10/14 - Anatomy of Hip Complex Flashcards
what type of joints comprise the SIJ
planar synovial joints
what is the composition of the pubic symphysis
fibrocartilaginous disc
what are 3 sites for tendinous attachments on the pelvic complex and what are the attachments
- ASIS - sartorius
- AIIS - rectus fem
- IT - hamstrings
how does SIJ pathology usually present
post joint pain
what is the significance of the tendinous attachments in the hip complex in a younger pt population
common places for avulsions
- not really true fx
what ms directly attach to the sacrum
piriformis is the ONLY MUSCLE
what contributes to making the pelvic complex so stable
extensive ligamentous support
- sacrotuberous - post
- sacrospinous - ant
how many degrees of freedome are allowed by the bony anatomy of the pelvis
3
what is the function of the proximal femur in WB
prox femur transmits greater tensile & compressive load than anywhere in body
how is the acetabulum oriented
ant
lat
inf
due to the orientation of the acetabulum, what directions will the hip have more stability in
sup and post
what structures deepen the hip socket and how
acetabular labrum
transverse ligament
- ligament completes inf portion of the acetabular labrum
what is the orientation of the capsule fibers and why is this significant
longitudinal
oblique
arcuate
circular
4 different orientations - this is what makes the hip more stable than shoulder and also less mobile
what are the intra-articular ligaments
ligamentum teres
transverse ligament
what is the function of ligamentum teres
encloses the obturator a. to the femoral head
- this is significant in the pediatric population
what is the function of the transverse ligament
- crosses acetabular fossa
- completes 180deg rim around acetabulum (w the labrum)
what are the extra-articular ligaments
iliofemoral (Y-ligament)
pubofemoral
ischiofemoral
location and function of the iliofemoral ligament
ant - 2 bands
limits - ext, ER, ADD
location and function of the pubofemoral ligament
ant
limits ABD
location and function of the ischiofemoral ligament
post
limits IR, ext
what are the clinically significant bursa and why
trochanteric
iliopectineal
ischiogluteal
clinically significant bc more common to see sx of true inflammatory irritation, tendinopathy, tendon irritation
where is the trochanteric bursa located
b/w ITB, glut med, glut min -AND- greater troch
where is the iliopectineal bursa located
b/w iliopsoas -AND- iliopectineal eminence along sup rim of acetabulum
where is the ischiogluteal bursa located
b/w common hamstring tendon -AND- ischial tub
what does lateral hip pain usually indicate
gluteal tendinopathy (limited inflammation)
- can usually have more than one gluteal tendon impacted
how does trochanteric bursitis typically present
globally uncomfortable at the joint, not just tendon attachments
what are the contents of the femoral triangle
femoral v
femoral a
femoral n
what are the borders and floor of the femoral triangle
lat border - sartorius
med - ADD longus
sup - inguinal ligament
floor - iliopsoas, pectineus
what specific mobs should be done cautiously d/t location of femoral triangle
an ant-post force
- careful not to drive force into this triangle
flex ROM norm
120
ext ROM norm
20
ABD ROM norm
40
ADD ROM norm
25
IR (@0 and 90) ROM norm
35
ER (@0 and 90) ROM norm
45
arthokinematics of hip joint
convex fem head on concave acetabulum
flex and IR = post glide
ext and ER = ant glide
when are the arthrokinematics of the hip especially applicable
when considering THA approach and precautions
what is the significance of the open-packed position
greatest laxity
- position for joint mobilization and assessment
what is the open pack position of the hip
30 flex
30 ABD
5 ER
what is the significance of the closed packed position of the hip
max tension on capsuloligamentous structures
what position is the closed pack position for the hip
full ext
slight ABD
what are transverse plane abnormalities
version
torsion
version vs torsion
VERSION = position in space relative to a body plane
- fem head/neck w frontal plane
TORSION = twist of bone along longitudinal axis
- fem head/neck w fem condyles
norm angle for version and torsion?
12deg for both
- are often used interchangeably but how you get there is different
what is the normal position of the femoral head/neck relative to distal femoral condyles
angle of inclination is ant
- normal 8-20deg
what is anteversion
angle of inclination of fem head/neck is more ant relative to frontal plane >15deg
what body compensations are seen as a result of anteversion
position yields ER
compensatory IR to seat head in acetabulum
- limited ER ROM d/t shortened IR musculature
what is antetorsion
angle of inclination of femoral head/neck is more ant relative to distal fem condyles >15deg
what body compensations are seen as a result of antetorsion
position yields IR
- evidenced by toe-in posture
limited ER ROM d/t shortened IR musculature
what are reasons up the chain for toe in (4)
anteversion
shortened hip IR
lengthened hip ER
internal rotation at knee (down the chain)
why are anteversion and antetorsion grouped together
will see the same compensations
- IR with IR ms shortening and limited ER ROM
what are 3 functional impacts of anteversion/antetorsion
- inc demand on posterolateral hip & thigh soft tissues
- trochlear groove of femur faces medially = “squinting”
- angle of gait dec
what soft tissues of the hip does anteversion/antetorsion impose and inc demand on
post-lat ms:
- ITB
- vastus lateralis
- biceps fem
resulting ms weakness and tightness d/t anteversion/antetorsion?
tight hip IRs
weak hip ERs
what is a common sx that can be seen as a result of “squinting” (medially facing trochlear groove)
ant knee pain or patello-femoral pain
what are sx of the functional effects of anteversion/antorsion (4)
ITB
piriformis
trochanteric bursitis
patellofemoral dysfunction
how can anteversion/antetorsion functionally impact gait
late phase supination d/t progression of WB forces
what is the significance of “W” sitting in children
may accentuate altered position during development
“miserable misalignment”
open physis - putting the femur in position of anteversion and when physis close can close w femur IR and tibia ER
what pt population do you see “W” sitting a lot in
kids w low tone
- creates a wider BOS and is more stable
what is retroversion and the resulting compensations
angle of inclination of fem head/neck is more post relative to frontal plane <15deg
yields IR
- compensatory ER to seat head in acetabulum
limited IR ROM
- ER ms shortened
what is retrotorsion and the resulting compensations
angle of inclination of fem head/neck is more post relative to distal fem condyles <15deg
position yields ER
- evidenced by toe out posture
limited IR ROM
- ER ms shortened
what are 3 functional effects of retroversion/retrotorsion
- inc demand on anteromedial hip and thigh soft tissues
- trochlear groove of femur faces laterally - “frog eyed”
- angle of gait inc
why are retroversion/retrotorsion often grouped together
result in same compensations
- ER w shortened ER ms and limited IR ROM
what is squinting
when trochlear groove of femur faces medially
what is frog eyed
trochlear groove of femur faces laterally
what ms weakness and tightness will you see d/t retroversion/retrotorsion
tight hip ERs
weak hip IRs
what soft tissues does retroversion/retrotorsion place an inc demand on
ant-med tissues
- iliopsoas
- ADD
- rectus fem
what are common sx from the functional effects of retroversion/retrotorsion (3)
iliopsoas strain
ADD strain
psoas bursitis
how does gait change as a result of retroversion/retrotorsion
late phase pronation d/t progression of WB forces
what is the take home of the impact of transverse plane abnormalities
changes the angle of gait
in-toeing in early and late stances of gait
early stance = pronation
- talus ADD at contact
late stance = supination
- COM lat to STJ axis
out-toeing in early and late stances of gait
early stance = supination
- talus ABD at lat heel strike
late stance = pronation
- COM med to STJ axis
what is the normal femoral position in the frontal plane
angle of inclination of fem neck to shaft is approx 120-125deg
what is coxa valga
angle of inclination >135
how does the body compensate for coxa valga
fem ABD needed to seat head in acetabulum
- resultant genu varum
what is coxa valga primarily associated with
inherent joint instability
what are 4 functional implications of coxa valga
- narrow BOS
- inc need for STJ pronation to bring medial calcaneus to ground during gait
- medial knee compression
- lateral knee tension
what is coxa vara
angle of inclination <120deg
how does the body compensate for coxa vara
fem ADD needed to seat fem head in acetabulum
- resultant genu valgum
what is coxa vara primarily associated with
limping gait d/t functional hip ABD weakness
what are 5 functional implications of coxa vara
- wider BOS
- inc need for STJ supination to bring lateral calcaneus to ground during gait
- “forced” pronation if loading is medial to STJ axis
- medial knee tension
- lateral knee compression
transverse vs frontal plane abnormalities’ impact on gait
transverse = angle of gait
frontal = base of gait
how does sagittal plane dysfunction present during gait
vertical displacement
what phase of gait do you typically see sagittal plane abnormalities present
during late stance
- ability to smoothly transition over foot in gait cycle is impaired
what are the primary vs secondary hip flexors
PRIMARY
- iliopsoas
- rectus fem
SECONDARY
- sartorius
- TFL
- adductor longus
- pectineus
what ab primary hip flexors should be noted with regard to the proximity to hip joint
in close proximity to ant capsule and labrum
- in close proximity to joint itself
for hip flexion to occur, what ms work in combination with the hip flexors
coordinated contraction of abs
what impact does the close proximity of the hip flexors to the joint itself have on the diagnostic process of ant hip pain
people w ant capsule issues can be misdiagnosed w hip flexor tendinopathy early on
- dt close proximity of structures
what ms operate in the sagittal plane
hip flex and ext
what are the primary hip extensors
glut max
hamstrings
- semimembranosus
- semitendinosus
- biceps femoris
what are secondary hip extensors
glut med
- middle and post fibers
adductor magnus
- ant head
what is a common MOI for hamstring tendinopathy
overuse of hamstrings if glut max is weak
- hamstrings have an important function at the knee
what force couple is seen in the sagittal plane
hip ext and abdominals
- post tilt of pelvis
what ms act in the transverse plane
ER and IR
what are primary ERs (6)
glut max
piriformis
obturator externus/internus
gemellus sup
gemellus inf
quad fem
what are 4 secondary hip ERs
glut med (post fibers)
glut min (post fibers)
sartorius
biceps fem (long head)
what do you see if hip ER doesn’t work eccentrically to decelerate IR
more valgus at knee
force at tibia
pronation at foot
what position is the hip in when you land
IR
what is the function of the ERs
joint compression
- like the RC of the hip
what is the largest hip ms
glut max
how does the approach for a THA impact the ERs
post approach disrupts ER tendons
what does it meant that ERs have a reversal of action
d/t orientation of fibers depending on position of the hip
- ER can work as IR when hip flex
how does the priformis’s function change with varying levels of hip flex
<60deg flex - piriformis ER
60-90 - pure ABD
>90 - IR
how does the glut max funciton change w varying levels of hip flex
<45-60 = ER
>90 = IR
what position is optimal for piriformis stretching given the properties of reversal of action
seated
- inc length compared to upright standing
when do hip ERs work as IR
when hip in varying levels of flexion
what passes thru the greater sciatic foramen
piriformis (only ms to do so)
7 nerves (ie sciatic n.)
3 arteries
3 veins
what can post pain be indicative of and what should be noted ab this
can indicate piriformis syndrome
- but not necessarily always piriformis when in pain
what should be suspected if sx of nerve involvement present post on the hip
sciatica
- but not always
what are the primary internal rotators
n/a
need eccentric control of IR by using ER
what are the secondary internal rotators (6)
glut min (ant fibers)
glut med (ant fibers)
TFL
ADD longus
ADD brevis
pectineus
what ms act in the frontal plane
ADD and ABD
what are primary ADDs (4)
ADD longus & brevis
ADD magnus
pectineus
gracilis
what are secondary ADDs
n/a
what secondary functions do ADD longus and brevis have to ADD
hip flex when in hip ext
hip ext when in hip flex
what secondary function does ADD magnus have to ADD
hip ext
what are primary ABDs
glut med (all fibers)
glut min (all fibers)
what are secondary ABDs
TFL
glut max
piriformis
sartorius
why do we care so much ab glut med and what is so significant about its function
it prevents trendelenberg in SLS
- keeping pelvis/hip stable on limb
why do we care so much ab glut med and what is so significant about its function
it prevents trendelenberg in SLS
- keeping pelvis/hip stable on limb
significant - 2x body weight is required to prevent trendelenburg in SLS (its giving girlboss)
where would ABD pain present
laterally
- prob at greater troch attachment point
what can tears & degeneration of glut med/min be misdiagnosed as
trochanteric bursitis
what ms have the greatest hip ABD cross sectional area
glut med - 60%
glut min - 20%
TFL - 11%
why is glut med such a primary ABD
largest hip ABD
largest ABD moment arm
what positions in the frontal plane does the hip have the greatest and least torque? what are the significance of these positions?
greatest - 10deg ADD
- SLS phase of gait
least - 40deg ABD
- position of MMT
what is a trendelenburg test
SLS
hike pelvis on unweighted limb
(-) level
(+) dropped
