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

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”.

Osseous Structures

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

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

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

Osseous Structures

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

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

Hip Flexors

Active Motions of the Hip Extension: 17-25 degree End Feel: Tissue Stretch Major Muscle Movers: Gluteus Maximus Gluteus Medius Hamstrings Piriformis Adductor Magnus (posterior)

Hip Extensors

Active Motions of the Hip Abduction: 35-40 degrees End Feel: Spring/Tissue Stretch Major Muscle Movers: Gluteus Medius Tensor Fasciae Latae Gluteus Minimus Piriformis Gluteus Miminus Iliopsoas

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

Active Motions of the Hip Internal Rotation: 30-35 degrees End Feel: Tissue Stretch/ Springy Major Muscle Movers: Tensor Fasciae latae Gluteus Medius (Anterior) Adductor Longus & Brevis Gluteus mininus

Active Motions of Hip Joint External Rotation: 35- 40 degrees End Feel: Tissue Stretch/ Spring Major Muscle Movers: Piriformis Gemellus Obturatorius Internus & Externus Quadratus Femoris Gluteus Maximus Sartoruis Posterior Gluteus Medius

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

Connective Tissue

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

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

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

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 - 135 Extension - 20-30 Abduction - 45 Adduction - 20-30 IR - 30-40 ER - 40-50

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

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

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

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

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

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

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

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

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

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

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.

Craig’s Test

Angle of Inclination at Hip

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

Bursitis

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

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 ***

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

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

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

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

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

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