The Hip

Chapter 20
The Hip
Copyright 2005 Lippincott Williams & Wilkins

Primary Roles of Hip
 Support weight of head, arms, trunk

during upright postures and dynamic
weight-bearing activities.
 Provides a pathway for transmission of

forces between the lower extremities
and pelvis.

Anatomy and Kinesiology
Osteology and Arthrology
Acetabulum
Fusion of ilium, ischium,

and pubis

Anatomy and Kinesiology
Osteology and Arthrology
Articulation of the
femoral head with the
acetabular labrum

Two Angular Relationships
Angle of inclination of
femoral head

Angular Relationships
Angle of torsion
Projection of the long

axis of the femoral
head and the
transverse axis of
femoral condyles

Ligaments of Hip

Muscles of the Hip
Flexors Extensors
 Iliopsoas  Gluteus maximus

 TFL  Hamstrings
 Rectus femoris  Posterior fibers of gluteus
 Sartorius medius
 Adductor magnus,  Piriformis
longus, brevis
 Pectineus
 Gracilis

Muscles of the Hip
Abductors Adductors
 Gluteus medius  Adductor group

 TFL
 Quadratus femoris
 Superior gluteus
maximus  Pectineus
 Gluteus minimus  Obturators
 Gracilis
 Medial hamstrings

Muscles of the Hip (cont.)
Medial Rotators Lateral Rotators
 TFL  Piriformis
 Gluteus minimus  Obturator interior/exterior
 Anterior fibers of gluteus
 Gemelli
medius
 Adductor magnus, longus  Quadratus femoris
 Semimembranosus/  Glut maximus
tendinosis  Posterior fibers of gluteus
medius
 Biceps femoris
Nerve and Blood Supply
Nerve Supply Blood Supply for Head

of Femur
 Lumbar plexus  Artery of ligamentum
teres
(L1-L4)
 Sacral plexus (L4-S3)  Medium and lateral
circumflex arteries

Kinematics
ROM
 Varies with age, sex
 Flexion 120–135 degrees with knee
flexed 90 degrees
 Extension 0–15 degrees
 Abduction 0–30 degrees
 Rotation generally 45 degrees in
each direction (more LR with males,
more MR with females)

Relationship of Hip and Pelvic Motion
in Sagittal Plane

Lateral Pelvic Tilt – Frontal Plane

Rotation of Pelvis and Hip
Transverse Plane

Kinetics and Kinematics of Gait
Single limb stance component of gait

Anatomic Impairments
Angles of Inclination

Angle of Torsion

Center Edge Angle –
Angle of Wiberg
Average adult –
22°–42°

Leg Length Discrepancy (LLD)
Unilateral difference in the total length of one leg

compared with another.
 Anatomic LLD – Actual osseous length

difference between the hemipelvis, femur, tibia.
 Functional LLD – Position of osseous structures
as they relate to each other and to the
environment during weight-bearing function.

Examination and Evaluation
 History
 Lumbar spine clearing examination
 Other clearing tests (visceral
involvement, knee involvement)

Examination and Evaluation (cont.)
 Balance and gait
 Joint Mobility and integrity
 Muscle performance
 Pain and inflammation
 Posture and movement
 Range of motion and muscle length
 Work, community, and leisure integration or
reintegration
 Special tests

Balance
 Balance tests are often included in hip examinations due
to high incidence of falls resulting in hip injury:
 Berg balance scale
 Dynamic gait index
 Balance self-perception test
 History of balance problems
 Type of assistive device used for ambulation

Gait
 Gait evaluation is an important component of the
examination of a person with a hip dysfunction.
 Analysis of gait should include observation of the hip
along all three planes of movement during each critical
phase of gait.
 Of particular importance are the relationships between
the hip and the rest of the kinetic chain.
 Video analysis can assist in this complex examination
procedure.

Joint Mobility and Integrity
 Quantity of motion, end feel, and

presence/location of pain should be noted during
the following tests:
 lateral/medial translation
 distraction
 compression
 anteroposterior/posteroanterior glides

Muscle Performance
 MMT of hip musculature
 Specialized tests looking at positional strength to
determine length-associated changes
 Selective tissue tension tests to diagnose
noncontractile versus contractile lesions
 Resisted tests to determine severity of the tissue
lesion
 Resisted tests can also screen neurologic cause
of muscle performance impairment

Pain and Inflammation
 Examination is done in conjunction with other

tests to determine source (if possible) and cause
of pain.
 Source diagnosis often requires additional tests
that are beyond the scope of physical therapy.

Posture and Movement
 Specific lumbopelvic and lower quadrant alignment
should be examined about all three planes.
 Hypothesis can be developed regarding the contribution
of faulty alignments at the ankle, foot, knee, and
lumbopelvic regions to the alignment of the hip.
 Hypothesis can be generated regarding muscle lengths
related to posture alignment.
 Initial screening for LLD can be performed.

Range of Motion and Muscle Length
 Quick tests: placing foot on standard step, forward

bending, squatting, sitting with leg crossed
 AROM/PROM in open kinetic chain
 Muscle length tests:
Medial/lateral hamstrings
Individual hip flexor lengths
Hip adductors/abductors
Hip rotators

Work, Community, and Leisure
Integration or Reintegration
 Functional ability can be measured directly

through observation of functional tasks.
 Self-report measures can also be used.
 Harris hip function scale is another self-report
measure that is specific to degenerative joint
conditions.

Special Tests
 Trendelenburg test
 Trochanteric prominence angle test (TPAT)
 LLD tests
 Indirect method – Iliac crest palpation and
book correction (ICPBC)
 Direct method – Measure distance of fixed
bony landmarks using a measuring tape

Impaired Muscle Performance
Result of:
 Neurologic pathology
 Muscle strain
 Altered length-tension relationships
 General weakness from disuse
 Pain and inflammation

Neurologic Pathology
 Neuromusculoskeletal or neuromuscular
in origin
 Neuromusculoskeletal – Pathology at nerve
root or peripheral nerve
 Treat origin of pathology to positively affect
muscle force/torque production

Muscle Strain
 Hamstring strains/overuse are common
 Treatment focuses on cause of strain
 Improving motor control and muscle
performance of underused synergists (e.g.,
gluteus maximus and hip lateral rotators)
 Correct biomechanical factors contributing to
underused synergists

Treatment of Underused Synergist in
Hamstring Strain

Functional
Progression

Functional
Progression

Quality of Step-Up Movement Pattern

Muscle Strain
 Overstretch can also be a contributing factor to muscle
strain.
 For example: gluteus medius on high iliac
crest side
 Strengthen gluteus medius in short range
 Taping in short range
 Correct posture habits and movement patterns that
maintain muscle in lengthened state

Taping to Support Strained Gluteus
Medius Muscle

Gluteus Medius Strength Progression

Disuse and Deconditioning
 Results from injury, pathology, acquired

movement patterns contributing to disuse and
deconditioning of specific synergists.
 Consider acquired postures and movement
habits.
 Optimize length-associated relationships and
restore motor control and force/torque
contributions from underused synergists.

ROM, Muscle Length, Joint Mobility
Hypermobility
 Often associated with impairment in the
developing hip.
 With increasing use of arthroscopy,
diagnosis of acetabular labral tears is
more common.
 Labral tears are a possible precurser to
OA

Hypermobility
 Hip joint hypermobility has been shown to be
associated with OA in numerous studies.
 Treatment for developing hip consists of
positioning, bracing, or surgery.
 Treatment for adult hypermobile hip consists of
specific therapeutic exercise, posture education,
movement training.

Etiology of Hypermobility
 Can be either arthrokinematic or osteokinematic.

 Arthrokinematic hypermobility is defined as
linear translation that is excessive.
 Osteokinematic hypermobility is defined as
angular translation that is excessive.

Sahrmann Hip Syndromes
Arthrokinematic Hypermobility
 Femoral anterior glide syndrome
 Femoral lateral glide syndrome
Osteokinematic Hypermobility
 Femoral adduction with medial rotation
syndrome
 Femoral adduction syndrome
Sahrmann SA. Diagnosis and Treatment of Movement Impairment

Syndromes. St. Louis: Mosby, 2002.
Primary Objective of Treatment
 Promote joint stability

 Prevent continuous stress to overstretched or
torn tissues
 Posture and movement pattern training
 Strengthen lengthened muscles in short range
 Improve muscle performance of deep
musculature to enhance core stability

Anteversion
 Whenever excessive medial rotation ROM is

measured, screen for anteversion (TPAT test).
 When excessive medial rotation ROM is present,
focus on strengthening deep hip LRs.
 Educate regarding posture habits and movement
patterns.

Functional Approach to
Treating Medial Hip
Rotation Tendencies

Functional Approach to Treating Medial
Hip Rotation Tendencies

Compensation of
Limited Hip Lateral
Rotation ROM

Hypomobility

Hypomobility (cont.)
 Look at relationships to other regions in the

kinetic chain to treat hip hypomobility.
 For example, lumbar spine relative flexibility
during forward bending with associated stiff hips
in the direction of flexion.
 For example, knee flexion relative flexibility
during standing knee bends with associated stiff
hips in direction of flexion.

Hypomobility (cont.)
 Hip extension stiffness is often associated with

anterior pelvic tilt and lumbar extension relative
flexibility.
 Specific muscle length tests are necessary to
prescribe accurate exercises to address muscle
length impairments.
 Train proper movement patterns to utilize hip
extension ROM once achieved via specific
exercise (i.e., late stance phase of gait).

Hypomobility – Improving ROM

Balance
 Falls are the leading cause of morbidity and
mortality in persons older than 65 years.
 T’ai Chi has been shown to be valuable in
promoting posture stability and balance control
in the well elderly.
 Force-platform biofeedback is another mode
used to improve balance.
 Clinical trials have not demonstrated a reduction
in falls among older persons using force-platform
biofeedback systems.

Pain
 Differential diagnosis of etiology and cause of

pain.
 Pain can be referred to the groin, laterally or
posteriorly radiate down the anterior and medial
thigh, or to the knee.
 Treatment must focus on alleviating impairments
related to the underlying cause of symptoms.

Guidelines for Pain Relief
 Activity modification
 Physical agents or electrotherapeutic modalities
 Manual therapy
 Therapeutic exercise intervention
 Assistive devices
 Weight loss
 Biomechanical support (i.e., foot orthotics)

Posture and Movement Impairment
 Optimize kinetics and kinematics at the

hip and other joints in the kinetic chain
 ALL patients should be educated on
details of posture and movement that
contribute to the cause of symptoms.
 Hip alignment – Influenced by other joint
angles (e.g., knee and pelvis),
hypo/hypermobilities, length-tension
relationships, muscle performance, etc.

Posture and Movement Impairment
(cont.)
 Changes in posture and movement require basic skills in
mobility, muscle performance, and motor control.
 These skills must be at functional levels to intervene at
the level of posture and movement.
 Initially, the goal is to improve all associated impairments
to functional levels.
 Gradual transition to functional activities with emphasis
on optimal posture and movement.

Leg-Length Discrepancy (LLD)
3 Categories
 Mild (0-30 mm)
 Moderate (30-60 mm)
 Severe (>60 mm)
Treatment ranges from shoe inserts,

posture training, and movement training to
various surgical techniques.

Functional LLD
Example – Femoral and tibial medial rotation
 Lengthened or weak posterior gluteus medius

and deep hip lateral rotators
 Lengthened or weak foot supinators
 Postural foot pronation or supination

Therapeutic Exercise Interventions for
Common Diagnoses
Osteoarthritis
ROM and Mobility

1. Passive stretch
2. Active stretch
3. Active exercises

Osteoarthritis – Muscle Performance
 Functional exercises should be included
whenever possible.
 Use of adjuncts may be necessary to reduce
joint reaction forces.
 Always include core activation.
 Step-up activities stimulate hip extensor
recruitment, facilitate hip flexion mobility.
 Alter step height and resistance (adding weight)
to ensure proper technique.

Osteoarthritis – Balance/Posture/Adjuncts
Balance – After establishing muscle balance in single limb
stance, progress to balance activities.
Posture and movement – Educate patients on positioning,

core training, and assistive devices during functional
activities.
Adjunctive interventions – Non-weight-bearing activities

(aquatics, etc.) are recommended.

ITB – Related Diagnoses
 ITB fascitis (inflammation from overuse)
 Trochanteric bursitis (bursa becomes
inflamed)
 ITB friction syndrome (pain localized to
lateral femoral condyle)
 Patellofemoral dysfunction
 TFL strain (overuse of short or stretched
TFL/ITB)
 Faulty movement patterns

Synergistic Relationships Associated
with ITB/TFL Overuse
 Anteromedial TFL dominates in hip flexion force
couple = underuse of iliopsoas.
 Posterolateral TFL dominates in hip abductor +
medial rotator force couple = underuse of
gluteus medius, upper fibers of gluteus maximus
and minimus.
 Overuse of ITB may contribute to underuse of
quadriceps.

TFL/ITB Stretches

Adjunctive Intervention – Taping

Nerve Entrapment Syndrome
Piriformis syndrome (stretched)
Signs Key Tests
 Hip flexion with medial  Standing alignment

rotation
 Tissue tension tests
 Lordosis and anterior
pelvic tilt  ROM
 High iliac crest on  Palpation
involved side  Positional strength
 Lateral rotation and  Functional tests
abduction reduces
symptoms  Lumbar clearing exam

Strengthening Piriformis in
Shortened Range

Summary
 Hip is designed for stability and transmission of
kinetic forces.
 Angles of inclination and torsion are critical to
ideal functioning.
 Hip osteokinematic ROM is closely linked to
lumbopelvic region.
 It is important to understand function of all
muscles that cross the hip and associated
relationships.

Summary (cont.)
 Thorough hip examination is necessary to

understand anatomic/physiologic impairments in
hip and related regions.
 Impairments in muscle performance, gait,
balance, posture and movement, ROM, and
mobility commonly occur together.
 Primary focus of treating OA is to improve joint
loading.

Summary (cont.)
 Restoring mobility and force are often

prerequisites to restoring endurance and
improving posture.
 Numerous ITB-related syndromes exist.
 Stretched piriformis syndrome can mimic lumbar
radiculopathy.

The Hip

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Chapter 20

Copyright 2005 Lippincott Williams & Wilkins

 Support weight of head, arms, trunk

 Provides a pathway for transmission of

Copyright 2005 Lippincott Williams & Wilkins

Fusion of ilium, ischium,

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Projection of the long

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

 Iliopsoas  Gluteus maximus

Copyright 2005 Lippincott Williams & Wilkins

 Gluteus medius  Adductor group

Copyright 2005 Lippincott Williams & Wilkins

Medial Rotators Lateral Rotators

Nerve Supply Blood Supply for Head

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Unilateral difference in the total length of one leg

 Anatomic LLD – Actual osseous length

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

 Quantity of motion, end feel, and

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

 Examination is done in conjunction with other

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

 Quick tests: placing foot on standard step, forward

Copyright 2005 Lippincott Williams & Wilkins

 Functional ability can be measured directly

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

 Results from injury, pathology, acquired

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

Copyright 2005 Lippincott Williams & Wilkins

 Can be either arthrokinematic or osteokinematic.

Copyright 2005 Lippincott Williams & Wilkins

Sahrmann SA. Diagnosis and Treatment of Movement Impairment

 Promote joint stability