Chapter 17 The Hip. Overview The hip articulation is formed between the head of the femur and the acetabulum of the pelvic bone The hip articulation is.

Chapter 17Chapter 17

The HipThe Hip

OverviewOverview

The hip articulation is formed The hip articulation is formed between the head of the femur and between the head of the femur and the acetabulum of the pelvic bonethe acetabulum of the pelvic bone

Due to its location and function, the Due to its location and function, the hip joint transmits truly impressive hip joint transmits truly impressive loads, both tensile and compressive. loads, both tensile and compressive. In addition, the hip provides a wide In addition, the hip provides a wide range of lower limb movementrange of lower limb movement

AnatomyAnatomy

The os coxa (hip bone) initially The os coxa (hip bone) initially begins life as three individual begins life as three individual bones:bones:– IliumIlium– IschiumIschium– PubisPubis

AnatomyAnatomy

IliumIlium– The ilium is the largest of these The ilium is the largest of these

three bonesthree bones– It is composed of a large fan-like It is composed of a large fan-like

wing (ala), and an inferiorly wing (ala), and an inferiorly positioned bodypositioned body

– The body of the ilium forms the The body of the ilium forms the superior two-fifths of the superior two-fifths of the acetabulumacetabulum

AnatomyAnatomy

IschiumIschium– The ischium is composed of a body, The ischium is composed of a body,

which contributes to the which contributes to the acetabulum, and a ramusacetabulum, and a ramus

– The ischium forms the posterior two-The ischium forms the posterior two-fifths of the acetabulum. Together, fifths of the acetabulum. Together, the ischium and the ramus form the the ischium and the ramus form the ischial tuberosityischial tuberosity

AnatomyAnatomy

PubisPubis– The pubis is the smallest of the The pubis is the smallest of the

three bones, and consists of a body, three bones, and consists of a body, and inferior and superior rami. The and inferior and superior rami. The pubis forms the anterior one-fifth of pubis forms the anterior one-fifth of the acetabulumthe acetabulum

AnatomyAnatomy

AcetabulumAcetabulum– The ilium, ischium and pubis fuse The ilium, ischium and pubis fuse

together within the acetabulumtogether within the acetabulum– While the majority of acetabular While the majority of acetabular

development is determined by the development is determined by the age of 8, the depth of the age of 8, the depth of the acetabulum increases additionally at acetabulum increases additionally at puberty, due to the development of puberty, due to the development of three secondary centers of three secondary centers of ossificationossification

AnatomyAnatomy

AcetabulumAcetabulum– The acetabulum is angled laterally, The acetabulum is angled laterally,

inferiorly and anteriorlyinferiorly and anteriorly– The acetabular rim, or labrum, The acetabular rim, or labrum,

deepens the acetabulum thereby deepens the acetabulum thereby increasing the stability of the hip increasing the stability of the hip jointjoint

– The whole of the acetabulum is The whole of the acetabulum is covered with hyaline cartilage, covered with hyaline cartilage, except for the fovea capitisexcept for the fovea capitis

AnatomyAnatomy

FemurFemur– The femur is the strongest and the longest The femur is the strongest and the longest

bone in the bodybone in the body– The proximal end of the femur consists of a The proximal end of the femur consists of a

head, a neck, and a greater and lesser head, a neck, and a greater and lesser trochantertrochanter

– Approximately two thirds of the femoral Approximately two thirds of the femoral head is covered with a smooth layer head is covered with a smooth layer cartilage except for a depression, the fovea cartilage except for a depression, the fovea capitis, which serves as the attachment of capitis, which serves as the attachment of the ligamentum teresthe ligamentum teres

AnatomyAnatomy

FemurFemur– The trabecular bone in the femoral neck The trabecular bone in the femoral neck

and head is specially designed to and head is specially designed to withstand high loadswithstand high loads

– The design incorporates both primary and The design incorporates both primary and secondary compressive and tensile secondary compressive and tensile patterns. However, within this trabecular patterns. However, within this trabecular system, there is a point of weakness called system, there is a point of weakness called the Ward triangle, which is a common site the Ward triangle, which is a common site of osteoporotic fractureof osteoporotic fracture

AnatomyAnatomy

FemurFemur– The greater trochanter serves as the The greater trochanter serves as the

insertion site for several muscles that act on insertion site for several muscles that act on the hip jointthe hip joint

– The lesser trochanter, located on the The lesser trochanter, located on the posterior-medial junction of the neck and posterior-medial junction of the neck and shaft of the femur, is created from the pull shaft of the femur, is created from the pull of the iliopsoas muscleof the iliopsoas muscle

– The angle that the femoral neck makes with The angle that the femoral neck makes with the acetabulum is called the angle of the acetabulum is called the angle of anteversion/declination anteversion/declination

AnatomyAnatomy

Extra-articular ligamentsExtra-articular ligaments – Three extra-articular ligaments help Three extra-articular ligaments help

provide stability at the hip joint:provide stability at the hip joint: Iliofemoral ligament of Bertin/BigelowIliofemoral ligament of Bertin/Bigelow Pubofemoral ligamentPubofemoral ligament Ischiofemoral ligamentIschiofemoral ligament

AnatomyAnatomy

Iliofemoral ligamentIliofemoral ligament– Consists of two parts: an inferior Consists of two parts: an inferior

(medial) portion and a superior (medial) portion and a superior (lateral) portion(lateral) portion

– The iliofemoral ligament is the The iliofemoral ligament is the strongest ligament in the bodystrongest ligament in the body

– The ligament is oriented superior-The ligament is oriented superior-laterally and blends with the laterally and blends with the iliopsoas muscle iliopsoas muscle

AnatomyAnatomy

Pubofemoral ligamentPubofemoral ligament– Blends with the inferior band of the Blends with the inferior band of the

iliofemoral, and with the pectineus iliofemoral, and with the pectineus musclemuscle

– The orientation of the pubofemoral The orientation of the pubofemoral ligament is more inferior-medial ligament is more inferior-medial

AnatomyAnatomy

Ischiofemoral ligament Ischiofemoral ligament – Winds posteriorly around the femur, Winds posteriorly around the femur,

and attaches anteriorly, and attaches anteriorly, strengthening the capsule. This strengthening the capsule. This ligament is more commonly injured ligament is more commonly injured than the other hip ligamentsthan the other hip ligaments

AnatomyAnatomy

Extra-articular hip ligamentsExtra-articular hip ligaments– All tighten with hip extension. In All tighten with hip extension. In

addition:addition: IliofemoralIliofemoral

– Lateral band of iliofemoral ligament limits adductionLateral band of iliofemoral ligament limits adduction

– Medial band of iliofemoral ligament limits external Medial band of iliofemoral ligament limits external rotationrotation

PubofemoralPubofemoral– Limits abductionLimits abduction

IschiofemoralIschiofemoral– Limits internal rotation of the hipLimits internal rotation of the hip

AnatomyAnatomy

MusclesMuscles– IliopsoasIliopsoas

Comprised of iliacus and psoas majorComprised of iliacus and psoas major The most powerful of the hip flexorsThe most powerful of the hip flexors

– PectineusPectineus An adductor, flexor and internal rotator of the An adductor, flexor and internal rotator of the

hiphip

– Rectus femorisRectus femoris The rectus femoris combines movements of The rectus femoris combines movements of

flexion at the hip and extension at the kneeflexion at the hip and extension at the knee

AnatomyAnatomy

MusclesMuscles– Tensor fascia lataeTensor fascia latae (TFL) (TFL)

Assists in flexing abducting and Assists in flexing abducting and internally rotating the hipinternally rotating the hip

– SartoriusSartorius Responsible for flexion, abduction, and Responsible for flexion, abduction, and

external rotation of the hip, and some external rotation of the hip, and some degree of knee flexiondegree of knee flexion

AnatomyAnatomy

MusclesMuscles– Gluteus maximusGluteus maximus

Largest and most important hip extensor and Largest and most important hip extensor and external rotator of the hipexternal rotator of the hip

– Gluteus mediusGluteus medius The main abductor of the hipThe main abductor of the hip

– The anterior portion works to flex, abduct and The anterior portion works to flex, abduct and internally rotate the hipinternally rotate the hip

– The posterior portion extends and externally The posterior portion extends and externally rotates the hiprotates the hip

– Gluteus minimusGluteus minimus The major internal rotator of the femurThe major internal rotator of the femur

AnatomyAnatomy

MusclesMuscles– PiriformisPiriformis

An external rotator of the hip at less than 60° of An external rotator of the hip at less than 60° of hip flexionhip flexion

At 90° of hip flexion, the piriformis reverses its At 90° of hip flexion, the piriformis reverses its muscle action becoming an internal rotator and muscle action becoming an internal rotator and abductor of the hipabductor of the hip

– Small external rotatorsSmall external rotators Include obturator externus and internus, Include obturator externus and internus,

superior and inferior gemelli, and quadratus superior and inferior gemelli, and quadratus femorisfemoris

AnatomyAnatomy

MusclesMuscles– Hamstrings. Hamstrings. The hamstrings muscle The hamstrings muscle

group consists of the biceps femoris, group consists of the biceps femoris, the semimembranosus and the the semimembranosus and the semitendinosussemitendinosus The biceps femoris, extends the hip, The biceps femoris, extends the hip,

flexes the knee and externally rotates flexes the knee and externally rotates the tibiathe tibia

The semimembranosus and The semimembranosus and semitendinosus extend the hip, flex the semitendinosus extend the hip, flex the knee and internally rotate the tibiaknee and internally rotate the tibia

AnatomyAnatomy

MusclesMuscles– Hip adductorsHip adductors. The adductors of the . The adductors of the

hip include the adductor magnus, hip include the adductor magnus, longus, and brevis, and the gracilislongus, and brevis, and the gracilis

AnatomyAnatomy

BursaBursa– There are more than a dozen bursae in There are more than a dozen bursae in

this regionthis region The iliopsoas (iliopectineal) bursa is located The iliopsoas (iliopectineal) bursa is located

under the inguinal ligament, between the under the inguinal ligament, between the iliopsoas tendon and the iliopectineal iliopsoas tendon and the iliopectineal eminence of the superior pubic ramus eminence of the superior pubic ramus

The subtrochanteric bursa is located The subtrochanteric bursa is located between the greater trochanter and the between the greater trochanter and the TFL TFL

AnatomyAnatomy

Femoral triangleFemoral triangle– The femoral triangle is defined superiorly The femoral triangle is defined superiorly

by the inguinal ligament, medially by the by the inguinal ligament, medially by the adductor longus, and laterally by the adductor longus, and laterally by the sartoriussartorius

– The floor of the triangle is formed by The floor of the triangle is formed by portions of the iliopsoas on the lateral side, portions of the iliopsoas on the lateral side, and by the pectineus on the medial sideand by the pectineus on the medial side

– A number of neurovascular structures pass A number of neurovascular structures pass through this triangle. These include (from through this triangle. These include (from medial to lateral) the femoral vein, artery, medial to lateral) the femoral vein, artery, and nerveand nerve

AnatomyAnatomy

NeurologyNeurology– The posterior gluteal region receives cutaneous The posterior gluteal region receives cutaneous

innervation by way of the subcostal nerve, the innervation by way of the subcostal nerve, the iliohypogastric nerve, the dorsal rami of L1, L2, iliohypogastric nerve, the dorsal rami of L1, L2, L3 and the dorsal primary rami (cluneal nerves) L3 and the dorsal primary rami (cluneal nerves) of S1, S2, and S3of S1, S2, and S3

– The anterior region of the hip has its cutaneous The anterior region of the hip has its cutaneous supply divided around the inguinal ligament. supply divided around the inguinal ligament.

The area superior to the ligament is supplied by the The area superior to the ligament is supplied by the iliohypogastric nerveiliohypogastric nerve

The area inferior to the ligament is supplied by the The area inferior to the ligament is supplied by the subcostal nerve, the femoral branch of the subcostal nerve, the femoral branch of the genitofemoral nerve, and the iliolingual nerve genitofemoral nerve, and the iliolingual nerve

AnatomyAnatomy Vascular supplyVascular supply

– The external iliac artery becomes the femoral artery The external iliac artery becomes the femoral artery as it passes underneath the inguinal ligamentas it passes underneath the inguinal ligament

– The femoral artery forms two branchesThe femoral artery forms two branches The anterior portion of the femoral neck and the anterior The anterior portion of the femoral neck and the anterior

portion of the capsule of the hip joint are supplied by the portion of the capsule of the hip joint are supplied by the lateral femoral circumflex artery (LFCA). lateral femoral circumflex artery (LFCA).

The medial femoral circumflex artery (MFCA) perforates The medial femoral circumflex artery (MFCA) perforates and supplies the posterior hip joint capsule and the and supplies the posterior hip joint capsule and the synoviumsynovium

– The deep branch of the MFCA gives rise to two to four The deep branch of the MFCA gives rise to two to four superior retinacular vessels and, occasionally, to inferior superior retinacular vessels and, occasionally, to inferior retinacular vesselsretinacular vessels

– Most of the femoral head is supplied by the lateral epiphyseal Most of the femoral head is supplied by the lateral epiphyseal artery, a terminal branch of the MFCAartery, a terminal branch of the MFCA

BiomechanicsBiomechanics

The hip joint is classified as an unmodified The hip joint is classified as an unmodified ovoid, (ball and socket) jointovoid, (ball and socket) joint

This arrangement permits motion in three This arrangement permits motion in three planes: sagittal (flexion and extension planes: sagittal (flexion and extension around a transverse axis), frontal around a transverse axis), frontal (abduction and adduction around an (abduction and adduction around an anterior-posterior axis), and transverse anterior-posterior axis), and transverse (internal and external rotation around a (internal and external rotation around a vertical axis)vertical axis)

All three of these axes pass through the All three of these axes pass through the center of the femoral headcenter of the femoral head

BiomechanicsBiomechanics

The angle between the femoral The angle between the femoral shaft and the neck is called the shaft and the neck is called the collum/inclination anglecollum/inclination angle– This angle is approximately 125-This angle is approximately 125-

130° but can vary with body types130° but can vary with body types– In a tall person the collum In a tall person the collum angleangle is is

larger (valga). The opposite is true larger (valga). The opposite is true with a shorter individual (vara).with a shorter individual (vara).

BiomechanicsBiomechanics

Anteversion is defined as the anterior Anteversion is defined as the anterior position of the axis through the position of the axis through the femoral condylesfemoral condyles

Retroversion is defined as a femoral Retroversion is defined as a femoral neck axis that is parallel or posterior to neck axis that is parallel or posterior to the condylar axisthe condylar axis

The normal range for femoral The normal range for femoral alignment in the transverse plane in alignment in the transverse plane in adults is 12 to 15° of anteversionadults is 12 to 15° of anteversion

ExaminationExamination

HistoryHistory– The hip is a common area of local and The hip is a common area of local and

referred painreferred pain– A pain diagram and a medical history A pain diagram and a medical history

questionnaire should be completed by the questionnaire should be completed by the patient. The history should determine the patient. The history should determine the patient’s chief complaint and the patient’s chief complaint and the mechanism of injury, if anymechanism of injury, if any

– The patient should be encouraged to The patient should be encouraged to describe the type and location of the pain describe the type and location of the pain

ExaminationExamination

Systems ReviewSystems Review– Pain may be referred to the hip region Pain may be referred to the hip region

from a number of sourfrom a number of sourcesces– Weight loss, fatigue, fever, and loss of Weight loss, fatigue, fever, and loss of

appetite should be sought out because appetite should be sought out because these are clues to a systemic illnessthese are clues to a systemic illness

– Other examples include an insidious onset Other examples include an insidious onset of symptoms, evidence of radiculopathy, of symptoms, evidence of radiculopathy, bowel and/or bladder changes, night pain bowel and/or bladder changes, night pain unrelated to movement, and severe pain unrelated to movement, and severe pain

ExaminationExamination

Tests and MeasuresTests and Measures– ObservationObservation

The patient is observed from the front, The patient is observed from the front, back and sides for general alignment of back and sides for general alignment of the hip, pelvis, spine and lower the hip, pelvis, spine and lower extremitiesextremities

ExaminationExamination

Active, Passive, and Resistive TestsActive, Passive, and Resistive Tests– During the examination of the range of motion, During the examination of the range of motion,

the clinician should note which portions of the the clinician should note which portions of the range of motion are pain-free, and which range of motion are pain-free, and which portion causes the patient to feel painportion causes the patient to feel pain

– At the end of available active range of motion At the end of available active range of motion passive overpressure is applied to determine passive overpressure is applied to determine the end-feelthe end-feel

– Resisted testing is performed to provide the Resisted testing is performed to provide the clinician with information about the integrity of clinician with information about the integrity of the neuromuscular unit, and to highlight the the neuromuscular unit, and to highlight the presence of muscle strains presence of muscle strains

ExaminationExamination

Special TestsSpecial Tests– Special tests are merely confirmatory Special tests are merely confirmatory

tests and should not be used alone to tests and should not be used alone to form a diagnosisform a diagnosis

– The results from these tests are used The results from these tests are used in conjunction with the other clinical in conjunction with the other clinical findings to help guide the clinicianfindings to help guide the clinician

– To assure accuracy with these tests, To assure accuracy with these tests, both sides should be tested for both sides should be tested for comparisoncomparison

InterventionIntervention

Acute phaseAcute phase– During the acute phase, the During the acute phase, the

principles of PRICEMEM (protection, principles of PRICEMEM (protection, rest, ice, compression, elevation, rest, ice, compression, elevation, manual therapy, early motion and manual therapy, early motion and medication) are applied as medication) are applied as appropriateappropriate

InterventionIntervention

The goals of the acute phase include:The goals of the acute phase include:– Protection of the injury siteProtection of the injury site– Restoration of pain-free range of motion in the Restoration of pain-free range of motion in the

entire kinetic chainentire kinetic chain– Improve patient comfort by decreasing pain Improve patient comfort by decreasing pain

and inflammationand inflammation– Retard muscle atrophyRetard muscle atrophy– Minimize detrimental effects of immobilization Minimize detrimental effects of immobilization

and activity restrictionand activity restriction– Maintain general fitnessMaintain general fitness– Patient to be independent with home exercise Patient to be independent with home exercise

programprogram

InterventionIntervention

The goals of the functional phase The goals of the functional phase include:include:– Attain full range of pain free motionAttain full range of pain free motion– Restore normal joint kinematicsRestore normal joint kinematics– Improve muscle strength to within Improve muscle strength to within

normal limitsnormal limits– Improve neuromuscular controlImprove neuromuscular control– Restore normal muscle force couple Restore normal muscle force couple

relationshipsrelationships