Hip Region Disorders & Treatment with Physiotherapy Techniques

1. HIP DISORDERS & TREATMENT WITH
MET, SOFT TISSUE TECHNIQUE &
MULLIGAN TECHNIQUE

2. HIP JOINT ANATOMY
• A synovial ball & socket joint; formed
by an articulation between pelvic
acetabulum & head of femur.
• Hip joint provides stability, balance &
weight bearing.

3. HIP LIGAMENTS HIP BURSAE

4. MUSCLES &
MOVEMENTS
OF HIP
JOINT

5. BLOOD SUPPLY NERVE SUPPLY

6. TREATMENT TECHNIQUES
I. MUSCLE ENERGY TECHNIQUE
II. SOFT TISSUE TECHNIQUE
III. MULLIGAN TECHNIQUE

7. MUSCLE ENERGY TECHNIQUE

8. MET
A manual therapy which uses a muscle’s own energy in the form of
gentle isometric contractions to relax the muscles via autogenic or
reciprocal inhibition, and lengthen the muscle.
It consists of two major types:
1. Autogenic Inhibition
2. Reciprocal Inhibition
 If a sub-maximal contraction of the muscle is followed by
stretching of the same muscle it is known as Autogenic Inhibition
and if a submaximal contraction of a muscle is followed by
stretching of the opposite muscle than this is known as Reciprocal
Inhibition.
Autogenic inhibition includes post isometric relaxation technique.

9. MET  Post Isometric Relaxation (PIR) is the effect of the
decrease in muscle tone in a single or group of
muscles, after a brief period of submaximal
isometric contraction of the same muscle.
 The PIR technique is performed as follows:
• The hypertonic muscle is taken to a length just
short of pain, or to the point where resistance to
movement is first noted.
• A submaximal (10-20%) contraction of the
hypertonic muscle is performed away from the
barrier for between 5 and 10 seconds and the
therapist applies resistance in the opposite
direction.
• After the isometric contraction the patient is
asked to relax & exhale while doing so.
Following this a gentle stretch is applied to take
up the slack till the new barrier. Starting from this
new barrier, the procedure is repeated 2-3 times.
 Reciprocal Inhibition Technique involves the
contraction of one muscle followed by
stretching of the opposite muscle.
 The Reciprocal Inhibition MET technique is
performed as follows:
• The affected muscle is placed in a mid-range
position.
• The patient pushes towards the
restriction/barrier whereas the therapist
completely resists this effort (isometric) or
allows a movement towards it (isotonic).
• This is followed by relaxation of the patient
along with exhalation, and the therapist
applies a passive stretch to the new barrier.
• The procedure is repeated between three to
five times and five times more.

10. QUADRICEP MUSCLE
• Patient is prone lying with cushion under the abdomen to help
avoid hyper lordosis.
• Affected leg is flexed at hip and knee.
• The practitioner can either hold the lower leg at the ankle, or the
upper leg can be cradled so that the hand curls under the lower
thigh and is able to palpate for bind, just above the knee, with the
practitioner’s upper arm offering resistance to the lower leg.
• Once the restriction barrier has been established, the decision will
have been made as to whether to treat this as an acute problem
(from the barrier) or as a chronic problem (short of the barrier).

11. QUADRICEP MUSCLE
• Appropriate degrees of resisted isometric effort
are then introduced. For an acute problem a mild
15% of MVC (maximum voluntary contraction), or
a longer, stronger (up to 25% of MVC) effort for a
chronic problem, is used as the patient tries to
both straighten the leg and take the thigh
towards the table (this activates both ends of
rectus).
• The contraction is followed on an exhalation, by
taking of the muscle to, or stretching through, the
new barrier, by taking the heel towards the
buttock with the patient’s help.
• Repeat once or twice using agonists or
antagonists.

12. ILLIOPSOAS MUSCLE
• The client is in a supine position with one thigh
hanging off the side of the table.
• The client holds the opposite thigh in a fully
flexed and bent knee position.
• The client attempts hip flexion of the hanging
thigh, while the practitioner offers resistance.
• The client holds the contraction for about 5–8
seconds, and then releases the contraction.
• As the client releases the contraction, the
practitioner pushes the thigh into extension to
stretch the iliopsoas muscle.
• If the client experiences discomfort, instruct the
client to further flex the opposite hip, which will
increase rotation of the pelvis, straighten the
spine & reduce facet joint compression.

13. ILIOPSOAS MUSCLE
• Can be treated in the prone position with cushion under the
abdomen to help avoid hyper lordosis while affected leg is flexed
at hip and knee.
• Do stretch following the patient’s isometric effort to bring the thigh
to the table against resistance would be concentrated on extension
of the thigh, either to the new barrier of resistance if acute or past
the barrier, placing stretch on psoas, if chronic.

14. LOWER HAMSTRING MUSCLE
• Patient’s treated leg is taken into full hip flexion (helped by patient
holding upper thigh with both hands) and then straightened by the
practitioner until the restriction barrier is identified.
• Isometric contraction against resistance is introduced at this ‘bind’
barrier (if acute) or a little short of it (if chronic).
• Following the 7–10 seconds of contraction, followed by complete
relaxation, the leg should, on an exhalation, be straightened at the
knee towards its new barrier (in acute problems) & through that
barrier, with a degree of stretch (if chronic), with the patient’s
assistance. This slight stretch should be held for not less than 10 (up to
30) seconds.

15. UPPER HAMSTRING MUSCLE
• The treatment is performed in the straight leg raised (SLR) position,
with the knee maintained in extension at all times.
• The procedures are the same as for treatment of lower hamstring
fibers except that the leg is kept straight.

16. ADDUCTOR MUSCLES
• Patients adducts his legs while therapist resists it.

17. TENSOR FASCIA LATA/ ILIOTIBIAL BAND
• Patient is supine lying with affected leg in extension while
unaffected leg with hip & knee flexion.
• Unaffected leg is crossed over affected one.
• Ask the patient to do abduction of affected leg while therapist
resists it.

18. PIRIFORMIS MUSCLE
• Patient is in prone position with the knee
flexed.
• Instruct the patient to hold the leg stationary
as therapist attempts to pull the leg laterally
(moving the thigh in medial rotation).
• This resisted movement engages an isometric
contraction.
• The patient holds the contraction for about 5–8
seconds and then releases the contraction.
• Upon release, therapist pulls the leg laterally
(thigh moving in medial rotation) thereby,
stretching the piriformis.

19. SOFT TISSUE TECHNIQUES

20. SOFT TISSUE TECHNIQUES
 Effleurage: In this technique, the hands mold to the body part being treated and a smooth
gliding stroke is applied parallel to the primary fiber direction.
 Sweeping cross fiber: It is primarily a gliding stroke, but there is a superficial cross fiber
component and stroke moves diagonally across fibers of the muscle being treated.
 Stripping: Application of deep & gliding pressure along the length of muscle fibers with
thumb, knuckles, forearm or elbow.
 Pin & stretch: The force of the stretch is focused on the region of the muscle that is between
the pinned point and the attachment that is moved.
 Static compression: A technique of pressing directly on soft tissue in one location without
moving the treatment hand.
 Deep longitudinal stripping: This technique involves a slow longitudinal gliding stroke
applied to muscle or other soft tissue with the intent of encouraging tissue elongation and
elasticity
 Friction: Apply deep pressure to the site of soft tissue lesion with thumb or finger.
 Active engagement lengthening: Use static compression, compression broadening, or deep
longitudinal stripping in combination with active movements of muscle.

21. PIRIFORMIS SYNDROME
Soft Tissue Techniques
• Sweeping cross fibers to
gluteal muscles
• Longitudinal stripping on
the piriformis
• Pin & stretch for piriformis
• Active engagement
lengthening to piriformis

22. LONGITUDINAL
STRIPPING OF
PIRIFORMIS
SWEEPING CROSS
FIBERS OF GLUTEAL
MUSCLES

23. PIN & STRETCH FOR
PIRIFORMIS
ACTIVE ENGAGEMENT
LENGTHENING TO
PIRIFORMIS

24. SACROILIAC JOINT DYSFUNCTION
Soft Tissue Techniques
• Sweeping cross fiber to gluteal
muscles
• Deep stripping to gluteus maximus
• Static compression to gluteal muscles
• Sweeping cross fibers to lumbar
muscles
• Deep longitudinal stripping on lumbar
• Friction to posterior sacroiliac
ligaments
• Deep longitudinal stripping on
hamstrings

25. DEEP STRIPPING ON
GLUTEUS MAXIMUS
STATIC COMPRESSION
TO GLUTEAL MUSCLES

26. DEEP LONGITUDINAL
STRIPPING ON
LUMBAR MUSCLES
SWEEPING CROSS
FIBER TO LUMBAR
MUSCLES

27. FRICTION TO
POSTERIOR
SACROILLIAC
LIGAMENT
DEEP
LONGITUDINAL
STRIPPING ON
HAMSTRINGS

28. TROCHANTERIC BURSITIS
Soft Tissue Techniques
• Sweeping cross fibers to gluteal
muscles
• Deep stripping to gluteus maximus
• Static compression to tensor fascia
lata
• Pin & stretch of tensor fascia lata

29. SWEEPING CROSS
FIBERS TO GLUTEAL
MUSCLES
DEEP STRIPPING TO
GLUTEUS MAXIMUS

30. STATIC COMPRESSION
ON TENSOR FASCIA
LATA
DEEP STRIPPING TO
TENSOR FASCIA LATA

31. ANTERIOR PELVIC TILT
Soft Tissue Techniques:
• Effleurage & sweeping cross
fiber to lumbar muscles
• Deep longitudinal stripping on
spinal extensors
• Deep stripping for quadratus
lumborum

32. SWEEPING CROSS
FIBERS TO LUMBAR
MUSCLES
DEEP LOGITUDINAL
STRIPPING OF
SPINAL EXTENSORS

33. DEEP STRIPPING FOR QUADRATUS LUMBORUM

34. POSTERIOR PELVIC TILT
Soft Tissue Techniques:
• Sweeping cross fibers of
rectus femoris
• Sweeping cross fibers of
hamstrings
• Deep longitudinal stripping of
hamstrings

35. CROSS FIBER
SWEEPING OF
RECTUS
ABDOMINUS
SWEEPING CROSS
FIBERS OF
HAMSTRINGS

36. DEEP LOGITUDINAL STRIPPING OF
HAMSTRINGS

37. LATERAL PELVIC TILT
Soft Tissue Techniques:
• Effleurage & sweeping cross
fiber of lumbar muscles
• Static compression to
hypertonic lumbar muscles
• Deep stripping to quadratus
lumborum
• Pin & stretch of quadratus
lumborum

38. SWEEPING CROSS
FIBERS OF LUMBAR
MUSCLES
STATIC
COMPRESSION TO
LUMBAR MUSCLES

39. PIN & STRETCH
TO QUADRATUS
LUMBORUM
DEEP STRIPPING
TO QUADRATUS
LUMBORUM

40. MULLIGAN TECHNIQUE

41. MOBILIZATION WITH MOVEMENT (MWM)
MWM is the concurrent application of sustained accessory mobilization applied
by a therapist and an active physiological movement to end range applied by
the patient. Passive end-of-range overpressure, or stretching, is then delivered
without pain as a barrier.
MWM procedure is as follows:
• Once the aggravating movement has been identified, an appropriate glide is
chosen.
• Decision to use weight-bearing or non-weight bearing movement depends upon
the severity, irritability & nature of the condition.
• Once the glide has been chosen, it must be sustained throughout the
physiological movement until the joint returns to its original starting position
• Mobilizations performed are always in resistance but without pain.
• Immediate relief of pain and improvement in ROM are expected.
• If this is not achieved, vary the glide parameters.

42. MWM FOR HIP ROTATION
For internal rotation in supine lying:
• Patient is supine lying with hip & knee
flexed.
• Treatment belt around patient’s upper thigh
& therapist’s upper thigh below the hip joint.
• Therapist’s left arm is around patient’s thigh
& lower leg.
• Therapist’s right hand is at patient’s lateral
ilium & right forearm is positioned to
stabilize patient’s pelvis.
• Passively internally rotate patient’s hip
while laterally gliding his femur by using
therapist’s thighs and belt.

43. MWM FOR HIP ROTATION
For internal rotation in standing:
• Patient is standing.
• Place belt around patient’s thigh & therapist’s
thigh.
• Therapist places his hands on patient’s ilium
for stabilization & apply lateral distraction
force by using his thighs.
• Sustain this & ask patient to internally rotate
his affected leg with his other leg held just off
the floor.
Same procedure is done for external rotation
and after applying glide, ask the patient to
do external rotation of his affected leg.

44. MWM FOR HIP FLEXION
• Patient is supine lying with hip & knee flexed.
• Treatment belt around patient’s upper thigh & therapist’s upper
thigh below the hip joint.
• Therapist’s left arm is around patient’s thigh & lower leg.
• Therapist’s right hand is at patient’s lateral ilium & right forearm is
positioned to stabilize patient’s pelvis.
• Therapist’s apply lateral glide to patient with his thighs & belt while
passively flexes patient’s hip with other hand.

45. MWM FOR HIP EXTENSION
• Patient is standing; facing a chair with the foot
of his unaffected leg on it while grasping the
back of chair for security.
• Therapist is standing on affected side with belt
around patient’s upper thigh along with his
own thighs in the belt.
• Therapist apply sustained lateral distraction
while patient flexes forward over his knees &
then extends his spine.

46. MWM FOR HIP ABDUCTION
• Patient is standing with his affected leg on floor &
his sound leg’s foot on a chair.
• Patient’s legs are as far apart as possible & he
holds back chair for security.
• Therapist wrap the belt around patient’s thigh &
his own thighs.
• Ask the patient to do knee flexion on the chair
further & shifts his pelvis sideways towards it.
• Stretch is accompanied by a posterior glide of his
hip joint by therapist, using a treatment belt while
therapist stabilizes patient’s ilium.

47. REFERENCES
• Manual Therapy by Brian R. Mulligan
• Mulligan Concept of Manual Therapy by Wayne Hing
• Orthopedic Massage Theory & Techniques
• Muscle Energy Techniques by Leon Chaitow
• https://teachmeanatomy.info/lower-limb/joints/hip-joint/
• https://emedicine.medscape.com/article/1898964-overview
• https://www.healthpages.org/anatomy-function/hip-structure-
function-common-problems/#Common_Problems_of_the_Hip
• https://www.healthline.com/health/hip-disorders#causes
• https://www.physio-pedia.com/Muscle_Energy_Technique
• https://www.physio-pedia.com/Mulligan_Concept