Download MSK-HIP ( Part I)

MSK-HIP
(Part I)
Anatomy and Physical
Exam
Yibing Li
01/07/2004
Hip Joint

The hip joint is a synovial
ball and socket joint,
formed by the reception of
the head of femur into the
cavity of acetabulum. It is
the largest weight bearing
joint in the body and is
surrounded by strong
ligaments and muscles.
 Due to high mobility, hip
joint pathology can be
manifested during weight
bearing, ambulation or
motion.
Hip Bones

The ilium, ischium,
pubis and femur are
the main bones at the
hip joints. The ilium,
ischium and pubis are
fused together to form
the pelvis girdle
(L+R).
Ligaments of the Hip Joints

Acetabular labrum
forms a complete ring
around the head of the
femur. Its function is
to hold the femoral
head in place.
 The ligament of the
head of femur attaches
the head of femur to
the acetabulum.
Ligaments (cont.)




There are 3 ligaments that
hold the head of femur to
the pelvis:
1. Iliofemoral lig.: the
strongest ligament; Its
function is to prevent
hyperextension, abduction
and lateral rotation.
2. Pubofemoral lig. : limits
abduction
3. Ischiofemoral lig. :
limits medial rotation.
The Capsule of Hip Joint

The articular fibrous
capsule extends from
the acetabular rim to
the intertrochanteric
crest forming a sleeve
that encloses the hip
joint and most of the
femoral neck.
Hip joint injection
Muscles of the hip and thigh
Muscles of the Hip & Thigh
Inferior Gemelli
Obturator Externus
Obturator Internus
Piriformis
Quadratus Femoris
Superior Gemelli
Gluteal Region (Hip-Joint
Stability)Deep
Gluteal Region (Hip-Joint
Stability)Deep
Gluteal Region (Hip-Joint
Stability)Deep
Gluteal Region (Hip-Joint
Stability)Deep
Gluteal Region (Hip-Joint
Stability)Deep
Gluteal Region (Hip-Joint
Stability)Deep
Ischial Tuberosity
Obturator Membrane (external
surface)
Obturator Membrane (internal
surface)
Greater Trochanter
Femur: Lateral Rotation
Greater Trochanter
Femur: Lateral Rotation
Anterior aspect of the Sacrum
Greater Trochanter
Greater Trochanter
(Superior aspect)Crest
Intertrochanteric
Femur: Lateral Rotation
Femur: Lateral Rotation |
Femur: Abduction
Ischial Tuberosity
(Quadrate Tubercle)
Femur: Lateral Rotation
Ischial Spine
Greater Trochanter
Femur: Lateral Rotation
Goes through Lesser Sciatic
Foramen
The big muscle in the gluteal
group
Directly above the obturator
internus
Gluteus Minimus
Gluteal Region (Hip-Joint
Stability)Superficial
Gluteal Region (Hip-Joint
Stability)Superficial
Gluteal Region (Hip-Joint
Stability)Superficial
Ilium, Sacrum, and Coccyx
Outer surface of il eum, between
top two gluteal lines
Outer surface of Ili um, between
bottom two gluteal lines
Iliopsoas
Thigh, Anterior
Lumbar spine and Iliac crest
Sartorius
Thigh, Anterior
Anterior Superior Iliac Spine
Tensor Fasciae Latae
Proximal femur
Vastus Medialis
Thigh, Anterior
Thigh, AnteriorQuadriceps
Femoralis
Thigh, AnteriorQuadriceps
Femoralis
Thigh, AnteriorQuadriceps
Femoralis
Thigh, AnteriorQuadriceps
Femoralis
Adductor Brevis
Thigh, MedialAdductor Group Pubic Bone
Thigh: Adduction
Adductor Longus
Thigh, MedialAdductor Group Pubic Bone
Thigh: Adduction
Lateral floor of Femoral
Triangle
Adductor Magnus
Thigh, MedialAdductor Group Pubic Bone
Thigh: Adduction | Thigh:
Extension
Adductor "Hybrid" Muscle
Gracilis
Thigh, MedialAdductor Group Pubic Bone
Pectineus
A good spare part; adduction
can occur without it.
Adductor "Hybrid" Muscle;
Floor of the Femoral Triangle
Semimembra nosus
Thigh, MedialAdductor Group Pubic Bone
Long Head: Ischial Tuberosity |
Thigh, PosteriorHamstring
Short Head: Femur (Linea
Muscles
Aspera)
Thigh, PosteriorHamstring
Muscles
Ischial Tuberosity
NONE | Thigh: Adduction
Thigh: Adduction | Hip:
Flexion
Head of the Fib ula
Medial condyle of
proximal tibia
Hip: Extension; Knee:
Flexion
Hip: Extension; Knee:
Flexion
Semitendinos us
Thigh, PosteriorHamstring
Muscles
Medial condyle of
proximal tibia
Hip: Extension; Knee:
Flexion
Gluteus Maximus
Gluteus Medius
Rectus Femoris
Vastus Intermedius
Vastus Lateralis
Biceps Femoris
Anterior Inferior Iliac Spine
Proximal femur
Proximal femur
Proximal femur
Ischial Tuberosity
Gluteal Tuberosity of
Femur and Iliotibial Tract
Greater Trochanter
(Lateral)
Greater Trochanter
(anterior)
Lesser Trochanter of
Femur
Directly below the obturator
internus
Hip: Extension
Femur: Abduction and
medial rotation
Femur: Abduction and
medial rotation
Femur: Flexion at hip
Hip: Flexion; Knee:
Posteromedial aspect of Extension | Femur:
proximal tibia
Lateral Rotation
Iliotibial Tract
Quadriceps Ten don
the superior Patella
Quadriceps Ten don
the superior Patella
Quadriceps Ten don
the superior Patella
Quadriceps Ten don
the superior Patella
Floor of the Femoral Triangle
Knee: Extension
Inferolateral base of Femoral
Triangle
Increases tension of fascia
lata and iliotibial tract, esp.
when standing upright; holds
knee in place
Acts on the hip joint; Crucial
role in knee stability
Knee: Extension
Crucial role in knee stability
Knee: Extension
Crucial role in knee stability
Knee: Extension
Crucial role in knee stability
Hip: Flexion; Femur:
Medial Rotation
on
on
on
on
Long head crosses both hip
and knee joints
Cross both hip and knee
joints
Cross both hip and knee
joints; medial to
semimembranosus
Movements at the Hip

1. Flexion / Extension
 2. Adduction / Abduction
 3. Lateral (external)Rotation / Medial
(internal) Rotation
Hip Flexors

Iliopsoas (prime hip flexor)
 Pectineus








Sartorius
Rectus femoris
Pectineus
Tensor fsaciae latae
Adductor brevis
Adductor longus
Adductor magnus (anterior head)
Rectus femoris
P90-iliopsoas
P96-pectineus
Hip Extensors

Gluteus maximus
 Biceps femoris (long head)
 Semitendinosus
 Semimembranosus

Adductor magnus (postrior head)
P86
P100-101 Hamstring
Hip Abductors

Gluteus medius
 Gluteus minimus


Tensor fasciae latae
Sartorius
p87
p88
Hip Adductors

Adductor brevis
 Adductor longus
 Adductor magnus
 Gracilis

Pectineus
p97
p98
p99
Internal Rotators of the Hip

Gluteus medius
 Gluteus minimus
 Tensor fasciae latae

Adductor magnus (anterior head)
p91
p89
Physical Exam of the Hip and
Pelvis

Inspection & Palpation
 ROM
 Neurologic exam
 Special tests
Inspection

Observe gait
 Check hip and pelvis area for skin
abrasions,abnormal swelling, etc.
 Check if the anterior superior iliac spines
are in the same horizontal plane or tilted
pelvis
 Observe the two discernible dimples to
check PSIS for pelvic obliquity
Gait

Antalgic gait: prolonged double support period, decreased stance
phase and step length on the unaffected side to reduce pain and avoid
weight bearing on the affected side.

Trendelenburg gait (hip abductor weakness)


---uncompensated gait: contralateral pelvic drop.
---compensated: lateral lurch over the affected side.(Tx with cane)

Extensor lurch gait(gluteus maximus weakness):
secondary to inferior gluteal N.injury or subtrochanteric hip fx. Unable
to decelerate the hip flexion moment at heel strike due to hip extensor
weakness. To compensate, pt lean upper body backward to keep the
center of gravity. Tx with two crutches or canes.
Palpation

----Anterior Superior Iliac Spines (ASIS): check
pelvic obliquity

----Iliac crest ( gluteus and sartorius muscles originate
just below it)

----Greater Trochanter (uneven in congenital hip
dislocation or poor-healed hip fx)
 ----PSIS (lie directly underneath the visible dimples just
above the buttocks, check for pelvic obliquity)

----Trochanteric Bursa (have pt lie on the side with hip
flexion; If it is inflamed, the area feels boggy and tender to
palpation)
ROM

Flexion: 120 degree
 Extension: 30 degree
 Abduction: 45-50
degree
 Adduction: 0-30
degree

External rotation: 35
degree
 Internal rotation: 45
degree
 (OA limits internal
rotation first)
Neurologic Exam

Muscle testing: test muscle strength in
functional groups.

Primary flexor: Iliopsoas (femoral N. L1,2,3)
Primary extensors: Gluteus Maximus (inferior gluteus N. S1)
Primary adductors: Adductor longus (obturator N. L2,3,4)
Primary Abductor: Gluteus medius( superior gluteal N., L5)




Sensation testing: for example, dermatomes
( T10-L3)
Special Hip Tests

1. Patrick (Fabere) test
 2. Thomas test
 3. Ober test
 4. Trendelenburg test
 5. Leg length discrepancy
Patrick test

This test is to assess Flexion, Abduction,
External Rotation
 Perform with pt supine, passively flex and
externally rotate and abduct the hip.
 Ipsilateral inguinal pain indicates pathology
in the hip joint or the surrounding muscles.
 Contralateral pain occurs in the
dysfunctional SI joint.
Thomas Test

To assess hip flexion contractures
 Perform the test with the pt supine, flex one hip
fully reducing the lumbar spine lordosis,
stabilizing the spine and pelvis, extend the
opposite hip.A flexion contracture is present if the
hip cannot fully extend. The degree of flexion
contracture can be done by estimating the angle
between the table and pt’s leg.
Ober test

To test for contraction of the fascia lata.
 Have pt lie on the side with involved leg
uppermost. Abduct the leg as far as possible
and flex the knee to 90 degree. If the thigh
remains abducted, there may be a
contracture of the tensor fascia lata or ITB.
Trendelenburg test

Test for gluteus medius weakness
 Perform with the pt standing erect, one foot is
raised off the floor, strength of the gluteus medius
of the supported side is assessed. A positive test
occurs when the pelvis on the unsupported side
descends or remains level.
 Conditions with gluteus medius weakness:--radiculopathies,poliomyelitis,meningomyelocele,
fx of the greater trochanter, slipped capital femoral
epiphysis, congenital hip dislocation.
Leg Length Discrepancy (LLD)

Leg Length Discrepancy (LLD)

True LLD: measure from ASIS to the medial malleoli. The
shortening may be due to fx crossing the epiphyseal plate
in children or poliomyelitis.
To determine the discrepancy from femur or the tibia:
(with pt supine, flex the knees to 90 and place feet flat on
the table) If the knee is higher than the other, that tibial is
longer ; if one knee projects further anteriorly, then that
femur is longer.

Leg length discrepancy

Apparent LLD: (determine no TLLD
first)with pt supine, measure from
umbilicus to the medial malleoli. Apparent
discrepancy may be caused by pelvic
obliquities or flexion or adduction
deformity of the hip.