Copyright 2005 Lippincott Williams & Wilkins Chapter 20 The Hip

Copyright 2005 Lippincott Williams & Wilkins Primary Roles of Hip  Support weight of head, arms, trunk during upright postures and dynamic weight- bearing activities.  Provides a pathway for transmission of forces between the lower extremities and pelvis.

Copyright 2005 Lippincott Williams & Wilkins Anatomy and Kinesiology Osteology and Arthrology Acetabulum Fusion of ilium, ischium, and pubis

Copyright 2005 Lippincott Williams & Wilkins Anatomy and Kinesiology Osteology and Arthrology Articulation of the femoral head with the acetabular labrum

Copyright 2005 Lippincott Williams & Wilkins Muscles of the Hip Flexors  Iliopsoas  TFL  Rectus femoris  Sartorius  Adductor magnus, longus, brevis  Pectineus  Gracilis Extensors  Gluteus maximus  Hamstrings  Posterior fibers of gluteus medius  Piriformis

Copyright 2005 Lippincott Williams & Wilkins Muscles of the Hip Abductors  Gluteus medius  TFL  Superior gluteus maximus  Gluteus minimus Adductors  Adductor group  Quadratus femoris  Pectineus  Obturators  Gracilis  Medial hamstrings

Copyright 2005 Lippincott Williams & Wilkins Muscles of the Hip (cont.) Medial Rotators  TFL  Gluteus minimus  Anterior fibers of gluteus medius  Adductor magnus, longus  Semimembranosus/ tendinosis Lateral Rotators  Piriformis  Obturator interior/exterior  Gemelli  Quadratus femoris  Glut maximus  Posterior fibers of gluteus medius  Biceps femoris

Copyright 2005 Lippincott Williams & Wilkins Nerve and Blood Supply Nerve Supply  Lumbar plexus (L1-L4)  Sacral plexus (L4-S3) Blood Supply for Head of Femur  Artery of ligamentum teres  Medium and lateral circumflex arteries

Copyright 2005 Lippincott Williams & Wilkins Kinematics ROM  Varies with age, sex  Flexion 120–135 degrees with knee flexed 90 degrees  Extension 0–15 degrees  Abduction 0–30 degrees  Rotation generally 45 degrees in each direction (more LR with males, more MR with females)

Copyright 2005 Lippincott Williams & Wilkins Leg Length Discrepancy (LLD) Unilateral difference in the total length of one leg compared with another.

Copyright 2005 Lippincott Williams & Wilkins Hip mobilization Flexion: Femur rolls superior and glides inferior on pelvis Abduction: Femur rolls lateral/superior & glides inferior on pelvis IR: Femur rolls medial & glides lateral on pelvis Extension: Femur rolls inferior & glides superior on pelvis Adduction: Femur rolls medial/inferior & glides superior on pelvis ER: Femur rolls lateral & glides medial on pelvis

Copyright 2005 Lippincott Williams & Wilkins Pelvic motions Hip flexors cause an anterior pelvic tilt Hip extensors a posterior pelvic tilt Abductors and adductors a lateral pelvic tilt Rotators of the hip cause rotation To prevent excessive pelvic motion when moving the femur at the hip joint, the pelvis must be stabilized by the abdominals, erector spinae, multifidus and quadratus lumborum muscles

Copyright 2005 Lippincott Williams & Wilkins Anterior pelvic tilt Results in hip flexion and increased lumbar spine extension Caused by hip flexors and back extensors Line of gravity falls anterior to the axis of the hip joint, stability is provided by the abdominals and hip extensors

Copyright 2005 Lippincott Williams & Wilkins POSTERIOR PELVIC TILT Results in hip extension and lumber spine flexion Caused by hip extensors and trunk flexors Line of gravity of the tunk falls posterior to the axis of the hip joints, dynamic stability is provided by the hip flexors and back extensors and passively by the iliofemoral ligament

Copyright 2005 Lippincott Williams & Wilkins Synergy patterns of the hip Flexor synergy Abduction and lateral rotation Extensor synergy Extension and medial rotation and adduction

Copyright 2005 Lippincott Williams & Wilkins Thomas test Asses for tight hip flexors Supine with lumbar spine stabilized & involved LE extended Flex contralateral hip to the abdomen

Copyright 2005 Lippincott Williams & Wilkins Ely’s test Assess for tight rectus femoris Sidelying to prone, hip extension Flex knee Inability to maintain hip extension when knee is flexed

Copyright 2005 Lippincott Williams & Wilkins Ober’s test Assess for tight ITB Sidelying with involved hip up Extend involved hip & allow LE to drop into adduction (+) if LE fails to drop

Copyright 2005 Lippincott Williams & Wilkins Scour test Assess for labral tear Supine flex hip to 90 IR/ER hip with abd/add while applying a compressive force down femur (+) clicking, grinding or pain due to arthritis, labral tear, avascular necrosis, osteochondral defect

Copyright 2005 Lippincott Williams & Wilkins Anterior and posterior labral tests Assess for labral tear Ant: Supine in PNF D2 flexion (flex, ER & Abd) Post: Supine in PNF D1 flexion (flex, IR & Add) To test Ant: Resist D2 extension (ext, IR &Add) Post: Resist D1 extension (ext, ER & Abd) (+) reproduction of pain or click

Copyright 2005 Lippincott Williams & Wilkins Faber (patrick’s) test Assess SI jt pathology Supine – passiely flex, abd & ER so that the lateral malleolus of the involved LE is on the other knee Apply overpressure to flexed knee (+) pain 2dary to OA, osteophytes, intracapsular FX or LBP 2dary to SI Px: tightness without pain is (- ) may indicate problem with sartorius muscle

Copyright 2005 Lippincott Williams & Wilkins Trendelenburg’s test Weakness of G.Med Standing Flex the contralateral LE: iliac crest on WB side should be lower than the NWB side (+) dropping of the NWB limb is 2dary to abductor weakness

Copyright 2005 Lippincott Williams & Wilkins Piriformis test Assess for tight piriformis Supine or contralateral sidelying Flex hip to with knee flexed & maximally adduct LE (apply downward force to the knee) (+) pain in buttock & sciatica; IR stresses superior fibers; ER stresses inferior fibers

Copyright 2005 Lippincott Williams & Wilkins Ortolani’s and barlow’s tests Ortolani’s test Asses for congenital hip dislocation Supine knees and hip flexed to 90; clinician’s thumbs are on the medial thigh and fingers on the lateral thigh Firmly traction the thigh while gently abducting the leg so that the femoral head is translated anterior into the acetabulum (+) reduction of the hip and audible clunk Barlow’s test Assess for hip dysplasia Supine 90/90; clinician’s thumbs are on the infant’s medial thigh & fingers on the lateral thigh Apply a posterior force thru the femur as the thigh Is gently adducted (+) examiner’s finger that is on the greater trochanter will detect a palpable dislocation

Copyright 2005 Lippincott Williams & Wilkins

Treatment of Underused Synergist in Hamstring Strain

Copyright 2005 Lippincott Williams & Wilkins Muscle Strain  Overstretch can also be a contributing factor to muscle strain.  For example: gluteus medius on high iliac crest side Strengthen gluteus medius in short range Taping in short range Correct posture habits and movement patterns that maintain muscle in lengthened state

Copyright 2005 Lippincott Williams & Wilkins Taping to Support Strained Gluteus Medius Muscle

Copyright 2005 Lippincott Williams & Wilkins Gluteus Medius Strength Progression

Copyright 2005 Lippincott Williams & Wilkins Hypomobility – Improving ROM

Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Interventions for Common Diagnoses Osteoarthritis ROM and Mobility 1.Passive stretch 2.Active stretch 3.Active exercises

Copyright 2005 Lippincott Williams & Wilkins Osteoarthritis – Muscle Performance  Functional exercises should be included whenever possible.  Use of adjuncts may be necessary to reduce joint reaction forces.  Always include core activation.  Step-up activities stimulate hip extensor recruitment, facilitate hip flexion mobility.  Alter step height and resistance (adding weight) to ensure proper technique.

Copyright 2005 Lippincott Williams & Wilkins Osteoarthritis – Balance/Posture/Adjuncts Balance – After establishing muscle balance in single limb stance, progress to balance activities. Posture and movement – Educate patients on positioning, core training, and assistive devices during functional activities. Adjunctive interventions – Non-weight-bearing activities (aquatics, etc.) are recommended.

Copyright 2005 Lippincott Williams & Wilkins ITB – Related Diagnoses  ITB fascitis (inflammation from overuse)  Trochanteric bursitis (bursa becomes inflamed)  ITB friction syndrome (pain localized to lateral femoral condyle)  Patellofemoral dysfunction  TFL strain (overuse of short or stretched TFL/ITB)  Faulty movement patterns

Copyright 2005 Lippincott Williams & Wilkins Synergistic Relationships Associated with ITB/TFL Overuse  Anteromedial TFL dominates in hip flexion force couple = underuse of iliopsoas.  Posterolateral TFL dominates in hip abductor + medial rotator force couple = underuse of gluteus medius, upper fibers of gluteus maximus and minimus.  Overuse of ITB may contribute to underuse of quadriceps.

Copyright 2005 Lippincott Williams & Wilkins TFL/ITB Stretches

Copyright 2005 Lippincott Williams & Wilkins Adjunctive Intervention – Taping

Copyright 2005 Lippincott Williams & Wilkins Nerve Entrapment Syndrome Piriformis syndrome (stretched) Signs  Hip flexion with medial rotation  Lordosis and anterior pelvic tilt  High iliac crest on involved side  Lateral rotation and abduction reduces symptoms Key Tests  Standing alignment  Tissue tension tests  ROM  Palpation  Positional strength  Functional tests  Lumbar clearing exam

Copyright 2005 Lippincott Williams & Wilkins Strengthening Piriformis in Shortened Range