An Overview of Hip Injuries in Running

[문형철]

참 재미있는 논문이넹

논문 하나더 추가

Evidence-Based Treatment of hip and pelvic injury in runner.pdf

Functional examination

1. Observation:

a. Static alignment of the lower extremity: Static alignment is suggestive but does not reveal how the pelvis, hip, knee, ankle, and foot interact in response to body weight and ground reaction force [24]. Williams and coworkers [25] noted that stiff-arched runners demonstrated increased loading rates which may predispose them to injury.

b. Running: Whenever practical, the clinician should watch the patient run. Compensatory strategies that are a source of overload might be seen at this time. Observation should be made regarding length of stride. Impact forces and vertical displacement increase with stride length [26]. A shortened stride may be related to a proximal or distal sagittal blockade at any of the joints of the lower extremity. The amount of trunk motion in all three planes relative to the pelvis is a key observation. Insufficient or excessive motion in a specific plane about the trunk may suggest difficulty or inability to load the abdominals eccentrically to stabilize the pelvis.

2. Unilateral squat (Fig. 1): The pronation phase of a single leg squat mimics, to some extent, the key events of the loading phase of running and walking. Special attention is paid to how the patient controls eccentric loading of the muscles of the hip and pelvis. Important events to observe by plane of motion:

a. Sagittal plane (SP): Excessive forward bending of the trunk relative to the amount of knee flexion is suggestive of quadriceps and gluteus maximus weakness or an overreliance on the hamstrings to decelerate anterior tilting of the pelvis and forward momentum of the trunk. This may result in a forward sway of the trunk in the initial stages of propulsion.

b. Frontal plane (FP): A Trendelenburg sign (frontal plane lurch) may be elicited with a single leg squat. This usually indicates gluteus medius and minimus weakness.

c. Transverse plane (TP): Rotation to the same side leg, to stabilize the hip over the femur, suggests weakness in the gluteus maximus in this plane of motion.

d. Special attention should be given to excursion (range of motion) and control of subtalar joint pronation. The rate of subtalar motion should be proportional to the rate of internal rotation/abduction at the tibia and femur. An immediate flattening of the longitudinal arch of the foot may be related to compromised control of pronation at the hip. Pronation that occurs too rapidly often is noted in the FP at the knee by excessive knee valgus as a result of poorly controlled

femoral abduction. This is correlated with a weakened gluteus medius. It was noted that female recreational runners exhibited greater TP and FP motion at the hip and knee. The ability to control this excursion range may play a key role in avoiding overload of the lower extremities, and ultimately, injury [27].

3. Core mobility testing: The relationship of mobility of the lumbopelvic region and distal joints is examined in each plane of motion.

a. Sagittal core (Fig. 2): The test is performed in a bilateral stance posture. The clinician demonstrates the test with minimal verbal coaching. Restriction of posterior to anterior translation during extension of the spine and extremities suggests tightness in the anterior hip capsule or psoas. Hyperextension of the lumbar spine and knee flexion are

common compensatory patterns to achieve anterior translation of the trunk. During the flexion phase of this examination, an early heel rise is noted if there is inadequate ankle dorsiflexion, which often is associated with gastrocnemius tightness. Excessive hip flexion often is seen as a compensatory motion for restricted ankle dorsiflexion.

b. Frontal core (Fig. 3): The starting position and instruction procedure is the same as with sagittal core testing. The primary observation is the ability to translate the pelvis in the frontal plane during truncal side-bending. Lateral translation of the pelvis to one side requires ipsilateral adduction and contralateral abduction of the hips. A restriction in abduction reflects tightness in the inferior or medial hip joint capsule, hip adductors, or medial hamstrings.

c. Transverse core (Fig. 4): This test provides a wealth of information for functional diagnosis and treatment. It is performed in symmetric stance posture with feet shoulder width apart. The following points are kept in mind when observing the runner:

(1) When compared with running and walking, the joint mechanics on the leg to the side of pelvic rotation are similar to those of the late stance phase of the propelling leg. The mechanics on the leg opposite the direction of pelvic rotation is similar to the loading portion of early stance. With supination, the pelvis, tibia, and femur are rotating externally (from top down), which results in subtalar joint inversion and locking of the foot. With supination, the pelvis goes through greater excursion (range) than the femur and tibia. This rotation of the pelvis relative to the femur maintains an ideal length tension for the gluteals, which are active in the later stages of propulsion [28].

(2) In the transverse core test, the subtalar joint on the side of pelvic rotation should be able to invert the calcaneus and lock up the midtarsal joint, as it does in the last phases of stance, without a notable change in the anterior to posterior orientation of the foot. Attention should be paid to the feet and midtarsal joints to see if they remain stable or twist or roll to the side of rotation. Excessive lateral movement of the foot in this test may be associated with tightness of any of the muscles and joint structures that could restrict hip internal rotation—primarily the psoas, short external rotators of the hip, and posterior hip capsule. As decelerators of pelvic rotation to the rear leg, the adductor longus and medial hamstrings are potential contributors to this deficit in hip internal rotation. At the ankle, a tight medial gastrocnemius is a limiting factor in the ability to rotate the tibia externally.

(3) At the leg opposite the side of pelvic rotation, the biomechanical events of pronation occur. The relationship of the foot to the hip on this side is demonstrated by the ability of the subtalar joint to convert the internal rotation of the femur and tibia into calcaneal eversion [29]. Because the knee tends to flex on this side, the influence of the gastrocnemius on the subtalar joint is lessened. As a result, a restriction in calcaneal eversion and ankle dorsiflexion tends to be more articular than soft tissue related. If a lack of calcaneal eversion is seen, then manual joint techniques of the subtalar joint may be useful to improve the ability of the entire chain to absorb shock. An excessively pronated foot, where the calcaneus is everted fully to end range in weight bearing, also can be a problem.

4. Eccentric-Concentric Control of the Core (ECC): These tests look at the ability of the core muscle groups, primarily the abdominals, spinal extensors, psoas, iliacus, quadratus lumborum, latissimus dorsi, and hip girdle muscles to control the body’s center of mass.

a. Sagittal ECC (Fig. 5): This test assesses the ability of the psoas, rectus femoris, short hip adductors, and rectus abdominis to control eccentrically extension of the spine and anterior translation of the pelvis. Each side is tested. Common compensatory patterns include restricted anterior translation of the pelvis with overextension by the lumbar or thoracic spine, excessive flexion of the knee, ‘‘clawing’’ of the toes, or hyperactivity of the toe extensors to stabilize distally.

b. Frontal ECC (Fig. 6): This test challenges pelvic stability in the frontal plane, which makes it an excellent test of gluteus medius function. Loss of balance or a Trendelenburg sign mark the onset of fatigue in this muscle and lateral stabilizers of the pelvis. This is a common finding, even in well-conditioned runners who train primarily in the SP, and derive minimal challenge to the FP activity of hip and thigh muscles.

c. Transverse (Fig. 7): On the stance leg, the external abdominal oblique, contralateral internal abdominal oblique, and psoas will rotate the spine contralaterally. The gluteus maximus and deep hip rotators will rotate the pelvis contralaterally. The pelvis and spine should rotate synchronously—ipsilaterally as these muscles lengthen and contralaterally as they shorten. Motion in the spine that markedly exceeds pelvic motion in relationship to the femur of the

stance leg indicates tightness in the short hip external rotators and posterior hip capsule. It also suggests an inability of the hip to load the gluteals eccentrically in the transverse plane during the propulsion stage of stance.

d. All of these tests can be made more or less challenging to meet the functional capabilities of the runner by modifying the amount of support, speed, number of repetitions, and the range of the excursion. A successful base test requires 10 controlled repetition on each side.

5. Hip-scapula reaction (HSR): The pelvic girdle, which is connected to the scapula by the axial skeleton and associated thoracolumbar soft tissues, induces a pattern of scapula motion in all three planes as a response to its movement (Table 1). Although this ‘‘scapula reaction’’ is not a mandatory movement, joint mechanics of the upper quarter are optimized by linked movements with the trunk and pelvis. Similarly, the mobility of the pelvis and function of the muscles of the torso and hips are influenced by the ability of the scapula and thoracic cage to move freely in all three planes (Figs. 8–10). In respect to running, HSR underscores the role of the abdominals in controlling the triplanar

아이고 넘 복잡하다.

An Overview of Hip Injuries in Running.pdf