Hip, Pelvis and Thigh : Anatomy, Evaluation

BONY ANATOMY

Hip Capsule Ligaments Iliopsoas bursa

Hip - Anatomy  Multiaxial ball & socket joint  Acetabulum 1/2 sphere  Femoral head 2/3 sphere  Strong ligaments & capsule  Maximally stable

Observation  Gait  Posture  Balance  Limb position  shortened, adducted, medially rotated  abducted, laterally rotated  shortened, laterally rotated  Leg shortening

Inspection  Pelvic unleveling (iliac crest levels)  Pelvic rotation (PSIS levels)  If asymmetric, measure leg lengths

Leg Length Measurements Eyeball method Measurement method

Range of Motion  Flexion: 110 to 120 degrees  Extension: 10 to 15 degrees

 Abduction: 30 to 50 degrees  Adduction: 30 degrees

 External rotation: 40 to 60 degrees  Internal rotation: 30 to 40 degrees

Examination  Strength testing  isometric  eccentric  knee extension  knee flexion

Hip Flexion Strength Iliopsoas, rectus femoris, sartorius, tensor fascia lata, pectineus

Hip Extension Strength Hamstrings, gluteus maximus

Hip Adduction Strength Adductor longus, adductor brevis, adductor magnus, gracilis, pectineus, oburator externus

Hip Abduction Testing Gluteus medius, gluteus minimus, tensor fascia lata

Internal Rotation Strength Gluteus medius, gluteus minimus, tensor fascia lata

External Rotation Strength Piriformis, Obturator internus & externus, Superior/inferior Gemelli, Quadratus femoris, Gluteus maximus

Special Tests  Patrick’s Test (FAbER)  hip joint  SI joint

Gaenslen’s Sign Pain at ipsilateral SIJ is positive test

Special Tests  modified Thomas Test  hip flexor and quad flexibility

Special Tests  Ober Test  iliotibial band flexibility

Special Tests  Piriformis Test  Piriformis flexibility or pain

Special Tests  Popliteal Angle  Hamstring flexibilty

Special Tests  Labral Injury  FAdAxL: flexion, Adduction, Axial Load + some IR/ER  pain +/- click

Weber-Barstow Maneuver *Can measure true vs. apparent

Gross Leg Length Discrepancy Magee 4 th Edition – pg. 628

Prone Knee Flexion Test for Tibial Shortening Magee 4 th Edition - pg. 630

Thomas Test 3 Muscle Kendall test As above….but also look at…. IP = hip flexor and hip ER RF = hip flexor and knee extensor TFL/ITB = hip flexor and hip abductor Magee - 4 th Edition

Ely’s Test  Prone, passive knee flexion  Positive for RF tightness if pelvic anterior tilting / hip flexion accompanies knee flexion before end range and if asymmetrical in bilateral comparison Magee 4 th Edition

FAIR Test Cleland, J. – Orthopedic Clinical Examination Fishman et. al (2002) Archives of Physical Medicine – 10 yr. Piriformis study  Sen..88  Spec..83 +LR= 5.2 -LR=.14 (+) = pain at intersection of sciatic nerve and piriformis

Ober Test Magee 4 th Edition – pg. 633 Reese and Bandy (2003) JOSPT Ober Test Modified Ober Test (4-5 0 > Ober test) Ober ICC=.90 Modified Ober ICC=.91

Leg Length Tests   True Leg Length Discrepancy  Measure ASIS to medial malleolus  Positive = cm   Apparent (Functional) Leg Length  Umbilicus to Medial malleolus

Trendelenberg Test   Pt Position = standing on one leg with WB leg being the involved limb   Positive = pelvis on opposite side drops   Indications = weak Gluteua medius

Kendall Test   Pt Position = supine with knees bent over the table   Evaluation  One hand under lordotic curve  Passively flex hip to chest  Allow opposite leg to rest on table   Positive = knee move into extension or leg rises off table

Thomas Test   Pt Position = supine with both leg on table   Evaluation  One hand under lumbar region  Passively flex one leg to chest   Positive = straight leg raises off table  Increased lordotic curve

Measurements   True leg length   Measure from A.S.I.S to inferior border of medial malleolus

Measurements   True Shortening   In true shortening the affected limb is physically shorter than the other and this may be caused by pathology proximal or distal to the trochanters.   True shortening from causes distal to the trochanters most frequently results from previous fractures of the femur or tibia or growth disturbance (e.g. from polio or epiphyseal trauma). Proximal to the trochanters causes include femoral neck fractures, OA and hip dislocation.

Measurements   Apparent leg length   Measure from tip of xiphoid process to inferior border of medial malleolus   Apparent Shortening   In apparent shortening the limb is not altered in length, but appears shortened. This may be as a result of an adduction contracture of the hip joint, which has to be compensated for by tilting of the pelvis, or SIJ pathology causing pelvic rotation.

Movement Expected Range of Movement   Flexion:0-130 Degrees   Abduction:0-45 Degrees   Adduction:0-30 Degrees   MR:0-45 Degrees   LR:0-60 Degrees   Extension:0-20 Degrees

Movements   Thomas’ test: Place your left hand in hollow of lumbar spine Flex hip and knee of unaffected side Look to see if hip of the affected side lifts from bed   Flexion: Flex hip and knee of affected side and note ROM (130°)

Movements   Abduction: Stabilise pelvis and hold ankle with other hand Abduct and note ROM (45°)   Adduction: As above and note ROM (30°)

Movements   Rotation: Flex hip and knee to 90 degrees, externally and internally rotate Note ROM (45°)   Abnormal Movement (telescoping): Alternately push and pull leg along its long axis – demonstrates marked instability

Trendelenberg Test   Used to assess the ability of the hip abductors to stabilise the pelvis on the femur.   A positive test demonstrates that the hip abductors are not functioning.   Causes: Disturbance in pivotal mechanism – dislocation or subluxation of hip, shortening of femoral neck Weakness of the hip abductors e.g. myopathy, neuropathy

Trendelenberg Test   The test is performed with the patients back to the examiner. The model stands on the normal leg and flexes the knee of the other leg to a right angle.   The pelvis should remain level or tilt slightly upwards on the unsupported side.   The model then stands on the affected leg and flexes the knee of the other leg.   If the pelvis tilts downwards on the unsupported side, then this confirms a positive Trendelenberg sign.

Trendelenberg Test