Chapter 20
The Hip
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Primary Roles of Hip
Support weight of head, arms, trunk during
upright postures and dynamic weightbearing activities.
Provides a pathway for transmission of
forces between the lower extremities and
pelvis.
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Anatomy and Kinesiology
Osteology and Arthrology
Acetabulum
Fusion of ilium, ischium,
and pubis
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Anatomy and Kinesiology
Osteology and Arthrology
Articulation of the
femoral head with the
acetabular labrum
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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
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Muscles of the Hip
Abductors
 Gluteus medius
 TFL
 Superior gluteus maximus
 Gluteus minimus
Adductors
 Adductor group
 Quadratus femoris
 Pectineus
 Obturators
 Gracilis
 Medial hamstrings
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Muscles of the Hip (cont.)
Medial Rotators
 TFL
 Gluteus minimus
 Anterior fibers of gluteus
medius
 Adductor magnus, longus
 Semimembranosus/
tendinosis
Lateral Rotators
 Piriformis
 Obturator interior/exterior
 Gemelli
 Quadratus femoris
 Glut maximus
 Posterior fibers of gluteus
medius
 Biceps femoris
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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
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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)
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Leg Length Discrepancy (LLD)
Unilateral difference in the total length of one leg
compared with another.
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Hip mobilization
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Flexion: Femur rolls superior and glides inferior on pelvis
Abduction: Femur rolls lateral/superior & glides inferior on pelvis
IR: Femur rolls medial & glides lateral on pelvis
Extension: Femur rolls inferior & glides superior on pelvis
Adduction: Femur rolls medial/inferior & glides superior on pelvis
ER: Femur rolls lateral & glides medial on pelvis
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Pelvic motions
Hip flexors cause an anterior pelvic tilt
Hip extensors a posterior pelvic tilt
Abductors and adductors a lateral pelvic tilt
Rotators of the hip cause rotation
To prevent excessive pelvic motion when moving
the femur at the hip joint, the pelvis must be
stabilized by the abdominals, erector spinae,
multifidus and quadratus lumborum muscles
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Anterior pelvic tilt
• Results in hip flexion and
increased lumbar spine
extension
• Caused by hip flexors and
back extensors
• Line of gravity falls anterior
to the axis of the hip joint,
stability is provided by the
abdominals and hip
extensors
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POSTERIOR PELVIC TILT
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Results in hip extension and
lumber spine flexion
Caused by hip extensors and
trunk flexors
Line of gravity of the tunk falls
posterior to the axis of the hip
joints, dynamic stability is
provided by the hip flexors and
back extensors and passively by
the iliofemoral ligament
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Synergy patterns of the hip
Flexor synergy
• Abduction and lateral
rotation
Extensor synergy
• Extension and medial
rotation and adduction
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Thomas test
• Asses for tight hip
flexors
• Supine with lumbar
spine stabilized &
involved LE extended
• Flex contralateral hip
to the abdomen
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Ely’s test
• Assess for tight rectus
femoris
• Sidelying to prone, hip
extension
• Flex knee
• Inability to maintain
hip extension when
knee is flexed
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Ober’s test
• Assess for tight ITB
• Sidelying with involved
hip up
• Extend involved hip &
allow LE to drop into
adduction
• (+) if LE fails to drop
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Scour
test
Assess for labral tear
Supine flex hip to 90
IR/ER hip with abd/add while applying a compressive
force down femur
(+) clicking, grinding or pain due to arthritis, labral tear,
avascular necrosis, osteochondral defect
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Anterior and posterior labral tests
• Assess for labral tear
• Ant: Supine in PNF D2 flexion (flex, ER & Abd)
• Post: Supine in PNF D1 flexion (flex, IR & Add)
• To test Ant: Resist D2 extension (ext, IR &Add)
Post: Resist D1 extension (ext, ER & Abd)
• (+) reproduction of pain or click
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Faber (patrick’s) test
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Assess SI jt pathology
Supine – passiely flex, abd
& ER so that the lateral
malleolus of the involved
LE is on the other knee
Apply overpressure to
flexed knee
(+) pain 2dary to OA,
osteophytes, intracapsular
FX or LBP 2dary to SI Px:
tightness without pain is () may indicate problem
with sartorius muscle
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Trendelenburg’s test
• Weakness of G.Med
• Standing
• Flex the contralateral
LE: iliac crest on WB
side should be lower
than the NWB side
• (+) dropping of the
NWB limb is 2dary to
abductor weakness
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Piriformis test
Assess for tight piriformis
Supine or contralateral
sidelying
Flex hip to 70-80 with knee
flexed & maximally adduct
LE (apply downward force to
the knee)
(+) pain in buttock &
sciatica; IR stresses superior
fibers; ER stresses inferior
fibers
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Ortolani’s and barlow’s tests
Ortolani’s test
Barlow’s test
• Asses for congenital hip
dislocation
• Supine knees and hip flexed to
90; clinician’s thumbs are on the
medial thigh and fingers on the
lateral thigh
• Firmly traction the thigh while
gently abducting the leg so that
the femoral head is translated
anterior into the acetabulum
• (+) reduction of the hip and
audible clunk
• Assess for hip dysplasia
• Supine 90/90; clinician’s
thumbs are on the infant’s
medial thigh & fingers on the
lateral thigh
• Apply a posterior force thru the
femur as the thigh Is gently
adducted
• (+) examiner’s finger that is on
the greater trochanter will
detect a palpable dislocation
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Treatment of Underused Synergist in Hamstring
Strain
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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
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Taping to Support Strained Gluteus Medius
Muscle
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Gluteus Medius Strength Progression
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Hypomobility – Improving ROM
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Therapeutic Exercise Interventions for Common
Diagnoses
Osteoarthritis
ROM and Mobility
1. Passive stretch
2. Active stretch
3. Active exercises
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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.
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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.
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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
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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.
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TFL/ITB Stretches
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Adjunctive Intervention – Taping
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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
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Strengthening Piriformis in
Shortened Range
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