Evaluation of the Hip & Pelvis

Outline of Presentation

• Anatomy• Steps in evaluation of the Hip• References

Anatomy

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

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

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

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

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

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

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

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

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

Anatomy

• Extra-articular ligaments – Three extra-articular ligaments help provide

stability at the hip joint:• Iliofemoral ligament of Bertin/Bigelow• Pubofemoral ligament• Ischiofemoral ligament

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

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

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

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

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

Anatomy

• Muscles– Hip adductors. The adductors of the hip include

the adductor magnus, longus, and brevis, and the gracilis

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

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

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

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

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

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

Palpation

• Iliac crest, Anterior Superior Iliac Spine• Tensor fascia lata• Posterior superior iliac spine, SI jt,ischial

tuberosity, hamstrings, lumbosacral jts• Greater trochanter

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

Active movts.

• Flexion/extension• Abduction/Adduction ( supine or Side lying)• Hip internal/ external rotation (sitting or

supine)

Passive movements

• As in active movts. if necessary

Resisted isometric

• Hip Flexion/Extension • Hip Abduction/Adduction• Hip medial Rotation/lateral • Knee flexion/extension

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

Functional tests

• Squatting• Going up and down stairs• Running straight ahead• jumping

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