Transcript Evaluation of the Hip & Thigh

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 balland–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
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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
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Each innominate bone made up of 3 fused
bones - ilium, ischium, pubis
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Ilium forms the major portion of the iliac crest
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ASIS - Anterior superior iliac crest
PSIS - Posterior superior iliac crest
Osseous Structures
Pelvic Girdle

Acetabulum
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Synovial Joint
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Has a labrum and
fibrocartilage that holds
the femoral head in
tight
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
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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
Piriformis
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
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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
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
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
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Extra-Capsular Lig.

Ischiofemoral Lig.
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Prevents IR and
adduction
Ligamentum Teres
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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
Flexion
Extension
Abduction
Adduction
Internal Rotation
External Rotation
Ligament that Restricts
Inferior portion of ischiofemoral
Medial portion of iliofemoral
Pubofemoral
Superior ischiofemoral
Superior portion of ischiofemoral
Lateral portion of iliofemoral
Femoral Triangle
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Contains:
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Inguinal ligament at
upper border
Sartorius at lateral
border
Adductor longus at
medial border
Inside the triangle is the
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Femoral artery
Femoral vein
Femoral nerve
Motions of Hip
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Flexion Extension Abduction Adduction IR ER -
135
20-30
45
20-30
30-40
40-50

Closed Packed
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Loose Packed
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30 flexion, 30
abduction, & slight ER
Capsular pattern
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Extension, IR, &
Abduction
Flexion, abduction, &
IR
End Feels

Tissue stretch except
for flexion and
adduction which are
tissue approximation
Ossesous Deformities

Four common osseous deformities of the proximal
femur are:
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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
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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
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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

Treatment
PT usually does not influence the degree of deformity
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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
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Results
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Substantial malaligment and numerous
compensation in the lower extremity
Clinical findings
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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
 Treatment
 Similar
 Foot
to femoral anteversion
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
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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
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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
 Treatment
 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
 Shoe
to Coxa Vara
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- L2L4
 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
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Myotomes
 L1-L2
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Hip Flexion
L3 – Knee
Extension
L4
Dorsiflexion
L5 Hallicus
Extension
S1
Hip extension
& Plantar
Flexion
S2
Knee Flexion
Blood Supply

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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
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Myositis Ossificans
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Resulted from a direct blow ; most common site is
the anterior lateral thigh
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
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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

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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
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Iliopsoas Bursitis


Occurs at the greater
trochanter
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
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Can lead to snapping hip syndrome
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Traumatic hip dislocations
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Athletes that ER the hip repetitively. This motion causes
the iliotibial tract snaps over the greater trochanter or the
snapping in the medial groin
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

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
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
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Superficial Thrombphlebitis
Deep Thrombophlebitis
Common Injuries

Hip fractures

Avulsion Fractures
occur during explosive muscular contractions
against fixed resistance or during rapid
acceleration
 Common sites
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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
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Usually do to excessive jogging or aerobic dance activity
with increase frequency of activity over short period of time
Common sites
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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
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Shock
Injuries to internal organs and genitourinary
Hemorrhage occurs within the pelvic cavity & is not
visible