고관절(hip joint) 관절가동, 수기저항운동, 자가운동, 기능적 운동법 - 정리중

[문형철]

고관절은 걷고, 달리고 앉고 일어서기를 반복하면서 끊임없이 체중부하에 노출되는 구상관절(ball and socket joint)

구상관절인데도 불구하고 대개 hypomobile dysfunction이 많은 관절

어떻게 관절 가동(oscillation, sustained translatory joint play)를 줄 것인가?

저항운동을 어떻게 할 것인가?

자가 운동, 기능적 운동을 어떻게 할 것인가?

panic bird...

Hip Joint (Fig. 5.44)

The concave acetabulum receives the convex femoral head. Biomechanics of the hip joint are reviewed in Chapter 20.

Resting Position

The resting position is hip flexion 30, abduction 30, and slight external rotation.

- 고관절의 열린자세는 고관절 30도 굴곡, 30도 외전, 약간 외회전 상태

Stabilization

Fixate the pelvis to the treatment table with belts. 

Hip Distraction of the Weight-Bearing Surface, Caudal Glide (Fig. 5.45)

N O T E : Because of the deep configuration of this joint, traction applied perpendicular to the treatment plane causes

lateral glide of the superior, weight-bearing surface. To obtain separation of the weight-bearing surface, caudal glide is used.

Indications

Testing; initial treatment; pain control; general mobility.

Patient Position

Supine, with the hip in resting position and the knee extended.

P R E C A U T I O N : In the presence of knee dysfunction, this position should not be used; see alternate position following.

Therapist Position and Hand Placement

Stand at the end of the treatment table; place a belt around your trunk, then cross the belt over the patient’s foot and

around the ankle. Place your hands proximal to the malleoli, under the belt. The belt allows you to use your body weight to apply the mobilizing force.

Mobilizing Force

Long-axis traction is applied by pulling on the leg as you lean backward.

Alternate Position for Hip Caudal Glide

Indication

To apply distraction to the weight-bearing surface of the hip joint when there is knee dysfunction.

Patient Position

Supine, with the hip and knee flexed.

Therapist Position and Hand Placement

Wrap your hands around the epicondyles of the femur and distal thigh. Do not compress the patella.

Mobilizing Force

The force comes from your hands and is applied in a caudal direction as you lean backward.

Hip Posterior Glide (Fig. 5.46)

Indications

To increase flexion; to increase internal rotation.

Patient Position

Supine, with hips at the end of the table.

The patient helps stabilize the pelvis and lumbar spine by flexing the opposite hip and holding the thigh against the chest with the hands. 

Initially, the hip to be mobilized is in resting position; progress to the end of the range.

Therapist Position and Hand Placement

Stand on the medial side of the patient’s thigh.

Place a belt around your shoulder and under the patient’s thigh to help hold the weight of the lower extremity. 

Place your distal hand under the belt and distal thigh.

Place your proximal hand on the anterior surface of the proximal thigh.

Mobilizing Force

Keep your elbows extended and flex your knees; apply the force through your proximal hand in a posterior direction.

Hip Anterior Glide (Fig. 5.47)

Indications

To increase extension; to increase external rotation.

Patient Position

Prone, with the trunk resting on the table and hips over the edge. The opposite foot is on the floor.

Therapist Position and Hand Placement

Stand on the medial side of the patient’s thigh.

Place a belt around your shoulder and the patient’s thigh to help support the weight of the leg.

With your distal hand, hold the patient’s leg. Place your proximal hand posteriorly on the proximal thigh just below the buttock.

Mobilizing Force

Keep your elbow extended and flex your knees; apply the force through your proximal hand in an anterior direction.

Alternate Position (Fig. 5.47B)

Position the patient side-lying with the thigh comfortably flexed and supported by pillows.

Stand posterior to the patient and stabilize the pelvis across the anterior superior iliac spine with your cranial hand.

Push against the posterior aspect of the greater trochanter in an anterior direction with your caudal hand.

고관절 운동법

3개의 인대

1) iliofemoral ligament

2) pubofemoral ligament

3) ischiofemoral ligament

이 표를 외워야 할까? 어떻게 핵심을 찾아내야

고관절의 roll and slide 움직임(arthrokinematic)은 osteokinematic 움직임인 굴곡, 신전, 외전, 내전, 내회전, 외회전시 규칙성있음.

Influence of the Hip Joint on Balance and Posture Control

The joint capsule is richly supplied with mechanoreceptors that respond to variations in position, stress, and movement

for control of posture, balance, and movement. Reflex muscle contractions of the entire kinematic chain, known as balance strategies, occur in a predictable sequence when standing balance is disturbed and regained. Joint pathologies, restricted motion, or muscle weakness can impair balance and postural control.33,48 Refer to Chapter 8 for an in-depth discussion of these concepts.

- 고관절 관절낭은 체중부하를 직접적으로 받기때문에 기계적 수용기가 풍부하여 "다양한 자세, 부하, 움직임, 균형"등에 반응함. 

- 반사성 근수축은 균형전략으로 알려진 전체적인 역학적 사슬관계에서 발생함. 

- 고관절의 병리는 움직임을 제한하고, 근육위약은 자세조절과 균형을 손상시킬 수 있음. 

FUNCTIONAL RELATIONSHIPS OF THE HIPS AND PELVIS

Pelvic Motions and Muscle Function

The pelvis is the connecting link between the spine and lower extremities (Fig. 20.3A). Movement of the pelvis causes motion at the hip joints and lumbar spine articulations. The hip musculature causes pelvic motion through reverse action. Hip flexors cause an anterior pelvic tilt; hip extensors, a posterior pelvic tilt; and abductors and adductors, a lateral pelvic tilt. Rotators cause pelvic rotation. To prevent excessive pelvic motion when moving the femur at the hip joint, the pelvis must be stabilized by the abdominals, erector spinae, multifidus, and quadrates lumborum muscles.

- 골반은 척추와 하지를 연결하는 역할. 골반의 움직임은 고관절과 요추관절면의 움직임을 야기함

- 고관절 근육은 역방향의 행위를 통해 골반을 움직임. 

- 고관절 굴곡근은 ant pelvic tilt를 야기하고, 고관절 신전근은 post pelvic tilt를 야기함.

- 고관절 내전근과 외전근은 lateral pelvic tilt를 야기함. 

- 고관절 회전근은 골반 회전을 야기함

- 과도한 골반 움직임을 방지하기 위해 고관절에서 대퇴골이 움직일때, 골반은 복부, 척추기립근, 다열근, 요방형근에 의해서 안정화되어야 함. 

골반전방틀어짐(ant pelvic tilt)

The anterior superior iliac spines of the pelvis move anteriorly and inferiorly and thus closer to the anterior aspect

of the femur as the pelvis rotates forward around the transverse axis of the hip joints (Fig. 20.3B). This results in hip 

flexion and increased lumbar spine extension.69

# Muscles causing this motion are the hip flexors and back extensors.

# During standing, the line of gravity of the trunk falls anterior to the axis of the hip joints; the effect is an anterior pelvic tilt moment. Stability is provided by the abdominal muscles and hip extensor muscles.

골반후방틀어짐(Posterior Pelvic Tilt)

The posterior superior iliac spines of the pelvis move posteriorly and inferiorly, thus closer to the posterior aspect of the femur as the pelvis rotates backward around the axis of the hip joints (Fig. 20.3C). This results in hip extension and lumbar spine flexion.69

# Muscles causing this motion are the hip extensors and trunk flexors.

# During standing when the line of gravity of the trunk falls posterior to the axis of the hip joints, the effect is a posterior pelvic tilt moment. Dynamic stability is provided by the hip flexors and back extensors and passive stability by the iliofemoral ligament.

골반이동(Pelvic Shifting)

During standing, a forward translatory shifting of the pelvis results in extension of the hip and extension of the lower lumbar spinal segments. There is a compensatory posterior shifting of the thorax on the upper lumbar spine with increased flexion of these spinal segments. This is often seen with slouched or relaxed postures (see Fig. 14.12B in Chapter 14). Little muscle action is required; the posture is maintained by the iliofemoral ligaments at the hip, anterior longitudinal ligament of the lower lumbar spine, and posterior ligaments of the upper lumbar and thoracic spine. 

Lateral Pelvic Tilt(hip hiking, hip or pelvic drop)

Frontal plane pelvic motion results in opposite motions at each hip joint. Pelvic motion is defined by what is occurring to the iliac crest of the pelvis that is opposite the weight-bearing extremity (that is, the side of the pelvis that is moving). When the pelvis elevates, it is called hip hiking; when it lowers, it is called hip or pelvic drop. On the side that is elevated, there is hip adduction; on the side that is lowered, there is hip abduction (Fig. 20.4A). 

During standing, the lumbar spine laterally flexes toward the side of the elevated pelvis (convexity of the lateral curve is

toward the lowered side).69 

#Muscles causing lateral pelvic tilting include the quadrates lumborum on the side of the elevated pelvis and reverse muscle pull of the gluteus medius on the side of the lowered pelvis.

# With an asymmetrical slouched posture, the person shifts the trunk weight onto one lower extremity and allows the pelvis to drop on the other side. Passive support comes from the iliofemoral ligament and iliotibial band on the elevated side (stance leg).

# When standing on one leg, there is an adduction moment at the hip, tending to cause the pelvis to drop on the  unsupported side (hip or pelvic drop). This is prevented by the gluteus medius stabilizing the pelvis on the stance side.

Pelvic Rotation

Rotation occurs around one lower extremity that is fixed on the ground. The unsupported lower extremity swings forward or backward along with the pelvis. When the unsupported side of the pelvis moves forward, it is called forward rotation of the pelvis.69 The trunk concurrently rotates in the opposite direction, and the femur on the stabilized side concurrently rotates internally. When the unsupported side of the pelvis moves backward, it is called posterior rotation; the femur on the stabilized side concurrently rotates externally, and the trunk rotates opposite (Fig. 20.4B). 

Lumbopelvic Rhythm

A coordinated movement between the lumbar spine and pelvis occurs during maximum forward bending of the trunk25 as when reaching toward the floor or the toes. As the head and upper trunk initiate flexion, the pelvis shifts posteriorly to maintain the center of gravity over the base of support. The trunk continues to forward-bend, being controlled by the extensor muscles of the spine, until at approximately 45. 

At this point for an individual with relatively normal flexibility, the posterior ligaments become taut, and the facets of the zygapophyseal joints approximate.

Both of these factors provide stability for the intervertebral joints, and the muscles relax.126 Once all of the vertebral segments are at the end of the range and stabilized by the posterior ligaments and facets, the pelvis begins to rotate forward (anterior pelvic tilt), being controlled by the gluteus maximus and hamstring muscles. The pelvis continues

to rotate forward until the full length of the muscles is reached. Final range of motion (ROM) in forward bending is dictated by the flexibility of the various back extensor muscles and fasciae as well as hip extensor muscles.

The return to the upright position begins with the hip extensor muscles rotating the pelvis posteriorly through reverse muscle action (posterior pelvic tilt) then the back extensor muscles extending the spine from the lumbar region upward. Variations in the normal synchronization of this activity occur because of training (as with dancers and gymnasts), faulty habits, restricted muscle or fascia length, or injury and faulty proprioception. 

Pathomechanics in the Hip Region

Abnormal structure or impaired function of the hip—such as a leg-length discrepancy, decreased flexibility, or muscle

imbalances—can contribute to stress in the spine or other joints of the lower extremities.

Decreased Flexibility

Decreased flexibility in the structures around the hip joint cause weight-bearing forces and movement to be transmitted to the spine rather than absorbed in the pelvis. Tight hip extensors cause increased lumbar flexion when the thigh flexes. Tight hip flexors cause increased lumbar extension as the thigh extends. Hip flexion contractures

with incomplete hip extension during weight bearing also place added stresses on the knee because the knee cannot

lock while the hip is in flexion unless the trunk is bent forward. During weight bearing tight adductors cause lateral pelvic tilt opposite the side of tightness and side bending of the trunk toward the side of tightness. The opposite occurs with tight abductors.

Asymmetrical Leg Length

Functional as well as structural asymmetries of the lower extremities affect the posture of the pelvis. 

1) Unilateral short leg. 

A unilateral short leg causes lateral pelvic tilting (drop on the short side) and side-bending of the trunk away from the short side (convexity of lateral lumbar curve toward side of short leg). This may lead to a functional or eventually a structural scoliosis. Causes of a short leg could be unilateral lower extremity asymmetries such as flat foot, genu valgum, coxa vara, tight hip muscles, anteriorly rotated innominate bone, poor standing posture, or asymmetry in bone growth.

2) Coxa valga and coxa vara. 

A pathologically large angle of inclination between the femoral neck and shaft of the femur is called coxa valga, and a pathologically smaller angle is called coxa vara. Unilateral coxa valga results in a relatively longer leg on that side and associated genu varum. Unilateral coxa vara leads to a relatively shorter leg with associated genu valgum. 

3) Anteversion and retroversion. 

An increase in the torsion of the femoral neck is called anteversion and causes the shaft of the femur to be rotated medially; a decrease in the torsion is called retroversion and causes the shaft of the femur to be rotated laterally. Anteversion often results in genu valgum and pes planus. Unilateral ante version results in a relatively shorter leg on that side; retroversion

causes the opposite effects.

Hip Muscle Imbalances and Their Effects

Muscles function through habit. Faulty mechanics from inadequate or excessive length and an imbalance in strength cause hip, knee, or back pain.116 Overuse syndromes, soft tissue stress, and joint pain develop in response to continued abnormal stresses. The related muscle imbalances due to postural impairments are summarized in Box 20.2. Common muscle length-strength imbalances include the following.

1) Shortened iliotibial (IT) band with shortened tensor fasciae latae (TFL) or gluteus maximus. 

Postural impairments often associated with a shortened TFL or gluteus maximus include an anterior pelvic tilt posture, slouched posture, or flat back posture (see Chapter 14).

2) Dominance of the two-joint hip flexor muscles (TFL, rectus femoris, sartorius) over the iliopsoas. 

This imbalance may cause faulty hip mechanics or knee pain from overuse of these muscles as they cross the knee. 

3) Dominance of the TFL over the gluteus medius. 

This imbalance leads to lateral knee pain from IT band tension or medial rotation of the femur with medial knee stresses from an increased bowstring effect.

4) Dominance of hamstring muscles over the gluteus maximus.

The gluteus maximus becomes short and the range of hip flexion decreases; compensation occurs with excessive lumbar spine flexion whenever the thigh is flexed. Limited mobility in the gluteus maximus also causes increased tension on the IT band with associated trochanteric or lateral knee pain. Overuse of the hamstring muscles causes decreased flexibility as well as muscle imbalances with the quadriceps femoris muscle

at the knee. 

The hamstrings dominate the stabilizing function by pulling posteriorly on the tibia to extend the knee in closed-chain activities. This alters the mechanics at the knee and may lead to overuse syndromes in the hamstring tendons or anterior knee pain from imbalances in quadriceps pull.

5) Use of lateral trunk muscles for hip abductors. 

This results in excessive trunk motion and increased stress in the lumbar spine.

THE HIP AND GAIT

During the normal gait cycle, the hip goes through a ROM of 40 of flexion and extension (10 extension at terminal stance to 30 flexion at midswing and initial contact). There is also some lateral pelvic tilt and hip abduction/adduction of 15 (10 adduction at initial contact, 5 abductionat initial swing); and hip internal/external rotation along with pelvic rotation totaling 15 transverse plane motion (peak internal rotation at the end of loading, peak external rotation at the end of pre-swing). Loss of any of these motions affects the smoothness of the gait pattern.105

Hip Muscle Function During Gait

Hip Flexors

The hip flexors control hip extension at the end of stance, then contract concentrically to initiate swing.105 With loss

of flexor function, a posterior lurch of the trunk to initiate swing is seen. Contractures in the hip flexors prevent complete

extension during the second half of stance; the stride is shortened. To compensate, a person increases the lumbar

lordosis or walks with the trunk bent forward.

Hip Extensors

The hip extensors control the flexor moment at initial foot contact, and the gluteus maximus initiates hip extension.105

With loss of extensor function, a posterior lurch of the trunk occurs at foot contact to shift the center of gravity of the trunk posterior to the hip. With contractures in the gluteus maximus, some decreased range occurs in the terminal swing as the femur comes forward, or the person may compensate by rotating the pelvis more forward. The lower extremity may rotate outward because of the external rotation component of the muscle, or the gluteus maximus may place greater tension on the iliotibial band through its attachment, leading to irritation along the lateral aspect of the knee with excessive activity.

Hip Abductors

The hip abductors control the lateral pelvic tilt during swinging of the opposite leg.105 With loss of function of the gluteus medius, lateral shifting of the trunk occurs over the weak side during stance when the opposite leg swings. This lateral shifting also occurs with a painful hip because it minimizes the torque at the hip joint during weight bearing. The tensor fasciae latae also functions as an abductor and may become tight and affect gait with faulty use.

Effect of Musculoskeletal Impairments on Gait

Bony and joint deformities change alignment of the lower extremity and therefore the mechanics of gait. Painful conditions

cause antalgic gait patterns, which are characterized by minimum stance on the painful side to avoid the stress of weight bearing.

REFERRED PAIN AND NERVE INJURY

The hip is innervated primarily from the L3 spinal level; hip joint irritation is usually felt along the L3 dermatome reference from the groin, down the front of the thigh to the knee.35,72 For a detailed description of referred pain patterns and peripheral nerve injuries in the hip and buttock region, see Chapter 13.

Major Nerves Subject to Injury or Entrapment

# Sciatic nerve. 

Entrapment may occur when the sciatic nerve passes deep to the piriformis muscle (occasionally it passes over or through the piriformis). 

# Obturator nerve. 

Isolated injury is rare, although uterine pressure and damage during labor may occur.

# Femoral nerve. 

Injury may result from fractures of the upper femur or pelvis, during reduction of congenital dislocation of the hip, or from pressure during a forceps labor and delivery.

Common Sources of Referred Pain in the Hip and Buttock Region

If painful symptoms are referred to the hip and buttock region from other sources, primary treatment must be directed to the source of the irritation. Common sources of referred pain into the hip and buttock region include: 

Nerve roots or tissues derived from spinal segments L1, L2, L3, S1, and S2.

Lumbar intervertebral and sacroiliac joints.

흔한 고관절 질환

고관절 rom증진을 위한 MWM

고관절 수술후 주의사항

#  ROM 

- 고관절 굴곡(80~90도), 중립위치를 벗어낸 내전과 내회전을 피해야

# ADL

- ....

자가 스트레칭

단계적으로 시행하는 고관절 운동법

1. 고관절 외전운동

1) Supine Abduction

Supine abduction is the easiest position in which to initiate motion because the effects of gravity on the abductors are

eliminated. Have the patient concentrate on isolated hip abduction while keeping the trunk still. Do not let the femur roll outward into external rotation. For very weak patients, provide assistance or place a

skate or towel under the leg to minimize the effects of friction.

If the patient is not strong enough to progress to the side-lying position, place a weight, such as a sandbag, along the outside of the thigh or ankle and have the patient push the weight outward.

2) Side-Lying Abduction

CF) Clamshell exercise

Have the patient flex the bottom leg for balance, and then lift the top leg into abduction, keeping the hip neutral to rotation and in slight extension. Do not allow the hip to flex or the trunk to roll backward. Add ankle weights to provide resistance as the patient’s strength improves. 

If the patient has difficulty controlling hip abduction in the side lying position, use the following training sequence.

First have the patient practice externally rotating the thigh. This may be done with the hip and knee in slight flexion while the patient lifts the uppermost knee off the mat or with the hip and knee extended while the patient rolls the uppermost  extremity outward.

Once the patient can control external rotation, have him or her extend the hip (without arching the spine) and then abduct the top leg (it should be aligned in the plane of the body). The patient then slowly adducts and abducts the thigh against gravity.

3) Standing Abduction

Have the patient, while standing on one leg, bring the other lower extremity out to the side. Instruct the patient to maintain the trunk upright, in neutral alignment, and not let the abducting hip flex or rotate. 

# Add resistance by applying an ankle weight on the moving  leg or by using pulleys or elastic resistance applied at right angles to the moving extremity.

# The abductors on the stationary lower extremity experience closed-chain resistance while stabilizing the pelvis,

and the abductors on the moving extremity experience open-chain resistance.

2. 고관절 신전운동

1) Gluteal Muscle Setting

Use gluteal setting exercises to increase awareness of the contracting muscle. Position the patient prone or supine

and teach the patient to “squeeze” (contract) the buttocks.

- 엎드리거나 앙와위로 누워서 둔부근육을 수축하기

2) Forward-Bending Leg Lifts

With the patient standing at the edge of the treatment table and the trunk flexed and supported on the table, have the

patient alternately extend one hip, then the other. This is done with the knee flexed to train the gluteus maximus while relaxing the hamstrings. If the hamstrings cramp from active insufficiency, the patient is attempting to use them and should practice relaxing them before progressing with this exercise. Progress by adding weights or elastic resistance to the distal thigh.

3) Quadruped Leg Lifts

Have the patient alternately extend each hip while keeping the knee flexed (Fig. 20.18). Combine this exercise with

trunk stabilization by first having the patient find the neutral pelvic position, drawing in the abdominal muscles, then extending the hip (see Chapter 16).

3. 고관절 외회전 운동법

Prone

The patient’s knees are flexed and about 10 inches apart. Have the patient press the heels together, causing an isometric

contraction of the external rotators.

Side-Lying

With both lower extremities partially flexed at the hips and knees and the heel of the top leg resting on the heel of the

bottom leg, have the patient lift the knee of the top leg, keeping the heels together.

Progression. Have the patient extend the top hip and knee, aligning the lower extremity with the trunk, then rolling the leg outward. Progress this to lifting the entire lower extremity into abduction once the hip is externally rotated. 

Standing

With feet parallel and about 4 inches apart, have the patient flex the knees slightly, then externally rotate the thighs (so the knees are pointing laterally) while keeping the feet stationary on the floor. Tell the patient to maintain external rotation while extending the knees, then relax the rotation slightly until the patellae point forward.

Sitting

With knees flexed over the edge of the treatment table, secure elastic material around the patient’s ankle and the table leg on the same side. Have the patient move the foot toward the opposite side, pulling against the resistance, causing external

rotation of the hip.

4. 고관절 내전 운동법

Side-Lying

With the bottom leg aligned in the plane of the trunk (hip extension) and the top leg flexed forward with the foot on

the floor or with the thigh resting on a pillow, have the patient lift the bottom leg upward into adduction. Weights can be added to the ankle to progress strengthening (Fig. 20.19A). A more difficult position is to have the patient hold the top leg in abduction and adduct the bottom leg up to meet it (Fig. 20.19B).

Standing

Have the patient adduct the leg across the front of the weight-bearing leg. Add ankle weights to provide resistance,

or fasten elastic resistance or a pulley at right angles to the moving leg.

5. HIp hiking/ pelvic drop exercise

런지 with cane

벽에 기대어 스쿼트

resisted walking

pretubation exercise

[heoss]

감사합니다.

[지오]

영어라서 시간이 걸리지만.. 사진만으로도 큰 도움이 됩니다 . 고맙습니다.

[한원주]

그리고 자꾸 잊어집니다. 좋은 자료 감사합니다.

[su76]

고맙습니다^^

[ChulhwanKim]

좋은글 감사합니다