After spending more time with the Movement Systems Impairment approach to evaluation and treatment, I’ve been feeling my entire exercise approach is more integrated than ever before. Specifically, the lower quarter has been easier to treat and I’ve been looking at all my more primitive position exercises as a specific preparation for upright postures. Specifically, I’m seeing positive results in treating knee and lateral hip pain. As much of the research on these areas suggests, hip abduction weakness is a key component. From a movement impairment perspective, this is easily seen with a pseudo trendelenburg gait pattern (I say pseudo because it is not true neurological weakness). I find this pattern to be most apparent during both walking and running gait and on stairs.
Looking more specifically at exercises, here is a list of things that I use and how I try to integrate them into treating the movement impairment. I’ll use a primitive pattern on up perspective:
1) Can the patient perform sidelying hip external rotation with the knees flexed to 45 (clamshell)? The reason this exercise is important is because it tells me whether the person has any awareness of the hip abductor / external rotator muscles that I want them to use. It also shows me how much they want to compensate with a hip abductor / flexor (TFL) and how much they would rather move their spine instead of moving their hip (relatively flexible spine). This is also very similar to the position of standing with one foot on a step and beginning to step up.
2) Can the patient perform hip extension in hooklying (bridge)? This exercise once again tells me about hip extensor vs. lumbar extensor awareness and ability to utilize glutes vs. hamstrings. Cramping of the hamstrings tells me we are a long way off from getting to doing anything standing up. Eventually this exercise needs to get progressed to 75% of weight on one leg and finally to a single leg bridge. It is crucial that the lumbar extensors do not substitute and the person does not feel their quadriceps working here – if you do, expect either anterior knee pain or lumbar extension pain. Lastly, similar to the sidelying hip external rotation exercise, this is the same position as one would be when putting a foot on a step and preparing to step up. This can be progressed to a hip thrust for those who have more problems walking or running vs. on stairs.
3) Can the patient perform kneeling to tall kneeling with a hip hinge? The shoulders should remain above the knees throughout the movement and the glutes should drive the movement. This is obviously very similar to a bridge, so once a patient can bridge, they should be able to connect these two movements. This will be what I’ll ask the person to do on a step as well, lift up with their glutes. I wish I had a way to do this unilaterally, but I haven’t quite figured it out.
4) Can the patient perform a standing hip thrust with a dowel connected to a band? This is an extension of the kneeling to tall kneeling. This gives great feedback of the hip thrusting motion that is required to step up with a hip extension dominant pattern.
5) Can the patient perform a standing hip hike with the stance leg hip abductors and contralateral abdominals? It’s important that the contralateral side does not move into hip flexion and anterior tilt and that the stance side moves from hip adduction toward hip abduction (the outer hip should move in). Inability to perform this movement suggests that it will be that much harder to do so while stepping up.
6) What is the result of stepping up with the shank stabilized? I like to hold the shank (or lower leg) still and have the person attempt to step up and over the leg. If this alleviates knee pain (more likely than affecting hip pain), then my diagnosis is a knee extension dominant pattern and the person need to work on hip extension patterning as much as possible. If there is still a trendelenburg pattern present, hip pain may still be there and the next exercise / test should be checked. I start this exercise with just holding the lower leg steady and then I progress the person to using my hands as guidance to where the lower leg should not go. The goal is to remove all external feedback and for the patient to visually or proprioceptively detect where his or her lower leg is in space.
7) What is the result of hiking the hip of the down leg prior to stepping up? If the patient can do this and maintain the position during the step up, hip or knee pain may be reduced. This suggests hip abduction strengthening in this pattern needs to be repeated until this becomes automatic. Performing Gray Cook’s RNT techniques (pulling the knee into valgus with elastic resistance) is a good option here. If this cannot be controlled, the patient may need UE support to maintain the opposite hip hiked position or may have to be regressed to more basic hip abduction exercises. This may include seated hip IR.
8) Can the patient exert equal force through each leg during a step up? I have been experimenting with putting a scale on a shorter step and having the patient load the scale prior to stepping up. It has been interesting to see deficits in ability to load a weaker or painful leg prior to stepping up, even though the loading it self is not painful. This suggests a pattern of disuse to me, which seems to improve fairly quickly with proper cuing.
9) Can the patient walk with steady hips? Have the patient walk with steady hips and see how it feels.
10) Is the gait pattern off? The biggest problems I see here are feet that are turned out too much (but check tibial torsion before you tell someone to walk with their feet straight) and hyperextended knees upon heel strike. The normal pattern is a slightly flexed knee upon heel strike that continues to flex with weight acceptance (Neumann, Rancho Los Amigos).
These are some of the main things I look at, but I also want to see if people can perform a side step exercise by pushing or reaching with either leg and for the person to help me understand if they feel asymmetry. This can be visually detected as well with practice, but many patients will understand.
For sit to stand, elevating seat heights and deadlifts make great training tools (although deadlifts have to come after bridges and kneeling to tall kneeling).
Lower abdominal progressions become more important depending on the results of the top two exercises above. This could span from Sahrmann’s lower abdominal progression to some of the DNS exercises 3 month, 4 month, 5 month positions, rolling supine to sidelying (hard rolling). Anti Rotation presses (or pallof presses) are a good option here for abdominals.
Foot and ankle problems can be harder to treat due to chronic changes in structure, but trying to stop the provocative movement pattern is the best place to start. A tripod foot is always a good place to start to look for where the person should be.