Hip Mobilisations

Original Editor - David Drinkard

Top Contributors - David Drinkard, Caroline Stone, Admin, Kim Jackson, George Prudden, 127.0.0.1, Nupur Smit Shah, Alexandra Stead, Rachael Lowe, Mariam Hashem, Kai A. Sigel and Samuel Winter  

Page Summary

• Hip joint mobilisations are manual therapy techniques that improve range of motion (ROM), reduce pain and temporarily improve muscle performance, possibly through a neurophysiological pain-modulating response.
• Reduced hip ROM is associated with osteoarthritis (OA), femoroacetabular impingement (FAI), future lower extremity injury and the development of anterior knee pain.
• Anterior glides encourage extension and external rotation, posterior glides internal rotation, inferior glides flexion and rotation, lateral glides abduction, and distraction relieves pain.
• Contraindications include current or recent fracture, recent surgery, anticoagulation medication, worsening symptoms, ligamentous laxity, joint effusion and inflammation, so clinical judgement must precede treatment.

Introduction

Limited hip range of motion (ROM) is considered a predisposing factor to hip osteoarthritis (OA), and decreased patient function. Patients with labral tears or femoroacetabular impingement (FAI) often exhibit reduced flexion, internal rotation and adduction ROM, which is also a predictor of the development of OA. Decreased hip abduction ROM has been suggested to predict the occurrence of future lower extremity injuries. Reduced hip joint ROM has also been found to be associated with the development of anterior knee pain. It is therefore important for clinicians to include treatments to improve ROM in the hip, such as joint mobilisations, to improve patient function and reduce risk of injury. Hip joint mobilisations may also result in a neurophysiological response leading to reduction of pain perception and further improving mobility and strength. Mobilisations may activate peripheral endocannabinoid systems, leading to reduced inflammation, which may restore ROM and reduce mechanical irritation to nociceptors, thus reducing pain.

For relevant hip anatomy, see Hip Anatomy. Hip mobilisations may also be beneficial for individuals with hip osteoarthritis; for more information, see CPR for hip mobs with knee OA.

Hip Mobilisations

There are a variety of techniques used to increase ROM of the hip complex. Mulligan Concept mobilisations with movement (MWM), as well as high velocity low amplitude thrust techniques have been shown to improve patient function, ROM and pain, compared to stretching of the hip only. Maitland's Mobilisations techniques are based on oscillatory techniques which is applied using various grades during each glide, and may also be used.

Contraindications

As with any manual therapy technique, contraindications must be cleared before performing. Contraindications for hip joint mobilisations, particularly for self-mobilisations, can include: current or recent history of fracture, recent surgery, anticoagulation medication, worsening of symptoms, generalized or localized ligamentous laxity, joint effusions or inflammation.

Clinical judgment should be used before applying any hip joint mobilisation to ensure patient safety.

Anterior Glide

Indication

Anterior glide is used to increase joint play and capsular stretch to encourage external rotation and extension ROM.

Technique

Patient is positioned in prone with knee of the involved side bent. Therapist supports the knee with one hand, while the opposite hand is placed on the posterior portion of the proximal femur on the involved side. The mobilising hand imparts a glide directly perpendicular to the long axis of the femur. The femur may be placed into varying degrees of abduction or rotation depending on desired effect. As with other glides, this glide can be performed in other positions. Anterior glides may result in a temporary improvement in gluteal muscle strength and could be beneficial to perform ahead of strengthening exercises.

Posterior Glide

Indication

This technique can be used to increase joint play necessary for internal rotation.

Technique

Patient is positioned supine. The knee is supported with the therapist's stabilising hand and the mobilising hand is placed on anterior portion of proximal femur. Using the heel of the hand, a posterior glide is imparted directly downward by keeping arm straight and leaning with the trunk. May also be performed with hands on top of the knee, providing a downward force.

Inferior Glide

Indication

This technique can be used for capsular stretching and to encourage accessory motion necessary for hip flexion and rotation.

Technique

Patient is positioned supine, with hip and knee flexed to 90 degrees. The opposite leg is supported on the therapist's shoulder in flexion. An inferior glide of the femur is applied through either the hands or a mobilisation belt. This technique can be performed with varying degrees of flexion and/or rotation depending on intended effect. At lower degrees of flexion, therapist may hold the patient's leg above the medial and lateral malleoli, allowing for grades I-V mobilisations. In higher degrees of flexion, the therapist will hold closer to the joint line for performance of a Grade III-IV mobilisation.

Hip Distraction

Indication

Pain relief and for the purpose of assessment.

Technique: Hip Distraction with Knee Extended

Patient is positioned supine, with hip in slight flexion and knee extended. A belt or therapist's hands are placed firmly around the patient's ankles. Hand position may vary depending on clinician preference. Distraction of the hip is produced by the therapist leaning backward, producing slight gapping at the femoroacetabular joint. This technique can be used for decreasing muscle spasm or pain, and is also useful to increase accessory joint movement for flexion and abduction movements. Oscillations may be added to help reduce tension in soft tissue of the hip, encourage relaxation of hip musculature and improve elasticity of the joint capsule.

Technique: Hip Distraction with Knee Flexed

Patient is positioned supine, target leg in "crook lying" hip at 50 degrees of flexion, knee at around 100 degrees of flexion. Therapist sits on the patient's foot. The forearm closest to the patient is between the thigh and lower leg and hand furthest from patient rests on patients thigh. Forearm and hand pulls towards therapist, distracting the knee.

Lateral glide

Indication

Pain relief and improved ROM, particularly into abduction and internal rotation. Grade III/IV mobilisations at 3x10 have been shown to improve adduction, internal and external rotation ROM.

With mobilisation belt: Patient positioned in supine, with the hip and knee flexed. Varying combinations of hip and knee flexion may be used, most commonly hip at 45 degrees of flexion/knee 135 degrees flexion or 90 degrees of flexion each. Mobilisation belt is placed around proximal femur, as close to the hip joint as possible, and around therapist's hip. Lateral glide is applied by leaning posteriorly, using hands to stabilise femur and avoid external rotation or abduction.

Without mobilisation belt: Patient is positioned supine, with the leg in "crook lying" position at 50-degree with knee in maximal flexion, but raised off plinth. The therapist "hugs the target leg" with forearms around the patients abductors and pulls the leg towards them. (Watch from 4:23).

Rotation Oscillations in Crook-Lying

Patient is positioned in supine, target leg in "crook lying" hip at 50-degree flexion, knee at around 100 degrees of flexion. The therapist places hands around either side of the knee, of target leg moving into abduction and adduction. Video below demonstrates glides in the crook lying position, starting at 3:30.

Internal Rotation with Knee Flexed

Indication

To improve internal rotation ROM of the hip

Technique

Patient is positioned in supine, target leg in "crook lying" hip at 50-degrees. Knee in maximal flexion, but raised off plinth. The therapist "hugs the target leg" with caudal forearm around the patients abductors, ventral hand on patients thigh. Therapist will internally rotate the femur, pulling thigh towards self.

Conclusion

Hip joint mobilisations are a safe and effective way to improve hip ROM, reduce pain, and temporarily improve muscle performance. They may also help reduce risk of further injury, development of OA and reduce incidence of anterior knee pain.