Hip and Trunk Exercise Program

Hip and Trunk Exercise Program Hip and Pelvis Exercise Program Gluteus Medius and Minimus (Hip Abductors) Page 2 Lateral Hip Rotators Page 6 Tensor Fascia Lata (TFL) and Illiotibial Band (ITB) Page 7 Lower Torso Exercise Program Lower Back Muscles (Erector Spinae) Page 10 Quadratus Lumborum (Deep muscles of the Back) Page 13 Illiopsoas (Hip Flexors) Page 14 Abdominals Page 17 120-602-12 th Ave SW Calgary Ab. T2R 1J3 -- Tel: 403-225-3842 -- Fax: 403-225-3914 info@proactivehealthgroup.ca --

HIP AND PELVIS EXERCISE PROGRAMS The muscles of the hip and thigh are often thought to consist of only a few very powerful primary movers of the lower extremities, including the gluteus maximus, quadriceps and hamstring muscles. However, there is also a network of smaller, intricate muscles that are responsible for some of the finer movements of the hip and pelvis. These smaller muscles are often predisposed to injury and dysfunction as a result of tightness, weakness, poor biomechanics and muscular imbalance. This can often lead to an undue amount of stress and strain being placed on these smaller muscles. As a result, it is no surprise that there are biomechanical implications when some or all of these muscles are dysfunctional, compromising the stability of the pelvis and lower limbs. Whether these muscles have become tight, weak, painful or any combination of symptoms, there are a number of activities that you can do to speed their healing and help prevent further injury. In conjunction, regular chiropractic treatment will help to decrease the resting muscle tension of these muscles and improve their function. The Small Muscles of the Hip and Pelvis Gluteus Medius and Minimus (Hip Abductors) The gluteus medius muscle is the most powerful thigh abductor (moves your leg out sideways from midline) and is responsible for stabilizing the pelvis during the weight-bearing portion of the gait cycle. This muscle prevents the pelvis from tilting excessively toward the unsupported side during ambulation. As well, the anterior fibers of the gluteus medius assist with internal rotation of the thigh. Similarly, the gluteus minimus muscle also acts to abduct the thigh and stabilize the pelvis, generally assisting the gluteus medius muscle in these actions. Following are a few corrective exercises and actions that will assist in stretching and strengthening these muscles. 1. Unilateral Hip and Knee Flexion With feet relatively close together, shift your weight to one leg and tighten your buttock muscles on that side. Slowly lift your other thigh up in front of you while bending the knee. Do not allow the hip to drop. Slowly lower your leg. Alternate sides and repeat 10 times for each side. 2. Lying Hip Rotation Stretch On your stomach, bring on knee to 90 o and slowly move your foot outwards. Hold for 30 seconds and move your foot as far inwards as you can. Hold for 30 seconds and repeat twice. Perform for both legs. Leaders in professional health care for the active individual 2 of 16

3. Lying Hip Abduction On your stomach with legs straight and close together, contract one buttock muscle to slide that leg out to the side. Do not let the pelvis move. Slowly return your leg to the staring position. Alternate sides and repeat 10 times for each side. 4. Side-Lying Hip Abduction On your side with the bottom leg bent, top leg straight and your hand on your gluteus muscles, slowly lift your thigh up and down. Perform 10 times each side. Leaders in professional health care for the active individual 3 of 16

5. Side-Lying Stretch Lying on your side with your back near the edge of the table or bed, assume the starting position as shown in diagram A. Gently press the legs together and hold for 5 seconds. Relax the legs and let the bottom leg hang off of the side of the table for 15 seconds. Repeat stretch several times to try and reach the final stretch position as shown in diagram B. 6. Resisted Hip Abduction Using a cable machine or rubber tubing (available from the Chiropractic Performance & Sports Therapy Centre), begin by standing with your feet close together and the cable around the ankle farthest from the machine. Support your upper torso by holding on to the machine and slowly raise your straight leg to the side, no more than 45 o. Slowly lower your leg to the starting position. 7. Quadrant Lunges Side-to-Side Beginning without resistance, stand with your feet shoulder width apart. Take a large step directly sideways. Slowly perform a squat with the leading knee bent to 90 o and then return to the starting position. Alternate sides and repeat 10 times for each side. Leaders in professional health care for the active individual 4 of 16

8. Ischemic Compression Lie on your back on top of a hard surface covered with a towel. Roll slightly to one side as you find a portion of the muscle that has a tight band of fibers and place a tennis ball between that spot and the hard surface. Roll flat on your back, compressing the tennis ball between yourself and the surface. You should feel some discomfort and possibly referral of that pain down your buttocks or into your low back. Hold for 30 seconds and repeat this procedure on other portions of the muscle. This exercise helps to remove metabolic waste products from the tissues and facilitate fresh blood and nutrient flow in to the tissues. 9. Safe and Unsafe Dressing Positions 10. Proper Sleeping Positions Sleeping on the back with a pillow beneath the knees is generally the best; however this may not be possible due to pain and discomfort in the gluteal muscles. If this is the case, try lying on the unaffected side with a pillow between the knees, ensuring that the knees are directly on top of one another to minimize pelvic rotation. Leaders in professional health care for the active individual 5 of 16

Lateral Hip Rotators The piriformis muscle primarily functions to externally rotate the thigh in the non-weight-bearing position when the hip is extended. Once the hip is flexed to 90 o this muscle also acts to abduct the thigh. However, at full hip flexion, the piriformis appears to internally rotate the thigh. The piriformis muscle comes under the greatest strain during weight-bearing activities as it resists internal rotation of the thigh. This occurs primarily during the early stance phase of walking and running as the foot begins to pronate (roll) under the body s weight, causing a resultant internal rotation of the lower leg and thigh. The remaining five lateral rotators of the thigh almost exclusively function to laterally rotate the thigh in either hip flexion or extension. The following exercises and actions will assist with regaining proper functioning of these muscles. 1. Piriformis Stretch Keep the low back and pelvis flat on the table. Hold for 30 seconds and alternate sides. Repeat twice. 2. Lying Hip Rotation Stretch As outlined for Gluteus Medius and Minimus above. 3. Side-Lying Hip Lateral Rotation Keep the pelvis still while concentrating on contracting these small muscles as you rotate your top leg so that your knee turns upwards. Leaders in professional health care for the active individual 6 of 16

4. Isometric Hip Lateral Rotation From this starting position, push your feet together by tightening your buttocks. Hold this position for 10 seconds. Relax and then repeat. 5. Proper Sleeping Positions As outlined for Gluteus Medius and Minimus above. Tensor Fascia Lata (TFL) and Iliotibial Band (ITB) The function of the TFL during normal gait is to assist with hip flexion during the swing phase, as well as to provide stability to the hip and pelvis during the stance phase. It provides assistance to flexion, abduction and internal rotation of the thigh, thereby assisting the gluteus medius and gluteus minimus muscles with stabilization of the pelvis. As well, the inferior tendon of the TFL joins with the ITB, inserting on the tibia below the level of the knee and providing stabilization to the knee. The following exercises and corrective actions will help to stretch, strengthen and minimize strain on these tissues. 1. TFL/ITB Stretch #1 Leaders in professional health care for the active individual 7 of 16

2. TFL/ITB Stretch #2 3. ITB/TFL Stretch #3 4. Foam Rolling Assume the same position as picture C in ITB/TFL Stretch #2 but place a 6 diameter high density foam roll under the affected TFL/ITB. Using the hands and unaffected foot for support, slowly roll the affected thigh back-and-forth along the foam roll. 5. Side-Lying Hip Abduction with Lateral Rotation Lying on your side with the bottom leg bent; place your hand on the area of your TFL. Bend your top leg to 45 o, point knee cap upwards and slowly raise the thigh. Slowly lower the thigh. Repeat 10 times for each side. Leaders in professional health care for the active individual 8 of 16

6. 30 o Resisted Hip Abduction Using a cable machine or rubber tubing (available from the Chiorpractic Performance Centre), begin by standing with your feet close together and the cable around the ankle farthest from the machine. Support your upper torso by holding on to the machine and slowly raise your straight leg to the side and forward at a 30o angle from where you stand. Slowly lower your leg to the starting position. 7. Quadrant Lunges - 45 o Side-to-Side Beginning without resistance, stand with your feet shoulder width apart. Take a large forward step 45 o from straight ahead. Slowly perform a squat with the leading knee bent to 90 o and then return to the starting position. Alternate sides and repeat 10 times for each side. 8. Sleeping: a) On your side, avoid the fetal position with the knees and hips strongly flexed. Place a pillow between your knees and keep your hips at more than 90 o of flexion b) On your back, make sure that a pillow beneath your knees is not too large to cause excessive hip flexion. 9. Sitting: a) Avoid sitting in the cross-legged lotus position. b) Ensure that chairs have an open angle at the hips to minimize prolonged hip flexion. If not, tilt the backrest backwards and lean against it or slope the front of the seat downwards. c) When driving for long periods, change the position of the lower limbs as often as possible. 10. Avoid walking or running up and down hills to reduce strenuous hip flexion and further aggravation of the ITB. A final key to hip and pelvis stabilization involves improving the performance of the abdominal muscles to control pelvic rotation during lower limb movements. The following exercises complement the training of the small muscles of the hips and pelvis but emphasize abdominal strengthening. This program begins quite simply but you need to progress to a more focused Core Stability Program. Please ask one of the doctors for a copy of this. Each of these exercises begins by contracting the abdominals, feeling as though your whole abdominal area and sides are tightening up. This is referred to as abdominal bracing. Be sure to maintain this contraction throughout each exercise. Leaders in professional health care for the active individual 9 of 16

LOWER TORSO EXERCISE PROGRAMS The muscles of the lower torso are a very dynamic group that endures some of the greatest strain on a constant basis as we propel ourselves through our daily activities. As a result, it is no surprise that there are biomechanical implications when some or all of these muscles become injured. There are a number of activities that you can do to speed the healing of these tight, weak and/or painful muscles and help prevent further injury. There are both superficial and deep muscles associated with lower torso pain. Superficial muscles include some of the paraspinal muscles (muscles that run parallel to the spine), as well as all of the abdominal muscles. The superficial paraspinals travel the entire length of your spine and function to extend the spine. Conversely, the abdominals generally act to flex the spine, although they also play a large role in rotation of the spine. The deep muscles of your lower torso include the deep paraspinals, the quadratus lumborum (QL) and iliopsoas muscles (major hip flexor). Each of these also have a distinct function. The deep paraspinals primarily rotate the spine; the QL muscles act to stabilize the lower torso and laterally bend the spine; the iliopsoas muscles act to flex the thigh (knee to chest movement) at the hip joint and also provide some extension to the lower spine so that an upright posture is maintained while standing. Together these muscles form the basis of support for your spine, much like a cylinder, and they endure the majority of the postural stress that keeps your torso upright. Following are a number of corrective actions and postures for each group of muscles. Lower Back Muscles (Erector Spinae) 1. Stretch the lower back muscles. Stretch #1 A. Lying on your back, slowly bring one knee up at a time towards the same shoulder and hold for 30 seconds. Perform stretch for the other side. Repeat stretch 2 times for each side. B. Lying on your back with both knees together, slowly bring your knees up to your chest while grasping your thighs. Hold the stretch for 30 seconds and repeat the stretch 2 times. Stretch #2 Resting on your knees on the floor, flex your torso forward with arms outstretched. Reaching as far as you can, bring your chest toward the ground. Hold this stretch for 30 seconds and repeat 2 times. Leaders in professional health care for the active individual 10 of 16

Stretch #3 Lying on your back, slowly flex your hip and knee to 90 o then cross your leg over top of the straight leg, stabilizing the knee with the opposite hand but not applying pressure. Hold this stretch for 30 seconds, perform with the other leg and repeat 2 times. 2. Perform Pelvic Tilt Exercises. These exercises will stretch the paraspinal muscles and strengthen the abdominal muscles at the same time. A. Lying on your back with your knees bent to 90 o and hips bent to 45 o with your hands separated and resting on the pelvis and lower rib cage. B. Contract your abdominal muscles, flattening your lower back toward to floor. C. Keeping your abdominals tight and the lower back flat raise your hips and pelvis off of the ground and hold this position for 3 seconds. Perform 10 repetitions for 3 sets with a 2 minute rest between sets. 3. Utilize the Proper Sit-to-Stand/Stand-to-Sit Technique. This movement helps to keep the spine erect throughout these motions. As well, this technique minimizes strain on the low back muscles when going from sitting to standing or standing to sitting by placing the load of the body weight on the hip and knee extensors instead of the low back musculature. Leaders in professional health care for the active individual 11 of 16

4. Correction of faulty body postures and modification of activities to reduce low back strain. A good example is when bending forward to pick up a large, heavy object. Performing this activity safely involves keeping the object close to the body and lifting with the hips and knees. This action reduces the compressive forces on the low back, transferring the load from the back muscles to hip and knee muscles while maintaining the centre of gravity through the pelvis. Quadratus Lumborum The Quadratus Lumboram muscle is one of the most commonly overlooked muscular sources of low back pain. It functions as a stabilizer of the lumbar spine and can act as a hip hiker and as a lateral flexor of the lumbar spine. 1. Perform Lying Self-Stretch. Hold for 30 seconds each side. Leaders in professional health care for the active individual 12 of 16

2. Perform Hip-Hike Exercise. Alternate sides, holding for 10 seconds each. Repeat twice 3. Utilize the Proper Sit-to-Stand/Stand-to-Sit techniques. As outlined above in Paraspinal Muscle section. 4. Avoid combined trunk flexion and rotation movements when bending forward or to the side, as well as combined trunk extension and rotation movements. 5. Ensure that you are using a firm mattress that does not sag. Avoid sleeping on your stomach; rather sleep on your back with a pillow beneath your knees or on your side with a pillow between your knees. For more information on sleeping proper sleeping habits please ask one of the health care professionals for a Sleep Hygiene handout. Iliopsoas (Hip Flexors) 1. Stretch the hip flexor muscles. Stretch #1 Lying on your back near the end of a table, bring both knees up to your chest. Keep your low back pressed down on the table by contracting your abdominal muscles. Hold on to the back of one thigh and slowly lower the other leg back to the table so that the lower leg hangs off of the edge of the table. Alternate sides and hold each stretch for 30 seconds. Repeat twice. Leaders in professional health care for the active individual 13 of 16

Stretch #2 Hip Extension with Knee Straight. Hold for 30 seconds and switch sides. Repeat twice. Stretch #3 Hip Extension with Knee Bent. Hold for 30 seconds and switch sides. Repeat twice. 2. Lying on your stomach with your legs straight, begin by contracting your abdominal muscles to keep your low back straight. Next, contract your buttock muscles and slowly lift one leg off of the table as without allowing your pelvis to move. Hold this leg off of the table for 10 seconds and slowly lower it to the starting position. Alternate sides and repeat exercise 2 times. 3. Lying on your stomach with one knee bent, contract your abdominals, then your buttock muscles and slowly lift the bent-knee leg off of the table without allowing your pelvis to move. Hold this leg off of the table for 10 seconds and slowly lower it to the starting position. Alternate sides and repeat exercise 2 times. For those experiencing lower back pain, place a pillow under the hips to keep the low back in a forward bent (flexed) position. Leaders in professional health care for the active individual 14 of 16

4. This exercise involves a progressive uncurling of the spine. Lie with your hips bent to 45 o, knees bent to 90 o and your feet flat on the floor. Using your arms (NOT YOUR ABS!), raise yourself to a seated position and slowly lower your back, shoulders and neck back down toward the floor as you breathe out. Rest for a few seconds between each repetition, completing a few repetitions initially. Progress to 3 sets of 15 repetitions with a 1 minute rest in between each set. Abdominals In the case of rehabilitating the abdominal muscles, their weakness is very detrimental. As a result, their strengthening should follow a progressive path from basic isolation of the muscles to combined movements that involve numerous muscles at a time. The following are a few of the basic exercises that will build a solid abdominal foundation, but be sure to quickly follow these up with our more detailed Core Stabilization Program which one of our health care professionals will provide for you. 1. Abdominal Bracing. Perform abdominal bracing as described above. Place your fingers on both sides of your abdomen. Bear down (like you re straining to go to the washroom) without holding your breath. Make sure you can feel your oblique muscles contracting under your fingertips at your sides. Learn to hold this for a few seconds and progress to being able to do this while walking and talking. Remember, practice makes perfect! 2. Heel Slides with Hip Flexion Begin lying flat on your back. Contract your abdominals and slowly slide one foot towards your buttocks, keeping it in contact with the ground. Be sure to not rotate the pelvis at all. Slowly slide your foot back to the starting position. Alternate sides and repeat 10 times for each side. 3. Heel Lifts with Hip Flexion With the hips bent to 45 o, and knees bent to 90 o, contract the abdominals and slowly raise one thigh toward your chest. Hold this thigh in place and slowly lift the opposite foot off of the ground 6-12. Be sure to not let the pelvis rotate at all. Keeping the abdominals contracted, slowly lower your legs to the starting position. Alternate sides and repeat 10 times for each side. Leaders in professional health care for the active individual 15 of 16

4. Bent Knee Fallouts With one knee bent, contract the abdominals and slowly let the thigh fall to the outside. Keeping the abdominals contracted, raise the thigh back up and slowly let it fall to the inside. Be sure to not let the pelvis rotate at all. Slowly raise the thigh back up to the starting position and repeat before 10 times before switching legs. 5. Bent-to-Straight Knee Fallouts Follow the same procedure as above but only let the thigh fall to the outside and then from that point, slowly straighten the leg. With the abdominals contracted and the pelvis stable, bend the knee and bring the thigh back to the starting position. Alternate sides and repeat 10 times for each side. NOTE: It is important for you to follow any specific instructions given to you by your Health Care Professional. Your active participation in your rehabilitation will dramatically improve your recovery time and aid in the effectiveness of your in office treatments. If you have any questions regarding the information provided in this handout, please do not hesitate to contact your Health Care Professional. Leaders in professional health care for the active individual 16 of 16