Journal of Orthopaedic & Sports Physical Therapy

Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association
I

Individual subscriptions are available to home addresses only. All subscriptions are payable in advance, and all rates include normal shipping charges. Subscriptions extend for 12 months, starting at the month they are entered or renewed (for example, September 2002-August 2003). Single issues are generally available at $20 per copy in the United States and $25 per copy when mailed internationally. USA Linn Harding, PT, MA, OCS 1 I $215.00 Institutional Mary Barbe, PhD 2 I $135.00 Individual Katherine Shepard, PT,I $75.00 PhD, FAPTA3 Student
4

Posterior-Anterior Glide of the Femoral Head in the Acetabulum: A Cadaver Study

International $265.00 I $185.00 I $125.00
I I

Please start my one-year subscription to the JOSPT.

Please renew my one-year subscription to the JOSPT.

Agency Discount $9.00

Subscription Total: $________________

Amy Marks, MPT 5 Raymond Ajai, Information Shipping/BillingMPT Jennifer Lardiere, MPT 6 Name _______________________________________________________________________________________________ Heather Sweringa, MPT 7
Address _____________________________________________________________________________________________ Address _____________________________________________________________________________________________ City _______________________________State/Province __________________Zip/Postal Code _____________________ Study Design: Descriptive study employing cadaver dissection and measurement of posterioroint mobilization has anterior (PA) glide of the femoral head in the acetabulum. moved well beyond the Phone _____________________________Fax____________________________Email _____________________________ Objective: To quantify PA glide of the femoral head in the acetabulum in a cadaveric sample. status of a new controverBackground: Posterior-anterior glide of the femoral head within notices? is a Would you like to receive JOSPT email updates and renewalthe acetabulumI Yesjoint I No sial technique and is mobilization procedure described in orthopaedic physical therapy texts, yet there is no published widely accepted and emevidence that the joint structures of the hip allow such movement. This study attempted to ployed by physical theraquantify PA glide of the femoral head in the hip joints of embalmed cadavers. pists practicing in this Payment Twelve hips, 3 male and 9 female, from 8 embalmed cadavers were employed in this Methods: Information country today.1,3,8,9 While joint study. Hips were dissected to the level of the joint capsule and a metal rod inserted through the mobilization can be a broad term I Check enclosed (made payable to the JOSPT). femoral neck served as a mobilizing handle. A load cell was installed into this handle so that referring to any active or passive I mobilizing forces couldone) Credit Card (circle be monitored. A dial gauge, which recorded displacement of the femoral movement of a joint, we are using MasterCard VISA American Express head, was mounted to the pelvis via bone pins and an external fixator. the term in the context of this Results. Using mobilizing forces of 89, 178, 267, and 356 N, mean femoral head displacements of Card Number ___________________________________Expiration Date _________________________________________ paper to refer to the passive appli0.57, 0.93, 1.20, and 1.52 mm were recorded. Within the 89-N trials, PA displacement ranged cation of accessory movements to from a minimum of 0.04 mm to a maximum of 1.54 mm. Within the 356-N trials, PA Signature ______________________________________Date __________________________________________________ a joint. Accessory movements are displacement of the femoral head ranged from a minimum of 0.25 mm to a maximum of 2.90 those movements which can be mm. Conclusion: In an embalmed cadaveric model, measurable PA glide of the femoral head within attained passively by the therapist To order call, fax, email or mail to: the acetabulum does exist and it is highly variable between individuals. J Orthop Sports Phys Ther, and are necessary for full physiologic range of motion (ROM), 1111 North Fairfax Street, Suite 100, Alexandria, VA 22314-1436 2003;33:118125. but cannot Phone 877-766-3450 Fax 703-836-2210 Email: subscriptions@jospt.org be voluntarily conKey Words: accessory movement, cadaver hip joint, joint mobilization, trolled by the patient.16,22,24,26 The posterior-anterior glide Thank you for subscribing! specific accessory movements available in a joint are determined by the anatomy of the articular and 1 Program Director, Physical Therapist Assistant Program, Western Institute of Science and Health, periarticular structures of the joint Rohnert Park, CA. in question.12,13,14,16,18,21,24,25,26,28 2

Associate Professor, Department of Physical Therapy, Temple University, Philadelphia, PA; Adjunct Associate Professor, Department of Anatomy and Cell Biology, Temple Medical School, Philadelphia, PA. 3 Professor and Director, PhD Program in Physical Therapy, College of Allied Health Professions, Temple University, Philadelphia, PA. 4 Staff Physical Therapist, Penn Medicine at Limerick, Limerick, PA. 5 Staff Physical Therapist, Hunterdon Developmental Center, Clinton, NJ. 6 Staff Physical Therapist, La Fortaleza Clinic, North Philadelphia, PA. 7 Student, Masters of Physical Therapy Program, College of Allied Health Professions, Temple University, Philadelphia, PA. This study was conducted at the Department of Physical Therapy, College of Allied Health Professions, Temple University, Philadelphia, PA. Direct all correspondence to Linn Harding, Western Institute of Science and Health, 130 Avram Avenue, Rohnert Park CA, 94928. E-mail: lharding@westerni.org

Functional Anatomy and Accessory Movements of the Hip Joint

The hip joint is an example of a ball-and-socket synovial joint having highly congruent joint surfaces: the convex femoral head and the concave articulating surface, the acetabulum. While man-

118

Journal of Orthopaedic & Sports Physical Therapy

ual mobilization of this joint has been reported,6,17,20 there is a lack of consensus regarding which accessory movements are available at the hip joint. Longitudinal distraction of the femoral head within the acetabulum has been described in entr y-level orthopaedic texts,16,18 postprofessional texts,10,22 and in the scientific literature,2,5 and a reasonable consensus appears to exist among these various authors regarding the details and clinical relevance of this accessory motion. Posterior-anterior (PA) glide of the femoral head is also described in entry-level16,18,25 and postprofessional orthopaedic texts,10,22 but within the scientific literature there is a striking lack of support for the existence of this movement. Despite a thorough literature search, we were unable to find any evidence that measurable PA glide actually exists at the hip joint. PA glide is presented as a manual technique to facilitate hip extension and is based on the premise that a PA gliding motion is actually present at the hip. In our minds, the performance of PA mobilization of the femoral head in the acetabulum can not be based on sound clinical reasoning unless evidence of such movement is provided. We are not the first to note this lack of evidence. John Mennell emphatically states, There is only one movement of joint play at the hip, namely, long-axis extension.23 Grays Anatomy similarly states, No accessory movements occur, except for very slight separation effected by strong traction.29 The purpose of this study was to quantify PA glide of the femoral head in the acetabulum in response to an applied force. Embalmed cadavers, dissected to the level of the joint capsule, were used for the purpose of this study. Additionally, longitudinal distraction was measured in 1 cadaver hip.

cm), and 1 large-framed (mass, 90 kg; height, 180188 cm) subject. For 1 of the therapists, no small-framed subject was available. Before applying the PA glide to any subject, each therapist was asked to practice the mobilization on a Jamar hand-held dynamometer (JA Preston Corp., Clifton, NJ) to become familiarized with the device and process. The dynamometer was located on a firm, flat surface at the same height as the plinth on which the mobilization of the subject was to be performed. The therapists were asked to apply force to the dynamometer in a similar fashion to that used on their patients. The dynamometer gauge was shielded from the therapists view. After the dynamometer trials, each subject was positioned prone on a standard plinth and each therapist was instructed to perform a grade III PA hip mobilization on the right hip. This technique required the therapist to effect a full-range anterior translation or gliding motion of the femoral head within the acetabulum, starting from a neutral position and continuing until the full range of anterior glide was attained.22 Therapists performed 3 trials on each subject. After each mobilization on the subjects hip, the therapist applied what he/she perceived to be an equal amount of force to the dynamometer. Force values were read and recorded after each trial. The means of these values are presented in Table 1.

Subjects and Inclusion Criteria

Eight embalmed cadavers were employed in this study and data were collected from 12 hips (3 male and 9 female). Age at death ranged from 70 to 104 years. Passive physiological ROM, measured after dissection of all muscle tissue crossing the hip joint, was measured goniometrically to assure that all hips included in the study demonstrated at least 90 flexion, 10 extension, 45 abduction, 35 internal rotation, and 35 external rotation. Hips were excluded from the study if these passive ROM criteria could not be met (1 female hip did not meet the extension requirement of 10) or if the articular structures of the hip had been surgically altered (3 hips had prosthetic components).
TABLE 1. Force (N) used by experienced manual therapists (n = 4) for posterior-anterior mobilizations of the femoral head in the acetabulum. Each clinician mobilized 1 small, medium, and large subject. Small Subject (Mass, 54 kg) Clinician Clinician Clinician Clinician 1 2 3 4 154.4 N 611.9 N 715.1 N Not available Medium Subject (Mass, 5472 kg) 230.5 686.2 648.4 238.5 N N N N Large Subject (Mass, 90 kg) 250.1 686.6 741.8 265.7 N N N N

METHOD Preliminary Study to Determine Mobilizing Force Employed by Clinicians

To determine the amount of force used for manual PA mobilization of the hip joint, we asked 4 experienced orthopaedic physical therapists to participate in a preliminary study which simulated the use of PA glide in a clinical setting. An experienced orthopaedic physical therapist was defined as a physical therapist who had practiced manual therapy for 5 or more years in an orthopaedic setting and who used PA glide of the hip in clinical practice. Because we suspected that the size of the subject might influence the magnitude of mobilizing force used, each of the 4 orthopaedic therapists performed PA hip mobilizations on each of the following 3 subjects: 1 smallframed (mass, 54 kg; height, 135165 cm), 1 medium-framed (mass, 5472 kg; height, 168178
J Orthop Sports Phys Ther Volume 33 Number 3 March 2003

RESEARCH REPORT

119

Preparation and Instrumentation of Cadavers

All soft tissue structures from the mid ilium to the distal femur on each cadaver hip were removed down to the periosteum anteriorly, posteriorly, medially, and laterally, except for the hip capsule, which was left undisturbed. After dissection, the cadaver was placed on a 3/4-in (1.91-cm) plywood surface. The pelvis was stabilized anteriorly by a piece of 111/8-in (2.542.540.32-cm) aluminum angle stock 45 cm long, placed across each anterior superior iliac spine (ASIS) and secured to the pelvis by placing a #62-in (#65.08-cm) screw through the aluminum stabilizer bar into each ASIS. The aluminum stabilizer bar was then bolted to the plywood base with 2 pieces of 5/16-in (0.79-cm) threaded rod passing through the ends of the stabilizer bar perpendicular to the plywood base. A level was incorporated into the stabilizer bar to insure that the pelvis was stabilized in a level position. This stabilizer bar, secured to the pelvis with screws and to the plywood base with 5/16-in (0.79-cm) threaded steel rods, was found to provide sufficient stability in all planes except for anterior and posterior pelvic tilt in the sagittal plane. An additional #83-in (#87.62-cm) screw through each anterior pubic ramus and into the plywood base provided adequate sagittal plane stabilization. Once the pelvis was stabilized, the hip joint was placed in a loose-packed position of 15 flexion, 15 external rotation, and 10 abduction, measured using a goniometer. The loose-packed position is thought to be a position in which accessory motions are maximized because articular surfaces are the least congruent and the joint capsule itself offers minimum constraint of accessory motion.18,25 The femur was stabilized in this position with a specially fabricated stabilization device which attached to the distal femur 5 cm proximal to the suprapatellar ridge with 2 1/4-in (0.64-cm) bolts and nuts. The device was fabricated to rigidly fix the distal femur in all 3 planes. To avoid the application of net anteriorposterior force to the hip joint, the stabilizer pivoted about a 3/8-in (0.95-cm) steel rod oriented in the frontal plane perpendicular to the long axis of the femur. This apparatus left the hip joint itself free to respond to anterior and posterior forces applied by the experimenters. With femoral stabilization achieved, a 1/4-in (0.64cm) hole was drilled midway between the greater and lesser trochanters on the intertrochanteric line. Care was taken to assure that this 1/4-in (0.64-cm) hole passed through the femoral neck in a line perpendicular to the frontal plane. A 1/4-in (0.64-cm) threaded steel rod was then passed through this hole and firmly secured to the femoral neck by means of a 1/4-in (0.64-cm) nut and washer on the anterior femoral surface and by another nut and washer posteriorly. An Omega LCF 500 tension/compression
120

load cell with a capacity of 0 to 2225 N (Omega Engineering, Inc., Stamford, CT) was mounted in the center of the 1/4-in (0.64-cm) threaded steel rod and a wooden dowel was mounted on the end of this rod to act as a handle for the experimenters to grasp to mobilize the femoral head (Figure 1). Voltage output of the load cell was amplified by an Omega-Omni-Amp-III DC signal amplifier (Omega Engineering, Inc., Stamford, CT) and displayed on a Tektronix 555A oscilloscope (Tektronix, Inc., Beaverton, OR). Visual markers were placed on the oscilloscope screen at voltage equivalents for 89, 178, 267, and 356 N in both posterior and anterior directions. The oscilloscope screen was calibrated in increments of 1.0 mm and during the 89- and 178-N trials 1.0 mm of deflection represented 4.45 N. During the 267and 356-N trials voltage gain was reduced so that 1.0 mm of deflection represented 7.12 N. Using a scalpel, a small window was cut, approximately 1 cm in diameter, at the thinnest portion of

FIGURE 1. Photographs merged with cartoons of cadavers showing the testing apparatus. A: pelvic (P) and distal femoral (F) stabilizers, mobilizing handle (M) with load cell (arrow) and dial gauge. B: close-up view of external fixator (E), dial gauge (D), part of the mobilizing handle (M) and pelvic stabilizer (P).
J Orthop Sports Phys Ther Volume 33 Number 3 March 2003

the anterior joint capsule to gain access to the femoral head. This window was located between the pubofemoral and iliofemoral ligaments on the anterior surface of the capsule and allowed the experimenters to visualize the femoral head. After drilling a hole 1/16 in (0.16 cm) in diameter and 13 mm deep into the femoral head and perpendicular to the frontal plane, a flat-headed nail was hammered in upon which the dial gauge sensor would rest. A standard metric dial gauge was employed (Central Tool Company, Inc., Cranston, RI). The instrument had a range of 0 to 25 mm and was calibrated in increments of 0.01 mm. The dial gauge was attached to a standard surgical external fixation device (Howmedica Osteonics, Rutherford, NJ) having 3 degrees of freedom. This allowed placement of the dial gauge perpendicular to the head of the nail. The fixator was attached to the lateral surface of the ilium via 2 Synthes 4-mm cancellous bone pins (Synthes, Monument, CO).

marker in the anterior direction was reached, this displacement value was recorded. It is important to note that reported PA displacement values therefore represent total displacement of the femoral head from a posterior to an anterior position. PA movement was recorded at 89, 178, 267, and 356 N. We conducted 5 trials at each force level. After collecting all PA displacement data, the apparatus was modified to measure displacement for longitudinal distraction. The lower extremity was amputated just proximal to the knee joint and the T-handle was attached to the distal femur. The dial gauge was reoriented to measure displacement in the longitudinal direction and the femur remained in the loose-packed position. Data were again collected at 89, 178, 267, and 356 N. These longitudinal distraction displacement data were collected on hip 10, a female hip of intermediate mobility.

Data Analysis
Descriptive statistics were calculated for each hip

Pilot Study to Determine Mobilizing Force to Be Used and group of 12 hips at each mobilization force by Authors condition. An ANOVA model for repeated measures
Employing the apparatus and stabilization methods already described, 1 cadaver served as the subject in a pilot study to determine the maximum mobilizing force that could be employed while maintaining the rigidity of our experimental apparatus. At tensile forces above 400 N the plywood platform had to be clamped to the table to avoid lifting the cadaver and the entire apparatus off of the table. Additionally, forces above 400 N were found to be physically demanding for the operator. A mobilizing force of 356 N (80 lb), which was found to be comfortable to the operator and showed no visual sign of straining the apparatus, was chosen as a maximum force for this study. Based on data presented in Table 1 and on this pilot study, the authors opted to conduct PA mobilization trials at 89, 178, 267, and 356 N. The cadaver serving as the subject for the pilot study was excluded from the data collection phase of the study. was used to analyze differences in femoral head displacement across force conditions using Statview 5.0 software (SAS Institute, Inc., Cary, NC). The ANOVA was followed by a Bonferroni post hoc analysis.

RESULTS
PA displacement values for all trials are presented for all 12 hips in Table 2. The mean PA displacement values at each mobilizing force are presented for each of the 12 hips in Figure 2. As shown in Figure 2, the least mobile hip (hip 2) demonstrated 0.25 mm of movement during the 356-N trials, whereas the most mobile hip (hip 5) demonstrated 2.90 mm of PA movement. Displacement values for the 89-N trials ranged from 0.04 (hip 2) to 1.54 mm (hip 5). Figure 3 presents mean displacement and SD for the trials at 89, 178, 267, and 356 N for all 12 hips. These data range from 0.57 mm for the 89-N trials to 1.52 mm for the 356-N trials. Displacement was found to be significantly different (P 0.01) between trials at different forces. Post hoc analysis showed a significant increase in femoral head displacement at 178, 267 and 356 N (P 0.01 each) compared to that at 89 N. The trials at 356 N showed significantly increased femoral displacement compared to those at 178 N (P 0.01). Long-axis distraction values for hip 10, which was a female hip of intermediate mobility, are presented in Figure 4, where they are compared to the mean PA translation data. With 89 N of force, 1.95 mm of longitudinal distraction was observed compared to 0.45 mm of PA translation. With 356 N of force, 6.42 mm of longitudinal distraction was observed compared to 1.07 mm of PA translation.
121

RESEARCH

Data Collection and Procedure

The researcher operating the T-handle pushed posteriorly with 89 N of force while 2 other researchers observed to ensure the mobilizing force remained perpendicular to the frontal plane. The same researcher operated the T-handle for all trials. To avoid parallax, the researcher faced the oscilloscope directly. As the researcher applied a posteriorly directed force, he watched the oscilloscope for the 89 N marker in the posterior direction. As soon as this marker was reached, the dial gauge was zeroed as the posteriorly directed force was maintained. With the dial gauge zeroed, the T-handle operator then applied an anteriorly directed force. When the 89-N
J Orthop Sports Phys Ther Volume 33 Number 3 March 2003

REPORT

TABLE 2. Posterior-anterior femoral head displacement (mm) in response to varying force applications for each of 12 cadaver hips. Data are presented for each of the 5 trials along with the means (x) and standard deviations (SD). 89 N (20 lb) Hip 1 Hip 2 Hip 3 Hip 4 Hip 5 Hip 6 Hip 7 Hip 8 Hip 9 Hip 10 Hip 11 Hip 12 0.12, 0.11, 0.11, 0.09, 0.09 x = 0.10, SD = 0.013 0.05, 0.04, 0.02, 0.01, 0.06 x = 0.04, SD = 0.021 0.97, 0.90, 0.95, 0.93, 0.95 x = 0.94, SD = 0.027 0.07, 0.10, 0.09, 0.09, 0.11 x = 0.09, SD = 0.015 1.52, 1.56, 1.52, 1.55, 1.54 x = 1.54, SD = 0.018 1.48, 1.47, 1.48, 1.45, 1.48 x = 1.47, SD = 0.013 0.34, 0.38, 0.32, 0.29, 0.29 x = 0.32, SD = 0.038 0.68, 0.65, 0.64, 0.63, 0.62 x = 0.64, SD = 0.023 1.05, 1.04, 1.02, 0.98, 1.04 x = 1.03, SD = 0.028 0.51, 0.43, 0.45, 0.47, 0.41 x = 0.45, SD = 0.039 0.06, 0.07, 0.07, 0.07, 0.09 x = 0.07, SD = 0.011 0.09, 0.10, 0.12, 0.12, 0.14 x = 0.11, SD = 0.020 178 N (40 lb) 0.25, 0.24, 0.22, 0.24, 0.24 x = 0.24, SD = 0.011 0.10, 0.11, 0.11, 0.12, 0.13 x = 0.11, SD = 0.014 1.56, 1.62, 1.60, 1.64, 1.64 x = 1.61, SD = 0.034 0.17, 0.18, 0.16, 0.17, 0.18 x = 0.17, SD = 0.008 2.02, 2.06, 2.04, 2.01, 1.98 x = 2.02, SD = 0.030 2.07, 1.93, 1.92, 1.96, 1.87 x = 1.95, SD = 0.075 0.80, 0.82, 0.79, 0.72, 0.72 x = 0.77, SD = 0.047 1.54, 1.69, 1.62, 1.50, 1.50 x = 1.57, SD = 0.083 1.43, 1.42, 1.45, 1.47, 1.45 x = 1.44, SD = 0.020 0.68, 0.66, 0.70, 0.68, 0.73 x = 0.69, SD = 0.027 0.16, 0.18, 0.18, 0.18, 0.18 x = 0.18, SD = 0.009 0.34, 0.32, 0.33, 0.31, 0.30 x = 0.32, SD = 0.016 267 N (60 lb) 0.35, 0.36, 0.33, 0.35, 0.33 x = 0.34, SD = 0.013 0.19, 0.21, 0.22, 0.19, 0.23 x = 0.21, SD = 0.018 1.94, 1.95, 1.95, 1.97, 1.98 x = 1.96, SD = 0.016 0.22, 0.20, 0.23, 0.23, 0.27 x = 0.23, SD = 0.026 2.48, 2.46, 2.45, 2.53, 2.58 x = 2.50, SD = 0.054 2.52, 2.43, 2.45, 2.46, 2.46 x = 2.46, SD = 0.034 1.13, 1.14, 1.16, 1.22, 1.12 x = 1.15, SD = 0.040 1.95, 2.05, 2.04, 2.05, 1.98 x = 2.01, SD = 0.046 1.95, 2.05, 2.04, 1.98, 1.97 x = 2.00, SD = 0.044 0.91, 0.91, 0.86, 0.85, 0.83 x = 0.87, SD = 0.036 0.21, 0.22, 0.24, 0.26, 0.23 x = 0.23, SD = 0.019 0.55, 0.55, 0.49, 0.48, 0.49 x = 0.51, SD = 0.035 356 N (80 lb) 0.34, 0.36, 0.36, 0.34, 0.33 x = 0.35, SD = 0.013 0.29, 0.23, 0.23, 0.24, 0.28 x = 0.25, SD = 0.029 2.76, 2.82, 2.77, 2.77, 2.73 x = 2.77, SD = 0.032 0.37, 0.38, 0.42, 0.42, 0.43 x = 0.40, SD = 0.027 2.94, 2.83, 2.92, 2.93, 2.90 x = 2.90, SD = 0.044 2.88, 2.72, 2.70, 2.84, 2.87 x = 2.80, SD = 0.086 1.42, 1.44, 1.42, 1.33, 1.51 x = 1.42, SD = 0.064 2.72, 2.73, 2.68, 3.05, 2.78 x = 2.79, SD = 0.149 2.49, 2.51, 2.45, 2.51, 2.45 x = 2.48, SD = 0.030 1.17, 1.00, 1.00, 1.03, 1.16 x = 1.07, SD = 0.086 0.29, 0.29, 0.28, 0.25, 0.25 x = 0.27, SD = 0.021 0.68, 0.71, 0.78, 0.74, 0.76 x = 0.73, SD = 0.040

3.5 89 N 3.0 Displacement (mm) 2.5 2.0 1.5 1.0 0.5 0.0 1 2 3 4 5 6 7 8 9 10 11 12 Hip Number
Displacement (mm)

3.0 * 2.5 * 2.0 * 1.5 1.0 0.5 0.0 89 178 267 356 Force (N)

178 N 267 N 356 N

FIGURE 2. Mean posterior-anterior femoral head displacement in response to varying force application.

FIGURE 3. Mean (SD) posterior-anterior femoral head translation in response to varying force application (n = 12). Significantly greater than displacement at 178 N (P 0.01). * Significantly greater than displacement at 89 N (P 0.01).

DISCUSSION
It is important to note that this study did not attempt to recreate or accurately simulate the entire clinical situation of a patient undergoing manual mobilization of the hip. The study was designed to isolate the articular structures of the hip joint and subject those structures to appropriate forces to answer the biomechanical question: Does PA movement of the femoral head within the acetabulum exist, and if so, how much movement is present? This study represents the first attempt to quantify PA glide at the hip that we are aware of and provides
122

a preliminary answer to this question. Quantification of this movement is of clinical interest because it is the accessory movement involved during PA mobilization of the hip (a manual technique frequently cited and employed in an attempt to increase the physiological motion of hip extension). Because of the lack of data regarding the existence of this accessory movement at the hip, therapists employing this technique have had nothing more than theory, anecdotal evidence, or their own opinion to cite in support of the technique. Others have cited the hip joints
J Orthop Sports Phys Ther Volume 33 Number 3 March 2003

7 Displacement (mm) 6 5 4 3 2 1 0 89 178 267 356 Force ( N)

FIGURE 4. Mean posterior-anterior (PA) femoral head translation versus longitudinal distraction (LD) produced in hip number 10 in response to varying force application.

LD PA

remarkable stability and the high degree of congruence of the articular surfaces to speculate that there is no accessory movement upon which a joint mobilization procedure could logically be based. The current study provides a first step in documenting the existence of PA translation of the femoral head.

Limitations of Study and Recommendations for Future Research

Any investigator collecting movement data from cadaveric specimens and then generalizing these data to living patients must acknowledge the limitations inherent in that process. These limitations are of even greater concern when embalmed cadavers are employed instead of fresh cadavers. Four specific actions were taken to mitigate the limitations inherent in this embalmed cadaver model. First, the scope of the research question was limited to determining whether or not the articular structures of the hip joint allow a specific movement. This is a narrow, but important, question. Second, as stated earlier, all specimens included in this study demonstrated full passive physiological ROM at the hip. This was accomplished by removal of all soft tissues crossing the hip joint. If passive ROM is representative of the living hip, this at least suggests that accessory movements will be as well. Third, using the same apparatus and procedures employed throughout the study, we measured longitudinal distraction. Longitudinal distraction is the one accessory movement that has been well documented in the living hip. Arvidsson2 demonstrated the presence of joint separation from 0.1 to 1.4 mm with a manual traction force of 200 N. The distance increased to a range of 0.8 to 3.0 mm with a force of 400 N. Although no significant differences were present between males versus females, there was considerable variability between individuals. Byrd and Chern5 found a longitudinal distraction of 2.8 to 10.3 mm with an average of
J Orthop Sports Phys Ther Volume 33 Number 3 March 2003

6.2 mm due to traction applied at the joint during hip arthroscopy. Living, ambulatory, adult humans served as subjects in both of these previous studies. We chose to measure longitudinal distraction on hip 10 (Figure 3) because it was a hip of intermediate mobility, its PA displacement data being close to the mean (Figures 1 and 2). The longitudinal displacement values observed for hip 10 were comparable to those previously reported.2,5 Having evidence that the hips employed in this study demonstrate full passive physiological ROM and longitudinal distraction similar to that reported in the living hip increases our confidence in the use of an embalmed cadaver model for the purposes of this study. Fourth, our data were examined for any evidence of the failure of cadaveric tissues during testing. Performing mobilization trials with incrementally greater forces versus randomizing the order of mobilization forces gave the ability to monitor PA movement data for discontinuities within trials that might have indicated structural failure or breakage of tissue. No such discontinuity was observed within trials and there was no indication that tissues were failing during testing. Another possible limitation concerns our preliminary study in which clinicians performed a PA mobilization of the hip and then reproduced this force on a dynamometer. It has been demonstrated that this force reproduction is likely to be inaccurate unless the clinicians are given training trials to increase their accuracy.15 While clinicians in our study were first familiarized by practice trials using the dynamometer, they did not undergo training to assure accurate force reproduction. While such training would have strengthened our preliminary study, the literature also indicates that therapists are likely to employ a wide range of forces when performing a joint mobilization technique15 and our data support this same conclusion. Using a mechanical force transducer similar to those employed by previous investigators15 to simulate the process of joint mobilization, forces ranging from 154.4 to 741.8 N were observed. The mobilizing force was limited to 356 N because with our apparatus this was the maximum value that could be used and still maintain precise directional control and satisfactory stabilization of the cadaver. We feel that because the force was applied directly to the femoral head through a rigid steel rod, and because the hip was thoroughly stabilized, virtually none of the force was dissipated through soft tissues or extraneous movement. It could be argued that had we used a greater mobilizing force we would have seen more femoral head displacement. While we agree that this is most likely true, we feel that the forces we employed, applied directly to the femoral
123

RESEARCH REPORT

head through a rigid steel rod, were sufficient for our purposes and were comparable to those previously reported in studies of accessory motions of the hip.2,5 Because we did not observe leveling off of displacement data, but continued to see increased femoral displacement as mobilizing forces increased, we suggest that future investigators consider exploring the effects of even higher mobilizing forces. An additional factor limiting our study is the small sample size compounded by the great variation among subjects. (Note the relatively large SD reported in Figure 3.) While this large variation between subjects has been encountered in other investigations of accessory motions of the hip,2,5 it nevertheless interacts with our small sample size to limit our ability to draw conclusions regarding the general population. While we cannot be certain how the age of the subjects at their time of death may have affected the amount of PA mobility their hips demonstrated, it is possible that their advanced age may have affected the observed movement data. A final limitation of the current study is that our method provides no means for determining how much of the observed PA movement might represent actual clearance between the femoral head and the acetabulum and how much of the movement might represent strain or elastic deformation of bone and cartilaginous tissues. This limitation is inherent in any study measuring the movement of a bony element in response to a mobilizing force. It has been clearly demonstrated that neither bone nor cartilage is a rigid material and that both demonstrate elastic deformation4,19,27 that could well have contributed to the PA values reported in this study. The possibility exists that this tissue deformation may be an important factor not only in the current study, but also in the clinical process of joint mobilization.

ACKNOWLEDGMENTS
The authors thank Ron Medori of the Medical Services Laboratory of Temple University for his support throughout this study.

REFERENCES
1. American Physical Therapy Association. Guide to Physical Therapist Practice. Second Edition. Phys Ther. 2001;81(1):9746. 2. Arvidsson I. The hip joint: forces needed for distraction and appearance of the vacuum phenomenon. Scand J Rehabil Med. 1990;22(3):157161. 3. Ben-Sorek S, Davis CM. Joint mobilization education and clinical use in the United States. Phys Ther. 1988;68(6):10001004. 4. Burr DB, Milgrom C, Fyhrie D, et al. In vivo measurement of human tibial strains during vigorous activity. Bone. 1996;18(5):405410. 5. Byrd JW, Chern KY. Traction versus distension for distraction of the joint during hip arthroscopy. Arthroscopy. 1997;13(3):346349. 6. Cibulka MT, Delitto A. A comparison of two different methods to treat hip pain in runners. J Orthop Sports Phys Ther. 1993;17(4):172176. 7. Craik RL. Disability following hip fracture. Phys Ther. 1994;74(5):387398. 8. Di Fabio RP. Efficacy of manual therapy. Phys Ther. 1992;72(12):853864. 9. Fitzgerald GK, McClure PW, Beattie P, Riddle DL. Issues in determining treatment effectiveness of manual therapy. Phys Ther. 1994;74(3):227233. 10. Greenman PE. Principles of Manual Medicine. Baltimore, MD: Lippincott, Williams and Wilkins; 1989. 11. Guccione AA, Fagerson TL, Anderson JJ. Regaining functional independence in the acute care setting following hip fracture. Phys Ther. 1996;76(8):818826. 12. Harryman DT, 2nd, Sidles JA, Clark JM, McQuade KJ, Gibb TD, Matsen FA, 3rd. Translation of the humeral head on the glenoid with passive glenohumeral motion. J Bone Joint Surg Am. 1990;72(9):13341343. 13. Howell SM, Galinat BJ, Renzi AJ, Marone PJ. Normal and abnormal mechanics of the glenohumeral joint in the horizontal plane. J Bone Joint Surg Am. 1988;70(2):227232. 14. Kaltenborn FM. Manual Therapy for the Extremity Joints Specialized Techniques: Tests and Joint Mobilization. 2nd ed. Oslo, Norway: Olaf Norlis Bokhandel; 1976. 15. Keating J, Matyas TA, Bach TM. The effect of training on physical therapists ability to apply specified forces of palpation. Phys Ther. 1993;73(1):4553. 16. Kessler R, Hertling D. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. Philadelphia, PA: Harper and Row; 1990. 17. King L. Case study: physical therapy management of hip osteoarthritis prior to total hip arthroplasty. J Orthop Sports Phys Ther. 1997;26(1):3538. 18. Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. Philadelphia, PA: F. A. Davis Company; 1996. 19. Lanyon LE, Hampson WG, Goodship AE, Shah JS. Bone deformation recorded in vivo from strain gauges attached to the human tibial shaft. Acta Orthop Scand. 1975;46(2):256268. 20. Loudon JK. Manual therapy rounds. J Man Manip Ther. 1999;7:203208.
J Orthop Sports Phys Ther Volume 33 Number 3 March 2003

CONCLUSION
This study provides evidence that in an embalmed cadaveric sample measurable PA movement of the femoral head within the acetabulum exists and that, like longitudinal distraction of the femur, it is highly variable between individuals. We view the current study as a first step in providing meaningful data upon which an informed discussion of PA mobilization of the hip can be based. It is our hope that future clinical or biomechanical research will further investigate the efficacy of joint mobilization at the hip and the role, if any, played by PA glide of the femoral head within the acetabulum. Given the prevalence of hip dysfunction in the general patient population seen by physical therapists,6,7,11 we conclude that the topic warrants further investigation.
124

21. MacConaill MA. The movements of bones and joints. J Bone Joint Surg [Br]. 1953;53:290297. 22. Maitland GD. Peripheral Manipulation. East Kilbride, Scotland: Thomson Litho, Ltd.; 1995. 23. Mennell JB. Joint Pain: Diagnosis and Treatment using Manipulative Techniques. Boston, MA: Little, Brown, and Company; 1964. 24. Mennell JB. Physical Treatment by Movement, Manipulation and Massage. 3rd ed. London, England: J and A Churchill; 1934. 25. Norkin C, Levangie P. Joint Structure and Function: A Comprehensive Analysis. 3rd ed. Philadelphia, PA: F. A. Davis; 2001.

26. Paris SV. Mobilization of the spine. Phys Ther. 1979;59:988. 27. Perusek GP, Davis BL, Sferra JJ, Courtney AC, DAndrea SE. An extensometer for global measurement of bone strain suitable for use in vivo in humans. J Biomech. 2001;34(3):385391. 28. Poppen NK, Walker PS. Normal and abnormal motion of the shoulder. J Bone Joint Surg [Br]. 1976;58:195 201. 29. Williams P, Warick R, Dyson M, Bannister L. Grays Anatomy. 38th ed. London, UK: Churchill Livingstone; 1995.

RESEARCH REPORT

J Orthop Sports Phys Ther Volume 33 Number 3 March 2003

125