Revision of the Hip
Anatomy
Joint: Synovial ball and socket with a Fibro-cartilagenous labrum
Capsule: Longitudinal (contains blood vessels) and Circular fibres (zona articularis)
Ligaments:
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Blood supply:
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Pubofemoral : Prevents Extension
Iliofemoral: Prevents Extension
Ischiofemoral: Prevents: Flexion
Ligamentum Teres
Medial and Lateral circumflex femoral arteries from Profunda A from Femoral
Obturator arteriy via ligamentum teres
Cruciate anastamosis
Trochanteric anastamosis
Arterial development: At birth lig teres is not present. Circumflex arteries supply the head
and neck.
Epiphyseal ossification begins at 4 months and lateral ascending branch supplies the head
until 7 years old.
After 7 years lig teres becomes more reliable
At 10 years the trochanter has ossified and growth plate extends over the femoral capital
epiphyses
Fusion of the epiphyses at 14-17 years old
Nerve Supply:
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Revision of the Hip
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Femoral nerve L2-4
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Obturator nerve L2-4
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Sciatic nerve L4-S3
Bursae:
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Trochateric
lies between gleut max and posterior
lateral prominence of the greater
trochanter
Test Flex hip and INT ROT
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Iliopsoas/iliopectineal bursa
Between psoas and hip capsule can ref
pain into the anterior thigh if swollen
irritating the femoral nerve
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Ischial tuberosity
Over the ischeal tuberosity.
Proloonged sitting = weavers bottom
Angles:
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Inclination 20
Antiversion 15
Neck shaft - 120
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Revision of the Hip
Muscles of the Hip:
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External rotation (30’ with hip EXT, 50’ with hip FLEX)
 Gleuteus MAX/MED/MIN
 Quadratus Femoris
 Obturator Internus, Externus
 Iliopsoas
 Adductor Magnus, Longus, Brevis, Minimus
 Piriformis
 Sartorius
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Internal rotation (40’)
 Gleuteus MED/MIN
 TFL
 Adductor Magnus
 Pectineus
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Extension (20’)
 Gleuteus MAX/MED/MIN
 Adductor Magnus
 Piriformis
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Flexion (140’)
 Iliopsoas
 TFL
 Pectineus
 Adductor Longus/Brevis
 Gracillis
 Rectus Femoris
 Sartorius
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Abduction (50’)
 Gleuteus MED/MIN/MAX
 TFL
 Piriformis
 Obturator INT
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Adduction (30’ with EXT, 20’ with FLEX)
 Adductor Magnus/Longus/Brevis/Minimus
 Pectineus
 Quadratus Femoris
 Semitendinosus
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Revision of the Hip
Trigger points that cause hip pain:
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TFL
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QL
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Piriformis
Referral patterns from the hip:
Medial knee pain referral from the obturator nerve which supplies the inferior joint capsule
via irritation of the inferior join capsule from articular debris. Also causes adductor spasm.
Groin pain
Hip #
Meralgia Parestherica – burning pain, numbness over LAT thigh (possibly ANT thigh.
Compression of the lateral cutaneous nerve of the thigh (L2-3) as it passes under the
inguinal ligament and over sartorius
Examination routine:
1.
Observation
2.
Active movements: squat and twist
3.
Special tests: Trendelenberg
4.
Palpation
5.
Active resisted movements
6.
Passive movements: Flex, Ext, Int, Ext Rot, Abd, Add
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Revision of the Hip
7.
Special tests for the Hip
Supine
Gillets’s test – aka stalk test. Palpate the PSIS and the Sacrum and as
the leg is raised the PSIS should move inferiorly. If it moves superiorly
this is suggested to be hypomobile.
Trendelenberg test
Tests the integrity of the hip. Also used to demonstrate varicose veins
Stand on 1 leg and flex the other to 90’ If the hip drops on one side =
+ve test identifying weak hip abductors, bone defects
Sitting Passive INT and EXT ROT – if pain is replicated then it might
indicate the hip
FABER test – Flexion, Abduction, External ROT
S/L
If pain in the groin it suggests the hip
If pain posteriorly or when pushing on knee and contralateral ASIS it
suggests the SIJ
Thomas test:
lay supine with the legs extended and flex the good leg to flatten the
l.sp. A fixed flexion deformity will be visible as the bad hip will be lifted
up.
Barlows test – (putting the hip back!)
Flex hip, Push posteriorly
Ortalani’s test – (relocate the hip)
If dislocated it cannot be abducted
To relocate the hip pull on the femur and the femoral head should
“clunk” into the acetabulum.
Scour test – downward pressure with the hip flexed and adducted and
INT and EXT ROT applied
Ober test – for tight ITB
Standing
Sitting
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Revision of the Hip
Vindicater of Hip pain
Vascular:
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Avascular necrosis (Perthes) – damage/weakness to the arterial supply
of the hip joint. 3months – 3 years
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DVT,
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Meralgia Parestherica (lateral cutaneous nerve of the thigh)
Infective/Inflammatory:
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Septic arthritis – infection in the joint via blood, surgery or injury to
joint. Associated with red, hot swollen joint with fever and malaise.
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Synovitis
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Protrusio acetabuli
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TB (focused in the neck of the femur)
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Still disease
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Syphillis
Neoplastic:
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Primary cancers from leukaemia, multiple myeloma, osteosarcoma,
chondrosarcoma, Ewings sarcoma, Sarcoma
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Secondary cancers from : Breast, Thyroid, Lung, Prostate, Kidney
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Padgets – disorder of normal bone remodelling
Degenerative:
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OA – Non inflammatory degenerative joint disease marked by:
degeneration of the articular cartilage, hypertrophy of bone at the margins,
and changes in the synovial membrane accompanied by pain and stiffness
Hip flexed, increased lordosis, increased tension on thoracolumbar fascia and
hamstrings
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Labral tear - Damage to the labrum, a ring of cartilage found in hip and
shoulder joints to reduce friction, provide stability and yet allow flexibility and
motion.
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Secondary Protrusio acetabuli from OA
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Femoral acetabular impingement – abnormal rub of the femoral head
or reduced ROM of the acetabulum can cause damage to the articular
cartilage or labrum. Associated with sports. 3 forms:
o CAM (deformity of femoral head. Congenital),
o Pincer (deformity of acetabular rim), Combined CAM and Pincer. In
young and active people. Hip and groin pain.
Iatrogenic:
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DDH – shallow acetabulum, deformation and misalignment of the hip.
10* more common in breach births, Females > Males and 1st borns
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Snapping hip – ITB tract moving over the gluteal tuberosity on FLEX
ADD and ROT most common. ilio psoas tendon. Labrum. X-ray to check joint.
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Revision of the Hip
Ultrasound and MRI scans inconcluive.
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Test for labrum – push down femur and the rotate medially and
laterally.
Congenital:
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DDH
Auto immune:
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Secondary Protrusio acetabuli from AS
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Revision of the Hip
Vindicator of hip pain continued
Trauma
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SUFE – slippage of growth plates due to trauma, Males>Females,
Obese, Endocrine abnormalities. 14-17 years old due to hypervascular state
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Labral tear - Damage to the labrum, a ring of cartilage found in hip and
shoulder joints to reduce friction, provide stability and yet allow flexibility and
motion.
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# or stress #
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Protrusio acetabuli
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L.sp disc prolapse
Endocrine:
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Protrusio acetabuli
Rheumatological:
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RA – a large amount of synovium in hip joint. In RA there is a
proliferation of the synovium leading to erosion of articular cartilage.
Persistent pain, can be night pain.Severe stiffness
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Secondary Protrusio acetabuli from RA
The acetabulum can soften and protrude into the pelvis “protrusion acetabuli”
Conditions by age
Acetabular dysplasia
Developmental dislocation of hip
Avascular necrosis
Infection e.g. TB
Transitury arthritis
Slipped capital femoral epiphysis
Osteochondrosis dissecans
Protrusio Acetabulli
Muscle lesion
Lig, Capsule, Labrum lesion
Bursitis
Arthritis (OA, RA, AS)
Bursitis/Transient synovitis
Loose bodies
Avascular necrosis
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Revision of the Hip
Treatment of Hip OA:
Soft Tissue
Why: The hip is held in Flexion,
Adduction and External rotation
MET
Consider that an MET can bring two
surface together, Potentially stretch
out the joint and tissues first
Articulation
Consider reducing joint compaction
prior to Artic due to grinding the joint
surfaces toether
HVT
Transitional areas often get restricted
due to facet angle changes of force
through the regions.
Hip Flexors : Psoas, Rec Fem
Hip Adductors: Gracillis, Adductors
Hip Ext Rot: Gamellae, Obturators, Piriformis
Psoas MET
Rectus fem MET
Adductor MET
Piriformis MET (prone and taken to a point of
stretch ,MED ROT, and MET)
Hip distraction and traction
Hip harmonics into INT and EXT ROT
L.sp
SIJ
Knee
Junctional areas: T/L, L/S,
SIJ, Superior Tib Fib
Upper lumbar spine – affect the nerve supply of the
hip L2-4
Local joints to improve gait and force
transferrance
Autonomic nerve supply to the hip
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Revision of the Hip
Medical ttt of Hip OA
Surgery
Total Hip Replacement:
http://orthoinfo.aaos.org/topic.cfm?topic=a00377
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Metal on Plastic (Steel, Cobalt,
Titanium)
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Metal on Metal
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Ceramic on Ceramic
Hip resurfacing:
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Metal cap and cup
Arthroscopy:
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Following surgery
Key hole tidy up
For the first few weeks no flexion beyond
90’, No abduction, No Adduction, No
excessive INT or EXT ROT.
Good leg up, bad leg down the stairs
Sleep with a pillow between knees
Graded walks
Aquatherapy – ROM exx and
strengthening
Theraband exx to strengthen
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