BPK 241 Lecture 8

Hip Bone

Femur

Pelvis

• Innominate

  • Iluim (superiorly)

    • NB., ASIS, AIIS, crest

  • Ischium (inferior posterior)

  • Pubis (inferior anterior)

    • NB., ramus, symphysis

Hip Articulation

• Head of femur with acetabulum

  • Socket deepened by acetabular labrum

• Ball & socket joint

• Synovial joint

  • Capsule

Labrum

• Tough fibrous material (tough cartilage)

• Hold on to head of femur

• Distribute force

Avascular Necrosis

A condition that occurs when bone tissue dies due to lack of blood supply

Hip movement

• Circumduction

  • Flexion & extension

  • Abduction & Adduction

  • Internal & external rotation

Flexion/ Extension

120º of flexion and 20º-30º of extension

Abduction/ Adduction

50º of abduction and 20º-30º of adduction

Internal/ External Rotation

45º external and 35º internal

Capsule = ligaments

• Iliofemoral

• Ischiofemoral

• Pubofemoral

Bursae

• Iliopsoas

• Trochanteric

Iliopsoas bursae

Between iliopsoas muscle and anterior joint capsule

Trochanteric bursae

Between greater trochanter of femur and gluteus maximus muscle

Hip Sprain & Strains

• Hx:

  • Violent torsion or extension

  • Hip flexion is resistant (iliopsoas strain)

• SSx:

  • Deep pain, worse with movement

• Tx:

  • Rest, NSAID, physiotherapy

Subluxation vs Snapping Hip

• Tendon sliding on a bump

• Gymnastics, dancing, martial arts (shallow acetabulum?)

• Often chronic; may lead to osteoarthritis

• Tx=rest, exercises

• Change activity

• symptomatic?

Hip Dysplasia

Checking for subluxation

Hip Bursitis

• Hx: overuse or direct blow

• SSx = tenderness, pain on movement

• Tx = POLICE, NSAID, rest, physiotherapy

Labral Tear

• Shearing, excessive forces at hip joint (internal rotation)

• Hip Labrum pulls away from acetabulum

• SSx: Deep groin/ buttock pain

  • Pain/stiffness moving hip in certain directions

  • Feeling clicking/locking when moving hip joint

3 Main causes of Labral Tear

• Trauma (ie. MAVA)

• Hip abnormalities (hip dysplasia, FAI)

• Repetitive movements (most common)

  • Twisting (ie hockey/golf)

  • Extreme end range movements (ballet, gymnastics)

  • Repetitive joint loading (marathoners)

Labral Tear Treatment

• Conservative

  • Rest, NSAIDs, injections, physiotherapy

• Surgical

  • Arthroscopic labral debridement

  • Arthroscopic labral repair

  • Arthroscopic labral replacement

• Labral tear predisposes athlete to articular cartilage degeneration, osteoarthritis

Fracture/ dislocation

• Hx: severe trauma (MVA), or elderly person (neck or femur)

• SSx: extreme pain, markedly reduced ROM, deformity (may not be present)

• Tx: recognize, stabilize, transport (NPO)

Thigh Bone

• Femur

  • Head, neck, greater & lesser trochanters, shaft, condyles

Thigh Artery

• Femoral

  • Becomes popliteal artery

Thigh Nerves

• Femoral (L2 - L4 nerve roots)

• Sciatic (L4 - S3 nerve roots)

Thigh Muscles

• Anterior

  • Quadriceps femoris

• Posterior

  • Hamstring

Hip/Thigh Flexors

• Iliopsoas

  • Illiacus

  • Psoas (come off lumbar vertebrae)

• Rectus femoris

• Sartorius (largest in body)

Hip/Thigh Extensors

• Gluteus Maximus

• Hamstrings

Hip/Thigh Adductors

• Adductor

  • Longus

  • Brevis

  • Magnus

• Pectineus

• Gracilis

Hip/Thigh Abductors

• Gluteus Medius

• Gluteus Minimus

• Tensor Fascia Latae (TFL)

• Gluteus Maximus

• Others: Hip rotators are intrapelvic

Hip External Rotators

• Piriformis (sciatic nerve under it - if tight, it can pinch nerve)

• Obturator externus and internus

• Superior and inferior gemellus

• Quadratus femoris

Hip Internal Rotators

• TFL

• Gluteus medius (anterior fibres)

• Adductors

• Pectineus

Iliotibial Band (ITB)

• The ITB is not a single band but a lateral thickening of the fascia latae - similar to a stocking

• The source of pain is from a richly innervated and vascularized layer of fat and connective tissue between ITB and lateral epicondyle

Hip Contusion

• Hx: direct blow

• SSx:

  • Pain, bruising

  • Tenderness/ firm on palpation

  • Swelling (circumscribed?)

  • Decreased ROM

  • Limp

• Tx:

  • POLICE

  • NO heat NO massage directly over contusion

  • Padding

  • ROM exercises & physiotherapy

Thigh Compartments

• Thigh divided into 3 compartments by intermuscular septa

  • Anterior (quadriceps)

  • Medial (adductors)

  • Posterior (Hamstrings)

Anterior Compartment:

Quadriceps muscle group

• Primary knee extensors

• Rectus femoris

• Vastus lateralis

• Vastus intermedius

• Vastus medialis

Posterior Compartment:

Hamstring muscle group

• Primarily knee flexors

• Biceps femoris

• Semitendinosus

• Semimebranosus

Medial Compartment: Adductor Muscle Group

Adductor Muscle Group

• Adductor magnus

• Adductor longus

• Adductor brevis

• Pectineus

• Gracilis

Myositis Ossificans

• Several contusions or mishandling of severe contusion

• ROM not returning after Quad contusion

• Thigh firm on palpation several weeks to months later

• Send for imaging

Thigh Strain

• Hx:

  • Resisting a force, torsion, hyperextension, abduction

  • Predisposed by decreased strength or flexibility, previous strains

• SSx:

  • 1st degree

    • Pain (worse with resistance)

    • Tenderness

    • No limp, snap or pop

  • 2nd degree

    • Pain & tenderness, bruising

    • Snap or pop felt/heard

    • Limp

  • 3rd degree

    • As above, & gap in middle

Thigh Strains Treatment

• 1st degree

  • POLICE

  • ROM exercises, tape (compression wrap)

• 2nd degree

  • As above

  • Rest for 2 to 6 weeks

  • Physiotherapy & rehabilitation

• 3rd degree

  • NPO

  • Stablize

  • Transport to hospital (surgery)

  • Rest, physio, rehabilitation

Hamstring Strains

• Causes

  • Inflexible

  • Improper warm up

  • Temperature

  • Fatigue

  • Violent contraction

• Tx: POLICE, rest, stretching delayed, strengthening (eccentric), gradual return to activities, hamstring tensor wrap/core shorts

Iliotibial Band Friction Syndrome

• Clinical features

  • Subjective: ache on lateral aspect of the knee - worse with cycling, downhill running

• Objective:

  • TOP (tenderness on palpation) over lateral femoral epicondyle

  • +ve Ober’s

  • w or w/out burning sensation

  • Overdeveloped Vastus Lateralis

  • Overpronation - increased tibial rotation

  • Increased internal femoral rotation/ genu valgrum

ITBFS Treatment

• Pathology is distal but often need to treat proximal

• Exercise therapy similar to PFPS

  • strengthen hip abductors

• Release GluteMax, TFL, vastus lateralis

• Soft Tissue Release (Massage, Foam Rolling, Stretch)

• Dry Needle

Thigh Fracture

• Femoral fracture

• Major trauma

• SSx: severe pain, inability to weight bear

• Tx: stabilize, NPO, get to hospital ASAP

  • Surgery, internal fixation with rod or plate

• Rehab: gradual progression of ROM and strengthening/progressively weigh bearing over 4 to 6 months

Scrotal contusion

• Pain subsides over five minutes

• Tx = hip flexion, gentle breathing

Traumatic Hydrocoele

• Delayed complications of contusion (days, weeks, months)

• Appearance of cluster of swollen veins

• Tx = surgical, if warranted

Torsion of spermatic cord

• Pain increases over time

• Nausea, vomiting

• Shock (rapid HR & RR; clammy skin)

• Swelling, extreme tenderness

• Surgical emergency

• NPO, transport ASAP

Hip pointer

• Hx = contusion of iliac crest

• SSx:

  • Pain, tenderness, bruising

  • Circumscribed swelling, limp

  • Difficulty with flexing thigh or rotating trunk

• Tx:

  • Ice , rest, padding, physio

Coccygeal contusion

• Hx = direct blow (fall,kick)

• SSx:

  • Pain, bruising, tenderness

• Tx:

  • Hospital for X-Ray

  • NSAID, warm baths

  • May need surgery