Unlock the Hip: Using Joint

Mobilizations to Improve Mobility

Great Lakes Athletic Trainers Association
45st Annual Winter Meeting
Wheeling, IL
March 16, 2013

Scott Lawrance, DHS, LAT, ATC, MSPT, CSCS

Objectives
Lecture
Attendees will understand the importance of hip
mobility and how a lack of hip motion can affect
function within the kinetic chain
Attendees will be able to assess hip joint mobility to
determine the appropriateness for therapeutic
intervention
Attendees will be able to discuss the indications,
contraindications, and application of joint
mobilizations to improve mobility
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Objectives
Lab
Attendees will be able to perform static and dynamic
joint mobilizations for the hip in both weightbearing
and non-weightbearing positions
Attendees will be able to demonstrate and instruct a
mobility exercise program to allow for maximal gain
following joint mobilization

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When did this become bad?

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and how does this become that?

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Neurodevelopment
As babys we have tremendous
amount of joint mobility
We maintain this as children
through play
As adults we start to loose
mobility mostly due to
positional and postural habits

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The Adult Hip

Generally has poor
mobility
Result of:
Sitting posture
Lack of squatting

Causes:
Decreased length in hip
flexors
Reciprocal inhibition of
the gluteal muscles

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The Athletic Hip

FMS administered to all incoming
and transfer athletes at UIndy Fall
2012
Average deep squat score: 2.04

Football: 2.14
Mens Soccer: 1.20
Volleyball: 1.42
Womens Soccer: 1.75

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Sequelae of Hip Hypomobility

Changes in functional
movement
Increased mobility needed
above and below
Increased lumbar spine/SI
joint mobility and increased
lordosis
Increased mobility in the knee
and lower kinetic chain

Increased muscular
activation in hamstrings,
piriformis, erector spinae
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Sequelae of Hip Hypomobility

Changes in athletic performance
Decreased strength
Decreased power
Decreased speed

Limits potential exercises that can be performed in

the weight room
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Assessment of Hip Mobility

History and Observation!
Deep Squat Movement Test
Table Mobility Assessment

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Movement Assessment:
Squat Test

Have your athlete stand with

feet shoulder width apart and
arms overhead. Instruct them
to squat and look to see if they
can maintain upright posture,
hip/knee/ankle alignment and
feet flat on the floor

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Table Assessment:
Pelvic Alignment/Hip Extension

Note: is the pelvis balanced? If not need to start there. Does

the hip extend and is the resistance similar side-to-sideis this
from tight musculature or from joint tightness??? What are the
arthrokinematics that link these?
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Table Assessment:
Supine Mobility

After assessing pelvis/SI joint and hip extension

look at passive:
Hip flexion
Hip flexion/adduction
Hip flexion/abduction
Hip internal rotation
Hip external rotation

Note ROM, end-feel, quality of motion,

restrictions present
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Treating Hip Mobility

Lots of options
Stretching of hip flexor, hamstrings, adductors, IT
band, quadriceps
Foam roller
Therapeutic exercise
(capsular)

But
Do these really treat ALL of the problem?
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Treating Hip Mobility

Due to hip joint structure
(deep articulating balland-socket) and muscle
bulk, mobilization of the
joint is needed to provide
a lasting change

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What is a Joint Mobilization?

AKA - Joint Mob
Manual therapy technique

Used to modulate pain

Used to increase ROM
Used to treat joint dysfunctions that limit ROM by
specifically addressing altered joint mechanics

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History
Hippocrates (4th century BC physician) may have
been first recorded to perform joint
manipulations and spinal traction
English physicians in the 1700 and 1800s
believed in strict rest after a joint injury, while
bonesetters would treat patients with
manipulations
Dr. Wharton Hood wrote the first medical book
on manipulation in the 1870s
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History
Kaltenborn - Scandinavian who merged what he
considered the best of chiropractic, osteopathy,
and physical medicine
Maitland - Australian PT who focused primarily
on mobilizations rather than manipulation, and
has meticulous examination skills that heavily
guide his treatments

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Terminology
Mobilization passive joint movement for increasing
ROM or decreasing pain

Applied to joints & related soft tissues at varying speeds &

amplitudes using physiologic or accessory motions
Force is light enough that patient can stop the movement

Manipulation passive joint movement for increasing

joint mobility

Incorporates a sudden, forceful thrust that is beyond the

patients control
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Movement Types
Physiologic movement: movements the patient
can perform voluntarily
Accessory movements: movement the patient
cannot perform actively, but are necessary for
normal ROM

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Accessory Motion Arthrokinematics

5 types of arthrokinematics
Roll, Slide (Glide), Spin, Compression, Distraction

3 components of joint mobilization

Roll, Slide (Glide), Spin

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Roll
A series of points on one articulating surface
come into contact with a series of points on
another surface
Rocking chair analogy; ball rolling on ground
Example: Femoral condyles rolling on tibial
plateau
Roll occurs in direction of movement

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Slide (Glide)
Characteristics of one bone
sliding on another
For a pure slide, the surfaces must be
completely congruent
Car hitting brakes analogy
Surfaces must be congruent for this to
occur

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Spin
Occurs when one bone rotates around a
stationary longitudinal mechanical axis
Same point on the moving surface creates an arc of a circle as
the bone spins
Car spinning its wheels analogy
Example: Radial head during pronation/supination

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Convex/Concave Rule
Basic concept of correct mobilization application
Is this the whole
picture?

Realize:
1. This is only a tool
2. This is a helpful method to understand where to
mobilize
3. This does not take into account dynamic forces
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Convex moving on Concave

When convex is moving and
concave is stable:
Glide and roll are OPPOSITE
Joint surfaces slide in the
OPPOSITE direction of the bone
movement

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Concave moving on Convex

When concave is moving and
convex is stable:
Roll and glide occurs in the
SAME direction
Joint surfaces slide in the SAME
direction as the bone
movement

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Joint Mobilizations Grades

I
II
III
IV
V
Available Joint
Play

The oscillation grading system

was developed by the Australian
PT Maitland.
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Stretch

Indications
Grades I and II - primarily used for pain
Pain must be treated prior to stiffness
Painful conditions can be treated daily

Grades III and IV - primarily used to increase

motion
Stiff or hypomobile joints should be treated 3-4 times
per week alternate with active motion exercises
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Effects of Joint Mobilization

Mechanical effects
Improves mobility

Neurophysiological effects
Stimulates mechanoreceptors to decrease pain

Nutritional effects
Improved synovial fluid movement and nutrient
exchange in articular cartilage

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Contraindications for Mobilization

Contraindicated for:
Inflammatory conditions or acute inflammatory
process
Malignancy
Osteoporosis
Ligamentous rupture
Herniated disks with nerve compression
Bone disease
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Would you perform a Joint Mob

on any of these athletes?
Beighton Index

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Before You Begin

Warm tissue prior to mobilization
Muscle relaxation techniques may be needed

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Joint Mobilization Application

Patient should be relaxed
Explain purpose of treatment & sensations to expect to
patient
Evaluate BEFORE & AFTER treatment (comparable sign)
Use proper body mechanics
Remove jewelry
Begin & end treatments with Grade I or II oscillations
Stop the treatment if it is too painful for the patient
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Treatment Force and Direction of

Movement
Treatment force is applied as close to the
opposing joint surface as possible
The larger the contact surface is, the more
comfortable the procedure will be (use flat surface of
hand vs. thumb)

Direction of movement during treatment is either

PARALLEL or PERENDICULAR to the treatment
plane
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Treatment Direction
Treatment plane lies on
the concave
articulating surface,
perpendicular to a line
from the center of the
convex articulating
surface

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Speed, Rhythm, and Duration of

Movements
Joint mobilization sessions
usually involve:
3-6 sets of oscillations
Perform 2-3 oscillations
per second
Lasting 20-60 seconds for
tightness
Lasting 1-2 minutes for
pain 2-3 oscillations per
second

Apply smooth, regular

oscillations

For painful joints, apply

intermittent distraction for
7-10 seconds with a few
seconds of rest in between
cycles
For restricted joints, apply a
minimum of a 6-second
stretch force, followed by
partial release then repeat
with slow, intermittent
stretches at 3-4 second
intervals

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Patient Response
May cause soreness
Perform joint mobilizations on alternate days to allow
soreness to decrease & tissue healing to occur
Patient should perform ROM techniques
Patients joint & ROM should be reassessed after
treatment, & again before the next treatment
Pain is always the guide

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The Hip Joint

Concave acetabulum and
convex femoral head
Open packed position:
Hip flexion 30 degrees,
abduction 30 degrees, slight
external rotation

Close packed position:

Hip extension, slight internal
rotation

Designed for stability

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Static Hip Mobilizations

Lateral Glide
Technique for general mobility and/or pain control

Posterior Glide
Used to increase hip flexion and internal rotation

Anterior Glide
Used to increase hip extension and external rotation

Inferior Glide
Used to increase hip flexion or rotation
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Mobilizations with Movement

(MWM)
Mulligan concept of introducing dynamic motion
as the mobilization is performed
Advantage:
Can move into the restriction while performing mobilization
Neural pathways activated when active motion is applied
Athlete can get immediate positive feedback
comparable sign

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Mobilizations with Movement

(MWM)
Principles
Maintain joint mobilization through entire movement
Move through as much of a full ROM as possible
Force should remain constant
Movement should be painfree

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How do you follow-up?

After mobilizing the joint, need to follow-up with
mobility exercises
Reinforce the new mobility gained and new
movement pattern
Home program vs. in clinic/athletic training room

Correct underlying postural deficiencies

Rebalance the joint (if needed)

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Summary
Mobilize joint based on convex/concave rule
Select appropriate grade of mobilization to
perform
Always follow static mobilization with dynamic
mobilization
Always issue home exercise mobility exercises if
able to take advantage of ROM gains

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Questions?

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Lab Set-up
Please find a partner(s) of similar build to work
with during lab
You will need a mobilization belt
If you do not feel comfortable with any of the
mobilizations being performed on you, please do
not do them!
If you need help or have a question, please ask us

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Lab

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Setting up the Belt

Know the type of belt
youre working with

Clinician body mechanics

Set up belt to wrap around patients proximal thigh
and your hips/greater trochanter

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Hip Lateral Glide

Good general
technique to loosen
capsule and improve
general mobility,
control pain
Sit backward into hips,
but keep good stance

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Hip Posterior Glide

Increase hip flexion or
internal rotation
Hip flexed, adducted,
and slightly externally
rotated with foot on
table
Use hand across table to
apply downward into hip
toward table
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Hip Anterior Glide

Increase hip extension or
external rotation
Hip neutral position
Can bias capsule by addition of
IR/ER

Apply force at gluteal fold

in anterior direction
Beware of pain in the low back!
(may need to flex the hip)
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Hip Inferior Glide

Inferior glide with hip flexed
places stress into posteriorinferior joint capsule
Helps to increase hip flexion
and rotation

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Dynamic Hip Mobilizations

In general:
Movement of the joint should be through the full
ROM if possible
Perform 5-10 repetitions (passive and then activeassisted)
Take care of the skin (belt)

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Dynamic Hip Mobilizations

All performed using the belt
Supine joint distraction with
Flexion
Internal Rotation
External Rotation

Standing lunge position with

Forward lunge
Lateral lunge
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Dynamic Hip Flexion Mobilization

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Dynamic Hip Internal Rotation

Mobilization

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Dynamic Hip External Rotation

Mobilization

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Dynamic Forward Lunge

Mobilization

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Dynamic Lateral Lunge

Mobilization

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Hip Dynamic Mobility

Exercises

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Hip Dynamic Mobility

Exercises
Leg swings
Front/back
Lateral/across body

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Hip Dynamic Mobility

Exercises
Hurdle step over/under drills
Forward
Lateral
Backward
Alternating
Squatting

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Summary
Practice mobilization to refine technique
Apply according to treatment parameters and
patient goals
Use good body mechanics to apply the most
effective treatment and protect yourself
Follow up with mobility exercises to maximize
benefits

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Acknowledgements
Performance Rehab Products
Mobilization Belts

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Dont Ever Mistake Activity for Achievement!

- John Wooden

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Questions?
Thank you for attending our Learning Lab session!
Scott Lawrance, DHS, ATC, MSPT, CSCS
University of Indianapolis
1400 East Hanna Avenue
Indianapolis, IN 46227
(317) 788-3248
lawrances@uindy.edu

GLATA 2013 WHEELING, IL