Hip Flashcards
1
Q
What is the key function of the hip?
A
To provide dynamic support to the body and trunk while facilitating force and load transmission through the lower extremities, allowing for mobility.
2
Q
What are the two key elements which ensure hip stability?
A
- The shape of the acetabulum and its depth allow it to encompass almost the entire head of the femur.
- The acetabular labrum, a fibrocartilaginous collar, surround the acetabulum and helps transmit load, maintain negative pressure and regulate synovial fluid.
3
Q
Which movements are possible at the hip joint?
A
- Flexion
- Extension
- Abduction
- Adduction
- Medial rotation
- Lateral rotation
4
Q
What type of joint is the hip?
A
A synovial ball and socket joint
5
Q
Where does the hip capsule sit?
A
It covers the whole acetabular rim and extends down to the intertrochanteric line.
6
Q
What is the key articulation at the hip joint?
A
The convex femoral head articulates with the lunate concave surface of the acetabulum. Both bones are coated with hyaline cartilage.
7
Q
Which elements of the hip joint can be palpated?
A
- ASIS
- AIIS
- PSIS
- Iliac crest
- Ischial tuberosity
- Pubis
- Greater trochanter
- Adductor tubercle
8
Q
Which part of the femoral head is not covered with hyaline cartilage and why?
A
The fovea capitis. This is the site of attachment for ligamentum teres.
9
Q
What is the difference between the anatomical neck and surgical neck of the femur?
A
The anatomical neck is the connection between the femoral head and the shaft. The surgical neck sits inferiorly and is used to allow removal and replacement of the femoral head and section of the bone below.
10
Q
What is the acetabulum?
A
It is a concave bone structure formed at the point where the ilium, ischium and pubis bones merge.
11
Q
What is the one non-articular region of the acetabulum?
A
It is a region in the centre called the acetabular fossa which is covered with a fat pad.
12
Q
What is responsible for deepening the acetabulum?
A
A fibrocartilaginous labrum attached to the bony rim. This labrum cups around the femoral head creating negative pressure and holding it firmly in the acetabular socket.
13
Q
In which directions is the hip joint capsule thickest?
A
Anteriorly and superiorly
14
Q
Where does the hip joint capsule attach?
A
The acetabular rim down to the intertrochanteric line.
15
Q
How thick is the labrum and what is it made of?
A
2-3mm thick and made mainly of type I collagen.
16
Q
What are the layers of the labrum?
A
- An internal articular avascular layer
- An external articular vascular layer which contacts the joint capsule
- A basal layer attached to the acetabular bone and ligaments
17
Q
What are the functions of the hip joint labrum?
A
- Joint stabilisation
- Shock absorption
- Joint lubrication by sealing the joint, keeping synovial fluid in
18
Q
What is the strongest ligament in the body?
A
Iliofemoral ligament
19
Q
What is the function of the iliofemoral ligament?
A
It sits on the anterior aspect of the hip joint and prevents hyperextension.
20
Q
What are the attachments of the iliofemoral ligament?
A
- Inferior surface of the AIIS and adjacent acetabular rim
- One band attaches to the femoral head
- One band attaches to the intertrochanteric line
21
Q
What percentage of hip dislocations occur posteriorly and why?
A
90% because the anterior aspect of the hip joint is reinforced so strongly by the iliofemoral ligament.
22
Q
What is the function of the pubofemoral ligament?
A
Preventing excessive extension and abduction
23
Q
What are the attachments of the pubofemoral ligament?
A
- Iliopubic eminence and superior pubic ramus
- Lower part of the intertrochanteric line
24
Q
Which is the weakest of the 3 hip joint ligaments?
A
Ischiofemoral
25
What is the structure of the ischiofemoral ligament?
It is a triangular band of fibres which make up the posterior of the hip joint capsule.
26
What are the attachments of the ischiofemoral ligament?
* Ischium behind the acetabulum
* Base of the greater trochanter
27
Which movement is limited by the ischiofemoral ligament?
Extension
28
What is the tranverse ligament?
This is a small ligament across the acetabular notch. At this notch there is no rim to support the inferior of the humeral head so instead this ligament provides inferior support to the joint.
29
What is the inguinal ligament formed from?
An aponeurosis from the lower border of the external abdominal oblique muscle.
30
What are the attachments of the inguinal ligament?
* ASIS
* Pubic tubercle
31
What is the function of the inguinal ligament?
It forms the floor of the inguinal canal, protecting structures passing between the pelvis and thigh e.g., psoas major, iliacus, pectineus, femoral artery and deep circumflex iliac artery.
32
What are the attachments of ligamentum teres?
* Apex of the cotyloid notch on the acetabulum
* Fovea capitis
33
What is the function of ligamentum teres?
It serves as a carrier for the foveal artery which provides nutrients to the femoral head.
34
What are the origins of pectineus?
Superior pubic ramus
35
What are the insertions of pectineus?
Pectineal line on the femur
36
What actions are mediated by pectineus?
* Hip adduction
* Hip flexion
* Medial rotation (while the hip is extended and adducted)
* Lateral rotation (while the hip is flexed and abducted)
37
Which nerves supply pectineus?
* Femoral nerve
* Obturator nerve
38
Which blood vessels supply pectineus?
* Circumflex femoral artery
* Obturator artery
39
Which structures are posterior to pectineus?
* Obturator externus
* Adductor magnus
* Adductor brevis
40
Which structures are anterior to pectineus?
Femoral vessels
41
Which structures sit laterally to pectineus?
* Hip joint capsule
* Iliopsoas
42
Which structures sit medially to pectineus?
Adductor longus
43
How can you strengthen pectineus?
* Side lunges with resistance bands
* Supine leg lifts and holds
44
How can you stretch pectineus?
* Seated bent knee fall out with feet together
* Place one foot on a raised surface and push hips forward
45
How do you palpate pectineus?
1. Ask the patient to place their hand over their genitalia as a border
2. Palpate the ASIS and follow the inguinal ligament down to the pubic tubercle
3. Drop downwards and sink into the triangle and push upward to feel pectineus.
4. Ask the patient to bring their knee up towards their opposite shoulder and you will feel pectineus contract
46
What type of muscle is pectineus?
Parallel non-fusiform
47
What are the origins of rectus femoris?
* AIIS
* Supraacetabular groove of the ilium
48
What are the insertions of rectus femoris?
Tibial tuberosity via the quadriceps femoris tendon
49
What actions are mediated by rectus femoris?
* Hip flexion
* Knee extension
50
Which nerves innervate rectus femoris?
Femoral nerve
51
Which blood vessels supply rectus femoris?
* Femoral artery
* Lateral circumflex femoral artery
52
Which structures sit posteriorly to rectus femoris?
* Iliofemoral ligament
* Vastus intermedius
53
Which structures sit anteriorly to rectus femoris?
Sartorius
54
Which structures sit laterally to rectus femoris?
Tensor fascia latae
55
Which structures sit medially to rectus femoris?
Vastus medialis
56
How can you strengthen rectus femoris?
* Straight leg raises
* Squats
* Knee extensions
57
How can you stretch rectus femoris?
* Pull your ankle towards your bum
* Kneeling lunge whilst pushing your hips forward and holding on to your back ankle
58
How do you palpate rectus femoris?
1. Palpate ASIS and move down to AIIS
2. Ask the patient to lock their knee and tension will be created in rectus femoris
3. Ask the patient to lift their extended leg into the air and hold it
4. Rectus femoris will be clearly visible and palpable on the anterior thigh and it can be followed down to the patella.
59
What type of muscle is rectus femoris?
Bipennate
60
What are the origins of semitendinosus?
Ischial tuberosity
61
What are the insertions of semitendinosus?
Medial aspect of the proximal tibia.
62
Which actions are mediated by semitendinosus?
* Hip extension
* Knee flexion
* Knee medial rotation
63
Which nerves innervate semitendinosus?
Tibial branch of the sciatic nerve
64
Which blood vessels supply semitendinosus?
* Medial circumflex femoral artery
* Deep femoral artery
65
Which structures sit anteriorly to semitendinosus?
Semimembranosus
66
Which structures sit laterally to semitendinosus?
* Long head of biceps femoris
* Tibial collateral ligament
* Anserine bursa
67
How do you palpate semitendinosus?
1. Palpate the ischial tuberosity
2. Ask the patient to flex their knee
3. Identify the semitendinosus tendon just above the knee and palpate up towards the ischial tuberosity
68
How can you strengthen semitendinosus?
* Nordic hamstring curls
* Leg curls
* Less press
* Romanian deadlift
69
How do you stretch semitendinosus?
* Place your heel on a chair and lean forward towards the leg
* Stand behind a chair and lean forward keeping legs straight
* Resistance band stretch of gastrocnemius and hamstrings
70
What type of muscle is semitendinosus?
Fusiform
71
Which muscles form pes anserinus?
* Semitendinosus
* Gracilis
* Sartorius
72
What are the origins of semimembranosus?
Ischial tuberosity (lateral aspect)
73
What are the insertions of semimembranosus?
Medial condyle of the tibia
74
Which actions are mediated by semimembranosus?
* Hip extension
* Knee flexion
* Knee medial rotation
75
Which nerves innervate semimembranosus?
Tibial branch of sciatic nerve
76
Which blood vessels supply semimembranosus?
Deep femoral artery
77
How do you strengthen semimembranosus?
* Nordic hamstring curls
* Leg curls
* Leg press
* Romanian deadlift
78
How do you stretch semimembranosus?
* Place the bottom of your heel on a raised surface and lean into that leg
* Stand behind a chair and lean forward, keeping legs straight
* Resistance band stretch of gastrocnemius and hamstrings
79
How do you palpate semimembranosus?
1. With the knee in resisted flexion palpate the semitendonsus tendon
2. Palpate either side of the semitendinosus tendon and you will be able to feel semimembranosus more deeply
80
What type of muscle is semimembranosus?
Unipennate
81
What structure does a distal tendon from semimembranosus give rise to?
The oblique popliteal tendon
82
What are the origins of biceps femoris?
* Ischial tuberosity (long head)
* Linea aspera and lateral supracondylar line (short head)
83
What are the insertions of biceps femoris?
Head of fibula
84
Which actions are mediated by biceps femoris?
* Hip extension
* Knee flexion
* Knee lateral rotation
85
Which nerves innervate biceps femoris?
* Tibial branch of sciatic nerve (long head)
* Common fibular branch of sciatic nerve (short head)
86
Which blood vessels supply biceps femoris?
* Deep femoral artery
* Inferior gluteal artery (long head only)
* Circumflex femoral artery (long head only)
87
Which structures sit posteriorly to biceps femoris?
Gluteus maximus
88
Which structures sit anteriorly to biceps femoris?
* Femur
* Adductor magnus
* Vastus lateralis
* Sciatic nerve
89
Which structures sit laterally to biceps femoris?
Iliotibial tract
90
Which structures sit medially to biceps femoris?
* Semitendinosus
* Semimembranosus
91
How do you strengthen biceps femoris?
* Nordic hamstring curls
* Leg curls
* Leg press
* Romanian deadlift
92
How do you stretch biceps femoris?
* Place the bottom of your heel on a raised surface and lean into that leg
* Stand behind a chair and lean forward, keeping legs straight
* Resistance band stretch of gastrocnemius and hamstrings
93
How do you palpate biceps femoris?
1. Place the patient in prone with knee slightly flexed
2. Locate the lateral proximal border of the popliteal fossa to find the tendinous insertion
3. Ask the patient to perform resisted knee flexion and palpate up from the tendinous insertion to the ischial tuberosity
94
What type of muscle is biceps femoris?
Fusiform parallel muscle
95
What structure does biceps femoris contribute to?
Popliteal fossa
96
What are the origins of gluteus maximus?
* Ilium posterior to the posterior gluteal line
* Posterior sacrum and coccyx
* Sacrotuberous ligament
97
What are the insertions of gluteus maximus?
* Gluteal tuberosity of the femur
* Tubercle of the iliotibial tract on the tibia via the IT band
98
Which functions are mediated by gluteus maximus?
* Hip extension
* Hip lateral rotation
* Hip abduction
99
Which nerves innervate gluteus maximus?
Inferior gluteal nerve
100
Which blood vessels supply gluteus maximus?
Superior and inferior gluteal arteries
101
Which structures sit deep to gluteus maximus?
* Gluteus medius
* Trochanteric and sciatic bursae
* Sciatic nerve
102
Which structures are superficial to gluteus maximus?
* Gluteal fascia
* Subcutaneous gluteal tissue
103
How can you strengthen gluteus maximus?
* Bridging
* Sideways lunge
* Step ups
* Superman pose
* Squats
104
How do you stretch gluteus maximus?
* Seated figure 4 stretch on a chair, leaning slightly forward, hinging at the hips
* Supine pulling your knee towards opposite shoulder
105
How do you palpate gluteus maximus?
1. Palpate the PSIS
2. Place your palm with fingers pointed inferiorly and medially
3. The upper hand now covers the origins and the bulk of the muscle is under the palm
4. Resisted hip extension can make this muscle fire off and make palpation easier
106
What type of muscle is gluteus maximus?
Multipennate
107
What are the origins of adductor magnus?
* Inferior pubic ramus
* Ischial ramus
* Ischial tuberosity
108
What are the insertions of adductor magnus?
* Gluteal tuberosity
* Linea aspera
* Medial supracondylar line
* Adductor tubercle
109
Which actions are mediated by adductor magnus?
* Hip adduction
* Hip extension
* Hip flexion
110
Which nerves innervate adductor magnus?
* Obturator nerve
* Tibial branch of sciatic nerve
111
Which blood vessels supply adductor magnus?
* Deep femoral artery
* Obturator artery
* Femoral artery
112
Which structures are posterior to adductor magnus?
* Biceps femoris
* Semimembranosus
* Semitendinosus
* Sciatic nerve
113
Which structures are anterior to adductor magnus?
* Adductor brevis
* Adductor longus
* Pectineus
* Deep femoral vessels
114
Which structures are medial to adductor magnus?
Gracilis
115
How can you strengthen adductor magnus?
* Banded adduction
* Lateral lunges
* Copenhagen adductor strengthening
* Side lying leg lifts
116
How do you stretch adductor magnus?
* Sumo squat
* Supine knee drop out with soles of feet together
117
How do you palpate adductor magnus?
1. Place the patient in side lying with their top leg bent out of the way
2. Palpate the ischial tuberosity and move anteriorly to find the ischial ramus
3. Ask the patient to adduct and you will feel activation of adductor magnus
118
Which is the most powerful hip adductor?
Adductor magnus
119
What type of muscle is adductor magnus?
Triangular
120
What are the origins of adductor longus?
Anterior surface of the body of pubis
121
What are the insertions of adductor longus?
Middle third of linea aspera
122
Which actions are mediated by adductor longus?
* Hip adduction
* Hip flexion
123
Which nerves innervate adductor longus?
Obturator nerve
124
Which blood vessels supply adductor longus?
* Deep femoral artery
* Medial circumflex femoral artery
125
Which structures are posterior to adductor longus?
* Adductor brevis
* Adductor magnus
* Deep femoral artery
126
Which structures are anterior to adductor longus?
* Sartorius
* Vastus medialis
* Femoral artery
127
Which structures are lateral to adductor longus?
Pectineus
128
Which structures are medial to adductor longus?
Gracilis
129
How can you strengthen adductor longus?
* Banded adduction
* Lateral lunges
* Copenhagen adductor strengthening
* Side lying leg lifts
130
How do you stretch adductor longus?
* Sumo squat
* Supine bend knee fallout with soles of feet together
131
How do you palpate adductor longus?
1. Place the patient in supine
2. Place their knee and hip into flexion and support this position by placing your knee under theirs
3. Get the patient to perform resisted adduction and you will see two muscles fire off, the more anterior is adductor longus and the posterior is gracilis
132
What structures does adductor longus contribute to?
* Adductor canal
* Femoral triangle
133
What type of muscle is adductor longus?
Fusiform
134
What are the origins of adductor brevis?
* Body of pubis
* Inferior pubis ramus
135
What are the insertions of adductor brevis?
Proximal third of the medial lip of linea aspera
136
Which actions are mediated by adductor brevis?
Hip adduction
137
Which nerves innervate adductor brevis?
Obturator nerve
138
Which blood vessels supply adductor brevis?
Deep femoral artery
139
Which structures are posterior to adductor brevis?
* Adductor magnus
140
Which structures are anterior to adductor brevis?
* Adductor longus
* Pectineus
141
How do you strengthen adductor brevis?
* Banded adduction
* Lateral lunges
* Copenhagen adductor strengthening
* Side lying leg lifts
142
How do you stretch adductor brevis?
* Sumo squat
* Supine bent knee fallout with soles of feet together
143
How do you palpate adductor brevis?
1. Place the patient in supine
2. Place their knee and hip into flexion and support this position with your knee beneath theirs
3. Ask the patient to perform resisted adduction and the more anterior muscle is abductor longus
4. Ask the patient to make a border for their genitalia
5. Hook your fingers beaneath the posterior border of adductor longus and you will feel adductor brevis
6. You can palpate up towards inferior pubic ramus or down the linea aspera on the medial lip
144
What type of muscle is adductor brevis?
Triangular muscle
145
What are the origins of gracilis?
* Body of pubis
* Inferior pubic ramus
146
What are the insertions of gracilis?
Medial aspect of the proximal part of the tibia
147
Which actions are mediated by gracilis?
* Hip adduction
* Knee flexion
* Knee medial rotation
148
Which nerves innervate gracilis?
Obturator nerve
149
Which blood vessels supply gracilis?
* Deep femoral artery
* Deep circumflex femoral artery
150
Which structures are posterior to gracilis?
Semitendinosus
151
Which structures are anterior to gracilis?
Sartorius
152
Which structures are lateral to gracilis?
* Adductor longus
* Adductor magnus
* Semimembranosus
* Tibial collateral ligament
* Anserine bursa
153
How do you strengthen gracilis?
* Banded hip adduction
* Adductor machines
* Resisted butterfly stretch
154
How do you stretch gracilis?
* Bent knee fallout with soles of feet together
* Wide side lunges
155
How do you palpate gracilis?
1. Place the patient in supine
2. Place their knee and hip into flexion and put your knee beneath theirs for support
3. Ask them to push their heel into the bed and pull their foot towards them and you will see gracilis fire medially
4. You can palpate towards the inferior pubic ramus (origin) if the patient creates a genital border with their hand
5. You can also follow it towards the insertion at the medial tibia but it overlaps with sartorius at this point
156
What type of muscle is gracilis?
Long fusiform
157
How is gracilis often used in surgery?
It is widely used as a grafting muscle to replace muscle tissue after wide margin tumour biopsies. It is very good at maintaining its contractile abilities after grafting.
158
What are the origins of gluteus medius?
* Posterior of the ilium between the anterior and posterior gluteal lines
159
What are the insertions of gluteus medius?
Lateral aspect of the greater trochanter of the femur.
160
Which actions are mediated by gluteus medius?
* Hip abduction
* Hip medial rotation
161
Which nerves innervate gluteus medius?
Superior gluteal nerve
162
Which blood vessels supply gluteus medius?
Superior gluteal artery
163
Which structures are deep to gluteus medius?
* Ilium
* Gluteus minimus
* Trochanteric bursa of gluteus medius
164
Which structures are superficial to gluteus medius?
* Gluteus maximus
* Tensor fascia lata
* Iliotibial tract
165
Which structure is inferior to gluteus medius?
Piriformis
166
How can you strengthen gluteus medius?
* Hip abduction
* Hip hitches
* Single leg glute bridges
* Clamshells
167
How can you stretch gluteus medius?
* Sitting cross legged and gently leaning your torso towards the floor with arms outstretched
* Standing side bend against a wall with your furthest leg crossed in front of your other, pushing your upper body away from the wall and your hip towards it
168
How do you palpate gluteus medius?
1. Place the patient in side lying
2. Palpate the PSIS and move just anterior to the posterior gluteal line which travels upwards and merges with the iliac crest
3. Then palpate inferior from the PSIS into a large dip, the sciatic notch, and trace towards the iliac tubercle anterolaterally. This is the anterior gluteal line
4. Between those two lines is the origin of gluteus medius and it narrows in a triangular fashion to the lateral aspect of the greater trochanter.
5. Ask the patient to perform resisted abduction and you will feel the muscle switched on.
6. To isolate from gluteus minimus, add extension and lateral rotation to the abduction.
169
What type of muscle is gluteus medius?
Convergent
170
What are the origins of tensor fascia lata?
* ASIS
* Anterior third of the outer lip of the iliac crest
171
What are the insertions of tensor fascia lata?
Tubercle of the iliotibial tract on the tibia via the IT band
172
What actions are mediated by tensor fascia lata?
* Hip abduction
* Hip flexion
* Hip medial rotation
173
Which nerves innervate tensor fascia lata?
Superior gluteal nerve
174
Which blood vessels supply tensor fascia lata?
* Lateral circumflex femoral artery
* Superior gluteal artery
175
Which structures are deep to tensor fascia lata?
* Gluteus medius
* Gluteus minimus
* Deep layer of iliotibial tract
176
Which structures are superficial to tensor fascia lata?
Superficial layer of iliotibial tract
177
Which structures are medial to tensor fascia lata?
* Sartorius
* Rectus femoris
178
How can you strengthen tensor fascia lata?
* Clamshells
179
How do you stretch tensor fascia lata?
Supine with feet flat on the floor about twice hip width apart, bring one knee down medially at a time
180
How do you palpate tensor fascia lata?
1. Palpate the ASIS
2. Move laterally along the iliac crest until you reach the anterior tubercle. The origin is between these two points
3. Ask the patient to medially rotate their hip and lift their leg off the table and abduct
4. Resist this movement and the muscle belly will be very clear and can be palpated down to the IT band which can be followed down below the knee
181
What type of muscle is tensor fascia lata?
Fusiform
182
What are the origins of gluteus minimus?
The ilium between the anterior and inferior gluteal lines
183
What are the insertions of gluteus minimus?
Anterolateral aspect of the greater trochanter
184
Which actions are mediated by gluteus minimus?
* Hip abduction
* Hip medial rotation
185
Which nerves innervate gluteus minimus?
Superior gluteal nerve
186
Which blood vessels supply gluteus minimus?
Superior gluteal artery
187
Which structures are deep to gluteus minimus?
* Hip joint capsule
* Ilium
* Trochanteric bursa of gluteus medius
188
Which structures are superficial to gluteus minimus?
* Gluteus medius
* Gluteus maximus
* Tensor fascia lata
189
Which structures are inferior to gluteus minimus?
Piriformis
190
How can you strengthen gluteus minimus?
Clamshells
191
How do you stretch gluteus minimus?
Pigeon stretch
192
How do you palpate gluteus minimus?
1. Place the patient in side lying
2. Palpate the PSIS and palpate inferiorly into the sciatic notch
3. Palpate the iliac tubercle and between this and the sciatic notch is the anterior gluteal line
4. Palpate from the sciatic notch to the gap between ASIS and AIIS and this is the inferior gluteal line.
5. Between these lines is the origin of gluteus minimus
6. This can be followed to the superior aspect of the greater trochanter
7. If you palpate deeply at the superior aspect of the greater trochanter then hip abduction will cause gluteus minimus to push your fingers out of this space
193
What type of muscle is gluteus minimus?
Convergent
194
What are the origins of gemellus superior?
Ischial spine
195
What are the insertions of gemellus superior?
Medial aspect of the greater trochanter
196
Which actions are mediated by gemellus superior?
* Hip lateral rotation
* Transverse abduction
197
Which nerves innervate gemellus superior?
Obturator nerve
198
Which blood vessels supply gemellus superior?
* Inferior gluteal artery
* Inferior pudendal artery
199
Which structures are deep to gemellus superior?
Hip joint
200
Which structures are superficial to gemellus superior?
* Gluteus maximus
* Sciatic nerve
201
Which structures are inferior to gemellus superior?
Obturator internus
202
Which structures are superior to gemellus superior?
Piriformis
203
How do you strengthen gemellus superior?
* Clamshells
* In prone, place knees 10 inches apart and push heels together to isometrically contract external rotators
204
How can you stretch gemellus superior?
* Seated figure 4 stretch
* Pigeon pose
205
How do you palpate gemellus superior?
1. Palpate the ischial tuberosity and palpate just medially and superiorly to the ischial spine
2. Palpate to the lateral part of the ischial spine and this is the origin of gemellus superior.
3. Palpate towards the medial aspect of the greater trochanter for the insertion.
4. This muscle is challenging to separate from other external rotator muscles like piriformis
206
What type of muscle is gemellus superior?
Convergent
207
What are the origins of gemellus inferior?
Lateral aspect of ischial tuberosity
208
What are the insertions of gemellus inferior?
Medial aspect of greater trochanter of the femur
209
Which actions are mediated by gemellus inferior?
* Hip lateral rotation
* Transverse hip abduction
210
Which nerves innervate gemellus inferior?
The nerve to quadratus femoris (L5-S1)
211
Which blood vessels supply gemellus inferior?
Medial circumflex femoral artery
212
How can you strengthen gemellus inferior?
* Clamshells
* In prone, knees 10 inches apart push heels together for isometric external rotator contraction
213
How do you stretch gemellus inferior?
* Seated figure 4 pose
* Pigeon pose
214
How do you palpate gemellus inferior?
1. Palpate the ischial tuberosity then move laterally and an inch superiorly to find the ischial spine, the origin of gemellus inferior
2. Palpate the medial aspect of the greater trochanter (as far as possible) to find the insertion. The area between these two points is gemellus inferior but it is challenging to separate out the external rotator muscles from one another.
215
Which structures are deep to gemellus inferior?
Hip joint capsule
216
Which structures are superficial to gemellus inferior?
* Gluteus maximus
* Sciatic nerve
217
Which structures are inferior to gmellus inferior?
Quadratus femoris
218
Which structures are superior to gemellus inferior?
Obturator internus
219
What type of muscle is gemellus inferior?
Convergent
220
What are the origins of obturator externus?
External surface of the obturator membrane, running along the pubic ring
221
What are the insertions of obturator externus?
Trochanteric fossa of the femur
222
Which actions are mediated by obturator externus?
Hip lateral rotation
223
Which nerves innervate obturator externus?
Obturator nerve
224
Which blood vessels supply obturator externus?
* Obturator artery
* Medial circumflex femoral
225
Which structures are posterior to obturator externus?
* The obturator foramen
* Quadratus femoris
226
Which structures are anterior to obturator externus?
* Neck of the femur
* Hip joint capsule
* Pectineus
* Adductor brevis
227
How do you strengthen obturator externus?
* Clamshells
* In prone place knees 10 inches apart and push heels together
228
How do you stretch obturator externus?
* Seated figure 4 stretch
* Pigeon pose
229
How do you palpate obturator externus?
You can't.
230
What type of muscle is obturator externus?
Convergent
231
What are the origins of obturator internus?
* Internal surface of obturator membrane (along the back of the pubic ring)
232
What are the insertions of obturator internus?
Medial aspect of greater trochanter
233
Which actions are mediated by obturator internus?
Hip lateral rotation
234
Which nerves innervate obturator internus?
L5-S1 nerve roots
235
Which blood vessels supply obturator internus?
* Obturator artery
* Internal pudendal artery
236
Which structures are deep to obturator internus?
* Hip joint capsule
* Sciatic bursa of obturator internus
237
Which structures are superficial to obturator internus?
* Obturator fascia
* Gluteus maximus
* Sciatic nerve
238
Which structures are inferior to obturator internus?
Gemellus inferior
239
Which structures are superior to obturator internus?
Gemellus superior
240
How do you strengthen obturator internus?
* Clamshells
* In prone, with knees 10 inches apart, push the heels together isometrically
241
How do you stretch obturator internus?
* Seated figure 4 stretch
* Pigeon pose
242
How do you palpate obturator internus?
1. Palpate the ischial tuberosity and hook fingers medially and move superiorly to just below the ischial spine. This is where obturator internus exits the obturator foramen.
2. Palpate between here and the medial aspect of the greater trochanter.
3. As with the other external rotators, their palpation can be difficult to separate.
243
What type of muscle is obturator internus?
Multipennate
244
What are the origins of quadratus femoris?
Lateral face of the ischial tuberosity
245
What are the insertions of quadratus femoris?
Quadrate tubercle of the femur
246
What actions are mediated by quadratus femoris?
Hip external rotation
247
Which nerves innervate quadratus femoris?
L5-S1 nerve roots
248
Which blood vessels supply quadratus femoris?
* Medial circumflex femoral artery
* Inferior gluteal artery
249
Which structures are posterior to quadratus femoris?
Sciatic nerve
250
Which structures are anterior to quadratus femoris?
Obturator externus
251
Which structures are superior to quadratus femoris?
Gemellus inferior
252
How can you strengthen quadratus femoris?
* Forward or side lunges
* Clamshells
* Heels together isometric contractions in prone
253
How do you stretch quadratus femoris?
* Seated figure 4 stretch
* Pigeon pose
254
How do you palpate quadratus femoris?
1. Palpate the ischial tuberosity and move laterally and superiorly to the lateral face of the ischial tuberosity
2. You can run your fingers over the muscle belly by pushing up and down and you will feel this small cuboid muscle which inserts just below the medial surface of the greater tochanter
255
What type of muscle is quadratus femoris?
A quadrilateral muscle
256
What are the origins of piriformis?
* Pelvic surface of the sacrum
* Sacrotuberous ligament
257
What are the insertions of piriformis?
Superior border of the greater trochanter
258
Which actions are mediated by piriformis?
Hip external rotation
259
Which nerves innervate piriformis?
S1-S2 nerve roots
260
Which blood vessels supply piriformis?
* Superior gluteal artery
* Inferior gluteal artery
* Internal pudendal artery
* Lateral sacral artery
261
Which structures are posterior to piriformis?
* Sacrum
* Gluteus maximus
262
Which structures are anterior to piriformis?
* Hip joint capsule
* Sacral plexus
* Sciatic nerve
263
Which structures are inferior to piriformis?
* Coccygeus
* Superior gemellus
* Inferior gluteal artery
* Inferior gluteal nerve
264
Which structures are superior to piriformis?
* Gluteus medius
* Superior gluteal artery
* Superior gluteal nerve
265
How do you strengthen piriformis?
* Clamshells
* Isometric heel exercise in prone
266
How do you stretch piriformis?
* Seated figure 4 stretch
* Pigeon pose
267
How do you palpate piriformis?
1. Palpate the PSIS and move inferiorly into the sciatic notch
2. Palpate laterally to the edge of the sacrum and place the hip into external rotation and palpate deeply through gluteus maximus and follow piriformis along to the superior border of the greater trochanter
268
What type of muscle is piriformis?
Convergent
269
What is the most common site of fracture in elderly women?
Neck of femur
270
Why are fractured neck of femurs so common in Caucasian women in their 60s and 70s?
Due to the high prevalence of osteoporosis.
271
What are common risk factors for fractured neck of femur?
* Osteoporosis
* Osteomalacia
* Diabetes
* Stroke
* Alcoholism
* White ethnicity
272
What is osteomalacia?
This is inadequate mineralisation of bone tissue due to lack of vitamin D, calcium or phosphate. This leads to softening of bones.
273
Which classification is used to classify fractured neck of femurs?
Garden classification
274
What are the 4 stages of the garden classification?
1. Incomplete impacted fracture where the neck undergoes a valgus tilt.
2. Complete fracture but not displaced.
3. Complete fracture with moderate displacement.
4. Complete fracture with severe disaplcement.
275
Which blood vessels supply the femoral head?
80% of blood flow to the femoral head is supplied by:
* Intermedullary vessels in the femoral neck
* Ascending cervical branches of medial and lateral circumflex anastomoses
20% comes from vessels within ligamentum teres.
276
Why is bone ischaemia a major risk in fractured neck of femur?
Fracturing the neck of the femur can disrupt intermedullary vessels and medial and lateral circumflex anastomoses, interrupting 80% of blood flow to the femoral head. This leaves only 20% of blood flow left so there is high risk of ischaemia.
277
How does synovial fluid affect healing of fractured neck of femur?
The relatively large flow of synovial fluid in the hip joint capsule slows clotting of the fracture haemotoma, slowing healing.
278
How can fractured neck of femurs be managed?
* Pain relief
* Splinting
* Internal fixation/pinning if there is displacement
* Hip replacement in higher grade fractures
279
What are potential complications in management of fractured neck of femur?
* Normal surgical complications e.g., DVT, PE, pneumonia etc
* Femoral head ischaemic necrosis
* Non-union of the femoral head and neck
280
In what percentage of femoral neck fractures is there non-union of the head and neck of the femur?
30%
281
What type of fracture is most common in women with osteoporosis in their 70s?
Intertrochanteric fractures of the femur
282
What are the most common causes of intertrochanteric fractures of the femur?
* Falling onto the greater trochanter
* Indirect twisting injuries
283
What causes an intertrochanteric femoral fracture to be classed as unstable?
* Poor contact between fracture fragments
* A fracture pattern where weight bearing causes further displacement
284
What are the clinical features of intertrochanteric fractures?
* Inability to stand
* Shortening and external rotation of the injured leg
285
How are intertrochanteric fractures best managed?
Internal fixation
286
What can be a major challenge in the repair and healing of femoral shaft fractures?
The large muscles surrounding the break can contract and displace the fracture.
287
What are the different patterns of femoral shaft fracture?
* Spiral fracture where the root was anchored but a twisting force was applied to the femur
* Transverse or oblique fractures in response to direct violence
288
What displacement pattern is often seen in proximal femoral shaft fractures?
Flexion, abduction and external rotation of the proximal fragment due to gluteus medius and iliopsoas activity. The distal fragment undergoes adduction.
289
What displacement pattern is often seen in mid shaft femoral fractures?
Flexion and external rotation of the proximal fragment due to gluteus medius and iliopsoas activity.
290
What displacement pattern is commonly seen in lower femoral shaft fractures?
Rotation of the distal fragment due to pull from gastrocnemius.
291
What are the clinical features of femoral shaft fractures?
* Swelling and deformity of the limb
* Pain on any attempt to move the limb
292
What is a key first aid step to rduce bleeding and facilitate transfer with femoral shaft fractures?
The patient should undergo traction by pulling their leg straight and threading it through the ring of a splint and firmly bandaging them together.
293
How are femoral shaft fractures managed?
* Traction
* Plaster casts
* Sometimes plates and screws
294
What are potential complications of femoral shaft fractures?
* Early blood loss
* Fat emboli from bone marrow causing pulmonary embolism
* DVT
* Infection
* Non-union
* Re-fracture
295
What is the difference between primary and secondary OA?
Primary OA is idiopathic and occurs in previously intact joints with no initiating factor.
Secondary OA results from predisposing trauma, infection, congenital deformity, obesity etc which adversely alter articular cartilage or subchondral bone, starting the degenerative process of OA.
296
What is the structure of cartilage?
It is made of collagen fibres (mainly type 2) intertwined with proteoglycans. The proteoglycans have a backbone of hyaluronic acid with GAGs attached by linker proteins. These draw water into the cartilage.
297
How does cartilage promote joint lubrication?
Proteoglycans in cartilage draw water in and so when cartilage is squeezed and deformed the water is squeezed into the joint space, lubricating the joint.
298
Why are cartilage damage injuries poorly repaired?
Chondrocytes, the cells that produce hyaline cartilage, have little cell division capacity.
299
What is synovium?
Synovium is a thin membrane, richly supplied by blood or lymph vessels and nerves. It produces synovial fluid, a viscous plasma containing hyaluronan and lubricin which lubricate joints. Synovial fluid also contains nutrients for avascular cartilage.
300
What percentage of the world's population have OA?
3.5%
301
What are risk factors for OA?
* Older age
* Female sex
* Obesity
* Muscle weakness
* Joint injury
* Joint abnormalities e.g., through trauma, congenital disorders, osteoporosis etc
302
How can labral tears in the hip joint accelerate OA?
Labal tears result in reduction of the efficacy of the labrum in forming a seal to keep synovial fluid in, resulting in reduced joint lubrication and greater inflammation.
303
What is the basic pathophysiology of OA?
1. Abnormal joint mechanics stimulate inflammation
2. Inflammation activates protease production and release
3. Proteases like collagenases, stromelysin and MMPs break down cartilage
4. Cartilage breakdown stimulates IL1 and TNFa release which drive further protease production by surroudning chondrocytes.
304
What changes does osteoarthritis cause to bone?
* Damaged collagen is often replaced by osteophytes
* There is subchondral bone sclerosis
* Thickening of the cortical plate in response to microfracture
* Extensive trabecular remodelling
* Subchondral cysts can form if synovial fluid enters microfractures
305
How does subchondral bone turnover differ in OA compared to healthy individuals?
Subchondral bone turnover is 20-fold faster in OA compared to healthy individuals, possibly due to increased production of alkaline phosphatase, osteocalcin and osteopontin.
306
How does osteophyte function in OA lead to ligamentous instability?
Osteophytes narrow the joint space and cause less need for ligamentous activity to maintain joint stability so ligaments become lax.
307
What does stabbing pain in OA often indicate?
Loose bodies in the joint
308
What does throbbing pain in OA often indicate?
Inflammatory response. This is most commonly seen at night.
309
Other than joint surface changes and osteophyte formation, how can OA cause reduced ROM?
Pain in OA can cause maladaptive postures which lead to shortening of muscles which impacts on ROM.
310
In hip OA, which muscles show reduced strength?
* Hip flexors
* Hip extensors
* Hip abductors
* Knee flexors
* Knee extensors
This weakness is seen also in the contralateral limb.
311
Which muscles have reduced volume in patients with hip OA?
* Quadriceps
* Hamstrings
* Adductors
* Gluteus minimus
* Gluteus maximus
312
What are the 4 stages of OA classification?
1. Minimum disruption but approximately 10% cartilage loss
2. Joint space begins to narrow, greater cartilage breakdown, formation of osteophytes
3. Worsening joint space reduction, gaps in cartilage down to bone in some areas
4. Joint space greatly reduced, >60% cartilage loss, large osteophytes
313
What are the 5 key elements that produce confidence in an OA diagnosis?
* Pain that is worse with activity and better with rest
* Age >45
* Morning stiffness >30 minutes
* Bony joint enlargement
* Limited ROM
314
How should OA be medically managed?
* NSAIDs
* Analgesia
* Glucocorticoid injections
315
How can OA be physically managed?
* Exercises to improve strength and ROM
* Braces, splints, canes etc to offload joints
* Avoidance of activities which exacerbate pain
* Manual therapy as an adjunct to exercise
* Weight loss >5%
316
Is land-based or water-based exercise better for OA?
Land-based
317
What are the 5 indications for total hip replacement?
1. Hip pain that limits everyday activities e.g., walking or bending
2. Hip pain at rest
3. Stiffness in the hip that limits the ability to move or lift the leg
4. Inadequate pain relief from NSAIDs, physiotherapy and walking aids
5. Hip pain causing depression and inability to engage socially and in work
318
How do total hip replacements occur?
The top of the femur is removed and part of the inside of the bone is removed to provide a fit for the stem of the prosthetic.
319
Why do hip joint prostheses have a porous surface?
This encourages colonisation by bone.
320
What are potential complications of total hip replacement?
* Infections
* Blood clots
* Leg length discrepancies
* Dislocation (particularly during healing)
321
What are key considerations in post-surgical after care of total hip replacements?
* Avoid hip flexion beyond 90 degrees
* Avoid twisting or swivelling motions
* Take small steps while turning around
* Do not cross your legs
* Do not apply pressure to the wound
* Avoid low chairs and toilet seats
* Be extremely careful to avoid falls
322
What is the pathophysiology of osteoporosis?
Decreasing circulation of sex hormones, particularly oestrogen, results in alterations in bone architecture and loss of mineral bone density. This then increases the risk of fragility fractures.
322
What are risk factors for osteoporosis?
* Caucasian ethnicity
* Older age
* Prior history of fracture
* Corticosteroid use
* Low BMI
* Smoking
* High alcohol intake
323
What are the clinical features of osteoporosis?
* Low vitamin D and calcium
* Low DEXA scan bone density
* Fractures
324
How can osteoporosis be managed?
* Weight bearing physical activity
* Smoking cessation
* Alcohol reduction
* Vitamin D and calcium supplementation
* Bisphosphonates
* Hormone replacement therapy
* RANKL inhibitors
325
What does a comprehensive falls risk assessment include?
* Discussion of falls history
* Assessment of gait, balance, mobility and muscle weakness
* Assessment of osteoporosis risk
* Assessment of perceived function and fear of falling
* Assessment of visual impairment
* Assessment of cognitive impairment
* Assessment of home hazards
326
What can falls prevention interventions include?
* Strength and balance training
* Home hazard assessment and intervention
* Vision asssesment and referral
* Medications reviews
* Patient education about how to reduce risk of falls
327
What are the 3 classes of hamstring injury according to the British Athletics Muscle Injury Classification?
1. Myofascial
2. Musculotendinous
3. Intratendinous
328
What are myofascial hamstring injuries according to BAMIC?
Injuries resulting in damage to myofascia which connects deep fascia to the epimysium. This does not involve damage to contractile units. It is associated with sudden or gradual onset thigh pain but heals in around 3 weeks.
329
What are musculotendinous hamstring injuries according to BAMIC?
These are injuries which damage contractile muscular tissue. They cause pain, muscle weakness and reduced ROM and take around 3 weeks to heal. Its healing is associated with collagen deposition and satellite cell proliferation.
330
What are intratendinous hamstring injuries according to BAMIC?
These are injuries to the hamstring tendon caused by high velocity stretch. This leads to antalgic gait and significant losses of ROM and power. It is associated with initial type II collagen deposition followed by type I deposition. It takes around 6 weeks to recover.
331
What are the 3 stages of the tendinopathy continuum?
1. Reactive tendinopathy
2. Tendon disrepair
3. Degenerative tendinopathy
332
What is reactive tendinopathy?
This is a non-inflammatory proliferative process in the cell matrix in response to compressive or tensile overload. Collagen and proteogylcan production is reduced which also draws water to the area. This thickens tendons, increasing their stiffness and reducing stress.
333
What is tendon dysrepair?
This is a progression from reactive tendinopathy where there is increased protein production, disorganisation in the cell matrix, increased vascularisation and increased neural ingrowth.
334
What is degenerative tendinopathy?
This is a progression from tendon dysrepair where irreversible changes occur such as cell death, general matrix disorganisation and tenocyte exhaustion.
335
What are risk factors for tendinopathy?
* HRT
* Oral contraceptives
* Diabetes
* Obesity
* Poor ROM/inflexibility
336
What are the clinical features of tendinopathy?
* Pain
* Swelling
* Redness
* Atrophy (in chronic tendinopathy)
* Focal nodular areas or tendon thickening (in degenerative tendinopathy phase)
337
How can tendinopathy be managed?
* Early eccentric exercises
* Corticosteroid injections
338
What are muscle strains?
Tears in muscle fibres in response to overload. It is most often due to powerful eccentric contractions.
339
What are the grades of muscle strain?
Grade 1 - Mild strain affecting few fibres. Does not reduce strength or ROM. Often presents with pain and tenderness the day after injury.
Grade 2 - Moderate strain with up to 50% of fibres torn. Often presents with significant pain and swelling and small decreases in muscle strength.
Grade 3 - Severe strains with complete muscle rupture e.g., bisection of the muscle belly or separation from the tendon. This is associated with severe pain and swelling and complete loss of function.
340
What are risk factors for muscle strains?
* Two joint muscles
* Eccentric muscle contractions
* High type II percentage fibres
341
What are the clinical features of muscle strains?
* Swelling, bruising or redness
* Pain at rest
* Inability to use the muscle
* Weakness
342
How can muscle strains be treated?
* Protection
* Rest
* Ice
* Compression
* Elevation
* NSAIDs
* Mobilisation
343
What are the 4 classes of quadriceps injury?
1. Myofascial
2. Myotendinous
3. Free tendon injury
4. AIIS avulsion
344
What is Corker's thigh?
This is a condition where a direct blow to the quadriceps muscle causes muscle rupture laeding to myonecrosis and haemotoma. This causes pain and loss of function. A scar forms as the muscle regenerates.
345
What are the grades of Corker's thigh?
Mild - Active knee flexion >90 degrees, mild soreness and tenderness
Moderate - Active knee flexion 45-90 degrees, antalgic gait with swelling, pain and tenderness
Severe - Active knee flexion <45 degrees, severely antalgic gait with rapid swelling and bleeding on injury, severe pain and tenderness.
346
How can Corker's thigh be managed?
* NSAIDs
* RICE for 24-48 hours
* Quadriceps stretching
* Functional rehabilitation exercises
347
How do you perform longitudinal caudad glide?
For grade 1/2:
1. Place the knee into 30 degrees of flexion and place your knee beneath theirs for support
2. Press the feels of the hand into the distal end of femur and the sternum is placed over the hands for stability
3. A gentle oscillating movement is used to move the joint caudally
For grade 3/4:
1. Put the hip into 90 degrees flexion and keep it there with your neck and shoulders
2. Interlock your fingrs at the proximal end of the femur and pull the hip caudally.
348
How are grade 1/2 passive physiological medial rotations performed?
1. Place the patient in supine
2. Place your knee beneath theirs
3. Hold the distal femur and proximal tibia and rotate the femur internally
349
How are grade 3/4 passive physiological medial rotations performed?
1. Place the patient in prone with knee flexed to 90 degrees
2. Hold the bottom of the foot and move the heel outward to medially rotate the femur
3. You can place your knee against the patients to make sure the movements are consistently the same magnitude
4. These higher grade movements can move the opposite hip so consider fixing this with one hand.
350
How can you control measurements of hip flexion?
Place your thumb on the ASIS to ensure that pelvic rotation is not skewing hip flexion readings
351
How should a goniometer be positioned in measuring hip flexion?
* Axis on the greater trochanter
* Stationary arm parallel to the mid-axillary line
* Moveable arm parallel to the longitudinal axis of the femur
352
What is a normal hip flexion ROM?
110-120 degrees
353
What ROM is normal for hip extension?
10-15 degrees
354
How is lateral rotation at the hip tested?
1. Patient in supine
2. Hip and knee are brought to 90 degrees flexion with the knee supported in one hand and the heel in the other
3. The heel is brought medially to externally rotate the hip.
Or the patient in prone can help to stabilise the hip jiont
355
How can you measure hip external rotation with a goniometer?
If the patient is sat on the edge of the plinth, place the static arm and moveable arm at the base of the patella, perpendicular with the floor and in line with the tibia. Follow the lower leg with the moveable arm.
If the patient is in prone, place both arms against the plinth in line with the tibia and follow the lower leg with the moveable arm.
356
What is a normal range for hip external rotation?
40-60 degrees
357
What is a normal range for hip medial rotation?
30-45 degrees
358
How is abduction tested?
The patient lies diagonally on the plinth with one leg hanging off and they remain flat on their back and abduct outwards.
359
How is hip abduction measured with a goniometer?
* Axis on ASIS
* Stationary arm between both ASISs
* Moveable arm parallel with longitudinal axis of the femur
360
What is a normal range of motion for hip adduction?
15-25 degrees
361
From what landmarks should leg length be measured?
Actual leg length - ASIS to medial malleolus
Apparent leg length - Belly button to medial malleolus
362
What is Trendelenburg's sign indicative of?
Weakness in hip abductor muscles.
363
What is a Thomas test?
This is a test for hip flexor contractures.
1. The patient is in supine and their lumbar lordosis is assessed as excessive lumbar lordosis can be a sign of tight iliopsoas.
2. The patient then brings their knee to their chest and holds it.
3. If their opposite leg (extended leg) lifts off the table then this is a positive test. If the extended leg abducts this is known as the J sign and is indicative of tight iliopsoas.
364
What is Obers test?
This is a test for tight IT band and short tensor fascia lata.
1. The patient is in side lying and the therapist fixes the pelvis with one hand and support the knee with the other
2. The hip extended back and adducted to see if it can touch the bed. If it cannot then this is a positive test
365
What is the hip quadrant test?
This is a test to identify labral damage, arthritic changes or loose bodies in the joint.
1. Patient in supine
2. Place the patient's hip into flexion, adduction and medial rotation
3. Apply force through the femur and make small semicircles to scour the joint for detritis.
