The Hip

The Hip Hip. Pelvis & Lumbar Spine

Hip & Femur Ligaments of the Hip

 Muscles of the Hip Muscles of the Hip & Lumbar Spine

Anterior Posterior

Muscle Balance in the Hip The Hip

Hip Pathology
„ Strains (adductor, abductors, hamstrings, rectus
femoris)
„ Dislocations
- traumatic
- CDH (Congenital Dislocation of the Hip)
„ Bursitis (Psoas, trochanteric)
„ Coxa vara
„ Legg Perthes Disease
„ Slipped Capital Femoral Epiphysis
„ Malalignment/ Leg length discrepancy
„ Hip impingement/ labral tears
„ Osteoarthritis
The Hip

Hip Pain
 The Hip Observation
„ Posture
„ Bone & Soft Tissue Contours
„ Leg Alignment
„ Balance
„ Limb position
„ Gait

Posture

„ Normal standing posture?

Observation „ Can patient get into neutral pelvis?
„ Can Patient hold neutral pelvis
statically?
Posture „ Can patient hold neutral pelvis
Bony & Soft Tissue Contours dynamically

Posture Posture
 Pathological Lordosis With Pathological Lordosis with
Compensatory Forward Compensatory Forward
Head Posture Head Posture
Elongated and Weak:
z Anterior abdominals
Body Segment Alignment: z Small muscles of Lumbar spine (multifidus,
rotatores)
z Pelvis is anteriorly tilted with lordosis
increased • Lower & middle trapezius
z Knees are hyperextended with ankle z Hamstrings may lengthen initially or shorten
joints slightly plantar flexed to compensate where posture has been
present for some time
z Rhomboids?
z Upper (thoracic & cervical) erector spinae
z Hyoid muscles

Pathological Lordosis with Pathological Lordosis with

Compensatory Forward Compensatory Forward
Head Posture Head Posture
Joints Commonly Affected:
Short and Strong: • Lumbar spine
z Lumbar erector spinae • Pelvic/ Hip joints
z Hip flexors
• Thoracic Spine
• Upper trapezius
• Scapulothoracic “joint”
z Pectoralis major & minor
z Levator scapulae • Glenohumeral joints
z Sternocleidomastoid • Cervical spine
z Scalenes • Atlanto – occipital joints
z Suboccipital muscles
• Temporomandibular joints

Observation

Balance
Limb Position
 Limb Position

Observation

Leg Alignment

Short Leg Gait

Psoatic Limp

Leg Alignment - Deviations Hip Deviations

„ Leg Length
„ Coxa vara/valga „ Excessive anteversion
„ Anteversion/retroversion
„ Retroversion (retrotorsion)
„ Femoral torsion
„ Coxa vara
„ Genu varum/genu valgum
„ Genu recurvatum „ Coxa valga
„ Tibial torsion „ Femoral torsion
„ Pronation/supination
„ Rearfoot varum/ rearfoot valgum
„ Forefoot varum/ forefoot valgum

Leg Length Discrepancy Structural Leg Length

Discrepancy may be due to:

„ ASIS to malleolus (true leg length) „ True anatomical length

„ Greater trochanter to iliac crest differences in bone
„ Greater trochanter to knee joint line
(done on lateral side) „ Bony deformity
„ Knee joint line to medial malleolus
(done on medial side)
 Functional Leg Length Hip Anteversion
Discrepancy may be due to:

„ Alignment deformities in the

pelvis, hip, knee, foot

Normal Excessive

Anteversion – forward torsion of the femoral neck

Hip Anteversion Excessive Hip Anteversion

Related Posture Compensating postures

„ Toeing – in (pigeon „ Lateral tibial
toes) torsion
„ Subtalar pronation „ Lateral rotation at
„ Lateral patellar knee
subluxation (tilt or „ Lateral rotation of
deviation) tibia, femur &/or
„ Medial tibial torsion pelvis
„ Medial femoral „ Lumbar rotation on
torsion same side

Excessive Hip Retroversion

HIP
Related Posture Compensating Posture
„ Toeing – out „ Medial rotation at
„ Subtalar supination knee Anteversion/Retroversion
„ Lateral tibial „ Medial rotation of
torsion tibia, femur &/or
pelvis Look at relation of Greater
„ Lateral femoral
Lumbar rotation on Trochanter to Foot Angle
torsion „
the opposite side
 Coxa Vara & Valga Coxa Vara

Related Postures Compensating Postures

„ Pronated subtalar joint „ Subtalar supination on

„ Medial rotation of the leg same side
„ Subtalar pronation on
„ Short leg on same side
opposite side
„ Anterior pelvic rotation „ Plantar flexion on same
side
„ Genu recurvatum on
same side
„ Hip &/or knee flexion on
same side
„ Posterior pelvic rotation
& lumbar rotation on
same side

Example Causes of Coxa Vara

Coxa Valga
HIP
Related Posture Compensating Posture
„ Supinated subtalar joint „ Subtalar pronation on same
Lateral rotation of the leg side
„

„ Long leg on same side „ Subtalar supination on Coxa Vara / Coxa Valga
opposite side
„ Posterior pelvic tilt
„ Plantar flexion on opposite
side Look at relation of Greater
Genu recurvatum on same
Trochanter to Iliac Crest
„
side
„ Hip &/or knee flexion on
same side
(ie the distance)
„ Anterior pelvic rotation on
same side & lumbar rotation
on opposite side
 Femoral Deviations (Torsion)
Total Leg Torsion or Rotation
Consists of :
„ Medial
Femoral Torsion
+ „ Lateral
Femoral
Anteversion/retroversion
+
Tibial Torsion

Medial Femoral Torsion

FEMORAL TORSION
Related Postures Compensatory Postures
„ Excessive subtalar „ Excessive subtalar
Medial or Lateral pronation supination
„ In – toeing „ Functional forefoot
„ Medial facing or valgus
Look at relation of greater tilted patella
trochanter to patella (“squinting patella)

Lateral Femoral Torsion

Related Postures Compensating

Postures
„ Excessive subtalar „ Excessive subtalar Observation
supination pronation
„ Out – toeing „ Functional forefoot
„ Lateral facing or varus
tilted patella GAIT
(“grass hopper
eyes patella”)
 Trendelenberg (Gluteus Medius)
Gait

Normal Abnormal

The Hip Hip Examination

Active Movements of the Hip -

Active Movements of the Hip
Supine
„ Flexion
„ Abduction
„ Adduction Supine

„ Rotation (medial & lateral) in 90º Flexion

„ Extension
Prone
„ Rotation (medial & lateral) in neutral Flexion Abduction
„ Combined Movements (if necessary)
„ Repetitive Movements (if necessary)
„ Sustained Position (if necessary)

WATCH FOR PELVIC MOVEMENT

Adduction
Rotation
 Active Movements of the Hip -
Force Couple Action
Prone

Flexion

Extension
Rotation

Note Excessive Lumbar

Spine Movement

Loss of
Medial Rotation
on the right

Increased Lateral Rotation

 Hip Examination Passive Movements of the Hip
„ Flexion
„ Abduction
„ Adduction
„ Medial rotation
„ Lateral rotation
„ Extension

Looking at: End Feel

Capsular Pattern
ROM

Passive Movement Hip Examination

„ Increased anteversion increases

medial rotation
„ Increased retroversion increases
lateral rotation

Resisted Isometric Movements

Resisted Isometric Movement
of the Hip
„ Flexion „ Concentric
„ Extension Movement if
„ Abduction necessary
„ Adduction „ Eccentric
Movement if Flexion Extension
„ Medial Rotation necessary
„ Lateral Rotation „ Econcentric
„ Knee Extension Movement if
„ Knee Flexion necessary

Adduction Abduction
 Econcentric Movement
Resisted Isometric Movement
(Hamstrings)

Medial Rotation Lateral Rotation

Knee Flexion Knee Extension

Hip Examination Hip Examination

Functional Tests for the Hip
„ Sitting (chair, toilet)
„ Squatting
„ Kneeling
„ Crossing Legs
„ Climbing Stairs (normal, 1 @ a time)
„ Going Down Stairs
„ Walking (distance & tolerance)
„ Putting on Shoes & Socks
„ Walking Aids
„ Balance

Shoulder Examination

Hip Pathology

Patrick (FABER, Figure 4) Test

 Patrick’s Test Negative

Positive

Hip Pathology

Trendelenberg Test or Sign

Trendelenberg Test Positive Trendelenberg Sign

Negative Positive
 Anterior Labral Tears

Hip Pathology

Labral Tears

Start End

May cause hip impingement

Quadrant (Scouring) Test

Posterior Labral Tears
(Impingement)

Start End

May cause hip impingement

Craig Test for Anteversion

Hip Pathology

Test for Anteversion

 Start Position

ASIS level

Hip Pathology Legs at 90º

to ASIS line

Leg Length Discrepancy

Weber-Barstow Maneuver for Leg

Length Asymmetry

Leg Length Measurement

Leg Measurement Divisions

9Neck Shaft Angle

To medial Malleolus To lateral malleolus
9Femur
9Tibial
 Neck – Shaft (coxa vara/valga)
Femur Length
Iliac crest to greater trochanter

Tibia Length

Galleazzi’s Sign
 Femoral Shortening

Thomas Test ( Hip Flexors)

Hip Pathology

Muscle Tightness

Negative Positive

Ely’s Test (Hip Flexors) Rectus Femoris Test

Start Positive
Negative Positive
 Abduction – Adduction
Contracture

Noble Compression Test

Ober’s Test (Iliotibial Band)
(iliotibial Band Friction Syndrome)

Note: flexion of the knee also tests

the femoral nerve (Femoral
Nerve stretch test)

Piriformis Syndrome Testing for Piriformis Tightness

60º
90º – 90º Straight Leg Raise
Hamstring Contracture Test
(Hamstrings)

Hypomobile

Hypermobile

Tripod Sign (Hamstrings) Gluteus Maximus Tightness

To 110 - 120º before

ASIS moves up normal

Congenital Dislocation of
Pediatric Tests for Hip
the Hip (CDH)
Pathology
or
9Ortolani’s Sign
Developmental Dysplasia of
9Barlow’s Test
9Telescoping Sign
the Hip
 Features CDH/DDH Signs & Symptoms
Types: Taratologic : 2% Early Late
Typical: 98%
„ Positive Barlow „ Positive Galleazzi
„ Positive or „ Telescoping
Typical Types: Unstable (dislocatable)
- Positive Barlow Negative Ortolani „ Waddling gait
- Negative Ortolani
„ Unequal fat folds „ Positive
Dislocated
- Positive Barlow
„ Limited abduction Trendelenberg
- Positive Ortolani (diapers)

Limited Abduction

Extra Fat Folds

Telescoping
 X - ray Signs

„ > acetabular index

„ < in size of femoral head
„ > anteversion

Barlow’s Test

CDH/DDH – Conservative
Treatment
Ortolani’s Test
(Dislocated)

Dislocable
 Legg-Perthes Disease
Other Pediatric Hip Pathologies
“Head at Risk” Signs
„ Gage’s sign – small
osteoporotic,
„ Legg-Calvé-Perthes Disease – translucent segment
avascular necrosis of femoral on lateral aspect of
head epiphysis
„ Lateral subluxation
„ Slipped capital femoral „ Abnormal growth
epiphysis plate
„ Lateral calcification
„ Abnormal epiphysis
„ Metaphyseal
reaction
Slipped Capital Femoral
Epiphysis
 Hip Examination Dermatomes of the Hip

Sensory Distribution of Peripheral

Referred Pain
Nerves

Note: Especially in
children, hip pain
may be referred to
the knee
Hip Examination Joint Play Movements of the Hip

Traction Compression

Distraction

Hip Examination

Hip Examination