Hip & Pelvis

The Chain of Forces and Kinetic Chain Connection

  • The concept of the chain emphasizes where forces are transferred in the body, noting the anchorage to the ground.

  • The kinetic chain highlights the connection from the lower extremities up into the axi skeleton, providing support and stability for the trunk as well as enabling mobility for locomotion, which is essential for walking.

Overview of Hip and Pelvis Bones

  • The bones that comprise the hip and pelvis include:

    • Innominate Bones: A collective term for three bones:

    • Ilium: The large, flared bone at the top of the pelvis, located where hands are placed when one stands with hands on hips.

    • Ischium: The lower part of the pelvis, commonly referred to as the "sitting bones" (ischial tuberosities).

    • Pubis: The front bone of the pelvis, situated where buttons of jeans are positioned.

  • Each side of the pelvis consists of a right innominate and a left innominate, both made up of the ilium, ischium, and pubis.

  • Important hip structure includes:

    • Acetabulum: The hip socket formed by the convergence of the three innominate bones; plays a critical role in the hip joint.

Joint Articulations in the Hip and Pelvis

  • Sacroiliac Joint (SI Joint):

    • Located in the back, comprises the articulation between the innominate (ilium) and the sacrum.

    • Each side possesses a right and left SI joint, designed to limit movement due to its fibrous nature.

  • Acetabulofemoral Joint (Hip Joint):

    • Commonly referred to as the hip joint; allows multi-planar mobility due to its ball-and-socket structure.

    • Clinical terminology emphasizes the use of “acetabular joint” rather than “hip joint” for precision in diagnostics.

  • Pubic Symphysis:

    • The joint at the front of the pelvis; completes the pelvic ring structure.

    • Described as a fibrocartilaginous joint, it permits some movement and undergoes stress absorption.

Characteristics of Different Hip Joints

  • Sacroiliac Joint:

    • Functions to limit excessive movement, providing firm stability for transferring weight from the hip joint into the lower back.

  • Acetabular Femoral Joint:

    • Allows for extensive mobility and is characterized by its ball-and-socket functionality.

  • Pubic Symphysis:

    • Facilitates shock absorption and contains a fibrous capsule filled with fluid.

Stability and Mobility in the Hip Joint

  • The stability of the acetabulofemoral joint is primarily provided by:

    • Ligaments:

    • Ileofemoral Ligament (Y-ligament): It extends from the ilium to the femur, restricting hip hyperextension.

    • Pubofemoral Ligament: Restricts extension and abduction due to its attachment from the pubic bone to the femur.

    • Ischiofemoral Ligament: Located posteriorly, limits both internal rotation and also plays a role in restricting certain flexion of the hip.

  • The ligaments ensure the femur is securely pulled into the acetabulum, contributing to joint stability without sacrificing mobility.

Bursa and Their Importance

  • Bursa: Fluid-filled sacs that reduce friction between tendons/muscles and bones.

    • Trochanteric Bursa: Located between the gluteus maximus and the greater trochanter, potential site for soreness when pressed.

    • Ischial Bursa: Situated between the gluteus maximus and the ischial tuberosity.

    • Iliopsoas Bursa: Found between the iliopsoas muscle and the anterior hip capsule; significant in hip dynamics.

  • Management of bursitis often requires addressing chronic movements to alleviate inflammation and friction.

Clinical Considerations and Abnormalities in Hip Assessment

  • Abnormalities observed during clinical examination require careful documentation and consideration of potential outcomes rather than immediate medical responses.

  • Key assessments often include identifying pelvic tilt versus neutral positions:

    • Neutral Pelvic Position: Achieved when hands placed at acetabular joints are level.

    • Posterior Pelvic Tilt: Thumbs move back while maintaining level, which may be an individual's normal position.

    • Anterior Pelvic Tilt: Thumbs move forward while maintaining level, which might also be a normal condition for some individuals.

  • Common Hip Injuries:

    • Labral Tears:

    • Etiology: Repetitive hip motion, trauma, or congenital conditions such as FAI (femoral acetabular impingement).

    • Symptoms: Development of deep groin pain, potential clicking or catching sensations, limited range of motion, and hip "sticking" requiring external assistance for mobilization.

    • Management: Relying on rest, glute strengthening, and if severity demands, surgical intervention is an option.

    • FAI:

    • Etiology: Congenital structural anomalies resulting in abnormal contact between the femoral head and acetabulum with three types being identifiable (cam deformity, pincer deformity, and combined).

    • Symptoms typically include anterior hip pain and limited internal rotation capabilities.

    • Management involves activity modifications and strengthening with mobility focus.

    • Snapping Hip Syndrome:

    • Caused by tightness in iliopsoas or IT band muscles leading to audible snapping over bones.

    • Typically characteristic in athletes and managed through muscle conditioning, stretching, and in cases of inflammation, reducing activity, icing, and seeking recovery.

    • Hip Pointers:

    • Resulting from contusions on the iliac crest or greater trochanter, managed with rest, ice, and careful protective padding to allow healing without distress.

    • Bursitis: Localized pain associated with overuse, necessitating proper management to avoid further inflammation and friction.

      • Diagnosis difference between bursitis and other conditions includes assessing symptoms based on movements and localized pain responses.

    • Adductor and Hip Flexor Strains:

      • Etiology often linked to sudden overstretching or eccentric loads, presenting as localized pain, muscle weakness, and management similarly involves rest and gradual reconditioning through controlled activities.

Assessment Techniques for Hip

  • Key tests for evaluating hip function include:

    • FABER Test (Flexion, Abduction, External Rotation): Determines if pain arises from the hip joint, SI joint, or other locations.

    • Resistance Tests for Hip Muscles:

    • Resistant hip abduction/adduction tests allow for exploration of muscle strength deficits and pain involvement based on muscle action.

    • Hip Scouring Test: Evaluates labral integrity by observing pain response to axial loading and rotation of the femur in the acetabulum; a reaction indicating potential labral compromise.

    • SLR Test (Single Leg Raise): Screen for sciatic nerve involvement or hamstring tightness using dorsiflex feedback.

    • Trendelenburg Test: Identifies glute medius weakness by assessing pelvic alignment during single leg standing.

Conclusion

  • Understanding the complications and dynamics of the hip and pelvis entails recognizing the multifaceted roles of supporting structures, bursa, joints, and normal mobility range, which is crucial for developing a thorough clinical assessment and management strategy.

The Chain of Forces and Kinetic Chain Connection

  • The chain concept addresses force transfer and ground anchorage.

  • The kinetic chain links lower extremities to the axial skeleton for trunk support, stability, and locomotion.

Overview of Hip and Pelvis Bones

  • The hip and pelvis comprise innominate bones (ilium, ischium, pubis) on each side.

  • The acetabulum is the hip socket where these three bones converge.

Joint Articulations in the Hip and Pelvis

  • Sacroiliac (SI) Joint: Posterior joint between innominate and sacrum, designed for limited movement and stability.

  • Acetabulofemoral (Hip) Joint: A ball-and-socket joint allowing extensive multi-planar mobility.

  • Pubic Symphysis: Anterior fibrocartilaginous joint completing the pelvic ring, providing shock absorption.

Stability and Mobility in the Hip Joint

  • Hip joint stability is mainly provided by ligaments:

    • Ileofemoral Ligament: Restricts hip hyperextension.

    • Pubofemoral Ligament: Restricts extension and abduction.

    • Ischiofemoral Ligament: Limits internal rotation and certain hip flexion.

Bursa and Their Importance

  • Bursae are fluid-filled sacs that reduce friction.

  • Key bursae include the Trochanteric, Ischial, and Iliopsoas bursae.

Clinical Considerations and Abnormalities in Hip Assessment

  • Pelvic position can be neutral, posteriorly tilted, or anteriorly tilted, with variations being normal for individuals.

  • Common Hip Injuries:

    • Labral Tears: Deep groin pain, clicking, limited range of motion, often due to repetitive motion or trauma; managed with rest, strengthening, or surgery.

    • FAI (Femoral Acetabular Impingement): Congenital structural anomalies causing abnormal contact, leading to anterior hip pain and limited internal rotation; managed with activity modification and strengthening.

    • Snapping Hip Syndrome: Caused by tight iliopsoas or IT band, resulting in audible snapping; managed with muscle conditioning and stretching.

    • Hip Pointers: Contusions on the iliac crest or greater trochanter; managed with rest, ice, and padding.

    • Bursitis: Localized pain from overuse and friction; requires addressing chronic movements.

    • Adductor and Hip Flexor Strains: Localized pain and weakness due to sudden overstretching; managed with rest and gradual reconditioning.

Assessment Techniques for Hip

  • FABER Test: Assesses pain origin (hip, SI joint).

  • FADIR Test: Assesses for hip impingement and anterior joint pain by flexing, adducting, and internally rotating the hip.

  • Resistance Tests: Evaluates muscle strength and pain.

  • Hip Scouring Test: Checks labral integrity.

  • SLR Test (Single Leg Raise): Screens for sciatic nerve issues or hamstring tightness.

  • Trendelenburg Test: Identifies gluteus medius weakness.

Conclusion

  • A comprehensive understanding of hip and pelvis structures, joints, bursa, and mobility is crucial for effective clinical assessment and management.

Which ligament restricts hyperextension of the hip?

The iliofemoral ligament, also known as the Y ligament of Bigelow, is primarily responsible for restricting hyperextension of the hip joint.

Restricts extension and abduction?

pubofemoral ligament

limits internal rotation and certain hip flexion