IBIZA DC.

GONZAGA | 2PTD ❖ Acetabular Anteversion

MSK LEC #3.2 – Hip Joint

BONES, JOINTS, & LIGAMENTS

• PELVIS: aka innominate bone or os coxa
a) Ilium: superior part; 2/5 of the acetabulum
 ASIS – inguinal ligament, sartorius
 AIIS
 PSIS
 PIIS
 Iliopectineal line o Acetabular Anteversion: 20*
b) Ischium: inferior and posterior part; 2/5 of the
acetabulum ❖ Hip Joint
 Ischial spine o CPP: EAbIR (ligamentous); 90* slight abd & ER (bony)
 Ischial tuberosity o OPP: 30* flex, 30* abd, slight ER (FABER)
c) Pubis: inferior and anterior part; 1/5 of the acetabulum o Ligament: Y bigelow/iliofemoral (one of the strongest in
 Superior pubic ramus – origin of pectineus the body), ischiofemoral, pubofemoral – LIMIT
 Inferior pubic ramus – gracilis, adductor magnus & EXTENSION
brevis
 Body – adductor longus ❖ Angle of femoral inclination / neck-shaft angle
• Angle of Pelvic Inclination/ Fick’s Angle

o N value: 125*
 ↑ – coxa valga; lengthen; dislocation
 ↓ – coxa vara; shortening; fracture d/t lever

❖ Angle of femoral torsion

- N value: 50*-60*
- Movement of lumbar spine will also have movement of
pelvis
- Tight hip flexors → ant pelvic tilt → ↑ lumbar lordosis &
counternutation of sacrum

HIP JOINT: Coxal Joint/ Acetabulofemoral

- Most stable joint in the body d/t ligaments & muscles o Femoral anteversion: 13*-18*
around it o Concomitant in-toeing
a) Acetabulum (aka vinegar’s cup)
o faces laterally, inferiorly and anteriorly (ALI) ❖ Muscles
o acetabular labrum/cotyloid ligament o Muscles of the hip and thigh
o transverse acetabular ligament o Muscles of the leg
b) Femoral head o Muscles of the foot
o head-faces superiorly, anteriorly, and medially (SAM)
o 2/3 of a sphere LOWER EXTREMITY MUSCULOSKELETAL
o fovea capitis – depression in femoral head CONDITIONS
• DISLOCATIONS
❖ Center Edge Angle/ Angle of Wiberg/ Roof of  Anterior Hip Dislocation
Acetabulum o Presentation: Pain
o Hip is positioned in: FABER
o Associated Nerve Injury: FEMORAL NERVE
 Posterior Hip Dislocation
o MOST LIKELY DIRECTION of dislocation
o Presentation: Severe pain
o Hip is positioned in: FADIR
o Associated Nerve Injury: SCIATIC NERVE

- N value: 35*
- Most commonly affected in pediatric joint affectation
• DEVELOPMENTAL DYSPLASIA OF THE HIP • SLIPPED CAPITAL FEMORAL EPIPHYSIS
o AKA: CHD/ Congenital Hip Dislocation (True Dislocation o Unilateral sliding of the femoral head inferiorly from the
of the hip is rarely present at birth underlying bone
o Risk factors: o Etiology:
 First Born » Rapid growth
 Female » Obliquity of epiphyseal plates
 Funny presentation – lots of anomalies in the different » Traumas: Acute high impact or low impact
joints not only in hip, but it is most commonly affected o Most common in boys between 10-16 y/o (ave: 12y/o)
 Family History » Tall and obese
o Epidemiology: High Incidence in Japan and Italy
(Swaddling clothes: adducted and extended hip) • SNAPPING HIP SYNDROME
o A.k.a. “Coxa Saltans”
• COXA VALGA  Internal Snapping
o Increased neck shaft angle: Angle of inclination of the » Snapping is felt anteriorly when the hip is moving from
femoral neck is >125° in 45° flexion to hip extension
o Hip ADDuction is limited » Sliding of iliopsoas tendon over osseous ridge of the
o ↓ hip stability → predisposed to hip dislocation lesser trochanter or anterior acetabulum
o Affected limb is lengthened » Iliofemoral ligament sliding over femoral head
 External Snapping
• COXA VARA » Most common type of snapping hip syndrome
o Decreased neck shaft angle: Angle of inclination of the » Snapping is felt at laterally when the internally rotated
femoral neck is <125° hip is moving from flexion to extension
o Hip ABDuction is limited » cause: Tight ITB or gluteus maximus tendon sliding
o ↑ hip stability, but ↑ risk in femoral neck fracture over greater trochanter of femur
o Affected limb is shortened  Intra-articular

• AVASCULAR NECROSIS OF THE FEMORAL HEAD • APOPHYSEAL INJURIES

o A.k.a. Chandler’s disease - for adults (chandler – tander)  Iliac crest apophyseal injury
o Ischemic necrosis due to occlusion of the blood supply to » Hip pointer injury
the femoral head caused by a fracture of femoral neck » Mechanism of injury
o Roentgenograph: o Trauma or direct blow to the iliac crest
» (+) Crescent sign: fracture of the subchondral area o Repetitive or sudden contraction of the abdominal
» Flattening of the head and incongruity of the femoral muscles opposed by the forceful contraction of the
head with the acetabulum gluteus medius and TFL on a planted leg
» Signs and symptoms
• LEGG-CALVE-PERTHES DISEASE o Pain and tenderness at iliac crest
- Aggravated by active hip abduction
o Trendelenburg gait
 ASIS, AIIS apophyseal injury
» Sprinter’s fracture
» Mechanism of injury
o Forceful sartorius muscle contraction or
hyperextension of the spine (ASIS injury)
o Forceful rectus femoris contraction (AIIS injury)

• REFERRED PAIN OF THE HIP JOINT

o Idiopathic form of osteonecrosis of the femoral head in
o Skin in front and medial side of the thigh (femoral nerve)
CHILDREN
o Knee joint (obturator nerve)
o A.k.a. “Coxa plana”- flattening of the femoral head
o Self-limiting unilateral osteonecrosis of the femoral head
• OSTEITIS PUBIS
(2-3 years)
o Chronic inflammation of pubic symphysis
o Common in boys 3-12 y/o (ave: 7 y/o)
» Short and thin o Due to repetitive stress of the muscles attaching to pubic
» Unilateral > Bilateral symphysis such as rectus abdominis, gracilis and
adductor longus
o Presentation:
➢ Stages
1) Necrosis  Pain in the groin upon palpation
o Cause by idiopathic decrease in blood flow  Abdominal and adductor muscle spasm
 Antalgic gait (painful gait)
(rupture of ligamentum teres) → ischemia
2) Fragmentation
o Crescent sign – subchondral fracture • BURSITIS
o Bone resorption of the head of the femur  Trochanteric bursitis
3) Revascularization o Commonly seen in the elderly or long distance
4) Remodeling runners
5) Healed o Pain and tenderness on the lateral aspect of the thigh,
posterolateral to the trochanter felt when the hip is
resisted in Extension, ER and ABDuction and during
stretching of GMAX (FADIR)
  Ischial bursitis • MYOSITIS OSSIFICANS
o A.k.a. “Tailor’s or weaver’s bottom” o Most common extraskeletal bone-forming lesion
o Pain on ischial area, particularly in sitting o d/t trauma
 Heterotopic Ossification (HO): joint
• PIRIFORMIS SYNDROME  MO: muscle
o Due to inflammation or spasm of the piriformis muscle o Develops within 3 weeks after the trauma
o Affects sciatic nerve o MOST FREQUENT SITE: Anterior Thigh
o Presentation: o Other sites: Brachialis, Pectoralis Major (Rifleman),
 Pain in the buttocks and posterior thigh (sciatic Adductor muscles (horseback riders)
distribution) – thick wallet syndrome
 Pain with walking, ascending stairs and trunk rotation

• STRAINS
Grade Tissue Injury Presentation
I Little tissue disruption (-) weakness, (-) LOM
II Some disruption of muscle Decreased strength and ROM;
fibers significant pain
III Complete rupture Complete loss of strength; (+)
palpable defect

 Quadriceps Strain
o Commonly seen in young athletes
o MOI: Rapid Deceleration from a sprint
o MOST COMMONLY AFFECTED: RECTUS FEMORIS
o Signs and symptoms:
» 1st to 2nd degree strain
- Pain upon passive stretch or deep palpation
» 2nd to 3rd degree strain
- Pain upon passive stretch or deep palpation
- Swelling and discoloration

 Adductor Strain
o Most common injury to the medial thigh
o “Groin Pulls”
o Adductor longus > magnus: most commonly affected
o Mechanism of injury
- Repetitive forceful hip adduction or sudden hip
abduction when hip is in ER
o Frequently seen in: ICE HOCKEY PLAYERS

 Hamstrings Strain
o Most common injury of the thigh
o most commonly strained muscle in the body: Short
head of the biceps femoris
» because it has different nerve innervations from other
hamstring muscles
» Asynchronous firing at high recruitment frequencies
» Mechanism of injury: eccentric overload; Due to
rapid uncontrolled stretch or forceful contraction
(Maximal HIP FLEXION WITH KNEE EXTENSION)

• QUADRICEPS TENDON RUPTURE

o Commonly seen in older athletes
o Rupture of the quadriceps tendon at its insertion on the
proximal patellar pole
o Rectus femoris: most commonly affected
o End result of repeated strain injuries

• QUADRICEPS CONTUSION
o Most common contusion in the body
o “Charley Horse Syndrome”
o Direct blow to the muscle
o Presentation:
 Pain with ambulation
 Inability to perform full flexion and extension of the
knee
 Inability to perform SLR or Quads ISOMS
 Palpable Hematoma