Hip

Orthopaedic Assessments

The Hip Joint

Agenda Introduction Applied anatomy of the pelvis Kinematics New terminology Coxa Vara & Valga Patient History Observation Examination Active movements Passive movements Isometric Special tests

The Hip – Multiaxial ball-and-socket joint – One of the largest and most stable joints in the body –Possesses a strong capsule reinforced by strong muscles and ligaments – Is the proximal link to the lower limb

Forces on the Hip Standing: Standing on one limb: Walking: Walking up stairs: Running:

0.3 x BW 2.4-2.6 x BW 1.3-5.8 x BW 3 x BW 4.5+ x BW

Applied Anatomy of the Hip MUSCLES Reaquaint yourselves with the muscles that control hip movement Actions of muscles is testable material

Applied Anatomy of the Hip MUSCLES

Hip Flexors Hip Extensors Hip Abductors Hip Adductors Internal Rotators External Rotators

Applied Anatomy of the Hip LIGAMENTS (1) Iliofemoral Ligament (2) Ischiofemoral Ligament (3) Pubofemoral Ligament

Iliofemoral Ligament aka. Y ligament of Bigelow Strongest ligament in body Proximally, attaches to AIIS and acetabular rim Distally, attaches to the intertrochanteric line

Prevents excessive hip extension Maintains upright posture at the hip

Iliofemoral Ligament Prevents excessive hip extension Acts by “screwing” the femoral head into the acetabulum Stretch the upper fibers by: ADDUCTION with extension and external rotation Stretch the lower fibers by: ABDUCTION with extension and external rotation

Ischiofemoral Ligament Origin: Ischial part of acetabular rim Inserts: Medial greater trochanter Weakest of the three hip ligaments

Ischiofemoral Ligament Winds tightly on extension helping to prevent hyperextension Stretch by: ABDUCTION with internal rotation and extension

Pubofemoral Ligament Origin: pubic bone Inserts: iliofemoral portion of capsule and intertrochanteric crest

Pubofemoral Ligament Prevents excessive abduction of the femur and limits extension Stretch with: ABDUCTION, external rotation and extension

HIP JOINT Resting Position

Close Packed Position Capsular Pattern

30° flexion, 30° abduction, slight lateral rotation Extension, medial rotation, abduction Flexion, abduction, medial rotation (usually)

KINEMATICS Take home message: ► When the pelvis moves, movement also occurs at both hips and in the lumbar spine SO ALWAYS BE SURE TO CLEAR THE JOINTS ABOVE AND BELOW.

Coxa Vara & Valga Coxa Vara A deformity of the hip whereby the angle b/w the head and neck of the femur and its shaft is less than 120°-135°. This will result in shortening of the leg.

Coxa Valga A deformity of the hip whereby the angle formed b/w the head and neck of the femur and its shaft is greater than 120°-135°.

Coxa Vara & Valga

Patient History refer to handout

Snapping Hip Syndrome (A) Internal Snapping (B) External Snapping (C) Intra-Articular Snapping

Snapping Hip Syndrome INTERNAL SNAPPING • Iliopsoas tendon snapping over bony edges • Iliofemoral ligament snapping over femoral head • Occurs at approximately 45° of hip flexion • The “snap” is palpated anteriorly

Snapping Hip Syndrome

EXTERNAL SNAPPING • Tight ITB or gluteus maximus tendon riding over the greater trochanter • Noted during flexion and extension, especially with internal rotation

Snapping Hip Syndrome INTRA-ARTICULAR SNAPPING • May be indicative of labral tears or loose bodies within the joint • Pain felt into groin and anterior thigh • Aggravated with pivoting motions and passive extension, adduction and external rotation

OBSERVATION •GAIT should always be observed when looking at the hip •Increased knee flexion to absorb shock •Stride length is shorter on affected side •The trunk and leg swing simultaneously

OBSERVATION •Use of a cane ●Should be held in the hand opposite the affected side •Symmetry ●Limb positions, limb lengths, muscle mass, soft tissue swelling

OBSERVATION Look at the balance b/w hip flexors and extensors  The trunk will try to compensate by either flexing or extending in turn 

ie. bilateral hip flexor contracture

Look at hip rotation Lateral rotators are more often dominant than medial rotators 

“squinting patellae”

OBSERVATION •Balance ●The individual may have lost proprioceptive control ●Look for the same features as noted in the lumbar spine and pelvic examinations

PHYSICAL ASSESSMENT -ROM -Active, passive, isometric -Special tests -Hip pathology -Leg length -Muscle pathology -Palpation -Length & Strength Tests

Active ROM Flexion 110 - 120° Extension 10 - 15° Abduction 30 - 50° Adduction 30° Lateral Rotation 40 - 60° Medial Rotation 30 – 40° Sustained postures (if necessary) Repetitive movements (if necessary) Combined movements (if necessary)

Standing/ supine/prone

Active ROM Active movements of the Hip Remember: painful movements should be performed last ●Be on the look out for 'trick movements' ie. not being able to keep the movements localized to the hip

Active ROM – Critical Thinking Q: Why keep the knee flexed during active hip flexion? Q: How might you be fooled into thinking that there is more hip extension than there truly is? Q: How might you be fooled into thinking that there is more hip abduction/ adduction than there truly is?

Passive ROM (Performed supine/prone) Flexion Tissue approximat'n or tissue stretch Extension Tissue stretch Abduction Tissue stretch Adduction Tissue approximat'n or tissue stretch Lateral Rotation Tissue stretch Medial Rotation Tissue stretch

Passive ROM REMEMBER: •don't forget to take note of the endfeel type at the end of a passive ROM test •the pelvis should not move during passive testing of the hip

Resisted Isometric Testing * can all be performed in supine pos'n

-Flexion of the hip -Extension of the hip -Abduction of the hip -Adduction of the hip -Medial rotation of the hip -Lateral rotation of the hip -Flexion of the knee -Extension of the knee

Resisted Isometric Testing – Critical Thinking

Q: Why do we include isometric resisted flexion and extension of the knee when performing isometric resisted testing of the hip?

Resisted Isometric Testing •Isometric testing is performed with the client in the supine position •Hip muscles are very strong – client and examiner positioning is important “don't let me move you” •Most painful movements should be performed last

Special Tests – Hip Pathology

(1) Patrick-FABER's Test aka Patrick's Test; Figure 4 Test

(2) Trendelenberg's Sign/Test

Special Tests – Hip Pathology Patrick-FABER's Test (1) Client supine (2) Place client's test leg so that the foot of the test leg is put on top of the opposite knee (3) Examiner slowly lowers the test leg (crossed leg) downward POSITIVE: leg remains above the opposite straight leg INDICATES: hip joint dysfunction, iliopsoas spasm, or SIJ involvement

Special Tests – Hip Pathology Patrick-FABER's Test

Special Tests – Hip Pathology Trendelenburg Sign/Test (1) Client standing; ask to balance first on one leg than the other (2) Observe for movement of the pelvis ➔ Does pelvis on nonstance side rise or fall? POSITIVE: pelvis on nonstance (!!) side falls INDICATIVE OF: weakness or instability of hip abductor muscles (primarily GLUTEUS MEDIUS) on the stance (!!) side

Special Tests – Leg Length Tests

(1) Measuring True Leg Length (2) Weber-Barstow Manoeuver (3) Prone Knee Flexion Test for tibial shortening (4) Femoral Shortening

Special Tests – Leg Length Tests

2 types of leg length discrepancies: (1) True Leg Length Discrepancy True shortening; anatomical or structural change exists Often affects spine and pelvis (lateral tilting and scoliosis)

Special Tests – Leg Length Tests

(2) Functional Leg Length Discrepancy Result of compensation for a change that may have occurred b/c of positioning rather than structure. 

ie. unilateral pes planus; pelvic tilt

Special Tests – Leg Length Tests Measuring True Leg Length (1) Client supine with ASISs level and lower limbs perpendicular to the line joining the ASISs (2) Using a tape measure, measure distance from ASIS to ipsilateral medial malleolus (3) Difference of 1 to 1.3cm (0.5 to 1 inch) is considered normal POSITIVE: distances greater than 1 inch INDICATIVE OF: leg length inequality (structural or functional?)

Special Tests – Leg Length Tests Measuring True Leg Length ASIS

Medial Malleolus

Special Tests – Leg Length Tests Measuring True Leg Length – Critical Thinking Q: If x-ray studies demonstrate that no leg length inequality exists in a respective client, yet you consistently measure a difference in leg lengths (ie. greater than 1 inch difference between the lengths of the two lower limbs), (A) assuming your technique is correct, what might the reason be for the discrepancy? (B) what might the underlying etiology be?

Special Tests – Leg Length Tests Weber-Barstow Manouever (1) Client supine with hips and knees flexed (90°) (2) Standing at the client's feet, therapist palpates for distal aspect of medial malleoli (thumbs) (3) Client asked to lift pelvis off table and back down again. (4) Therapist then PASSIVELY extends client's legs and compares positions of the malleoli

POSITIVE: leg length difference – reflects a TRUE leg length difference

Special Tests – Leg Length Tests Prone Knee Flexion Test (tibial shortening) (1) Client prone with knees passively bent to 90° (2) Therapist places thumbs transversly across soles of feet (just in front of heels) (3) Relative height of thumbs are noted POSITIVE: tibial leg length difference

Special Tests – Leg Length Tests Femoral Shortening (1) Client supine with hips and knees flexed such that knee flexion is approx. 90° (2) Observe from the side (3) Note relative height of knees POSITIVE: femoral leg length difference

Special Tests – Muscle Pathology

-Thomas Test -Rectus Femoris Contracture -Ely's Test -Ober's Test -Piriformis Test -Noble Compression Test -Hamstring Contracture Test -Tripod Sign -90-90 Straight Leg Raise

Special Tests – Muscle Pathology Thomas Test

(1) Client supine; therapist should look for excessive lumbar lordosis (2) Passively flex client's hip to their chest and ask client to hold it (3) Observe opposite straight leg on table POSITIVE: straight leg on table rises INDICATES: hip flexion contracture

Special Tests – Muscle Pathology Thomas Test Negative Test

Positive Tests

Special Tests – Muscle Pathology Rectus Femoris Contracture Test (1) Client supine with knees bent over the edge of table (2) Client pulls one knee to chest and holds (3) Observe hanging leg. Knee should remain hanging at approx. 90° POSITIVE: straightening (extension) of hanging knee INDICATES: contracture of rectus femoris

Special Tests – Muscle Pathology Rectus Femoris Contracture Test

DID YOU NOTICE THAT THIS TEST IS VIRTUALLY IDENTICAL TO GAENSLEN'S TEST?

Special Tests – Muscle Pathology Ely's Test

(1) Client prone (2) Therapist passively flexes client's knee (heel to buttock) (3) Observe ipsilateral hip POSITIVE: ipsilateral hip raises INDICATES: contracture of rectus femoris

Special Tests – Muscle Pathology Ely's Test

Special Tests – Muscle Pathology Ely's Test – Critical Thinking Q: Other than demonstrating a rectus femoris contracture, what other structure(s) might this test elicit a true positive with and how?

Special Tests – Muscle Pathology Ober's Test (1) Client side lying with lower leg flexed at the hip and knee for stability (and comfort) (2) Therapist passively extends client's upper leg (knee may be straight or flexed to 90°) off table (3) While stabilizing the pelvis, slowly lower the leg and observe for final distance dropped POSITIVE: leg remains abducted (does not drop below level of table) INDICATES: ITB contracture

Special Tests – Muscle Pathology Ober's Test

What important nerve will most likely undergo a stretch when Ober's is performed with a flexed knee?

Special Tests – Muscle Pathology Piriformis Test (1) Client side lying (2) Therapist flexes top hip to approx. 60° with the knee flexed (3) While stabilizing the hip with one hand, use the other hand to apply a downward pressure to the knee POSITIVE: pain (hypertonic piriformis); sciatica symptoms (piriformis pinching sciatic nerve) INDICATES: piriformis contracture; Piriformis syndrome

Special Tests – Muscle Pathology Piriformis Test

Special Tests – Muscle Pathology Noble Compression Test (1) Client supine with passive hip and knee flexion (2) Therapist applies pressure with thumb to the lateral femoral epicondyle or 1-2 cm proximally (3) Maintaining pressure, slowly extend knee and hip to 0° (straight leg) POSITIVE: pain under thumb or at lateral femoral condyle at approx. 30° of flexion INDICATES: ITB friction syndrome near the knee

Special Tests – Muscle Pathology Noble Compression Test

Special Tests – Muscle Pathology Hamstring Contracture Test

(1) Client sitting with one knee and hip flexed to chest and the other extended (2) Ask client to try to touch the toes of straight leg POSITIVE: client cannot touch his/her toes INDICATES: hamstring contracture on the side of the extended leg

Special Tests – Muscle Pathology Hamstring Contracture Test

Knee/hip should be pulled in close to chest

Special Tests – Muscle Pathology Tripod Sign (1) Client seated with knees at edge of table (2) Therapist passively extends one knee (3) Observe client for trunk extension POSITIVE: trunk extension (client leans backwards) INDICATES: ipsilateral hamstring contracture

Special Tests – Muscle Pathology 90-90 Straight Leg Raise (1) Client supine with both hips and knees flexed to 90° (2) Ask client to hold on to both thighs so as to stabilize thighs at 90° of hip flexion (3) Ask client to then extend as much as possible each of the knees in turn (4) Knee extension should be within 20° of full extension

POSITIVE: more than 20° to full extension INDICATES: ipsilateral hamstring contracture

Special Tests – Muscle Pathology 90-90 Straight Leg Raise

Test should be performed with both hips and knees simultaneously starting at 90° of flexion.

Special Tests – Joint Play Scouring Test (aka Quadrant Test) (1) Client supine (2) Therapist flexes and ADducts client's hip so that hip/knee is pointing to opposite shoulder (3) Flex & adduct to the point of resistance (4) Maintaining resistance, move hip into ABduction while maintaining flexion in an arc of movment POSITIVE: irregularity in movement (“bumps”), pain, client apprehension INDICATES: generally, problem with articular cartilage, acetabulum or labral tear

MUSCLE LENGTH & STRENGTH TESTS Hip flexor Length Iliopsoas Strength TFL Strength Medial and Lateral Hip Rotators Strength Hip Abductors Strength Hip Adductors Strength

MUSCLE LENGTH & STRENGTH TESTS HIP FLEXOR LENGTH Exactly the same as THOMAS TEST

CRITICAL THINKING Q: If no excessive lordosis exists in a person while in the standing position (normal lumbar curve), but exist when the same person is kneeling, what would that tell you about the involved hip flexor musculature?

MUSCLE LENGTH & STRENGTH TESTS ILIOPSOAS STRENGTH Identical to isometric resisted hip flexion test TFL STRENGTH Near identical to isometric resisted hip abduction test Must also have hip in slight flexion and internal rotation Resistance only to abduction and flexion (NOT rotation)

MUSCLE LENGTH & STRENGTH TESTS MEDIAL/LATERAL HIP ROTATOR STRENGTH Identical to isometric resisted internal/external hip rotator test Can also perform in the sitting position ABDUCTION/ADDUCTION STRENGTH Identical to isometric resisted abduction/adduction test