DPT 623 Movement Science I

THE HIP

A. Palpation

Osteology
Greater trochanter of femur Ischial tuberosity
ASIS Pubic tubercle
PSIS (~ S2) Inferior pubic ramus
Myology
Adductor longus O: Pubis where crest meets
symphysis
I: Middle 1/3 linea aspera
medial femur
Adductor magnus O: Pubis, inferior ramus,
ischium (ramus, tuberosity)
I: Linea aspera length, medial
supracondylar line
Biceps femoris O: Long head- ischium, short
head- linea aspera of femur,
lateral lip
I: Fibular head
Gluteus maximus O: Ilium, sacrum, coccyx,
erector spinae aponeurosis,
sacrotuberous ligament
I: ITB tract, gluteal tuberosity
of femur
Gluteus medius O: Ilium, between crest and
posterior gluteal line
I: Greater trochanter
Gracilis O: Pubis (inferior ramus),
ischial ramus
I: Medial tibia (pes anserine)
Iliopsoas Iliacus: O- ilium, iliac crest,
sacrum; I- Lesser trochanter
via psoas major tendon
Psoas Major: O- L1-5
transverse processes, T12-L5
vertebral bodies; I- Lesser
trochanter
Pectineus O: Pecten pubis between
iliopectineal eminence and
Iliac crest (~ L4)
Sacrum
Hip ADD, FLEX, ROT
(dependent on thigh
position)
Hip ADD, FLEX (superior), EXT
(inferior)
Hip EXT, ER
Knee FLEX, ER
Posterior pelvic rotation
Hip EXT, ER, ABD (upper),
ADD (lower)
Posterior pelvic rotation
Hip ABD, IR (anterior), ER
(posterior), FLEX (anterior),
EXT (posterior)
Hip ADD
Knee FLEX, IR
IIiacus- Hip FLEX, Anterior
pelvic rotation
Psoas major- Hip FLEX, ER
Trunk FLEX, LAT FLEX
Hip FLEX, ADD

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 pubic tubercle
I: Femoral shaft from lesser
trochanter to linea aspera
Piriformis O: Sacrum, ilium (gluteal Hip ER, ABD the flexed hip
surface near PIIS),
sacrotuberous ligament
I: Greater trochanter,
superior border of medial
femur
Rectus femoris O: AIIS of ilium, acetabular Hip FLEX,
groove above posterior rim Knee EXT
I: Quad tendon, patellar base
Sartorius O: ASIS of ilium Hip ER, ABD, FLEX
I: Tibia (proximal medial shaft Knee FLEX, IR
distal to tibial condyle)
Semimembranosus O: Ischium Hip EXT, IR
I: Tibia (tubercle on medial Knee FLEX, IR
condyle) Posterior pelvic rotation
Semitendinosus O: Ischium Hip EXT, IR
I: Shaft of proximal medial Knee FLEX, IR
tibia, fascia of leg Posterior pelvic rotation
Tensor fascia lata O: Ilium (crest, anterior outer Hip FLEX, IR (primarily from
lip, ASIS) ER), ABD
I: Iliotibial band
Vastus lateralis O: Linea aspera, greater Knee EXT
trochanter, anterior and
inferior femoral borders,
gluteal tuberosity
I: Quad tendon, patella
Vastus medialis O: Longus- Femur Knee EXT
intertrochanteric line, linea
aspera, medial lip; Oblique-
linea aspera, medial
supracondylar line, tendon of
add magnus
I: Quad tendon, patella
Other
Sciatic nerve Femoral artery Inguinal ligament

B. Goniometry

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 Review the following goniometric measurements in text and videos. Complete the
normal end feel and ROM. If possible, practice measurement with a colleague or family
member and be prepared to demonstrate. There is variability in norms. Ranges: Reese
N, Bandy W. Joint Range of Motion and Muscle Length Testing, 3rd ed. Elsevier, 2017;
Norkin C, White D. Measurement of Joint Motion, 5th ed. FA Davis, 2016.

Joint Movement Normal End Normal ROM Passive ROM

Feel
Hip Flexion Soft or Firm 120-140°
Extension Firm 10-20°
Abduction Firm 40-50°
Adduction Firm 20-25°
Medial Rotation Hip Flexed Firm 30-50
Lateral Rotation: Hip Flexed Firm 30-50
Medial Rotation: Hip Firm ---
Extended
Lateral Rotation Hip Firm ---
Extended

MOTION ALIGNMENT POSITION

Hip Flexion Stationary: Lateral midline pelvis and trunk Supine

Axis: Greater trochanter
Moving: Lateral femoral epicondyle
Hip Extension Stationary: Lateral midline pelvis and trunk Prone
Axis: Greater trochanter
Moving: Lateral femoral epicondyle
Hip Abduction Stationary: Towards contralateral ASIS Supine
Axis: Ipsilateral ASIS
Moving: Midline femur, patella
Hip Adduction Stationary: Towards contralateral ASIS Supine
Axis: Ipsilateral ASIS
Moving: Midline femur, patella
Hip Lateral Rotation with Stationary: Perpendicular to floor Seated
Hip Flexed Axis: Midpoint of patella
Moving: Anterior tibial crest
Hip Medial Rotation with Stationary: Perpendicular to floor Seated
Hip Flexed Axis: Midpoint of patella
Moving: Anterior tibial crest
Hip Lateral Rotation with Stationary: Perpendicular to floor Prone
Hip Extended Axis: Midpoint of patella
Moving: Anterior tibial crest

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 Hip Medial Rotation with Stationary: Perpendicular to floor Prone
Hip Extended Axis: Midpoint of patella
Moving: Anterior tibial crest

C. Manual Muscle Testing

Review the following manual muscle tests for the shoulder girdle region as described by
Avers & Brown. If possible, practice the testing with a colleague or family member. Be
prepared to demonstrate.

1. Hip flexion
2. Hip flexion, abduction, and external rotation with knee flexion
3. Hip extension
4. Hip abduction
5. Hip abduction from flexed position
6. Hip adduction
7. Hip external rotation
8. Hip internal rotation

D. Functional Motions & Movement Analysis

1. Perform the following actions. Ensure that you can differentiate between each of
them and that you can differentiate between closed-chain and open-chain activities.
a. Anterior and posterior pelvic tilt, lateral pelvic tilt, forward and backward
rotation
b. Hip flexion and extension, abduction and adduction, medial and lateral
rotation

2. Perform a movement analysis of the following actions.

Movement: From a seated position, tie your shoe

Joint Motion (s)
Key agonist (s)
Type of muscle action of agonists
Key synergists
Type of muscle action of synergists
Role played by synergists

Movement: From a standing position, lunge forward

Joint Motion (s)

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Key agonist (s)
Type of muscle action of agonists
Key synergists
Type of muscle action of synergists
Role played by synergists

WORKSHEET

1. While standing, perform an anterior and posterior pelvic tilt. How would the degree of
pelvic tilt affect the diameter of the intervertebral foramen?

 Anterior pelvic tilt will increase the lordosis, posterior tilt will decrease the lordosis. An
increase in the lordosis will reduce the diameter of the intervertebral foramen, a
decrease will increase the diameter.

2. Stand with one foot on a 2” book with both knees straight. What is the position of each
hip joint?

 The lower limb on the book will move into more hip adduction as the opposite pelvis
drops.

3. What motion occurs at the right hip as you:

a. Turn your trunk to look back over the right shoulder: Medial rotation
b. Turn your trunk to look back over the left shoulder: Lateral rotation
c. Shift weight over your right foot: Adduction
d. Shift weight over your left foot: Abduction

4. Stand unilaterally on the right leg. What muscle group must contract in this position to
stabilize the pelvis in the coronal plane? If the pelvis drops on the left during this
maneuver, what is this called?

 Right hip abductors. Positive Trendelenburg

5. Ask a partner to reach for the floor with the fingertips, keeping the knees and hips
straight, bending only at the spine. Measure the distance from the tip of the middle
finger to the floor and record.____________. Ask your partner to reach for the floor
bending only the hip joints, keeping the spine straight. Measure the distance and
record____________. Now ask your partner to combine hip and lumbar flexion while
reaching for the floor. Measure the distance and record____________.

a. What is this coordinated activity called? Lumbopelvic rhythm

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 b. What is the normal movement of the pelvis during forward bending? Anterior
tilt

c. Why might this observation be clinically important during your examination of an

individual with low back pain?

 In the presence of decreased lumbar mobility, excessive movement may occur

elsewhere, ie, at the hip to compensate during functional tasks. Alternatively, an
individual with restricted hip ROM, ie, due to tight hamstring or joint hypomobility, may
use excessive lumbar motion to perform the task, increasing strain on the lumbar spine.
Assessment of both regions is necessary and will guide your exercise prescription.

5. In supinelying, perform a bilateral straight leg raise. As the hips flex, what position does
the lumbar spine tend to move towards? Which muscle group(s) contract to prevent
this motion and protect the lumbar spine from excessive strain?

 The lumbar spine will tend to move into extension with lumbar lordosis due to the pull
of the iliopsoas. To minimize the anterior tilt, posterior pelvic rotators must be
contracting, ie, abdominals

6. Position your partner to muscle test the iliopsoas with the least contribution from the
rectus femoris. Why did you select that position?

 Place the limb in a position in which the rectus femoris is actively insufficient, ie, hip
flexion with knee extension.

7. In pronelying, observe the amount of passive hip rotation in your partner.

a. Which motion is greater, medial or lateral rotation?

 Dependent on the individual

b. Is excessive medial or excessive lateral hip rotation a more common finding of

increased femoral anteversion?

 Excessive medial rotation

c. Which structures normally limit hip medial rotation?

 Tension in the posterior joint capsule, ischiofemoral ligament, piriformis, obturators,

gemelli, quadratus femoris, posterior gluteus medius and gluteus maximus

d. Which structures normally limit hip lateral rotation?

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  Tension in the anterior joint capsule, iliofemoral ligament, pubofemoral ligament,
anterior portion of gluteus medius, gluteus minimus, adductor magnus/longus,
pectineus and piriformis

8. In supinelying, move your hip into combined flexion, abduction and slight external
rotation. Now move the hip into extension, abduction and internal rotation.

a. In which position of the hip are the articular surfaces of the hip more congruent?

 Congruency: Flexion, abduction, slight ER

b. What is the close-packed position of the hip?

 Close packed: Extension, abduction, MR (ligamentous)

c. Why do these positions differ?

 Structure and function of the ligaments in the region creates tautness in a

position that differs from articular congruency

9. Is the rectus femoris more effective as a hip flexor if the knee is flexing with the hip, or if
the knee is extending? Why?

 Knee flexing
 Optimal length tension of the 2-jt muscle; active insufficiency will occur if the knee is
extending at the same time

10. What is the difference in passive range of motion between hip flexion with the knee
flexed and with the knee extended? Why?

 Increased hip flexion with knee flexion. Passive insufficiency of the hamstrings with
knee extended

11. Design and perform a method of stretching the gluteus maximus muscle without
interference from the hamstrings.

 Hip flexion with knee flexion to slacken the hamstrings

12. Is the adductor magnus a hip flexor, hip extensor, or both? Explain the mechanism.

 Adductor magnus may be a flexor when the hip is in neutral or extended, and an
extensor when the hip is already flexed. Inversion of function occurs due to the large
ROM at the hip and the change in relationship of the muscle to the joint axis. The line of
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 pull of the adductors is anterior to the hip joint axis when the hip is in extension, and
posterior to the hip joint axis when the hip is in flexion.

13. Describe the motion resulting from an active contraction of the gluteus maximus muscle
without concurrent contraction of the gluteus minimus muscle. Explain the mechanism.

 Extension with lateral rotation of the hip. Medial rotation provided by a simultaneous
contraction of the gluteus minimus neutralizes the lateral rotation component of the
gluteus maximus, allowing pure extension

14. Position your partner to test for tightness of the piriformis muscle. Describe your
position(s).

 Medial rotation with the hip extended or lateral rotation with the hip flexed. In hip
flexion beyond 90 degrees, the pirifromis appears to be an internal rotator. With the hip
in extension, it is an external rotator

15. Palpate the femoral artery. What are the structures housed within the femoral triangle?
What are the borders of the triangle?

Structures: Femoral nerve and its branches, femoral sheath and its contents, femoral
artery and several of its branches, femoral vein and its proximal tributaries
Borders:
o Superiorly: Inguinal ligament
o Medially: Adductor longus
o Laterally: Sartorius
o Base: Inguinal ligament
o Apex: Where the lateral border of the sartorius crosses the medial border of
adductor longus

16. Assume that your patient has a recently undergone a right total hip arthroplasty and is
ready for single crutch ambulation. Right hip abductor weakness is present. Should the
crutch be carried ipsilateral or contralateral to the affected hip? Explain your rationale.

 Contralateral to the affected hip

 In the opposite hand, the weight passing through the affected hip is reduced, the cane
assists the abductor muscles in providing a countertorque to the torque of gravity,
latissimus dorsi contraction creates an upward pull on the iliac crest on the side of the
cane (creating an abduction torque around the supporting hip joint which helps to offset
the gravitational adduction torque around that hip)

17. Estimate the degree of hip flexion necessary for the following activities:
a. Sitting erect in a straight back chair:

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 b. Sitting slumped in a conventional chair:
c. Tying a shoe while sitting in a chair:
d. Climbing the steps to get on a bus:
e. Level walking:
f. Squatting to pick up a pen:
g. Sitting on a standard height toilet:

If an individual’s hip flexion is limited to 70 o, which of the activities listed above would
require modification in movement pattern for completion of the task?

Only walking on level surface will likely be unaffected by the range of motion limitation.

CASE STUDY ANALYSIS

1. Your patient is a 16-yr-old male soccer player who strained his right medial thigh during
a game four days ago. Complaints include medial thigh pain aggravated by kicking,
running and extending the leg out to the side. Pt also notes some discomfort when
walking quickly. Tenderness and ecchymosis are present at the superior medial thigh at
the musculotendinous region of the adductors. Pt has a game Saturday morning and
would like to play, but his coach is waiting to speak with you before making the decision.

Perform the following and discuss what you might expect to find on performance of
these techniques if your patient presents with hip adductor muscle strain.

Palpation: Adductor longus, inguinal ligament, gracilis, femoral pulse

Goniometry: Hip abduction

MMT: Hip adductors
Activity: From a standing position, kicking motion (as if kicking a soccer ball):
pelvis & hip

2. Your patient is a 75-yr-old female who fell on the ice 1 week ago twisting her left hip and
falling on her buttock region. ER radiographs were negative. Pt was instructed to rest
and use a heating pad and now presents with a large hematoma in the right posterior
thigh and buttock extending to the sacral region, hip pain with ambulation and sit to
stand transfers. Her husband has been assisting, but pt is worried that she is too much
work for him. She would like to care for herself as soon as possible.

Perform the following and discuss what you might expect to find on performance of
these techniques if your patient strained her piriformis muscle and bruised her hip.

Palpation: Piriformis, semitendinosus, biceps femoris, gluteus maximus

Goniometry: Hip medial rotation

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 MMT: Hip lateral rotators
Activity: From a standing position, step onto a small stool and return to the floor:
pelvis & hip

3. Your patient is a 45-yr-old female with a 2-month history of right lateral hip and thigh
pain. Pt noted a gradual onset, and reports that she has been unable to participate in
her Pilates and walking program three times/wk at the YMCA due to increasing
discomfort. She is awakened at night if she rolls onto her right side, and is
uncomfortable if she sits too long at work. She tried anti-inflammatory medicine, but it
upsets her stomach. Her physician suggested a cortisone injection, but she asked if she
could try anything else first and was referred to physical therapy.

Perform the following and discuss what you might expect to find on performance of
these techniques if your patient presents with trochanteric bursitis.

Palpation: Greater trochanter, gluteus medius, sartorius, tensor fascia lata

Goniometry: Hip extension
MMT: Hip abductors
Activity: From a standing position, squat to pick up a small object: pelvis & hip

LIGAMENTOUS FUNCTION
Complete the following table describing the location and function of hip ligaments.

Ligament Location Function

Iliofemoral (“Y” Attaches, above, to the lower Limits hip extension, lateral rotation,
Ligament of part of the anterior inferior iliac adduction (superior fibers), medial
Bigelow) spine; below, it divides into two rotation
bands, one passes downward
and is fixed to the lower part of
the intertrochanteric line; the
other is directed downward and
laterally and is attached to the
upper part of the same line.
Connected with the joint
capsule.
Ischiofemoral Attaches to the ischial portion Limits hip extension, medial rotation,
of the rim of the acetabulum; a adduction when the hip is flexed
portion runs horizontally (superior fibers), flexion (inferior
reinforcing the capsule fibers)
posteriorly; another portion
projects superiorly spiraling

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 over the superior medial
aspects of the greater
trochanter
Pubofemoral Attaches, above, to the
obturator crest and the
superior ramus of the pubis;
below, it blends with the
capsule and with the deep
surface of the vertical band of
the Iliofemoral ligament.
Ligamentum Teres Attaches by its apex into the
(Ligament of the antero-superior part of the
Head of the Femur) fovea capitis; its base is
attached by two bands, one
into either side of the
acetabular notch, and between
these bony attachments it
blends with the transverse
ligament. Intra-articular, extra-
synovial accessory joint
structure.
Limits hip abduction, extension, lateral
rotation (in hip extension)
Conduit for the secondary blood
supply from the obturator artery to
the femoral head. This arterial branch
is not present in everyone but may
become the only blood supply to the
femoral head when the neck of the
femur is fractured or disrupted by
injury in childhood. May have a minor
role in hip stability tightening during
adduction, flexion, lateral rotation
(Martin et al).

Transverse Spans the acetabular notch Bridges the acetabular notch

Acetabular near the rim of the acetabulum

References
1. Neumann D, Kinesiology of the Musculoskeletal System, 3rd ed. Mosby, 2016
2. Levangie P, Norkin C. Joint Structure and Function, 5thed. FA Davis, 2010
3. Oatis C. Kinesiology, 3rd ed. Lippincott Williams Wilkins, 2016

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