1. OA 1.13
Please have your binder out and ready for notes.

2. Chapter 18 (pp )
The Pelvis & Thigh

3. Objectives Identify… The bones of the hip & thigh
The ligaments of the hip & thigh
The muscles of the hip & thigh
Other structures

4. Skeletal anatomy

5. The pelvic girdle Illium, pubis, ischium Acetabulum Sacrum Coccyx
Two innominate bones
Acetabulum
Portion of all 3 bones
Sacrum
5 fused vertebrae
Coccyx
4-6 fused vertebrae

6. The pelvic girdle

7. The pelvic girdle Ilium Ischium Pubis Forms upper 2/5 of acetabulum
Forms posterior /5 of acetabulum
Pubis
Forms anterior 1/ of acetabulum

8. The pelvic girdle The ilium Anterior Superior Iliac Spine (ASIS)
Anterior Inferior Iliac Spine (AIIS)
Posterior Superior Iliac Spine (PSIS)
Posterior Inferior Iliac Spine (PIIS)

9. The pelvic girdle The ilium Iliac fossa (not shown) Iliac crest
Greater sciatic notch

10. The pelvic girdle The ischium Ischial tuberosity Obturator foramen

11. The pelvic girdle The pubis Pubic symphysis Pubic tubercle
Obturator foramen

12. The pelvic girdle The sacrum Connects spine to pelvis
Stabilizes pelvis
Coccyx connects inferiorly
Fused vertebra

13. The femur Largest, strongest bone in the body Head Neck
Greater trochanter
Lesser trochanter

14. Articulations

15. ARTICULATIONS
Sacroiliac Joint
Pubic Symphysis
Acetabular Joint

16. Sacroiliac joint
Fusion of the sacrum and posterior ilium
Immobile

17. Pubic symphysis Joining of the two sides of the pelvic girdle
Dense, fibrous connective tissue
Immobile

18. Acetabular joint Ball and socket joint Fibrous capsule Very stable
Relatively immobile
Fibrous capsule
Encloses the head and most of the neck of the femur

19. Ligaments & Joint Capsule

20. Hip joint ligaments Ligamentum teres Ligamentum capitis Round ligament
Ligament to the head of the femur
All same thing!

21. Inguinal ligament From ASIS to the pubic tubercle
Functions to contain soft tissues as they pass from the trunk to the lower extremities

22. Joint capsule Synovial joint Reinforced by: Iliofemoral ligament
“Y” ligament
Ligament of Bigelow
Strongest ligament
Pubofemoral ligament
Ischiofemoral ligament

24. Joint capsule The acetabulum is surrounded by a labrum
Extension of cartilage to deepen the joint

27. Muscular anatomy

28. Anterior hip & thigh Iliacus Psoas major
Muscles that cross the hip
Muscles that don’t cross the hip
Iliacus
Psoas major
Rectus femoris (crosses hip & knee)
Sartorius (crosses hip & knee)
Pectineus
Vastus Medialis
Vastus Intermedius
Vastus Lateralis

31. Lateral hip & thigh
Tensor Fascia Latae
Gluteus Medius
Gluteus Minimus

33. OA 1.14 How are the anterior muscle of the hip & thigh categorized?
List them into their respective categories.

34. Posterior hip & thigh Gluteus Maximus Biceps Femoris Semitendinosus
Semimembranosus
Posterior fibers of Adductor Magnus

35. Deep posterior hip & thigh
EXTERNAL ROTATORS
Piriformis
Obturator Internis
Gemellus Superior
Gemellus Inferior
Quadratus Femoris
Obturator Externis

37. Medial hip & thigh Adductor Longus Adductor Brevis Adductor Magnus
Gracilis

38. Other structures

39. bursa
Iliopsoas bursa
Trochanteric bursa

40. Circulatory anatomy Iliac artery Femoral artery
Femoral circumflex arteries
Surrounds the head & neck of the femur

41. Neural anatomy Femoral nerve Sciatic nerve Obturator nerve
Anterior thigh
Sciatic nerve
Posterior thigh
Tibial and common peroneal
Obturator nerve
Medial thigh

42. Femoral triangle Superior: inguinal ligament Lateral: sartorius
Medial: adductor longus
Femoral artery, femoral vein, femoral nerve, and lymph nodes run through
Palpate femoral pulse

43. OA 1.21
A basketball player was going up for a lay up and got her feet taken out from under her. She lands hard on her left hip.
What questions would you ask to gather clues about what is going on?
What are some relevant observations to make regarding their body?

44. History & Observation

45. objectives
Identify…
Pertinent information to gather during a hip & thigh evaluation
Important observations to make during a hip & thigh evaluation
???

46. introduction Must understand anatomy & biomechanics
Examination process is on-going
Initial  rehab  RTP
Must be systematic and methodical
Must understand differential diagnosis (DDx)
Options that a specific injury could be
Pathologies often have similar S&S
Rule out emergency situations quickly
If unsure, err on side of caution

47. history Start with generic history questions Chief complaint Age
Occupation / sport / position etc.
General health condition
Activity level
Medications

48. history History of previous injuries What happened? Who did you see?
What did they tell you?
How long were you out?
Has it fully resolved?

49. history Mechanism of injury Tension = sprain; fracture; strain
How did it happen?
Tension = sprain; fracture; strain
Torsion = sprain/labrum; fracture
Compression = contusion; fracture
Shear = fracture; sprain

50. history Mechanism of Injury – Hip & Thigh specific Compression
Internal/External rotation of the femur
Overuse

51. history Ask these questions regarding PAIN
P-rovocation – what causes it? what makes it better?
Q-uality – what does it feel like? neurological symptoms?
R-egion – where does it hurt? can you point w/one finger?
S-everity – how bad does it hurt? (1-10)
T-iming – when does it hurt? how long?

52. history Type of Pain Structure Cramping, dull, aching Muscle
Ligament, joint capsule
Sharp, bright, lightning-like, burning
Nerve
Deep, nagging, dull
Bone
Sharp, severe, intolerable
Fracture
Throbbing, diffuse
Vasculature

53. history Sounds & sensations
Did you hear any sounds? Did you hear any pops, crackles, snaps, clicking?
What could this indicate???
Did you feel anything unusual?

54. history Specific to the HIP & THIGH Link the anatomy to the pathology
AKA: Where it hurts = what is injured
Focus on the onset/duration
Link the start of symptoms to changes in activity, training, etc.
Prior medical conditions
Congenital abnormalities

55. observation When does this begin?
Compare each side bilaterally to identify what is normal for that person
We look for:
Deformity, asymmetry, edema, ecchymosis

56. observation Gross motor function
Can the athlete move the limb on their own through normal function?
Can they bear full body weight?

57. observation Leg alignment Genu valgum – knocked knee’d
Genu varum – bow-legged
Squint eye patella – points medially
Frog eye patella – points laterally

59. observation Additional examinations:
Q-angle – degree of valgus alignment between anterior hip & tibia
Leg Length
Gait analysis

60. Q-Angle

61. Critical thinking… Iliac crest ASIS AIIS Rec fem Sartorius
A hurdler comes to see you about pain she is having in her anterior hip. She was at practice yesterday and on her last hurdle she felt a “funny pull” in her lead leg. There was an immediate shot of pain to the front of her hip bone, and she immediately had to stop running. She iced it when she got home and took some meds for the pain. Today she felt worse. She could barely walk and wasn’t able to lift her leg to go up/down the stairs. Now her hip is all bruised and is very tender to the touch.
What anatomy would you consider inspecting & palpating? List all possibilities—bones, landmarks, muscles, ligaments, etc.
What other history questions would you ask? List 5.
What injury/injuries do you think this is?
How would you treat this athlete initially?
Iliac crest
ASIS
AIIS
Rec fem
Sartorius
Inguinal ligament
Greater trochanter
Gluteus medius/minimus
TFL
Adductor group/gracilis

62. Critical thinking… Answer: avulsion fx to the ASIS.
A hurdler comes to see you about pain she is having in her anterior hip. She was at practice yesterday and on her last hurdle she felt a “funny pull” in her lead leg. There was an immediate shot of pain to the front of her hip bone, and she immediately had to stop running. She iced it when she got home and took some meds for the pain. Today she felt worse. She could barely walk and wasn’t able to lift her leg to go up/down the stairs. Now her hip is all bruised and is very tender to the touch.
What anatomy would you consider inspecting & palpating? List all possibilities—bones, landmarks, muscles, ligaments, etc.
What other history questions would you ask? List 5.
What injury/injuries do you think this is?
How would you treat this athlete initially?
Answer: avulsion fx to the ASIS.

63. Critical thinking…
A hurdler comes to see you about pain she is having in her anterior hip. She was at practice yesterday and on her last hurdle she felt a “funny pull” in her lead leg. There was an immediate shot of pain to the front of her hip bone, and she immediately had to stop running. She iced it when she got home and took some meds for the pain. Today she felt worse. She could barely walk and wasn’t able to lift her leg to go up/down the stairs. Now her hip is all bruised and is very tender to the touch.
What anatomy would you consider inspecting & palpating? List all possibilities—bones, landmarks, muscles, ligaments, etc.
What other history questions would you ask? List 5.
What injury/injuries do you think this is?
How would you treat this athlete initially?

64. Range of Motion

65. Remember…
History
Asking questions to gather information regarding what happened & what the patient is experiencing
Clues to solve the puzzle of diagnosing the issue

66. remember… Observation Deducing relevant signs of problems
Uses our senses of sight & sound to gather more clues

67. From SKILLS LAB… Palpation Allows us to feel what is going on
Comparison of normal to abnormal

68. Range of motion For the hip… ROM occurs at the coxofemoral joint
Acetabular joint
Articualtion between the acetabulum & femur

69. Movements Primary movements Flexion Extension Adduction Abduction
Internal Rotation
External Rotation

70. Hip movements
Flexion – decreasing the joint angle between the femur and pelvic girdle
Tested with & without knee flexion
Aka: straight leg raise
Aka: knee to chest
Normal: 120o

72. Hip movements
Extension– increasing the joint angle between the femur and pelvic girdle
Tested with & without knee flexion
Aka: straight leg raise
Aka: lift foot off table
Normal: 10-20o

74. Hip movements Abduction– movement of the leg away from the midline
Tested in sidelying
Aka: straight leg raise
Normal: 45o

75. Hip movements ADDuction– movement of the leg towards the midline
Tested in sidelying with opposite knee bent in front of test leg
Normal: 30o

76. Hip movements
External Rotation– Rotation of the femur away from the midline
Tested in a seated position with the knee bent
Toes move opposite of hip movement
Normal: 50o

78. Hip movements
Internal Rotation– Rotation of the femur towards the midline
Tested in a seated position with the knee bent
Toes move opposite of hip movement
Normal: 45o

80. Range of motion Definition:
Range of motion refers to the distance and direction a joint can move between the flexed position and the extended position
In true clinical settings, we use a goniometer to measure ROM

81. Range of motion Types Active range of motion (AROM)
Passive range of motion (PROM)
Resistive range of motion (RROM)

82. Range of motion AROM PROM RROM
The patient’s ability to move a joint under their own strength
PROM
The joint’s ability to be moved through a range of motion
RROM
Measurement of the muscle strength of a joint through the ROM

83. Allows us to get a look at what is normal for that athlete!
Range of motion
Performed bilaterally on the uninjured side first
Why??
Allows us to get a look at what is normal for that athlete!

84. Testing order R flexion – Straight Leg & Bent Knee L flexion – SL & BK
R abduction – sidelying
L adduction – sidelying
R extension – SL & BK
L extension – SL & BK
L abduction – sidelying
R adduction – sidelying
R ER & IR - seated
L ER & IR - seated

85. Testing order
Test AROM, PROM, RROM for all patient positions before moving into a new position
AKA: AROM flexion, PROM flexion, RROM flexion THEN move the sidelying

86. Active Range of motion
Have the patient move their knee through the movements
Lay face up: lift your leg straight up; now drive your knee to your chest
Lay on your left side: lift your right leg up; plant your right knee and lift your left leg up

87. Active Range of motion
Have the patient move their knee through the movements
Lay face down: lift your leg straight off the table; now bend your knee and lift your foot into my hand
Lay on your right side: life your left leg up; now plant your left knee and lift your right leg up

88. Active Range of motion
Have the patient move their knee through the movements
Sit at the end of the table: rotate your right leg in, then out; repeat with the left leg

89. Passive range of motion
The examiner will move the hip through the ROMs to the extreme end – why??
I am going to move your hip/leg for you. Just try to relax and let me know if you feel discomfort, pain, or anything unusual.

90. Resistive range of motion
The athlete will move through each ROM as the examiner places resistance against the movement
Repeat the ROM with resistance placed at or below the knee

91. Muscles & tendons
Anterior aspect – flex & IR the hip (and extend the knee)
Quadriceps femoris group
Sartorius
Iliacus
Psoas major
TFL

92. Muscles & tendons
Posterior aspect – extend the hip* (and flex the knee)
Hamstrings group
Gluteus maximus

93. Muscles & tendons Lateral aspect – abduct & ER the hip* Gluteus Medius
TFL
Gluteus Medius
Gluteus Minimus

94. Muscles & tendons Medial aspect – adduct & IR the hip* Adductor Longus
Adductor Brevis
Adductor Magnus
Gracilis

95. Muscles & tendons Piriformis Obturator Internis Gemellus Superior
EXTERNAL ROTATORS
Piriformis
Obturator Internis
Gemellus Superior
Gemellus Inferior
Quadratus Femoris
Obturator Externis

96. Items to note: When assessing, make note of: differences in AROM
Pain during PROM
Decreased strength during RROM
But WHY??

97. Grading ROM
AROM & PROM are graded as within normal limits (WNL) or decreased/limited & why
AROM: R = WNL, L = decreased DF due to pn

98. Grading ROM
RROM is graded on a 0-5 scale

99. Documenting ROM
When documenting ROM, each movement must be listed & assessed.
AROM: R = WNL, L = WNL
PROM: R = WNL, L = WNL with Pn
RROM: R = 5/5DF, 5/5PF, 5/5INV, 5/5EV; L = 5/5DF, 3/5PF due to Pn, 3/5INV due to Pn, 2/5EV due to Pn