Dysfunctional Trunk Rotation and/or Dysfunctional Hip Abduction Functional Movement Tests

in 2 Movement Tests Lower Quarter, Active Trunk Rotation, All Lower Quarter, Hip ABD Firing Pattern

Dysfunctional Trunk Rotation and/or Dysfunctional Hip Abduction Functional Movement Tests

These dysfunctional movement tests can be best addressed by mobilizing any spinal dysfunctions that are found at the thoracolumbar junction and/or by stretching the quadratus lumborum and piriformis muscles. It is also sometimes helpful to mobilize the inferiomedial hip capsule and stretch the hip adductors as covered in 4b. These sources of inhibition should be addressed before attempting retraining.

Anatomy and Biomechanical Considerations:

Quadratus Lumborum, Piriformis and Posterior Hip Capsule

Observations:

Hypertonicity in the quadratus lumborum on one side is associated with a FRS dysfunction at the TL junction on that side, i.e., hypertonic right QL found with an FRS R at T12-L1.
Pinching in the anterior groin with FADIR test or when attempting to stretch the piriformis is related to a tight posterior hip capsule. “Groin pain is posterior hip capsule tightness until proven otherwise”, Dr. Philip Greenman.
An apparent tightness in the posterior hip capsule dissipates, often times dramatically, after mobilizing the upper lumbar spine for FRS dysfunctions on the same side, ie., tight R posterior hip capsule, FRS R at L1,2 or L2,3 will be present.
Therefore, before we treat the quadratus lumborum, piriformis and posterior hip capsule we need to first identify and treat any FRS dysfunctions found between T12-L2.

Quadratus Lumborum

Three distinct divisions:
- Lateral (global mobilizer)
- Iliolumbar
- Lumbocostal
Function – stabilizer of the lumbar supine, a lateral flexor of the lumbar spine and a hip hiker
Innervation – thoraco-lumbar spinal nerves
Most frequent muscular cause of back pain (Travell and Simons, 1992)

PIRIFORMIS: Origin at S 2-4, exits to insert at greater trochanter.

It crosses the SI joint and hypothetically influences the oblique axis of the sacrum during coupled motion.

Attaches to the anterior surface of S2, 3, 4 and
inserts into the greater trochanter
Below 90º of hip flexion it abducts and ER the hip
Above 90º of hip flexion it abducts and IR the hip
Innervation – S1 and 2

FIVE EXTERNAL ROTATORS OF HIP
Obturator internus
Obturator externus
Gemellus superior
Gemellus inferior
Quadratus femoris

(These muscles are intimately attached to the posterior hip capsule.)

Alternative Test for Hip Abduction: (Hip Clam)

in 2 Movement Tests Lower Quarter, All Lower Quarter, Hip ABD Firing Pattern

Alternative Test for Hip Abduction: (Hip Clam)

To test the right side:

Patient is lying on their left side with a pillow under the head and the shoulder and hips perpendicular to the table.
The hips are flexed to approximately 45º with the knees flexed and the feet touching.
Ask the patient to slowly raise the right knee as high as possible keeping the feet in contact.
Compare the right to the left side, and compare any limitations noted in range of motion with the degree of inhibition of the gluteus medius on that side.

Forward Bending in Right Step Standing

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, Pelvic Clocks, Self-mobilization, Supine Curl Up

Forward Bending in Right Step Standing

Forward Bending in Right Step Standing

For an ERS Left and or high tone in the Left Erector Spinae:

The patient starts in standing and places their right foot up on a chair.
Instruct the patient to place their hands around each side of their right knee and slide their hands down the leg towards the ankle attempting to bring the chest down towards the right knee.
They hold the stretch for 5 to 10 seconds then return to upright standing.
Have the patient repeat this sequence 8 to 10 times.
For an ERS Right they place the left foot up on a chair.

Hip Diagonals

in 2 Movement Tests Lower Quarter, 4 Manual Therapy Strategies, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, All Manual Therapy, Manual Stretching, Mobilization, Muscle Energy, Self-mobilization

Hip Diagonals

Hip Diagonals

To treat an ERS Right and/or high tone in the Right Erector Spinae:

The patient starts this exercise in the hands and knees position and is instructed to sit back diagonally as though attempting to sit onto their right hip.
Instruct the patient to sit back as far as they can without holding onto the table with their hands.
Have them hold the position for 5 seconds then come back up to the original hands and knees position without pulling up with their arms.
Have them repeat 8 to 10 times.

Bilateral Knees to Chest

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, Pelvic Clocks, Self Stretch, Self-mobilization, Supine Curl Up

Bilateral Knees to Chest

Bilateral Knees to Chest

To stretch an ERS and/or tight erector spinae to increase lumbar flexion:

Have the patient lying on their back and ask them to bring both knees up to the chest with their hands.
Instruct them to hold the stretch for 5 to 10 seconds and repeat 10 times to mobilize the lumbar spine into further flexion.

Prayer Stretch

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, Pelvic Clocks, Self Stretch, Self-mobilization, Supine Curl Up

Prayer Stretch

Prayer Stretch

To increase lumbar flexion:

Starting in hands and knees have the patient sit back on their heels to stretch the low back.
To increase the stretch have the patient reach forward with their hands as far as possible.
They hold the stretch position for 30 to 60 seconds.
Have them repeat the stretch 2 to 3 times.

Muscle Energy Technique: ERS Dysfunction in the Lower Thoracic Spine

in 2 Movement Tests Lower Quarter, 4 Manual Therapy Strategies, Active Trunk Rotation, All Lower Quarter, All Manual Therapy, Hip ABD Firing Pattern, Muscle Energy, Rolling, Supine Curl Up, Supine Heel slide, Supine Hip ABD and ER

Muscle Energy Technique: ERS Dysfunction in the Lower Thoracic Spine

The therapist places their L index and middle fingers on the L side of the spinous processes and translates the spine towards him looking for any restriction in L to R translation (L side bending). If the restriction is worse in flexion and improves in extension the diagnosis is an ERS R.
To treat the ERS R the therapist has the patient sit up tall initially, then introduces flexion from above down and below up creating an apex for flexion at the palpated segment. L side bending is then introduced by translating the patient’s shoulders from L to R to the feather edge of the L side bending barrier.
The patient is instructed to gently side bend to the R for 5-7 seconds and then relax.
The therapist takes up the slack by further translating the shoulders to the R. This is repeated 3-4 times.

Dysfunctional Supine Curl Up Functional Movement Test

in 2 Movement Tests Lower Quarter, All Lower Quarter, Supine Curl Up

Dysfunctional Supine Curl Up Functional Movement Test

This dysfunctional movement test can be best addressed by first mobilizing any ERS spinal dysfunctions that are found in the lower thoracic spine and thoracolumbar junction that restrict spinal flexion followed by stretching the erector spinae muscles. These inhibitory influences should be addressed before attempting to retrain this dysfunctional test.

It is also sometimes helpful to stretch the hip flexors as covered in #3b and c.

Anatomy and Biomechanical Considerations:

The erector spinae muscles consist of the longissimus thoracis and iliocostalis thoracis and iliocostalis lumborum muscles. These muscles working unilaterally rotate the spine to the ipsilateral side and when working bilaterally they extend the spine. The longissimus thoracis muscle becomes hypertonic when there is a non-neutral dysfunction in the thoracic spine. This hypertonicity, which is often seen unilaterally, results in inhibition of the abdominals and interferes with the ability to perform a curl up and/or reverse the lumbar lordosis during forward flexion.

Anterior Innominate Self Correction: Home Self-Mobilizing Exercise

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, Hip ABD Firing Pattern, Hip EXT Firing Pattern, Self-mobilization, Supine Heel slide, Supine Hip ABD and ER

Anterior Innominate Self Correction: Home Self-Mobilizing Exercise

Anterior Innominate Self Correction

To correct an Anterior Innominate on the right:

The patient is lying on their back keeping the left leg out straight. Using both hands they bring their R knee up towards their chest then out towards their right shoulder.
Instruct the patient to hold the right leg firmly and do not allow the leg to move as they attempt to straighten the right hip. They hold the contraction for 4-5 seconds.
When they relax instruct the patient to bring the right leg further up and out towards the R shoulder and repeat 3 to 4 times.

Supine Heel Slide and/or Prone Hip Extension

in 2 Movement Tests Lower Quarter, 4 Manual Therapy Strategies, All Lower Quarter, All Manual Therapy, Manual Stretching

Supine Heel Slide and/or Prone Hip Extension

Hip Flexors

Iliopsoas:

Psoas attaches to the transverse processes and vertebral bodies from T12 to L5
Iliacus attaches to the iliac fossa and sometimes anterior sacral base
Powerful hip flexor and slight ER of the hip, side bends the LS to the same side and rotates away, when hypertonic these muscles limit hip extension
Innervation: Femoral nerve – L2, 3 and 4

Tensor Fascia Latae:

Attached at the anterior iliac crest and ASIS
Inserts into the IT band
Flexes, abducts and internally rotates the hip, externally rotates the knee
Innervation –Superior gluteal n. L4,5 and S1

Rectus Femoris:

Attached to the AIIS and the anterior hip capsule
Flexes the hip and extends the knee
Pain in the front of the knee cap is often a sign of a tight rectus femoris
Innervation – femoral n. L2, 3, and 4

All Lower Quarter