1. Chapter 20 The Hip

2. 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.

3. Anatomy and Kinesiology Osteology and Arthrology
Acetabulum
Fusion of ilium, ischium, and pubis

4. Anatomy and Kinesiology Osteology and Arthrology
Articulation of the
femoral head with the
acetabular labrum

5. Two Angular Relationships
Angle of inclination of femoral head

6. Angular Relationships
Angle of torsion
Projection of the long axis of the femoral head and the transverse axis of femoral condyles

7. Ligaments of Hip

8. Muscles of the Hip Flexors Extensors Iliopsoas TFL Rectus femoris
Sartorius
Adductor magnus, longus, brevis
Pectineus
Gracilis
Extensors
Gluteus maximus
Hamstrings
Posterior fibers of gluteus medius
Piriformis

9. Muscles of the Hip Abductors Adductors Gluteus medius Adductor group
TFL
Superior gluteus maximus
Gluteus minimus
Adductors
Adductor group
Quadratus femoris
Pectineus
Obturators
Gracilis
Medial hamstrings

10. 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

11. Blood Supply for Head of Femur
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

12. 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)

13. Relationship of Hip and Pelvic Motion in Sagittal Plane

14. Lateral Pelvic Tilt – Frontal Plane

15. Rotation of Pelvis and Hip Transverse Plane

16. Kinetics and Kinematics of Gait
Single limb stance component of gait

17. Anatomic Impairments Angles of Inclination

18. Angle of Torsion

19. Center Edge Angle – Angle of Wiberg
Average adult –
22°–42°

20. Leg Length Discrepancy (LLD)
Unilateral difference in the total length of one leg compared with another.
Anatomic LLD – Actual osseous length difference between the hemipelvis, femur, tibia.
Functional LLD – Position of osseous structures as they relate to each other and to the environment during weight-bearing function.

21. Examination and Evaluation
History
Lumbar spine clearing examination
Other clearing tests (visceral involvement, knee involvement)

22. Examination and Evaluation (cont.)
Balance and gait
Joint Mobility and integrity
Muscle performance
Pain and inflammation
Posture and movement
Range of motion and muscle length
Work, community, and leisure integration or reintegration
Special tests

23. Balance
Balance tests are often included in hip examinations due to high incidence of falls resulting in hip injury:
Berg balance scale
Dynamic gait index
Balance self-perception test
History of balance problems
Type of assistive device used for ambulation

24. Gait
Gait evaluation is an important component of the examination of a person with a hip dysfunction.
Analysis of gait should include observation of the hip along all three planes of movement during each critical phase of gait.
Of particular importance are the relationships between the hip and the rest of the kinetic chain.
Video analysis can assist in this complex examination procedure.

25. Joint Mobility and Integrity
Quantity of motion, end feel, and presence/location of pain should be noted during the following tests:
lateral/medial translation
distraction
compression
anteroposterior/posteroanterior glides

26. Muscle Performance MMT of hip musculature
Specialized tests looking at positional strength to determine length-associated changes
Selective tissue tension tests to diagnose noncontractile versus contractile lesions
Resisted tests to determine severity of the tissue lesion
Resisted tests can also screen neurologic cause of muscle performance impairment

27. Pain and Inflammation
Examination is done in conjunction with other tests to determine source (if possible) and cause of pain.
Source diagnosis often requires additional tests that are beyond the scope of physical therapy.

28. Posture and Movement
Specific lumbopelvic and lower quadrant alignment should be examined about all three planes.
Hypothesis can be developed regarding the contribution of faulty alignments at the ankle, foot, knee, and lumbopelvic regions to the alignment of the hip.
Hypothesis can be generated regarding muscle lengths related to posture alignment.
Initial screening for LLD can be performed.

29. Range of Motion and Muscle Length
Quick tests: placing foot on standard step, forward bending, squatting, sitting with leg crossed
AROM/PROM in open kinetic chain
Muscle length tests:
Medial/lateral hamstrings
Individual hip flexor lengths
Hip adductors/abductors
Hip rotators

30. Work, Community, and Leisure Integration or Reintegration
Functional ability can be measured directly through observation of functional tasks.
Self-report measures can also be used.
Harris hip function scale is another self-report measure that is specific to degenerative joint conditions.

31. Special Tests Trendelenburg test
Trochanteric prominence angle test (TPAT)
LLD tests
Indirect method – Iliac crest palpation and book correction (ICPBC)
Direct method – Measure distance of fixed bony landmarks using a measuring tape

32. Impaired Muscle Performance
Result of:
Neurologic pathology
Muscle strain
Altered length-tension relationships
General weakness from disuse
Pain and inflammation

33. Neurologic Pathology Neuromusculoskeletal or neuromuscular in origin
Neuromusculoskeletal – Pathology at nerve root or peripheral nerve
Treat origin of pathology to positively affect muscle force/torque production

34. Muscle Strain Hamstring strains/overuse are common
Treatment focuses on cause of strain
Improving motor control and muscle performance of underused synergists (e.g., gluteus maximus and hip lateral rotators)
Correct biomechanical factors contributing to underused synergists

35. Treatment of Underused Synergist in Hamstring Strain

36. Functional Progression

37. Functional Progression

38. Quality of Step-Up Movement Pattern

39. 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

40. Taping to Support Strained Gluteus Medius Muscle

41. Gluteus Medius Strength Progression

42. Disuse and Deconditioning
Results from injury, pathology, acquired movement patterns contributing to disuse and deconditioning of specific synergists.
Consider acquired postures and movement habits.
Optimize length-associated relationships and restore motor control and force/torque contributions from underused synergists.

43. ROM, Muscle Length, Joint Mobility Hypermobility
Often associated with impairment in the developing hip.
With increasing use of arthroscopy, diagnosis of acetabular labral tears is more common.
Labral tears are a possible precurser to OA

44. Hypermobility
Hip joint hypermobility has been shown to be associated with OA in numerous studies.
Treatment for developing hip consists of positioning, bracing, or surgery.
Treatment for adult hypermobile hip consists of specific therapeutic exercise, posture education, movement training.

45. Etiology of Hypermobility
Can be either arthrokinematic or osteokinematic.
Arthrokinematic hypermobility is defined as linear translation that is excessive.
Osteokinematic hypermobility is defined as angular translation that is excessive.

46. Sahrmann Hip Syndromes
Arthrokinematic Hypermobility
Femoral anterior glide syndrome
Femoral lateral glide syndrome
Osteokinematic Hypermobility
Femoral adduction with medial rotation syndrome
Femoral adduction syndrome
Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby, 2002.

47. Primary Objective of Treatment
Promote joint stability
Prevent continuous stress to overstretched or torn tissues
Posture and movement pattern training
Strengthen lengthened muscles in short range
Improve muscle performance of deep musculature to enhance core stability

48. Anteversion
Whenever excessive medial rotation ROM is measured, screen for anteversion (TPAT test).
When excessive medial rotation ROM is present, focus on strengthening deep hip LRs.
Educate regarding posture habits and movement patterns.

49. Functional Approach to Treating Medial Hip Rotation Tendencies

50. Functional Approach to Treating Medial Hip Rotation Tendencies

51. Compensation of Limited Hip Lateral Rotation ROM

52. Hypomobility

53. Hypomobility (cont.)
Look at relationships to other regions in the kinetic chain to treat hip hypomobility.
For example, lumbar spine relative flexibility during forward bending with associated stiff hips in the direction of flexion.
For example, knee flexion relative flexibility during standing knee bends with associated stiff hips in direction of flexion.

54. Hypomobility (cont.)
Hip extension stiffness is often associated with anterior pelvic tilt and lumbar extension relative flexibility.
Specific muscle length tests are necessary to prescribe accurate exercises to address muscle length impairments.
Train proper movement patterns to utilize hip extension ROM once achieved via specific exercise (i.e., late stance phase of gait).

55. Hypomobility – Improving ROM

56. Balance
Falls are the leading cause of morbidity and mortality in persons older than 65 years.
T’ai Chi has been shown to be valuable in promoting posture stability and balance control in the well elderly.
Force-platform biofeedback is another mode used to improve balance.
Clinical trials have not demonstrated a reduction in falls among older persons using force-platform biofeedback systems.

57. Pain Differential diagnosis of etiology and cause of pain.
Pain can be referred to the groin, laterally or posteriorly radiate down the anterior and medial thigh, or to the knee.
Treatment must focus on alleviating impairments related to the underlying cause of symptoms.

58. Guidelines for Pain Relief
Activity modification
Physical agents or electrotherapeutic modalities
Manual therapy
Therapeutic exercise intervention
Assistive devices
Weight loss
Biomechanical support (i.e., foot orthotics)

59. Posture and Movement Impairment
Optimize kinetics and kinematics at the hip and other joints in the kinetic chain
ALL patients should be educated on details of posture and movement that contribute to the cause of symptoms.
Hip alignment – Influenced by other joint angles (e.g., knee and pelvis), hypo/hypermobilities, length-tension relationships, muscle performance, etc.

60. Posture and Movement Impairment (cont.)
Changes in posture and movement require basic skills in mobility, muscle performance, and motor control.
These skills must be at functional levels to intervene at the level of posture and movement.
Initially, the goal is to improve all associated impairments to functional levels.
Gradual transition to functional activities with emphasis on optimal posture and movement.

61. Leg-Length Discrepancy (LLD)
3 Categories
Mild (0-30 mm)
Moderate (30-60 mm)
Severe (>60 mm)
Treatment ranges from shoe inserts, posture training, and movement training to various surgical techniques.

62. Example – Femoral and tibial medial rotation
Functional LLD
Example – Femoral and tibial medial rotation
Lengthened or weak posterior gluteus medius and deep hip lateral rotators
Lengthened or weak foot supinators
Postural foot pronation or supination

63. Therapeutic Exercise Interventions for Common Diagnoses
Osteoarthritis
ROM and Mobility
Passive stretch
Active stretch
Active exercises

64. 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.

65. 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.

66. 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

67. 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.

68. TFL/ITB Stretches

69. Adjunctive Intervention – Taping

70. 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

71. Strengthening Piriformis in Shortened Range

72. Summary
Hip is designed for stability and transmission of kinetic forces.
Angles of inclination and torsion are critical to ideal functioning.
Hip osteokinematic ROM is closely linked to lumbopelvic region.
It is important to understand function of all muscles that cross the hip and associated relationships.

73. Summary (cont.)
Thorough hip examination is necessary to understand anatomic/physiologic impairments in hip and related regions.
Impairments in muscle performance, gait, balance, posture and movement, ROM, and mobility commonly occur together.
Primary focus of treating OA is to improve joint loading.

74. Summary (cont.)
Restoring mobility and force are often prerequisites to restoring endurance and improving posture.
Numerous ITB-related syndromes exist.
Stretched piriformis syndrome can mimic lumbar radiculopathy.