MUSCULOSKELETAL EXAMINATON HIP AND PELVIS (P2: HIP Anatomy and Subjective)

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True or False:

The hip joint is a multiaxial ball-and-socket joint that has minimal stability because of its similarity with the shoulder joint.

False:

The hip joint is a multiaxial ball-and-socket joint that has maximal stability because of the deep insertion of the head of the femur into the acetabulum

To allow sufficient movement and proper alignment to occur at the hip joint, the femur has a longer neck than the humerus and is (anteverted/retroverted?)

To allow sufficient movement and proper alignment to occur at the hip joint, the femur has a longer neck than the humerus and is anteverted

The __________ is formed by fusion of parts of the ilium, ischium, and pubis

The ilium, ischium and pubis grouped together is called what?

acetabulum

innominate bone or pelvis

True or False:

The normal acetabulum opens outward, backward, and downward

False:

The normal acetabulum opens outward, forward, and downward

Remember SAM (femur) and LIA (acetabulum)

• Femur faces superoanteromedially (SAM)

• Acetabulum faces Lateral, Inferior and Anteriorly (LIA)

True or False:

The femoral head is half of a sphere, and the acetabulum is two-thirds of a sphere.

False:

The acetabulum is half of a sphere, and the femoral head is two-thirds of a sphere.

Hip Joint

Resting position:

Close packed position:

Capsular pattern:

Hip Joint

Resting position: 30° flexion, 30° abduction, slight lateral rotation

Close packed position: Full extension, medial rotation, abduction

Capsular pattern: Flexion, abduction, medial rotation (but in some cases, medial rotation is limited)

This is a dense, horseshoe-shaped fibrocartilaginous structure runs around the perimeter of the acetabulum and holds the femoral head in the acetabulum at extreme ranges of motion (ROM), stabilizing the hip.

Acetabular labrum

Other functions of the GOAT Acetabular LaBrum:

(no need to memorize just read through, you’ll remember)

• It increases the articular surface area and volume of the acetabulum

• provides proprioceptive feedback for dynamic stability

• maintains a negative intra-articular pressure (i.e., a suction seal)

  • Allows femoral head to float protecting the cartilage

• resists fluid flow by regulating synovial fluid, which enhances nutrition

• acts as a shock absorber when assisting in force distribution during load bearing.

• plays a secondary role in stabilizing the hip during lateral rotation

• prevents anterior translation

How many percentage of patients with with labral pathology have associated bony abnormalities?

90%

True or False:

The labrum is avascular except at its center and therefore has poor healing potential.

False:

The labrum is avascular except at its margins and therefore has poor healing potential.

Mechanisms of injury to the LaBrum:

• hip hyperabduction

• twisting

• falling

• hyperextension

• dislocation,

• direct blow

• motor vehicle accident

Labral tears can be seen in the following conditions:

• femoroacetabular impingement (FAI)

• hip dysplasia (e.g., Legg-Calvé-Perthes disease)

• slipped capital femoral epiphysis (SCFE)

• trauma

• osteoarthritis

• iliopsoas impingement

Both of the following are occurrences of a labral tear:

• an activity-induced or positional pain that fails to improve

• a sudden twisting or pivoting motion with a click, pop, or locking sensation.

Which is more common?

A tear to the labrum may occur as an activity-induced or positional pain that fails to improve (most common).

What condition causes abnormal loading on the acetabular rim, which can lead to labral tears, damage to the chondral surface, and capsular laxity?

Hip dysplasia

twisting and pivoting movements, especially at the end range of rotation and falling, lead to labral fraying, chondral degeneration, or delamination and can ultimately lead to what condition?

Osteoarthritis.

The hip, already a stable joint because of its bony configuration, is supported by three strong ligaments, enumerate.

• iliofemoral

• ischiofemoral

• pubofemoral ligaments

Which hip ligament is the strongest

iliofemoral ligament (Y ligament of Bigelow)

is considered to be one of the strongest ligaments in the body

iliofemoral ligament (Y ligament of Bigelow) prevents excessive hip _____________

Also prevents translation in what direction?

Extension

Anterior Translation

Aside from extremes of extension, the iliofemoral ligament also tightens during which hip motions?

lateral rotation and adduction

Repeated forced lateral rotation of the hip can lead to ___________ insufficiency

Repeated forced lateral rotation of the hip can lead to iliofemoral insufficiency

True or False:

If a patient has iliofemoral insufficiency, rotating (twisting) the hip can lead to feeling pain.

False:

If a patient has iliofemoral insufficiency, rotating (twisting) the hip can lead to a feeling of instability.

Which ligament is the weakest hip ligament?

ischiofemoral ligament

ischiofemoral ligament tightens during which hip actions

• Extension

• Medial rotation

• Abduction

Repeated forced medial rotation of the hip can lead to ___________ insufficiency

Repeated forced medial rotation of the hip can lead to ischiofemoral insufficiency

The pubofemoral ligament prevents excessive ________ of the femur and limits ________ rotation, especially in (flexion/extension?).

The pubofemoral ligament prevents excessive abduction of the femur and limits lateral rotation, especially in extension

Pubofemoral limits what hip motions?

Lateral rotation and abduction.

All three ligaments also limit ________ rotation of the femur.

All three ligaments also limit medial rotation of the femur

This is the 4th ligament, intra-articular, strong and acts as a hip stabilizer.

Ligamentum Teres / Ligament of the head

The ligamentum teres acts as a hip stabilizer especially in these positions: (enumerate)

• adduction

• flexion

• lateral rotation

when the hip is in its least stable position

What position cause the ligamentum teres to be lax?

abduction and medial rotation

True or False:

The ligamentum flavum provides a physical attachment of the head of the femur to the acetabulum

False

The ligamentum teres provides a physical attachment of the head of the femur to the acetabulum

The ligamentum teres prevents subluxation forces:

• Prevents ________ subluxation during abduction

• Prevents ________ subluxation during medial rotation

• Prevents ________ dislocation during lateral rotation

The ligamentum teres prevents subluxation forces:

• Prevents inferior subluxation during abduction

• Prevents posterior subluxation during medial rotation

• Prevents anterior dislocation during lateral rotation

True or False:

If the ligamentum teres is torn, macroinstability of the hip results, which can damage the labrum and cartilage, resulting in possible chondral lesions.

False:

If the ligamentum teres is torn, microinstability of the hip results, which can damage the labrum and cartilage, resulting in possible chondral lesions.

The instability is most evident in flexion, adduction, and lateral rotation of the hip (actions limited by the ligamentum teres)

Others feel that the ligamentum teres also has a proprioceptive role and may help to distribute synovial fluid over the femoral head via what effect.

Windshield-wiper effect

Tears of the ligamentum teres are associated with ___________

Dislocations

Partial tears arise from:

• flexion/adduction stresses

• hyperabduction

• a fall on the ipsilateral knee with the hip flexed

• sudden twisting injury

Basta partial tear pag hindi dislocation

an area of the femoral head where there is no cartilage; it provides an insertion point for the ligamentum teres and is the point in the acetabulum where the ilium, ischium, and pubis meet

Fovea Capitis

The arcuate ligament is part of the posterior capsule and reinforces the hip during extremes of what motions?

Flexion and Extension

a circular ligament, surrounds the neck of the femur and lies inferior to the femoral head

Zona Obicularis

The zona obicularis resists ________ distraction forces and aids in stabilization.

The zona obicularis resists inferior distraction forces and aids in stabilization.

True or False:

Under low loads, the hip joint surfaces are congruous; under heavy loads, they become incongruous.

False:

Under low loads, the hip joint surfaces are incongruous; under heavy loads, they become congruous.

Forces on the Hip: (read)

• Standing: 0.3 times body weight

• Standing on one limb: 2.4–2.6 times body weight

• Walking: 1.3–5.8 times body weight

• Walking up stairs: 3 times body weight

• Running: 4.5+ times body weight

True or False:

congenital hip dysplasia is seen in infancy, primarily in males although its effect is often greater in adolescents and young adults.

False:

congenital hip dysplasia is seen in infancy, primarily in girls although its effect is often greater in adolescents and young adults.

Legg-Calvé-Perthes disease is more common in (girls/boys?) of how many years?

Boys

3 to 12 years old

True or False:

elderly women are more prone to osteoporotic femoral neck fractures.

True

no shit sherlock

True or False:

In young people, issues related to physeal injuries state of skeletal maturity and morphological abnormalities have clinical features similar to or associated with labral tears and chondral injuries.

True

Typically, __________ hip symptoms are worse with activities.

Typically, mechanical hip symptoms are worse with activities

Patients may also complain of dyspareunia (i.e., painful sexual intercourse)

The labrum may be injured with lateral rotation when the hip is ________________.

The labrum may be injured with lateral rotation when the hip is hyperextended

Labrum may also be injured due to traction from the (what muscle?), occurring primarily during kicking or sprinting

or (what muscle contraction?), primarily occurring during a change of direction

Labrum may also be injured due to traction from the rectus femoris, occurring primarily during kicking or sprinting

or iliacus contraction, primarily occurring during a change of direction

Hip injuries may cause mechanical symptoms:

• clicking

• giving way

• locking

• catching

Labral injuries cause an abnormal gait with a shortened _______ phase.

Stance Phase

Labral tears rarely occur in isolation. what is/are commonly associated with labral tears?

Chondral lesions

True or False:

Femoral neck stress fractures occur when excessive or repetitive stress is applied to the cortical bone in the femoral neck

False:

Femoral neck stress fractures occur when excessive or repetitive stress is applied to the trabecular bone in the femoral neck

Femoral Neck Stress Fractures categorized as:

• ______________ sided

• Occur at the _____________ neck

• Unlikely to _____________

Femoral Neck Stress Fractures categorized as:

• compression sided

• Occur at the inferomedial neck

• Unlikely to displace

___________ fractures occur at the superolateral neck and, and are more likely to be displaced

Traction-sided fractures occur at the superolateral neck and, and are more likely to be displaced

True or False:

The traction type is usually treated conservatively, whereas the compression type, is a high risk stress fracture that may require surgical intervention.

False:

The compression type is usually treated conservatively, whereas the traction type, which may displace, is a high risk stress fracture that may require surgical stabilization

True or False:

Acute groin injuries are usually due to high running loads, changes in direction, or kicking

True

With a posterior dislocation (most common):

• hip is slightly (extended/flexed?)

• adducted/abducted?

• (laterally/medially?) rotated

• leg (shortened/lengthened?)

With a posterior dislocation (most common):

• hip is slightly flexed

• adducted

• medially rotated

• leg shortened

Opposite for anterior dislocation

True or False:

Hip dislocations warrant examinations of the sciatic and femoral nerves + examination of the knee

True

In the presence of a dislocation, reduction should be performed within how many hours?

6 hours

Microinstability or atraumatic instability occurs with repetitive microtrauma from axial loading and ________ rotation and is associated with _______.

Microinstability or atraumatic instability occurs with repetitive microtrauma from axial loading and lateral rotation and is associated with FAI.

True or False:

If the static stabilizers are compromised, then the dynamic stabilizers must work harder to stabilize the joint

True

Causes modification of biomechanics leading to abnormal movement patterns

if a patient presents with an internally snapping hip , a labral tear, and a pincer-type FAI, it is called?

triple impingement

If the hip is at fault, the patient may demonstrate what sign?

hint : if asked to show where the pain is, the patient will cup a hand above the greater trochanter with the fingers gripping the anterior groin, describing the pain as deep in the joint

“C” Sign

True or False:
In older adults, osteoarthritis and spondylitis should be considered first.

False:

In older adults, osteoarthritis and fractures should be considered first.

Anterior or groin pain may be related to:

• Intra-articular / extra-articular hip problems?

• apophysitis in children where?

• Tendinitis of which muscle / muscle group?

• FAI, labral or chondral injuries, or athletic pubalgia (no question for this #freebie)

Anterior or groin pain may be related to:

• Intra-articular hip problems

• apophysitis in children at ASIS or AIIS

• Tendinitis of the iliopsoas or adductors

• FAI, labral or chondral injuries, or athletic pubalgia

Lateral hip pain may be related to:

• Intra-articular / extra-articular hip problems?

• adductor/abductor injuries?

• ____________ pain syndrome

• ____________ dysplasia

Lateral hip pain may be related to:

• extra-articular hip problems

• abductor injuries

• Greater trochanteric pain syndrome

• acetabular dysplasia

Isolated posterior buttock pain is usually related to:

• _____________ pathology

• issues with the _______ nerve

• superficial/deep gluteal pain syndrome?

Isolated posterior buttock pain is usually related to:

• lumbar or sacroiliac pathology

• issues with the sciatic nerve

• deep gluteal pain syndrome

True or False:

Hip intra-articular pain including labral tears, FAI, and L4 nerve root pain is felt mainly in the groin and along the front or medial side of the thigh to the knee.

True

It is often described as a sharp, stabbing pain often accompanied by catching, locking, or clicking.

True or False:

Buttock pain, on the other hand, is associated with posterior labral tears and lumbar spine problems.

True

Gradual onset of pain usually indicates ____________

osteoarthritis

Adductor pain may be the result of overactive adductors caused by pelvic _________

Adductor pain may be the result of overactive adductors caused by pelvic instability

Pain when doing resisted sit-ups, hip flexion, or adduction may indicate ____________

Pain when doing resisted sit-ups, hip flexion, or adduction may indicate athletic pubalgia

True or False

Pain from the lumbar spine may commonly be referred to the back or medial aspect of the hip.

False:

Pain from the lumbar spine may commonly be referred to the back or lateral aspect of the hip.

This hernia is commonly caused by a deficient inguinal canal posterior wall, nerve entrapment, or adductor tendonopathies

Sports Hernia

Sports Hernia Pain:

• MAY have an insidious onset

• unilateral/bilateral?

• description of pain?

• location of pain?

• Radiates to?

• Aggravating movements?

Sports Hernia Pain:

• MAY have an insidious onset

• unilateral

• Dull, aching or sharp, burning

• Groin

• Radiates to proximal thigh, low back, lower abdominal muscles, perineum and/or scrotum.

• Sudden acceleration, cutting or kicking

True or False:

Lateral hip pain may be due to a trochanteric bursitis or tear of the gluteus medius tendon, most commonly in younger patients.

False:

Lateral hip pain may be due to a trochanteric bursitis or tear of the gluteus medius tendon, most commonly in older patients.

True or False:

Lateral hip pain may also simulate L5 nerve root pain; therefore assessment of the lumbar spine should also be considered for lateral or posterior symptoms

False:

Lateral hip pain may also simulate L4 nerve root pain; therefore assessment of the lumbar spine should also be considered for lateral or posterior symptoms

Lateral hip pain may also be referred to the knee or back and may_____________ on walking.

Lateral hip pain may also be referred to the knee or back and may increase on walking.

Clicking is common with labral tears when the hip moves into ________________

Clicking is common with labral tears when the hip moves into medial or lateral rotation.

What is snapping in and around the hip called

extra-articular sound.

Coxa saltans

Most common cause of coxa saltans

Slipping of the iliopsoas tendon

over the osseous ridge of the lesser trochanter or anterior acetabulum

Causes of coxa saltans:

If due to the iliopsoas tendon or iliofemoral ligament

(internal coxa sultans):

• snapping often occurs at approximately ___° of flexion

• hip is moving from _________ to ___________

• especially with the hip __________ and _________rotated

If due to the iliopsoas tendon or iliofemoral ligament

(internal coxa sultans):

• snapping often occurs at approximately 45° of flexion

• hip is moving from flexion to extension

• especially with the hip abducted and laterally rotated

external coxa saltans:

• felt more laterally/medially?

• occurs when the hip is brought from the _____, _______, and _______ rotated position into _______and _______ rotation

• during hip _______ and _________

• especially if the hip is held in __________ rotation

• it may be made worse if the ____________ bursa is inflamed.

external coxa saltans:

• felt more laterally

• occurs when the hip is brought from the flexed abducted and laterally rotated position into extension and medial rotation

• during hip flexion and extension

• especially if the hip is held in medial rotation

• it may be made worse if the trochanteric bursa is inflamed.

Common age of intra-articular snapping?

20 and 40 years of age

Where is the complaint of sharp pain in intra-articular snapping?

groin and anterior thigh

especially on pivoting movement

Passively, clicking may be felt and heard when the extended hip is ____________ and _____________ rotated.

Passively, clicking may be felt and heard when the extended hip is adducted and laterally rotated.

Bursitis that often results from abnormal running mechanics with the feet crossing over midline, a wide pelvis and genu valgum, or running on running tracks with no banking.

Trochanteric Bursitis

Pain on sitting may be due to pinching of an inflamed ______ bursa or an FAI

Pain on sitting may be due to pinching of an inflamed psoas bursa or an FAI

In this condition sciatic nerve may be compressed, the piriformis muscle is tender, and hip abduction and lateral rotation are weak.

piriformis syndrome / deep gluteal space syndrome

END

P2 SOON?