Ch 4 - MSK: Hip and Pelvis Flashcards
What are the 5 joints of the pelvic girdle?
Bilateral femoroacetabular (hip) joints Pubic symphysis Bilateral sacroiliac (SI) joints
What is the angle between the femoral neck and shaft of the femur?
Males: 125°
Females: 115°–120°
What is Coxa vara?
Femoral neck and shaft angle is decreased
Affected leg is shortened
Hip abduction limited
Knee valgus deformity
What is Coxa valga?
Femoral neck and shaft angle is increased
Affected leg is lengthened
Knee varus deformity
Describe muscles and innervation of hip flexion.
- Iliopsoas (nerve to iliopsoas or femoral nerve: L1, L2, L3)
- Sartorius (femoral n: L2, L3, L4)
- Rectus femoris (femoral n: L2, L3, L4)
- Pectineus (femoral n: L2, L3, L4)
- Tensor fasciae lata (TFL) (superior gluteal n: L4, L5, S1)
- Adductor brevis (obturator n: L2, L3, L4)
- Adductor longus (obturator n: L2, L3, L4)
- Adductor magnus (obturator and sciatic [tibial division] nerves: L2, L3, L4, L5, S1)
- Gracilis (obturator n: L2, L3, L4
Describe muscles and innervation of anteriorly placed hip adductors.
- Gracilis (obturator n: L2, L3, L4)
- Pectineus (femoral n: L2, L3, L4)
- Adductor longus (obturator n: L2, L3, L4)
- Adductor brevis (obturator n: L2, L3, L4)
- Adductor magnus (obturator and sciatic [tibial division] n: L2, L3, L4, L5, S1)
Describe muscles and innervation of posteriorly placed hip adductors.
- Gluteus maximus (inferior gluteal n: L5, S1, S2)
- Obturator externus (obturator n: L3, L4)
- Gracilis (obturator n: L2, L3, L4)
- Long head of the biceps femoris (sciatic n [tibial division]: L5, S1, S2)
- Semitendinosus (sciatic n [tibial division]: L4, L5, S1, S2)
- Semimembranosus (sciatic n [tibial division]: L5, S1, S2)
Describe muscles and innervation of hip abduction.
- Gluteus medius (superior gluteal n: L4, L5, S1)
* Gluteus minimus (superior gluteal nerve: L4, L5, S1)
Describe muscles and innervation of hip internal rotators and abductors.
• TFL (superior gluteal n: L4, L5, S1)
• Sartorius (femoral ne: L, L3, L4)
• Piriformis (nerve to piriformis: L5, S1, S2)
• Gluteus max, superior fibers (inferior
gluteal n: L5, S1, S2)
Describe muscles and innervation of hip extension.
• Gluteus max (inferior gluteal n: L5, S1, S2)
• Gluteus med, posterior fibers (superior gluteal n: L4, L5, S1)
• Gluteus min, posterior fibers (superior gluteal nerve: L4, L5, S1)
• Piriformis (nerve to piriformis: S1, S2)
• Adductor magnus (sciatic-innervated part: L2, L3, L4)
• Hamstring muscles (tibial division of the sciatic n):
– Long head of the biceps femoris (L5, S1, S2)
– Semimembranosus (L5, S1, S2)
– Semitendinosus (L4, L5, S1, S2
Describe muscles and innervation of hip external rotation.
- Piriformis (nerve to the piriformis: S1, S2)
- Obturator internus (nerve to the obturator internus: L5, S1)
- Superior gemellus (nerve to the superior gemellus: L5, S1, S2)
- Inferior gemellus (nerve to the inferior gemellus: L5, S1, S2)
- Obturator externus (L5, S1, S2)
- Quadratus femoris (nerve to the quadratus femoris: L4, L5, S1)
- Gluteus max (inferior gluteal n: L5, S1, S2)
Describe muscles and innervation of hip internal rotation.
“TAGGGSS”
• TFL (superior gluteal n: L4, L5, S1)
• Adductor magnus (obturator n and sciatic [tibial division] n: L2, L3, L4, L5, S1)
• Adductor longus and adductor brevis (obturator n: L2, L3, L4)
• Gluteus med (superior gluteal n: L4, L5, S1)
• Gluteus min (superior gluteal n: L4, L5, S1)
• Gracilis (obturator n: L2, L3, L4)
• Semitendinosus (sciatic n [tibial division]: L5, S1, S2)
• Semimembranosus (sciatic n [tibial division]: L5, S1, S2)
What is the function of the acetabular labrum?
Deepen the acetabulum and hold femoral head in place
Where does the acetabular fibrous capsule extend?
Acetabular rim to intertrochanteric crest
What is the strongest ligament in the body?
Iliofemoral ligament (Y-ligament of Bigelow)
Where does the Iliofemoral ligament extend?
ASIS to intertrochanteric line
What is the function of the Iliofemoral ligament?
Limit extension, abduction, and external rotation of the hip
Where does the Ischiofemoral ligament extend?
From the ischium behind the acetabulum to blend with the capsule
What is the function of the Ischiofemoral ligament?
Limit hip abduction
Where does the capitus femoris ligament extend?
Acetabular notch to the femur
What is the function of the capitus femoris ligament?
80% carry small artery to femoral head
Describe normal ROM of the hip.
- Flexion: 120°
- Extension: 30°
- Abduction: 45° to 50°
- Adduction: 0° to 30°
- ER: 35°
- IR 45°
What hip ROM direction will be limited by OA first?
Internal rotation
What is Patrick’s Test?
Provocative maneuver to assess for intra-articular hip pathology or SI joint dysfunction
Motion: FABRE
(+) Groin pain: hip
(+) Posterior pain: SI
What is Thomas’ Test?
Assesses hip contractures
Pt supine, one hip flexed
(+) Opposite hip doesn’t extend
What is Ober’s Test?
Test for ITB tightness
Pt side lying with involved leg knee flexed to 90°, hip extended to 0°, and abduct the involved leg as far as possible
(+) leg remains abducted
What does Trendelenburg test assess?
Gluteus medius weakness
What are causes of gluteus medius weakness?
– Radiculopathies – Poliomyelitis – Meningomyelocele – Fx of the greater trochanter – SCFE – Congenital hip dislocation – Deconditioning
What is Ely’s test?
Assesses femoral nerve irritation
Pt prone with knee > 90° and hip extended
(+) Anterior thigh pain
How is true leg length discrepancy assessed?
Patient supine, measure from the umbilicus to the medial malleoli
How is pelvic obliquity assessed?
Observing the levelness of the ASISs or PSISs
What is the normal strength ratio of hamrstings to quadriceps?
3:5
When are hamstrings placed under maximal stretch?
Hip is forced into flexion and knee into extension
When and where do hamstring injuries typically occur?
Eccentric phase Myotendinous junction
Lateral hamstrings
What are risk factors for hamstring strain?
Inadequate warm-up Poor flexibility Exercise fatigue Poor conditioning Muscle imbalance (Rehab focuses on these and core strengthening)
What are the grades of hamstring strains?
Grade I: strain
Grade II: partial tear
Grade III: complete tear
Who is commonly affected by hamstring strains?
Gymnasts
Track athletes
What are clinical features of hamstring strains?
- Pain w loss of function
- TTP over the muscle belly or origin
- Ecchymosis may descend to the thigh and present at the distal thigh or back of the knee or calf
- Ischial pain with knee flexion
When can athletes RTP after hamstring strain?
Variable
3 weeks to 6 months depending on severity of injury
What sports are hip flexor strains typically seen in?
Sprinting Soccer Baseball Football Gymnastics
What causes hip flexor strain?
Eccentric overload of psoas muscle or as the athlete tries to flex the fully extended hip, such as in hurdling or kicking
What is the clinical presentation of a hip flexor strain?
TTP over the area and with resisted hip flexion and passive hip extension
What imaging should be done in a hip flexor strain?
AP and frog leg lateral views are used to exclude bony injury such as an apophyseal avulsion fracture
Where are avulsion fractures seen with hip flexor strain?
ASIS AIIS Ischial tuberosity Lesser trochanter Iliac crest
What can occur in adolescents with hip flexor strain?
Injury to the apophyseal plate
What are treatments of hip flexor strain?
• Protected weight bearing, icing, and gentle active ROM as soon as possible
• Strengthening exercises when gait is nonantalgic and ROM is full and pain free
• Strength: closed to open kinetic chain
• Eccentric and
plyometric training to prevent recurrent injury
What is the clinical presentation of piriformis syndrome?
- Pain in lateral buttock, posterior hip, proximal posterior thigh, SI
- Exacerbated by walking up stairs, hip IR and poor body mechanics
What exam test evaluations piriformis syndrome?
Pain with hip Flexion, Adduction, and Internal Rotation (FAIR)
What does rehab seek to do in piriformis syndrome?
Reduce pain/ spasm Recover full hip IR
What is the clinical presentation of Iliopsoas bursitis/tendonitis?
Pain with resisted hip flexion
Hip snapping with hip flexion
TTP over iliopsoas
What is External snapping hip syndrome?
Tight ITB or gluteus maximus snapping over the greater trochanter
What is Internal snapping hip syndrome?
– Tight iliopsoas tendon snapping over the iliopectineal prominence of the pelvis
– Less commonly, acetabular labral tear or loose body in the hip joint
What are provocative tests for External snapping hip syndrome?
IR and ER the hip passively while the patient is in the lateral decubitus position
What are provocative tests for Internal snapping hip syndrome?
Extend, abduct, and ER the affected hip
What is the cause of adductor groin strain?
Resisted forceful abduction of the hip
What are risk factors of adductor groin strain?
Relative weakness and tightness of the adductor muscle groups
What is important to differentiate adductor groin strain from?
Adductor avulsion fracture with x-rays
What is the clinical presentation of adductor groin strain?
Pain in the adductors distal to their origin at the ramus or adductor tubercle
What is greater trochanter bursitis?
Inflammation of the bursa located over the greater trochanter, which is located deep to the gluteus medius and gluteus minimus and TFL
What conditions are associated with greater trochanter bursitis?
Altered gait mechanics Muscle imbalance Reduced flexibility Hip OA Obesity Leg length discrepancy Direct trauma Overuse Herniated lumbar disc Hemiparesis
What is the clinical presentation of greater trochanter bursitis?
Night pain Unable to lie on the affected side TTP over GT Pain with moving from full extension to flexion Snap over GT
What is the most common type of hip dislocation?
90% posterior
What is the cause of posterior hip dislocation?
automobile accident MVA hip is flexed, adducted, and medially rotated.
Knee strikes dashboard diving femur posterior
What can be injured with hip dislocation?
Sciatic nerve can be compressed or stretched
What is the clinical presentation of posterior hip dislocation?
- Hip flex, ADD, and IR • Affected leg shorter d/t dislocated femoral head higher
- Inability to ABD hip
What is the cause of avascular necrosis of the femoral head?
Interruption of the vascular supply
What conditions are associated with avascular necrosis of the femoral head?
Alcohol abuse
Steroid use
What is the clinical presentation of avascular necrosis of the femoral head?
- Pain in groin, anterior thigh, or knee
- Insidious onset of sx
- Short swing and stance phase on the affected side
- Loss of ER and IR
- Hip ER on flexion
- Pain with ROM
How does AVN of the femoral head appear on radiographs?
Irregular or mottled femoral head
What imaging is indicated in AVN of the femoral head?
MRI of both hips
MRI more sensitive to early changes than bone scan
What is seen on T1 MRI images in AVN of the femoral head?
Low signal intensity that may appear as rings, wedges, or irregular configurations
What is seen on T2 MRI images in AVN of the femoral head?
Double line sign with a high signal intensity zone inside of a low signal intensity margin
What is the main objective in treatment of AVN of the femoral head?
Maintain the femoral head within the acetabulum while healing and remodeling occur
What is the treatment of AVN of the femoral head in pediatric patients?
Bracing and casting
When is osteotomy used for the treatment of AVN of the femoral head?
Osteotomy of the femoral head and pelvis may be used to treat patients sx and if the disease is not significantly advance
