OA 1.13
• Please have your binder out and ready
for notes.
1
Chapter 18 (pp 456-470)
The Pelvis & Thigh
Objectives
Identify…
• The bones of the hip & thigh
• The ligaments of the hip & thigh
• The muscles of the hip & thigh
• Other structures
Skeletal anatomy
The pelvic girdle
• Illium, pubis, ischium
– Two innominate bones
• Acetabulum
– Portion of all 3 bones
• Sacrum
– 5 fused vertebrae
• Coccyx
– 4-6 fused vertebrae
The pelvic girdle
The pelvic girdle
• Ilium
– Forms upper 2/5
of acetabulum
• Ischium
– Forms posterior
2/5 of acetabulum
• Pubis
– Forms anterior
1/5
of
acetabulum
The pelvic girdle
• The ilium
– Anterior Superior
Iliac Spine (ASIS)
– Anterior Inferior
Iliac Spine (AIIS)
– Posterior Superior
Iliac Spine (PSIS)
– Posterior Inferior
Iliac Spine (PIIS)
The pelvic girdle
• The ilium
–Iliac fossa
(not shown)
–Iliac crest
–Greater
sciatic notch
The pelvic girdle
• The ischium
–Ischial tuberosity
–Ischial tuberosity
–Obturator
foramen
Obturator foramen
The pelvic girdle
• The pubis
– Pubic symphysis
– Pubic tubercle
– Obturator
foramen
The pelvic girdle
• The sacrum
– Connects spine to
pelvis
– Stabilizes pelvis
– Coccyx connects
inferiorly
– Fused vertebra
The femur
• Largest, strongest
bone in the body
– Head
– Neck
– Greater trochanter
– Lesser trochanter
Articulations
ARTICULATIONS
• Sacroiliac Joint
• Pubic Symphysis
• Acetabular Joint
Sacroiliac joint
• Fusion of the
sacrum and
posterior ilium
• Immobile
Pubic symphysis
• Joining of the two
sides of the pelvic
girdle
• Dense, fibrous
connective tissue
• Immobile
Acetabular joint
• Ball and socket
joint
– Very stable
– Relatively immobile
• Fibrous capsule
– Encloses the head
and most of the
neck of the femur
Ligaments &
Joint Capsule
Hip joint ligaments
•
•
•
•
Ligamentum teres
Ligamentum capitis
Round ligament
Ligament to the
head of the femur
All same thing!
Inguinal ligament
• From ASIS to the
pubic tubercle
• Functions to contain
soft tissues as they
pass from the trunk
to the lower
extremities
Joint capsule
• Synovial joint
• Reinforced by:
– Iliofemoral ligament
• “Y” ligament
• Ligament of Bigelow
• Strongest ligament
– Pubofemoral ligament
– Ischiofemoral ligament
Joint capsule
• The acetabulum is
surrounded by a
labrum
– Extension of cartilage to
deepen the joint
Muscular anatomy
Anterior hip & thigh
Muscles that cross the
hip
Muscles that don’t cross
the hip
• Iliacus
• Psoas major
• Rectus femoris
(crosses hip & knee)
• Sartorius
(crosses hip & knee)
• Pectineus
•
•
•
•
Vastus Medialis
Vastus Intermedius
Vastus Lateralis
Vastus Medialis
Lateral hip & thigh
• Tensor Fascia
Latae
• Gluteus Medius
• Gluteus Minimus
OA 1.14
• How are the anterior muscle of the hip &
thigh categorized?
• List them into their respective
categories.
33
Posterior hip & thigh
•
•
•
•
•
Gluteus Maximus
Biceps Femoris
Semitendinosus
Semimembranosus
Posterior fibers of
Adductor Magnus
Deep posterior hip & thigh
EXTERNAL ROTATORS
•
•
•
•
•
•
Piriformis
Obturator Internis
Gemellus Superior
Gemellus Inferior
Quadratus Femoris
Obturator Externis
Medial hip & thigh
•
•
•
•
Adductor Longus
Adductor Brevis
Adductor Magnus
Gracilis
Other structures
bursa
• Iliopsoas bursa
• Trochanteric bursa
Circulatory anatomy
• Iliac artery
• Femoral artery
• Femoral circumflex
arteries
– Surrounds the head
& neck of the femur
Neural anatomy
• Femoral nerve
– Anterior thigh
• Sciatic nerve
– Posterior thigh
– Tibial and
common peroneal
• Obturator nerve
– Medial thigh
Femoral triangle
• Superior: inguinal
ligament
• Lateral: sartorius
• Medial: adductor longus
• Femoral artery, femoral
vein, femoral nerve, and
lymph nodes run through
• Palpate femoral pulse
OA 1.21
A basketball player was going up for a lay
up and got her feet taken out from under
her. She lands hard on her left hip.
• What questions would you ask to gather
clues about what is going on?
• What are some relevant observations to
make regarding their body?
History & Observation
objectives
Identify…
• Pertinent information to gather during a hip &
thigh evaluation
• Important observations to make during a hip
& thigh evaluation
introduction
• Must understand anatomy & biomechanics
• Examination process is on-going
– Initial  rehab  RTP
• Must be systematic and methodical
• Must understand differential diagnosis (DDx)
– Options that a specific injury could be
– Pathologies often have similar S&S
• Rule out emergency situations quickly
– If unsure, err on side of caution
history
• Start with generic
history questions
– Chief complaint
– Age
– Occupation / sport /
position etc.
– General health
condition
– Activity level
– Medications
history
• History of
previous injuries
– What happened?
– Who did you see?
– What did they tell
you?
– How long were you
out?
– Has it fully
resolved?
history
• Mechanism of injury
– How did it happen?
•
•
•
•
Tension = sprain; fracture; strain
Torsion = sprain/labrum; fracture
Compression = contusion; fracture
Shear = fracture; sprain
history
• Mechanism of Injury – Hip & Thigh
specific
– Compression
– Internal/External rotation of the femur
– Overuse
history
• Ask these questions regarding PAIN
• P-rovocation – what causes it? what makes it
better?
• Q-uality – what does it feel like? neurological
symptoms?
• R-egion – where does it hurt? can you point
w/one finger?
• S-everity – how bad does it hurt? (1-10)
• T-iming – when does it hurt? how long?
history
Type of Pain
Structure
Cramping, dull, aching
Muscle
Dull, aching
Ligament, joint capsule
Sharp, bright, lightning-like, burning
Nerve
Deep, nagging, dull
Bone
Sharp, severe, intolerable
Fracture
Throbbing, diffuse
Vasculature
history
• Sounds & sensations
– Did you hear any
sounds? Did you
hear any pops,
crackles, snaps,
clicking?
• What could this
indicate???
– Did you feel
anything unusual?
history
• Specific to the HIP & THIGH
– Link the anatomy to the
pathology
• AKA: Where it hurts = what is
injured
– Focus on the onset/duration
• Link the start of symptoms to
changes in activity, training, etc.
– Prior medical conditions
• Congenital abnormalities
observation
• When does this begin?
• Compare each side bilaterally
to identify what is normal for
that person
We look for:
• Deformity, asymmetry, edema,
ecchymosis
observation
• Gross motor
function
– Can the athlete
move the limb on
their own through
normal function?
– Can they bear full
body weight?
observation
• Leg alignment
– Genu valgum –
knocked knee’d
– Genu varum –
bow-legged
– Squint eye patella –
points medially
– Frog eye patella –
points laterally
observation
• Additional examinations:
– Q-angle – degree of valgus alignment
between anterior hip & tibia
– Leg Length
– Gait analysis
Q-Angle
Critical thinking…
A hurdler comes to see you about pain she is having in
her anterior hip. She was at practice yesterday and on her
last hurdle she felt a “funny pull” in her lead leg. There
was an immediate shot of pain to the front of her hip bone,
and she immediately had to stop running. She iced it
when she got home and took some meds for the pain.
Today she felt worse. She could barely walk and wasn’t
able to lift her leg to go up/down the stairs. Now her hip is
all bruised and is very tender to the touch.
• What anatomy would you consider inspecting &
palpating? List all possibilities—bones, landmarks,
muscles, ligaments, etc.
• What other history questions would you ask? List 5.
• What injury/injuries do you think this is?
• How would you treat this athlete initially?
Critical thinking…
A hurdler comes to see you about pain she is having in
her anterior hip. She was at practice yesterday and on her
last hurdle she felt a “funny pull” in her lead leg. There
was an immediate shot of pain to the front of her hip bone,
and she immediately had to stop running. She iced it
when she got home and took some meds for the pain.
Today she felt worse. She could barely walk and wasn’t
able to lift her leg to go up/down the stairs. Now her hip is
all bruised and is very tender to the touch.
• What anatomy would you consider inspecting &
palpating? List all possibilities—bones, landmarks,
muscles, ligaments, etc.
• What other history questions would you ask? List 5.
• What injury/injuries do you think this is?
• How would you treat this athlete initially?
Critical thinking…
A hurdler comes to see you about pain she is having in
her anterior hip. She was at practice yesterday and on
her last hurdle she felt a “funny pull” in her lead leg.
There was an immediate shot of pain to the front of her
hip bone, and she immediately had to stop running.
She iced it when she got home and took some meds for
the pain. Today she felt worse. She could barely walk
and wasn’t able to lift her leg to go up/down the stairs.
Now her hip is all bruised and is very tender to the
touch.
• What anatomy would you consider inspecting &
palpating? List all possibilities—bones, landmarks,
muscles, ligaments, etc.
• What other history questions would you ask? List 5.
• What injury/injuries do you think this is?
• How would you treat this athlete initially?
Range of Motion
Remember…
• History
– Asking questions to gather information
regarding what happened & what the
patient is experiencing
– Clues to solve the puzzle of diagnosing the
issue
remember…
• Observation
– Deducing relevant signs of problems
– Uses our senses of sight & sound to gather
more clues
From SKILLS LAB…
• Palpation
– Allows us to
feel what is
going on
– Comparison of
normal to
abnormal
Range of motion
• For the hip…
– ROM occurs at
the coxofemoral
joint
• Acetabular joint
• Articualtion between
the acetabulum &
femur
Movements
Primary movements
• Flexion
• Extension
• Adduction
• Abduction
• Internal Rotation
• External Rotation
Hip movements
• Flexion –
decreasing the
joint angle
between the
femur and
pelvic girdle
• Tested with &
without knee
flexion
• Aka: straight leg
raise
• Aka: knee to
chest
• Normal: 120o
Hip movements
• Extension–
increasing the
joint angle
between the
femur and pelvic
girdle
• Tested with &
without knee flexion
• Aka: straight leg
raise
• Aka: lift foot off table
• Normal: 10-20o
Hip movements
• Tested in sidelying
• Abduction–
movement of the • Aka: straight leg
raise
leg away from
• Normal: 45o
the midline
Hip movements
• Tested in sidelying
• ADDuction–
movement of the with opposite knee
bent
in
front
of
test
leg towards the
leg
midline
• Normal: 30o
Hip movements
• Tested in a seated
• External
position with the
Rotation–
knee
bent
Rotation of the
femur away from • Toes move opposite
of
hip
movement
the midline
• Normal: 50o
Hip movements
• Internal
Rotation–
Rotation of the
femur towards
the midline
• Tested in a seated
position with the
knee bent
• Toes move opposite
of hip movement
• Normal: 45o
Range of motion
Definition:
– Range of motion refers to the distance
and direction a joint can move between
the flexed position and the extended
position
In true clinical settings, we
use a goniometer to
measure ROM
Range of motion
• Types
– Active range of motion (AROM)
– Passive range of motion (PROM)
– Resistive range of motion (RROM)
Range of motion
• AROM
– The patient’s ability to move a joint under
their own strength
• PROM
– The joint’s ability to be moved through a
range of motion
• RROM
– Measurement of the muscle strength of a
joint through the ROM
Range of motion
• Performed bilaterally on the
uninjured side first
– Why??
Allows us to get a look at what
is normal for that athlete!
Testing order
• R flexion – Straight Leg
& Bent Knee
• L flexion – SL & BK
• R abduction – sidelying
• L adduction – sidelying
• R extension – SL & BK
•
•
•
•
•
L extension – SL & BK
L abduction – sidelying
R adduction – sidelying
R ER & IR - seated
L ER & IR - seated
Testing order
• Test AROM, PROM,
RROM for all patient
positions before
moving into a new
position
• AKA: AROM flexion,
PROM flexion,
RROM flexion THEN
move the sidelying
Active Range of motion
• Have the patient move their knee
through the movements
– Lay face up: lift your leg straight up;
now drive your knee to your chest
– Lay on your left side: lift your right leg
up; plant your right knee and lift your
left leg up
Active Range of motion
• Have the patient move their knee
through the movements
– Lay face down: lift your leg straight off
the table; now bend your knee and
lift your foot into my hand
– Lay on your right side: life your left leg
up; now plant your left knee and lift
your right leg up
Active Range of motion
• Have the patient move their knee
through the movements
– Sit at the end of the table: rotate
your right leg in, then out; repeat with
the left leg
Passive range of motion
• The examiner will move the hip
through the ROMs to the extreme
end – why??
– I am going to move your hip/leg for
you. Just try to relax and let me know
if you feel discomfort, pain, or
anything unusual.
Resistive range of motion
• The athlete will move through each
ROM as the examiner places
resistance against the movement
– Repeat the ROM with resistance
placed at or below the knee
Muscles & tendons
• Anterior aspect – flex
& IR the hip (and
extend the knee)
– Quadriceps femoris
group
– Sartorius
– Iliacus
– Psoas major
– TFL
Muscles & tendons
• Posterior aspect –
extend the hip* (and
flex the knee)
– Hamstrings group
– Gluteus maximus
Muscles & tendons
• Lateral aspect –
abduct & ER the
hip*
• TFL
• Gluteus Medius
• Gluteus Minimus
Muscles & tendons
• Medial aspect –
adduct & IR the
hip*
• Adductor Longus
• Adductor Brevis
• Adductor Magnus
• Gracilis
Muscles & tendons
EXTERNAL ROTATORS
•
•
•
•
•
•
Piriformis
Obturator Internis
Gemellus Superior
Gemellus Inferior
Quadratus Femoris
Obturator Externis
Items to note:
• When assessing, make note of:
– differences in AROM
– Pain during PROM
– Decreased strength during RROM
But WHY??
Grading ROM
• AROM & PROM are graded as within
normal limits (WNL) or
decreased/limited & why
– AROM: R = WNL, L = decreased DF due to
pn
Grading ROM
• RROM is graded on a 0-5 scale
0.
1.
2.
3.
4.
5.
Absent – no muscle contraction
Trace – contraction without movement
Poor – full ROM without gravity
Fair – full ROM against gravity
Good – 3 + some resistance
Normal – 3 + full resistance
Documenting ROM
• When documenting ROM, each movement
must be listed & assessed.
AROM: R = WNL, L = WNL
PROM: R = WNL, L = WNL with Pn
RROM: R = 5/5DF, 5/5PF, 5/5INV, 5/5EV;
L = 5/5DF, 3/5PF due to Pn,
3/5INV due to Pn, 2/5EV due to
Pn