hip, pelvis and thigh : anatomy, evaluation. bony anatomy
TRANSCRIPT
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Hip, Pelvis and Thigh : Hip, Pelvis and Thigh : Anatomy, EvaluationAnatomy, Evaluation
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BONY ANATOMYBONY ANATOMY
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Hip Capsule LigamentsHip Capsule Ligaments
Iliopsoas bursa
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Hip - AnatomyHip - Anatomy
Multiaxial ball & socket jointMultiaxial ball & socket joint AcetabulumAcetabulum
1/2 sphere1/2 sphere Femoral headFemoral head
2/3 sphere2/3 sphere Strong ligaments & capsuleStrong ligaments & capsule Maximally stableMaximally stable
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ObservationObservation
GaitGait PosturePosture BalanceBalance Limb positionLimb position
shortened, adducted, medially rotatedshortened, adducted, medially rotated abducted, laterally rotatedabducted, laterally rotated shortened, laterally rotatedshortened, laterally rotated
Leg shorteningLeg shortening
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InspectionInspection
Pelvic unleveling (iliac crest levels)Pelvic unleveling (iliac crest levels) Pelvic rotation (PSIS levels)Pelvic rotation (PSIS levels) If asymmetric, measure leg lengthsIf asymmetric, measure leg lengths
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Leg Length MeasurementsLeg Length Measurements
Eyeball methodEyeball method Measurement methodMeasurement method
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Range of MotionRange of Motion
Flexion: 110 to 120 Flexion: 110 to 120 degreesdegrees
Extension: 10 to 15 Extension: 10 to 15 degreesdegrees
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Abduction: 30 to 50 Abduction: 30 to 50 degreesdegrees
Adduction: 30 Adduction: 30 degreesdegrees
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External rotation: 40 External rotation: 40 to 60 degreesto 60 degrees
Internal rotation: 30 Internal rotation: 30 to 40 degreesto 40 degrees
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ExaminationExamination
Strength testingStrength testing isometricisometric eccentriceccentric knee extensionknee extension knee flexionknee flexion
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Hip Flexion StrengthHip Flexion Strength
Iliopsoas, rectus femoris, sartorius, tensor fascia lata, pectineus
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Hip Extension StrengthHip Extension Strength
Hamstrings, gluteus maximus
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Hip Adduction StrengthHip Adduction Strength
Adductor longus, adductor brevis, adductor magnus, gracilis, pectineus, oburator externus
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Hip Abduction TestingHip Abduction Testing
Gluteus medius, gluteus minimus, tensor fascia lata
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Internal Rotation Internal Rotation StrengthStrength
Gluteus medius, gluteus minimus, tensor fascia lata
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External Rotation External Rotation StrengthStrength
Piriformis, Obturator internus & externus, Superior/inferior Gemelli, Quadratus femoris, Gluteus maximus
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Special TestsSpecial Tests
Patrick’s TestPatrick’s Test(FAbER)(FAbER) hip joint hip joint SI jointSI joint
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Gaenslen’s SignGaenslen’s Sign
Pain at ipsilateral SIJ is positive test
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Special TestsSpecial Tests
modified Thomas Testmodified Thomas Test hip flexor and quad flexibilityhip flexor and quad flexibility
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Special TestsSpecial Tests
Ober TestOber Test iliotibial band flexibilityiliotibial band flexibility
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Special TestsSpecial Tests
Piriformis TestPiriformis Test Piriformis flexibility or Piriformis flexibility or
painpain
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Special TestsSpecial Tests
Popliteal AnglePopliteal Angle Hamstring flexibiltyHamstring flexibilty
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Special TestsSpecial Tests
Labral InjuryLabral Injury FAdAxL: FAdAxL: flexion, flexion,
Adduction, Axial Adduction, Axial Load + some IR/ERLoad + some IR/ER pain +/- clickpain +/- click
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Weber-Barstow Maneuver
*Can measuretrue vs. apparent
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Gross Leg Length Discrepancy
Magee 4th
Edition – pg. 628
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Prone Knee Flexion Test for Tibial Shortening
Magee 4th
Edition - pg. 630
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Thomas Test
3 Muscle Kendall testAs above….but also look at….IP = hip flexor and hip ERRF = hip flexor and knee extensorTFL/ITB = hip flexor and hip abductor
Magee - 4th Edition
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Ely’s Test
Prone, passive knee flexion
Positive for RF tightness if pelvic anterior tilting / hip flexion accompanies knee flexion before end range and if asymmetrical in bilateral comparison
Magee 4th Edition
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FAIR Test
Cleland, J. – Orthopedic Clinical Examination
Fishman et. al (2002) Archives of Physical Medicine – 10 yr. PiriformisstudySen. .88Spec. .83+LR= 5.2-LR=.14
(+) = pain atintersection ofsciatic nerveand piriformis
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Ober Test
Magee 4th Edition – pg. 633
Reese and Bandy (2003) JOSPTOber Test
Modified Ober Test (4-50 > Ober test)
Ober
ICC=.90
Modifie
d Ober
ICC=.91
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Leg Length Tests
True Leg Length Discrepancy Measure ASIS to
medial malleolus Positive = 1-1.5 cm
Apparent (Functional) Leg Length Umbilicus to Medial
malleolus
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Trendelenberg Test
Pt Position = standing on one leg with WB leg being the involved limb
Positive = pelvis on opposite side drops
Indications = weak Gluteua medius
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Kendall Test
Pt Position = supine with knees bent over the table
Evaluation One hand under lordotic
curve Passively flex hip to chest Allow opposite leg to rest
on table Positive = knee move
into extension or leg rises off table
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Thomas Test
Pt Position = supine with both leg on table
Evaluation One hand under lumbar
region Passively flex one leg to
chest
Positive = straight leg raises off table Increased lordotic curve
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Measurements
True leg length Measure from A.S.I.S
to inferior border of medial malleolus
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Measurements
True Shortening In true shortening the affected
limb is physically shorter than the other and this may be caused by pathology proximal or distal to the trochanters.
True shortening from causes distal to the trochanters most frequently results from previous fractures of the femur or tibia or growth disturbance (e.g. from polio or epiphyseal trauma). Proximal to the trochanters causes include femoral neck fractures, OA and hip dislocation.
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Measurements
Apparent leg length Measure from tip of xiphoid
process to inferior border of medial malleolus
Apparent Shortening In apparent shortening the
limb is not altered in length, but appears shortened. This may be as a result of an adduction contracture of the hip joint, which has to be compensated for by tilting of the pelvis, or SIJ pathology causing pelvic rotation.
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MovementExpected Range of Movement Flexion: 0-130
Degrees Abduction: 0-45 Degrees Adduction: 0-30 Degrees MR: 0-45 Degrees LR: 0-60 Degrees Extension: 0-20 Degrees
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Movements
Thomas’ test:• Place your left hand in hollow of lumbar spine• Flex hip and knee of unaffected side • Look to see if hip of the affected side lifts
from bed Flexion:• Flex hip and knee of affected side and note
ROM (130°)
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Movements
Abduction:
• Stabilise pelvis and hold ankle with other hand
• Abduct and note ROM (45°)
Adduction:
• As above and note ROM (30°)
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Movements
Rotation:• Flex hip and knee to 90 degrees, externally
and internally rotate• Note ROM (45°)
Abnormal Movement (telescoping):• Alternately push and pull leg along its long
axis – demonstrates marked instability
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Trendelenberg Test
Used to assess the ability of the hip abductors to stabilise the pelvis on the femur.
A positive test demonstrates that the hip abductors are not functioning.
Causes:• Disturbance in pivotal mechanism – dislocation
or subluxation of hip, shortening of femoral neck• Weakness of the hip abductors e.g. myopathy,
neuropathy
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Trendelenberg Test
The test is performed with the patients back to the examiner. The model stands on the normal leg and flexes the knee of the other leg to a right angle.
The pelvis should remain level or tilt slightly upwards on the unsupported side.
The model then stands on the affected leg and flexes the knee of the other leg.
If the pelvis tilts downwards on the unsupported side, then this confirms a positive Trendelenberg sign.
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Trendelenberg Test