1. Evaluation of the Hip & Pelvis

2. Outline of Presentation Anatomy Steps in evaluation of the Hip References

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

4. 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

5. 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

6. 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

7. 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

8. 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

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 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

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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 Walking – analysis of the gait and supine Pain may be referred to the Hip joint from the lumbar spine and the sacroiliac joint. These must be assessed

25. Palpation Iliac crest, Anterior Superior Iliac Spine Tensor fascia lata Posterior superior iliac spine, SI jt,ischial tuberosity, hamstrings, lumbosacral jts Greater trochanter

26. Active movements The most painful ones are done last Some movts are tested with the patient in supine & others in prone position Hip Extension done in prone

27. Active movts. Flexion/extension Abduction/Adduction ( supine or Side lying) Hip internal/ external rotation (sitting or supine)

28. Passive movements As in active movts. if necessary

29. Resisted isometric Hip Flexion/Extension Hip Abduction/Adduction Hip medial Rotation/lateral Knee flexion/extension

30. Special tests Use only tests that are necessary Faber Tests for Leg length – true, functional Proprioception/balance Thomas test – used to assess hip flexion contracture. Sign of the buttock- to assess whether pain is from Sciatica OR hamstrings Trendelenburg test- hip abd weakness

31. Functional tests Squatting Going up and down stairs Running straight ahead jumping

32. Suggested text Orthopaedic Physical Assessment by David Magee Orthopaedic Medicine by Monica Kesson and Elaine Atkins Living Surface Anatomy by Philip Harris and Craig Ranson