consistency, you will be able to move into new, further ranges of motion.
The runner lunge position is great to lengthen the hip flexors, and can be incorporated into dynamic warm-up routines before this muscle is activated, such as with running or squatting.
When working on stretching hip flexors in other positions, be sure to add a posterior pelvic tilt. This will help lengthen that muscle group, optimizing the stretch! Be sure to watch for pelvic positioning when stretching the hips, as the pelvis and hip work in tandem with one another.
Staying in a static position at the hip and moving from a different area at the body is a great way to attack hip mobility! Start by getting into a 90/90 position. If it is too difficult to get into this position, you can use a yoga block to elevate your hips, making it more comfortable. When in this position, rotate from your spine towards each leg. You can add a reach as well to create an even deeper stretch.
We know that our spine is connected to our pelvis, which is connected to our hips! Our body is a kinetic chain. Think outside the box with your mobility interventions. This shows you that you can move the hip joint in so many different ways.
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Step #3: Hip Joint Mobilizations
There are various ways to mobilize a hip either with manual therapy or by educating your patients to perform self joint mobilizations. The purpose of these mobilizations is to improve capsule and connective tissue mobility. What is important about hip joint mobilizations is to combine them with intentional movements after they are performed. Specifically, muscular re-education exercises that activate surrounding hip musculature will create long-term carryover of these mobilizations. You must create hip mobility programs that branch out beyond just the mobilizations and dynamic stretching! Remember, active problems require active solutions.
- Convex on Concave: With convex on concave joints, the roll and glide occur in opposite directions. In regards to hip mobilizations, the hip has a convex femoral head moving on a concave acetabulum. Therefore, whichever way the roll occurs, the glide will occur in the opposite direction. We target our mobilizations in the direction of the glide!
- Clinical Pearl: Although you have learned this concept in your training and education, more recent literature supports that this rule may not matter so much when performing mobilizations. It is great to know your anatomy as well as your osteokinematics; however, don’t boggle yourself up in all the small details. To keep it simple, when working on joint mobilizations, target the joint, and just move it!!
Below are examples of various self hip joint mobilizations that can be prescribed in the clinic and/or a home exercise program.
Posterior or inferior mobilizations of the hip help promote improvements in hip flexion and adduction. What is important with this exercise is to ensure that the spine is kept in a neutral position, by avoiding rounding of the pelvis when rocking back towards the heels. This is particularly helpful for patients who have femoral acetabular impingement (FAI) or hip osteoarthritis.
This is another posterior hip mobilization, but in a different position. The half kneel position allows the rectus femoris muscle to be on stretch in addition to the iliopsoas. Don’t forget that the rectus femoris crosses 2 joints, both the hip AND the knee! Be sure to include interventions that enhance tissue extensibility of this muscle if limited in patients you are treating.
Anterior hip mobilizations are not as commonly prescribed; however, they still are important to consider, especially if someone is lacking hip extension.
In an article from the International Journal of Sports Physical Therapy by Reiman and Matheson in 2013, the authors suggested that limitations in hip extension has been a possible cause of anterior pelvic tilt and lumbar lordosis during running. Although research specifically around limited hip extension and injury is limited, mobility in this plane should still be taken into consideration when rehabilitating patients.
There has been supportive research that suggests individuals with hip pathologies such as FAI or hip osteoarthritis have limited depth of their squat secondary to poor pelvic motion in the sagittal plane. This is a great mobilization with movement for individuals who have limited hip flexion in a loaded position, such as a squat!
This is a great way to improve hip internal rotation, as well as an excellent transition into our next section on muscle activation for hip mobility! Arash adds active hip IR ROM in this same position after using the dowel for assistance to work on activating his internal rotators with his improved hip mobility.
This is a key take-home message of this clinical pearl, which is: utilize the new range of motion you have acquired from assistive mobilizations/stretches etc. by pairing them with muscular activation exercises!
Step #4: Don’t Forget About Muscle Activation!
When you hear the word ‘mobility’, the first associated words that come to your mind usually include phrases such as ‘flexibility’, ‘stretching’, ‘mobilizations’, etc. However, in order to gain LONG TERM mobility, we need to ACTIVATE our musculature within new ranges of motion we achieve! If we solely rely on passive approaches to gaining mobility such as dynamic stretching for example, we often fall back into our limited ranges of motion.
In a study by Winter, the author investigated the effectiveness of targeted home-based hip exercises in individuals with non-specific chronic or recurrent low back pain with reduced hip mobility. The results demonstrated that the majority of individuals in all groups had clinical improvements in pain, but only the hip strengthening group had the majority of participants (80%) exhibit clinical improvements in function.
Below are some hip stability and strengthening exercises that can be paired with other hip mobility interventions.
After working on hip internal rotation mobilizations and/or dynamic stretches, this is a great way to actively recruit the hip internal rotators. If it is too challenging for someone with a resistance band, simply start in side lying without a band against gravity, and progress as able. You can view various reverse clam progressions and regressions in our exercise library.
You can add external rotation to the reverse clam to also activate hip external rotators in this side lying position.
The hip 3 way works on active hip mobility of hip abduction, flexion, and extension, while also promoting muscle activation of our hip abductors in a weight-bearing position. Very functional exercise that targets key, movement functions, including stability, mobility, motor control, and proprioception.
A key with this exercise is to ensure that patients are activating their hip abductors on the stance limb, which arguably is the bearer of more work with this exercise. This helps enhance pelvic control in weight bearing while performing a dynamic movement.
Also, when performing hip extension, be on the lookout for compensations of excessive lumbar extension due to glute max inhibition and/or a forward trunk lean to gain more range of motion and leverage. Many people think that because their hip does not move far back into extension, they have to create more motion. Hip extension is more limited in comparison to other movements of the hip joint!
We have a plethora of side plank variations in our exercise library. This is a great way to target the gluteus medius, one of our key hip abductors in the frontal plane.
Functional Range Conditioning For Hip Activation
FRC is defined as strength and control in order to expand upon usable ranges of motion, articular resilience (i.e. load bearing capacity), and overall joint health. Prioritizing FRC principles in your training and [P]Rehab program can be a huge game changer! The mechanoreceptors that innervate our joint capsules provides the CNS with afferent feedback carrying signals that pertain to what is going on within the joint. More stimulus to the mechanoreceptors means more afferent feedback to the CNS, which causes more efferent output back to the musculoskeletal system, ultimately inducing more control.
Each time when performing CARs, try to create larger “circles” to improve control on the outer limits of your range, thus enhancing the adaptability of your tissues and aiding in joint health, integrity, and protection. Also, to increase the intensity of this exercise, you can increase the resistance through the air from 0% to 100%. This will help create more tension throughout the body to ultimately improve muscular and neurological control. This is a great intro to FRC and excellent starting point!
Hip PAILS and RAILS
Progressive Angular Isometric Loading (PAIL) and Regressive Angular Isometric Loading (RAIL) are specific types of FRC exercises. These techniques help teach the central nervous system (CNS) how to control and function in newly acquired ranges. Utilizing isometric contraction teaches the nervous system to have active control over a particular range (i.e. shortened or lengthened positions). These techniques help expand available range of motion. In addition, PAILs and RAILs will help build strength and tissue adaptation in both the shortened and lengthened ranges of motion. A key component while performing PAILs and RAILs is to irradiate, which means create tension throughout the body.
Searching For A More Comprehensive, User-Friendly Exercise Library
To improve hip mobility, we not only need to perform the right type of exercises, but we also have to set ourselves up for success. Everything we do outside of exercise also plays an integral role in our body’s health. Education for our patients is the starting point. From there, develop a wholesome approach to moving the hip, with activation exercises being the quarterback. The rest of the team consists of self mobilization exercises dynamic flexibility exercises to enhance overall movement capacity. Even if someone may not have limited mobility within a particular plane of motion at the hip, still move within all planes of hip movement! The more individuals are able to move their hips within the sagittal, frontal, and transverse planes, the more adaptable the hip will be to all movements it can perform.
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Sherif Elnaggar, PT, DPT, OCS