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Chapter 17

Chapter 17. The Hip. Overview. The hip articulation is formed between the head of the femur and the acetabulum of the pelvic bone

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Chapter 17

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  1. Chapter 17 The Hip

  2. 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

  3. Anatomy • The os coxa (hip bone) initially begins life as three individual bones: • Ilium • Ischium • Pubis

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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 posterior-medial 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

  12. Anatomy • Extra-articular ligaments • Three extra-articular ligaments help provide stability at the hip joint: • Iliofemoral ligament of Bertin/Bigelow • Pubofemoral ligament • Ischiofemoral ligament

  13. 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

  14. 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

  15. 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

  16. Anatomy • Extra-articular hip ligaments • All tighten with hip extension. In addition: • Iliofemoral • Lateral band of iliofemoral ligament limits adduction • Medial band of iliofemoral ligament limits external rotation • Pubofemoral • Limits abduction • Ischiofemoral • Limits internal rotation of the hip

  17. Anatomy • Muscles • Iliopsoas • 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

  18. 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

  19. 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

  20. Anatomy • Muscles • Piriformis • 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

  21. 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

  22. Anatomy • Muscles • Hip adductors. The adductors of the hip include the adductor magnus, longus, and brevis, and the gracilis

  23. 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

  24. 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

  25. 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

  26. 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

  27. Biomechanics • 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

  28. 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).

  29. Biomechanics • 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

  30. 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

  31. 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

  32. Examination • 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

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