evaluation of the hip & thigh dr. sue shapiro associate professor barry university department of...
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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