Evaluation of the Hip & Thigh Dr. Sue Shapiro Associate Professor Barry University Department of Sports and Exercise Science.

Evaluation of the Hip & Thigh

Dr. Sue Shapiro Associate Professor Barry University Department of

Sports and Exercise Science

Hip & Thigh

Anatomy The hip is a multiaxial ball-

and–socket joint that has maximum stability due to the deep insertion of the head of the femur into the acetabulum

The hip forms the critical link between the lower extremity and the trunk. Critical for ambulation, it has been described ad the “pivot upon which the body moves”.

Osseous Structures

Hip Joint

Articulations between the acetabulum of pelvis and head of femur Ball and Socket joint Femoral head is 2/3 of a

sphere Inside the acetabulum is a

labrum Synovial joint surround by

strong lig. -Capsular lig. Heavy musculature

Hip Joint

Inside the acetabalum of the glenoid labrum made of fibrocartilage and holds the head of femur in tight.

Acetabulum made up of the 3 bones of the pelvis together - ilium forms superior portion, inferior is the ischium and internal medially is the pubis

Synovial joint surrounded by strong ligaments. The whole attachment of the synovial lining is referred to as capsular ligament

Heavy musculature causes strong stability

Pelvic Girdle

4 fused bones make up the girdle2 innominate bones, sacrum, and coccyx

Anterior articulation at the pubis symphysis Posterior articulation at the sacrum and

sacroiliac jointEach innominate bone made up of 3 fused

bones - ilium, ischium, pubis Ilium forms the major portion of the iliac crest

ASIS - Anterior superior iliac crest PSIS - Posterior superior iliac crest

Osseous Structures

Pelvic Girdle

Acetabulum Has a labrum and

fibrocartilage that holds the femoral head in tight

Synovial Joint The whole attachment of

the synovial lining is referred to as capsular lig.

Bursas Iliopsoas bursa Deep Trochanteric bursa

Active Motions of the Hip

Flexion – 110 to 122 degrees

End Feel – Soft Tissue Approximation

Major muscle movers: Iliopsoas Rectus Femoris Sartorius Pectineus Adductor longus and

brevis Tensor Fasciae Latae

Hip Flexors

Active Motions of the Hip

Extension: 17-25 degree End Feel: Tissue Stretch Major Muscle Movers:

Gluteus Maximus

Gluteus Medius

Hamstrings

Piriformis

Adductor Magnus (posterior)

Hip Extensors

Active Motions of the Hip

Abduction: 35-40 degrees

End Feel: Spring/Tissue Stretch

Major Muscle Movers: Gluteus Medius Tensor Fasciae Latae Gluteus Minimus Piriformis Gluteus Miminus Piriformis Iliopsoas

Active Motions of the Hip

Adduction: 30 degrees End Feel: Soft Tissue

Approximation Major Muscle Movers:

Adductor longus & brevis

Adductor magnus

Pectineus

Gracilis

Oburatorius externus

Active Motions of the Hip

Internal Rotation: 30-35 degrees

End Feel: Tissue Stretch/ Springy

Major Muscle Movers: Tensor Fasciae latae Gluteus Medius

(Anterior) Adductor Longus &

Brevis Gluteus mininus

Active Motions of Hip Joint

External Rotation: 35- 40 degrees

End Feel: Tissue Stretch/ Spring Major Muscle Movers: Piriformis Gemellus Obturatorius Internus & Externus Quadratus Femoris Gluteus Maximus Sartoruis Posterior Gluteus Medius

Ligaments of Hip

Capsular Ligament Intra capsular - fibers

attached to rim of acetabulum and femur

Extra-Capsular Lig. Iliofemoral Lig. or Y Lig. of

Bigelow - limits hip hypertension,

ER, & Adduction Pubofemoral Lig.

Prevents abduction and excessive ER

Connective Tissue

Ligaments of Hip

Extra-Capsular Lig. Ischiofemoral Lig.

Prevents IR and adduction

Ligamentum Teres Serves as vascular

conductent for the medial and lateral circumflex arteries

May cause a disruption of these arteries

Hip Joint Motions Restricted by Ligaments

Motion Ligament that Restricts

Flexion Inferior portion of ischiofemoral

Extension Medial portion of iliofemoral

Abduction Pubofemoral

Adduction Superior ischiofemoral

Internal Rotation Superior portion of ischiofemoral

External Rotation Lateral portion of iliofemoral

Femoral Triangle

Contains: Inguinal ligament at

upper border Sartorius at lateral

border Adductor longus at

medial border Inside the triangle is the

Femoral artery Femoral vein Femoral nerve

Motions of Hip

Flexion - 135 Extension - 20-

30 Abduction -45 Adduction - 20-

30 IR - 30-40 ER - 40-50

Closed Packed Extension, IR, &

Abduction Loose Packed

30 flexion, 30 abduction, & slight ER

Capsular pattern Flexion, abduction, & IR

End Feels Tissue stretch except for

flexion and adduction which are tissue approximation

Ossesous Deformities

Four common osseous deformities of the proximal femur are: Coxa Vara Coxa Valga Femoral Anteversion Femoral Retroversion

Can occur as a primary problem or a sequela problem Can occur unilateral or bilateral Effects of osseous deformities are they can lead to

alteration in wt. Bearing in the lower extremity and spine

Hip Joint

In the transverse plane the relationship between the femoral and femoral shaft is the ANGLE OF TORSIONNormal angle of 15 degrees and this is

measured on x-ray but can also be eyed balled

Angle of Torsion A decrease angle

between the femoral condyle and femoral head is termed Retroversion (Duck footed or toeing out)

An increased angle is called Anterversion (Pigeon Toed or Toeing In)

Angles below 15 represent retroversion and angles above 15 represents anteversion

Angle of Torsion

A condition in which the angle of torsion between the femoral neck and the femoral shaft on the transverse plane is greater than 15 degrees in adults

Angle of Torsion- Anteversion Signs and Symptoms

The ipsilateral lower limb appears to be excessively internally rotated when the femoral head is in the neutral position within the acetabulum

Typically this condition is bilateral and has been implicated in the etiology of numerous lower extremity disorder

Subtalar pronation & lateral patella subluxation

Femoral Anteversion

Clinical findings Patients complain of

pain in a variety of sites in the lower extremity of low back

Toe-in gait with concurrent malalignment of the lower limb

Usually a greater ROM of hip IR than ER

Craig Test is positive

Femoral Anteversion Treatment

Treatment

PT usually does not influence the degree of deformity Foot orthotics can greatly improve the lead-bearing dynamics

of the lower extremity General conditioning and flexibility exercises for the lower

extremity may be useful in reducing the effect of lower extremity malalignment

Athletes who are engaged in running or aerobics may be at increased risk to develop overuse syndromes in the lower extremities

Encourage this type of athletes to cross train by cycling or swimming

Femoral Retroversion

There is a decrease in the angle between femoral head and shaft on the transverse plane to the degree that an obvious outward rotation of the lower extremities is observable

Femoral Retroversion

Results Substantial malaligment and numerous

compensation in the lower extremity

Clinical findings Externally rotates appearance of the lower

extremity Greater ROM of hip ER than IR Craig’s Test is positive for inward pointing of the

tibias in the prone subject Subtalar supination with toeing out

Femoral Retroversion Treatment

TreatmentSimilar to femoral anteversion

Foot orthoticsGeneral conditioning and flexibility

exercises for the lower extremityMinimize repetitive lower extremity impact

loading

Craig’s Test

If athlete has visible internal rotation of one or both lower limbs, excessive femoral anteversion may be present: Lie the athlete prone with knee flexed to 90 degrees. The examiner rotates the hip while palpating the greater trochanter. When the greater trochanter is felt to be in a midposition, such as parallel to the floor, the examiner then views the angle of the tibia relative to the long axis of the body. In a normal adult hip it should be roughly perpendicular to the floor. Excessive anteversion is present if the tibia is pointing outward, away from the midline of the athletes body.

Craig’s Test

Angle of Inclination at Hip

Hip Joint Angle of Inclination

Femoral head is angled at 125 degree in frontal plane This relationship of

femoral head is known as the ANGLE OF INCLINATION and changes through a person’s development.

Slightly higher in women.

Increase in angle is Coxa Valga

Decrease in angle is Coxa Vara

Angle of inclination

An increase in the angle is referred to as coxa valga

A decrease in the angle is referred to as coxa vara

In either case the mechanical advantage of the gluteus medius is reduced by alternating its line of pull on the femur.

X-ray is necessary to determine angle accurately

Coxa Vara

Occurs when the angle between the femoral shaft and the femoral neck in the frontal plane (angle of inclination) is less than 125 degrees

Coxa Vara

Results in Ipsilateral limb

shortening which alters the biomechanics of the hip by shifting the wt. Bearing superiorly and laterally to the femoral head

The moment arm acting or the hip abductors is reduced resulting in weakness of the hip abductors

Anterior Pelvic Tilt

Coxa Vara

Developmental and acquired conditions resulting from Coxa VaraIntertrochanteric fractureSlipped Capital Femoral EpiphysisLe-Calve-Perthes DiseaseCongential Hip Dislocations

Coxa Vara

Clinical findings A leg length difference Gait abnormality associated with a Trendenleburg

Gait Hip abduction is restricted by the superior portion of

the femoral neck or greater trochanter (Impingement)

Hip abductor muscle contractures occur Pronated subtalar joint Medial rotation of leg

Treatment for Coxa Vara

TreatmentUse of shoe lift to equalize leg lengths

may be very helpfulStrengthening hip abductorsAvoid high impact sports

Coxa Valga

The angle between the femoral shaft and the femoral neck on the frontal plane is greater than approximately 125 degrees at skeletal maturation

Caused by Ipsilateral limb

lengthening resulting in a characteristics adducted posture of the lower limb. On wt. Bearing, the forces are shunted closer to the center of the head of the femur, which can cause hip dysplasia

Coxa Valga

Clinical findings of unilateral coxa valga includeLeg length difference, with the involved side

being longerPosterior pelvic tilt

With either bilateral or unilateral there is a gait abnormality associated with a + Trendelenburg sign

Lateral rotation of leg

Coxa Valga

TreatmentSimilar to Coxa Vara

Shoe lift to equalize leg lengthStrengthen hip abductorsMinimize prolonged standing and avoid

high impact sports

Assessment of Abnormal Angle of Inclination

Long Sit Test – Looks for Leg Length Discrepancy

Results: Leg is shorter than

Anterior Pelvic Tilt Coxa Vara Leg is Longer than

Posterior Pelvic Tilt Coxa Valga

Nerves of the Hip

Lumbar Plexus- T12-L5 Femoral Nerve- L2-L4

Innervating anterior thigh

Obturator Nerve- L2-L4

Innervating the hip adductor

Sacral Plexus- L4-S4 Sciatic nerve- L4,L5,

S1-S3- innervates posterior leg

3 segments: Tibial nerve; common peroneal; slip of tibial nerve that innervates hamstrings

Myotomes & Dermatomes

Myotomes L1-L2

Hip Flexion L3 – Knee

Extension L4

Dorsiflexion L5 Hallicus

Extension S1 Hip extension

& Plantar Flexion

S2 Knee Flexion

Blood Supply

The external iliac arteries become the femoral arteries at the thigh.

The femoral artery divides into deep femoral which serves the posterior and lateral thigh

Common Injuries

Contusions Resulted from a direct blow ; most common site is the

anterior lateral thigh

Myositis Ossificans Abnormal ossification involving bone deposition

within tissue due to severe quadriceps contusion from direct blow or repetitive blows to anterior and lateral thigh

Hip pointer Contusion to an unprotected iliac crest that can be

traumatic in nature to fracture.

Myositis ossificans

Abnormal ossification involving bone deposition with in muscle tissue

Common in quadriceps contusion

Caused by single blow or repeated blows to area

Anterior and Lateral thigh are common sites

Evidence of calcification on a radiograph is visible after 3-4 weeks

Hip Pointer

Contusion to iliac crest Due to abdominal and trunk

muscle attachment any movement is painful

Signs: discoloration, spasm, loss of function

In severe cases crutches will be necessary

Can cause fx. of iliac crest: avulsion of sartorius muscle

Common Injuries Piriformis Syndrome

Spasms or hypertrophy of the piriformis places pressure on the sciatic nerve, mimicking the signs & symptoms of lumbar nerve root compression or sciatica in the buttock or posterior leg

Common Injuries

Bursitis Trochanteric Bursitis

Occurs at the greater trochanter

Iliopsoas Bursitis Occurs at the lesser

trochanter

Ischial Bursitis Pain usually do to a

direct blow or fall on the ischial tuberosity

Bursitis

Common Injuries

Chronic Bursitis Can lead to snapping hip syndrome

Athletes that ER the hip repetitively. This motion causes the iliotibial tract snaps over the greater trochanter or the snapping in the medial groin

Traumatic hip dislocations Due to violent twisting actions or car accidents

where knees are jammed into the dash board.

Sprains Occur to Acetabulofemural and Sacroiliac ligs.

Surrounding the pelvic region

Common Injuries

StrainsHamstrings Strain

The most frequently strained muscleCould become a chronic problem for the athlete

Adductor StrainCommon in sports that require quick changes of

direction & explosive propulsion & accelerationQuadriceps Strains

Common in Sartoris, ilipsoas, and rectus femoris

*** The key is early detection ***

Common Injuries

Vascular Disorders Legg-Calve-Perthes

Disease Avascular necrosis

of the proximal femoral epiphysis.

Caused by diminished blood supply to the capital region of the femur

Common Injuries

Vascular DisordersThrombophlebitis

An acute inflammation of the vein phlebothrombosis is a clotting in a vein without overt inflammatory signs or symptoms.

Two types Superficial Thrombphlebitis Deep Thrombophlebitis

Common Injuries

Hip fracturesAvulsion Fractures

occur during explosive muscular contractions against fixed resistance or during rapid acceleration

Common sites ASIS, AIIS, Ischial tuberosity, Lessor Trochanter

Femoral Fractures’Unusual but very serious injuryOpen or closed fracture with significant bleeding

at fracture site

Common Injuries

Hip Fractures Ephiphyseal Fractures

Slipped Capital Femoral Epiphysis

A congenital disorder that develops over time

Usually seem in adolescent boys age 8-15 occurring across the capital femoral epiphysis

Common Injuries

Hip Fractures Stress Fractures

Usually do to excessive jogging or aerobic dance activity with increase frequency of activity over short period of time

Common sites Inferior Pubis Ramis, Femoral Neck and proximal 1/3 of the

femur Osteitis Pubis

A stresss Fx of the symphysis pubis from repeated overload of the adductor muscle or from repetitive stress activities: long distance running

Pain is localized over the symphysis and increase with activity

Common Injuries

Hip FracturesPelvic Fractures

Displaced and nondisplacedUsually occur 2 crushing injury producing severe

pain, total loss of function and severe loss of blood leading to hypovolemic shock

Complications Shock Injuries to internal organs and genitourinary Hemorrhage occurs within the pelvic cavity & is not

visible