Hip, Pelvis and Thigh : Hip, Pelvis and Thigh : Anatomy, EvaluationAnatomy, Evaluation

BONY ANATOMYBONY ANATOMY

Hip Capsule LigamentsHip Capsule Ligaments

Iliopsoas bursa

Hip - AnatomyHip - Anatomy

Multiaxial ball & socket jointMultiaxial ball & socket joint AcetabulumAcetabulum

1/2 sphere1/2 sphere Femoral headFemoral head

2/3 sphere2/3 sphere Strong ligaments & capsuleStrong ligaments & capsule Maximally stableMaximally stable

ObservationObservation

GaitGait PosturePosture BalanceBalance Limb positionLimb position

shortened, adducted, medially rotatedshortened, adducted, medially rotated abducted, laterally rotatedabducted, laterally rotated shortened, laterally rotatedshortened, laterally rotated

Leg shorteningLeg shortening

InspectionInspection

Pelvic unleveling (iliac crest levels)Pelvic unleveling (iliac crest levels) Pelvic rotation (PSIS levels)Pelvic rotation (PSIS levels) If asymmetric, measure leg lengthsIf asymmetric, measure leg lengths

Leg Length MeasurementsLeg Length Measurements

Eyeball methodEyeball method Measurement methodMeasurement method

Range of MotionRange of Motion

Flexion: 110 to 120 Flexion: 110 to 120 degreesdegrees

Extension: 10 to 15 Extension: 10 to 15 degreesdegrees

Abduction: 30 to 50 Abduction: 30 to 50 degreesdegrees

Adduction: 30 Adduction: 30 degreesdegrees

External rotation: 40 External rotation: 40 to 60 degreesto 60 degrees

Internal rotation: 30 Internal rotation: 30 to 40 degreesto 40 degrees

ExaminationExamination

Strength testingStrength testing isometricisometric eccentriceccentric knee extensionknee extension knee flexionknee flexion

Hip Flexion StrengthHip Flexion Strength

Iliopsoas, rectus femoris, sartorius, tensor fascia lata, pectineus

Hip Extension StrengthHip Extension Strength

Hamstrings, gluteus maximus

Hip Adduction StrengthHip Adduction Strength

Adductor longus, adductor brevis, adductor magnus, gracilis, pectineus, oburator externus

Hip Abduction TestingHip Abduction Testing

Gluteus medius, gluteus minimus, tensor fascia lata

Internal Rotation Internal Rotation StrengthStrength

Gluteus medius, gluteus minimus, tensor fascia lata

External Rotation External Rotation StrengthStrength

Piriformis, Obturator internus & externus, Superior/inferior Gemelli, Quadratus femoris, Gluteus maximus

Special TestsSpecial Tests

Patrick’s TestPatrick’s Test(FAbER)(FAbER) hip joint hip joint SI jointSI joint

Gaenslen’s SignGaenslen’s Sign

Pain at ipsilateral SIJ is positive test

Special TestsSpecial Tests

modified Thomas Testmodified Thomas Test hip flexor and quad flexibilityhip flexor and quad flexibility

Special TestsSpecial Tests

Ober TestOber Test iliotibial band flexibilityiliotibial band flexibility

Special TestsSpecial Tests

Piriformis TestPiriformis Test Piriformis flexibility or Piriformis flexibility or

painpain

Special TestsSpecial Tests

Popliteal AnglePopliteal Angle Hamstring flexibiltyHamstring flexibilty

Special TestsSpecial Tests

Labral InjuryLabral Injury FAdAxL: FAdAxL: flexion, flexion,

Adduction, Axial Adduction, Axial Load + some IR/ERLoad + some IR/ER pain +/- clickpain +/- click

Weber-Barstow Maneuver

*Can measuretrue vs. apparent

Gross Leg Length Discrepancy

Magee 4th

Edition – pg. 628

Prone Knee Flexion Test for Tibial Shortening

Magee 4th

Edition - pg. 630

Thomas Test

3 Muscle Kendall testAs above….but also look at….IP = hip flexor and hip ERRF = hip flexor and knee extensorTFL/ITB = hip flexor and hip abductor

Magee - 4th Edition

Ely’s Test

Prone, passive knee flexion

Positive for RF tightness if pelvic anterior tilting / hip flexion accompanies knee flexion before end range and if asymmetrical in bilateral comparison

Magee 4th Edition

FAIR Test

Cleland, J. – Orthopedic Clinical Examination

Fishman et. al (2002) Archives of Physical Medicine – 10 yr. PiriformisstudySen. .88Spec. .83+LR= 5.2-LR=.14

(+) = pain atintersection ofsciatic nerveand piriformis

Ober Test

Magee 4th Edition – pg. 633

Reese and Bandy (2003) JOSPTOber Test

Modified Ober Test (4-50 > Ober test)

Ober

ICC=.90

Modifie

d Ober

ICC=.91

Leg Length Tests

True Leg Length Discrepancy Measure ASIS to

medial malleolus Positive = 1-1.5 cm

Apparent (Functional) Leg Length Umbilicus to Medial

malleolus

Trendelenberg Test

Pt Position = standing on one leg with WB leg being the involved limb

Positive = pelvis on opposite side drops

Indications = weak Gluteua medius

Kendall Test

Pt Position = supine with knees bent over the table

Evaluation One hand under lordotic

curve Passively flex hip to chest Allow opposite leg to rest

on table Positive = knee move

into extension or leg rises off table

Thomas Test

Pt Position = supine with both leg on table

Evaluation One hand under lumbar

region Passively flex one leg to

chest

Positive = straight leg raises off table Increased lordotic curve

Measurements

True leg length Measure from A.S.I.S

to inferior border of medial malleolus

Measurements

True Shortening In true shortening the affected

limb is physically shorter than the other and this may be caused by pathology proximal or distal to the trochanters.

True shortening from causes distal to the trochanters most frequently results from previous fractures of the femur or tibia or growth disturbance (e.g. from polio or epiphyseal trauma). Proximal to the trochanters causes include femoral neck fractures, OA and hip dislocation.

Measurements

Apparent leg length Measure from tip of xiphoid

process to inferior border of medial malleolus

Apparent Shortening In apparent shortening the

limb is not altered in length, but appears shortened. This may be as a result of an adduction contracture of the hip joint, which has to be compensated for by tilting of the pelvis, or SIJ pathology causing pelvic rotation.

MovementExpected Range of Movement Flexion: 0-130

Degrees Abduction: 0-45 Degrees Adduction: 0-30 Degrees MR: 0-45 Degrees LR: 0-60 Degrees Extension: 0-20 Degrees

Movements

Thomas’ test:• Place your left hand in hollow of lumbar spine• Flex hip and knee of unaffected side • Look to see if hip of the affected side lifts

from bed Flexion:• Flex hip and knee of affected side and note

ROM (130°)

Movements

Abduction:

• Stabilise pelvis and hold ankle with other hand

• Abduct and note ROM (45°)

Adduction:

• As above and note ROM (30°)

Movements

Rotation:• Flex hip and knee to 90 degrees, externally

and internally rotate• Note ROM (45°)

Abnormal Movement (telescoping):• Alternately push and pull leg along its long

axis – demonstrates marked instability

Trendelenberg Test

Used to assess the ability of the hip abductors to stabilise the pelvis on the femur.

A positive test demonstrates that the hip abductors are not functioning.

Causes:• Disturbance in pivotal mechanism – dislocation

or subluxation of hip, shortening of femoral neck• Weakness of the hip abductors e.g. myopathy,

neuropathy

Trendelenberg Test

The test is performed with the patients back to the examiner. The model stands on the normal leg and flexes the knee of the other leg to a right angle.

The pelvis should remain level or tilt slightly upwards on the unsupported side.

The model then stands on the affected leg and flexes the knee of the other leg.

If the pelvis tilts downwards on the unsupported side, then this confirms a positive Trendelenberg sign.

Trendelenberg Test