The hip is considered the “power source” of the body during activity. Clinicians often associate lower extremity motion and forces as being exerted through the hip. This means that the hip joint may be implicated as a source of injury or dysfunction or as a site of compensatory adjustment to maintain function. Therefore, improving hip excursion or mobility has the potential to treat a variety of impairments.
For the hip, the goal would be to have the patient explore the triplanar motion for which this joint is designed. Often, tightness in the low back, hamstrings, glutes, or hip rotators will result in a reduction of hip excursion, particularly when most activities focus on flexion and extension only. Using the hip musculature, the hip can be positioned to restore functional movement, which often promotes greater mobility in the low back as well. Throughout these exercises, the patient should not work through pain in the hip, and the positions and forces can be modified as needed to improve overall excursion (Figure).
Figure. Hip excursion treatment starting position. (A) Hands should reach overhead throughout the exercise to provide tension on the hip joint and extension of the spine. (A–B) Place the hip (in a figure 4 position, with hip, knee, and ankle at 90°) on a high-low table for ease of patient height preference. A pillow may be placed under the knee if the patient is less flexible, and the knee flexion angle can be decreased if there is any knee discomfort. The patient should report feeling an extreme gluteal stretch when in the proper excursion position. In this position, the patient will perform the 6 exercises described previously. The patient should perform 15 repetitions of each exercise while in the position shown. The patient then repeats the treatment on the contralateral hip.
The patient should begin the treatment session with a warm-up. Then a modified Thomas test for hip flexor stretch and gluteal and external rotators stretch are performed. While in the position shown in the Figure, the patient performs 6 exercises. Each of the exercises stresses the hip in the triplanar motion and does not result in a great deal of motion but emphasizes small repetitive motions to “unlock” the hip. The patient will first perform anterior pelvic tilts, followed by lateral pushes to the left and right. Next, the patient will rotate left and right on the standing leg to create a motion at the treating hip that mimics opening and closing the hip joint. The patient will then end with small-circle oscillations clockwise and counterclockwise. The patient then repeats the exercises on the opposite hip.
Theoretically, treatments to improve hip excursion in multiple planes of movement should create a more mobile segment to allow for proper movement and produce stability through activation of the musculature. The hip excursion treatment technique described in the Figure emphasizes mobility with warm up and stretching, then use of capsular work (excursion), and finally is combined with strength exercises. This technique can be augmented with modalities and other rehabilitation techniques, such as flexibility exercises, to allow for proper recovery of injury or implementation in a prevention plan.
This rehabilitation technique is an example of the practical application of a concept described as Functional Manual Reaction (FMR), a phrase proposed by the Gray Institute ( http://www.grayinstitute.com), which encompasses a philosophy of rehabilitation that integrates the understanding of the biomechanical demands of the body with movement. Clinicians should understand these mechanisms for clinical application to appreciate the human body as an integrated, segmental system directed by different forces that should affect other body segments in a predictable manner. Forces experienced in the body may lead to a chain reaction that can change normal movement patterns. The concept of FMR utilizes the idea that instead of agonists and antagonists assisting each other to create motion and movement, the body has muscles that work synergistically to create successful movements.