1. Evaluation of the Hip & Thigh
Dr. Sue Shapiro
Associate Professor
Barry University
Department of Sports and Exercise Science

2. 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”.

3. Osseous Structures

4. 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

5. 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

6. Pelvic Girdle 4 fused bones make up the girdle
2 innominate bones, sacrum, and coccyx
Anterior articulation at the pubis symphysis
Posterior articulation at the sacrum and sacroiliac joint
Each 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

7. Osseous Structures

8. Pelvic Girdle Acetabulum Synovial Joint Bursas
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

9. 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

10. Hip Flexors

11. Active Motions of the Hip
Extension: degree
End Feel: Tissue Stretch
Major Muscle Movers:
Gluteus Maximus
Gluteus Medius
Hamstrings
Piriformis
Adductor Magnus (posterior)

12. Hip Extensors

13. Active Motions of the Hip
Abduction: degrees
End Feel: Spring/Tissue Stretch
Major Muscle Movers:
Gluteus Medius
Tensor Fasciae Latae
Gluteus Minimus
Piriformis
Gluteus Miminus
Iliopsoas

14. 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

15. Active Motions of the Hip
Internal Rotation: degrees
End Feel: Tissue Stretch/ Springy
Major Muscle Movers:
Tensor Fasciae latae
Gluteus Medius (Anterior)
Adductor Longus & Brevis
Gluteus mininus

16. Active Motions of Hip Joint
External Rotation: degrees
End Feel: Tissue Stretch/ Spring
Major Muscle Movers:
Piriformis
Gemellus
Obturatorius Internus & Externus
Quadratus Femoris
Gluteus Maximus
Sartoruis
Posterior Gluteus Medius

17. 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

18. Connective Tissue

19. 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

20. 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

21. Femoral Triangle Contains: Inside the triangle is the
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

22. Motions of Hip Flexion - 135 Extension - 20-30 Abduction - 45
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
Flexion
Extension
Abduction - 45
Adduction IR ER

23. 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

25. Hip Joint
In the transverse plane the relationship between the femoral and femoral shaft is the ANGLE OF TORSION
Normal angle of 15 degrees and this is measured on x-ray but can also be eyed balled

26. 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

27. 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

28. 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

29. 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

30. Femoral Anteversion 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

31. 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

32. Femoral Retroversion Results Clinical findings
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

33. Femoral Retroversion Treatment
Similar to femoral anteversion
Foot orthotics
General conditioning and flexibility exercises for the lower extremity
Minimize repetitive lower extremity impact loading

34. 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.

35. Craig’s Test

36. Angle of Inclination at Hip

37. 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

38. 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

39. 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

40. 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

41. Coxa Vara
Developmental and acquired conditions resulting from Coxa Vara
Intertrochanteric fracture
Slipped Capital Femoral Epiphysis
Le-Calve-Perthes Disease
Congential Hip Dislocations

42. 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

43. Treatment for Coxa Vara
Use of shoe lift to equalize leg lengths may be very helpful
Strengthening hip abductors
Avoid high impact sports

44. 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

45. 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

46. Coxa Valga Clinical findings of unilateral coxa valga include
Leg length difference, with the involved side being longer
Posterior pelvic tilt
With either bilateral or unilateral there is a gait abnormality associated with a + Trendelenburg sign
Lateral rotation of leg

47. Coxa Valga Treatment Similar to Coxa Vara
Shoe lift to equalize leg length
Strengthen hip abductors
Minimize prolonged standing and avoid high impact sports

48. 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

49. 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

50. Myotomes & Dermatomes Myotomes L1-L2 Hip Flexion L3 – Knee Extension
L4 Dorsiflexion
L5 Hallicus Extension S1
Hip extension & Plantar Flexion S2
Knee Flexion

51. 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

52. Common Injuries Contusions Myositis Ossificans Hip pointer
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.

53. 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

54. 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

55. 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

56. Common Injuries Bursitis Trochanteric Bursitis Iliopsoas 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

57. Bursitis

58. Common Injuries Chronic Bursitis Traumatic hip dislocations Sprains
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

59. Common Injuries Strains *** The key is early detection ***
Hamstrings Strain
The most frequently strained muscle
Could become a chronic problem for the athlete
Adductor Strain
Common in sports that require quick changes of direction & explosive propulsion & acceleration
Quadriceps Strains
Common in Sartoris, ilipsoas, and rectus femoris
*** The key is early detection ***

60. 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

61. Common Injuries Vascular Disorders Thrombophlebitis
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

62. Common Injuries Hip fractures Avulsion Fractures Femoral 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 injury
Open or closed fracture with significant bleeding at fracture site

63. 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

64. 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

65. Common Injuries Hip Fractures Pelvic Fractures
Displaced and nondisplaced
Usually 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