1. Chapter 17
The Hip

2. Overview
The hip articulation is formed between the head of the femur and the acetabulum of the pelvic bone
Due to its location and function, the hip joint transmits truly impressive loads, both tensile and compressive. In addition, the hip provides a wide range of lower limb movement

3. Anatomy
The os coxa (hip bone) initially begins life as three individual bones:
Ilium
Ischium
Pubis

4. Anatomy Ilium The ilium is the largest of these three bones
It is composed of a large fan-like wing (ala), and an inferiorly positioned body
The body of the ilium forms the superior two-fifths of the acetabulum

5. Anatomy
Ischium
The ischium is composed of a body, which contributes to the acetabulum, and a ramus
The ischium forms the posterior two-fifths of the acetabulum. Together, the ischium and the ramus form the ischial tuberosity

6. Anatomy
Pubis
The pubis is the smallest of the three bones, and consists of a body, and inferior and superior rami. The pubis forms the anterior one-fifth of the acetabulum

7. Anatomy
Acetabulum
The ilium, ischium and pubis fuse together within the acetabulum
While the majority of acetabular development is determined by the age of 8, the depth of the acetabulum increases additionally at puberty, due to the development of three secondary centers of ossification

8. Anatomy
Acetabulum
The acetabulum is angled laterally, inferiorly and anteriorly
The acetabular rim, or labrum, deepens the acetabulum thereby increasing the stability of the hip joint
The whole of the acetabulum is covered with hyaline cartilage, except for the fovea capitis

9. Anatomy
Femur
The femur is the strongest and the longest bone in the body
The proximal end of the femur consists of a head, a neck, and a greater and lesser trochanter
Approximately two thirds of the femoral head is covered with a smooth layer cartilage except for a depression, the fovea capitis, which serves as the attachment of the ligamentum teres

10. Anatomy
Femur
The trabecular bone in the femoral neck and head is specially designed to withstand high loads
The design incorporates both primary and secondary compressive and tensile patterns. However, within this trabecular system, there is a point of weakness called the Ward triangle, which is a common site of osteoporotic fracture

11. Anatomy
Femur
The greater trochanter serves as the insertion site for several muscles that act on the hip joint
The lesser trochanter, located on the posterior-medial junction of the neck and shaft of the femur, is created from the pull of the iliopsoas muscle
The angle that the femoral neck makes with the acetabulum is called the angle of anteversion/declination

12. Anatomy Extra-articular ligaments
Three extra-articular ligaments help provide stability at the hip joint:
Iliofemoral ligament of Bertin/Bigelow
Pubofemoral ligament
Ischiofemoral ligament

13. Anatomy Iliofemoral ligament
Consists of two parts: an inferior (medial) portion and a superior (lateral) portion
The iliofemoral ligament is the strongest ligament in the body
The ligament is oriented superior-laterally and blends with the iliopsoas muscle

14. Anatomy Pubofemoral ligament
Blends with the inferior band of the iliofemoral, and with the pectineus muscle
The orientation of the pubofemoral ligament is more inferior-medial

15. Anatomy Ischiofemoral ligament
Winds posteriorly around the femur, and attaches anteriorly, strengthening the capsule. This ligament is more commonly injured than the other hip ligaments

16. Anatomy Extra-articular hip ligaments
All tighten with hip extension. In addition:
Iliofemoral
Lateral band of iliofemoral ligament limits adduction
Medial band of iliofemoral ligament limits external rotation
Pubofemoral
Limits abduction
Ischiofemoral
Limits internal rotation of the hip

17. Anatomy Muscles Iliopsoas Pectineus Rectus femoris
Comprised of iliacus and psoas major
The most powerful of the hip flexors
Pectineus
An adductor, flexor and internal rotator of the hip
Rectus femoris
The rectus femoris combines movements of flexion at the hip and extension at the knee

18. Anatomy Muscles Tensor fascia latae (TFL) Sartorius
Assists in flexing abducting and internally rotating the hip
Sartorius
Responsible for flexion, abduction, and external rotation of the hip, and some degree of knee flexion

19. Anatomy Muscles Gluteus maximus Gluteus medius Gluteus minimus
Largest and most important hip extensor and external rotator of the hip
Gluteus medius
The main abductor of the hip
The anterior portion works to flex, abduct and internally rotate the hip
The posterior portion extends and externally rotates the hip
Gluteus minimus
The major internal rotator of the femur

20. Anatomy Muscles Piriformis Small external rotators
An external rotator of the hip at less than 60° of hip flexion
At 90° of hip flexion, the piriformis reverses its muscle action becoming an internal rotator and abductor of the hip
Small external rotators
Include obturator externus and internus, superior and inferior gemelli, and quadratus femoris

21. Anatomy
Muscles
Hamstrings. The hamstrings muscle group consists of the biceps femoris, the semimembranosus and the semitendinosus
The biceps femoris, extends the hip, flexes the knee and externally rotates the tibia
The semimembranosus and semitendinosus extend the hip, flex the knee and internally rotate the tibia

22. Anatomy
Muscles
Hip adductors. The adductors of the hip include the adductor magnus, longus, and brevis, and the gracilis

23. Anatomy Bursa There are more than a dozen bursae in this region
The iliopsoas (iliopectineal) bursa is located under the inguinal ligament, between the iliopsoas tendon and the iliopectineal eminence of the superior pubic ramus
The subtrochanteric bursa is located between the greater trochanter and the TFL

24. Anatomy Femoral triangle
The femoral triangle is defined superiorly by the inguinal ligament, medially by the adductor longus, and laterally by the sartorius
The floor of the triangle is formed by portions of the iliopsoas on the lateral side, and by the pectineus on the medial side
A number of neurovascular structures pass through this triangle. These include (from medial to lateral) the femoral vein, artery, and nerve

25. Anatomy
Neurology
The posterior gluteal region receives cutaneous innervation by way of the subcostal nerve, the iliohypogastric nerve, the dorsal rami of L1, L2, L3 and the dorsal primary rami (cluneal nerves) of S1, S2, and S3
The anterior region of the hip has its cutaneous supply divided around the inguinal ligament.
The area superior to the ligament is supplied by the iliohypogastric nerve
The area inferior to the ligament is supplied by the subcostal nerve, the femoral branch of the genitofemoral nerve, and the iliolingual nerve

26. Anatomy Vascular supply
The external iliac artery becomes the femoral artery as it passes underneath the inguinal ligament
The femoral artery forms two branches
The anterior portion of the femoral neck and the anterior portion of the capsule of the hip joint are supplied by the lateral femoral circumflex artery (LFCA).
The medial femoral circumflex artery (MFCA) perforates and supplies the posterior hip joint capsule and the synovium
The deep branch of the MFCA gives rise to two to four superior retinacular vessels and, occasionally, to inferior retinacular vessels
Most of the femoral head is supplied by the lateral epiphyseal artery, a terminal branch of the MFCA

27. Biomechanics
The hip joint is classified as an unmodified ovoid, (ball and socket) joint
This arrangement permits motion in three planes: sagittal (flexion and extension around a transverse axis), frontal (abduction and adduction around an anterior-posterior axis), and transverse (internal and external rotation around a vertical axis)
All three of these axes pass through the center of the femoral head

28. Biomechanics
The angle between the femoral shaft and the neck is called the collum/inclination angle
This angle is approximately ° but can vary with body types
In a tall person the collum angle is larger (valga). The opposite is true with a shorter individual (vara).

29. Biomechanics
Anteversion is defined as the anterior position of the axis through the femoral condyles
Retroversion is defined as a femoral neck axis that is parallel or posterior to the condylar axis
The normal range for femoral alignment in the transverse plane in adults is 12 to 15° of anteversion

30. Examination
History
The hip is a common area of local and referred pain
A pain diagram and a medical history questionnaire should be completed by the patient. The history should determine the patient’s chief complaint and the mechanism of injury, if any
The patient should be encouraged to describe the type and location of the pain

31. Examination Systems Review
Pain may be referred to the hip region from a number of sources
Weight loss, fatigue, fever, and loss of appetite should be sought out because these are clues to a systemic illness
Other examples include an insidious onset of symptoms, evidence of radiculopathy, bowel and/or bladder changes, night pain unrelated to movement, and severe pain

32. Examination Tests and Measures Observation
The patient is observed from the front, back and sides for general alignment of the hip, pelvis, spine and lower extremities

33. Examination Active, Passive, and Resistive Tests
During the examination of the range of motion, the clinician should note which portions of the range of motion are pain-free, and which portion causes the patient to feel pain
At the end of available active range of motion passive overpressure is applied to determine the end-feel
Resisted testing is performed to provide the clinician with information about the integrity of the neuromuscular unit, and to highlight the presence of muscle strains

34. Examination Special Tests
Special tests are merely confirmatory tests and should not be used alone to form a diagnosis
The results from these tests are used in conjunction with the other clinical findings to help guide the clinician
To assure accuracy with these tests, both sides should be tested for comparison

35. Intervention Acute phase
During the acute phase, the principles of PRICEMEM (protection, rest, ice, compression, elevation, manual therapy, early motion and medication) are applied as appropriate

36. Intervention The goals of the acute phase include:
Protection of the injury site
Restoration of pain-free range of motion in the entire kinetic chain
Improve patient comfort by decreasing pain and inflammation
Retard muscle atrophy
Minimize detrimental effects of immobilization and activity restriction
Maintain general fitness
Patient to be independent with home exercise program

37. Intervention The goals of the functional phase include:
Attain full range of pain free motion
Restore normal joint kinematics
Improve muscle strength to within normal limits
Improve neuromuscular control
Restore normal muscle force couple relationships