Anatomy and Physical Exam Yibing Li 01/07/2004 MSK-HIP (Part I)

Anatomy and Physical Exam

Yibing Li

01/07/2004

MSK-HIPMSK-HIP(Part I)(Part I)

Hip JointHip Joint

The hip joint is a synovial ball and socket joint, formed by the reception of the head of femur into the cavity of acetabulum. It is the largest weight bearing joint in the body and is surrounded by strong ligaments and muscles.

Due to high mobility, hip joint pathology can be manifested during weight bearing, ambulation or motion.

Hip BonesHip Bones

The ilium, ischium, pubis and femur are the main bones at the hip joints. The ilium, ischium and pubis are fused together to form the pelvis girdle (L+R).

Ligaments of the Hip JointsLigaments of the Hip Joints

Acetabular labrum forms a complete ring around the head of the femur. Its function is to hold the femoral head in place.

The ligament of the head of femur attaches the head of femur to the acetabulum.

Ligaments (cont.)Ligaments (cont.)

There are 3 ligaments that hold the head of femur to the pelvis:

1. Iliofemoral lig.: the strongest ligament; Its function is to prevent hyperextension, abduction and lateral rotation.

2. Pubofemoral lig. : limits abduction

3. Ischiofemoral lig. : limits medial rotation.

The Capsule of Hip JointThe Capsule of Hip Joint

The articular fibrous capsule extends from the acetabular rim to the intertrochanteric crest forming a sleeve that encloses the hip joint and most of the femoral neck.

Hip joint injectionHip joint injection

Muscles of the hip and thighMuscles of the hip and thighMuscles of the Hip & Thigh

Inferior GemelliGluteal Region (Hip-Joint Stability)Deep Ischial Tuberosity Greater Trochanter Femur: Lateral Rotation

Directly below the obturator internus

Obturator ExternusGluteal Region (Hip-Joint Stability)Deep

Obturator Membrane (external surface) Greater Trochanter Femur: Lateral Rotation

Obturator InternusGluteal Region (Hip-Joint Stability)Deep

Obturator Membrane (internal surface) Greater Trochanter Femur: Lateral Rotation

Goes through Lesser Sciatic Foramen

PiriformisGluteal Region (Hip-Joint Stability)Deep Anterior aspect of the Sacrum

Greater Trochanter (Superior aspect)

Femur: Lateral Rotation | Femur: Abduction

Quadratus FemorisGluteal Region (Hip-Joint Stability)Deep Ischial Tuberosity

Intertrochanteric Crest (Quadrate Tubercle) Femur: Lateral Rotation

The big muscle in the gluteal group

Superior GemelliGluteal Region (Hip-Joint Stability)Deep Ischial Spine Greater Trochanter Femur: Lateral Rotation

Directly above the obturator internus

Gluteus MaximusGluteal Region (Hip-Joint Stability)Superficial Ilium, Sacrum, and Coccyx

Gluteal Tuberosity of Femur and Iliotibial Tract Hip: Extension

Gluteus MediusGluteal Region (Hip-Joint Stability)Superficial

Outer surface of il eum, between top two gluteal lines

Greater Trochanter (Lateral)

Femur: Abduction and medial rotation

Gluteus MinimusGluteal Region (Hip-Joint Stability)Superficial

Outer surface of Ili um, between bottom two gluteal lines

Greater Trochanter (anterior)

Femur: Abduction and medial rotation

Iliopsoas Thigh, Anterior Lumbar spine and Iliac crest Lesser Trochanter of Femur Femur: Flexion at hip Floor of the Femoral Triangle

Sartorius Thigh, Anterior Anterior Superior Iliac Spine Posteromedial aspect of proximal tibia

Hip: Flexion; Knee: Extension | Femur: Lateral Rotation

Inferolateral base of Femoral Triangle

Tensor Fasciae Latae Thigh, Anterior Proximal femur Iliotibial Tract Hip: Flexion; Femur: Medial Rotation

Increases tension of fascia lata and iliotibial tract, esp. when standing upright; holds knee in place

Rectus Femoris Thigh, AnteriorQuadriceps Femoralis Anterior Inferior Iliac Spine

Quadriceps Ten don on the superior Patella Knee: Extension

Acts on the hip joint; Crucial role in knee stability

Vastus Intermedius Thigh, AnteriorQuadriceps Femoralis Proximal femur

Quadriceps Ten don on the superior Patella Knee: Extension Crucial role in knee stability

Vastus Lateralis Thigh, AnteriorQuadriceps Femoralis Proximal femur

Quadriceps Ten don on the superior Patella Knee: Extension Crucial role in knee stability

Vastus Medialis Thigh, AnteriorQuadriceps Femoralis Proximal femur

Quadriceps Ten don on the superior Patella Knee: Extension Crucial role in knee stability

Adductor Brevis Thigh, MedialAdductor Group Pubic Bone Thigh: Adduction

Adductor Longus Thigh, MedialAdductor Group Pubic Bone Thigh: Adduction Lateral floor of Femoral Triangle

Adductor Magnus Thigh, MedialAdductor Group Pubic Bone Thigh: Adduction | Thigh: Extension Adductor "Hybrid" Muscle

Gracilis Thigh, MedialAdductor Group Pubic Bone NONE | Thigh: Adduction A good spare part; adduction can occur without it.

Pectineus Thigh, MedialAdductor Group Pubic Bone Thigh: Adduction | Hip: Flexion

Adductor "Hybrid" Muscle; Floor of the Femoral Triangle

Biceps Femoris Thigh, PosteriorHamstring Muscles

Long Head: Ischial Tuberosity | Short Head: Femur (Linea Aspera) Head of the Fib ula

Hip: Extension; Knee: Flexion

Long head crosses both hip and knee joints

Semimembra nosus Thigh, PosteriorHamstring Muscles Ischial Tuberosity

Medial condyle of proximal tibia

Hip: Extension; Knee: Flexion

Cross both hip and knee joints

Semitendinos us Thigh, PosteriorHamstring Muscles Ischial Tuberosity

Medial condyle of proximal tibia

Hip: Extension; Knee: Flexion

Cross both hip and knee joints; medial to semimembranosus

Movements at the HipMovements at the Hip

1. Flexion / Extension2. Adduction / Abduction3. Lateral (external)Rotation / Medial

(internal) Rotation

Hip FlexorsHip Flexors

Iliopsoas (prime hip flexor)Pectineus Sartorius Rectus femoris Pectineus Tensor fsaciae latae Adductor brevis Adductor longus Adductor magnus (anterior head) Rectus femoris

P90-iliopsoasP90-iliopsoas

P96-pectineusP96-pectineus

Hip ExtensorsHip Extensors

Gluteus maximusBiceps femoris (long head)SemitendinosusSemimembranosus Adductor magnus (postrior head)

P86P86

P100-101 HamstringP100-101 Hamstring

Hip AbductorsHip Abductors

Gluteus mediusGluteus minimus Tensor fasciae latae Sartorius

p87p87

p88p88

Hip AdductorsHip Adductors

Adductor brevisAdductor longusAdductor magnusGracilis Pectineus

p97p97

p98p98

p99p99

Internal Rotators of the HipInternal Rotators of the Hip

Gluteus mediusGluteus minimusTensor fasciae latae Adductor magnus (anterior head)

p91p91

p89p89

Physical Exam of the Hip and Physical Exam of the Hip and PelvisPelvis

Inspection & PalpationROMNeurologic exam Special tests

InspectionInspection

Observe gaitCheck hip and pelvis area for skin

abrasions,abnormal swelling, etc.Check if the anterior superior iliac spines

are in the same horizontal plane or tilted pelvis

Observe the two discernible dimples to check PSIS for pelvic obliquity

GaitGait

Antalgic gait: prolonged double support period, decreased stance phase and step length on the unaffected side to reduce pain and avoid weight bearing on the affected side.

Trendelenburg gait (hip abductor weakness) ---uncompensated gait: contralateral pelvic drop. ---compensated: lateral lurch over the affected side.(Tx with cane)

Extensor lurch gait(gluteus maximus weakness): secondary to inferior gluteal N.injury or subtrochanteric hip fx. Unable to decelerate the hip flexion moment at heel strike due to hip extensor weakness. To compensate, pt lean upper body backward to keep the center of gravity. Tx with two crutches or canes.

PalpationPalpation

----Anterior Superior Iliac Spines (ASIS): check pelvic obliquity

----Iliac crest ( gluteus and sartorius muscles originate just below it)

----Greater Trochanter (uneven in congenital hip dislocation or poor-healed hip fx)

----PSIS (lie directly underneath the visible dimples just above the buttocks, check for pelvic obliquity)

----Trochanteric Bursa (have pt lie on the side with hip flexion; If it is inflamed, the area feels boggy and tender to palpation)

ROMROM

Flexion: 120 degree Extension: 30 degree Abduction: 45-50

degree Adduction: 0-30

degree

External rotation: 35 degree

Internal rotation: 45 degree

(OA limits internal rotation first)

Neurologic ExamNeurologic Exam

Muscle testing: test muscle strength in functional groups.

Primary flexor: Iliopsoas (femoral N. L1,2,3) Primary extensors: Gluteus Maximus (inferior gluteus N. S1) Primary adductors: Adductor longus (obturator N. L2,3,4) Primary Abductor: Gluteus medius( superior gluteal N., L5)

Sensation testing: for example, dermatomes ( T10-L3)

Special Hip TestsSpecial Hip Tests

1. Patrick (Fabere) test 2. Thomas test3. Ober test4. Trendelenburg test5. Leg length discrepancy

Patrick testPatrick test

This test is to assess Flexion, Abduction, External Rotation

Perform with pt supine, passively flex and externally rotate and abduct the hip.

Ipsilateral inguinal pain indicates pathology in the hip joint or the surrounding muscles.

Contralateral pain occurs in the dysfunctional SI joint.

Thomas TestThomas Test

To assess hip flexion contractures Perform the test with the pt supine, flex one hip

fully reducing the lumbar spine lordosis, stabilizing the spine and pelvis, extend the opposite hip.A flexion contracture is present if the hip cannot fully extend. The degree of flexion contracture can be done by estimating the angle between the table and pt’s leg.

Ober testOber test

To test for contraction of the fascia lata.Have pt lie on the side with involved leg

uppermost. Abduct the leg as far as possible and flex the knee to 90 degree. If the thigh remains abducted, there may be a contracture of the tensor fascia lata or ITB.

Trendelenburg testTrendelenburg test

Test for gluteus medius weakness Perform with the pt standing erect, one foot is raised

off the floor, strength of the gluteus medius of the supported side is assessed. A positive test occurs when the pelvis on the unsupported side descends or remains level.

Conditions with gluteus medius weakness:--- radiculopathies,poliomyelitis,meningomyelocele, fx of the greater trochanter, slipped capital femoral epiphysis, congenital hip dislocation.

Leg Length Discrepancy (LLD)Leg Length Discrepancy (LLD)

Leg Length Discrepancy (LLD) True LLD: measure from ASIS to the medial malleoli. The

shortening may be due to fx crossing the epiphyseal plate in children or poliomyelitis.

To determine the discrepancy from femur or the tibia: (with pt supine, flex the knees to 90 and place feet flat on the table) If the knee is higher than the other, that tibial is longer ; if one knee projects further anteriorly, then that femur is longer.

Leg length discrepancyLeg length discrepancy

Apparent LLD: (determine no TLLD first)with pt supine, measure from umbilicus to the medial malleoli. Apparent discrepancy may be caused by pelvic obliquities or flexion or adduction deformity of the hip.