Hip mechanics to understand before rehab or surgery

This is session number 34 of the Performance Place Sports Care Podcast. That actually is how old I am. Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, everyone. It's Dr. Sebastian Gonzales with the Performance Place Sports Care Podcast. And today, we're going over specifically the hip. And I actually feel like I learned a couple things getting some feedback on the knee one that we did. I believe it was in number, geez, I think it was 31, session 31.

I want to make sure that we get through the actual joint, joint mechanics, anatomy, and everything before we actually get too much into actually rehab in more complex terms. And if you listened to that knee one, you know that I started off with anatomy. And I got some feedback from some people that were like, gosh, you know, like the second part, the second part was really good. Like they thought, wow, I started to really understand, but they had to really just push through the first part. And my argument was like, hey, I want you guys to learn the bones, the joints, the muscles, the tendons, the ligaments, carlage, all important stuff.

And they're like, I know it was really, really painful, though. I kind of want to feel like I'm winning before I start to feel like I'm losing. So in this one, when we talk about hip, I'm going to go into mainly the mechanics first. And the reason why you guys should be listening to this, by the way, if you haven't picked up the reason why you're like, why should I stay and listen to this podcast when I can listen to the next one? It's number one, that you won't understand everything we're talking about unless you listen to this one first. Okay. And the things that I want you to, the reason why I want you to listen to this is because we're going to go over cases that, types of conditions such as hip impingement, hamstring strains or tears, trochanteric bursitis or bursitis of the hip, knee flexor syndrome or tightness or injury, piriformis syndrome, sciatica, tendonitis of the hip, and also like gluteus medius types of things in and around there.

So these are really common issues that people get. And it's not limited to only this today. But I'm going to try to explain some of joint mechanics and the reasons why we design rehab programs the way we do. And because I think that's a missing factor in a lot of rehab here is that we don't spend the time to educate. So this podcast is intended to let you understand. I want to make sure that everyone understands so they comply with the reason for the rehab. So this is the parts I'm going to go into today is number one, we're going to start with. So mainly the ideas, the areas of the body that are critical to hip rehab and function and I'll name those off at least right now.

So first we're going to go into muscles surrounding the joint, the actual joint, hip joint proper. Why are they important? Next we're going to go into the core muscles. Why are they important? And then we're going to go into how to move your body or how you move and use your body and how important they are to limiting hip injuries as well as rehabbing them. And then we're going to go a little bit into open and closed chain hip mechanics or kind of what that means there. After that, since I did learn something from the knee one, is that then I will go into some of the movements of the hip, and then anatomy, the bones, the cartilage, ligaments, tendons, muscles.

And then I'll go through some, the variant to try to keep you around for a little bit because that's going to be the tough part in the middle. Then we're going to go into just some recommendations that I like. And you're going to hear different ideas from different people on the podcast throughout the hopefully years that I'm doing this podcast. The next one's going to be, it's going to be from a PT. So she might have a different recommendation list than I might. But either way, we all have really good success rates with, or the people that I'm going to interview have good success rates with the injuries that I'm interviewing them for.

So with that being said, let's just start right into it. By the way, if you're listening to this first, if you're listening to this on anyone's website, or you don't, if you're not listening to it on anything except for iTunes, you need to go to iTunes and subscribe. Okay, that's the only way you're going to get this podcast weekly. And it's the only way to review and get some of the show notes. The show notes are actually listed as well on my site. That's p2sportscare.com slash podcast. And any of the links and references that I make today, I'm going to put on there. There'll also be some on iTunes, but there won't always be clickable links.

So if you want to be more interactive with this and go reference the stuff later that I'm talking about, then you need to go on to iTunes, subscribe, find the show notes on my page, p2sportscare.com slash podcast. And then you will be fully in the know about hip rehab. So let's start right into the muscles surrounding the joint. So you guys might know this as, you know, the hip rotators, the adductors, the hip flexor and all this kind of stuff. But for the most part today, with this section, we're going to talk about the hip rotators and adductors. And I always like to tell people that they are very closely related in function as the rotator cuff of the shoulder.

Because most people are familiar with the rotator cuff of the shoulder. They might not know what it does, but they're familiar about what it is. It's these muscles and tendons which cover this ball and socket. And most people kind of think that it keeps it in place and they just raise it and lower it and rotate it and so on. But they actually help with a concept called centralization or dynamically stabilizing or keeping the ball and socket centered into the area where it's supposed to be. Now, this is extremely important in regards to keeping function and limiting injury with the rotator cuff.

And now when we go down into the hip, we have to keep those muscles healthy in order to preserve the joint capsule, the bones, let's see, the cartilage, and all the stuff that we'll talk about later in the section on actual anatomy. But centralization is where we keep that ball located in the socket where it should be. And if we take gravity and body weight into account, we can kind of see, if you saw a picture of the hip, you'd see the ball comes from a, so the thigh bone, that long bone, and it comes into a little neck and then it turns into a little ball. It's almost like a cane. Now, the end of the cane is driven up into the socket.

And if we let gravity and our body weight do all the work that it's going to do and say there's no muscles or collage or any other type of component there, say we just use the pure bony anatomy, we'd be driving that hip or that ball through the socket up towards our head because gravity goes up and down, right? And especially when we run and jump and weight lift and especially if you're doing a bunch of squatting and you have a ton of weight on you, it's up and down, right? So we need to redirect this force a little bit to save our bones and joints and let them move properly. So our body is going to disperse this force of gravity and landing through the pelvis so we can actually keep this whole structure kind of working.

Now, if you don't really understand or can visualize this concept, I know one thing that I really thought of in the past is think of those old mailboxes, you know, those old school ones that are like out on the farm and like you have this long driveway and you have to take a big long stroll out there to get your mail every time and have a little arm that goes up and so on. So some of these mailboxes, I mean, they're all kind of sitting on post unless they're on like a fence, I'm guessing. I haven't been to the country much, but I always imagine them just on a single post. And I can always imagine those kids coming by and like, I think it was a baseball, you play, you end up hitting them with a baseball bat to like knock them over.

Messed up kids. But anyways, they're on a post and they're suspended there. And the mailbox is essentially probably kind of top heavy if you put too much mail in it. So if you get a bunch of mail or if you end up getting like a package full of lead weights, at some point, this thing, if it wasn't centered, this box, if it wasn't centered on that post, it would eventually fall over. Or it would eventually also too, it would start tilting the post out of the ground. And this would come more so, especially probably when it started raining and the ground got really soft. And for that reason, we have to center that box right on top of the post, okay?

Now, not all mailboxes are really centered in the center of that post. Some of them are kind of off shooting forward, like so the mailman can kind of drive up a little bit closer, I think. Or maybe it's just for style, I have no idea. But you eventually put, in order to keep that box actually on top of the post, you have to have some type of support underneath it. And it'll come in the shape of an angle. So it'll be an angle from the post to the other side of the box and it gives it that off-centered look. But it still has the stabilization to where if you got that box full of weights, full of lead, fishing lead, you wouldn't want to go fishing.

Then it would still stay on the post, right? So the muscles of the hip kind of operate in the same way, except they're a little bit better. Because they have the ability to contract and stabilize based upon what's going on at that certain time. So they have that ability to contract. And especially if you're in an unstable surface, if you're changing direction, if you're jumping, if you have a larger hip range of motion, this is when those muscles really come into effect. When that joint becomes more at its extreme. But it is, they are working throughout the entire day where they want to keep everything kind of centered right there.

And that happens with normal walking, sitting, going to the restroom, sitting up and down and so on. And if these muscles became damaged and they were forced to work too hard or became irritated, then the hip joint, the bones, the cartilage, the ligaments, and all the tendons really just start to suffer. And not to mention, it does allow dysfunctional movement to travel throughout the body, which is going to be the lower back, the knee, and we can even say the other side of the body as well. So a lot of times if you have a condition of like one side or one limb, the hip, the knee, the ankle, you start to favor the other side.

You go to the other side and you make that side work a little bit harder to favor the load. And eventually this becomes a whole other issue on the other side. So an example of this, basically what I said was centralization is, so that there was actually a study done in 2004. It was by Norris. I have this written down in my notes somewhere and by God, I cannot find it. I got a really good resource or I got it from a really, really credible source. A guy I respect a lot. So I'm taking it as gold there. If I find this link, I will put it on my site. But anyways, so the gluteus medius, which is one of those muscles of the hip, it basically has the ability to change the force of the body weight on the femoral neck, which is the area between the ball and the thigh bone.

And it prevents the femoral neck from fracturing. Okay. And especially when you do something like running, where you're subjected to about three times that of your normal body weight, just on your impact, this is how we stop our bones from fracturing. Our muscles will help center and disperse that load and move the forces to the parts of the body that can tolerate it. Okay. Now, there are other muscles of the hip which can do the same thing. They have names you're probably not familiar with. Again, I will go over some of these in the anatomy section. Now, you might be wondering, you might be thinking these muscles are super important now.

And you're wondering, oh, well, I don't want them to be torn up or irritated or damaged or so on. So how can we preserve the health of these muscles? And all the muscles of the body do not work in isolation. And we're going back, if we go back and talk about the rotator cuff of the shoulder, especially while pitching, it's extremely dependent upon the function of the core, the lower body, and throwing mechanics or how you use it. So the hip muscles are kind of the same way, except for now if we say it's more dependent upon the core and the pelvis, and also, again, how you use it. Now, this will kind of lead us into the second section, or the second section, which is going to be the core muscles are important.

So when I do say core, by the way, I don't mean the six-pack muscles. I don't even care if you can see it. I don't care if you have a little bit of a belly. I actually have no idea if people that are obese have the ability to have core strength. I'm sure they do. If you have a reference on that, I would love to see it. I'm sure, but also, too, I've seen people who have, they're just completely shredded. They're strong. They're leaner than me. And they have totally dysfunctional cores. So I don't mean looking good at all in this. So I'm talking about the whole abdomen, the low back, the lats, the diaphragm, the pelvis, or the pelvic floor, and much, much more.

So a lot of patients usually have a poor idea what the core really is, and they think they know. But for this reason, I really try not to use the word core. So everything that I usually say is trunk. But I get a lot of questions from people. They're like, what are you talking about with this trunk? I'm like, well, you mean the core. And they're like, oh, yeah, the core. And then they go back to their idea of what they understand what the core is. So the trunk really encompasses all of that stuff that I said. So, again, the low back, the lats, the diaphragm, the pelvic floor, the abdomen or front side, and a ton more.

So I want you to think of the trunk as a means to have a nice, functioning, non-sloppy core or non-sloppy pelvis. Okay, I'm going to say it again. The trunk is a means to control the pelvis, which will then, in turn, control the hip, which will control the knee, which then goes all the way down into ground contact. Now, I want you to think of this. Think of the pelvis and the core's relationship as one of those orange Home Depot buckets. And if you're not by Home Depot, then just think of a bucket. Okay, a bucket that can carry water. It has a single strap on top or some type of metal hanger. It almost looks like a hanger, but I guess it's a handle.

So a handle attaching directly to the top of it. Okay, and these Home Depot buckets, a lot of times, are very, I mean, they're like $5. They're not super, super strong. I mean, at any point you put too much weight in it or hit something, you can knock one of the handle sides off, and the whole thing will go spilling everywhere. And this is pretty much how the core functions with the pelvis. So the core area or the trunk acts as the handle. Okay, and now imagine more than just one handle. Imagine like three handles to go into different parts, almost cutting the top part of that bucket up like a piece of pizza or an old pizza.

So you have identical slices. So when one tears off or one stops working well, one edge or one handle portion, then the other ones have to take a little bit more load in it. But let's just say we get to the whole, let's just say we go back to the analogy of only having one handle with it. So imagine this handle breaking and the whole thing kind of collapsing down. This collapse affects not only the top part of the bucket, but the bottom. The whole thing tilts and you lose all the contents from it. So this is what it has to do with the hip. Think of the bottom part of the bucket as being the hip portion.

Okay, this is called the acetabulum or the acetabular socket or the socket. And it has a really, really big effect on impingement and other types of pathology of the hip. Now one example is in 2014, they actually demonstrated how this quote-unquote dropping the bucket effect or really affects the hip joint in cases of hip impingement. So they actually said, I'm going to quote it, and I'll have the link in the show notes as well to this article. So dynamic changes in pelvic tilt significantly influence the functional orientation of the acetabulum, by the way, that's socket. And this must be considered when you're rehabbing cases of impingement or even in cases that are quote-unquote surgical.

You have to consider how the pelvis influences the orientation of where the ball and socket come together. Okay, think back to that bucket. They actually found in this study that this forward tilt of the pelvis, which most people would call an anterior tilt, would predict who felt the pinch sooner. And I'm not talking about sooner in time. I'm talking about sooner in range of motion than those who actually had the backwards tilt, which would be the posterior tilt or neutral. So what this means, again, is that if you are squatting down and you feel a pinch in the front part of the hip here, and you're only about, I don't know if I should do degrees or feet, let's just say you only squatted down like six inches, then maybe a posterior tilt will get you another six inches.

And this is not to say it'll fix that pinch right there, but it can help with decreasing the inflammation or the irritation, rather, to the joint, which then in turn will help us rehab it better. As I tell most people who have hip conditions, I say, if we control the pelvis, then we can control the hip. And a lot of times they're like, well, but my hip, let's do something for my hip. Well, I told you, we're controlling the pelvis or the trunk. We're controlling the trunk to control the pelvis to control the hip. And if we go even further down into the knee stuff, just add all that up and now say knee at the end.

Okay, all of it is really, really important. And they've actually found through studies with ACL programs, I believe that the American College of Sports Medicine did a, they have a write-up on their statement. Their official statement for ACLs was that you can totally decrease the prevalence or possibility of you having an ACL injury, non-traumatic one, anyways. So the muscles around the hip, they have a need for stabilization from the core again, and they need this to work at their best. And the reason, there's many reasons why we actually would be stabilizing the trunk to make it so the hip works better or the hip muscles work better.

But I'm not going to get into it too much on this podcast because it can get a little bit more complex. The idea of this podcast, again, if you've been listening since the beginning of our journey through the podcast, is my idea is to educate patients and clients and athletes and people who don't know the stuff out there. I can get more into depth, but at the same time, I'm not trying to educate a whole team of rehab docs in this explanation. So generally speaking, the local hip muscles and the muscles around the joint are not happy, or if they're not happy, they don't function well. So they need to be in good health and they need to be able to do their job well.

This will decrease the possibility of having injuries to the bone, the cartilage, the ligaments, and even the rest of the tendons and muscles of the hip. Now you might be wondering if you have a hamstring injury, you probably haven't heard a thing about hamstrings yet, and it's already been almost 20 minutes into this podcast. But this is part of hamstring rehab, and the reason why, and I'm not going to designate this only for the hamstring, is because the hamstring, the adductor, the rectus somoris, and some of the other muscles, which go down towards the knee, actually attach up into the hip, or sorry, they attach up into the pelvis.

So they are affected by that dropping of the bucket analogy. So they actually had a study in 2006 where they showed it was, they were mainly looking at hamstring conditions, and again, I will have a link in this, in the show notes, or you can find them at p2sportscare.com slash podcast. So they showed that hamstring length was increased when the hip flexors and spinal rectors were activated. So the takeaway on this is that the muscles of the core have an effect on the muscles of the hip, and even the ones which go down into the knee. Now let's go into the third idea, which I spoke about in the beginning, which is how you move and how you use your body are important.

And this goes from mainly a logical standpoint first. So if you treat something like crap, it's eventually going to break. And the body is really no different in this case. And I know that some of you are probably thinking, well, I remember my friend, like he started running those marathons, and all of a sudden he got hurt. His hips started hurting. And I'm not meaning the amount of volume in all the stuff that you do. And I know my dad the other day, actually, I was going to play baseball. And so I'm about 35 right now. And he's like, hey, you need to be careful. I'm like, be careful? Of what?

And he's like, well, you might get hurt playing baseball. I'm like, I've been playing baseball for like almost 30 years now. And I haven't really, I mean, I've been hurt once, but it was more from trauma. But the amount of games and reps that I've taken in baseball are very low in relationship or very high in relationship to the times I've gotten injured. So, and I actually train during the week and off season to play in this season that I have. Although it's an adult league, I believe if you're going to be playing a sport, even if it's one day a week, you need to be responsible with your body to do that.

So to define the treating your body like crap thing, it has nothing to do with being active. So does it have to do with anything like running a lot of miles? And no, I don't think so. And I don't think it has anything to do with age. So playing sports into your 40s, 50s, 60s, I think it doesn't really matter then. So I don't think it's about age or duration of play or which sport you play, but it's more about how you do it, how you prep for it. An example would be like with running. So I know they just had the Boston Marathon recently. You've seen people running that just look like gazelles and they look effortless and they're quick and they run for long distance.

And you think if you were doing that, you're like, God, I would fall apart. Like I'm sure my hip would start hurting and I don't know if that's for me. And you go back to default with, I don't know if the amount of miles is for me. And I don't know about, I'm 50. I don't know if that'll work and so on. But these are an example of seamless movements. Okay. And I don't know the winner of the Boston Marathon, but for the most part, they probably, if they excelled at that level, they probably do a lot to take care of their body in many, many facets of health. I bet they eat well. I bet they take days off.

I bet they strength train or resistance train. I bet they stretch. I bet they do tissue work. They probably work on their form and they do different types of intensities of work throughout the week. So they're actually treating their body well and conditioning it to take the exercise that they're doing with their body or the activity they're throwing at it. So an example of treating your hip like crap is imagine the guy who just, he walks into the gym. Um, you know, he hasn't been there for about a month or so and maybe the other night, like he was had a six pack of beer with his friends and he's like, you know what?

I think I'm going to go to the gym. I'm going to get back in shape again. So he drinks a six pack, maybe not Bud Light. He does like an IPA, something heavier, you know, so he really got messed up that night. He wakes up, skips breakfast, skips a warmup and just loads the bar for a one rep max, even a five rep max, something like that. And then he hurts his hip and he wonders, well, I don't know if this is for me. I don't know. I might take another month off. Maybe I should rest it, you know? But the difference is, I mean, look what they did to prepare. Look how they treated their body throughout the week, throughout the month, throughout the year, even to take the amount of activity that you're asking of it.

So how you move and how you prep your body for the movements will assist you in your rehab. And I would say that perfect practice makes perfect. And you shouldn't expect your brain and your body to remember how to move well. If you don't practice it every day, you're going to do it poorly. And I've seen it over and over again. I have a guy that just, he just came back after a couple of weeks. He did an event. He did a run and we spent a lot of time doing rehab. And he was one of the ones I took, I don't want to say the most care with, but he was really diligent about wanting to know about how to program rehab, how to get the form right.

How did he want to know everything about it? So I actually developed the, I don't know if you guys have seen it yet. We're starting to do courses on the website. It's ptsportscare.com slash courses where I'm going over all, a whole library of exercises needed for that pathology. And this guy was actually the reason why I developed the playing card system of rehab. It is something that it's on that site. Basically, we use a deck of cards and I show people how to program rehab with that. So usually when this guy comes in, since he is the main reason why he created it, I don't even write his rehab on the board.

I just write a couple categories here and there and I ask him to fill it in. And it's only been two weeks. Keep that in mind. And so I'm like, okay, what do you want to do for warmup? And the whole time I would correct him if he did, if he said something which wasn't going to work for his condition. So he looks at me and he's like, I can't remember any of it. And eventually I refreshed him. He started to know, he knew the movements, but it took him a little bit while, a while to get them right. And he had a lot of questions on it. And I told him, you know, I just learned something from you right now is that for the amount of time that we spent learning rehab and learn how to do it well, I'm guessing the people that do it one time a week or even one time period have almost no possibility of retaining it.

Almost no. So for this reason, I think that you need to practice it. If you don't do it every day, you will lose it. And in case you've listened to this whole entire section and you're thinking, well, I move. I move all the time. I'm moving right now. You know, like I think I should maybe define movement. You know, I'm talking about more of the movements that can create hip pain when done poorly. And some examples of things that you might not do every day, but you definitely do during your activity or your recreational time are squatting, running, pivot and turns or change of direction, sprinting, jumping, picking up heavy objects.

So when's the, just think about it. When's the last time you actually took 30 minutes to improve your body's ability to do any of these motions? And I'm not talking about you spent 30 minutes doing squats at the gym. I'm talking about actually focusing in on form and movement. Okay. Now that you got that number in your head, let's think about how many times during the week you spent doing it. And now how about, how about the month? And if you're hardly doing it at all, I think it's hard to say that you're, you've mastered them. And I think most people, when you think deep down inside, you think about, uh, you think about, yeah, I can get better at that, you know, but sometimes when you're forced to do something, you don't want to do it.

There's a resistance to it. Um, but these movements will come throughout the day. I mean, squatting, you do it to get, uh, on the restroom, you know, um, running or sprinting. Like you might do it when you're, you know, you're crossing the street and all of a sudden you see a bus coming, you know, these are the things that when you need them, you need to train for them. Um, and you're especially going to do it during your recreational time. And by the way, I don't mean this to sound lecture-y today. I, I'm just, I'm just going through the things that I think that you guys will need to hear. Now let's go into open versus closed chain hip mechanics.

And I was actually talking to a trainer a couple of weeks ago and I was talking about open chain, closed chain. And, um, finally he said, what's closed chained, you know, and, um, most trainers, a lot of trainers will know it. Um, some people will know it or closed kinetic chain. Um, but it's the idea of usually when you talk about it, and this guy eventually when we talked about it, he understood what I was talking about. So it's a terminology issue. Um, but it's the idea of basically having your foot on the ground or in the air. Okay. So open chain is having foot off ground and closed chain is having foot on ground.

So when we walk, run, jump, these are closed chained or your foot's on the ground at, I mean, I guess jumping, it's not on the ground when you're jumping, but when you're landing when you're pushing off, it is so just like the same physics class, you know, ground has an equal and opposite reaction to our push off. So we are actually using that ground to react against. And in rehab, we sometimes start people on their backs, their sides, seated, kneeling, standing, single leg. You know, these are all different variations. And it's really dependent upon the injury state that you're in. And if you've had the proper building blocks to actually do the more advanced things successfully, again, there's no point in doing poor movements repetitively because it won't always get better.

So when at all possible, I personally try to start them on their feet with hip rehab as soon as possible. Um, and this is so we can train their brain to control their body when their foot is in contact with the ground. Since this is normal everyday life and recreational activity, I want to prep you for the stuff you're going to experience when you actually leave my office. So if you're going to have a flare up, honestly, it's probably going to be with something like, again, you, you stepped off a curb, you know, you had to push your grandma across the parking lot in her wheelchair. It's usually not going to be, you know, I was sleeping on it.

I was laying down. I was watching TV and my hip began to flare up. I injured it. You know, you might notice it then, but it's very rarely does it happen from that. It's usually irritated doing something else. So why do we actually go into closed chained or foot on ground rehab? And the reason is because the joints, muscles, tendons, and even the cartilages react differently when the foot is actually on the ground versus in the air. Again, there is a merit. There's a time and place to having foot off the ground, but eventually you do want to get to on the ground. So, I mean, you think about when you, if you're jumping off of a step, I mean, what would happen if you actually, before you landed, you went limp like a noodle or say you all of a sudden die when you're in the middle of the air and you hit the ground, you'd crumple, you know, your knee would cave, you'd fall to one side or even forward.

So think about what makes you keep your composure and stand and not crumple over and land well. What disperses the load throughout the proper channels of your body into the pelvis, into the other areas that which can tolerate that force of jumping off the curb, the box, whatever you jumped off of. Obviously, a curb's not that much, but believe it or not, people do get hurt jumping off the curbs. So your muscles, tendons, bones, ligaments, cartilage, they do all this stuff. They're reacting to the ground when you land and it's not always about how you jump, but oftentimes it's how you land too.

So walking and running have their own types of considerations as well. So just don't think I'm harping on running. So this is the basic idea of hip rehab. So I want you to understand, number one, going back, the muscles surrounding the joint are important. The core muscles are important. How you use your body and how you don't treat your body like crap are important or your hip, don't treat your hip like crap. And lastly is open and, I guess there's more of theory in this last one, open versus closed chain mechanics of the hip. Now, you might be wondering, like, what are the best ways to rehab now that I talked about them?

Because everyone wants something actionable. They're like, well, what can I do right now? You know, and I do have some suggestions on my site. I will give you the link. But for the most part, if you go through the website and you go start here and you go to self-education after that, there's hip dots on these people or the athletes in there. So just hit the dot and you scroll through there, find your injury, and then you end up finding some rehab there. Not everything's there. There is more in the course. I try to give away really good stuff for free, but then I keep some of the best stuff, the very, very best stuff on, that's for posterity.

So I've got to make a living somehow, right? Um, now we're going to go into, uh, anatomy and don't tune out. Okay. I'll try to blow through this as quickly as I can, but still, uh, responsibly. And then I will actually go into some of the suggestions that I would have for rehab. And in those, I'm going to go over, actually, I won't even tease you with that one yet, but we are going to go into that later. So, uh, first with the, we're going to start with the motions of the hip. So these are the terminologies that you're going to hear when you read articles on the hip. Next, we're going to go into anatomy, which is the bones, then the cartilage, then the ligaments, then the muscles of the hip, and then muscles of the trunk, because I told you they were that important.

Okay. Onward and upward with that anatomy of the hip. So let's start with the bones. So first note, there's mainly four bones of the hip. There is a femur, ischium, ilium, and pubic bone. So the femur is probably known to you guys as the thigh bone. Okay. It's the muscle or it starts the bone, which goes all the way up from the knee. It's the thigh and the, it's made like a shaft and, uh, it has a neck and a head on it. And the head goes into the ball and it's the ball and it has the socket right there. So the next part, the other three ones are mainly what we call the pelvic ring. So the pelvic ring is made of the, it made, made of the ischium, the ilium, and the pubic bone.

And the ilium is what we would probably know as the sit bone. And the pubic bone, if you slide your hand all the way down from your belly button and kind of hit something hard, that is parts of your pubic bone called the pubic symphysit. Now the cartilage of the hip, there's mainly two types. There is cartilages for different types of purposes. Um, in this area, there is articular cartilage and fibrocartilage. The articular cartilage is located around the ball and the socket. Um, or sorry, it's more so around the ball or the femoral head, we call it. And the purpose of the articular cartilage is to decrease friction.

And it also makes a really nice smooth surface for the bones to slide together and not really have a lot of friction. So there's also articular cartilage on deep part, inside part of the socket of the hip. There's also fibrocartilage, which fibrocartilage makes up what we call the labrum. And the labrum is on the inner portion of the socket area or the acetabulum. And it almost makes like an O-ring or a gasket. Fibrocartilage is very different of a substance than articular cartilage because it's for a different purpose. So again, it acts as that O-ring or gasket and it creates a really tight seal for stabilization of this already really mobile joint.

Next, we have some ligaments, which I won't go extremely deep into, but there's mainly three ligaments, uh, around the portion of the hip that I would talk about. Um, and there's one on the inside. So we call them extracapsular and intracapsular. So intra means in, extra means outside. So, uh, for those, that's kind of all I'm going to go into that part, but there's the iliofemoral ligament, ischiofemoral ligament, and pubofemoral ligament are extracapsular on the outside. Intracapsular is the ligamentum teres. Um, so that one is inside the joint, but for the most part, um, ligaments confuse a lot of people.

Um, just know that there are ligaments around there and there's also joint capsule, which is made up of ligaments as well. Now on to muscles of the hip, and some of these ones you might be more familiar with than others. There is the hip flexor, which is the main, uh, or the main hip flexor is called the iliopsoas, which some might call it the psoas, but really it's made up of two muscles, the iliacus and the psoas major. There's also the psoas minor in there. So collectively, we call that the iliopsoas, or you would say the hip flexor. Next, we have the rectus femoris, which is one of the, well, I would say long quad muscles.

It bends the hip, uh, in a seated position, it moves your hip up and it extends your knee. Standing or running, it does a little bit different stuff, which again, we talked about closed and open chain exercise or activity, and things change a little bit when you're going foot on ground versus not on ground. But for the sake of talking about muscles, let's just talk about, um, the ways that you guys remember the most, because I mainly want you to know where they're at. Now, the hamstrings are on the backside of the thigh and they go all the way up into the sit bone. And there's three of them, which go that high into the hip.

And there's one, which is mainly at the knee. It doesn't go up to the hip. So the three, which go up to the hip from the back of the knee are the semi-tendinosus, semi-membranosus, which are on the inner side. The biceps femoris long head is on the outer side. There is a short head, but it's way down by the knee and it mainly attaches to the femur. It doesn't really go all the way up into the hip. Now, up into the hip or what you would call the lateral rotators or in the butt cheek area, the outer butt cheek, there is the gluteus medius, which is one that you guys probably know. It's kind of like when you put your hand on your hip like you're trying to be sassy and then you slide it down and you get to a fleshy area right below that ridge.

That's the gluteus medius and it works as a lateral stabilizer of the hip as well as a few other things. There's the tensor fascia latae or the TFL, which you've probably heard. It is in that same general vicinity that I just spoke about. So say you have your hand on your hip. The thumb is, let's see, most people are sassy with the thumb in the back. So where your index finger kind of lies is where the top of the gluteus, or sorry, the top of the tensor fascia latae is going to be. And that kind of blends in with the gluteus medius. It blends in with the IT band a little bit. So it is mainly a weak hip flexor and it does some stabilization in the hip as well in the side to side plane.

Now, the IT band is one which everybody's probably heard of and they try to stretch it and so on and I don't think that's what we should do. So just know that its function is lateral stabilization again. It's supposed to keep you from falling over to the side. So it comes down from that same section we talked about with the sassy hand, slide it all the way down, it goes to the side of the thigh. Now, one thing that people don't tend to realize is that the fleshy part on the side of the thigh is actually a quad muscle. It's called the vastus lateralis. It's the lateral or outer quad. And the IT band is thin-like.

It's almost like paper. I mean, it's just underneath the skin surface and it just goes right over top. So a lot of times if you feel like a spasm there, it's probably going to be the lateral quad muscle more so than the band. Or it could be a referred pain from a disc injury or a radiculopathy as well, which we're not going to go too much into in this one. Now, the gluteus medius, or sorry, gluteus maximus is the large butt cheek muscle. You have one on both sides. The piriformis is one of the ones that are the hip external rotator that you'll probably call it. But it also limits the amount of internal rotation that the hip performs as well.

If you've listened to, or actually the podcast didn't come up yet, but you'll hear in one of the other ones, that it has a fascial connection with the pelvic floor as well. So the pelvic diaphragm has a correlation with the piriformis probably. That study's not published yet, but it sounds like it's going to be piriformis syndrome or hip conditions are going to be strongly related to the pelvic floor, I believe. So also that is one of the muscles which they've said is an issue when it comes to sciatica or piriformis syndrome. But just know there's all this rehab stuff we're talking about today does go hand in hand with that same type of thing.

That's why I mentioned in the beginning sciatica as a possibility of things that we would work with this. Other external rotators, which I won't spend too much time on, are the superior and inferior gemelli or glamelis, depends how you call it. The obturators, the quadratus femoris. The pectineus is on the front side. It's going to feel like it's right deep within the groin. It's one of the high adductors up there and it's going to feel like it's just below if you put your hands kind of where you would feel your artery in there. It's just in and around there. Now the adductor longus, magnus, and brevis are some of the larger hip adductor group.

And the adductor is in the inner part of the thigh and they go up and attach right to that bone that we mentioned earlier, which is when you slide your hand down from the belly button, you'll hit a bump. And that is the pubic symphysis and some of the pubic ramus is down there as well. So it's extensions of that pubic bone. Now a couple different muscles are the sartorius and the gracilus. We won't go into those as much because they're not as important, but they do have some correlation with hip injuries. Now muscles of the trunk are, I just want to name them off just so you're familiar because when we're talking about the quote unquote core or trunk, these are muscles which you're going to notice are strongly prevalent to hip conditions.

So if you don't know the names, you're not going to know where they're at. So there is the internal oblique, the external oblique, the rectus abdominis, the transverse abdominis or the TA, some people call it. There is a quadratus laborum, multifidus, paraspinalis, lumbosacral fascia, latissimus dorsi, diaphragm, pelvic floor, levator ani, and we can go even further and some people say the glutes are as well. So we can go on and on with that, but I'm going to try to stop right there at the pelvic floor. So know those ones again. I'll say them one more time. Internal oblique, which some people say IO on some of the studies.

External oblique or EO. RA is going to be the rectus abdominis. Transverse abdominis is usually TA. Quadratus laborum, which again, why do we always abbreviate? It seems like we abbreviate these trunk muscles a lot. So quadratus laborum is QL. Multifidus, I haven't seen an abbreviation for it. Paraspinalis, lumbosacral fascia, the lats, the diaphragm, and the pelvic diaphragm or levator ani. So those are the muscles of the trunk. Now we're going to go into just some examples of some recommendations that I usually give in regards to some hip rehab. And keep in mind, this is not everything because that would be a whole of the complete podcast.

And I really want to reserve some of the expertise on this as well to some of my guests. So that's why I'm having different guests on. And next week we're going to have, we're going to have Dr. Helwig, Dr. Helwig talk about some of the hip stuff that she works on as well. And we'll have many, many over time. So just know this is not set in stone here. This is just a rough idea of a lot of things that I like to do here in the office. Now I like to give everyone the idea that we have to, number one, rehab locally and globally. And what that means is, and say we're talking about a knee condition, I want to rehab around the knee to make sure that all these structural problems that we might find on an exam, if we don't find any, we don't have to worry about it.

But if we find that there's a structural issue, like something broke, something tore, something you know, is frayed, then we need to address it. And that would be a local treatment or rehab. Globally, we have to consider why did it happen if it wasn't trauma. And globally, we'd look at the core, the trunk, the landing pattern, the pelvis, the hips. So we look at a lot of things. And even looking even deeper into the neurological system, I think is important as well. We won't go too much into that, but there's a whole other podcast featuring Dr. Reese from Minnesota, who will talk about some of those neurological changes you can make.

Now, after a lot of times the local stabilization, a lot of times we do it in open chain. I know we've spoken about open chain. So that in regards to the hip, we're looking at stabilizing locally the ball and socket. In the case of like a labrum, we might want to decrease the possibility of the pinching effect or the catching. We might do some open chain core exercise as well. But when at all possible, we try to get them to a closed chain activity. And the way we typically use our core and trunk every day is with standing motion. So we try to get them to closed chain motion as soon as possible.

Now, once we've gone to closed chain motion, a lot of times I like to have people, so this would be number two, is we like to learn the movements. By the way, I guess I should start with what our sequence is going to be. So number one, rehab locally and globally. Number two, learn the movements. Number three, load the movements gradually. Fourth is unilateral loading or training the other planes of the hip. Fifth is change of direction training. And then six is just, we're going to talk about stable and unstable services. So back to number two. Again, learning the movements, we have to teach people how to move sometimes.

And this could be teaching the brain how to talk to the body. It could be a whole other issue with the body, you know. So a lot of times it's multifactorial that we're working with. But for the most part, the things that we try to get people to do are squat, hip hinge, carry, lunge, push, and pull. And I'll break this down really quick again. So the squat, you have to learn how to sit down into a chair. Go to the restroom. Those are things that you might want to be really good at and get it so your hip can go through motion cleanly without having any catches and frays and so on. Next, we want to go into the hip hinge, which would be a lot of times picking up heavy objects.

Like you're going to pick up a rock, pick up a child. I had a patient recently who had a hip condition that they said it bothered them a lot when they were picking up their daughter to jump through the waves in Hawaii. And she demonstrated it and she was way too far out. I'm like, why didn't you hip hinge them up? Why didn't you deadlift them up? So that is a lot of times we have to teach them when to use it as well after they learn to use it well. Next, we have a lunge. You might lunge down to tie a shoe. You might carry something, carrying bags of groceries, pushing somebody in a swing, say.

Pulling, you got to pull things sometimes. I don't think I need an example of that. But those are things we need to learn how to do really well. Next, we need to load these motions gradually, but only after you've had mastery. So fourth, unilateral loading or training in other planes is something that has come to light to me over the last few years. And with the hip being a ball and socket the way it is, it has potential to do so many different movements. And we need to make those hips work. We need to make those hips move. And one example of a guy that I had come in before was that he talked about a back condition that he had.

And he was saying that it hurt only when he would move to, he would twist, he showed he was twisting his back to put stuff into his car. And I'm like, well, how about if you move with the hips? And he's like, oh, that feels perfectly fine. So a lot of times to decrease the potential of further injuries happening, we have to get the hips to start moving better. You know, for all we know, that person had a severe osteoarthritis of the hip. They had, you know, they could have had impingement. They could have a tendonitis and all of a sudden their body started guarding against the movements. So we need to get the hips to rotate and laterally bend as well.

So three different planes of motion we're working in. Next, change of direction is more of like, if you considered ACL injuries or ACL prevention, it all starts with the core and the hip. And after that, it turns into, can we stack the knee properly with changing the direction in the other direction, okay? So I like to show people how to do this first very slowly, maybe lateral hop holds, maybe doing cone drills, doing it in the grass, ideally. So in getting them aware of what stacking patterns we're looking for, eventually they have to do it quick if they're going to do it in a sports setting.

This is a whole other podcast we can do on this, but for the most part, change of direction usually does come later, as well as plyometrics I like to do in this realm as well. Lastly, talking about stable and unstable services, because I know that there's been a push for years to use really wobbly pads and unstable services for rehab. I'm not a huge fan. I do use it sometimes, but I don't love it, because the reason is because we don't really have wobbly surfaces all the time in life. We might have it every once in a while, so it would be nice to be able to control that sometimes. But a lot of times, with the things that we're doing, picking up kids and so on, we find our footing first.

We fully make sure that we know that we're not standing in a sandbox that has absurdly loose sand. Actually, I guess that's an example where it would work. But nothing more than that, really. We wouldn't stand on a wobble board or a ball and then try to lift a kid. We'd find some really stable footing. So if you're going to do balance training, I would just make sure to work it in slowly into your program and don't use it excessively, because when we are using, when we're training the body to be able to move loads and disperse force, we really need to have that stable footing. And we want to set it up so you can win.

You have to be able to win. Like in sand, we can set the footing and just gradually the ankle's kind of off kilter, and that's about it. But by no means are you wobbling around like crazy, like you're on a lily pad. Or what do they have those? American Ninja Warriors. I think that's the show I'm thinking about. But everything is really wobbly. And it's just no surprise that everyone gets hurt when they end up doing those types of obstacle courses. So, or maybe not everybody, but you see people. You see people get hurt. I remember I did a Tough Mudder, or this was a Tough Mudder. And they had an obstacle just like that.

And I actually opted to walk around it. I was like, this is not, this is not what I want to be known for hurting my hip and neon. I'm not going to bother with it. It's not that important to me. Plus, I didn't train well for it anyway. So, okay. So that is the conclusion of our hip podcast. And if you want to see, actually see some good pictures of the hip and all the stuff, I'm going to actually have all of these notes that we did. It might not be immediately, but I'm going to have someone edit them and make sure that I put a good resource for you guys to go up to. I will put a link to that in these show notes.

And again, this might not be immediately, since it does take a little bit of time to proofread and find some good pictures and references for you guys. But it will be in the show notes. And you can find that at p2sportscare.com slash podcast. Now, if you aren't listening on iTunes, you need to go to that podcast page, click on one of the buttons, it'll push you over to iTunes, and just subscribe to this. Because if you want the next podcast by someone who works on hips all the time and see their take on rehab of the hip, even if you didn't like mine, you need to go on there and subscribe. By the way, once you're on there, please give me a thumbs up or a five-star review.

And only if you liked it, by the way. I like honest reviews. Hopefully, those people with one star has put some constructive criticism on there. Thanks. But yeah, review it on there. It really, really helps me out. And I want to continue to do this podcast for a very long time to share information for all you people to learn and get better and so on. So I think that's all I have here today. So if you have an expert that you want on the podcast, please, please have them contact me as well on the website. If you have a question that you want answered, you'll have a minute and a half to state your case.

And that is right on the website as well, p2sportscare.com. It's a voicemail right there. You don't even need a phone to contact me. Just leave it there. Click on it. Put your name. Put your email. Put your phone number. And it will release it to me quickly. And if I think your question's really good and people will learn from it, I'll have it on air. And you'll be right here on air with me. And one day we're going to do live sessions as well. I haven't figured out how to do the formatting yet on it. That's why I haven't done it yet. But I would love to have questions on random stuff all the time.

So thank you so much for listening. I'm really grateful for everybody tuning into the podcast and sharing it. It's been fun so far. It's only been, gosh, since I really started to commit to it, I feel like it's only been since like less than five months now, six months. But everyone seemed to have a good response to it. So take care, guys. I will talk with you soon. See you next week.