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Case study: Hip clunking while walking - part 1

Brief history: My client fell on his right hip 10 weeks ago when someone pushed him. Immediately after this incident, he could not walk properly due to the pain and instability he felt when bearing his weight on his right limb. Soon after this incident, he had a consultation with an orthopedic surgeon and was treated by a physiotherapist to manage the injury. His acute symptoms mostly settled down, but he still experiences considerable difficulty walking. He reports a feeling of clunking in his right hip when walking, which also makes him limp.

I found that there was a small amount of clunking in his right hip during passive hip flexion in a non-weight-bearing position. He also reports a feeling of impingement with the passive hip flexion. In addition, the internal rotation range of the right hip was considerably limited. These findings could indicate a structural instability of his hip. However, I did not focus too much on possible intra-articular pathology other than asking him to send me a copy of any imaging exams. This is because he is working with me to optimize his function and focus on what he can do while managing any underlying structural issues. Depending on what I will see in the imaging reports, I may need to reach out to his orthopedic specialist. Nevertheless, there are still lots of things I can do to help him move better. Movement function is not confined by medical pathology. This session focused on helping him restore the hope of moving better and feeling better.

At this point, I am thinking more about what could have affected the positioning and stability of the hip other than the structural issues within the hip joints. An imbalance of activation or tone of the muscles around the hip and/or alignment of the pelvis can affect hip stability. Because the end-feel at the end-range internal rotation (with the hip flexed 90 degrees) felt more like a muscular rather than a bony end-feel, I first suspected that his deep hip rotators could be overtoned. However, the palpatory assessment did not confirm that.

What stood out to me was that the front part of his pelvis was lower on the right side based on the palpation of his anterior superior iliac spine (ASIS) of the pelvis. This indicated an anteriorly rotated pelvis (innominate) on the right side. His right medial malleolus of the ankle was also lower than the left medial malleolus, indicating that the right leg could have become longer following suit of the anterior rotation of the pelvis. These findings gave me more clues as to why the right hip flexion was limited. Anterior rotation of the pelvis usually accompanies external rotation of the pelvis (innominate) relative to the femur (thigh bone). This is also often called an outflare of the pelvis. Out-flaring of the pelvis can make the femoral neck meet the rim of the acetabulum (edge of the hip socket) too early, thereby limiting hip flexion. I suspected this mechanism was contributing to his limited hip flexion and impingement during hip flexion as I also felt that his femur was sliding outward along the edge of the hip socket during the passive hip flexion. The right deep hip flexors were tested weaker than the left side. This could indicate that the deep hip flexors on the right side may be in a positionally non-optimal length due to the imbalance within the pelvis. Given the role of the deep hip flexor in stabilizing the hip joint, recovering the strength of this muscle is important.

So I decided to help him correct anteriorly rotated right pelvis. It is important to address any muscular imbalance around the hip and pelvis before attempting to correct the balance of the pelvis. So I palpated around the hips and pelvis. Hip flexors are typically tight for people who demonstrate an anteriorly rotated pelvis. However, his hip flexors felt fine. Instead, I found over-toned tissues in the left flank. Tightness or shortening of the left flank can make the left pelvis sit relatively higher than the right side; thereby creating an alignment that resembles anteriroly rotated right pelvis. The tissues I felt could be internal abdominal oblique, quadratus lumborum, or connective tissues like fascia. Due to the myofascial connection, they probably collectively contribute to the tightness in the area I palpated. Nevertheless, it is worth testing their individual function to improve the precision of manual release. Therefore, I tested the activation / strength of quadratus lumborum and oblique muscles. They were all within normal. The only clear finding was that the passive side bending towards the right side was limited compared to the left bending. This usually indicates shortened tissues on the left side of the spine that have longitudinal fiber orientation. These tissues include but not limited to quadratus lumborum, erector spinae, abdominal obliques, and fascia surrounding and within these muscles.

I decided to collectively lengthen the longitudinal fibers of the left trunk muscles rather than focusing on a specific muscle. I used a combination between manual release and the client's active motion to do so.

After the manual release / lengthening of the left flank, he is ready to use his own muscular activation to regain the balance within the pelvis. I used combined isometric activation of right glute / hamstring and left hip flexors to guide him to create gentle posterior rotation of the right pelvis and anterior rotation of the left pelvis (this is the opposite of the position he was in). After this isometric activation method, I found that his ASISs on both sides are more level as well as the medial malleoli on both sides. This indicates that his pelvis is in more balanced state now. He now has improved hip flexion range of motion and decreased sensation of the impingement during hip flexion. Understandably, it is not perfect yet but we brought a positive change into his body. Importantly, his deep hip flexion strength has improved, thereby increasing the chances of using the deep hip flexors to stabilize his hip joint.

In summary, improving the balance within the pelvis helped him immediately improve the range of motion and stability of the injured hip. Seeing an immediate result like this is always promising and rewarding. However, our work is not done yet. He needs an exercise/movement re-training strategy to maintain the effect of today's treatment while continuously progressing. The true value of the kinesiology approach lies in long-term effects rather than immediate results. The exercise strategies for him to get the long-term effects are explained in part 2 of this case study.

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