A 25-year-old married woman, a recreational runner presents herself to the office with the chief complaint of right hip pain. The pain has been present for 3 weeks, worse during her last run after slipping off a curb awkwardly. The pain gets worse with activity and with prolonged sitting, it lightens during rest. She is currently training for a marathon. Her last menstrual period was within the last month. She is not pregnant and she uses oral contraception regularly. She is not taking any other medications other than an occasional acetaminophen or ibuprofen for headaches and menstrual pain. Her past medical and surgical histories are negative, and she has never been pregnant. She has no known allergies. She denies tobacco use of any kind, nor any illicit drugs. She admits to having an occasional glass of wine, and she drinks coffee in the mornings.

Physical examination reveals stable vital signs. She has a positive Ober’s test on the right. Her popliteal angle is 140° bilaterally. She has a positive modified Thomas test on the right as well as a positive standing and seated flexion test on the right. She has mild tenderness over her right greater trochanter as well as the right sacroiliac (SI) joint. Her sacral sulcus is deep on the left, and the inferior lateral angle (ILA) of the sacrum is shallow on the right. She has good motion of the sacral base on the left, with none on the right and minimal motion of the right ILA. She has decreased internal and external rotation of the hip on the right compared to the left. Patrick/FABER test is negative. Her piriformis muscle is tight on the right with several noted tender points on both the right piriformis and psoas (Fig. 11.1).

X-rays of the hip and pelvis are negative for evidence of fracture, arthritis, and other bone abnormalities.

The hip and pelvis are built for support and motion. Composed of the largest bones and muscles in the body forming foundation for locomotion . The body’s center of gravity is located in the pelvis, just anterior to the second sacral vertebra. Once the provider understands the anatomy of the hip and pelvis, it is easy to understand how dysfunction (decrease in motion) of the hip can produce not only lower extremity pain, but also low back pain, pelvic pain, and changes in the gait cycle that may lead to other pain syndromes [4, 10, 11].

Functional anatomy relationships of the hip and pelvis are the key to determining the cause of the dysfunction and correcting it. The inominates articulate with the sacrum via the sacroiliac joints. The pubic symphysis acts as an anterior static bar providing stability to the pelvis during both ambulation and sitting. Tension on the ligaments, which cross the SI joint, can cause dysfunction in the leg. Patients with iliolumbar ligament sprains often present thinking they have an inguinal hernia; however, the physical findings are not supportive. Somatic dysfunction of the sacrum, inominates, and lubosacral junction are common causes of hip and pelvic pain in active patients. In a subset of patients the sciatic nerve divides before entering the gluteal region and the peroneal portion passes through the piriformis muscle; in small percentage, it will pass superior to the piriformis muscles. The piriformis muscle is found in the midpoint of a triangle made between the posterior superior iliac spine (PSIS), the coccyx, and the superior aspect of the greater trochanter (Fig. 11.2). When the composite sciatic nerve is compressed secondary to piriformis spasm, the superficial nerve bundles are mechanically irritated and the resultant pain can radiate down the leg, usually not below the knee. Pain from nerve root pressure usually radiates below the knee [8, 11–13].

The hip is the term for the composite of the inominate bone, the head of the femur, and the acetabular joint. The acetabulum of the inominate is composed of portions of the ilium, ischium, and the pubic bone. The femur travels along three axes in the hip joint. The transverse axis is where flexion (130°) and extension (35°) occur. Abduction (55°) and adduction (35°) occur along the anteroposterior (AP) axis, and internal rotation (35°) and external rotation (45°) occur along the longitudinal axis.

It is the minor motions, not the major motions that usually become restricted when somatic dysfunction occurs, and it is the compensations for these minor motion restrictions that become the issue over a period of time. Posterior and anterior glide of the femoral head in relation to internal and external rotation of the hip are the minor motions. Flexion, extension, abduction, and adduction are considered the major motions of the hip [12, 14–16].

As other chapters of this book focus on various treatments of the pelvis and hip in regard to sports medicine and primary care, this chapter will focus on manual medicine techniques. The use of manual therapy is an ancient healing form that has been documented as early as 2,700 b.c. [17]

Before we can discuss manual treatments, we must first understand some basics about manipulations. Osteopathic and chiropractic manipulations are forms of manual medicine that stress the need for normal and symmetrical motion in the joints. These manipulations are done to enhance or restore motion in a joint. By restoring motion to a joint and homeostasis to the tissues we are allowing the body to function in a more optimum state of health. The growth of manual medicine has been fueled by patient outcome. The rise of modern-day manipulative medicine by osteopathic physicians, chiropractors, and physical therapists has come behind that of efficacy studies such as the RAND study by Dr. Paul Shekelle, who said: “Spinal Manipulation is the most commonly used conservative treatment for back pain supported by the most research evidence of effectiveness in terms of early results and long term effectiveness.” (SOR = B) [18].

There are three general considerations that a provider must understand before deploying manual medicine as a treatment option : (1) One technique may treat more than one type of dysfunction; (2) More than one technique may be required to treat a single type of dysfunction; and (3) All techniques work best when applied to a specific diagnosis. The goals of treatment are to enhance the movement of body fluids, modify somatosomatic, viscerosomatic, and viscerosomatovisceral reflexes, provide maintenance treatment to irreversible conditions (osteoarthritis), and to mobilize articular restrictions.

There are various activating forces that are used in treating somatic dysfunction. Many are beyond the scope of this text. If further reading is desired, please refer to the references at the end of this chapter. The activating forces discussed here will be discussed in detail in the treatment section of this chapter. Patient cooperation is an activating force that is required when treating dysfunction with strain/counter strain (treatment of tender points) and when using muscle energy. The patient is instructed to move his/her body in specific directions involving various planes of articulation to aid in the mobilizing of an area of restriction. In muscle energy techniques, the activating force is the patient’s contraction of muscles in a specific direction against the physician’s counterforce. A physician guiding force is exerted when the physician positions the patient away from the restrictive barrier to a point of release and then guides the tissue or joint somatic dysfunction through various positions that move with ease until the dysfunctional pathway has been completely retraced. Springing is also known as the low velocity moderate amplitude force: the provider makes contact upon the restrictive barrier and with variable degrees of force, springs the structure with intermittent pressures. High velocity low amplitude (HVLA ) is used only with direct methods: the restrictive barrier is properly engaged to yield along one of the planes of a joint. A HVLA force is applied to move the joint or tissues through the restrictive barrier. An articulatory procedure is of a low velocity and low to a high amplitude technique where a joint is carried through its full range of motion [9, 14, 19–22].

The primary goal of treatment is to restore function to the tissues. Hypo or hyper mobility of a joint leads to muscle imbalance, altered movement, and eventually pain syndrome. The few contraindications to manual medicine are listed in Table 11.2.