by Jeffrey H. Tucker, DC, DACRB
This article explains the importance and purpose of measuring medial and lateral rotation of the hips with the patient in the prone position. Insufficient hip rotation control can cause local hip pain, a pain-producing compensation in the lumbopelvic region or the knees. The ideal range of medial hip rotation motion is approximately 35 degrees (without pelvic rotation). The ideal range of lateral hip rotation is approximately 35 degrees from neutral without pelvic motion.1
I am not as interested in the exact number of degrees of rotation as I am interested in testing for excessive or decreased degrees of the range of rotation. In Shirley Sahrmann’s book Diagnosis and Treatment of Movement Impairment Syndromes, she notes less than 30 degrees of lateral or medial rotation is movement impairment. I am also looking for symmetry or asymmetry of these movements. Evaluating excessive motion and/or decreased range of movement will provide information about the quality of movement at the hips. This is sometimes referred to as neuromotor control or movement coordination.
This evaluation will add another piece of the puzzle to understanding the biomechanics of the lower extremities during physical activities such as gait. It has been my experience that altered movement patterns in the hips may result in alterations of the load distribution across the patellofemoral joint2,3,4 and lumbosacral region,5 causing pain and dysfunction in these areas.
Gathering information about movements is part of a functional examination. Poor quality or altered movement patterns are usually more easily detected when we break down a component of the overall movement (e.g., gait). Recognizing poor hip rotation in the prone position may be easier than recognizing a faulty gait pattern during physical activities. Measuring the hips in a supine position with the hips flexed 90 degrees does not seem as functional as measuring the hips in a prone position with the knees together.
The patient should be in the prone position on a flat table. Stand to the contralateral side of the table, to the side of the hip being examined (stand on the left side of the patient while testing the right hip). Grasp the patient’s foot and passively bend (flex) the knee to 90 degrees. Make sure the knees are together and the thigh is in the neutral position. Slowly move the foot away from you, causing medial rotation of the hip. Evaluate how far the hip moves without moving the pelvis. Is it more than 35 degrees? Is it less than 30-35 degrees? Slowly move the foot toward your body, producing lateral rotation of the hip. Is it more than 35 degrees? Is it less than 30-35 degrees?
Excessive medial rotation of the hip (common): This indicates poor stability (ability to maintain a stabile core and move the extremities) function or excessive length of the hip joint capsule and the lateral rotator stability muscles, posterior gluteus medius and intrinsic hip lateral rotators (piriformis, gemellus superior, obturator internus, gemellus inferior, obturator externus, quadratus femoris).
The gluteus medius arise from the outer surface of the ilium, anterior to the TFL. The muscle converges to form a tendon that attaches to the lateral surface of the greater trochanter. The gluteus medius has fibers that attach forward and posterior of the greater trochanter. The posterior border of the gluteus medius may blend with the piriformis. Together with the glute minimus, the glute medius abducts and medially rotates the hip joint.
Therefore, if the G med is not firing properly, there will be excessive medial rotation at the hip. The glute minimus and medius are fundamental in keeping the trunk in an upright position when the contralateral foot is raised during walking. The hip joint capsule surrounds the acetabulum and neck of the femur. A number of ligament bands help keep the femur and acetabulum in check. The capsule can get tight or become loose.
Excessive lateral rotation of the hip: This indicates either poor stability function or excessive length of the medial rotator stability muscles (anterior gluteus medius and minimus).
Decreased lateral rotation of the hip (common): This includes shortening of capsule and shortening of myofascial structures (TFL/ITB). To differentiate between capsule or TFL, examine the end feel. Take the leg into abduction by 1 inch and if decreased restriction occurs, the TFL/ITB is limiting the movement. If there is no change, the capsule is causing the decreased lateral rotation.
The tensor fascia lata arises from the anterior part of the outer lip of the iliac crest, the lateral aspect of the anterior superior iliac spine and the upper part of the anterior border of the iliac wing. You should keep in mind that in addition to arising from the iliac crest, the iliotibial band (ITB) attaches into the posterior gluteus maximus muscle in the back. The gluteus maximus through the ITB also attaches on the tibia distally.
This is an important point to remember because the TFL/ITB muscle is producing movement of both the proximal and distal aspects of the thigh, which reinforces the maintenance of a relatively constant position of the femoral head in the acetabulum during hip extension. The TFL assists in the flexion, abduction and medial rotation of the hip joint and extension of the knee joint. Use specific muscle length tests to confirm myofascial shortening.
Decreased medial rotation of the hip: This includes shortening of the capsule and myofascial structures (piriformis or superficial fibers of gluteus maximus). The superficial fibers of the gluteus maximus attach proximally to four structures: the thoracolumbar fascia, the iliac crest, the sacrum and the coccyx. They travel distally to the deep part of the muscle and end in a tendinous sheet, which passes lateral to the greater trochanter and is attached to the iliotibial tract of the fascia lata. The iliotibial tract runs down the anterior lateral side of the thigh. It blends with the capsule of the knee joint to attach to Gerdy’s tubercle, the lateral condyle of the tibia and the head of the fibula. Again, poor control at the hip does cause knee dysfunction.
The piriformis arises from the anterior aspect of the second to fourth segment of the sacrum between and lateral to the sacral foramina. Its tendon is attached to the upper border and medial aspect of the greater trochanter. The piriformis laterally rotates the extended hip joint and abducts the flexed hip joint. Differentiate by end feel. Assess specific muscle-length tests to confirm myofascial shortening.
When the glute maximus and piriformis are the dominant muscles producing hip extension, their proximal attachments provide more optimal control of the femur in the acetabulum than do the hamstring muscles. If the attachments of the piriformis and glute maximus muscles are overactive at the femur, they will not provide proper control of the proximal femur during hip extension.
- Van Dillen LR, Sahrmann SA, Norton BJ et al. Reliability of physical examination items used for classification of patients with low back pain. Phys Ther 19998;78:979.
- Brody LT, Thein JM. Nonoperative treatment for patellofemoral pain. J Orthop Sports Phys Ther 1998;28:336-44.
- Witvrouw E, Lysens R, Bellemans J, Cambier D, Vanderstraeten G. Intrinsic risk factors for the development of anterior knee pain in an athletic population. A two-year prospective study. Am J Sports Med 2000;28:480-9.
- Cesarelli M, Bifulco P, Bracale M. Study of the control strategy of the quadriceps muscles in anterior knee pain. IEEE Trans Rehabil Eng 2000;8:330-41.
- Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med 2000;10:169-75.
Part 2 of this article, will focus on specific corrective exercises for the hip.
by Jeffrey H. Tucker, DC, DACRB
There is a lot of excitement and “buzz” about kettlebells in the weight room and the rehab setting these days, so I want to make sure everyone is familiar with this valuable piece of fitness equipment. A “kettlebell” or girya is a traditional Russian cast-iron weight that looks like a cannonball or bowling ball with a handle. The kettlebell goes way back: The term first appeared in a Russian dictionary in 1704. So popular were kettlebells in Tsarist Russia that any strongman or weight-lifter was referred to as a girevik or “kettlebell man.”
Kettlebells come in several sizes/weights, from 5 lbs all the way up to 105 lbs. You can do standard weight-training exercises with kettlebells, including bench presses, overhead presses, curls, squats and rows. However, the unique value of kettlebells is derived from ballistic (fast exercise) work such as snatches, swings, cleans and jerks.
For those of you who don’t know me, I really do prescribe exercise in my practice. Exercise is a natural drug. We need to deliver the right drug, at the right dose, at the right frequency to get the right result. Learning to make good exercise selections is purposeful and designed to decrease pain, prevent injury, decrease body fat, and increase lean muscle mass, strength, endurance, flexibility and overall athletic performance. Currently, I am using kettlebells in my small-group exercise classes to achieve the above goals.
I became intrigued by the claims of the advantages of kettlebells, so I decided I wanted to learn how to use them. I met a well-known kettlebell expert and took workshops from him. I also met with Pavel Tsatsouline, the person responsible for popularizing kettlebells in the U.S. He taught me some of his stretching routines. Once I learned about kettlebells, I immediately realized the benefits to my rehab practice.
The All-in-One Workout Tool
Kettlebells develop all-round fitness and teach kinetic linking. For example, the kettlebell “swings” makes the deadlift functional. It gets you connected to the ground, draws energy from the ground and transfers energy through the shoulder. Kettlebells enhance awareness of posture, position, breath and grip.
Here is a short list of workout equipment the kettlebell replaces: barbells, dumbbells, belts for weighted pull-ups and dips, thick bars, lever bars, medicine balls, grip devices and cardio equipment. The good news is you don’t need to spend thousands of dollars on expensive equipment. For most of your clients, all you need are two or three kettlebells of varying weights. They do not take up much space, so you can train in a small area. In the office, you can get a great workout in a limited space while improving strength, agility and stamina.
I especially like the cardio benefits clients can get from kettlebells. It’s easy to use interval training principles (go slow, go fast, repeat). I have been teaching a twice-weekly exercise class for the past four years. When I first started the class, we used body-weight exercises, balance balls and bands. Each year since starting the class, I’ve introduced a more challenging tool or device. Last year I added telescopic stick/band training to the class, which provided great variety and core work with bands. In January 2008, I started using kettlebells. The participants in my class are noticing more dramatic changes in body composition from kettlebell training than from anything else we’ve done in the past. Kettlebells develop shoulders, back muscles, arms, forearms, a cut-up midsection and strong legs.
Ballistic kettlebell drills involve a snapping action of the hips, and I have found this movement targets the gluteals better than bridges and are as good as squats. Once my clients can perform 50 consecutive bridges in a variety of poses, they are ready for the kettlebell swings. Whatever rehab techniques you use in your office, I always teach and recommend that you start and concentrate on functional asymmetries (right/left differences). Accumulation of asymmetries over time can lead to significant injury.
Most of us have learned something from the Janda method of movement pattern analysis. Kettlebell exercises are movement-based, not just lifting-based. You’re getting movement training with weight instead of weight training with single-plane movement. We’re not just trying to hypertrophy muscles like a bodybuilder; we’re trying to groove movement patterns throughout the body that are both strong and stable.
For sports, you need explosive hips, stable joints and quick hands. Kettlebell training develops those attributes. Most of the moves are done standing (bilateral or single-leg stance), and many moves are done lying supine. Multi-joint movements comprise most of the drills. Kettlebells complement core stabilization, body-weight exercises and telescopic stick/band exercises. Many are characteristic of work, sports, and activities of daily living. With kettlebells, we don’t need machines, so we have more room in our workout areas!
Building Muscle, Losing Fat
With kettlebells, your clients will build muscular endurance when performing high repetitions, and with proper nutrition they will lose fat. Ballistic exercises are not the only exercises to help accomplish this; the Turkish get-up, press and windmill will develop hard midsections and increase shoulder flexibility and stability. Some of my favorite kettlebell exercises include the clean and press, front squat, renegade row, swings and the double clean (holding a kettlebell in each hand).
I love free weights and try to get most of my clients on a free-weight program, but you really can’t do the above exercises with dumbbells. I think kettlebells are actually more challenging than dumbbells. Kettlebell handles are much thicker and will give you a vice grip in no time. Also, the off-centered weight of a kettlebell will force you to use more stabilizer muscles and work the targeted muscles through a longer range of motion.
Progressive, Whole-Body Training
Kettlebell rehab exercise progressions are the same as with other exercise programs. Progress from slow to fast – start a skill at a speed that allows success. Slow down to gain control, and then once it can be mastered, progress to explosive speed. Progress from simple to complex. Finally, build from stable to unstable: a client does not belong in single-leg stance, on a ball or on any unstable surface if they cannot stabilize on the ground with both feet first. Only progress to a less stable environment when the initial exercise is completely mastered and no longer provides a training effect.
I want my clients to get out of pain as quickly as possible so I can begin to train them for fitness. Being fit is a means toward an end, not an end in itself. I use kettlebells to develop complementary motor skills and abilities, and couple effort with execution. Power, flexibility, agility, speed and endurance are the elements of athleticism. Each is trainable, but they must be trained collectively because they are parts of a larger whole. None is a separate entity or more important than another. Sometimes we need to train isolated muscles, but most of the time we train movement patterns, not individual muscles. Kettlebells help achieve this.
No-Nonsense Exercises to Build Core Strength and Tone Your Entire Body
by Jeffrey H. Tucker, DC, DACRB
Your core is your center of gravity, located around your trunk and pelvis, and having a strong core is vital to good posture, muscle control, injury prevention, maximum athletic performance and even basic activities of daily living. There are a variety of ways to work the core muscles, and these days, it’s not always necessary to use free weights or weight machines. Body weight, foam rolls, stability balls, bands, tubing and medicine balls are tools that can be used at home, on your own, to create a solid foundation for developing dynamic strength in your torso, shoulders, arms and legs.
For example, body-weight exercises such as squats, lunges, push-ups, and pull-ups can target the small and large muscles that influence the spine. Working out with balls and bands can help develop a lean torso and abs, build muscles in your pelvis, lower back, hips, abdomen, arms, and create flexibility. And using a foam roll can relieve tension in tight, overactive muscles.
It doesn’t take very much equipment to get started. In my own experience working out at home on a daily basis for the past 15-plus years, a disk used to move furniture becomes the perfect tool to perform sliding lunges. A chin-up bar replaces a lat machine. A chair or a bench becomes a platform to perform step-ups and step-downs. An 8 lb medicine ball can be thrown against an outside wall while performing a chest press. A padded surface or a rocker board/ balance board can be used to perform single-leg stance movements and improves joint stability. A band with handles works just as well as barbells or dumbbells. (Band training provides variable resistance to the popular exercises we use machines or free weights for, such as pressing, rowing, squatting and many others ). A stability ball can be used instead of a flat bench.
What exercises should beginners start with? The National Academy of Sports Medicine recommends starting a workout using the foam roll for what is known as “self myofascial release.” Pressure placed on tender points within the muscle are held for 30 seconds. This allows for optimal muscle lengthening and acts as part of the warm-up phase. Next are lengthening or stretching maneuvers. After stretching only tight, overactive muscles, you then perform basic exercises and progress to advanced strength movements. Maneuvers requiring co-contraction of the small stabilizer and larger mobilizer muscles, such as the”plank” exercise (see below) are great for the abs. Pick exercises that target the front, rear and side muscles of the trunk.
Plank: Start to assume a push-up position, but bend your elbows and rest your weight on your forearms instead of your hands. Your body should form a straight line from your shoulders to your ankles. Pull your abdominals in; imagine you’re trying to move your belly button back to your spine. Hold for 20 seconds, breathing steadily. As you build endurance, try to do one or two 60-second sets.
Side Bridge: Lie on your side with the forearm on the floor and your elbow under your shoulder. For beginners, start with your knees bent 90 degrees. For advanced exercisers, start with your body forming a straight line from head to ankles. Pull your abs in as far as you can, hold the abs stiff throughout and raise the hips off the floor. Hold this position for 10 to 60 seconds, breathing steadily. Relax down slowly. Repeat on your other side. If you can do 60 seconds, do one repetition per side. If not, try for any combination of reps that gets you up to 60 seconds.
Traditional ab crunch: Lie on your back with your knees bent and your hands behind your ears. Slowly crunch up, bringing your shoulder blades off the ground. Perform 1-3 sets, 12-15 repetitions per set.
Ball and Band Exercises
Everyone wants to learn more “butt” or gluteals exercises. The gluteus maximus and gluteus medius are important muscles of the body and often need extra work. The following are good exercises to target the gluteals:
Gluteal ball bridge: Lie on the ball with your head and upper back resting on the ball, feet on the floor with knees bent. Squeeze your gluteals and then push your hips up until there is a straight line through the knee and hip to the upper body. Shoulders remain on the ball. Beware of rising too high or flaring the ribs, which will push the back into hyperextension. Hold the “up” position for two breaths. Let your butt come down and then repeat. Perform 2-3 sets, 10-12 repetitions per set.
Supine ball bridge: Lie on your back with your heels on the top of a stability ball, hip-width apart to aid stability. Suck in the abdominals and squeeze up from your gluteals, lifting your hips until there is a straight line from heels to upper back. Shoulders and head stay firmly on the floor. Take care not to lift the hips too high or flare the ribs so your back hyperextends. Hold for 30 seconds and lower. Perform 2-3 sets, 10-12 repetitions per set.
Lateral band walking: With elastic tubing around both ankles, stand with toes straight ahead, knees over feet and hands on hips. Draw abdomen in and step to right while maintaining upright posture. Don’t rock your upper body when stepping. Step again with the right foot, bringing your feet back to shoulder-width distance. Repeat for six steps to the right and then six steps to the left. This exercise strengthens the glutes, core, and abductors and adductors (the muscles of the outer and inner thigh, respectively). Perform sets of six steps to each side until you feel a slight burn in the gluteal muscle.
Ball back extension: Training the important posture muscles of the thoracic (middle) and lumbar (lower) portions of the spine also can be done on the ball. Position yourself with your chest on the ball and hook your feet under a leg anchor, or put them up against the bottom of a wall. Hold your arms straight out in front of you. Your body should form a straight line from your hands to your hips. Raise your upper body until it’s slightly above parallel to the floor. At this point, you should have a slight arch in your back and your shoulder blades should be pulled together. Pause for a second and then repeat. You can perform this exercise with the arms in a 10 o’clock and 2 o’clock position or a 3 o’clock and 9 o’clock pose. Perform one set of 12-15 reps.
Stability ball push-ups: If you want to build big arms, especially the triceps, stability ball push-ups will take you to next level. Do a push-up with your feet on a stability ball. Keep your body straight – don’t let your hips sag or stick your butt up in the air. Switching positions and having your feet on the floor and hands on the ball challenges the core further. The instability of the ball increases the level of trunk muscle activation. Do as many as you can with strict form, until you feel fatigue; at least 10-15 repetitions.
Band lunge press: If you want more intensity, working with the bands performing pull and push moves is ideal. The band lunge-press helps develop strength, endurance, balance and coordination; there’s not much this exercise doesn’t hit. With a band securely in place behind you, grip the handles and hold them at shoulder level, palms facing toward each other and elbows bent. Feet should be shoulder-width apart. As you step forward into a lunge position, press the handles forward and finish the press with outstretched arms. Return to the starting position. Form is key: Make sure your front knee is aligned over the heel in the lunge position and concentrate on keeping your upper body erect, chin up, eyes staring forward throughout, as if you were trying to balance a book on your head. Do 10-15 lunges with each leg.
Swimmer’s lat pull is a back exercise you’ll feel throughout your entire body. Use an anchored resistance band. With feet shoulder-width apart and knees slightly bent, lean over at the hip – don’t roll your back – until your upper body is almost parallel with the floor. Extend your arms in front of you and grab the band handles. Dynamically draw your arms down and extend them in back of you until they’re at hip level. Think of the motion of a swimmer doing a butterfly stroke – the arm breaking the surface of the water and then continuing down and back. Slowly reverse the motion. Perform 1-2 sets, 10-15 repetitions per set.
Up-chop kneel develops excellent core stability and trunk rotation strength. Kneel with a band or tubing handle attached below hip height. Grasp the handle in both hands to the side of the hip nearest the band. Lift the arms up and at the same time, rotate the shoulders away from the anchor, keeping hips facing forward and arms straight. Complete 1-2 sets of 10 reps on each side.
Down-chop kneel is the opposite of the up-chop. Begin with the handle attached above head height, grasping the handle in both hands above the head to the side of the band. Keeping the hips facing front and the arms straight, pull the hands down and turn the shoulders away from the band. Perform 1-2 sets, 10 repetitions (each side) per set.
Medicine ball slams are a great ab exercise. This exercise involves complete integration of the total body. It will also teach you power development from the ground up and get your heart racing. Take a medicine ball and get in an athletic-ready position (knees slightly bent, ball held with both hands in front of you, as if you’d just caught it) . Bring the ball overhead really fast and slam it down to the floor or ground as hard as you can. Make sure you do a few slow reps first to get a feel for the bounce of the ball, since you have to catch it. Perform 2-3 sets, 10-12 repetitions per set.
Other Tips to Maximize Results
If you work out with another person like your kids or a spouse, you can practice speed and agility drills. Speed is the rate at which something is done or occurs. Agility is the ability to move our body quickly in many directions and speeds with great control. All forms of tag and chase games improve reaction time.
Diversifying your workout will provide new stimulus to muscles and variety of movement. It’s important to change your workout program every 8-10 weeks. One of the biggest mistakes I see my patients do is repeat the same workout over and over again. Show me variety! Often time’s client’s workouts were the first workout they ever learned and it’s the same workout they were doing several elections ago.
Whenever you work out, check yourself for muscle weakness and imbalances from the right side to the left side. Asymmetries cause problems. Exercises that balance your muscles help to avoid injuries, especially those involving the back, groin, hamstrings and knee. A combination workout consisting of foam rolling, band and tubing exercises, medicine ball training, and stability ball exercises can improve your spine and help increase power and performance.
Most people are familiar with Pilates and yoga; these are systems that provide stretching, strength training (especially for the core area), balance training and endurance.
Home exercise programs should include the same fitness challenges and include cardiovascular training (walking, bike, elliptical), reactive training, and speed/agility training.
Getting fit and, training without actually going to the gym is possible when you follow a proper progression and give yourself enough variety of exercises. Becoming your own personal trainer, identifying and fixing muscle weaknesses will benefit your core strength and overall fitness. Your doctor can give you more tips on which exercises and equipment will best help achieve your individual fitness goals.
The Power of the Exercise Band
A recent study published in the Journal of Strength and Conditioning Research suggests a short-term resistance exercise program utilizing exercise bands is as effective as a weight-machine program in increasing strength and reducing fat. The study, which compared the effects of each type of exercise program in 45 previously inactive women (average age: 51-54) for 10 weeks, yielded similar results in terms of functional capacity (assessed by knee push-up and 60-second squat tests) and loss of fat mass. The study authors concluded, “[Exercise bands] can thus offer significant physiological benefits that are comparable to those obtained from [weight machines] in the early phase of strength training of sedentary middle-aged women.”
||Rest (Between Sets)
||30 seconds per tender point
||N/A (one-time warm-up)
||1 or 2 (build to 60-second holds)
||1 per side, 60 seconds each side
|Traditional Ab Crunch
||Build to 3 sets of 12-15 repetitions per set
|Glute Bridge on Ball
||2-3 sets of 10-12 repetitions per set
|Supine Ball Bridge
||2-3 sets of 10-12 repetitions per set
|Lateral Band Walk
||6 per side or until you feel fatigue
|Back Extensions on Ball
|Stability Ball Push-Up
||10-15 repetitions or until you feel fatigue
|Band Lunge Press
||10-15 repetitions per leg
|Swimmer Lat Pull
||1-2 sets of 10-15 repetitions per set
||1-2 sets of 10 repetitions per set
||1-2 sets of 10 repetitions per set
||2-3 sets of 10-12 repetitions per set
|Note: Total workout time should be approximately 30-45 minutes. Be intense! Be consistent! Change your workout routine every 8-10 weeks. You can complete the entire program three to four times per week, or pick a few each day to create a daily 20-minute workout.
Dr. Jeffrey H. Tucker graduated from Los Angeles College of Chiropractic in 1982. He is a diplomate of the American Chiropractic Rehabilitation Board and teaches a 14-hour postgraduate diplomate series on cervical and TMD rehab and lumbar spine biomechanics and rehab. Dr. Tucker practices in West Los Angeles and Encino, Calif.