Early Rehab for Anterior Lumbo-Pelvic-Hip Injuries

Sports Hernia, Abdominal Strain, Osteitis Pubis, Adductor Strain...

Call it what you want, but if it doesn't warrant surgical intervention, the principles behind exercise intervention generally stay the same...

Where I think most rehab protocols fail is in their reductionist approach to targeting specific tissues. In the grand scheme of things, I personally could care less what tissue is injured. Because if the big picture doesn't return to "normal", one year it will be an adductor longus strain, the next year osteitis pubis, the following year rectus femoris strain, return to adductor longus strain and so on.

It's a never ending cycle.

Granted, "contemporary" treatment generally consists of any or all of the following:

• Soft tissue release of the symptomatic region until the athlete reports decreased pain
• E-stim to the symptomatic region until the athlete reports decreased pain
• Corticosteroid injection into the symptomatic region then the athlete reports decreased pain
• Wall squats with a ball between valgus knees until the athlete is fed up with paying for 6 months of rehab with no improvement
• You get my point

But ultimately, the athlete never recovers 100%. Sometimes the athlete just ends up sitting out for more than a year until retirement then 2 years later finally "feels" better and other times it just spirals negatively into a vicious cycle and subsequently succumbs to several "failed" surgeries/repairs.

I don't think they're a lost cause. Especially if they're an athlete willing to do whatever it takes physically to get better.

The athlete who is patient and diligent is my favorite type but as a whole, they need us to get better.

For most athletes, I don't think its a full-fledged psychosocial game where you just talk them out of pain. How you communicate is definitely 100% important and you should never be iatrogenic, but something is definitely up with this injured group and we have to help them fix it.
In no particular order, some of the things I look for below the pelvis initially are:

• Adductor length and quality
• Quadriceps length and quality
• Lateral hip stabilizer tone and quality
• Posterior hip capsule mobility

From a core integrity standpoint, I generally look for:

• Expiratory position ability of the lower rib cage
• Breathing pattern
• Abdominal tissue quality
• Cylindrical muscle activity
• Compensatory muscle activity in the "core"
• Ability to engage instantaneously

Note that while I'm in a profession that places a ton of weight on structural positioning, I generally keep this last on my list. I do think it's important but for the most part, I think it'll take care of itself. If it's staring at me in the face, I'll take care of it. If not, she'll be fine.

Once I have the big picture in mind, I think it is reasonable to restore tissue quality and tone. I'm generally an "exercise first" type o' guy, but in relatively nagging or recurrent cases, especially if I'm seeing them for the first time, I don't want my biases to hold me back from getting us where we need to be.

I think scouring the hip is a good place to start.

Pinching is common here so detonating the anterior-lateral hip is the way to go. Use whatever means you want but my preference is with the tip of my thumb or a pointer plus.

Next, I generally want to see what FABER has to say. If the athlete reports a "pull" or tightness, out comes combo #3 consisting of ART, PIR and FAT.

Posterior P-A challenge will tell me if more mobility is needed and the Multi-Segmental Extension Top Tier from the SFMA I performed early on will let me know if I have to go after the paraspinals.

The tip of my thumb and his friend contract-relax apparently have an excellent relationship with the QL.

Every now and again, the presence of a tendinopathy will warrant some IASTM but I'd say this is rare.

But all in all and as I said earlier, I want to make sure that nothing is holding me back once the athlete is on the floor.

Several key points with this exercise:

• The wall push is the help the athlete achieve expiratory position (if they can't get it on their own, passive positioning or balloon breathing may be warranted)
• 360 degrees of cylindrical muscle activity is paramount
• This includes the ability to pressurize the lower lateral abdominal region just medial to the ASIS' (I don't care what you're trying to activate here, just get it all working - and with respiratory control)
• The hips are both passively (not shown) and actively rotated internally and externally to make sure that they're free and easy. Again, we don't want compensatory muscle activity here so  you gotta keep them loose

​Once they can demonstrate the ability to isolate free hips, you can progress them into the standard Kolar Dying Bug.

Key Points:

• I like kicking the hips out over dropping the heels but ultimately you have to find the most appropriate exercise along the regression/progression continuum
• Reverse Russian Pyramids work best in my opinion, either holding for time (10 seconds) with respiratory control and optimal cylindrical activity or better yet, counting down breath cycles.
• If they can't get cylindrical activity either in this exercise or the one above, pull out the tennis balls or weight belt to help with indirect cueing.

​Aside from nailing it on their back, babies also need to nail it on all fours. The Kneeling Plank Walkout is a decent choice here.

Points with the Kneeling Plank Walkout

• I've been using this more lately as opposed to Quadruped Rockback RNT, because, sometimes the athlete will report pinching in the hips with the latter. That said, if compensatory activity is absent, I have no issues with Q-ped Rockbacks.
• It's important to ensure rib cage positioning here as well as maximizing hip translation. You don't want lumbar extension here. This is an anti-extension exercise so make sure you watch for it...sweat the small stuff!
• Reverse Russian Pyramids will be a common theme throughout

Ipsilateral patterns progress to contralateral patterns as per DNS so depending on whether I need to improve hip control or that of the lumbo-pelvic-hip complex, I try to choose the most appropriate intervention.
For hip control, I like Single Leg Glute Bridge vs the Wall Progressions:

Key Points:

• Because I want to ensure core control, I'll start with "vs the Wall" versions if necessary. And "if necessary" means most of the time in this population
• The version you see above is the Single Leg Glute Bridge but you can start with Double Leg Bridge into Single Leg Hold with Miniband, Single Leg Bridge with Miniband, Cook Hip Lift or other. Your call...no wait, actually it's "patient-presentation call". Their presentation dictates your intervention. Remember that.

Valslides are staples when working with athletes suffering from these injuries and as I noted last year, are key to improving lumbo-pelvic-hip control when on all fours. Make sure you attack each hip in both their supporting and stepping limb functions as if there's anything we've learned from recurrent ACL injuries, it's that far too often we forget about the "good" leg.

Valslide Hip Stability Points:

• Control, control, control.
• Just in case, make sure you fully emphasize control in this exercise. Better yet, make sure you do so with every exercise, but especially this one.
• The neck and the thoraco-scapulo-humeral regions are important here, as in everywhere, so don't forget to centrate
• Underdo the range of translation in this exercise and make sure they nail it. It's easy to go awry here, so again, sweat the small stuff

Now as you can see, these are exercises you can integrate into the early phases of rehab but ultimately, you'll need to progress them into more upright positions. I may or may not, post upright progressions sometime down the road but one thing you won't see is a squat with a ball between an athlete's legs. I know that Tyler et al said adduction strength is important a decade ago, but I strongly believe that that doesn't give anyone a free pass to squat with a ball between their legs.
I hope this post gives you some ideas when it comes to rehabbing athletes with these injuries that plague two of the major sports I work with (among others), but if there's anything you can take away it's this:
Being diligent and meticulous with motor control will go a long way.