PPT PART 1 - BONES AND JOINT

1/5 of the acetabulum is formed by the pubis

2/5 for the ilium and ischium

Full ossification of pelvis occurs at age 20-25

Hip joint is made for stability and weight bearing at the expense of mobility which is in contrast with the
glenohumeral joint which makes mobility as the primary function

Hip joint supports the weight of the head, arms and trunk (HAT)

Acetabulum is further deepened by the acetabular labrum which is analogous to the tibiofemoral joint

The labrum makes the concavity even more pronounced however, the acetabulum does not complete
the circle below and is horse shoe shaped

Below, there is a space called the acetabular notch which is completed by the transverse acetabular
ligament

The spherical femoral head has a non articular pit called the fovea capitis
Fovea capitis - serves as an attachment for the round ligament/ligamentum teres

Acetabulum is oriented Anteriorly, Laterally and Inferiorly (ALI)

Femoral head is oriented Superiorly, Anteriorly and Medially (SAM)

Stability of hip joint is provided by the

joint congruence, negative atmospheric pressure and joint capsule

Since the acetabulum and femoral head are both oriented anteriorly, it shows an incongruence in the
anterior area when the joint is in neutral position

Kapandji suggested that the true physiological position of the hip joint is in flexion, slight abduction and
slight external rotation (though it is not in close packed, there is an increase in the articulation of the
femur and acetabulum especially in the non weight bearing position)

Non weight bearing position (frog leg position)

Close packed position

⁃ Where the hip joint is in maximal congruence
 ⁃ Yields the greatest stability on the hip joint
Open packed position
⁃ Should not be confused with the true physiologic position
⁃ Anterior shift of the femoral head is amplified thus further decreasing the bony
congruence of the joint
⁃ Ligaments are too slack therefore in the cross sitting position, the hip joint is technically
loose
⁃ Hip becomes even more unstable when combining flexion, abduction and internal
rotation (W sitting position); move the femoral head out of the socket thus making the joint very
unstable

Negative atmospheric pressure

⁃ creates the negative atmosphere of the joint which forms the suction effect and makes
the joint stable
⁃ Researchers show that this pressure in hip flexion plays stronger role in hip stabilization
as compared to capsuloligamentum structures

Joint Capsule
⁃ thick anterosuperiorly and thin posteroinferiorly
⁃ Capsule is lax at 30 deg flexion, 30 deg abduction and slight ER (OPP)
⁃ Capsuloligamentum structures are taut in extension, abduction and ER making it the
ligamentous close packed position of the hip joint

At the base of the femoral neck, there is the tight ring that encircles it called the zona orbicularis

Zona orbicularis: provides stability on the hip joint during destructive forces
Femoral Head
⁃ made up of hyaline cartilage however, no hyaline cartilage is found at its center which is
the area of the fovea capitis
⁃ Fovea capitis: serves as an attachment for the ligamentum teres but aside from that, a
small blood vessel passes through it called the ligamentum teres artery

The ligamentum teres artery is just the secondary supply of blood to the femoral head and it is only
present when the bone is already matured

The ligamentum teres artery is derived from the obturator artery

The primary blood supply to the femoral head is from the medial circumflex femoral artery which is a
branch of the profunda femoris artery coming from the femoral artery

The proximal joint capsule is supplied by the superior and inferior gluteal arteries

The distal joint capsule is supplied by the lateral and medial circumflex femoral artery

If there is a problem in the vascular supply, it will result to the avascular necrosis of the femoral head.
Usually happens in children ages 7; called the leg calves perthes disease
Its counterpart for the adult is know as the chandler’s disease

PPT PART 2 - ANGLES AND LIGAMENTS

Center edge angle

⁃ also known as angle of wiberg or vertical center anterior angle
⁃ Measured using radiographic means or xray
⁃ Measured between the vertical line through the center of the femoral head and the
second line from the center to the outer edge of the acetabular roof
⁃ Ranges between 25-40 degrees

Acetabular dysplasia
⁃ abnormally shallow acetabulum which results to hip instability because the center edge
(CE) is <25 deg

Coxa Profunda
⁃ Too much CE angle (>40 degrees)
⁃ Where acetabulum covers the femoral head
⁃ Results to LOM
Acetabular protrusio
⁃ Too much CE (>40 degrees)
⁃ Femoral head projects too medial to the acetabulum
⁃ Results in LOM

Acetabular Anteversion Angle

⁃ determined through radiographic methods or xray
⁃ Angle is determined by drawing the first line connecting the anterior and posterior
edges of the acetabulum
⁃ The second line is drawn forward to complete the angle
⁃ Its angle is 20 degrees
⁃ An increase on this angle is called pathologic acetabular anteversion at which the
acetabulum is far too anterior in the transverse plane (results to hip instability because of the less
coverage of the femoral head to the acetabulum
⁃ A decrease in the angle is called acetabular retroversion resulting to over coverage of
the femoral to the acetabulum resulting to LOM

Angle of Inclination
 ⁃ formed by the first line meeting the axis of the femoral shaft and the second line
meeting the axis of the femoral head and neck
⁃ Normal value: 120-125 degrees
⁃ At birth, the normal value is 150 degrees
⁃ As the person starts to bear weight on the lower extremity where the child stands up,
the femoral angle of inclination decreases to 120-125 degrees
⁃ In a matured femur, an abnormal decrease in angle is called coxa vara; may result to
greater stabilization however, it increases the risk for femoral neck fracture (another advantage is it
increases the moment arm of the gluteus medius muscle thus reducing the force necessary for the
muscle to generate the torque)
⁃ An abnormal increase in angle is called COXA VALGA; the moment arm of gluteus
medius is decreased thus needing more force to create muscle torque (it also makes the joint unstable
because of the less coverage of the femoral head in the socket

Angle of Torsion
⁃ First line is formed from the long axis of the femoral head and neck
⁃ Second line from the femoral condyles
⁃ This angle represents the twisting of the femoral bone at which the femoral head is
twisted to face anteriorly
⁃ Normal value: 15-20 degree usually it is lower for males at 15 deg as compared to
females at 18 deg
⁃ If it is abnormally increased, it is called femoral anteversion/antetorsion (stability is
decreased considering the acetabulum is also oriented anteriorly
⁃ If it faces too anterior, the femoral head may also hit the capsuloligamentous structure
in front therefore, the person may have the tendency to IR the femur which will eventually result to
malalignment of the tibia by also rotating internally
⁃ The lower extremity joints work closely in closed kinematic chain therefore, any
alteration on the hip joint may also affect the knee and the ankle joints
⁃ If angle of torsion is decreased, it is called femoral retroversion/retrotorsion
⁃ It increases the congruence of the articulation which results to greater stability
however, ROM of hip is limited
LIGAMENTS

Ligamentum Teres
⁃ which transmits blood vessels which contributes to the blood supply of the femoral
head
⁃ Checks on the destructive forces on the hip joint when the femoral head is being pulled
away from the acetabulum

HIP JOINT LIGAMENTS

Iliofemoral ligament or Y ligament of Bigelow

⁃ attached from the apex of ASIS and divides into two arms giving it an inverted Y shape
attaching on the superior and inferior aspect of the intertrochanteric line of the femur
⁃ Superior band is stronger than inferior band
⁃ Serves as the primary stabilizer of the anterior aspect of the hip
 ⁃ Since it is on the anterior, it prevents excessive HYPEREXTENSION of the hip
⁃ Most of its fibers controls too much HIP EXTERNAL ROTATION
⁃ However, looking at the posterior view some of its fibers also crosses behind thus
providing some control towards HIP INTERNAL ROTATION
⁃ Because of its two arms, the superior band restricts ADDUCTION
⁃ Inferior band restricts ABDUCTION

Pubofemoral Ligament

⁃ Attached from the pubic ramus to the intertrochanteric line

⁃ Being on the anterior side, it prevents HIP EXTERNAL ROTATION IN EXTENDED
POSITION, HYPEREXTENSION AND EXCESSIVE ABDUCTION OF THE HIP
⁃ Together with the iliofemoral ligament, forms a Z shaped ligament on anterior aspect
(collectively they are called the Z LIGAMENT)
⁃ Z Ligament: prevents HYPEREXTENSION OF HIP

Ischiofemoral Ligament
⁃ Posterior
 ⁃ Attaches from the posterior acetabular rim and acetabular labrum and spirals around
the femoral neck to attach to the intertrochanteric line of the femur
⁃ Other fibers are horizontally oriented to attach to the inner surface of the greater
trochanter
⁃ Prevents HIP ER, ABDUCTION
⁃ The spiral fibers prevents too much HYPEREXTENSION OF THE HIP

⁃ These three ligaments acts on hip joint distraction forces

⁃ It controls EXTENSION, ABDUCTION AND EXTERNAL ROTATION (which is the ligamental
close packed position of the hip joint)

PPT PART 3 - MOTIONS AND MUSCLES

SAGITTAL PLANE

When the knee is bent, ILIOPSOAS AND GLUTEUS MAXIMUS primarily contracts in hip flexion and
extension respectively
When KNEE IS EXTENDED, the multijointed RECTUS FEMORIS which is part of the quads, and
HAMSTRING are activated in hip flexion and extension respectively

FRONTAL PLANE

When KNEE IS BENT, the single jointed gluteus medius for hip abduction and short adductor muscles in
hip adduction primarily contracts

When KNEE IS EXTENDED, the combined action of gluts max and TFL via the ITB does the hip abduction
and gracilis is the double jointed hip adductor

MOTIONS OF HIP JOINT IN CLOSED KINEMATIC CHAIN

The proximal segment which is the pelvic bone moves on the fixed femur

CKC: SAGITTAL PLANE

Anterior pelvic tilt
⁃ Pelvic rocks forward at which the ASIS moves inferiorly and PSIS moves superiorly

Posterior pelvic tilt

⁃ Pelvic rocks backward at which the ASIS moves superiorly and PSIS moves inferiorly

CKC: FRONTAL PLANE

Lateral pelvic tilting (AKA hip hiking or pelvic drop

⁃ The pelvis on the other side moves upward which results to relative hip abduction
⁃ Why relative hip abduction? Because the angle between the pelvis and the femur
increases in the frontal plane which similarly happens during open kinematic hip abduction movement
⁃ Right pelvic hike = left hip abduction
⁃ Pelvic drop involves pelvic movement of the contralateral pelvis which results to relative
hip ADDUCTION
⁃ Right pelvic drop = left hip adduction
⁃ In right lateral pelvic shift, the simultaneous right hip adduction and left hip abduction
occurs
CKC: TRANSVERSE PLANE

Hip forward and backward rotation usually happens when we walk or take a step

Left forward step

⁃ Pelvis rotates forward on the advancing extremity and concurrently, a relative posterior
rotation on the right side
⁃ Left forward rotation = A relative left hip ER and right hip IR takes place

Left backward step

⁃ Pelvis rotates backward on the advancing extremity and anterior rotation on the right
side
⁃ Left backward rotation = left hip IR and right hip ER happens

LUMBOPELVIC RHYTHM / PELVIFEMORAL MOTION

⁃ Movement of lumbar and pelvic region that happens in the SAGITTAL PLANE
⁃ When bending forward during flexion, movement starts at the LUMBAR REGION then by
the PELVIS and HIP
⁃ In extension, the opposite happens
⁃ Open kinematic = distal segment is fixed as the proximal segment moves

MUSCLES OF THE HIP

HIP FLEXORS PRIMARY AGONISTS

Rectus femoris
⁃ Does hip flexion regardless of knee position
⁃ Hip flexor that also crosses the knee joint
⁃ Its active insufficiency is simultaneous hip flexion and knee extension
⁃ Passive insufficiency (stretch position) is simultaneous hip extension and knee flexion

Tensor fascia latae

⁃ FABIR but flexion is its main action

Sartorius
⁃ Though it crosses the knee joint, its action remains unaffected by the position of the
knee is because it is attached on proximal aspect of the tibia
HIP FLEXORS SECONDARY AGONISTS

These three muscles are primary adductors since their fibers are anterior to the axis of the hip joint at
40-50 degrees of hip flexion in the sagittal plane, they assists in the flexion motion

HIP EXTENSORS PRIMARY AGONISTS

Gluteus maximus
⁃ being single jointed, it remains active on any knee position

Hamstrings
⁃ Tibia’s position can isolate the contraction of these muscles
⁃ Biceps femoris is active on hip extension when knee is simultaneously flexing with tibia
in ER
⁃ Semimembranosus and semitendinosus is active on hip extension when knee is
simultaneously flexing with tibia in IR
HIP EXTENSORS SECONDARY AGONISTS

Gluteus medius
⁃ Primary abductor but since some fibers are posterior to the hip joint axis, also
contributes to hip extension

Adductor magnus (posterior fibers)

⁃ Primary abductor but some fibers are posterior to the hip joint axis

Piriformis
⁃ Primary rotator of the hip but acts as a secondary hip extensor

HIP ADDUCTORS

Pectineus, Adductor longus, Adductor brevis and Adductor magnus are called short adductor muscles
and are single jointed. Therefore, their activation is not influenced by knee position

Gracilis
⁃ Two jointed hip adductor that is activated when the knee is extended
HIP ABDUCTORS PRIMARY AGONISTS
“Rotator Cuff” of the Hip

Gluteus minimus
⁃ Anterior fibers acts as a weak hip flexor

HIP ABDUCTORS SECONDARY AGONISTS

Gluteus maximus and Sartorius acts as secondary hip abductors when RESISTANCE is applied

TFL is activated in hip abduction with simultaneous hip flexion

HIP ER PRIMARY AGONISTS
“Red Carpet” muscles

Obturator externus and Quadratus femoris remains active in hip ER whether the hip is flexed or
extended

Piriformis is active in hip ER if hip is extended or if hip is flexed in less than 90 degrees

Piriformis
⁃ External rotator at initial ranges of hip flexion because the fibers are posterior to the hip
joint axis
 ⁃ If >90 degrees hip flexion, the fibers crosses anteriorly to the hip joint axis so it becomes
an INTERNAL ROTATOR

Piriformis can also compress the sciatic nerve which results to SCIATICA; a condition with paresthesia,
tingling and numbness that run from the buttocks down to the leg (The Piriformis Syndrome)

HIP ER SECONDARY AGONISTS

Posterior fibers of the gluteals because of the backward pull of their fibers resulting to rolling backwards
of the femur

HIP IR PRIMARY AGONISTS

 ⁃ No muscles

PPT PART 4 - FUNCTIONAL APPLICATION

STRUCTURAL ADAPTATIONS TO WEIGHT BEARING

⁃ In standing, the femoral head receives the weight of the HEAD, ARM AND TRUNK (at the
same time, the ground exerts an upward force against the weight of the body and is called the GROUND
REACTION FORCE passing through the femoral shaft)
⁃ These upward and downward forces creates bending moment on the femoral neck such
that tensile force happens on the superior part and compressive force is exerted on the inferior part
Trabecular system
⁃ Is a soft connective tissue which forms in the cancellous part of the bone

Medial Compressive system

⁃ Following wolff’s law, the pattern represents the course of stress lines along the bone
thus in the fem head, the medial compressive system represents the weight of the body that is being
transmitted vertically which explains the vertical trabecular system

Secondary Compressive System

⁃ Between the greater and lesser trochanters

Lateral Tensile System

⁃ Runs from the greater trochanter to the inferior part of the fovea capitis

These three systems leave the zone of weakness (Ward’s Triangle) and is a potential site for femoral
neck fracture

Trochanter System
⁃ On the most lateral system
⁃ Responds to the pull of various muscles that are attached to it

GAIT/AMBULATION

HIP MOTION DURING GAIT

⁃ At stance phase, the hip starts at flexion as it steps on the ground and it moves towards
extension
⁃ As the walking moves to swing phase, it moves from extension to flexion
 ⁃ Since walking is a continuous activity, the values of the hip joint angle is usually
represented by a continuous graph as shown above

When we walk at mid stance where only one extremity is in weight bearing, the contralateral hip has a
tendency to slightly drop but it is controlled by the gluteus medius.
Lateral swaying is also evident when we walk and is caused by the later shifting movements in the pelvis.

In walking, when you step one extremity forward the contralateral extremity is left behind. This creates
rotational movement of the pelvis in the transverse plane.

For example, when we step forward the left extremity, the left pelvis anteriorly rotates and posterior
rotation of the right pelvis happens

When we anteriorly rotate the pelvis, there is an associated hip ER

When we posteriorly rotate the pelvis, there is an associated hip IR

EFFECTS ON POSTURE

MOTION OF THE PELVIS ON FEMUR

Tilting the pelvis anteriorly, exaggerates the lumbar lordosis considering the pelvis works as a chain with
the lumbar segment

Tilting the pelvis posteriorly, flattens the lumbar segment

If the pelvis shifts forward and tilts backward together with the exaggeration of the lumbar segment
lordosis is called the SWAYBACK posture

HIP JOINT FORCES

IN ERECT BILATERAL STANCE
⁃ The line of gravity passes slightly posterior to the hip joint thus creating slight
hyperextension
⁃ The line of gravity being posterior to the hip joint also creates posterior tilting of the
pelvis
⁃ 2/3 of the weight of the HAT is equally distributed on each extremity

WHEN SHIFTED TO THE RIGHT

⁃ As the person shifts the weight to the right side, there is a relative right hip adduction
and left hip abduction
⁃ From neutral to the right weight shifting, external forces such as gravity acts as the
primary force and the muscles of the body contracts eccentrically to control the movement or else, you
will fall on that side
⁃ The right hip abductors and left hip adductors contract eccentrically
⁃ When returning back to the neutral position, these same muscles contract
concentrically
IN UNILATERAL STANCE
⁃ From bilateral stance to unilateral stance, adduction torque is produced due to the
weight of the HAT and the contralateral extremity
⁃ This adduction torque needs to be counteracted by the hip abductors
⁃ If hip abductors are weak, to counteract the adduction torque, a compensatory lateral
lean of the trunk or trunk listing occurs. This is done in order to reduce the adduction torque especially if
the weight of the HAT is too heavy to be counteracted by the hip abductors
IPSILATERAL USE OF CANE
⁃ If hip is painful such as in unilateral hip osteoarthritis, the goal is to reduce the weight-
bearing force on the joint
⁃ So if you use the cane ipsilaterally when you push down on it, reduces the compression
force on the affected hip by 15%
⁃ However, the gluteus medius continues to contract to counteract the pelvic drop when
the opposite extremity is lifted when walking
⁃ Thus, this contraction of the gluteus medius still creates compression on the hip joint
resulting to painful hip

CONTRALATERAL USE OF CANE

⁃ Also reduces the compressive force by 15%
⁃ But as you push down using the contralateral upper extremity, the latissimus dorsi on
the side of the cane also contracts on its revers action
⁃ Therefore, pulling the pelvis upwards and preventing it from dropping
⁃ As such, no contraction is necessary for the gluteus medius and results to a less painful
hip joint