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Goniometry: Hip Internal Rotation at 90 Degree of Hip Flexion (90/90 Hip IR)
Goniometry: Hip Internal Rotation at 90 Degree of Hip Flexion (90/90 Hip IR) is an orthopedic test used to measure the range of motion of the hip joint. It is a combination of hip flexion with simultaneous hip internal rotation and is used to assess gluteal, external and rotator muscle strength as well as joint laxity and hip impingement. The patient is typically in a siting or supine position and the practitioner manually moves the
Transcript
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This is Brent of the BrookBush Institute
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at the Independent Training Spot going
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over our next goniometric assessment video, which is supine 90-90 hip
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internal rotation goniometry. Now I know what you're thinking we just went over
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internal rotation goniometry in prone. These are not the same assessment.
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They're both very commonly used, however what they're going to tell us about the
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hip and the restrictions at the hip is slightly different, and could give us a
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little bit more information to use when we create our intervention. I'm going to
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have my friend Melissa come out, she is going to help me demonstrate
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this goniometric assessment. Now the first thing we need to do is know where
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our two lines are right, where is the line for the stabilization arm, where is
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the line for the movement arm of our goniometer. Now stabilization arm is
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going to go straight through the midline, or a line parallel to the midline of
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Melissa's body here, or a line, you guys can think of a line that runs parallel
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to this table, the edge of this table. The movement arm, you guys can see I put a
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little tape here, the movement arm is going to go through the center of the
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knee, and line up with the tibial tuberosity. This is the same line we
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created in hip internal rotation in prone right. We don't want to just follow
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the tibia because the crest of the tibia isn't straight, so that could lead to
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some inaccuracy in our measurements. Now the way I like to do this guys is I like
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to to go ahead and put my goniometer down to start, bring Melissa's hip here
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in to 90 degrees, make sure her knee is directly over her hip, no adduction or
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abduction, no flexion or extension, just right at 90 degrees. I'm going to
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go ahead and take her into internal rotation until I get that firm end feel,
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which is the normal end feel at the hip. Alright this will be a
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slightly softer end feel than we felt in the prone hip internal rotation, but
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still a firm end feel nonetheless. I'm then going to have Melissa try to give
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me a little help, can you hold this position. This is not an easy position
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for her to hold, so what I'm going to do is once i got my goniometer and i got
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her kind of set up, I'm gonna wrap my arm around, i'm going to stabilize her leg,
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kind of reposition. Make sure i'm as accurate as possible, that her knee is
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directly over her hip, make sure she's at that end range, and then i'm going to go
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ahead and line up my stabilization arm here, get my movement arm lined up, and I
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got 36 degrees. So that's hip internal rotation goniometry
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at 90 degrees. Let me do that one more time for you guys, real quick just
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as I would do it in my own clinic. Hip flexion, no adduction or abduction. Good take
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her to her end range. Can you hold that for me Melissa, good. Make sure your not hip
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hiking for me. Good, setup my stabilization arm, my movement arm ,make
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sure I have, go ahead and relax, make sure she's all lined up, and that time I got
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38 degrees, good. If I wanted to be as accurate as possible I might take up to
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three measurements and average those, but you guys can see how this measurement is
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done. Now the next question is what do we do with it, thank you Melissa. Guys can
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see the board back here? Again if we're doing goniometric assessment, remember
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we have to assess for one of two reasons, we either assessing to clear our
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patients and clients, and make sure that they are prepared for intervention, that
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they're able to work with us, nothing's contraindicated, all right or we're
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trying to figure out what we're going to do in our intervention, in whether it's
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our exercise, or physical therapy, or athletic training, we need to figure out
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how we're going to affect this test that we just did. Goniometry is a
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flexibility assessment, so I need to think about what are the restrictions to
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this goniometric assessment. In the case of hip internal rotation at 90
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degrees this is a slightly confusing graph actually, we're going to start with
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muscles. Alright so the first thing that restricts hip internal rotation at 90
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degrees, and this is a puzzling one, it's probably your TFL and your gluteus
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minimus, and I know what some of you guys are thinking, some of you guys were up on
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your functional Anatomy, wait a second those are internal rotators, so how are
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they going to restrict hip internal rotation? And that's a great question and
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I'll give you guys my theory on that, which is the TFL and gluteus minimus can
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also superiorly and anteriorly glide the femoral head in the acetabulum.
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So we're probably seeing when we have somebody who's restricted in hip
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internal rotation, is we start getting a little bit of impingement on that
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capsule, or we start running out of room right where the the femoral head is
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rolling, but not gliding posteriorly enough. So we're going to release these
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muscles to actually help improve arthrokinematics. The next thing I'm
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going to go after is the adductors, now which adductor? Great question. Once we
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get into hip flexion at 90 degrees, we've lengthened the adductor Magnus, we've
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shortened the anterior adductors right, but both seem to be able to restrict
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this range of motion. So I'm going to go ahead and start releasing and thinking
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about stretching those adductors. The next thing I'm going to go after is the
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deep rotators, but for those of you guys were really really up on your
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kinesiology, you guys might remember that the piriformis above 90 degrees is
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actually a hip internal rotator. So it's not going to restrict this motion. So you
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guys got TFL and glute min, adductors and deep rotators are probably the first
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three muscles or three muscle groups that I'm going to go after. However don't
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count out the psoas and iliacus, biceps femoris, and rectus femoris, these could
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also contribute. Once I get through all of this muscle stuff, what if I still
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have restriction in the hip? Well probably the most impactful thing is
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when we get actual restriction in the joint capsule itself. So I'm going to
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start looking for posterior and inferior capsule shortening, and the techniques
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I'm going to use for that is either the self administered hip joint mobilization
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I did in a previous video, or we're going to have to look towards some of those
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manual techniques. I know you guys are familiar with like your lateral
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distraction, or your posterior glide of the hip. The sacroiliac joint, I think
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I've mentioned this in a couple videos since like the piriformis and some
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other structures cross that sacroiliac joint, through either a fascial connection
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or a direct connection. If that sacroiliac joint gets bound down, becomes
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dysfunctional, it could change the tonicity of muscles that cross both the
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sacroiliac joint and the hip, and affect our range of motion. So now I got all of
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these muscles I could think of working on. I got these two joints that I could
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think about working on. Don't forget about the fascial component alright, so my
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lateral fascia lata, as well as my posterior hip. All of you guys using your
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PIN and stretch techniques, and your instrument assisted soft tissue
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mobilization, and your self administered myofascial release, think towards these
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areas, and go well if I've already done the muscle stuff, and the hip stuff, maybe
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I need to work on that fascial component. And of course we also need to think
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nerves. Now goniometery is not a great assessment of which nerve is
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restricted, or whether we had a nerve restriction. The most important thing to
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remember is if I happen to be doing this, and Melissa had got paresthesia right,
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she had got that pins and needles feeling, the tingling down the
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back of her leg, do I have sciatic nerve impingement. So these deep rotators,
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one of them is my gemellus superior, and then i have my piriformis, on top of that
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my sciatic nerve runs between those two muscles. If I crank her into internal
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rotation, what I do is I tighten my gemellus superior, and pinch up on my
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sciatic nerve. Nerves that are normally functioning
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will not cause paresthesia. If she has a dysfunctional sciatic nerve for some
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reason and I impinge it, it's going to give her sensation, and I need to go
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ahead and move on to my neurodynamic tests. We might also have some sensation in
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the posterior femoral cutaneous nerve. So once again we had this huge complicated
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graph, so let me kind of break this down for you guys. I use this goniometric
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assessment probably more than any other assessment for the hip, and the reason
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being is is it gives me all of these potential ways to correct hip
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dysfunction, and what I find which is most important, is that if i can get hip
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internal rotation at 90 degrees back to optimal, that I've probably done a really
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good job at removing as many restrictions as I can at the hip. So
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while the prone hip internal rotation is nice and gives me a lot of great
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information, this is the one where I go okay if I got this one, I got them
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back to close to normal and I know I'm on the right track. I hope i just gave
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you guys a ton of information, a ton of things to think about, and i hope you
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guys understand hip internal rotation goniometry at 90 degrees of hip
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flexion. Thank you.
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