Hip Flashcards
What are the 2 primary roles of the hip?
- Supports weight of head, arms, and trunk during upright postures and dynamic weight-bearing activities
- Provides pathway for transmission of forces between the lower extremities and pelvis
What 3 bones combine to form the acetabulum?
- Ilium
- Ischium
- Pubis
What is the role of the labrum of the hip?
- Adds stability to the joint
What is the normal angle of inclination of the femoral head? What is the angle of inclination of the femoral head?
- Angle between axis of femoral shaft and axis of head and neck of femur
- 125 degrees normally
What is the angle of torsion? How many degrees is the angle of torsion typically?
- Angle of axis of femoral head and transverse axis of femoral condyles
- 12 - 15 degrees
What are the 3 main ligaments of the hip?
- Iliofemoral
- Pubofemoral
- Ischiofemoral
What 9 muscles flex the hip?
- Iliopsoas
- Tensor fascia lata
- Rectus femoris
- Sartorius
- Adductor magnus
- Adductor longus
- Adductor brevis
- Pectineus
- Gracilis
What are the 4 hip extensor muscles?
- Gluteus maximus
- Hamstrings
- Posterior fibers of gluteus medius
- Piriformis
What is unique about the muscles that cross the hip joint?
- They have a regional impact
Ex) Iliopsoas affects hip and lumbar spine
What are the 4 hip abductor muscles/ groups?
- Gluteus medius
- Tensor fascia lata
- Superior gluteus maximus
- Gluteus minimus
What are the 6 hip adductor muscles/ groups?
- Adductor group
- Quadratus femoris
- Pectineus
- Obturators
- Gracilis
- Medial hamstrings
What hip motion is commonly impaired?
- Hip abduction
What 7 muscles medially rotate the hip?
- Tensor fascia lata
- Gluteus minimus
- Anterior fibers of gluteus medius
- Adductor magnus
- Adductor longus
- Semimembranosus
- Semitendinosis
What 8 muscles laterally rotate the hip?
- Piriformis
- Obturator internus
- Obturator externus
- Gemelli
- Quadratus femoris
- Gluteus maximus
- Posterior fibers of gluteus medius
- Biceps femoris
What group of muscles typically implicated in impairments of flexibility?
- Medial rotators
What is the nerve supply of the hip?
- Lumbar plexus (L1 - L4)
- Sacral plexus (L4 - S3)
What is the blood supply for the head of the femur?
- Artery of ligamentum teres
- Medial circumflex artery
- Lateral circumflex artery
What is normal flexion of the hip? (ROM)
120 - 135 degrees
knee flexed 90 degrees
What is normal extension of the hip? (ROM)
0 - 15 degrees
What is normal abduction of the hip? (ROM)
0 - 30 degrees
What is normal rotation of the hip? (ROM)
45 degrees in each direction.
Which gender has more lateral rotation and which has more medial rotation?
More LR –> Males
More MR –> Females
What lumbar motion and hip extension is associated with a posterior tilt of the pelvis?
- Lumbar flexion
- Hip extension
What lumbar motion and hip extension is associated with a anterior tilt of the pelvis?
- Lumbar extension
- Hip flexion
What are the combine movements of a lateral pelvic tilt?
-
What is the term for an increased angle of inclination?
Coxa valga.
What is the term for an decreased angle of inclination?
Coxa varus.
What is the term for an increased angle of torsion?
- Anteversion
What is the term for a decreased angle of torsion?
- Retroversion
How do individuals typically compensate for anteversion of the hip?
- IR
- Foot will kick up when running
What is leg length discrepancy?
- Unilateral difference in the total length of one leg compared to another.
What is the difference between anatomic leg length discrepancy and functional leg length discrepancy?
Anatomic refers to the length difference between the hemipelvis, femur and tibia of each side, while functional leg length discrepancy refers to the position of the bones during weight-bearing function.
What is the typical force through the hip in bilateral standing?
- 0.3 times body weight
What is the typical force through the hip in unilateral standing?
- 2.4 - 2.6 times body weight
What is the typical force through the hip during walking? (low and high)
1.3 - 5.8 times body weight
What is the typical force through the hip walking up stairs?
3 times body weight
What is the typical force through the hip during running?
More than 4.5 times body weight
What are balance tests usually included in examination of the hip joint?
- High incidence of falls resulting in hip injury
What are 4 functional scales of balance that can be used for the hip?
- BERG balance scale
- Mini- BESTest of dynamic balance
- Dynamic gait index
- Balance self-perception test
Which functional balance test is used for individuals that are higher functioning?
- BESTest
What functional test is used for patients with impaired balance?
- BERG balance scale
Besides functional tests, how else can balance be assessed?
- History
- Type of assisstive device
Besides balance, what other functional test is an important component of the examination of gait?
- Gait analysis
How should the hip be assessed throughout the gait cycle?
- The motion/ position through the 3 planes of movement during each phase of gait, as well as the relationship between the hip and the rest of the kinetic chain
What tool can assist in analyzing gait?
Video analysis
What 4 tests should be used to assess hip joint mobility and integrity, and what 3 factors are being assessed during this time?
- Lateral/ medial translation
- Distraction
- Compression
- Anterioposterior/ posterioanterior glides
Assess:
- Quality of motion
- End feel
- Presence/ location of pain
By what 4 methods can muscle performance be measured at the hip?
- MMT
- Tests at different positions to assess length changes
- Selective tissue tension (contractile vs non-contractile)
- Resisted tests (measures severity of tissue lesion or neurologic impairment)
What can be used to determine the source of pain in hip impairment?
- Special tests
- May be beyond scope of PT
What types of alignment about the hip should be assessed when examining posture? What hypothesis can be made about muscles by observing posture?
- Lumbopelvic and lower quadrant alignment in all 3 planes
- May hypothesize muscle length
What type of screening may be performed at the hip regarding posture?
Leg length discrepency
What are 6 quick tests to assess ROM and muscle length at the hip?
- Placing foot on standard step
- Forward bending
- Squatting
- Sitting with leg crossed
- PROM Open chain
- AROM Open chain
What muscle groups are involved in muscle length assessment at the hip?
- Hamstrings (medial and lateral)
- Individual hip flexors
- Hip adductors and abductors
- Hip rotators
How are everyday functional tasks measured for the hip?
- Observation
- “Show me how you do that”
- Self-report measures
What functional scale is related to OA of the hip?
Harris hip function scale
What are 7 functional tests of the hip?
- Squatting
- Reciprocal stairs
- Crossing ankle to opposite knee in sitting
- Stairs 2 at a time
- Running in straight plane and decelerating
- One legged hop
- Jumping
What are 5 sources of impaired muscle performance?
- Neurologic pathology
- Muscle strain
- Altered length-tension relationships
- General weakness from disuse
- Pain and inflammation
What is neuromusculoskeletal pathology?
Pathology at nerve root or peripheral nerve level
How is neuromusculoskeletal pathology treated?
- Treat origin of impairment.
What muscle strain is common related to the hip?
- Hamstring strain
What are 3 causes of muscle strains?
- Muscle imbalance
- Behavior
- Training schedule
How are hamstring muscle strains treated?
- Treat cause
- Utilize underused synergists
- Assess kinetic chain for biomechanical deficits
What are 2 synergist muscles of the hamstrings?
- Gluteus maximus
- Hip lateral rotators
Describe an exercise that trains the patient to move their hip independent of the spine.
- Lie prone with pillow under stomach
- Activate core; squeeze “seat” muscles
- Barely lift thigh off floor
- Return to floor, and repeat with other leg
Describe a technique to train a patient to move the body over the hip efficiently.
Level 1:
- Staggered stance, involved leg in front
- Feet straight ahead
- Knees straight ahead with no rotation
- Hips and pelvis forward and level
- Slowly bend front hip and knee leaning towards front leg
- Hold knee at position of foot. Hold for 10”.
- Activate core and squeeze seat muscles
- Tighten quads
- Hold arch of foot up, while toes are down
Level 2:
- Lift back heel upwards and straighten front knee
- Maintain alignment
- Hold for 3 seconds
- Bring back thigh forward and hold single leg stance for 30 seconds
Level 3:
- Staggered stance, with involved leg forward
- Lean toward front limb
- Keep spine, pelvis, hips, knees and ankles steady
- Slowly lower until pelvis tilts or rotates
- Isolate movement at hips and knees
- Hold weight over front limb
- Rise upwards keeping weight forward
- Repeat in position
Describe a ther-ex to strengthen spine, hip, knee, ankle, and foot muscles, as well as improve balance.
Step-up, step-down
Step-up
- Lift leg onto step with thigh in midline, pelvis level
- Check foot (Arch up, big toe down)
- Lean onto step; keep knee and pelvis in alignment
- Don’t flex knee past foot and keep trunk and tibia parallel
- Step up keeping pelvis over toes, arch up; lean into hip without tilting pelvis
- Can do side step up variation
- Can toe tap back down keeping weight through quads
Step down
- Dorsiflex foot of step down leg
- Bend hip/ knee
- Lean forward, but do not bend knee past foot
- Stop before touching floor
- Hold alignment
- Can use AD to maintain balance
- Add arm movement for difficulty
How is the step-up movement pattern changed with an upright trunk?
- More focus on quads
What force on a muscle can cause a strain?
- Overstretch
How is an overlengthened muscle strain treated?
- Strengthen in shortened range
- Proprioceptive taping
- Correct posture and movements that hold muscle lengthened
Describe a gluteus medius strength progression.
- Line prone with stomachs under abdomen
- Legs in line with hips and slight ER
- Activate core to stabilize pelvis
- Squeeze glutes
- Slightly lift leg, and abduct until pelvis tilts
- Hold for 10 seconds
- Can add theraband for resistance
- Can also do this in sidebending position
What 4 factors can cause disuse and deconditioning?
- Injury
- Pathology
- Acquired movement patterns
- Deconditioned syndergists
How is disuse and deconditioning treated?
- Correction of postures and movements
- Optimize length relationships
- Restore motor control and relationships
What type of movement, and what structural change is related to OA of the hip joint?
- Labral tears
- Hypermobility
Diagnosis of labral tears is becoming more common due to increasing use of what imaging technique?
Arthroscopy
How is hypermobility of a developing hip treated?
- Positioning
- Bracing
- Surgery
How is hypermobility of the adult hip treated?
- Therapeutic exercise
- Posture education
- Movement training
What is the theory behind treatment of an OA hip?
- Promote joint stability
- Prevent continuous stress to overstertched/ torn tissues
- Posture and movement pattern training
- Strengthen muscles in short range
- Improve performance of deep musculature for core stability
What should be screened for when excessive medial rotation of the hip is measured? (What is the screening test?)
- Anteversion
- Trochanteric angle test
What are the components of treatment for excessive IR of the hip?
- Strengthen deep hip lateral rotators
- Educate on posture habits, and movement patterns
Describe a standing position to help teach the patient proper hip/ LE alignment.
- Standing with weight evenly distributed between both feet
- Pelvis level from side to side
- Knees in line with feet
- Feet hip width apart with a slight outpointing
- Arch elevated with big toe down
- Pelvis in neutral from sagittal view
- Knees not bent or locked in sagittal view
- Ankle below knee, and leg and foot at 90 degree angle
Describe 4 pointers you can give your patient related to gait patterns.
- Don’t let your knee lock as your body weight passes over your foot. Knee slightly flexed when your foot hits the floor, and then slightly straightens
- Squeeze your buttocks when your foot hits the ground to prevent your knees from turning in
- Use your foot muscles to prevent your arch from dropping as your body moves over your foot
- Keep your core activated to prevent your pelvis from tilting, especially when your body moves past your foot (your pelvis may tilt instead of your hip extending)
What 2 methods can be used to prevent compensation for limited hip ER?
- Coming up from bending forward
- Rising Upward from a Squatting position
Describe patient instruction on coming up from bending forward.
- Lead with your hips by activating your seat muscles
- Do not arch your back by activating your core, and bringing your belly button towards your spine
- Bring pelvis back to neutral before finishing spine movements
Describe patient instruction on rising from a squatting position.
- Fully extend your hips until your pelvis is neutral to complete the position
- Use inner core to maintain pelvis in neutral
What is the capsular pattern of the hip?
- 50 - 55 degrees limitation of Abduction
- No possible medial rotation
- 90 degrees limitation of flexion
- 10 - 30 degrees limitation of extension
- Normal femoral adduction
What should be assessed when examining hypomobility of the hip joint? What are 2 examples?
- Relationships to other links in the kinetic chain
- Lumbar spines flexbility during foward bending due to limited hip flexion
- Excess knee flexion during standing knee bends
What motion is associated with compensation for stiff hip extension?
- Anterior pelvic tilt
What types of tests are necessary to determine exercises to address hypomobility and associated hypermobility?
- Muscle length tests
Once optimum muscle length is achieved, how can that the ROM be maintained?
- Train proper movement pattern, such as gait to maintain ROM
Describe an exercise used to improve the range of motion of the hips, stretch posterior hip muscles, and train independent movement of the hips, pelvis, and spine.
Hand to Knee Rocking
- Position quadriped with hip over knees and hands under shoulders
- Knees and ankles hip width apart with feet pointing backwards
- Spine flat with slight curve in low back
- Pelvic tilted to form 90 degree angle in hip joint
- Pt rocks backward at the hip joint only. The movement is stopped when back movement is felt
Describe a technique to strength the hip flexors.
- Thomas test
What is the leading cause of morbidity in persons older than 65?
- Falls
What community activity has been proven to improve posture and stability in the elderly?
- T’ai Chi
What clinical technique is commonly used to improve balance in the olderly?
- Force-platform biofeedback systems
What is the main concern when evaluating pain?
- What is the cause?
- Do they belong in PT?
What are 7 general techniques for pain relief at the hip?
- Activity modification
- Physical agents
- Electrotherapeutic modalities
- Manual therapy
- Therex
- Assistive device
- Weight loss
- Biomechanical support (orthotics)
What is required to treat posture and movement impairment?
- Must first establish basic skills such as: mobility, muscle performance, and motor control at functional levels.
Once impairments have reached functional levels, how is posture and movement impairment treated?
- Emphasize optimal posture and movement
What are the measurements for mild, moderate, and severe leg length discrepancy?
Mild: 0 - 30 mm
Moderate: 30 - 60 mm
Severe: > 60 mm
What are 3 examples of functional leg length discrepancy?
- Lengthened or weak posterior gluteus medius or deep hip ERs (hip in lateral rotation)
- Lengthened or weak foot supinators (Medial collapse)
- Postural foot pronation or supination
What can be used to reduce joint reaction forces when increasing muscle performance in individuals with osteoarthritis?
- Adjuncts
What types of activities help stimulate hip extensor recruitment and hip flexion mobility>
- Step-up activities
How can proper step-up technique be ensured?
- Alter the step height
- Add resistance
What technique should always be including in a muscle strengthening program for a patient with OA of the hip?
- Core activation
What should be established before performing balance activities for a patient with OA of the hip?
- Establish muscle balance in single limb stance
What 3 methods should patients with hip OA be instructed in relating to posture and movement?
- Positioning
- Core training
- Assistive devices in functional activities
What adjunctive interventions are recommender for patients with OA of the hip?
- NWB activities such as aquatic therapy
What is ITB fascitis?
- Inflammation from overuse
What is trochanteric bursitis?
Bursa becomes inflamed
How does ITB friction syndrome present?
- Pain localized to lateral femoral condyle
What knee joint can become affected by the ITB?
- Patellofemoral
What can cause a TFL strain?
- Overuse of short or stretched TFL/ ITB
What can be an underlying cause of ITB pain?
- Faulty movement patterns
What muscle in underused when the anteriormedial TFL dominates hip flexion?
- Iliopsoas
What muscles are underused when the psoteriolateral TFL dominates the hip abductor and medial rotator force couple?
- Gluteus medius
- Upper fibers of gluteus maximus and minimus
What knee muscle group may be affected by overuse of the ITB?
Quadriceps
What are 2 ITB stretches?
- Ober’s stretch
- Kneeling squat with a drop in the forward leg, stretching the back leg’s ITB
How can the ITB be taped for unloading?
- Place tape anterior to posteriorly along lateral thigh
- Patella may need to taped medially to prevent lateral displacement
What are 4 signs of piriformis syndrome?
- Hip flexion with IR
- Lordosis and anterior pelvic tilt
- High iliac crest on involved side
- ER and abduction reduces symptoms
What are 7 tests for piriformis syndrome (lengthened piriformis)?
- Standing alignment
- Tissue tension tests
- ROM
- Palpation
- Positional strength
- Functional tests
- Lumbar clearing exam
Describe an exercise to strengthen the piriformis?
- Pt prone
- Hips abducted and laterally rotated with feet together
- Submaximally isometrically contract feet together (avoid accessory muscle use)
What neurological problem does a stretched piriformis mimic?
Lumbar radiculopathy
