The Hip
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Chapter 20 The Hip Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins Anatomy and Kinesiology Osteology and Arthrology Acetabulum Fusion of ilium, ischium, and pubis Copyright 2005 Lippincott Williams & Wilkins Anatomy and Kinesiology Osteology and Arthrology Articulation of the femoral head with the acetabular labrum Copyright 2005 Lippincott Williams & Wilkins Two Angular Relationships Angle of inclination of femoral head Copyright 2005 Lippincott Williams & Wilkins Angular Relationships Angle of torsion Projection of the long axis of the femoral head and the transverse axis of femoral condyles Copyright 2005 Lippincott Williams & Wilkins Ligaments of Hip Copyright 2005 Lippincott Williams & Wilkins Muscles of the Hip Flexors Iliopsoas TFL Rectus femoris Sartorius Adductor magnus, longus, brevis Pectineus Gracilis Extensors Gluteus maximus Hamstrings Posterior fibers of gluteus medius Piriformis Copyright 2005 Lippincott Williams & Wilkins Muscles of the Hip Abductors Gluteus medius TFL Superior gluteus maximus Gluteus minimus Adductors Adductor group Quadratus femoris Pectineus Obturators Gracilis Medial hamstrings Copyright 2005 Lippincott Williams & Wilkins Muscles of the Hip (cont.) Medial Rotators Lateral Rotators TFL Gluteus minimus Anterior fibers of gluteus medius Adductor magnus, longus Semimembranosus/ tendinosis Piriformis Obturator interior/exterior Gemelli Quadratus femoris Glut maximus Posterior fibers of gluteus medius Biceps femoris Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins 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) Copyright 2005 Lippincott Williams & Wilkins Relationship of Hip and Pelvic Motion in Sagittal Plane Copyright 2005 Lippincott Williams & Wilkins Lateral Pelvic Tilt – Frontal Plane Copyright 2005 Lippincott Williams & Wilkins Rotation of Pelvis and Hip Transverse Plane Copyright 2005 Lippincott Williams & Wilkins Kinetics and Kinematics of Gait Single limb stance component of gait Copyright 2005 Lippincott Williams & Wilkins Anatomic Impairments Angles of Inclination Copyright 2005 Lippincott Williams & Wilkins Angle of Torsion Copyright 2005 Lippincott Williams & Wilkins Center Edge Angle – Angle of Wiberg Average adult – 22°–42° Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins Examination and Evaluation History Lumbar spine clearing examination Other clearing tests (visceral involvement, knee involvement) Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins Impaired Muscle Performance Result of: Neurologic pathology Muscle strain Altered length-tension relationships General weakness from disuse Pain and inflammation Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins Treatment of Underused Synergist in Hamstring Strain Copyright 2005 Lippincott Williams & Wilkins Functional Progression Copyright 2005 Lippincott Williams & Wilkins Functional Progression Copyright 2005 Lippincott Williams & Wilkins Quality of Step-Up Movement Pattern Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins Taping to Support Strained Gluteus Medius Muscle Copyright 2005 Lippincott Williams & Wilkins Gluteus Medius Strength Progression Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins Functional Approach to Treating Medial Hip Rotation Tendencies Copyright 2005 Lippincott Williams & Wilkins Functional Approach to Treating Medial Hip Rotation Tendencies Copyright 2005 Lippincott Williams & Wilkins Compensation of Limited Hip Lateral Rotation ROM Copyright 2005 Lippincott Williams & Wilkins Hypomobility Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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). Copyright 2005 Lippincott Williams & Wilkins Hypomobility – Improving ROM Copyright 2005 Lippincott Williams & Wilkins 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 forceplatform biofeedback systems. Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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) Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Interventions for Common Diagnoses Osteoarthritis ROM and Mobility 1. Passive stretch 2. Active stretch 3. Active exercises Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins TFL/ITB Stretches Copyright 2005 Lippincott Williams & Wilkins Adjunctive Intervention – Taping Copyright 2005 Lippincott Williams & Wilkins 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 Copyright 2005 Lippincott Williams & Wilkins Strengthening Piriformis in Shortened Range Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins 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. Copyright 2005 Lippincott Williams & Wilkins
