Hello, my name is Kristen Taylor and I'm a physical therapist with Midwest Orthopedics at Rush Physical Therapy. Today I will be speaking on the topic of rehabilitation for hip and pelvic pain. Rehab for hip and pelvic pain includes a complex patient population with multiple overlapping symptomologies and it requires specific differential diagnosis. It needs to be determined if your patient is truly musculoskeletal dysfunction or if there's underlying neuromuscular or vascular dysfunction or does this patient actually need to be referred out due to visceral or other system involvement. Due to direct access in physical therapy, it is imperative to utilize differential diagnosis and expert clinical decision making in order to determine if the patient is within your scope of practice. Evaluating it needs to be determined what structures are possibly involved and pain generating at that time. Is it intra-articular dysfunction such as FAI, chondral damage, or a labral tear? Or are the symptoms related to extra-articular dysfunction such as athletic pubalgia, snapping hip, muscular dysfunction, or nerve-related pain? Many times these patients have multiple dysfunctions and their participation in PT is like peeling away the layers of an onion in order to improve function in the patient. As you can see here, the referral patterns of pelvic floor dysfunction are very similar patterns to those of posterior musculature referred pain. Lumbar referral and sacroiliac joint referral also have similar pain patterns, thus demonstrating the complexity of treating this patient population and the significant amount of overlap that may be presenting in the clinic for your diagnosis. Things to consider when formulating your plan of care. Length of time from injury to surgery or participation in acute physical therapy. If this has been ongoing for an extended period of time, what complications have presented between initial onset that may alter your ability to obtain a clear diagnosis? Consider any underlying comorbidities with lumbopelvic girdle dysfunction. Any kinesiophobia they may have developed over time. Many times patients will say, it used to hurt when I did that, so I don't really want to do that now. Or they may be very guarded in specific ranges of motion or movements that were initially pain generating for them. It's also important to know your patient's goals. Are there any sport-specific or activity-specific goals your patient may have in order to feel that they have had a successful recovery from their injury or their surgery? What the literature tells us is that persons with chronic hip pain may demonstrate the following. Inhibition of the gluteus medius, transverse abdominus, and several other muscles crossing the hip joint, painful facilitation of hip and pelvic floor musculature, including but not limited to the obturator internus. These patients demonstrate decreased hip range of motion. They display decreased lumbopelvic stability and poor lumbopelvic rhythm. They demonstrate altered mechanics throughout the pain. It's important to keep all of these factors in mind when choosing the plan of care for your patient. In your plan of care, you should move through the developmental stages for your progression. Patients should not be performing single limb activities if they are not yet able to stabilize in a half-kneel position. Keep in mind the principles of reciprocal inhibition, co-contraction, and stability versus mobility. And always remember, movement is dynamic, so your treatment should be dynamic as well. As you move through your progression, remember to utilize functional diagonals and include the anterior, posterior, longitudinal, and lateral slings, and keep training as functional as possible. In this complex patient population, it is important to address the soft tissue and take a hands-on approach. This is a former collegiate dancer, and you can see the anterior pelvic tilt with shortening of the anterior structures. When asked to perform a posterior pelvic tilt, you can see the compensation both anteriorly and posteriorly throughout the chain. We as clinicians should be addressing the tissues to allow the space for the activities that we are asking them to perform. This may include any combination of the following, instrument-assisted soft tissue mobilization, dry needling, ART, strain-counter strain, myofascial release, and internal pelvic floor PT. It's important to lengthen when appropriate in order to obtain optimal muscle tension relationships. Research tells us that persons with FAI and those with chronic hip pain have altered muscle activity as well as altered weight-bearing within the joint. Take a hands-on approach to facilitate pelvic mobility on the frontal and transverse planes, facilitate hip extension, glute activation, and cue quadriceps contraction in early stages of recovery. Patients should be walking with intention at all times to avoid falling back into aberrant movement patterns. As clinicians, we should be diligent in choosing specific exercise that is needed for each individual. This study was done by Chris Powers and colleagues, where they used fine wire electrodes to specifically the TFL and gluteus medius and had the participants perform a list of exercises that are commonly used in therapy clinics. What's interesting is that they found significantly greater TFL activity during side-lying hip abduction, step-up, hip hike, lunge, and squatting activities, so facilitation should be appropriate and individualized for the plan of care. Here are just a few examples of activities to gain motor control with stability and mobility. There is no reason that someone should be advancing in their complex strengthening if they do not have a normalized gait pattern. If they cannot perform their regular ADLs like walking, transfers, and self-care with good form, they should not be progressing to more advanced activities as it is highly likely they will facilitate their poor movement patterns that they have developed in a painful state. Let's talk about rotational stability, mobility, and the specific demands of the different activities and positions these individuals need to master. Utilize compliant surfaces, multiple points of contact for resistance, and dynamic movement throughout this phase of recovery. Sport-specific and activity-specific training. I use the term activity in that, for example, a patient who likes to recreationally hike To them means they trail hike in the woods on uneven surfaces for several hours a week. This patient will require stability, concentric and eccentric control, and different physical demands than that of a dancer or a football player. In this phase, sport-specific testing should take place such as hop testing, plyometrics, agility training, video analysis, and return to sport-specific tests. It is important to understand the demands of the individual when in a competitive state for them to keep in mind endurance and performing when fatigued. Clinical pearls. Differential diagnosis is key. It is crucial to individualize care for each patient. Neuromuscular control at the pelvis is essential. Always take a hands-on approach. And remember, hip rehab is not linear and multiple approaches and at times multiple professionals may be needed to reach your patient's goals.

rehabilitation

hip and pelvic pain

differential diagnosis

physical therapy

musculoskeletal