Set-Up
- The patient should be supine, closer to the side of the table of the affected hip. The practitioner should be standing on the patient's affected side.
- The table should be at a height that allows the belt to be parallel with the floor when wrapped around the practitioner's glutes and the patient's proximal inner thigh.
- If the technique is done without a belt, the table should be higher. The table height should allow the practitioner to place their chest against the patient's lateral thigh and wrap their hands around the patient's proximal inner thigh with elbows flexed to about 90°.
Lateral Mobilization
- Start by locating the inguinal line, the anterior superior iliac spine (ASIS), and the greater trochanter. These landmarks will be essential for optimally performing both the belted and hands-on techniques.
- The more proximal the belt or your hands are on the patient, the closer the application of force to the joint; and theoretically, the less force that will be needed for mobilization. Less force makes the technique more comfortable for both the practitioner and patient.
- You can ask the patient to "adjust and guard". That is, you can ask the patient to move "sensitive tissues" out of the way, and then "block/cover" those tissues with their hand. You can also ask the patient to position the belt low on their inner thigh themselves, to further reduce the risk of grazing "sensitive" tissue.
Belted
- The belt should be placed around the practitioner's buttock (not around the lower back), and the most proximal position that can be comfortably achieved on the patient's inner thigh.
- Bring the patient's knee and hip into flexion, and stabilize the patient's leg by firmly pressing it against your chest and under your arm, as if you were putting the leg in a "headlock". This will allow you to control the patient's leg by shifting your body weight and will be helpful if you choose to perform end-range hip flexion and/or internal rotation mobilizations.
- The other hand can be used to monitor joint motion, by placing the index and middle fingers on the ASIS and the thumb on the greater trochanter. The lateral distraction of the hip should result in the greater trochanter of the femur moving laterally relative to the ASIS of the pelvis.
- The mobilization force should be generated by sitting back into the belt; however, this is not to be confused with lumbar extension. "Sitting back" should occur by taking a staggered stance and shifting your body weight back into the belt and onto your back leg. The goal of this technique should be to move yourself and the patient's femur in one piece.
Hands-on
The hands-on technique is performed similarly to the belted technique; however, the hands will be positioned where the belt was.
- As described above, bring the patient's knee and hip into flexion, and hug the patient's leg firmly against your chest under your arm, as if you were putting the leg in a "headlock" with the arm closer to the patient's feet. This will allow you to control the patient's leg by shifting your body weight and will be helpful if you choose to perform end-range hip flexion and/or internal rotation mobilizations.
- Wrap both hands around the patient's inner thigh interlocking your fingers. Your pinkies should be as proximal as possible (not medial). Although you are close to sensitive areas, asking the patient to "adjust and guard" and maintaining your hands firmly against the patient's inner thigh should reduce the chance of grazing sensitive tissues.
- You want to be able to oscillate by rocking your body, this requires you to ensure that your elbows are near 90°, pulled back and tight into your sides, and the patient's thigh tight against your chest.
- The mobilization force should be generated by taking a staggered stance and shifting your body weight back onto your back leg. The goal of this technique should be to move yourself and the patient's femur in one piece.
Mobilization:
- Once you are comfortable with hand position (and/or belt position), start with small test oscillations to identify articular motion and any exquisite tenderness.
- When satisfied with the feel of the technique, identify the amount of pressure needed to feel the first resistance barrier just prior to articular motion, and then press harder to identify the most pressure that can be used and still result in articular motion. The point at which any further pressure fails to increase articular motion is the end of the articular range and no additional pressure should be used.
- Identify the mid-point between the first resistance barrier and articular end-range; approximately 50% resistance.
- Grade III - Larger oscillations between the first resistance barrier and approximately 50% resistance.
- Note, these oscillations are large compared to grade IV oscillations, but are still relatively small motions.
- Grade IV - Small oscillations at 50% resistance or more.
- Oscillate at 1 - 2 pulses per second.
- Continue oscillating until you feel a change in tissue resistance/joint stiffness.
