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Piriformis Stretch Below 90 Degrees of Hip Flexion

in 2 Movement Tests Lower Quarter, 4 Manual Therapy Strategies, Active Trunk Rotation, All Lower Quarter, All Manual Therapy, Manual Stretching, Muscle Energy, Rolling

Piriformis Stretch Below 90 Degrees of Hip Flexion

  • Therapist stands on the opposite side of the table and places the left hand on the L ASIS to stabilize
  • Patient’s left foot is placed outside of the right knee
  • Therapist adducts the leg to the barrier
  • Patient attempts to abduct the leg for 5 -7 seconds then relaxes
  • Repeat 3 to 4 times

Soft Tissue Mobilization of the Posterior Hip Capsule

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

Soft Tissue Mobilization of the Posterior Hip Capsule

  • Patient is positioned with the right hip off the table, but the PSIS is still on the table.
  • The therapist uses both arms to laterally distract the hip.
  • A strap can also be placed around the hip to apply lateral distraction.
  • Therapist slightly adducts and IR the hip then applies a posterior glide thru the femur.
  • If painful in the groin or SI, abduct the hip slightly.
 

Soft Tissue Mobilization of the Posterior Hip Capsule

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

Soft Tissue Mobilization of the Posterior Hip Capsule

Patient is side lying with the treatment side up. The therapist uses the elbow to scour around the posterior aspect of the hip capsule feeling for areas of tension. The therapist can also work from the posterior aspect of the greater trochanter back across the gluteal area to the sacrum and address any tension in the external rotators of the hip with deep friction massage.

Muscle Energy Technique for a FRS Right in R Side Lying

in 2 Movement Tests Lower Quarter, 4 Manual Therapy Strategies, Active Trunk Rotation, All Lower Quarter, All Manual Therapy, Hip ABD Firing Pattern, Hip EXT Firing Pattern, Muscle Energy, Pelvic Clocks, Rolling

Muscle Energy Technique for a FRS Right in R Side Lying

  • Extension is introduced from above down and from below up to the barrier
  • Rotation is then introduced from above down to the feather edge of the barrier
  • The segment to be treated must remain perpendicular to the table
  • Using the R forearm the therapist introduces L side bending thru the pelvis by pushing up in an anterior and superior direction
  • Patient is instructed to push the pelvis caudally to activate the R side benders
  • Upon relaxation the therapist takes up the slack thru the pelvis
  • Repeat 3 to 4 times
  • To finish the patient is asked to extend the top leg (L) back while the therapist maintains the correction

Passive Mobility Testing in Extension with Translation of the Shoulders from Right to Left to Detect FRS R Dysfunctions

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

Passive Mobility Testing in Extension with Translation of the Shoulders from Right to Left to Detect FRS R Dysfunctions

  • Patient is prone propped on elbows with their elbows together and hands under their chin.
  • Place your right thumb on the left side of the SP and rest your left forearm over the patient’s shoulders.
  • Translate the patient’s shoulders from right to left as you block the SP and assess for tightness. Repeat from T10 to L3
  • With an FRS R dysfunction you’ll feel a blockage when attempting to draw the spine over your stabilizing L thumb
  • FRS dysfunctions are commonly found with this test anywhere from T11- L2 resulting in a positive FADIR test that is perceived as a tight posterior hip capsule

Hip Clearing with Flexion, Adduction and IR (FADIR Test)

in 2 Movement Tests Lower Quarter, 4 Manual Therapy Strategies, All Lower Quarter, All Manual Therapy, Hip ABD Firing Pattern

Hip Clearing with Flexion, Adduction and IR (FADIR Test)

  • To test the right hip the therapist passively flexes, adducts and IR the hip, aiming the right knee toward the left shoulder
  • Pinching in the groin or anterior hip will limit the patient’s ability to stretch the piriformis
  • Indication of a tight posterior hip capsule or upper lumbar spine dysfunction, ie FRS at L1,2 or L2,3 on the same side as the pinching hip.
 

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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
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