2 Movement Tests Lower Quarter

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Hip Diagonals

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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

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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

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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

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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

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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.

Dysfunctional Hip Abduction and ER and/or Dysfunctional Hip Abduction Functional Movement Tests

in 2 Movement Tests Lower Quarter, Supine Hip ABD and ER

Dysfunctional Hip Abduction and ER and/or Dysfunctional Hip Abduction Functional Movement Tests

These dysfunctional movement tests are best addressed by mobilizing the inferiomedial hip capsule, stretching the hip adductors and/or obturator nerve, and mobilizing the sacral base to restore restricted anterior nutation on the dysfunctional test side before retraining is initiated. Also a pubic symphysis dysfunction needs to be addressed, if present, as it represents an imbalance in tone between the hip adductors and abdominals and can contribute to, or be the source of these dysfunctional movement tests.

Mobilizing the hip in an inferiomedial direction in side lying at 45 degrees of passive hip abduction has been shown to improve isometric torque in the hip abductors, in the short term, in healthy subjects. (Makofsky et al., 2007). This response is proposed to be due to a reduction of an inhibitory and dysfunctional arthrokinetic reflex from a tight inferiomedial joint capsule (Warmerdam, 1999).

Anatomy and Biomechanical Considerations:

Hip Adductors

  • Attach to the pubic ramus and ischial ramus to ischial tuberosity
  • Function to restrain abduction of the stance limb during gait
  • They also assist in internal rotation and flexion of the hip
  • Hypertonicity of the hip adductors can result in displacement of the femoral head superiorly and laterally
  • Innervation – obturator n. L2, 3 and 4

Anterior Oblique Sling

  • Adductors are functionally connected to the abdominal obliques on the contralateral slide to form an oblique sling of support for the anterior pelvis
  • When hypertonic the pull of the adductors can result in an inferior pubic shear

Anterior Innominate Self Correction: Home Self-Mobilizing Exercise

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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

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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

PNF Pelvic Diagonals (Hip Clocks)

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PNF Pelvic Diagonals (Hip Clocks)

PNF Pelvic Diagonals (Hip Clocks)

Pelvic diagonals on the right side:

Patient is lying on their left side with their shoulders and hips square on the table and their hips flexed to 60 degrees with their lumbar spine in neutral.

You ask the patient to imagine a clock resting on top of their right hip so that 12 is closest to the shoulder and 6 closest to their feet, 3 is in front and 9 is towards the back.

You tell the patient that we are going to work from 1-2 o’clock (anterior elevation) down to 7-8 o’clock (posterior depression).

Start first by asking the patient to isometrically hold various positions along the diagonal from 1-2 down to 7-8 o’clock then work eccentrically giving you resistance as you pull down towards 7-8 or push up towards 1-2. You finish by asking the patient to pull the hip up towards 1-2 or push down and back towards 7-8 against your resistance.

The patient must avoid activating the right shoulder and right side of the neck during this activity and avoid moving out of the neutral position in their low back.

Manual Therapy for Restricted 9 o’clock – restricted pelvic rotation to the R and/or restricted sacral anterior nutation on the L

Treated as above except the patient is lying on their R side working through the pelvis from 10-11 o’clock (anterior elevation) down to 4-5 o’clock (posterior depression).

Hip Extension Test

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Hip Extension Test

How to Perform

Step 1: The patient is lying prone and the examiner palpates the gluteus maximus for activation during hip extension. Janda originally described an ideal hip extension firing pattern in which the hamstrings fired first followed by the gluteus maximus then the contralateral and finally ipsilateral lumbar erector spinae. (Janda, 1990). Subsequent studies have not supported this firing pattern. (Pierce and Lee, 1990; Vogt and Banzer, 1997). Clinically what seems to be most important is whether or not the gluteus maximus fires at all and how well are the pelvis and trunk stabilized during hip extension.

Step 2: The second part of the hip extension test is for the examiner to monitor the PSISs during active hip extension. Normally the PSISs should stay still or move slightly superior during the movement.

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