THE HIP JOINT

Type: Synovial joint.

Variety: Ball and socket joint.
Function: support weight of the Head, Arms & Trunk (HAT)
Articular surfaces :
Proximal articular surface: Acetabulum of pelvic bone.
Distal articular surface: Head of femur.

Proximal Articular Surface:

✓ Acetabulum of pelvic bone – laterally with inferior & anterior tilt.
✓ It is cup like concave socket.
✓ Periphery of acetabulum (lunate surface) is covered by hyaline cartilage
✓ Inner horse shoe shaped area of cartilage articulates with head of femur.
✓ Inferior aspect of the lunate surface is interrupted by deep notch called as acetabular notch.
✓ Acetabular notch is spanned by fibrous band – transverse acetabular ligament.
✓ It creates a fibro –osseous tunnel through which blood vessels pass into central portion of
acetabulum – acetabular fossa. (non – articular, it contains fat with synovial membrane.)
✓ Acetabulum is deepened by fibrocartilagenous – acetabular labrum.
Function:
1. It deepens the socket.
2. It increases stability of hip joint.
3. It acts as a seal to maintain negative intra articular pressure.
4. It decreases force transmitted to articular cartilage.
5. It provides proprioceptive feedback.
6. It is a source of pain.
Clinical aspect:
1. Acetabular dysplasia – abnormally shallow acetabulum that lacks femoral head coverage.
2. Coxa Profunda & acetabular protrusia –Acetabulum excessively covers the femoral head,
this leads to limited ROM and internal impingement.
3. Anteversion – acetabulum is positioned too anteriorly in transverse plane. (instability)
4. Retroversion - acetabulum is positioned too posteriorly in transverse plane. (over coverage
& impingement)
✓ Acetabular depth can be measured – as the center edge angle of wiberg.
✓ This angle is formed by a line connecting the lateral rim of the acetabulum & center of the
femoral head and a vertical line from the center of femoral head.
✓ Definite dysplasia - <16 deg.
✓ Possible dysplasia – 16 – 25 deg.
✓ Normal - >25 deg.
✓ Greater than normal – abnormal over coverage.

Distal articular surface:

✓ Head of femur
✓ There is a small roughened pit called fovea or fovea capitis.
✓ Fovea is not covered by articular cartilage.
✓ It is the point where ligament of the head of femur is attached.
Angulation of femur:
Two angulations –
1. Angle of inclination.
2. Angle of torsion.
✓ Angle of inclination – in frontal plane, an axis drawn through femoral head & neck and
longitudinal axis drawn through femoral shaft. (125 degree)
 It changes across life span – at birth -150 degree, but gradually declines to 125 degree at
skeletal maturity.
Clinicals –
Coxa Valga – pathological increase in the medial angulation between neck &shaft. (>125
degree)
Coxa Vara – pathological decrease in the medial angulation between neck &shaft. (<125
degree). This can lead to slipped capital femoral epiphysis.
✓ Angle of torsion:
In transverse plane, axis drawn through femoral head &neck and an axis drawn through
condyles. (15-20 degree)
Clinical aspect:
Femoral anteversion – angle of torsion is >15 – 20 deg.
Femoral retroversion – angle of torsion is <15 -20 deg.

In case of coxa valga & femoral anteversion – line of hip abductors will fall posterior to the joint.

This reduces moment arm for abduction.

So, additional abductor force is required by the joint., this consumes more energy, it will functionally
become weak.

Due to anteversion, anterior muscles, capsule, ligaments will push femoral head back into
acetabulum, causing femur to rotate medially.

This medial rotation will alter the plane of knee joint movements. (medial femoral torsion)

This results in toe in gait.

Articular congruence
✓ In erect standing, Acetabulum does not fully cover the head of femur superiorly and anteriorly.
✓ Articular contact is increased in flexion, abduction & lateral rotation. This position is called as
frog leg position& is true physiological position of hip joint.
Hip joint congruence is maintained by
1. Acetabular labrum
2. Joint capsule
3. Ligaments

Capsule:
❖ Capsule is irregular, dense fibrous structure with longitudinal & oblique fibers.
❖ Capsule is thickened at 3 areas.
❖ Capsule is attached – proximally to acetabular labrum, distally to femoral neck.
❖ Capsule just below the femoral head forms a tight ring – zona orbicularis.
❖ Function – provides stability
❖ Synovial membrane lines inner side of capsule.
❖ Anteriorly capsule has retinacular fibers (travel from neck towards head)
❖ These fibers carry blood supply.

Ligaments
1. Iliofemoral ligament.
2. Pubofemoral ligament.
3. Ischiofemoral ligament.
4. Ligamentum teres.
❖ Ligamentum teres: (Ligament of head of femur)
Triangular band attaches to the acetabular notch to the fovea of the femur. It is covered by synovial
membrane.
Function: 1. Conduit blood supply to the femoral head 2. Stabilizes hip joint.
❖ Iliofemoral ligament:
It is present anteriorly. It is fan shaped that resembles inverted letter “Y”.
It is otherwise called as Y ligament of bigelow. Apex of the ligament is attached to AIIS
Two arms of Y are attached to inter trochantric line of femur.
Superior band is strongest & thickest of all hip ligaments.
Action: It provides restraint to both medial & lateral rotation.
❖ Pubofemoral ligament:
It is present anteriorly.
It arises from ant. Aspect of sup. Ramus to the intertrochanteric fossa of femur.
Action:
It controls lateral rotation
Iliofemoral & pubofemoral ligaments form “Z” on anterior Capsule.
❖ Ischiofemoral ligament:
It is present posteriorly. It attaches to the acetabular rim & acetabular labrum, blend with the capsule
and attaches to inner surface of greater trochanter.
Function: Primary restraint of medial rotation of hip.

Capsuloligamentous tension
Closed pack position – extension, abduction, medial rotation.
Physiological position – flexion, abduction, lateral rotation.
Position vulnerable to injury – flexed & adducted.
Capsuloligamentous tension is least – flexion, abduction, mid rotation.
This is the position assumed when pain arises, it accommodates abnormal amount of fluids.
Structural adaptation to weight bearing
o In standing or upright weight bearing activities, half of the HAT pass through pelvis SI JT
Acetabulum to femoral head whereas ground reaction forces (GRF) travels up the shaft.
o Both the forces form force couple.
o These forces create bending moment across the femoral neck. (shear
forces)
o These shear forces will create tensile force on superior aspect of
femur & compressive forces in the inf. Aspect
o There are set of forces which will resist
shear force –
o Two major trabecular systems- medial
compressive & lateral tensile
o Three minor trabecular systems –
trochanter system, secondary tensile,
secondary compressive.
o Medial compressive trabecular system –
o arises from the medial cortex of upper femoral
shaft and radiates through
cancellous bone to cortical bone of
superior
aspect of femoral head.
o Lateral tensile trabecular system –
o arises from the lateral cortex of upper femoral
shaft, crosses medial system, terminates in the cortical bone on the inf. aspect of femoral head.
o The areas in which the trabecular system cross each other at right angles are the areas that
offer greatest resistance to stress &strain.
o There is an area which is relatively thin and do not cross each other – zone of weakness.
o This is a zone of failure, susceptible for bending forces – fracture.

Function of the hip joint

o Motion /movement of femur on acetabulum.
o Motion /movement of pelvis on femur.
 Motion /movement of femur on acetabulum:
Convex head of femur moves on concave acetabulum.
MOVEMENT AXIS /PLANE ROM MUSCLES INVOVED ARTHROKINEMATICS

Flexion Coronal axis, 90 deg Primary - Iliopsoas, Rectus Head of femur spins
Sagittal plane Femoris, Tensor Fasia Lata, posteriorly on acetabulum
Sartorius
Secondary - Pectineus,
Adductor Longus, Adductor
Magnus
Extension Coronal axis, 50 deg Gluteus Maximus, Hamstrings Head of femur spins
sagittal plane anteriorly on acetabulum

Adduction AP axis, frontal 50 deg Pectineus, Adductor Brevis, Convex head of femur rolls
plane Adductor Longus, Adductor superiorly and slides
Magnus, Gracilis inferiorly on concave
acetabulum
Abduction AP axis, 50deg – Primary: gluteus medius, Convex head of femur rolls
Frontal plane 0 deg gluteus minimus inferiorly & slides superiorly
Secondary: on concave acetabulum
Gluteus maximus, Sartorius.
Lateral rotation Transverse 40 - 45 Obturator internus, externus, Convex femoral head slides
plane, deg gemellus sup. & inf, anteriorly on concave
Vertical axis quadratus femoris, piriformis acetabulum
Medial rotation Transverse 40 - 45 Ant. Portion of gluteus Convex femoral head slides
plane, deg medius, gluteus minimus, posteriorly on concave
Vertical axis tensor fasia lata. acetabulum

Motion /movement of Pelvis on femur:

When hip joint is in weight bearing, the pelvis moves on the femur.
1. Anterior & posterior pelvic tilt.
2. Lateral pelvic tilt.
3. Forward & backward pelvic rotation

Anterior & posterior pelvic tilt:

o Sagittal plane, coronal axis.
o Anterior pelvic tilt causes hip flexion.
o During Anterior pelvic tilt, pelvis moves the ASIS anteriorly & inferiorly, inf. sacrum moves
farther from femur.
o Posterior pelvic tilt causes hip extension.
o During posterior pelvic tilt, symphysis pubis comes up and sacrum of the pelvis moves closer
to femur.

Lateral pelvic tilt:

o Fontal plane, ant –post axis.
o In lateral pelvic tilt, hip hiking or hip dropping.
o Right Hip hiking causes right will be adducted & Left will be abducted.

Forward and backward rotation:

 ❖ Transverse plane, vertical axis.

Hip joint forces and muscle function in stance

Bilateral stance:
o In erect bilateral stance, both hip joints are in slight extended position because the line of gravity
falls just posterior to the axis for flexion /extension of hip joint.
o This extension moment is checked by capsule, ligaments, iliopsoas muscle.
o In frontal plane, during bilateral stance, superincumbent body weight of HAT is transmitted
through pelvis SI JT Acetabulum to femoral head
o Hypothetically, the weight of the HAT is 2/3 of the total body weight.
o Each femoral head receives approximately half of the superincumbent weight. (i.e. half of 2/3)
o The joint axis of each hip lies at an equal distance from the body’s center of gravity.
o The distance from hip joint axis to the body’s center of gravity is called Gravitational moment
arm.
o Magnitude of Gravitational torque for right hip = weight on right femur x right gravitational
moment.
o Magnitude of Gravitational torque for left hip = weight on left femur x left gravitational moment
o Gravitational torque of right hip = Gravitational torque of left hip.
o This torque occurs in opposite direction at RT & LT hip Jt.
o Weight acting on right hip tends to drop the pelvis on the left. (RT adduction moment)
o Weight acting on left hip tends to drop the pelvis on the right. (LT adduction moment)
o The two opposing gravitational moments of equal magnitude balance each other, and the pelvis
is maintained in equilibrium without the assistance of active muscles.
o When bilateral stance is not symmetrical, frontal plane muscle activity will be necessary
o Hip joint compression can be altered by:
1. Unilateral stance
2. Leaning over lower extremity during single limb stance.
3. Use of cane either ipsilateral or contralaterally.
Unilateral Stance
▪ If the left leg has been lifted from the ground and the full superimposed body weight is being
supported by the right hip joint.
▪ The right hip joint must now carry the full burden, not only of entire HAT but also the weight of
the left leg.
▪ Of the one-third portion of the body weight found in the lower extremities, the non – supporting
limb must account for half of that, or one sixth of the full body weight.
▪ The magnitude of body weight (W) compressing the right hip joint in right unilateral stance,
therefore, is:
▪ Right hip joint compression = [2/3 x W] x [1/6 x W]
▪ Right hip joint compression = 5/6 x W
▪ In our hypothetical subject who weighs 825N,
▪ HAT in this individual weighs 550 N.
▪ One lower extremity weighs one sixth of body weight, or 137.5 N.
▪ Therefore, when this individual lifts one leg off the ground, the supporting hip joint will undergo
687.5 N (or five sixths of body weight) of compression from body weight alone.
▪ The force of gravity acting on HAT and the non–weight-bearing left lower limb (HATLL) will
create an adduction torque around the supporting hip joint;
▪ that is, gravity will attempt to drop the pelvis around the right weight-bearing hip joint axis.
▪ The abduction counter torque will have to be supplied by the hip abductor musculature.
▪ The result will be joint compression or a joint reaction force that is a combination of both body
weight and abductor muscular compression.
▪ Total hip joint compression or joint reaction forces are generally considered to be 2.5 to 3 times
body weight in static unilateral stance
▪ If the hip joint undergoes osteoarthritic changes that lead to pain on weight-bearing, the joint
reaction force must be reduced to avoid pain.
▪ If total joint compression in unilateral stance is approximately three times body weight, a loss of
1 N (~4.5 lb.) of body weight will reduce the joint reaction force by 3 N (13.5 lb.).
▪ The solution must be in a reduction of abductor muscle force requirements.
▪ If less muscular counter torque is needed to offset the effects of gravity, there will be a decrease
in the amount of muscular compression across the joint, although the body weight compression
will remain unchanged.
▪ The need to diminish abductor force requirements also occurs:
▪ when the abductor muscles are weakened through paralysis
▪ through structural changes in the femur that reduce biomechanical efficiency of the muscles
▪ through degenerative changes producing tears at the greater trochanter.
▪ Several options are available when there is a need
▪ to decrease abductor muscle force requirements.
▪ Some compression reduction strategies occur automatically, but at a cost of extra energy
expenditure and structural stress.
▪ Other strategies require intervention such as
▪ assistive devices but minimize the energy cost.

Compensatory Lateral Lean of the Trunk

➢ Gravitational torque at the pelvis is the product of body weight and the distance that the LOG lies
from the hip joint axis (MA).
➢ If there is a need to reduce the torque of gravity in unilateral stance and if body weight cannot be
reduced, the MA of the gravitational force can be reduced by laterally leaning the trunk over the
pelvis toward the side of pain or weakness when in unilateral stance on the painful limb.
➢ The compensatory lateral lean of the trunk toward the painful stance limb will swing the LoG
closer to the hip joint, thereby reducing the gravitational MA.
➢ Because the weight of HATLL must pass through the weight bearing hip joint regardless of trunk
position, leaning toward the painful or weak supporting hip does not increase the joint
compression caused by body weight.
➢ However, it does reduce the gravitational torque
➢ There is 50% reduction in joint compression which is enough to relieve some of the pain
symptoms experienced by a person with arthritic changes in the hip joint or to provide some
relief to a weak or painful set of abductors.
➢ The compensatory lean is instinctive and commonly seen in people with hip joint disability
➢ Although it is theoretically possible to laterally lean the trunk enough to bring the LoG through
the supporting hip (reducing the torque to zero) or to the opposite side of the supporting hip
(reversing the direction of the gravitational torque),
➢ these are relatively extreme motions that require high energy expenditure and would result in
excessive wear and tear on the lumbar spine.
➢ More energy efficient and less structurally stressful compensations can still yield dramatic
reductions in the hip abductor force

Pathologic Gaits
➢ When a lateral trunk lean is seen during gait and is due to hip abductor muscle weakness, it
is known as a gluteus medius gait
➢ If the same compensation is due to hip joint pain, it is known as an antalgic gait.
Use of a Cane Ipsilaterally
❖ Pushing downward on a cane held in the hand on the side of pain or weakness should reduce
the superimposed body weight by the amount of downward thrust; that is, some of the weight of
HATLL would follow the arm to the cane, rather than arriving on the sacrum and the weight-
bearing hip joint.
❖ The proportion of body weight that passes through the cane will not pass through the hip joint
and will not create an adduction torque around the supporting hip joint.
❖ The total hip joint compression when the cane is used ipsilaterally is still greater, however, than
the total joint compression of 1031.25 N found with a compensatory Lateral trunk lean.
❖ Although a cane used ipsilaterally provides some benefits in energy expenditure and structural
stress reduction, it is not as effective in reducing hip joint compression as the undesirable lateral
lean of the trunk. Moving the cane to the opposite hand produces substantially different and
better results.

Use of a Cane Contralaterally

❖ When the cane is moved to the side opposite the painful or weak hip joint, the reduction in
HATLL is the same as it is when the cane is used on the same side as the painful hip joint; that
is, the superimposed body weight
❖ passing through the weight-bearing hip joint is reduced by approximately 15% of body weight.
❖ cane is now substantially farther from the painful supporting hip joint
❖ that is, in addition to relieving some of the superimposed body weight, the cane is now in a
position to assist the abductor muscles in providing a counter torque to the torque of gravity.
Hip joint pathology
1.Arthrosis /osteoarthritis/ degenerative arthritis / hip joint arthrosis
The most common painful condition of the hip is due to deterioration of the articular cartilage and to
subsequent related changes in articular tissues.
Prevalence: rates are about 10% to 15% in those older than 55 years, with approximately equal
distribution among men and women.
Causes: Idiopathic, Trauma, Malalignment such as femoral anteversion
Pathology:
Changes may be due to subtle deviations present from birth
Due to the repetitive mechanical stress of loading the body weight on the hip joint over a prolonged
period.
The factors most closely associated with idiopathic hip joint arthrosis are increased age and
increased weight/height ratio

2. Fracture
Normally the trabecular systems are capable of resisting the bending forces, but abnormal
increases in the magnitude of the force or weakening of the bone can lead to bony failure.
The site of failure is likely to be in areas of thinner trabecular distribution such as the zone of
weakness. There is a predominance of fractures in women and of middle aged group
Causes: In 87% of cases of hip fracture among the elderly population, the precipitating factor
appears to be moderate trauma such as that caused by a fall from standing, from a chair, or from a
bed. Diminished bone density.

BONY ABNORMALITIES OF FEMUR

1. Coxa Vara
2. Coxa Valga
3. Femoral Anteversion.
4. Femoral Retroversion.