Hip Anatomy

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Hip Anatomy

• Anatomy
• The pelvis is formed by two innominate bones,
  each one is comprised of the ilium, ischium and
  the pubis. The acetabulum is the depression or
  fossa where the femoral head articulates. It is
  positioned in a downward and outwardly direction.
  It is surrounded by a labrum much like the gleno
  humeral joint of the shoulder. The labrum is
  thicker and more substantial superiorly than
  inferiorly which corroborates with the weight
  bearing nature of the joint.
• Anterior Superior Iliac Spine (ASIS)
• Iliac Crest
• Posterior Superior Iliac Spine (PSIS)
• Ischial Tuberosity
• SI Joint(s)

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The posterior portion of the pelvic girdle is
formed by the articulation with the sacrum. The
Sacro-Iliac joint (SI) is a bilateral joint that
fixates the spinal column to the pelvis. The
articular surfaces of the SI joint are very
irregular and when correctly matched with their
articulating facets, makes a very stable joint.
This is the largest and most stable of the
joints in the body. It is a multi axial ball and
socket type joint. It has a very strong capsule
and muscular control.
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The hip joint is the largest and most stable of
the joints in the body. It is a multi axial
ball and socket type joint. It has a very
strong capsule and muscular control.
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• The acetabulum is formed by the fusion of the
  ilium, ischium, pubis and deepened by a
  acetabular labrum much like a shoulder.
• The positioning of the acetabulum is outward,
  forward and downward. It allows approximately 30
  of freedom of movement in multi axial
  directions.

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• The femoral head is globular and is approximately
  one half (2) hemispherical in nature. The
  articular surface is covered with a thick
  articular cartilage except at the center where
  the ligamentum teres connects. The femur connects
  to the head via the femoral neck. The normal
  angle of inclination is approximately 1350. This
  angle is somewhat decreased in women and thus
  leads to the overall Q angle changes. The angle
  of torsion is the forward angle relationship of
  the head and neck. The angle of
  anteversion(torsion) is normally in the 12-1500
  range.

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• Distal to the femoral neck on the shaft of the
  femur is the lateral projecting greater
  trochanter and the medial projecting lesser
  trochanter.
• These sites serve as primary attachment points
  for the pelvic and hip musculature.
• The pelvic bones articulate anteriorly at a
  fairly immobile joint, the pubis symphysis. This
  is formed by the fibrocartilaginous interpubic
  disk. The movements that occur at this joint are
  small, but very necessary. They include
  spreading, compression and rotation. The
  posterior articulations occur at the SI joint.

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• SI Joint
• This joint is part synovial and part syndesmosis.
  The syndesmosis is a fibrous joint where the
  tissues form the ligament or membrane that
  provides the stability. No muscles cross the SI
  joint. The size, stability and associated
  roughness of the joint vary from patient to
  patient.
• This joint becomes progressively inflexible as
  the patient ages. The movements that occur in the
  SI joint are minute when compared to other joint
  motions. However, they are often very painful if
  moved to extremes due to the roughness of the
  joint surfaces.

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• Contra nutation - this movement occurs at the SI
  joint. It is characterized by an anterior
  rotation of the innominate on the affected side
  and posterior rotation of the sacrum on the ilium
  on the opposite side. The ASIS on the affected
  side will be lower, while the PSIS on the
  contralateral side will be higher. (position of
  lordosis)
• Nutation - is the opposite of contra nutation and
  is characterized by a backwards rotation of the
  innominate. The result will be a functional short
  leg on the affected side. (position of pelvic
  tilt)

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Movements that stress the SI Joint

• Forward flexion of the spine (40-600)
• Extension of the spine (20-350)
• Rotation of the spine (30-1800)
• Side flexion of the spine (15-2000)
• Flexion of the hip (100-1200)

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• Abduction of the hip (30-500)
• Adduction of the hip (300)
• Medial rotation of the hip (30-400)
• Lateral rotation of the hip (40-600)
• The resting position of the hip occurs at 300 of
  flexion, 300 of abduction and slight internal
  rotation.

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The hip joint is loaded in the following manner

• standing - 1/3 of body weight
• standing on one limb - 2-2.5x body weight
• walking - 1.5 - 5.5x body weight
• walking stairs - 3x body weight
• running - 4.5x gt body weight depending upon the
  ability of the runner and the type of running to
  be performed.

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Active movements of the hip

• Flexion - 110-1200
• Extension - 10-150
• Abduction - 30-500
• Adduction - 300
• Lateral rotation - 40-600
• Medial rotation - 30-400

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Musculature
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• Rectus Femoris
• Hip flexor, makes up part of the quadriceps
  group. 2 joint muscle (knee and hip).

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• Sartorius
• Flexes the knee, contributes to flexion,
  abduction and external rotation of the hip

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• Iliopsoas Group
• psoas major, psoas minor and iliacus make up this
  group. They are the primary hip flexors when the
  knee is extended and work with the rectus when
  the knee is flexed.

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• psoas minor

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• Iliacus 1
• The rectus, sartorius and iliacus can all rotate
  the pelvis at the SI joint as they contract.
  Thus, tightness in the anterior hip flexors can
  lead to increased stress on the SI joint via
  anterior rotation of the pelvis.

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• Gracilis
• Adductor, internal rotator
• Adductor group
• adductor longus, adductor magnus, adductor brevis
  are all adductors of the thigh. These muscles are
  supplemented by the pectineus.
• Gluteus Medius
• Superficial lateral muscle, primary abductor of
  the hip. It is also important in maintaining the
  torsos position during gait. Weakness in the
  gluteus medius results in the torsos bending
  toward the affected side when the opposite leg is
  non weight bearing. The compensating movement is
  termed Trendelenburgs gait pattern.

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• The tensor fascialatae is part of the
  iliotibial band and is an abductor an external
  rotator.

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• The cuff muscles of the hip are the
• Piriformis, posterior side.
• Quadratus femoris
• Obturator internus
• Obturator externus
• Gemellus superior
• Gemellus inferior

All of these muscles have the primary function of
acting as external rotators of the hip.
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• Gluteus maximus is the powerful extensor of the
  hip especially when the knee is flexed.
• The Hamstring group (semitendinosus,
  semimembranosus, biceps femoris) works as an
  extensor of the hip when the knee is extended.
  This group also performs the important task of
  decelerating hip flexion and knee extension
  during running via an eccentric contraction.

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• Femoral Triangle
• This is formed by the inguinal ligament, the
  sartorius laterally and the adductor longus on
  the medial side. This is a clinical landmark that
  is used as a reference point and because of the
  underlying structures. Parts of the femoral
  nerve, artery and vein are located within this
  area. The femoral pulse is palpable here as well
  as the lymph nodes if there is an infection or
  inflammation in the lower extremity.

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• Bursae
• Three bursae are found in the hip and pelvic
  region. The bursae act to decrease friction
  between the gluteus maximus and the bony
  structures. The trochanteric bursae lubricates
  the site at where the maximus passes over the
  greater trochanter, the gluteofemoral bursae
  separates the maximus and the vastus lateralis
  and the ischial bursae serves as a weight bearing
  structure when the patient is sitting.

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Neurological

• Sciatic Nerve
• The sciatic nerve is located midway between the
  greater trochanter and the ischial tuberosity.
  When the hip is extended. The nerve is covered by
  the gluteus maximus, when flexed, the maximus
  moves out of the way. Palpate by going half way
  between the tuberosity and the greater trochanter.

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Neuro Kinesiology

• Flexors -
• Iliopsoas, Secondary - rectus femoris
• Femoral Nerve, L1,2,3
• Extensors
• Gluteus Maximus, Secondary - hamstrings
• Inferior Gluteal Nerve, S1
• Abductors
• Gluteus Medius, Secondary Minimus
• Superior Gluteal Nerve, L5
• Adductors
• Adductor Longus, Secondary - Brevis, Magnus,
  Pectineus, Gracilis
• Obturator Nerve, L2,3,4

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Examination

• The cluneal nerves pass over the iliac crest
  between the middle of the crest and posteriorly
  and supply sensation to the skin. These nerves
  are significant when dealing with blunt trauma to
  the crest as you would find with a hip pointer
  type injury. These nerves are also commonly cut
  when a bone graft is taken.

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• Prior medical information is important because of
  congenital or child hood abnormalities can result
  in altered biomechanics. These conditions would
  include Legg Calve Perthes Disease or a slipped
  capital femoral epiphysis. (SCFE)
• Legg Calve Perthes Disease - avascular necrosis
  occurring in children are 3 to 12 years causing
  osteochondritis of the proximal femoral
  epiphysis.
• Slipped capital femoral epiphysis (SCFE) -
  displacement of the head relative to the femoral
  shaft common in boys aged 10-15. Primarily is
  prevalent in overweight and in persons with
  Hispanic heritage.

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Hip Injury Pathology
Pelvic Fractures     ASIS Avulsion            
The rectus femoris muscle may avulse from the the
ASIS on the iliac crest. This condition will
most likely occur in adolescent aged
athletes.     Iliac Crest Fracture      Describe
d by some in the literature as the "ultimate" hip
pointer, this is a stable fracture but will
remain quite sore for an extended period of
time. 
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Ischial Tuberosity Avulsion             The
hamstrings have their proximal attachment on the
ischial tuberosity. Adolescent athletes that 
experience point tenderness over the proximal
attachment should be carefully examined. While
x-rays will help confirm the presence of the
avulsion, the treatment remains the same.
However, the practitioner will know that the
recovery will be delayed. The patient will likely
complain of increased pain while seated. This
finding may be exacerbated as the avulsion heals
with the associated bony callus formation. 
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Other Pelvic Fractures             Pelvic
fractures involving the complete pelvic girdle
require great amounts of trauma and external
forces usually found associated with MVA's,
motorcycling, horseback riding and some extreme
sports. The "open book" pelvis fracture in which
the pelvis is split open from the front has been
seen with rodeo athletes. 
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Stress Fractures         Femoral neck stress
fractures are often associated with overuse. Bone
scans and MRI's are useful for assessment of this
condition. Deep bony pain that is located only on
one side of the body should be carefully
examined. 
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What is the Injury ?
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What is the Injury ?
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Femoral Neck Stress Fracture This patient
was a 24 y.o. female, former NCAA Division I
Cross Country runner that complained of deep
groin pain as well as nocturnal pain. she was
treated with a 3 month period of rest that
progressed through non weight bearing, partial
weight bearing and then to full weight bearing.
She was then progressed in a rehab protocol that
involved walking, water walking and water
running and finally a resumption of non
competitive levels of running. 
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Femoral Head Fractures     Also referred to as
a "Pipkin" fracture, these occur primarily in
association with hip dislocations.  Femoral
Shaft Fractures Fairly uncommon in occurrence,
however, this injury is more frequently seen in
younger aged athletic participants as well as
high energy level trauma situations. 
Hip fractures will almost always present with the
hip flexed and the femur externally rotated while
dislocations will present with the hip flexed and
the femur internally rotated. 
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The cluneal nerves pass over the mid posterior
portion of the iliac crest and supply sensation
to the skin. These nerves are significant when
dealing with blunt trauma to the crest as you
would find with a hip pointer type injury. These
nerves are also commonly cut when a bone graft is
taken. Prior medical information is important
because of congenital or child hood abnormalities
can result in altered biomechanics. These
conditions would include Legg Calve Perthes
Disease or a slipped capital femoral epiphysis.
(SCFE)
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These pictures represent AVN, Avascular Necrosis
of the Head of the Femur.This is a disease that
occurs infrequently but is very serious when it
does. This is the "Bo Jackson" injury that took
him out of football and baseball.
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The head of the left femur shows a dark area on
each view. This represents dead bone or bone that
no longer has any blood supply. This requires a
total hip replacement orthosis. AVN of the hip
is frequently associated with dislocations,
displaced femoral neck fractures, in patients
that have used catabolic steroids, alcoholics and
idiopathic AVN in which the cause is never
determined. 
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Legg Calve Perthes Disease - avascular necrosis
occurring in children are 3 to 12 years causing
osteochondritis of the proximal femoral
epiphysis.
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Slipped capital femoral epiphysis (SCFE) -
displacement of the head relative to the femoral
shaft common in boys aged 10-15. Primarily is
prevalent in overweight and in persons with
Hispanic heritage. These patients most frequently
present with knee pain. Always check hip function
in young patients.
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Tests and Conditions
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Thomas Test
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Positioning Patient is supine Bring both knees
to chest maintain pelvic tilt Action Patient
should lower the affected leg until it is relaxed
or the pelvic tilt is lost
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Positive test findings Lack of hip extension
with knee flexion at 45 degrees or greater is
positive. Tests iliopsoas - gt45 knee flexion
rectus femoris - lt rectus external
rotation IT band tightness
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SI Joint Stress Test
Compression Distraction Patient is supine and the
innominates are compressed from the outside
opening up the SI joint or they are pushed down
compressing the SI joint Test can also be
performed with the patient prone with direct
pressure over the SI joint
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Fabere Sign or Patrick's (Test for SI joint
pain)
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FABER Test
Flexion, Abduction, External Rotation Patient is
supine The knee is flexed, the hip is externally
rotated with abduction Positive finding if the
knee does not drop below the level of the
opposite hip
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90-90 Hamstring Test
Patient is supine Hip is flexed to 90
degrees Knee is flexed to 90 degrees Extend the
knee,if the patient can not get to less than 20
degrees of knee flexion, the hamstrings are
considered to be tight
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Ober Test for IT band tightness
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Patient is lying on their side, the affected leg
is superior in position The hip is stabilized
from rotating by the practitioner The hip is
extended , the leg is extended to position the IT
band behind the greater trochanter, Lower the
leg, if it does not drop to the table, the IT
band is tight.
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Piriformis Test
Patient is side lying Hip is flexed, the
practitioner stabilizes the hip, and downward
pressure is applied to the knee forcing the leg
into adduction Tightness and or pain in the hip
and buttocks are indicative of piriformis
tightness
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Quadriceps or Elys Test
Patient is prone Knee is flexed, compare
contralateral side for ROM. If the hip also
flexes, the quadriceps is considered to be
tight.
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Ortolani Click test (babies)SI Compression /
Distraction TestsPiriformis Syndrome TestLeg
LengthSlump Test
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Why do hamstrings pull?1. Lack of
flexibility2. Muscle Imbalance quad to quad
ratio 10 variance bilaterally, 5 normalquad
to hamstring ratio low speed 75 quad to
hamshigh speed 100 quad to hams3.Trunk
inflexibility4. Fatigue which often presents as
an eccentric loaded injury
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Hamstring retraction into the thigh as the result
of an avulsion from the Ischial tuberosity
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Notice the deficit in the Rt. Hamstring as noted
by the finger pointer.
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This athlete had immediate pain that was followed
by a 7-10 period of localized pain at the origin
site on the Ischial tuberosity. The represents a
partial avulsion type injury. This picture is 1
month post injury.
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Pectineus Muscle Avulsion
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Other Conditions
Muscular Contusions Quadriceps Myositis
Ossificans of the quadriceps Bursitis -
Trochanteric Hip Pointers -ASIS
-Posterior Osteitis Pubis Hip Dislocations
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Myositis Ossificans
Etiology Symptoms Treatment
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MO of the upper arm
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Hip Pointers
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Contusion to the Illiac Crest
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Osteitis Pubis
Etiology Symptoms Treatment
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Hip Dislocations
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