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Hip Anatomy

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The acetabulum is the depression or fossa where the femoral head ... Bursitis - Trochanteric. Hip Pointers -ASIS -Posterior. Osteitis Pubis. Hip Dislocations ... – PowerPoint PPT presentation

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Title: Hip Anatomy


1
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)

2
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.
3
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.
4
  • 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.

5
  • 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.

10
  • 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)

11
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.

13
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
16
  • 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

20
  • 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.

21
  • 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.

22
  • The tensor fascialatae is part of the
    iliotibial band and is an abductor an external
    rotator.

23
  • 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.

25
  • 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.

27
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

29
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.

30
  • 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.

31
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. 
32
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. 
38
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 ?
40
What is the Injury ?
41
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. 
42
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. 
43
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)
44
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.
45
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. 
46
Legg Calve Perthes Disease - avascular necrosis
occurring in children are 3 to 12 years causing
osteochondritis of the proximal femoral
epiphysis.
47
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
53
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
55
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
56
Fabere Sign or Patrick's (Test for SI joint
pain)
57
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
58
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
59
Ober Test for IT band tightness
60
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.
61
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
62
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.
63
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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