Download The Hip

Chapter 17
The Hip
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
Anatomy

The os coxa (hip bone) initially begins
life as three individual bones:
– Ilium
– Ischium
– Pubis
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
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
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
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
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
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
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
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 posteriormedial 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
Anatomy

Extra-articular ligaments
– Three extra-articular ligaments help
provide stability at the hip joint:
Iliofemoral ligament of Bertin/Bigelow
 Pubofemoral ligament
 Ischiofemoral ligament

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
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
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
Anatomy

Extra-articular hip ligaments
–
All tighten with hip extension. In addition:

Iliofemoral
–
–

Pubofemoral
–
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Lateral band of iliofemoral ligament limits adduction
Medial band of iliofemoral ligament limits external
rotation
Limits abduction
Ischiofemoral
–
Limits internal rotation of the hip
Anatomy

Muscles
– Iliopsoas
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
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
Anatomy

Muscles
– Tensor fascia latae (TFL)

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
Anatomy

Muscles
– Gluteus maximus

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
Anatomy

Muscles
– Piriformis
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
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
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

Anatomy

Muscles
– Hip adductors. The adductors of the hip
include the adductor magnus, longus, and
brevis, and the gracilis
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

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
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
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
Biomechanics
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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
Biomechanics

The angle between the femoral shaft
and the neck is called the
collum/inclination angle
– This angle is approximately 125-130° 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).
Biomechanics
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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
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
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
Examination
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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
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
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
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
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
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