Functional Anatomy and Exam of the Hip, Groin, and Thighforms.acsm.org/15TPC/PDFs/13 Johnson A.pdf · "The warrior above all others prays for peace, for it is the warrior above

San Antonio Military Medical Center

"The warrior above all others prays for peace, for it is the warrior above all others who must suffer and bear the deepest wounds and scars of war”

LTC ANTHONY E. JOHNSON, MD, FAAOS CHAIRMAN, DEPARTMENT OF ORTHOPAEDICS & REHABILITATION

CO-CHAIRMAN, U.S. ARMED FORCES SPORTS, MEDICAL ADVISORY GROUP TEAM PHYSICIAN, USA PARALYMPIC BASKETBALL

ACSM Team Physician Course 5 February 2015

Functional Anatomy and Exam of the Hip, Groin, and Thigh



• Hip Joint – True ball and socket joint – Intrinsic stability – Moves in all three planes, particularly during gait

• Pelvis – Moves in all three planes – Anterior tilting

• Changes degree of lumbar lordosis – Lateral tilting

• Changes degree of hip abduction

Functional Anatomy



ACETABULUM

FEMORAL HEAD

GREATER TROCHANTER

LESSER TROCHANTER

FEMORAL NECK

CORTICAL BONE

MEDULLARY BONE

FOVEA CAPITIS

Creative Commons Attribution ShareAlike 3.0 License: http://creativecommons.org/licenses/by-sa/3.0/

http://creativecommons.org/licenses/by-sa/3.0/





Articulation

• The cavity of acetabulum is deepened by a fibrocartilaginous acetabular labrum

• The articular surface of the acetabulum is horseshoe shaped – Deficient inferiorly at the acetabular notch

• The labrum bridges across the acetabular notch – The transverse acetabular ligament – Converts the notch into a tunnel

• Vessels and nerves enter the joint











Type & Capsule

• Synovial ball and socket joint – Enclosed by capsule

• Attachments – Medially: acetabular labrum – Laterally: intertrochanteric line of the femur in front

and along the posterior aspect of the neck



Ligaments of the Hip Joint

• Pubofemoral – A triangular ligament – Base attached to the superior ramus of the pubis – Apex attached to the the intertrochanteric line – Limits extension and abduction

• Ischiofemoral – A spiral shaped ligament – Base attached to ischium near the acetabular margin – Apex attached to the greater trochanter – Limits extension













Nerve Supply

• Femoral nerve – Arises from posterior divisions of of L2, L3, L4 – Passes inferolaterally thru psoas, over Iliacus muscle

• Enters thigh underneath the inguinal ligament

– Supplies quadriceps & anteromedial thigh • Continues on as the saphenous nerve

– Three (3) branches: • Pectineus (at level of inguinal ligament) • Sartorius • Quadriceps

http://www.wheelessonline.com/ortho/nerves_arising_from_l2



http://www.wheelessonline.com/ortho/psoas

http://www.wheelessonline.com/ortho/iliacus

http://www.wheelessonline.com/ortho/quadriceps_muscle

http://www.wheelessonline.com/ortho/saphenous_nerve

http://www.wheelessonline.com/ortho/pectineus

http://www.wheelessonline.com/ortho/sartorius

http://www.wheelessonline.com/ortho/quadriceps_muscle



Nerve Supply

• Obturator nerve – Formed from anterior branches of L2, L3, L4 – Largest nerve formed from anterior divisions of lumbar

plexus – Roots unite within the posterior psoas

• Runs over sacral ala into lesser pelvis – lateral to ureter & internal iliac vessels

• Enters the obturator foramen and subsequently divides into anterior and posterior branches






Nerve Supply

• Obturator nerve – Anterior Branch:

• Runs in front of obturator externus & adductor brevis • Runs behind the pectineus and adductor longus muscles • Gives off articular twig that enters hip joint thru acetabular notch

– Cutaneous Branch: • When present, innervates skin and fascia over distal 2/3 of thigh

– Posterior Branch: • Pierces anterior part of obturator externus • Runs inferiorly behind the adductor brevis & in front of the

adductor magnus

http://www.wheelessonline.com/ortho/adductor_brevis

http://www.wheelessonline.com/ortho/pectineus

http://www.wheelessonline.com/ortho/adductor_longus

http://www.wheelessonline.com/ortho/adductor_brevis

http://www.wheelessonline.com/ortho/adductor_magnus



Nerve Supply

• Sciatic nerve – Arises from lumbrosacral plexus: L4, L5, S1, S2, S3

• Nerve emerges from pelvis below piriformis • Enters thigh between ischial tuberosity & greater

trochanter – Descends near middle of thigh, lying on adductor

magnus muscle & being crossed obliquely by long head of biceps femoris

• Nerve usually separates in upper part of popliteal space – Gives off tibial and peroneal branches

http://www.wheelessonline.com/ortho/lumbrosacral_plexus



http://www.wheelessonline.com/ortho/nerves_arising_from_s1



http://www.wheelessonline.com/ortho/piriformis



http://www.wheelessonline.com/ortho/biceps_femoris



Nerve Supply

• Sciatic nerve – Tibal Nerve:

• Anterior branches of LS plexus: L4, L5, S1, S2, S3 • 2 branches from tibial division: below quadratus femoris:

– Upper branch innervates long head of biceps femoris & superior portion of semitendinosus

– Lower branch: innervates inferior portion of semitendinosus, semimembranous & ischiocondylar portion of adductor magnus

– Common Peroneal Nerve: • Posterior branches: L4, L5, S1, S2 • Nerve to short head of biceps femoris arises from lateral side of

sciatic nerve (common peroneal portion) in middle of thigh

http://www.wheelessonline.com/ortho/lumbrosacral_plexus






http://www.wheelessonline.com/ortho/tibial_nerve

http://www.wheelessonline.com/ortho/quadratus_femoris


http://www.wheelessonline.com/ortho/semitendinosus

http://www.wheelessonline.com/ortho/semitendinosus

http://www.wheelessonline.com/ortho/semimembranous


http://www.wheelessonline.com/ortho/peroneal_nerve






http://www.wheelessonline.com/ortho/peroneal_nerve















Movements

• Wide range of movement – Less so than the shoulder joint – Some movement sacrificed for stability – Dependent largely upon shape of articulating bones and on

strong ligaments • When the knee is flexed

– Flexion is limited by the anterior thigh contact with abdomen

• When the knee is extended – Flexion is limited by hamstring tension



Movements

• Abduction limited by tension of pubofemoral ligament • Adduction limited by

– Contact with contralateral limb – Tension of the ligament of the head of the femur

• External rotation limited by tension in the iliofemoral and pubofemoral ligaments

• Internal rotation limited by ischiofemoral ligament



Movements

• Flexion: – Primary: iliopsoas, rectus femoris, & sartorius – Secondary: adductor muscles

• Extension: – Gluteus maximus and hamstrings

• Abduction: – Primary: gluteus medius and minimus – Secondary: sartorius, tensor fasciae latae, & piriformis

• Adduction: – Adductor longus, brevis, and magnus



Movements

• External rotation: – Piriformis, obturator internus and externus, superior and

inferior gamelli • Internal rotation:

– Anterior fibers of gluteus medius and gluteus minimus and the tensor fasciae latae

• Circumduction: – Complex combination of the previous movements



Movements

• The extensor group of muscles is more powerful than the flexor group

• The lateral rotators are more powerful than the

medial rotators



Assessment of the Hip and Pelvis

• Injuries to the hip or pelvis cause major disability in the lower limbs, trunk, or both

• Low back may also become involved • History

– Onset (sudden or slow?) – Previous history? – Mechanism of injury? – Pain description, intensity, quality, duration, type, and

location?



• Observation – Symmetry - hips, pelvis tilt (anterior/posterior)

• Lordosis or flat back – Lower limb alignment

• Knees, patella, feet – Pelvic landmarks

• ASIS, PSIS, iliac crest – Single limb stance

• Pubic symphysis pain or drop to one side – Ambulation

• Antalgia?

Assessment of the Hip and Pelvis



• True or anatomical – Shortening may be equal throughout limb or localized in

femur or leg – Measure from ASIS to medial malleolus

• Apparent or functional – May result due to lateral pelvic tilt, flexion, or adduction

deformity – Measure from umbilicus to medial malleolus

Special Tests: Leg Length Discrepancy



Leg Length Discrepancy Measures



Popliteal – Femoral Angle

http://www.sportsdoc.umn.edu



Single Limb Stance

Evaluation of the Patient with Hip Pain. http://www.aafp.org



Provocative Test for Labral Pathology

Evaluation of the patient with Hip pain. http://www.aafp.org



Differential Diagnosis

• Contusion (Hip Pointer) • Strain • Avulsion

– ASIS: Sartorius – AIIS: Rectus Femoris – Ischial Tuberosity: Common Hamstring Origin

• AVN • Hip Dysplasia/Femoral-Acetabular Impingement

(FAI)



Hip Pointer

• A hip pointer is a contusion to the iliac crest, the surrounding soft tissue structures, or the greater trochanter of the femur

• Typically, the injury is caused by a direct blow or fall – Occur most commonly in contact sports (e.g., football, hockey) – Can also occur in noncontact sports as a result of a fall onto the hip or

side

• Pain and tenderness in this region can limit an athlete's participation in sports



HIP POINTER





Hip Avulsion Fractures
























FAI

http://orthoinfo.aaos.org









Documents

Functional Anatomy and Exam of the Hip, Groin, and Thighforms.acsm.org/15TPC/PDFs/13 Johnson A.pdf · "The warrior above all others prays for peace, for it is the warrior above