Hip joint is a ball-and-socket joint

It consists of the femoral head and the pelvic acetabulum

Resting postion: 30° flexion, 30° abduction, slight lateral rotation

Closed packed position: extension, medial rotation, and abduction

Capsular pattern: flexion, abduction, medial rotation

Attachment sites:

The greater trochanter – ◦ Abductor muscles: Gluteus medius and Gluteus

minimus◦ Obturator internus◦ Piriformis ◦ Quadratus femoris

The lesser trochanter- ◦ Hip flexor muscle: Iliopsoas

Flexion: 110° Extension: 10° Abduction: 30-50° Adduction: 30° Lateral Rotation: 40-60° Medial Rotation: 30°

Nerves that can affect muscle weakness and sensory alterations around the hip:

Sciatic Nerve: L4-S1 Superior Gluteal Nerve Fermoral Nerve: L2-L4 Obturator Nerve: L2-L4

Dislocation of the Hip Fracture of the Femur Fracture of the Pelvis Osteoarthritis Snapping Hip Strains Trochanteric Bursitis

Femoral head is displaced from the acetabulum

Posterior dislocation more common- 90%

Symptoms: ◦ Severe pain

Felt in the anterior aspect of the hip/ groin◦ Inability to move the LE

Physical Exam◦ Affected limb will appear shorter◦ Hip is in a fixed position of flexion, adduction, and

internal rotation Diagnostic Tests

◦ Radiograph to confirm

Differential Diagnosis◦ Fracture of the acetabulum◦ Fracture of the femoral shaft

Neaton’s Line- Imaginary line drawn from the ischial tuberosity of the pelvis to the ASIS of the pelvis on the same side◦ If greater trochanter is palpated well above the

line, positive for dislocation

Ortolani’s Sign – Pediatric Congential Hip Dislocation

Telescoping Sign- Pediatric Dislocated Hip

Usually due to high velocity injuries

Symptoms:◦ Severe pain in the thigh◦ Obvious deformity◦ Unable to move or bear weight on LE

Physical Exam◦ Inspect for deformity◦ Open injury

Diagnostic Test◦ radiograph

Differential Diagnosis◦ Fx of acetabulum◦ Malignant or metastatic lesion of femur◦ Osteomyelitis◦ Stress fracture of the femur

Fx of Femoral Neck

Common in elderly patients with osteoporosis◦ Chance of injury doubles every decade after 50 y.o.◦ Caucasian women are 2 times more likely to be

affected

Symptoms◦ Patients report a fall followed by the inability to

bear weight◦ Pain in the groin

Physical Exam◦ Pt. lies with the limb externally rotated, abducted

and shortened◦ Gentle rotation with the hip extended is painful

Diagnostic Tests◦ Radiograph, MRI

Differential Diagnosis◦ Pathologic fracture- due to tumor◦ Pelvic Fracture

Characterized by a dull, aching pain in the groin, lateral thigh, or buttocks region.

Pt. experiences morning stiffness with improvement with moderate activity, with increased pain with vigorous activity

Note a progressive limp, and limited ROM

Difficulty dressing and donning shoes

Physical Exam◦ Gait Abnormalities-

Antalgic Gait (short stance phase on the affected side) Trendelenburg Gait- develops with progressive loss of

cartilage Hip ROM is restricted

Differential Diagnosis◦ Ankylosing spondylitis◦ Gout◦ Infection◦ Osteoarthritis◦ Osteonecrosis◦ Reiter Syndrome◦ RA◦ Lupus◦ Trochanteric bursitis

Compression or entrapment of the lateral femoral cutaneous nerve is characterized by pain, burning, or hypoesthia over the lateral thigh

Causes:◦ Obesity◦ Compression from tight clothing or straps around

the waist (tool belt or backpack)◦ Trauma involving hip extension◦ Mild repetitive trauma over the nerve

Symptoms◦ Pain and dysesthesia in the anterolateral or lateral thigh that

sometimes extends to the lateral knee◦ Runners describe pain as “electric jab” when affected hip

extends

Physical Exam◦ NO muscle weakness- only a sensory nerve◦ Most reproducible spot of hypoestesia is above and lateral to

the knee with pressure

Differential Diagnosis◦ Lumbar disk herniation (L1-L4)◦ Trochanteric bursitis◦ Hip arthritis◦ Diabetes mellitus or other causes of peripheral neuropathy

Characterized by loss of articular cartilage of the hip joint

Symptoms◦ Gradual onset of anterior thigh or groin pain

(sometimes pain in the buttock or lateral thigh)◦ Initial pain only with activity, gradual increase in

frequency and intensity of pain◦ Decrease ROM◦ Difficulty dressing and donning shoes◦ Occasional limp and stiffness but little pain

Physical Exam◦ Earliest sign is loss of Internal Rotation◦ Decreased overall ROM◦ May develop a fixed External Rotation and Flexion

Contracture◦ Gait:

antalgic gait with decreased stance on affected leg Abductor Lurch- swaying the trunk far over the affected hip

Differential Diagnosis◦ Herniated lumbar disk◦ Inflammatory arthritis of the hip◦ Osteonecrosis of the femoral head◦ Trochanteric brusitis

Death of varying amounts of bone in the femoral head

Causative event may be traumatic disruption of the vascular supply to the femoral head or deficient circulation (sickle cell anemia)

Greatest frequency from 30-50 y.o.

Often bilateral

Risk Factors:◦ Hip dislocation◦ Femoral neck Fx◦ Alcohol abuse/Smoking◦ Sickle Cell Anemia◦ RA◦ Lupus

Symptoms◦ Slow onset of dull ache or a throbbing pain in the groin, lateral hip or

buttock area◦ Initial phase very painful during bone death◦ Secondary arthritis ◦ Limited ROM with progressive limp

Physical Exam◦ Pain with attempted SLR◦ ROM decreased especially in Internal Rotation◦ Gait:

Antalgic gait with short stance phase Trendelenburg gait once arthritis develops

Differential Diagnosis- Made with a radiograph◦ Fracture of the femoral neck◦ Muscle strain or groin pull◦ Osteoarthritis◦ Septic arthritis of the hip

Characterized by a snapping or popping sensation that occurs as tendons around the hip move over bony prominences

Most common site is iliotibial band snapping over greater trochanter

Also occurs when the iliopsoas tendon slides over the pectineal eminence of the pelvis

Symptoms:◦ Occurs with walking or rotation of the hip◦ Patients point to the trochanteric area◦ Iliopsoas snapping pain felt in the groin as the hip

extends from the flexed position (like rising from a chair)

Physical Exam◦ Recreate iliotibial band subluxation by having

patient stand and then rotate the hip while holding it in an adducted position- a snap can be palpated

◦ Iliopsoas snapping can be palpated as the hip extends from a flexed position

Differential Diagnosis◦ Osteoporsis ◦ Osteochondral loose body◦ Osteonecrosis of the femoral head

Cause is vigorous muscular contraction while the muscle is on stretch

Muscles to consider: abdominals, hip flexors(iliopsoas, sartorius, rectus femoris), and adductors

Symptoms:◦ Pain over the injured muscle

Physical Exam◦ Strain of Adductors- tenderness in the groin with

increase pain with passive abduction◦ Abdominals- increased pain when patient flexes trunk◦ Hip Flexor- pain is worse with flexion of the hip against

resistance, or passive extension of the hip◦ Iliopsoas- causes pain in deep groin or inner thigh◦ Proximal Sartorius- more superficial and lateral

Differential Diagnosis◦ Hip avulsion fracture◦ Osteonecrosis◦ Pelvic of femoral tumors

Inflammation and hypertrophy of the greater trochanteric bursa

Symptoms:◦ Pain and tenderness over the greater trochanter◦ Pain may radiate distally to knee or ankle but NOT

foot◦ Pain may radiate proximally to the buttock◦ Pain worse when first rising from the seated or

recumbent position◦ Pain recurs after walking >30 minutes◦ Night pain and inability to lie on affected side

Physical Exam◦ Palpate greater trochanter for point tenderness (this is

a must)◦ Pain exacerbated with active hip abduction◦ Increased discomfort with hip adduction

Differential Diagnosis◦ Gluteal Muscle Tendinitus- pain pattern may be

similar, however usually tenderness is ABOVE the trochanter

◦ Metastatic tumor◦ Osteoarthritis ◦ Sciatica◦ Snapping Hip

FABER test- Flexion Abduction External Rotation- positive test indicates hip joint dysfunction, possible iliopsoas spasm, or sacroiliac joint may be affected

Thomas Test-used to assess a hip flexion contracture, tight iliotibial band

Ober’s Test- tests tensor fasciae latae (iliotibial band) for contracture- can also suggest trochanteric bursitis if it is tender or femoral nerve pathology if neurological signs are present

Straight Leg Raise (SLR)- tight hamstrings, neurological symptoms could indicate lumbar disc dysfunction

Magee DJ. Orthopedic Physical Assessment. 4th ed. St. Louis: Saunders Elsevier. 2006: 425-465,879-903.

Griffin LY, ed. Essentials of Musculoskeletal Care. 3rd ed. Rosemont: American Academy of Orthopedic Surgeons. 2005:928-931