Exercises To Eliminate Pathokinematics - Part VI

Last week we talked about the King of all Exercises, the squat.  In the last couple of blogs, we have discussed a couple of ways to address the "lateral shift" with both the Squat Neuromuscular Retraining technique as well as with the squatting series.  It is imperative that the lateral shift is corrected in full body weight movements prior to the initiation of weighted movements. 

Just as equally important is the ability to teach the athlete the ability to discern the difference between lumbar motion and hip motion.  That is the reason for the Lumbar Hip Disassociation Exercise Series we will now investigate.

Lumbar Hip Disassociation Exercise Series: 

The next exercise series to use with the athlete to ensure that the rest of the progression is done correctly is the Lumbar Hip Disassociation Exercise Series. These exercises are used for retraining the athlete’s proprioception, strength and range of motion involving the hip and spine.  Teaching proper technique with this is essential to development of kinesthetic sense and in particular, differentiation between movement in the spine and movement in the hip.  The difference between movement at the hip and at the spine is notoriously difficult to train. 

Specifically, these exercises are designed to teach the athlete the difference between hip flexion and rotation and spinal flexion and rotation.  They are essential to master as they aid athletes’ ability to not only properly isolate the hip musculature which will allow for isolated strengthening but will also allow him or her the ability to activate these muscles during athletic participation.  These exercises are performed with a mirror and the subject is INITIALLY given lots of verbal and tactile or manual cueing at the hips to prevent spinal motion, and teach the athlete the difference between movement at the hip and movement at the spine.  Incorporation of additional visual cueing, like the Motion Guidance System or other similar device can aid in training this in the clinic and during their home exercise program. 

Keep in mind when doing these exercises:  If done in the recommended sequence, by the time that the athlete gets to latter exercises, the legs and hips are going to be tired.  This sequence is designed in this way deliberately.  The gluteus medius typically fails as a result of fatigue, so we want to challenge it as much as we can.  In addition, the gluteus medius also functions primarily in an eccentric fashion, so making sure we are pushing the eccentric phases of the exercise are critical to maximize carry over to sport.  It is VITAL that the athlete have success at these exercises before progressing.  So, if you see that they are failing due to fatigue, stop there.  You can attempt to perform with some slight modifications, but if unable to do that way correctly either, the routine should be concluded at this point.  The intent of this sequence is to teach the athlete the difference between lumbar motion, femoral motion and hip motion.  This sequence will take 15-20 minutes, and progresses in the following manner:

v  Prep Exercise: 

Level I:  First while standing in front of a mirror, in a stride stance with the back foot on your toes and front foot flat, and hands on hips, gently rotate the back stride leg into femoral internal and external rotation while maintaining lumbar neutral, hip in neutral position and “healthy knee alignment”.   Perform 3 sets of 10-20 reps on each leg.

Level II:   Now repeat this exercise while standing only on one leg with the hands on the hips.  Again, gently rotate into the back stride leg femoral internal and external rotation while maintaining lumbar neutral, neutral hips and “healthy knee alignment”.  Perform 3 sets of 10-20 reps on each leg.  

Level III: While standing on one leg with hands on hips in front of a mirror, have the athlete flex forward at this hips doing the “bird in the water glass” maneuver.  Only have them flex forward at the hips as far as they can WITHOUT allowing spinal flexion while maintaining lumbar neutral and “healthy knee alignment”.  The contralateral limb is maintained in hip neutral to slight hip extension.  Return to the starting position and immediately resume hip flexion.  Perform 3 sets of 20 reps on each leg. 

Level IV: While standing on one leg with hands on hips, rotate the stance hip into hip internal and external rotation while simultaneously maintaining hip flexion, as in the “bird in the water glass” maneuver.  Ensure during the course of the exercise that the athlete is maintaining the lumbar spine in a neutral position – e.g., only have them flex forward at the hips as far as they can WITHOUT allowing spinal flexion and while maintaining “healthy knee alignment”.  Return to the starting position and immediately resume hip flexion.  Perform 20 reps on each leg.  Perform 3 sets of 10-20 reps.

KEYS TO SUCCESS:   Only reach as far as possible without loss of a neutral spinal position or loss of control at the knee.  Only progress to those ranges of motion in which these alignments can be maintained.  This is an extremely difficult exercise and need to educate athletes to this fact prior to initiation.  Without this previous instruction, this can lead to frustration and mental fatigue.

Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.