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Revue de l’évidence scientifique de la mise en place du travail neuromusculaire de la hanche pour la correction du valgus de genou



Revue de l’évidence scientifique de la mise en place du travail neuromusculaire de la hanche pour la correction du valgus de genou

Introduction
Les exercices de renforcement neuromusculaire de la hanche ont prit une grande importance à la vue de son impact sur la prévention des pathologies du membre inférieur. Principalement pour la rupture du ligament croisé antérieur (LCA) et le syndrome fémoro-patellaire (SFP) pour lesquelles cette intervention permettra une amélioration réelle du contrôle neuromusculaire et du renforcement musculaire. 1 Le valgus dynamique du membre inférieur se définit par une association de mouvements et rotations incluant l’adduction et rotation interne de hanche, abduction du genou, rotation externe et translation antérieure du tibia, et éversion de la cheville. 3
C’est un facteur de risque pour une future lésion du LCA ou d’un SFP chez les jeunes athlètes féminines principalement, d’après les dernières études. 2 4 5

Si l’on analyse les différences entre les athlètes féminines et masculins voici ce qu’il en est :
  • Chez les femmes, on retrouve un valgus de genou beaucoup plus prononcé notamment lors des réceptions de saut et des mouvements en pivot. 6–18 Tandis que chez l’homme, de part son développement pendant la croissance et l’adolescence, on retrouve une plus grande force musculaire au niveau des hanches. 23
 
  • On se rend compte de l’importance des stratégies de contrôle neuromusculaire lors de la réception de sauts comme un facteur de risque de blessures du membre inférieur ou du LCA chez les athlètes féminines. 29,30
Lors des sauts verticaux, les femmes sollicitent beaucoup plus leur quadriceps tandis que les hommes sollicitent une plus grande flexion, puis extension de hanche.
C’est pour cela, que lors de l’entrainement neuromusculaire, on agit sur la cinétique et la cinématique de hanche. 35 Lephart et al35 ont démontré que lors de la plyométrie, on retrouve une plus grande flexion de hanche lors du contact initial, ainsi qu’une augmentation du pic de force lors de l’extension. Ces auteurs suggèrent donc que ces modifications au niveau de la hanche entraineraient une augmentation de la force musculaire des ischio-jambiers, protégeant ainsi le LCA. Le positionnement de la hanche jouerait un rôle important sur l’efficacité mécanique des ischio-jambiers par rapport au quadriceps. 36
La hanche joue donc un rôle central lors du valgus dynamique du membre inférieur. Le but de cette étude fut de mettre en place un protocole de correction ciblé sur la hanche, et basé sur l’activation musculaire de la hanche, renforcement musculaire,  à partir des données biomécaniques, afin d’établir un protocole clinique pratique.
Anatomie fonctionnelle
La musculature postéro-latérale de la hanche permet la stabilité proximale du membre inférieur et du bassin, ainsi que le contrôle de la rotation de hanche. 37–39,41,43,45,46
Le premier abducteur de hanche est le moyen fessier qui possède des fibres antérieures et moyennes (verticales), mais également postérieures (horizontales), et se contractent de manière plus ou moins simultanément suivant l’effort à réaliser sub-maximal (marche) ou plus intense (descente des escaliers). 42,43 Il est aidé par le petit fessier et le piriforme.
Le grand fessier permet quant à lui, l’extension de hanche associée à la rotation latérale. 37

Exercices d’activation musculaire à partir de la hanche
L’activation musculaire du moyen fessier, grand fessier a été mesurée par EMG en analysant le pourcentage de contraction volontaire isométrique maximale (%CVIM). On suggère que pour atteindre une activation suffisante permettant le renforcement musculaire, le pourcentage doit être de minimum entre 40%-60% CVIM. 50 
 
Revue de l’évidence scientifique de la mise en place du travail neuromusculaire de la hanche pour la correction du valgus de genou

Lors des exercices en décharge, la position du membre inférieur, et l’angulation ont une influence directe sur l’activation des muscles fessiers. Par exemple, pour l’exercice 2A, la rotation de hanche agira sur l’activation du moyen fessier (MF).64
Il fut démontré que lors de cet exercice, l’activation du MF était augmentée de 16% lors de la rotation interne de hanche plutôt qu’en position neutre.
Quant au grand fessier (GF), son activation sera influencée par le positionnement de la hanche dans le plan  sagittal.65 On retrouvera une activation améliorée de 12%–14% du GF à 30–60 degrés de flexion de hanche.
Revue de l’évidence scientifique de la mise en place du travail neuromusculaire de la hanche pour la correction du valgus de genou

La position du tronc lors des exercices en charge et lors des exercices fonctionnels semble influencer les sollicitations musculaires au niveau des hanches. Il semblerait que la flexion du tronc entrainerait une activation des muscles de la hanche pendant le saut et la course.67,68
Revue de l’évidence scientifique de la mise en place du travail neuromusculaire de la hanche pour la correction du valgus de genou

Seulement une étude a été réalisée sur l’influence de la position du tronc dans le plan sagittal et l’activation du grand fessier lors d’une fente avant. 69 Les auteurs en déduisent une activation améliorée de 6% du GF pendant une fente avant avec le tronc en flexion.
Données biomécaniques et force musculaire après protocole d’intervention sur la hanche
Revue de l’évidence scientifique de la mise en place du travail neuromusculaire de la hanche pour la correction du valgus de genou

Comme on peut voir dans le tableau ci-dessus, la mise en place de programmes a permit un gain de force musculaire de la hanche : 70–80
  • Rotation externe : 6-56%
  • ABD : 7-42%
  • Extension : 8%
Les gains de force se sont révélés significatifs surtouts lors des contractions isométriques, même si l’on sait que la force excentrique est sûrement la plus importante afin de contrôler le valgus dynamique du genou lors des sauts ou réceptions.
Mais le plus important encore, est que les gains de force ont entrainé des améliorations biomécaniques de la hanche et du genou lors de l’activité sportive (tableau 1). 



Les études effectuées démontrent que l’entrainement neuromusculaire de la hanche est un élément important à prendre en compte pour des pathologies de genou comme le LCA et le SFP. En ciblant l’activation musculaire de la hanche et le renforcement associé, on agira en prévention et pour la correction du valgus dynamique du membre inférieur, réduisant ainsi le risque de LCA et SFP. Les futures recherches devront étudier le lien entre les données biomécaniques des différents sports et la mise en place de protocoles neuromusculaires ciblés sur la hanche.
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