REGIONAL LE : HIP AND

THIGH

FUERTE-FELICANO-PASHA
TABAJONDA-VILLAHERMOSA

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ANATOMY
TABAJONDA
A. PELVIC BONES
(R) and (L) innominate bone or os coxa

A. Ilium
Triradiate
B. Ischium
Ligament
C. Pubis
4
1. ILIUM
(means wing/ ear) Largest,
Anterior and superior of the 3 pelvic bones.
Contributes to 40% of acetabulum
Upper 2/5 of pelvis

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 i.iliac crest = L4, highest point in the
pelvis (Homologous: Acromion)

ii.ASIS –(Origin of Sartorius, Inguinal

Ligament/ poupart’s)
- Impt landmark for assessing
pelvic position, leg length and Q angle
- Femoral Artery

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 iii..AIIS – origin of Rectus femoris straight head ;
Iliofemoral ligament
iv. PSIS – S2, Dimple of Venus
- COG
v- PIIS
vi- Iliac Tubercle- L5
vii- iliac fossa/ wing/ Ala of ilium
- muscle- Iliacus

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8
2. Ischium
-L Shaped structure
Posterior, inferior bone of the
pelvis
Makes up to 40% of acetabulum
Lower posterior 2/5 of pelvis

BODY- upper thicker portion

Ramus- lower thicker portion
- O: adductor Magnus,
Gracilis, Obturator Externus (MGO)

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 Ischial Spine – separate the greater & lesser
sciatic notch
: Gemellus Superior, Sacrospinos Ligament

Ischial tuberosity, (sit bone)

Functions: Weight bearing when sitting
Attachment of hamstring ms and a portion of
adductor magnus

Ischiogluteal bursa
i. Prolonged sitting causes bursitis, known as:
1. Tailor’s, Weaver’s, Boatman’s bottom

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3. Pubis
Contributes to 20% of acetabulum
Lower anterior 1/5 of pelvis

Body- unite symphsis pubis ; anteriorly

Superior Ramus- unite with ilium &
ischium @ acetabelum
-(O) Pectineus; Pubofemoral Ligament
Inferior Ramus- joins ramus
of ischium
@ obturator foramen

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 Pubic Crest- (O) MGBO= adductor
Magnus, Gracilis, adductor brevis,
Obturator Externus
Pubic Tubercle- Inguinal
Ligament/ Poupart’s
Ligament

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SACRUM
-consists of 5 rudimentary vertebrae
fused together to form a single wedge-
shaped bone with a forward concavity
Upper border or base of the bone
articulates with 5th lumbar vertebrae
Laterally , the sacrum articulates
with 2 iliac bones to form SI joint
Tilted forward so that it forms an
angle with the 5th lumbar vertebrae
called: Lumbosacral angle (140
degree)
COCCYX
-consists of 4 vertebrae fused
together to form a small triangular bone
PELVIS
- divided into 2 parts by pelvic brim

False Pelvis/Greater Pelvis/Upper Pelvis

ANT: Lower Part of abdominal wall
POST- Lumbar Vertebrae
Lat- Iliac fossa/Iliacus mm
PELVIS
True Pelvis/ Lesser/ Lower Pelvis
- has an inlet, outlet & a cavity

PELVIC INLET (SIS –IN) Ant-Post

ANT- symphysis pubis
LAT- Iliopectineal line
POST- Sacral Promontory

PELVIC OUTLET (PIC- OUT) Ant-Post

Ant- Pubic Arch
Lat- Ischial Tuberosity
Post- Coccyx

PELVIC CAVITY: b/w inlet & outlet

PELVIS
Caldwell & Moloy Classification:
Divided pelvis into four groups

Gynecoid, android, anthropoid &

platypelloid
GYNECOID
A gynecoid pelvis is oval at the inlet, has a
generous capacity and wide subpubic arch
This is the classical female pelvis.
Pelvic brim is a transverse ellipse
(nearly a circle)
Most favorable for delivery.
The gynecoid pelvis (sometimes called a “true
female pelvis”) is found in about 50% of the
women in America.
ANDROID
An android pelvis is more triangular in shape at
the inlet, with a narrowed subpubic arch.
Larger babies have difficulty traversing this pelvis
as the normal areas for fetal rotation and extension
are blocked by boney prominences
(Male type) Pelvic brim is
triangular Convergent Side Walls (widest
posteriorly) Prominent ischial spines, Narrow
subpubic arch
sometimes called a “true male pelvis
ANTHROPOID
like the gynecoid pelvis, basically oval at the
inlet, but the long axis is oriented vertically
rather than side to side.
Subpubic arch may be slightly narrowed.
This pelvis favors occiput posterior
presentations.
Much more common in black women
The anthropoid pelvis is very long and almost
“ovoid” in shape
 PLATYPELLOID/PLATYPOID
is flattened at the inlet and has a prominent sacrum.
The subpubic arch is generally wide but
the ischial spines are prominent.
This pelvis favors transverse
presentations.
Pelvic brim is transverse kidney
shape.
The platypelloid pelvis is very short (almost like a
“flattened gynecoid shape”)
 ACETABULUM
½ OF a SPHERE (deep depression)

Faces laterally, inferiorly and anteriorly (L-I-A)

Concave partner of femur to form the

acetabulofemoral joint
Periphery is covered by hyaline
cartilage except inferiorly- acetabular
notch
Acetabular Notch bridge by
Transverse acetabular ligament
Acetabular Fossa- provides negative
atmospheric Pressure
 Suctionary effect for joint stability

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FEMUR
Thigh bone ; 25% OF THE GENERAL
HEIGHT
Longest and strongest bone in the body

Head; orinted SAM – 2/3 of sphere

- articulates with acetabulum

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- Fovea Capitis- small depression at the center
of femoral head
- attachment of ligamentum teres/
ligament of the head of femur

NECK- connects head to the shaft

- downward , backward , laterally
- neck shaft angle
125 deg (adult)
160 deg (child)

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I-Greater trochanter
Attachment site for (insertion)
UPPER: RED CARPET MUSCLES
except Quadratus femoris
LAT:: GLUTEUS MEDIUS
MEDIAL:: OBTURATOR EXTERNUS
Landmark for measuring leg length
II. Lesser trochanter
Attachment site of iliopsoas muscle
Intertrochanteric Line (ANTERIOR)
attachment for Iliofemoral Ligament
-Intertrochanteric Crest (Posterior)
Insertion for Quadratus Femoris
III. Linea aspera
Attachment site of some adductor muscles 25

IV. Pectineal line

Attachment of pectineus muscle
26
 V. Condyle
Medial condyle - Larger and longer
a. MC osteochondritis dissecans
b. MC for OA
Lateral condyle - more anterior
a. MC for RA
*** MILA.
VI- Gluteal Tuberosity- insertion
of post surface of shaft of G. Troch

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HIP JOINT/COXOFEMORAL/ACETABULOFEMORAL/
COXAL JOINT
Articulation b/w acetabulum &
femoral head
Ball & socket
Best example of ball & socket joint
*** Acetabular Labrum –deepens
acetabulum (30%)
HIP JOINT/COXOFEMORAL/ACETABULOFEMORAL/
COXAL JOINT
RESTING POSITION: 3O deg
Flexion, 30 abduction, Slight ER

CLOSED PACK POSITION:

Ligamentous: EXABIR
Bony- FABER

CAPSULAR PATTERN- Flex>

Abd> IR
LIGMENTS OF HIP JOINT

A- ILIOFEMORAL OF
LIGAMENT
AKA- Y-LIGAMENT of BIGELOW
Strongest ligament in the body
Primary ligament the hip joint
Primarily limits hyperextension of
the hip
ATTACHMENT: AAIS UPPER &
LOWER PARTS OF
INTERTROCHANTERIC LINE
LIGMENTS OF HIP JOINT

B- PUBOFEMORAL LIGAMENT
-triangular
Superior ramus of pubis to lower part
of line
Limits hip abduction
LIGMENTS OF HIP JOINT

C- ISCHIOFEMORAL LIGAMENT
AKA: Ligament of Bertin
Weakest among the ligaments in the
hip joint
-Primarily imits internal rotation of
the hip
Attachment: Body of ischium to
Greater Trochanter
LIGAMENTUM TERES
Flat & triangular
Serves as a conduit of blood supply from obturator
artery

Child- Obturator Artery

-Artery of Trueta/ Lateral Epiphyseal Branch of
Medial Circumflex Artery -adult
SACROILIAC JOINT

- partly synovial , partly syndesmosis

Iliac surface = FIBROCARTILAGE
Sacral Surface= HYALINE CARTILAGE
“FISH”
SACROILIAC JOINT

DOF: TORSION, GLIDING & TILT

OPEN PACK POSITION/ RESTING
POSITION: NEUTRAL

LOOSE PACK POSITION/ FORCE

CLOSURE: COUNTERNUTATION

CLOSED PACK POSITION/ FORM

CLOSURE: NUTATION

CAPSULAR PATTERN: PAIN WHEN JOINT

ARE STRESSED
SYMPHYSIS PUBIS

Cartilaginous-Symphysis
(+) Fiibrocartilage (<1mm ) b/w the (2) pubic
bones and interpubic ligament

Movements: 2mm distraction , compression and

1-3 degrees rotation
Transfer weight from spine to LE (with the symphysis pubis)
** 7 jts participate :
(1) - lumbosacral (1) symphysis pubis
(2) - L & R SI (2) hip
(1) - sacrococcygeal

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 ARTHROKINEMATICS
LUMBAR SPINE MOVES ON FIXED PELVIS
LUMBAR SPINE PELVIS SACRUM

FLEXION

EXTENSION

I/L SIDE I/L SIDE

ROTATION

C/L SIDE C/L SIDE

LATERAL I/L SIDE I/L SIDE

FLEXION

C/L SIDE C/L SIDE

LUMBOPELVIC RHYTHM

2/3 of the rhythm

From erect standing to 60-70 degrees of
bending position
MUSCLE ACTIVATED: ERECTOR
SPINAE ; trunk flexion

1/3 of the Rhythm

From 60-70 degrees to further bending
position
MUSCLE ACTIVATED: HAMSTRING’S
MUSCLE & GLUTEUS MAXIMUS
FEMORAL TRIANGLE
Upper medial part of thigh; below inguinal ligament

BOUNDARIES:
Superiorly- Inguinal Ligament
Med- Adductor Longus
Lat- Sartorius

Roof : Skin & Fascia

Contents: Lat-med
N-Femoral nerve
A- Femoral Artery
V-Femoral Vein
L- deep Lymph Nodes

Floor- (L-M)
Iliopsoas- Pectineus- Adductor Longus
FEMORAL SHEATH
Compartments
Lateral- Femoral Artery (A)
Intermediate- Femoral Vein (V)
Medial- deep Lymph Nodes (L).

FEMORAL CANAL
-small compartment for deep lymph vessel
0.5 in/1.3 cm long
FEMORAL RING- upper opening
FEMORAL Septum- closes the ring to prevent herniation
ADDUCTOR CANAL
HUNTER’S CANAL /SUBSARTORIAL CANAL
medial aspect of middle 3rd of thigh
beneath Sartorius
From apex of femoral triangle to opening
in adductor magnus

WALLS-
AM- sartorius, fascia
Post- adductor longus & magnus
Lat- Vastus Medialis

Contents
Femoral Artery
Femoral Vein
Deep Lymph Nodes
Saphenou Nerve
Nerve to Vastus Medialis
Terminal Part of Obturator nerve
LUMBOSACRAL
PLEXUS
FUERTE
LUMBAR PLEXUS
Iliohypogastric
Nerve root: L1
Enters lateral &Anterior Abdominal Wall

-Cutaneous Distribution
-Skin of Anterior Abdominal Wall
Upper Lateral Buttocks

-Muscle Distribution
- Internal Oblique
External Oblique
Transversus Abdominis
ILIOINGUINAL NERVE
Nerve root: L1
Enteres the lateral &Anterior abdominal wall
Passes through the inguinal canal

Skin distribution:
Upper Medial aspect of the thigh, scrotum , root of penis ( Male), mons
pubis & labia majora (female)

Muscle Distribution:
Internal Oblique
External Oblique
Transversus Abdominis
GENITOFEMORAL NERVE
NERVE ROOT: L1-L2
Emerges on the anterior surface of the psoas

Skin distribution:
Anterior Surface of the thigh

Muscle Distribution:
CREMASTER MUSCLE
- Pathway for cremasteric reflex
LATERAL CUTANEOUS NERVEAN OF THE THIGH
NERVE ROOT: L2-L3
Crosses the iliac fossa in front of the iliacus muscle & enters the
thigh behind the lateral end of the inguinal ligament

SKIN DISTRIBUTION:
Anterior & Lateral thigh (Anterolateral)
Lower Lateral Quadrant of Buttocks
FEMORAL NERVE
NERVE root – L2-L3-L4
(ANTERIOR DIVISION)

2cutaneous Branch
Medial Femoral Cutaneous nerve of thigh
Intermediate femoral nerve of thigh

Muscle:
- SIP= SARTORIUS, ILIACUS, PECTINEUS
POSTERIOR DIVISION
-Saphenous Nerve
-largest cutaneous branch of femoral nerve
OBTURATOR NERVE
Nerve root: L2-L3-L4 (Anterior )
-it will leave the pelvis & enter obturator foramen

Skin distribution:
Medial thigh

Muscle Distribution:
Gracilis
- Adductors muscle
Pectineus
ACCESSORY OBTURATOR NERVE

Anterior division- L3-L4

SACRAL PLEXUS
Lies on the posterior pelvic wall ;infront of piriformis of muscle
Formed from anterior rami of L4-L5 and Anterior Rami 0f S1-S4
LUMBOSACRAL TRUNK
Formed by Anterior ramus of L4 and Anterior ramus of L5.
• Passes down into the pelvis and joins the sacral plexus as they
emerge from the anterior sacral foramina
• Passes infront of the sacroiliac joint
BRANCHES OF THE SACRAL PLEXUS
Branches to the lower limb that leave the pelvis through the
greater sciatic foramen
1. Sciatic Nerve
2. Superior Gluteal Nerve
3. Inferior Gluteal Nerve
4. Nerve to Quadratus Femoris
5. Nerve to Obturator Internus
6. Posterior Cutaneous nerve of the thig
BRANCHES OF THE SACRAL PLEXUS
• Branches to the pelvic muscles, pelvic viscera, and perineum
1. Pudendal Nerve
2. Nerve to Piriformis
3. Pelvic Splanchnic Nerves

• Perforating Cutaneous Nerve

FLEXORS
MUSCLES Adductor magnus
Iliopsoas- strongest hip ABDUCTORS
flexor >90 Gluteus medius
Rectus femoris Gluteus minimus
Sartorius TFL
Pectineus ADDUCTORS
Tensor fascia latae (TFL) Adductor longus
EXTENSORS Adductor brevis
Gluteus maximus Adductor magnus
Biceps femoris Gracilis 61

Semitendinosus Pectineus
Semimebranosus
MEDIAL ROTATORS Obturator internus
No primary muscle acs Obturator externus
as medial rotator but as Quadratus femoris
secondary movers
Gluteal minimus
(anterior fibers)
Gluteal medius (anterior
fibers)
TFL
LATERAL ROTATORS
Piriformis
Gemellus superior 62

Gemellus inferior
 FLEXORS
Iliopsoas
Strongest hip flexor
Tilts the pelvis anteriorly with the abdominals
Combined bilat action elevates trunk and flexes
pelvis on the femur (full sit-ups)
ILIACUS- FEMORAL nerve (L2-L4)
Psoas Major- Lumbar Plexus (L1-L3)
Insertion: Lesser Trochanter
Action: Hip Flexion /Abdominal Flexion
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Condition: Iliopsoas Bursitis
 FLEXORS
Rectus femoris
2 joint muscle
2heads:
i. Straight Head
ii. Reflected Head
Only quads muscle that crosses
hip and knee (active insufficiency)
Action: Hip Flexion & Knee Extension
(Active Insufficiency)
Passive Insufficiency- Hip extension &
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Knee Flexion
Innervated by Femoral NERVE
 FLEXORS
Sartorius
Tailor’s Muscle
Longest muscle in the body; 2 jointed
ms connecting to pes anserine (SGT)
FABER of hip
FIR of knee
Innervated by Femoral Nerve

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TFL

a. Innervated by Superior gluteal nerve (L4, L5, S1)

b. Action
i. Hip FABIR
ii. Knee EXER
c. Special Test:
Ober Test

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TFL
By tensing ITB, it provides
stabilization to your knee
and thigh during weight
bearing
FABIR

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-Adductor Magnus ADDUCTORS
a. Biggest, inserts in adductor tubercle
b. Hamstring (portion)
-Adductor Brevis
-thickest
Adductor Longus
Strongest Adductor
Gracilis
Weakest adductor
i. Innervated by obturator nerve except pectineus
ii. ER for hip flexion
iii. IR for hip extension
iv. Active in foot flat to midstance to heel off
Pectineus
-comb like 68

a. Not innervated by obturator nerve, femoral nerve

b. Action flexion and adduction, irregardless of position
Red Carpet muscles
P – Piriformis
i. ER in extension
ii. IR in flexion (similar to G. Max)
O – Obturator internus
O – Obturator externus
S – superior gemellus
I – inferior gemellus
Q – Quadratus femoris: inserts Quadrate tubercle
g. All: Inserts into greater trochanter
 Quadriceps
Action: knee extensors
Innervated by femoral nerve L2, L3, L4
Parts (4)
i. Rectus femoris
ii. Vastus lateralis -Strongest
iii. Vastus intermedius –deepest

iv. Vastus Medialis

1 VMO( workhorse)
a. Controls patellar tracking
b. 1st to atrophy, last to recover
2 VML

Condition
1. Weakness
a. Difficulty stairs
i. Ascending
ii. Descending (Most difficult)
iii. Ramps, sitting. Standing
2. ACL injury
a. Co-contraction hamstrings before quads
EXTENSORS
Gluteus Maximus
Innervated: Inferior Gluteal nerve
3 fibers
i. Upper - abduction
ii. Middle - Extension
iii. Lower- adduction
Action
i. Hip extension (active)
1. Strengthen by hip ext c ER
ii. Extension: ER
iii. Flexion: IR
Protected by large fat pad
Most active in initial contact
Covers the red carpet muscles
Hamstrings
. Innervated by sciatic nerve
Parts (4)
i. Semimembranosus
ii. Semitendinosus
iii. Biceps femoris
1. Long head ; Tibial branch of sciatic nerve
2. Short head, common peroneal nerve
iv. Adductor magnus (hamstring part)
1. Obturator/ sciatic nerve
Action Hip extension
Knee rotation by BF + ST (ER), SM(IR)
 ABDUCTORS
G. Medius (main abductors)
G. Minimus (main IR)
a. Abductors and IR
b. Innervated: Superior Gluteal nerve
(L4, L5, S1)

c. Gait: Waddling/Chorus Girl/ Mae West/

Cheerleader/ Trendelenburg
d. MC cause of trendelenburg gait is OA
i. Uncompensated (pelvis list/ obliquity drops to
opposite side of lesion
ii. Compensated (Trunk lean to ipsilateral side) 73

iii. (The foot that is in midstance is the weak side)

 LATERAL ROTATORS
Piriformis (uppermost)
ABER
PIRIFORMIS SYNDROME
Fat wallet/ Thick Wallet Syndrome
- Spasm of piriformis sciatic nn
Gemellus superior
Gemellus inferior
Obturator internus
Obturator externus
Quadratus femoris (lower most)
Run horizontally to greater trochanter and provides 74

compresision and stability to the hip joint

75
 MEDIAL ROTATORS
Gluteal minimus (anterior fibers)
Gluteal medius (anterior fibers)
TFL
Pectineus
Adductors

76
The line of pull and leverage affecting the muscle’s action
Hip flexion increases leverage for medial rotation
Hip extension increases leverage for external rotation
(gluteus medius and TFL)
Inversion of muscle action (piriformis)
Contrasts of action in same muscle by changing the
line of pull (gluteus medius)

77
 One joint versus two joint muscles
Rectus femoris
Hamstrings
Whether weight bearing or non-weight bearing
In weight bearing- function is to stabilize pelvis and carry body
weight over moving extremity
In non weight-bearing- function is to provide speed of movement
In closed kinematic chain, even small weakness leads to
noticable diminished muscle perfomance than in OKC
Sit ups
Abdominals will flex trunk concentrically until scapula clears
surface, hip flexor concentrically stabilizes pelvis
In full sit ups, abdominals maintains isometric contraction 78
while iliopsoas concentrically contracts to lift trunk and
pelvis on fixed femur
Straight leg Raises
abdominals provides lumbopelvic stabilization while
iliopsoas lifts LE
Using cane ipsilaterally
Reduces hip joint compression on painful side
Using cane contralaterally
Reduces hip joint compression + assists abductor
muscles in providing countertorque to gravity by
recruiting lats dorsi
Trendelenburg gait or Gluteus medius gait
Pelvis drops on contralateral side of weak (stance) gluts
medius with compensatory lateral trunk lenan towards 79

weak side
80
 FORCES ON THE HIP
Standing: 0.3x the body weight
Standing on one limb: 2.4- 2.6x the body weight
Walking: 1.3- 5.8x the body weight
Walking up stairs: 3x the body weight
Running: >4.5x the body weight

81
 BIOMECHANICAL ANGULATION OF
FEMUR
i. ANGLE OF INCLINATION
Frontal plane angulation
Shaft of femur to femoral head
Neck-shaft angle- (N) angle of 125
**Birth 150- acetabulum shallow, incongruent hip
**As we age, acetabulum deepens and angle of inclination
decreases
Coxa Valga (>130)
— Prone to dislocation/subluxation because of hip instability
82
Coxa Vara (<125)
— Prone to femoral neck fracture d/t increase tensile forces
83
ANGLE OF TORSION
Transverse plane angulation
Bird’s eye view of a line bisecting the femoral head and neck
forming an angle with the imaginary line connecting the 2 femoral
condyles
(N) angle of torsion is 10-20
At birth normal is as high as 40, decreases to adulthood
Femoral anteversion (>20)
Increase in medial hip rotation and “in-toeing”
Retroversion (<20)
Increase in lateral hip rotation and “out-toeing”

84
85
FEMORAL ANTEVERSION
Forward torsion of femoral neck
Craig’s test
Angle of the femoral neck witthe femoral condyles
At birth: ~30
Adults: 8-15

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87
88
89
SPECIAL TEST
FELICIANO
FULCRUM’S TEST
Procedure Positive Test Positive Test Implications

• Athlete is seated with pain in his/her thigh Possible femoral stress

his/her knees bent at the end
fracture
of the table
• Examiner places his/her
forearm or a similar bolster
underneath of the athlete's
mid–thigh
• Examiner uses other hand to
forcefully push down on the
athlete's distal anterior thigh

91
NELATON’S LINE
Ischial tuberosity to the ASIS of the same side
Palpate for the greater trochanter
Above the line –CDH or coxa vara

92
NECK - SHAFT ANGLE
At birth: 150-160
Adult:125-135

93
 BIOMECHANICAL ANGULATION OF
ACETABULUM
CENTER EDGE ANGLE
Angle of Wiberg
Indicates how much of the femoral head is covered by the
acetabulum
An angle formed by 2 lines from the center of the femoral
head- one oriented vertically, the other extends laterally
to the acetabulum
(N) is at least an angle of >25
94
95
ACETABULAR ANTEVERSION ANGLE
Transverse plane angulatiion
2 line from the posterior rim of acetabulum- one line
parallel to sagittal plane and the other line extends
obliquely to the anterior margin of acetabulum
(N) acetabular anteversion angles between 15-20
>20 means less containment of head;
more stress on hip joint, dysplasia, instability
<20 means excessive coverage of femoral head
Leads to limited ROM and impingement of femoral
head-neck 96
97
FABER / PATRICK TEST

Procedure Positive Test Positive Test Implications

• Patient is supine with the • Inability to lower • Ilipsoas tightness;

the flexed thigh hip pathology (groin
foot of the involved side
down to the level or inguinal area
crossed over the opposite of the leg on the pain);
thigh (figure–4 position) & table; • sacroiliac joint
• hip joint pain; pathology (pain
the leg resting in the full
• Sacroiliac pain during application of
external rotation overpressure in the
• Examiner has one hand on SI area)
the opposite ASIS & the
other hand on the medial
apsect of the flexed
kneeExaminer applies
overpressure at the knee & 98

ASIS
 THOMAS’ TEST
Procedure Positive Test Positive Test Implications

• Athlete is supine with • The knee of the • Rectus femoris

his/her knees bent at the
end of the table
• Examiner places one hand
between the lumbar lordotic
curve & the tabletop
• Examiner passively flexes
one of the athlete's legs to • the involved leg
his/her chest, allowing the
knee to flex during the
movement
• Examiner observes the
involved leg for movement
leg on the table tightness (the knee
cannot flex past extends as the
90° (i.e. the knee examiner flexes the
of the leg on the hip);
table will extend • iliopsoas tightness
as the examiner (the leg on the table
flexes the will rise off of the
contralateral hip); table)
(i.e. the leg on the
table) rises up off
the table (i.e. the
contralateral hip
to the one being
moved will flex)
99
 OBER’S TEST
Procedure Positive Test Positive Test Implications

• Perform the test as the patient is side lying •
with the involved leg uppermost. Abduct the
leg as far as possible and flex the knee to 90°.
If the thigh remains abducted • contracture of the fascia lata
there may be a contracture of
the tensor fascia lata or
iliotibial band

100
 TRENDELENBURG'S TEST
Procedure
• Patient stands on affected leg
(single leg stance)
Positive Test Positive Test Implications
Trendelenburg's sign: pelvis • Deficiency in the abductor(g.med)
droops on the unaffected side mechanism of the hip (either the
abductor musculature or the femoral
neck of the the hip joint)
• Occurs as a result of
Fracture of the femoral neck
Posterior dislocation of the hip
Abductor muscle paralysis (ie, polio myelitis)
Developmental dysplasia of the hip
Painful hip disorder such as rheumatic arthritis
or osteoarthritis
101
LEG LENGTH MEASUREMENT
TRUE APPARENT
(anatomical/structural) (functional)

(N) 1-1.5 cm Significance diff: >1.5

cm

Landmark: ASIS Umbilicus- Medial

Medial Malleolus Malleolus
KENDALL TEST/RECTUS FEMORIS CONTRACTURE TEST
ELY’S TEST/ TIGHT RECTUS FEMORIS
90-90 SLR

Hamstrings Contracture Method 1

HAMSTRINGS CONTRACTURE TEST
PEDIATRIC TEST FOR HIP PATHOLOGY
Abduction Test (Hart Sign)
GALEAZZI SIGN
TELESCOPING
 PELVIS AND HIP
111
INJURIES
PASHA & VILLANUEVA
Hip Sports Related
Injuries
PASHA
Hip Pointer Injury
- Direct blow to the pelvis brim, which results in a
contusion to the soft tissues and often the
underlying bone (transverse and oblique abdominal
muscles) or avulsion fracture.
- MC in contact sports: Football & Hockey
- Common areas affected: Greater Trochanter & Iliac
Crest

Hip Flexor Strain

- MOI: overload of the iliopsoas mm or an attempt to flex the the fully extended hip
- Commonly seen in soccer, baseball, football & sprinting
- Typically causes pain in the front of the hip or groin
Quadriceps Contusion/ Charlei
Horse/ Dead Leg/ Cork Thigh
- A direct blow to the thigh most commonly experienced in
contact sports
- MC involved portion – Rectus Femoris
- May lead to Compartment Syndrome and Myositis Ossificans

Quadriceps Strain
- D/t rapid acceleration or deceleration of the quadriceps
- Sprinting, jumping, kicking,
- General functional overload of quads
- ST: Ely’s, Thomas & Kendall
Pulled
Hamstring
- Defined as an excessive stretch or tear of muscle
fibers
- Biceps femoris long head is at the most risk for
injury

Adductor
Strain
- Occur most commonly when there is a forced
push-off (side-to-side motion). High forces occur
in the adductor tendons when the athlete must
shift direction suddenly in the opposite
direction.
- MC: Football & Soccer
HIP FRACTURES
Is a serious injury with complications that can be life threatening.
The risk of hip fracture rises with age.
Older people are at higher risk of hip fracture because bones tend to
weaken with age (osteoporosis).
FEMORAL NECK FRACTURES
A.k.a unstable fractures
a. Subcapital – fracture immediately beneath the articular surface of
the femoral head along the old epiphyseal plate;
Two types
1. Unimpacted type
2. Impacted type
b. Transcervical – fracture passes across the femoral neck between
the head and the greater trochanter.
MECHANISM

Most commonly: falls in the elderly

significant trauma (e.g. motor vehicle collisions) in younger patients
In elderly patients, the mechanism of injury various from falls
directly onto the hip to a twisting mechanism in which the patient’s
foot is planted and the body rotates. There is generally deficient
elastic resistance in the fractured bone.
The mechanism in young patients is predominantly axial loading
during high force trauma, with an abducted hip during injury
causing a neck of femur fracture and an adducted hip causing a hip
fracture-dislocation.
Duverney’s
o isolated fx of the iliac wing

Malgaigne’s
o Double vertical fx or
dislocation of the pelvis
 Walther’s
STRADDLE
Double vertical fracture or o Ischioacetabular fx
dislocation of the pubis o fx line passes through pubic
40% chance of injury to the ramus and terminates in the
gastrointestinal tract region of the sacroiliac joint
Caused by:
Fall from height
Motorcycle accident
ANCILLARY PROCEDURES
Physical Examination
Blood Test
X – ray
Bone scan
CT scan
MRI
MEDICATIONS
Pain Relievers
Antibiotics
NSAIDs
SNAPPING HIP
A.k.a Dancer’s hip
Is a condition in which you feel a snapping sensation or hear a
popping sound in your hip
When you walk, get up from a chair or swing your leg around
The snapping sensation occurs when a muscle or tendon (the strong
tissue that connects muscle to bone) moves over a bony protrusion
in your hip.
Although snapping hip is usually painless and harmless, in some
cases snapping hip leads to bursitis, a painful swelling of the fluid-
filled sacs that cushion the hip jt.
3 TYPES OF SNAPPING HIP SYNDROME
Internal snapping hip
External snapping hip
Intra-articular snapping hip
CAUSE
Is most often the result of tightness in the muscles and tendons
surrounding the hip.
People who are involved in sports and activities that require
repeated bending at the hip are more likely to experience snapping
hip, dancers are specially vulnerable.
Young athletes are also more likely to have snapping hip.
Common during adolescent growth spurts.
ANCILLARY PROCEDURE
Medical history and physical examination
Determine the exact cause of the snapping by discussing you r
medical history and symptoms and conducting physical
examination.

Imaging tests
x-ray
To rule out any problems with the bones or joint.
PT MANAGEMENT
Stretching ( iliotibial band stretch, piriformis stretch)
Strengthening

Home instruction
- reducing or modifying activity
- Applying ice
- Use over the counter pain relievers
PHARMACOLOGICAL MANAGEMENT
Corticosteroid injection
- If you have hip bursitis, your doctor may recommend an injection of
corticosteroid into the bursa to reduce painful inflammation.
SURGICAL TREATMENT
Hip arthroscopy
- surgeon inserts a small camera called a arthroscope, into your hip
joint.
Most often used to removed or repair fragments of a torn labrum.
SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCPE)
Most often observed in children between 10 and 15 years of age,
M>F
History of trauma of strain is elicited
Occurs predominantly in obsess children with undeveloped sexual
characteristics and less commonly in tall, thin children
Combination of rapid growth, obliquity of the epiphyseal plate and
minor trauma.
It is from increased force on the hip at a time when the femoral
head is not quite ready to support these forces. The femoral head
fails at the weakest point, through the epiphyseal plate. As a result,
a condition similar to a stress fracture develops.
SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCPE)
Symptoms: bearing). This determination has become
Difficulty walking, (walking with a limp) more important than acute versus chronic
due to the fact that unstable patients have
Knee pain
been found to have a high complication rate.
Hip pain
Determine the radiographic classification.
Hip stiffness This is determined by the percentage of
Outward-turning leg displacement of the hip in relation to the
Restricted hip movements neck. Type I is less than 33% displacement,
type II is 33-50% displacement, and type III
is greater than 50% displacement.
Classification schemes are as follows:
Determine whether the SCFE is acute (< 3
weeks), chronic (3+ weeks), or acute on
chronic (3+ weeks of symptoms with acute
exacerbation or change).
Determine whether the SCFE stable (able to
bear weight) or unstable (non-weight
SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCPE)
Differential Diagnoses Medications:
Femoral Head Avascular Necrosis Acetaminophen
Femoral neck Fracture Nonsteroidal anti-inflammatory
Femoral neck Stress Fracture drugs (NSAIDs)
Femur Injuries and Fracture Narcotics
Groin Injury
Osteitis Pubis
Ancillary procedures:
Xray

Treatment:
Surgery (Prophylactic fixation)
HIP BURSITIS
HIP BURSITIS
Hip bursitis is a common cause of hip pain.
Hip bursitis most commonly occurs when the large bursa on the outside
of the hip, where the hip bone meets the thigh bone, becomes inflamed.
Often called the "great mimicker," hip bursitis symptoms are similar to
those of other conditions, such as hip osteoarthritis and lower back
pain.
HIP BURSITIS
A bursa is a closed fluid-filled sac that functions as a gliding surface to
reduce friction between tissues of the body. "Bursae" is the plural form
of "bursa." The major bursae are located adjacent to the tendons near
the large joints, such as the shoulders, elbows, hips, and knees. When a
bursa becomes inflamed, the condition is known as "bursitis."
HIP BURSITIS
Types of hip bursitis:
Iliopectineal/iliopsoas bursitis
Deep trochanteric bursitis
Superficial trochanteric bursitis
Ischiogluteal bursitis
ILIOPECTINEAL/ ILIOPSOAS BURSITIS:

Location:
Between iliopsoas muscle and iliopectineal
eminence
Anterior aspect of the hip joint capsule
Frequently communicates with the joint cavity
Clinical features:
Tenderness
Pain
Hip usually held in flexion, abduction, and
external rotation (FABER)
Pain is elicited through extension, adduction, and
internal rotation (EXADIR)
ILIOPECTINEAL/ ILIOPSOAS BURSITIS:
Signs and Symptoms: Pain on passive hip
Pain is experienced at the extension.
front side of the hip. Stiffness and pain after rest
Radiation of pain into the or in the mornings.
knee. Aggravation of pain while
Tenderness in the upper performing activities.
quads and at the front side
of the hip.
Radiation of pain into the
lower back or buttocks.
A snapping sensation at the
front of the hip.
Pain on resisted hip flexion.
ILIOPECTINEAL/ ILIOPSOAS BURSITIS:

Rheumatoid Arthritis.
Dx: Hip problems.
Femoral hernia Recreational injuries such
as ballet, soccer, martial
Psoas abscess(groin) arts and jumping hurdles.
Synovitis Infection of hip bursa.
Infection of the hip joint
Other causes may include:
Iliopsoas tendonitis.
Tight hip flexor muscles.
Osteoarthitis.
ILIOPECTINEAL/ ILIOPSOAS BURSITIS:
Ancillary procedures: Subsides within several weeks
Ultrasound. Medications:
X-ray. Anti-inflammatory medications
MRI. such as ibuprofen, aspirin,
Bone scan. Celebrex and naproxen may help
in reducing inflammation and
Treatment: swelling and relieving pain
Bed rest with application of associated with hip bursitis.
traction on LE
Ice application (tender area) on the
anterior aspect of the hip
Avoiding repetitive activities.
Antibiotic therapy
ILIOPECTINEAL/ ILIOPSOAS BURSITIS:
PT Management:
Application of heat and ice.
Electrotherapy like TENS and
ultrasound.
Soft tissue massage.
Stretches.
Dry needling.
Joint mobilization.
Using crutches.
Correction of abnormal biomechanics
such as using orthotics.
Education.
Anti-inflammatory advice.
Exercises of the muscles and tendons
surrounding the area to improve
strength and flexibility.
Activity modification and training.
Appropriate plan for return to activity.
Exercise:
Hip flexor stretch ex
Straight leg raises exercise
Sitting hip flexion ex.
Standing resisted hip flexion ex
Gluteal stretch ex.
DEEP TROCHANTERIC BURSITIS
Location:
Behind greater trochanter
In front of the tendinous portion
of the gluteus maximus
Clinical features:
Radiating pain on the back of the
thigh
Discomfort in ROM
Dx:
Differentiated from infection of
the hip joint and from
osteomyelitis of the upper end of
femur
SUPERFICIAL TROCHANTERIC BURSA
Location:
Between the greater trochanter,
skin and the subcutaneous tissue
Clinical features:
Tenderness
Swelling
Pain on extreme adducction of the
hip
DEEP AND SUPERFICIAL TROCHANTERIC BURSITIS
Signs and symptoms: Pain when climbing stairs
Pain and swelling occurring over Pain in sitting with the legs
the side of the hip crossed
Referred pain that travels down Increased pain when walking,
the outside thigh and may cycling or standing for long periods
continue down to the knee of time
Pain when sleeping on your side;
especially the affected hip
Pain upon getting up from a deep
chair or after prolonged sitting (eg.
in a car)
DEEP AND SUPERFICIAL TROCHANTERIC BURSITIS
Ancillary procedures:
MRI
Ultrasound
Treatment:
Rest and ice application
When pyogenic infection is
present, treat with antibiotic
Consider drainage
Medications:
NSAIDs
TROCHANTERIC BURSITIS TREATMENT
Phase I- Pain relief and protection
Phase ii- Restoring Normal ROM, strength
Phase iii- Restoring full function
Phase iv- Preventing a Recurrence
DIFFERENTIAL DIAGNOSIS OF DEEP AND SUPERFICIAL
TROCHANTERIC BURSITIS
Femoral Head Avascular Piriformis Syndrome
necrosis Osteoarthritis
Femur Injuries and Fractures
Gluteal tendon injury
Gluteus medius bursitis
Gluteus medius partial tear
Gluteus medius tendinitis
Hip Fracture
Iliopsoas Tendinitis
Iliotibial band Syndrome
Lumbosacral Radiculopathy
ISCHIOGLUTEAL BURSITIS
Location:
Superficial to the tuberosity of the
ischium
Clinical features:
Tenderness over tuberosity of the
ischium
Pain radiating down the back of the
thigh (hamstring muscle)
ISCHIOGLUTEAL BURSITIS
Other causes may include: Leg length discrepancy.
Inappropriate and excessive training. Inadequate warm up.
Poor core stability.
Joint stiffness, specifically of the hip.
Muscle weakness particularly the
gluteals and hamstrings.
Chronic gout and ischial pain (Also
Read: Disability Benefits for Gout)
Neural tightness.
Poor biomechanics such as excessive
stride length.
Muscle tightness specifically the gluteals
and hamstrings.
Inadequate rehabilitation followed by a
previous buttock injury.
ISCHIOGLUTEAL BURSITIS
Signs and Symptoms:
Tenderness and pain in the ischial tuberosity.
Pain is experienced while stretching the hamstring and while flexing the knee against
resistance
Aggravation of pain on sitting.
Exacerbation of pain while performing activities such as running, walking, jumping,
kicking, climbing stairs and sitting excessively particularly on hard surfaces.
ISCHIOGLUTEAL BURSITIS
Pain is experienced on firmly touching the
hamstring tendon and ischiogluteal bursa.
In some cases weakness in the lower limb
could also be experienced, specifically
while attempting to accelerate during
running.
Ancillary procedures:
Xray
MRI
CT Scan
Ultrasound
ISCHIOGLUTEAL BURSITIS
Treatment: Joint mobilization.
Heat and rest Using crutches.
Pillow or cushion seat prevents Correction of abnormal biomechanics
reoccurrences such as using orthotics.
Procaine and hydrocortisone Anti-inflammatory advice.
Excision of bursa (persistent pain) Exercises for improvement of the
PTMX: strength, flexibility and core stability.
Application of heat and ice. Activity modification and training.
Electrotherapy like TENS and Appropriate plan for return to activity.
ultrasound. Exercise:
Soft tissue massage. Hamstring stretch
Stretches. Gluteal stretch
Dry needling.
TRANSIENT SYNOVITIS
Villahermosa
TRANSIENT SYNOVITIS
Can be symptomatic of hip
pain/spasm due to mild trauma
or infection (low grade)
Unilateral
Boys>girls
Ages 4-10 y/o
Clinical features:
Pain(hip, thigh, knee)
Tenderness over hip joint
Restriction of ROM (passive) by
muscle spasm constant finding
Hip is often flexed and abducted
Absent or slight systemic signs of
infection
Diagnosis:
Roentgenographs are negative
except for showing distention of
the joint capsule(
If doubtful aspiration of the hip
joint for culture and synovial fluid
examination is considered.
TRANSIENT SYNOVITIS
Treatment and prognosis:
Rest and heat application
Short period of traction (severe pain)
Outcome of recovery: quick and permanent but reoccurences may happen
Prolonged follow-up is indicated.
INTRAPELVIC PROTRUSION OF THE
ACETABULUM
INTRAPELVIC PROTRUSION OF THE ACETABULUM
Aka Protrusion acetabuli
Uncommon
Unknown etiology
Diagnosed in adults but may
begin in childhood
F>M, bilateral (extreme
disability) or unilateral
Probable causes:
Can be congenital or familial
(genetic) origin
Secondary to common affections
(RA or pyogenic arthritis)
Pathophysiology:
Deepening or inward protrusion of
the acetabulum
Allows the head of femur to project
farther into the pelvis
Roentgenographs
Thinning of walls of the
acetabulum
Increased bone formation resulting
in narrowing of cartilage space
Sometimes irregular contour or
enlarged head of femur
INTRAPELVIC PROTRUSION OF THE ACETABULUM
Clinical features :
Discomfort and LOM
Restriction of abduction and rotation
Little pain until osteoarthritis changes are superimposed
Ankylosis of the hip
Treatment unilateral little treatment unless the deformity is
accompanied by pain
Event rest and traction for several weeks followed by crutches
(symptomatic improvement)
Total hip arthroplasty: persistent disabling pain and bilateral cases
with stiffness.
AVASCULAR NECROSIS
OSTEONECROSIS (AVASCULAR
NECROSIS) OF THE FEMORAL HEAD
(ASEPTIC NECROSIS)
LEGG- CALVE- PERTHES DISEASE (LCPD)
Also called as COXA PLANA Found in children 4 and 8 years
Is a self limiting disease of age
secondary to avascular necrosis M>F (5:1)
of the femoral head Unilateral in 92-90% of cases
Classified as an osteochondrosis Etiology: unknown
Divided into four stages: Riskfactor:
1. incipient or synovitis stage Low birth weight
2. aseptic necrotic or avascular Positive family history
stage
3.regeneration or fragmentation
stage
4. residual stage
LEGG- CALVE- PERTHES DISEASE (LCPD)
Clinical presentation:
Differential diagnoses:
Pain and stiffness in the groin,
anteromedian aspect of the thigh, or Osteomyelitis
in the knee
Pyogenic arthritis
Antalgic gait
Transient synovitis
Limited internal rotation and
abduction abscess of the psoas muscle
Tenderness in the anterior hip Juvenile Rheumatoid Arthritis
Leg length discrepancy Hemophilia
Slipped Capital Femoral Epiphysis
neoplasm
LEGG- CALVE- PERTHES DISEASE (LCPD)
Ancillary procedure:
Xray
Findings:
Increased distance between the
ossified head and acetabulum
Widened epiphyseal line
Capital femoral epiphyseal more
opaque
Flattening of femoral head
Widening of femoral neck
Femoral head displaces laterally
MRI
CHANDLER’S DISEASE
Infarction of the femoral head mat be total or incomplete. If it is
incomplete, necrosis may be limited to one segment of the femoral
head or may be spotty in distribution. Infarction results in death of
the marrow elements, mainly fat in the case of the femoral head,
and in the death of the cancellous bone. This is manifested by
degeneration and disapperance of osteocytes from their lacunae
within the trabecular bone.
Resorption may be extensive at the periphery of the infarct,
weakening the cartilage support and resulting in a fx in the
subchondral area, which produces the cresent sign.
CLINICAL MANIFESTATION
Children: a limp and slight spasm about the hip are often first
clinical manifestation followed by pain present on weight bearing
and often referred to the thigh or knee.
Adults: pain in the groin is usually the first symptom. it may be
referred to the thigh or knee, may be sudden in onset, and is
usually worse on standing and walking and relieved by rest.
TREATMENT
In Child: protection of the hip joint in abduction for a prolonged
period until reconstruction of the femoral head is complete.
In Adult: surgical treatment is usually needed. Most often indicated
are intramedullary or muscle-pedicle bone grafting, osteotomy,
interposition or replacement arthroplasty, and arthrodesis.
In older patients and other patients whose activities are restricted,
total hip replacement is usually the treatment of choice.
CHONDROLYSIS (CARTILAGE NECROSIS)
CHONDROLYSIS
Characterized by progressive narrowing of the joint space due to
loss of cartilage from both acetabular and femoral surfaces
Seen: Slipped Capital Femoral Epiphysis or other hip d/o, surgery
as an idiopathic case.
Teenagers
Pathologic changes: Matrix loss, Degeneration of articular surfaces,
Mild inflammation (synovial membrane)
Clinical picture: Hip pain associated with a progressive loss of
mobility; Hip flexion and Abduction contractures (common)
 Roentgenographic changes: Loss of joint space; Oteoporosis of femoral
head and acetabulum
Mild case: hip symptoms may improve over time
Severe case: fibrous ankylosis

TREATMENT:
Rest of hip (restriction of ADL's)
Prevent or minimize the deformity (crutches , gentle active exercises)
Anti-inflammatory drugs (ex. Salicylates)
SURGICAL INTERVENTION:
Should not be considered until the d/o has been stabilized
Surgical corrections or arthrodesis may be required if there's pain or
deformities (flexion or adduction.)
 REFERENCES

Magee, D. (2014). Orthopedic physical assessment 6th ed.

SG: Saunders: Elsevier
Norkins. C. & White, D. (2009). Measurement of Joint
Motion A Guide to Goniometry 4th ed. PA: F.A. Davis Co.
Cuccurullo, Sara

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