Disassociating the Hip Joint from the Pelvis
Visualizing the CNS output as a river delta
In today’s case, I assessed straight-leg hip flexion (SLHF). This client has a plethora of issues, but most of all, within the lumbopelvic-hip complex, and further still, we have a lot to deal with within this complex.
I use the Functional Range Assessment in my practice. So, for the SLHF test, I palpated the sacroiliac joint on the side I was assessing as I passively raised his leg into the zone of flexion. This allows me to observe multiple things: at what angle am I able to feel the pelvis rotate into flexion as a compensatory action for the lacking hip joint? Secondly, what am I feeling, from “a distance,” so to speak, at the posterior thigh and other?
From the assessment, we found that at around 15 degrees, his pelvis, specifically at the sacroiliac joint where my hand was, began to roll and put pressure into me, indicating that his hip was no longer able to flex independently and that the action was bleeding up into the pelvis and lower back.
Given this client’s history and our long-term goals, my goal was less about improving the angle of hip flexion without his pelvis and low back chiming in to help, but rather teaching his nervous system about the things he had available to him but never uses, like his hamstrings.
It may seem counterintuitive to want more hip flexion by stimulating the hamstring group, but because of hamstring issues, he is not able to achieve hip flexion. This is where our disassociation journey begins.
Our inputs are to be neurological in nature. More specifically, we will constrain his nervous system so that he has no choice but to use the hamstrings as opposed to his “normal patterns” of organization, i.e., using his knee, ankle, and low spine, which currently pose as a hip—literally using every other joint other than the actual hip and hamstring group.
His neurological inputs were positional isometrics. Setting up in a position to constrain the forces generated by the CNS to be funneled specifically into the hip extensors or hamstrings, pushing into an immovable object at a low effort for durations of time.
With his leg straight at about 15 degrees, his heel resting on my bent thigh, his ankle in dorsiflexion (“foot off the gas”), and both butt cheeks must stay on the table, one of my hands poking his hamstrings for tactile feedback, and the other freehand cupping his heel, I provided one of two cues depending on his ability to execute the task; drive the heel into me at a low effort (push), or don’t let me lift your heel (hold). He responded better to the latter. I never took his heel off of my thigh because I would seamlessly switch the cue from my lifting him to letting him drive into my thigh, thus transitioning from a hold to a push.
I carefully observed, palpated, and coached him to continue for a duration of 15 to 30 seconds until force diminished or he began to compensate, and I would terminate the set. After a couple of sets, I would retest the hip flexion to see if we could get more SLHF relative to the pelvis. We ended up getting up to about 35 degrees. This was a secondary effect to the main goal of learning to use hip extensors to extend the hip rather than everything but.
It was great to see and feel his nervous system compress and learn to organize appropriately, like a river delta emerging with new outlets as more and more water flowed into it. With each iteration of the hip extension into my thigh, he was able to use his hamstrings appropriately. It was very difficult for him and will no doubt take a lot of practice, but we have a strategy from now on to continue to illuminate this area for his CNS to recruit and stimulate.
The river delta being a bifurcating system also helped him visualize what was happening. The water, or energy flow, from the CNS downstream pushing and creating new outlets helped us both comprehend the goings on and the importance of his continuous need to practice this task to constantly push energy flow into that system to create a new pattern of organization away from the compensatory patterns his CNS is used to. This, of course, will take time. However, as manual therapists, we have the advantage of seeing these changes occur in real-time.