HIP TREATMENT PROTOCOL

Manual Therapy General Guidelines

The goal of manual therapy: For this study, manipulative therapy includes specific manipulations (low-
amplitude, high-velocity thrust techniques) and specific mobilizations (low-velocity, oscillatory movements)
intended to modify the quality and range of motion of the target joint and soft tissue structures. To reflect actual
clinical practice, the clinician will be allowed to select which thrust or non-thrust manipulation procedure they
feel is most beneficial to their patient targeting the comparable site that reproduces the patient’s chief
complaint. Patient feedback following the selected technique will be used to modify position, angle, force, or
rate based on patient response. At least 1 manual therapy technique is required each visit.

Joint position. The therapist may select a joint position for treatment based on their assessment of the
irritability of the patient’s condition. Joint position can be altered in response to patient reporting or test: re-test
findings.

Patient position. The therapist may modify the patient’s starting position for treatment based on the patient’s
condition. Patient position can be altered in response to patient inability to achieve the standard position or
reporting discomfort.

Dose: At least 1 manual therapy technique is required each visit. To reflect actual clinical practice, the clinician
may alter or abandon a specific technique once they feel the patient has met their maximal improvement within
or between treatment sessions based on patient response resulting in decreased pain or improved movement.

Test-retest. The therapist can perform test: retest procedures throughout the treatment session as required.

Addition/dropping of techniques. At least 1 joint MT techniques should be performed at every visit. Some
techniques may be dropped at follow up sessions if goals have been reached

Absolute and Relative Contraindications to Manipulation/Mobilization

Absolute
Malignancy of the targeted physiological region
Cauda equina lesions producing disturbance of bowel or bladder
“Red flags” including signs of neoplasm, fracture, or systemic disturbance
Rheumatoid collagen necrosis
Coronary artery dysfunction
Unstable upper cervical spine
Practitioner lack of ability
Spondylolisthesis
Gross foraminal encroachment
Children
Pregnancy
Fusions
Psyhogenic disorders
Immediately postpartum

Relative
Active, acute inflammatory conditions
Significant segmental stiffness
Systemic diseases
Neurological deterioration
Irritability
Osteoporosis (depending on the intent and direction of movement)
Condition is worsening with present treatment
Acute nerve root irritation (radiculopathy)
When subjective and objective symptoms don’t add up
Any patient condition (handled well) that is worsening
Use of oral contraceptives
Blood-clotting disorder

Exercise General Guidelines

The goal of exercise: The exercise program is tailored to the individual patient needs as discerned by the
therapist. There are 4 main treatment goals on which exercise therapy focuses: 1) increase of muscle function,
including endurance, strength, and coordination; 2) improvement of range of motion; 3) decrease of pain; 4) and
improvement of functional ability. To reflect actual clinical practice, the clinician will be allowed to select
which exercise(s) are most beneficial to their patient targeting identified weaknesses based upon the initial
clinical examination. At least 1 exercise technique is required each visit.

Dose: Each strengthening exercise will be performed at 3 sets of 10 or until fatigue. Patient will be progressed
to the next level of strengthening when the exercise is no longer challenging and the patient can perform activity
with ease and good form.
Section 1: Primary Manual Therapy Techniques.
One of the following techniques must be chosen as part of the manual therapy component of the treatment
protocol.

Long axis distraction with thrust: This technique is the only MT technique that has been demonstrated to be
effective for hip OA. This technique has not been studied in this patient population. It has been evaluated in a
randomized, controlled trial. It was found to be safe and effective in older adults with moderate to severe hip
OA. The trial reported that 90% of patients received this intervention on every visit, with no adverse events
reported.

Caudal glide or distraction mobilizations, with the hip flexed: Ensure the belt is placed firmly in the
patient’s crease. Flex the patient’s hip to the first point of pain or restriction and use your body to impart a
caudally directed, passive accessory glide to the proximal hip. The joint position (amount of hip flexion,
rotation, add/abduction) and the direction of force (caudal, lateral, inferio-lateral) can be varied at the discretion
of the therapist to address movement restriction.
E.g. For hip flexion: hip flexed; distraction +/- caudal glide
For hip external rotation: hip externally rotated, lateral distraction
For hip internal rotation: hip internally rotated, lateral distraction +/- posterior glide

Antero-Posterior Progression (Posterior glide): to improve adduction and flexion by stretching the postero-
lateral capsule. With the patient supine, place the foot of the affected hip on the table across the opposite knee.
A mobilizing force is imparted through the long axis of the femur to the postero-lateral hip capsule using
passive accessory glides. The amount of hip flexion may be adjusted to find the position that most effectively
stretches the hip

Postero-Anterior Progression (Anterior glide): to improve extension by stretching the anterior capsule. With
the patient prone and the knee flexed, the therapist supports the lower extremity of the patients affected hip. A
mobilizing force is imparted to the hip through the proximal femur using passive accessory glides from
posterior to anterior. The amount of internal/external rotation is varied to find the position that most effectively
stretches the hip.

Postero-Anterior glide with flexion, abduction, and external rotation (Figure 4): With the patient prone,
position the affected hip on the table using a combination of flexion, abduction, and external rotation; adjust the
preceding motions to optimize the amount of stretch felt by the patient. A pillow may be placed under the
subject’s abdomen if the position is not initially tolerated. Contact the femur just distal to the greater trochanter.
A mobilizing force is imparted to the hip through the proximal femur using passive accessory glides from
posterior to anterior.

Lateral glide: to improve adduction and flexion by stretching the lateral capsule.

Internal Rotation in Prone: to improve internal rotation and extension of the hip by stretching the antero-
lateral capsule.

Acceptable variations include:

• Patient position (supine/sitting/weight bearing, with or without seat belt)
• Med/lat glides of tib/fem jt, with/without seatbelt
• Varus/valgus stresses, internal/external rots of tibia, for accessory and physiological movements
• Combining movements and accessories

Manual stretches to stretch Quad/ hip flexors, hamstrings, adductors, gluteus/ internal rotators, external
rotators. These can be discontinued when ROM goals are reached (refer to protocol for details).
Section 2: Primary Exercise Techniques
Strengthening: Exercises consist of muscle strengthening exercises with the use of weight or strengthening
equipment. All exercises performed as 3 sets of 10 or until fatigue.

• Hip Abduction: To improve weak hip abduction strength. Begin with standing hip abduction against
resistance with progression to sidestepping with theraband and single limb squat.

• Hip Extension: To improve weak hip extension strength. Begin with standing hip extension against
resistance with progression to supine bridging, quadruped hip extension, or single leg bridging over
theraball

• Hip External Rotation: To improve weak hip external rotation strength. Begin with sidelying clams
against resistance and progress to seated hip ER against resistance.

• Knee Extension: To improve weak knee extension strength. Begin with Shuttle machine (progressive
load), 3 x 10 reps, 70% MR, Knee flexion-extension on chair (progressive load), 3 x 10 reps, 70% MR,
Mini wall sits, Squats, lunges, step ups

• Abdominal Bracing: To improve decreased core stability. Begin with Transversus abdominus and
multifidus isolated contraction and associated light exercises, such as bridging and crouching, Progress
to lateral bridge, mini squat, Progress to swiss ball exercises (core stabilization with perturbation
forward, backward, side to side; sitting on swiss ball performing isometric hip adduction and ball toss;
movements with lower limbs holding a swiss ball between legs)

Stretching: Stretches consist of muscle lengthening exercises. Hold for 30 seconds and repeat.

• Hip Flexor: To improve decreased hip flexor length. Performed as ½ kneeling hip flexor stretch

• Hamstring stretch: To improve decreased hamstring length. Performed in standing or sitting leaning
forward from the pelvis keeping the back straight.

• FABER “Figure 4” stretch: To improve decreased external rotation muscle length. Performed in
supine with one leg crossed over the other just above the knee. Gently pull on the back of the thigh
bringing the leg toward you until a stretch is felt.

Neuromuscular control: Coordination is trained through balancing exercises with increasing complexity.
Can be a combination of techniques including: Balance, balance board, vibration plate, dynadisc, slide board
Progress to combine exercises with sports movements (kicking and throwing)
Impairment
Decreased Long axis Distraction / The patient is positioned supine. The therapist grasps involved leg,
hip motion thrust above malleoli. The patient’s hip is placed at the point of restriction
per the therapist’s discretion. The therapist performs an oscillatory
passive accessory mobilization force inferiorly feeling for the
restrictive barrier and imparts a thrust in an inferior direction.
Progression of the distraction position into more abduction to gain
further ROM. Repeated as necessary
Seatbelt The therapist uses a mobilization belt placed firmly in the patient’s
Glide or Distraction hip “crease”. The therapist flexes the patient’s hip to the restrictive
Techniques: barrier. The therapist uses their body to apply a caudally/laterally
Caudal/Lateral Glide directed force to the proximal thigh and performs an oscillatory
Progression passive accessory mobilization force. The amount of hip flexion,
rotation, & add/abduction can be varied to find the position of
optimal mobilization.
Antero-Posterior The therapist places the patient’s lower extremity with the hip in a
Progression (Posterior position of flexion and adduction. The therapist uses his body to
glide) impart an oscillatory, passive mobilizing force to the postero-lateral
hip capsule through the long axis of the femur. The technique is
progressed by adding more flexion, adduction, & / or internal
rotation.
Postero-Anterior With the patient in prone the therapist grasps and supports the
Progression patient’s lower extremity with his arm. The therapist places either
(Anterior glide) the 1st web space, thenar eminence, or hypothenar eminence of his
hand just inferior and medial to the greater trochanter. The therapist
brings the patient’s hip into varying degrees of flexion/extension,
abduction/ adduction, and internal/ external rotation to find the
vector of force that most effectively stretches the hip. The therapist
imparts an oscillatory, passive mobilizing force through the
proximal femur in a posterior to anterior direction. The stretch
should be felt by the patient in the anterior hip region
Tip: To progress the technique the therapist increases the amount of
extension, adduction, and internal rotation.
Can also modify by progressing into FABER position.
With the patient in prone the therapist brings the patient’s hip into
varying degrees of flexion, abduction and external rotation. If the
patient is extremely stiff, start with patient’s lower extremity on a
stool. Progress to lying flat on the table when able.
Postero-anterior glide With the patient positioned prone, the therapist positions the
with flexion, abduction, affected hip on the table using a combination of flexion, abduction,
and lateral rotation and lateral rotation; this can be adjusted to find the position that the
therapist believes most effectively stretches the hip joint and is
tolerated by the patient. A pillow may be placed under the patient’s
abdomen if the position is not tolerated initially. The therapist
contacts the femur just distal to the greater trochanter. A mobilizing
force is imparted to the hip through the proximal femur using
passive accessory glides from posterior to anterior.
 Internal Rotation in The therapist flexes the patient’s knee to 90 degrees and ensures
Prone that the hip is in neutral or slight adduction. The hip is internally
rotated until the contralateral ilium raises approximately 1-2 inches
from the table. The therapist stabilizes the lower leg and imparts an
oscillatory, passive mobilizing force through the contralateral
pelvis
Note: If the patient experiences knee discomfort, grasp the distal
thigh and place your forearm along the medial aspect of the
patient’s tibia
Quadrant Combined hip movements of flexion, adduction, and rotation as
needed are added. The therapist drapes hands and arms over the
knee and thigh and imparts an oscillatory, passive mobilizing force
in the direction of flexion, adduction, internal rotation. This
technique is effective for treating stiffness through combined
movements.
Manual Quad stretch/ The patient is positioned prone with the involved LE dangling over
hip flexor the edge of the plinth. The therapist sits alongside the involved LE
and flexes the knee just before the point of patient reported stretch
2 reps x 60 sec
OR
4 reps x 30 sec
OR
6 reps x 20 sec
Alternate position prone knee flexion with pelvis stabilized.
NB: Can be done along with STM Quads (above)
Manual hamstring The patient is positioned supine with knee extended. The therapist
stretch grasps the involved LE and flexes the hip while maintaining knee
extension to the point of stretch.
2 reps x 60 sec
OR
4 reps x 30 sec
Manual gluteus/ The patient is positioned supine. The therapist flexes the patient’s
external rotator stretch knee to 90, flexes and externally rotates the hip to the point of
stretch.
2 reps x 60 sec
OR
4 reps x 30 sec
Hip internal rotator The patient is positioned prone. The therapist flexes the patient’s
stretch knee to 90 degrees and ensures that the hip is in neutral or slight
adduction. The hip is internally rotated until a stretch is felt at the
anterior hip.
2 reps x 60 sec
OR
4 reps x 30 sec
 Impairment Intervention Details
Decreased hip Hip abduction progression Standing hip abduction/adduction (progressive load), 3 x
abduction strength 10 reps
Progress to Sidestepping gait with elastic band over
midfeet, 3 x 1 min
Progress to Dynamic valgus control with single limb
squat, 3 x 1 min
Progress to side plank with hip abduction, 1 x 30 sec
Decreased hip Hip external rotation Sidelying clam exercises (progressive resistance), 3 x 10
external rotation progression reps
strength
Seated ER (progressive resistance), 3 x 10 reps
Progress to dynamic valgus control with single leg stance
and eccentric external rotation control
Decreased hip Hip flexion progression Supine straight leg raise (add cuff weights as needed)
flexor strength with increased resistance
Standing hip flexion (add resistance as needed)
Standing hip flexion with cable machine (progressive
load), 3 x 10 reps
Decreased hip Hip extension progression Standing hip extension (progressive load), 3 x 10 reps
extension strength with increased resistance
Supine bridging
Supine unilateral bridge
Quadruped hip extension with knee bent or leg straight
Supine unilateral bridge over swiss ball
Kneeling gluteal squeeze against resistance
Decreased knee Knee extension Shuttle machine (progressive load), 3 x 10 reps, 70% MR
extension strength progression with increased
resistance/difficulty Knee flexion-extension on chair (progressive load), 3 x 10
reps, 70% MR
Mini wall sits
Squats
Lunges
Step-ups
Decreased core Core lumbopelvic Transversus abdominus and multifidus isolated
stability stabilization exercises contraction and associated light exercises, such as
bridging and crouching

Progress to lateral bridge, mini squat

Progress to swiss ball exercises (core stabilization with

perturbation forward, backward, side to side; sitting on
swiss ball performing isometric hip adduction and ball
toss; movements with lower limbs holding a swiss ball
between legs)
 Decreased Hamstring stretch Can be performed manually by the treating therapist or
hamstring muscle patient can assume standing or seated position
length
Decreased Hip flexor/quad stretch Can be performed manually by the treating therapist or in
iliopsoas muscle ½ kneeling hip flexor stretch/ Runner’s stretch
length
Decreased external Hip external rotator Can be performed manually by the treating therapist or
rotation muscle stretch patient can assume supine position and perform Figure 4
length stretch
Decreased Sensory motor training Balance, balance board, vibration plate, dynadisc, slide
neuromuscular board
control
Progress to combine exercises with sports movements
(kicking and throwing)