functional anatomy and exam of the hip, groin, and thighforms.acsm.org/15tpc/pdfs/13 johnson...
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San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
LTC ANTHONY E. JOHNSON, MD, FAAOS CHAIRMAN, DEPARTMENT OF ORTHOPAEDICS & REHABILITATION
CO-CHAIRMAN, U.S. ARMED FORCES SPORTS, MEDICAL ADVISORY GROUP TEAM PHYSICIAN, USA PARALYMPIC BASKETBALL
ACSM Team Physician Course 5 February 2015
Functional Anatomy and Exam of the Hip, Groin, and Thigh
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
• Hip Joint – True ball and socket joint – Intrinsic stability – Moves in all three planes, particularly during gait
• Pelvis – Moves in all three planes – Anterior tilting
• Changes degree of lumbar lordosis – Lateral tilting
• Changes degree of hip abduction
Functional Anatomy
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
ACETABULUM
FEMORAL HEAD
GREATER TROCHANTER
LESSER TROCHANTER
FEMORAL NECK
CORTICAL BONE
MEDULLARY BONE
FOVEA CAPITIS
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San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Articulation
• The cavity of acetabulum is deepened by a fibrocartilaginous acetabular labrum
• The articular surface of the acetabulum is horseshoe shaped – Deficient inferiorly at the acetabular notch
• The labrum bridges across the acetabular notch – The transverse acetabular ligament – Converts the notch into a tunnel
• Vessels and nerves enter the joint
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
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San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
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San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Type & Capsule
• Synovial ball and socket joint – Enclosed by capsule
• Attachments – Medially: acetabular labrum – Laterally: intertrochanteric line of the femur in front
and along the posterior aspect of the neck
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Ligaments of the Hip Joint
• Pubofemoral – A triangular ligament – Base attached to the superior ramus of the pubis – Apex attached to the the intertrochanteric line – Limits extension and abduction
• Ischiofemoral – A spiral shaped ligament – Base attached to ischium near the acetabular margin – Apex attached to the greater trochanter – Limits extension
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
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San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Creative Commons Attribution ShareAlike 3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Nerve Supply
• Femoral nerve – Arises from posterior divisions of of L2, L3, L4 – Passes inferolaterally thru psoas, over Iliacus muscle
• Enters thigh underneath the inguinal ligament
– Supplies quadriceps & anteromedial thigh • Continues on as the saphenous nerve
– Three (3) branches: • Pectineus (at level of inguinal ligament) • Sartorius • Quadriceps
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Nerve Supply
• Obturator nerve – Formed from anterior branches of L2, L3, L4 – Largest nerve formed from anterior divisions of lumbar
plexus – Roots unite within the posterior psoas
• Runs over sacral ala into lesser pelvis – lateral to ureter & internal iliac vessels
• Enters the obturator foramen and subsequently divides into anterior and posterior branches
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Nerve Supply
• Obturator nerve – Anterior Branch:
• Runs in front of obturator externus & adductor brevis • Runs behind the pectineus and adductor longus muscles • Gives off articular twig that enters hip joint thru acetabular notch
– Cutaneous Branch: • When present, innervates skin and fascia over distal 2/3 of thigh
– Posterior Branch: • Pierces anterior part of obturator externus • Runs inferiorly behind the adductor brevis & in front of the
adductor magnus
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Nerve Supply
• Sciatic nerve – Arises from lumbrosacral plexus: L4, L5, S1, S2, S3
• Nerve emerges from pelvis below piriformis • Enters thigh between ischial tuberosity & greater
trochanter – Descends near middle of thigh, lying on adductor
magnus muscle & being crossed obliquely by long head of biceps femoris
• Nerve usually separates in upper part of popliteal space – Gives off tibial and peroneal branches
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Nerve Supply
• Sciatic nerve – Tibal Nerve:
• Anterior branches of LS plexus: L4, L5, S1, S2, S3 • 2 branches from tibial division: below quadratus femoris:
– Upper branch innervates long head of biceps femoris & superior portion of semitendinosus
– Lower branch: innervates inferior portion of semitendinosus, semimembranous & ischiocondylar portion of adductor magnus
– Common Peroneal Nerve: • Posterior branches: L4, L5, S1, S2 • Nerve to short head of biceps femoris arises from lateral side of
sciatic nerve (common peroneal portion) in middle of thigh
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
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San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Creative Commons Attribution ShareAlike 3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Movements
• Wide range of movement – Less so than the shoulder joint – Some movement sacrificed for stability – Dependent largely upon shape of articulating bones and on
strong ligaments • When the knee is flexed
– Flexion is limited by the anterior thigh contact with abdomen
• When the knee is extended – Flexion is limited by hamstring tension
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Movements
• Abduction limited by tension of pubofemoral ligament • Adduction limited by
– Contact with contralateral limb – Tension of the ligament of the head of the femur
• External rotation limited by tension in the iliofemoral and pubofemoral ligaments
• Internal rotation limited by ischiofemoral ligament
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Movements
• Flexion: – Primary: iliopsoas, rectus femoris, & sartorius – Secondary: adductor muscles
• Extension: – Gluteus maximus and hamstrings
• Abduction: – Primary: gluteus medius and minimus – Secondary: sartorius, tensor fasciae latae, & piriformis
• Adduction: – Adductor longus, brevis, and magnus
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Movements
• External rotation: – Piriformis, obturator internus and externus, superior and
inferior gamelli • Internal rotation:
– Anterior fibers of gluteus medius and gluteus minimus and the tensor fasciae latae
• Circumduction: – Complex combination of the previous movements
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Movements
• The extensor group of muscles is more powerful than the flexor group
• The lateral rotators are more powerful than the
medial rotators
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Assessment of the Hip and Pelvis
• Injuries to the hip or pelvis cause major disability in the lower limbs, trunk, or both
• Low back may also become involved • History
– Onset (sudden or slow?) – Previous history? – Mechanism of injury? – Pain description, intensity, quality, duration, type, and
location?
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
• Observation – Symmetry - hips, pelvis tilt (anterior/posterior)
• Lordosis or flat back – Lower limb alignment
• Knees, patella, feet – Pelvic landmarks
• ASIS, PSIS, iliac crest – Single limb stance
• Pubic symphysis pain or drop to one side – Ambulation
• Antalgia?
Assessment of the Hip and Pelvis
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
• True or anatomical – Shortening may be equal throughout limb or localized in
femur or leg – Measure from ASIS to medial malleolus
• Apparent or functional – May result due to lateral pelvic tilt, flexion, or adduction
deformity – Measure from umbilicus to medial malleolus
Special Tests: Leg Length Discrepancy
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Leg Length Discrepancy Measures
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Popliteal – Femoral Angle
http://www.sportsdoc.umn.edu
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Single Limb Stance
Evaluation of the Patient with Hip Pain. http://www.aafp.org
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Provocative Test for Labral Pathology
Evaluation of the patient with Hip pain. http://www.aafp.org
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Differential Diagnosis
• Contusion (Hip Pointer) • Strain • Avulsion
– ASIS: Sartorius – AIIS: Rectus Femoris – Ischial Tuberosity: Common Hamstring Origin
• AVN • Hip Dysplasia/Femoral-Acetabular Impingement
(FAI)
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Hip Pointer
• A hip pointer is a contusion to the iliac crest, the surrounding soft tissue structures, or the greater trochanter of the femur
• Typically, the injury is caused by a direct blow or fall – Occur most commonly in contact sports (e.g., football, hockey) – Can also occur in noncontact sports as a result of a fall onto the hip or
side
• Pain and tenderness in this region can limit an athlete's participation in sports
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
HIP POINTER
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San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Hip Avulsion Fractures
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San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Hip Avulsion Fractures
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San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Hip Avulsion Fractures
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San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
Hip Avulsion Fractures
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San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
FAI
http://orthoinfo.aaos.org
San Antonio Military Medical Center
"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”
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