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  I have had the privilege of working with athletes at all levels and it has always fascinated me to watch them and see the differences in their coordination and performance of their sport as they mature.  I find it more interesting to witness sport movements performed with increased grace and fluidity as the athlete increases his or her skill level.  Athletes routinely use the entire kinetic chain to perform their sports, and I think most of us would agree that efficient use of the entire kinetic chain reduces both acute and chronic overuse injuries.  From a rehabilitation standpoint, it is imperative that this be considered when designing therapeutic exercise programs.  Not only is it more functional to use the entire kinetic chain, but from my experience, the athletes are also more compliant with these exercises because they immediately see the relationship to his or her sport.  Additionally, it is important to evaluate an athlete’s hips to see if they have the ability to use the powerful hips to their full potential to generate the power from below to translate to greater force production above.  Likewise, they need to also be able to use the hips to decelerate motion.  The purpose of this article is to discuss ways to evaluate for hip range of motion and an athlete’s ability to coordinate the hips to help the shoulder, as well as provide ideas on how to implement a total body approach into rehabilitation of the shoulder.

  Two thought processes give the foundation for this treatment premise.  First of all, there is a kinesiological concept called the “serape effect.”  A serape is a garment worn by Latin Americans, designed to drape around the shoulders from one hip to the other.  Thus, it crosses the body in a diagonal fashion.  The connection from the hip to the shoulder is analogous to the muscles of the trunk and their ability to help rotation occur within the trunk.  These muscles are the rhomboids, serratus anterior, and the external/internal obliques.  Collectively, contraction of these muscles cause motion from the lumbo-pelvic complex to the thoracic spine, and finally, to the shoulder girdle.

  Next, from his text Movement, Stability, and Low Back Pain, Vleeming describes four systems within the body.  Two of those systems are the Anterior Oblique System (AOS) and the Posterior Oblique System (POS).  The AOS comprises the external oblique and the opposite adductors of the hip, while the POS is comprised of the latissimus dorsi and the contralateral gluteus maximus.  While his book focuses on low back pain, the fascial connections of these two systems are in a diagonal fashion.  While it is proposed that they contribute to spinal stability, it is the transfer from lower to upper trunk that is key in not only stability, but also conversion to power and deceleration. 

  From a passive flexibility perspective, the known common clinical tests/measures for the hip are rather intuitive.  The Thomas Test and straight leg raise/90-90 position are quick and easy assessments for baseline testing of the hip flexors and hamstrings, respectively.  Despite the ease of application and relevancy, a more comprehensive analysis is required to have a true assessment of an athlete’s status. 

Clinically, tightness in either of these muscle groups can cause various pathologies.  For example, tight hip flexors may be a secondary cause to impingement syndrome.  Tight hip flexors will cause the rib cage to flex which in turn causes a thoracic kyphosis and then an obligatory internal rotation of the humerus, thereby putting the rotator cuff in an impingement position.  Conversely, tight hamstrings can cause low back pain with possible compensations in the shoulder, or through an excessive posterior tilt, the posterior shoulder muscles would be on a stretch weakness due to upper thoracic compensation for the loss of lumbar lordosis. 

To isolate medial and lateral hamstring tightness, the clinician can have the subject sit tall on the ischial tuberosities, maintaining lumbar lordosis, with the legs in a long sitting position.  You can then ask the subject to IR/ER their hip (Figure 1) and try to perform a straight leg raise.  The inability to either do the SLR or loss of lordosis would indicate tightness in the individual hamstrings (so in IR, the lateral hamstrings are implicated). 

Both of these muscle groups, if tight, will ultimately restrict the ability of the pelvis to rotate on the femur.  In the closed kinetic chain, pelvic rotation over a fixed femur, particularly internal rotation, enables the powerful gluteus maximus to “prestretch” and the stored elastic energy can then translate to greater force production.  Therefore, it is possible that a tight lateral hamstring will not allow complete internal rotation to occur.  On the other hand, tight hip flexors will restrict pelvic external rotation on a fixed femur.  Again, if this is the case, the upper trunk can not fully “open up,” thereby decreasing thoracic rotation and extension needed for the overhead throwing motion.

Perhaps the best way to illustrate this is by example.  Let’s say you have a right handed baseball pitcher.  He will use his right lower extremity to push off the mound towards the plate.  If his right hip flexor is tight, the trunk will not be able to extend and rotate to the left to achieve proper mechanics of the pitch.  Upon ball release, the pelvis must be able to rotate internally on the fixed left femur to help decelerate the trunk and ultimately the arm following delivery.

An effective way to evaluate the ability for the hip to rotate in closed chain is to have the athlete perform a single leg squat while reaching across the body (Figure 2 and 3).  In figure 2, the subject is internally rotated on the femur relative to the pelvis.  The athlete should feel a stretch in the left gluteus maximus/proximal hamstring, and the clinician should observe a “crease” in the hip, revealing the internal rotation of the femur.  As a clinician, you can compare side-to-side differences based on how far they can reach with the contralateral extremity.  In figure 3, the subject is externally rotated on a fixed femur.  In addition, the therapist can also have the subject perform a basic free standing squat with his/her hands resting on the head maintaining an erect posture.  The inability to prevent the trunk from flexing may also confirm tight hip flexor findings.  Keep in mind that the proposed closed chain tests do not necessarily isolate individual muscles, but rather the hip complex working in concert.  These tests coupled with the passive tests highlighted previously can collectively confirm your suspicions. 

To treat a shoulder, we can take basic exercises and make them a little more functional.  In figure 4 and 5, the subject is doing external rotation with tubing.  Commonly, the patient is standing still.  What you can do is have the athlete rotate the left hip in, then contract the gluteal musculature, as well as externally rotate the shoulder to complete the full range of motion.  The movement will also facilitate thoracic rotation, which will help direct the scapula to retract and downwardly rotate.  Secondly, you can have the athlete perform a step up on one lower extremity and perform end range flexion on the contralateral upper extremity, perhaps in a D2F pattern (Figure 6).

 Another exercise you can do is the D2 flexion/extension pattern (Figure 7, 8) in standing with emphasis on hip motion.  You can begin this exercise in a split stance position, and then to progress, you can move to single leg.  The deceleration component can be emphasized (Figure 7), or the concentric portion of a rowing motion (Figure 9).  Hopefully, the reader can see that this is more appropriate for athletes as opposed to doing this exercise in normal standing. 

Unfortunately, the hip/shoulder connection has not been proven in the research, but it is an accepted premise that an intimate connection exists between the two.  Because overhead athletes require the entire kinetic chain to perform their sport, it behooves a sports physical therapist to consider this when evaluating and treating an athlete’s shoulder.  If this is done effectively, a therapist can expect a reduction in injuries and possibly improved performance due to more efficient use of the entire body to generate movement.

Vleeming, A.  Movement, Stability, and Low Back Pain.  Churchill Livingstone: London, England.  1997.