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MOB TCD

Groin

Professor Emeritus Moira O’BrienFRCPI, FFSEM, FFSEM (UK), FTCD

Trinity CollegeDublin

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Groin

• Lower half of anterior abdominal wall• Proximal portion of the thigh• Pain in the groin may be due to local

structures

• Referred from other areas e.g. thespine or ureter

• Pain may be acute or chronic• Quality of pain• Rest or movement

MOB TCD

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Hip and Groin Pain

• Spinal problems such as disclesions

• Intra-abdominal problems• Gynecological disorders

• Urological problems• Urinary tract infection• Pelvic inflammatory conditions• Genital swelling or inflammation• Epididymis, hydrocele, variocele

MOB TCD

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• Os coxae (hip bone) femur • Pubic symphysis• Hip joint• Femoral artery

• Femoral vein• Long saphenous vein• Inguinal lymph glands• Nerves• Muscles• Bursae• Hernia

GroinMOB TCD

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Cutaneous NervesMOB TCD

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• Proximal group parallel toinguinal ligament• Enlarged tender inguinal

glands

• Part of a generalisedlymphadenopathy• Secondaries

Inguinal GlandsMOB TCD

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• Proximal group• Lesions in local structures• Skin of lower anterior abdominal

wall

• Gluteal region• Skin of scrotum or labia• Distal superficial glands• Skin of leg area drained by long

saphenous vein• All drain to deep inguinal glands

along femoral vein

Inguinal GlandsMOB TCD

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• Lower five intercostal nerves• Subcostal nerve T12• 10 thintercostal nerve is at the level of

the umbilicus

• Iliohypogastric nerve L1• Ilioinguinal nerve L1

Skin of Anterior Abdominal WallMOB TCD

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• Subcostal nerve T 12• Iliohypogastric nerve L1• Ilioinguinal nerve L1• Femoral branch of the genitofemoral

nerve L1,2• Lateral cutaneous nerve of the thigh

L2,3• Femoral nerve L2,3,4• Obturator nerve L2,3,4

Cutaneous Nerves of ThighMOB TCD

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• Superficial fatty layer • Membranous layer of superficial fascia• Below umbilicus• Continuous with Colles’ fascia in the

perineum

Anterior Abdominal WallMOB TCD

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• Intercostal vessels• Skin above umbilicus:

superficial veins and lymphatics drainto axilla

• Skin below umbilicus:superficial veins and lymphatics drainto long saphenous vein

• Superficial inguinal glands

Blood Supply and LymphaticsMOB TCD

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• External oblique• Internal oblique• Transversus• Rectus abdominus

• Pyramidalis• Nerves and vessels• Lie between internal oblique and

transversus

Abdominal MusclesMOB TCD

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• Origin• Outer surfaces lower borders lower eight ribs

• Interdigitating serratus anterior

• Latissimus dorsi

External ObliqueMOB TCD

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• Inserted into anterior half of anterior two thirds outer lip of iliaccrest

• Aponeurosis in inguinal region

passes anterior to rectus muscle• Forms the inguinal ligament• Lacunar ligament• Reflected portion of inguinal

ligament

Insertion – External ObliqueMOB TCD

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• Inguinal ligament:aponeurosis is folded backfrom anterior superior iliacspine to pubic tubercle toform inguinal ligament

• Lacunar ligament:triangular, attached topectineal line, lateral freeborder medial margin of femoral ring

Inguinal and Lacunar LigamentsMOB TCD

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• Pubic crest• Gap for superficial ring• Pubic bone• Linea alba• Anterior wall of the

rectus sheath• Zyphoid process

Insertion – External ObliqueMOB TCD

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• Muscular origin• Lateral two thirds of inguinal ligament

• Anterior two thirds

intermediate lip of iliaccrest• Lumbar fascia• Muscular fibres arch over

contents of inguinal canalanterior to rectus muscle

Internal ObliqueMOB TCD

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• Into the costal margin, upper three asfleshy fibres• Next three as aponeurotic• Inserted into linea alba

• Between zyphoid and half way betweenumbilicus and pubic symphysis,aponeurosis splits

• Anterior fuses with external oblique

• Posterior with transversus

Insertion – Internal ObliqueMOB TCD

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• Half way between umbilicus andpubic symphysis• Aponeurosis of the internal

oblique and transversus fuse toform conjoint tendon

• Anterior portion of rectus sheath• Inserted into pectineal line behind

superficial inguinal ring

Internal Oblique – Conjoint TendonMOB TCD

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• Origin• Lateral one third of inguinal ligament• Anterior two thirds of inner lip of iliac

crest

• Lumbar fascia• Lower border and inner surfaces lower

six ribs interdigitating with diaphragm

Transversus AbdominusMOB TCD

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• Into zyphoid, linea alba• Half way between umbilicus and

pubic symphysis• Fuses with posterior lamella of

the internal oblique• Below forms conjoint tendon• Inserted into pectineal line

behind superficial inguinal ring

Insertion – Transversus AbdominusMOB TCD

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• Segmental muscle• Two heads• Anterior pubic symphysis• Pubic crest

• Inserted anterior aspectof 5,6,7 th costal cartilages• Adhesions anterior • Segmental blood and

nerve supply fromintercostals

Rectus AbdominusMOB TCD

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• Lines deep aspect of transversus abdominus• Fuses with inguinal ligament• Continuous with iliac fascia

• Except in region femoralvessels

• Forms anterior wall of femoralsheath

Transversalis FasciaMOB TCD

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• Intramuscular canal• Deep inguinal ring• Superficial ring• Transmits spermatic cord in male

• Round ligament in female

Inguinal CanalMOB TCD

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• Triangular opening in aponeurosis of external oblique• Base pubic crest• Superior crus to pubic crest

• Inferior attached to pubic tubercle• External spermatic fascia arises from

its margins

Superficial Inguinal RingMOB TCD

MOB TCD

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• Oval opening 2.5 cm• Above the middle of inguinal ligament• Inferior epigastric artery medial to

ring

Deep Inguinal RingMOB TCD

MOB TCD

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• Anterior wall• External oblique• Whole anterior wall• Lateral half

• Internal oblique


MOB TCD

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• Posterior wall• Transversalis fascia• Whole of wall• Medial half conjoint tendon

• Medial quarter, reflected portionof inguinal ligament


MOB TCD

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• Roof • Arching fibres of internal oblique• Transversus as they arise from the

inguinal ligament

Roof of Inguinal CanalMOB TCD

MOB TCD

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• Floor • Inguinal ligamentmedial half

• Lacunar ligament

Floor of Inguinal CanalMOB TCD

MOB TCD

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• Vas deferens• Testicular artery• Pampiniform plexus of veins• Remains of processus vaginalis

• Genital branch of genitofemoral nerve• Lymphatics from testes• Cremaster artery

Passing through Deep RingMale

MOB TCD

MOB TCD

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• Everything that went through deep ring• Plus:• Ilioinguinal nerve• Internal spermatic fascia

• Cremaster muscle and fascia

Passing through Superficial RingMale

MOB TCD

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• Round ligament of uterus• Remains of processus vaginalis• Genital branch of genitofemoral

nerve

• Lymphatics from uterus, region of cornu

Passing through Deep RingFemale

MOB TCD

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• Everything that went throughdeep ring:

• Plus ilioinguinal nerve

Passing through Superficial RingFemale

MOB TCD

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•Contraction of the abdominalmuscles increases theobliquity of the inguinal canal

• Protecting the two ringsLytle, 1945

Inguinal Canal

MOB TCD

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• Pain aggravated by an increase inintraabdominal pressure

• Hernia• Inguinal or femoral hernia

• Entrapment of the ilioinguinal nerve

Increase inIntra Abdominal Pressure

MOB TCD

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• Chronic pain in the groin in anathlete• May be due to a hernia or a

potential hernia

Hernia

MOB TCD

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• Sudden severe pain in lower abdomen• Associated with lifting a heavy

object

• Common history of a directinguinal hernia

Inguinal Hernia

MOB TCD

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• Passes through• Deep inguinal ring• May extend to pass through

the superficial ring into thescrotum

• Congenital or acquired• Congenital inside the tunica

vaginalis (serous membrane,covers part of testes)

• Acquired outside

Indirect Inguinal Hernia

MOB TCD

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• Direct inguinal hernia• Enters through posterior wall of theinguinal canal

• Leaves through superficial inguinal ring

• Above and medial to pubic tubercle

Direct Inguinal Hernia

MOB TCD

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• Inguinal above and medial to pubictubercle• Femoral below and lateral

Inguinal Versus Femoral Hernia

MOB TCD

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Femoral Ring

MOB TCD

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• Enters through femoral ring• Enters femoral canal• Medial compartment of femoral

sheath

• More common in women

Femoral Hernia

MOB TCD

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Femoral Hernia

MOB TCD

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• Swelling is softand diffuse

• Empties onminimal pressure

• Refills on release• Cough impulse is

present

Saphenous Varix

MOB TCD

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•Common cause of chronic groinpain in field sports

• Particularly soccer players• Pain on any sudden change of

movement, sneezing, coughing

Gilmore’s Groin

MOB TCD

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•Trying to sprint will increase the pain• Pain is worse getting out of bed theday after a match or a trainingsession

Gilmore’s Groin

MOB TCD

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• Pain is increased by externalrotation

• Or hyperextension of hip• Pain is localised to lower

anterior abdominal wall• Adductor or perineal region

Gilmore’s Groin

MOB TCD

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• Torn external obliqueaponeurosis• Torn conjoint tendon• A dehiscence between conjoint

tendon and the inguinal ligament• The absence of a hernial sac• Superficial inguinal ring on the

affected side is dilated and

tender • Cough impulse

Gilmore’s Groin

MOB TCD

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• Treatment is surgical• 90% return to sport• Strengthen lower abdominal

muscles

Gilmore’s Groin Surgery

MOB TCD

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1. Plication of the transversalisfascia in ‘shouldice herniarepair’

2. Repair of torn conjoint tendon3. Approximation of conjoint

tendon to the inguinalligament

4. Repair of the external oblique5. Reconstitution of the

superficial inguinal ring

Gilmore’s Groin Surgery

MOB TCD

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• Dermatomes• Entrapment of nerves• Pierce muscle• Pierce fascia

• Repetitive movements

Anatomy of Nerve Injuries

MOB TCD

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• Must know the course of nerve• Dermatomes• Entrapment of nerves• Pierce muscle

• Pierce fascia• Repetitive movements

Anatomy of Nerve Injuries

MOB TCD

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• Nerves supply• Skin• Muscles (group)• Tendons

• Bones• Joints• Blood vessels

Dermatomes and Myotomes

MOB TCD

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• External forces• Fibro-osseous tunnels, tether the

nerve• Oedema

• Callus formation as a result of afracture

• External compression due to specificmovements

• Mechanical compression• Compartment syndromes• The nerve is tender at the site of compression

Extrinsic Factors

MOB TCD

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• Fibrous bands• Accessory muscles• Spurs• Narrow notches

• Anatomical variations of the nerve itself

Extrinsic Factors

MOB TCD

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Lumbo-Sacral Plexus

Entrapment SyndromesMOB TCD

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• Affects branches of lumbar or sacral plexuses• Pierces muscle• Pierces fascia

• Increase in compartmentpressure

• Compressed by externalpressure

Entrapment Syndromesin Lower Limb

MOB TCD

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• Lower five intercostal nerves• Subcostal nerve T12• 10 th intercostal nerves at the level of

the umbilicus

• Iliohypogastric nerve L1• Ilioinguinal nerve L1

Skin of Anterior Abdominal Wall

MOB TCD

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• Subcostal nerve T 12• Iliohypogastric nerve L1• Ilioinguinal nerve L1• Femoral branch of the

genitofemoral nerve L1,2• Lateral cutaneous nerve of thethigh L2,3

• Femoral nerve L2,3,4

• Obturator nerve L2,3,4

Cutaneous Nerves of Thigh

MOB TCD

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Cutaneous Nerves

MOB TCD

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• Branch of lumbar plexus• Lateral border of psoas• Anterior to quadratus lumborum• Neurovascular plane between internal

oblique and transversus• Lateral cutaneous supplies upper part of

buttock

Ilio-Hypogastric Nerve L1

MOB TCD

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• Pierces internal obliqueabove anterior superior iliac spine

• Pierces aponeurosis of external oblique an inch

above superficial ring• Supplies skin over lower

part of rectus sheath• Can be trapped piercing

aponeurosis

Ilio-Hypogastric Nerve

l lMOB TCD

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• Ilio-inguinal nerve• L1 branch of lumber plexus• Lateral border of psoas• Anterior to quadratus lumborum• Neurovascular plane between

internal oblique and transversus

Ilio-Inguinal Nerve

li i lMOB TCD

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• Pierces internal oblique4 cm medial to

• Anterior superior iliacspine

• Enters inguinal canal

• Leaves through superficialring

• Supplies the skin of themedial part of the thigh

• Adjoining portion of thescrotum and labia

Ilio-Inguinal Nerve

Ili I i l NMOB TCD

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• May be trapped postsurgery, due to adhesions

• Poor tone in abdominalmuscles

• Pain increased byincreased tension in theanterior abdominal wall

• Hyperextension of hip•

Tenderness 4 cm fromanterior superior iliac spine

Ilio-Inguinal Nerve

Ili I i l N EMOB TCD

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• Pain increased• Increased tension in the anterior

abdominal wall• Hyperextension of hip

• Tenderness 4 cm medial to anterior superior iliac spine

Ilio-Inguinal Nerve Entrapment

C NMOB TCD

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• Iliohypogastric in 5.6%• Ilioinguinal 90.7%• Union of branches of ilioinguinal

and genital branch of thegenitofemoral nerve 13%

• Genitofemoral passing throughsuperficial inguinal ring 35.2%

• Piercing inguinal ligament 5.6%• Femoral branch 13%

Akita et al., 1999

CutaneousNerves

G i f l NMOB TCD

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• Lumbar plexus L1,2• Anterior aspect of the psoas• Genital branch enters the deep

inguinal ring

• Femoral branch lies on the lateralside of femoral artery in thefemoral sheath

Genitofemoral Nerve

F l B h G it f lMOB TCD

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•Enters thigh on lateral aspect of femoral artery in femoral sheath

• Pierces anterior wall of thesheath

• Supplies skin a hands breathbelow the inguinal ligament

Femoral Branch Genitofemoral

G it f l NMOB TCD

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•Union with ilioinguinal nerve onanterior aspect of spermatic cord

• Supplies ventral aspect of scrotumand adductor region

• Cutaneous branch on the dorsal-caudal aspect• May also supply dorsal scrotum

Akita et al., 1999

Genitofemoral Nerve

G it f l NMOB TCD

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Genitofemoral Nerve

L t l C t NMOB TCD

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• The lateral cutaneous nerves of thethigh L2,3

• Lumbar plexus in psoas• Lateral aspect of psoas• Pierces inguinal ligament• Lies in fibrous tunnel• Divides into two• Pierces deep fascia

Lateral Cutaneous Nerve

L t l C t N f ThighMOB TCD

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• A centimeter medial to anterior superior iliac spine

• Crosses the lateral angle of femoral triangle

•Divides into two• Pierces deep fascia

• Anterolateral aspect of the thigh• Anterior portion of gluteal region

Lateral Cutaneous Nerve of Thigh

Lateral Cutaneous Nerve of ThighMOB TCD

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• Entrapment in the fascial tunnel• Injured in the thigh by asymmetric bars

in gymnastics• Causes meralgia paraesthetica• Post laparoscopic surgery

Lateral Cutaneous Nerve of Thigh

Femoral Nerve L2 3 4MOB TCD

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• The largest branch of the lumbar plexus• Lateral aspect of psoas• Passes under the inguinal ligament• Outside femoral sheath

• 2 cm below• Divides into terminal branches• Muscular • Articular

• Cutaneous

Femoral Nerve L2,3,4

Femoral NerveMOB TCD

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Muscular branches• Rectus femoris• Vastus medialis• Vastus lateralis• Vastus intermedius• Sartorius, pectineusCutaneous • Medial cutaneous nerves of thigh

• Intermediate cutaneous nerves of thigh• Saphenous Articular branches to hip and knee joints

Femoral Nerve


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• Dancers may stretch the nerveby prolonged hyperextension of the hip

• Compress the nerve under theinguinal ligament

• The nerve may also becompressed due to ahaematoma following a partialtear of the iliacus

O’Brien, 1997

Femoral Nerve


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Femoral nerve

Saphenous

Femoral Nerve

Obturator NerveMOB TCD

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• The obturator nerve L2-3-4

• Lumbar plexus in psoas• Medial aspect of psoas• Side wall of pelvis under peritoneum• Leaves through obturator foramen• Divides into anterior and posterior

divisions

Obturator Nerve


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• Supplies the parietal peritoneumon side wall of the pelvis

• It is related to the ovary• Pathology in the ovary or

endometriosis may result inreferred pain to the hip, knee or medial side of the high

Obturator Nerve

Anterior Divison ObturatorMOB TCD

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• The anterior division of theobturator leaves pelvis

• Anterior to obturator externus

• Descends in front of adductor brevis

• Behind pectineus andadductor longus

obturator nerve

Anterior Divison Obturator

Anterior Divison ObturatorMOB TCD

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• Adductor longus• Adductor brevis• Gracilis• It gives an articular twig to the

hip joint• Skin on the medial side of thethigh

Anterior Divison Obturator


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Obturator Nerve

Posterior Divison ObturatorMOB TCD

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• It may be entrapped as it leaves the pelvis• Pierces and supplies the obturator externus• Causing spasm of the adductor muscles

Posterior Divison Obturator

Posterior Divison ObturatorMOB TCD

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• Supplies adductor portion of adductor magnus,above hiatus

• Articular twig to knee joint and cruciateligaments

• Causing spasm of the adductor muscles• It may be entrapped as it leaves the pelvis or

between fascial planes

Posterior Divison Obturator


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obturator nerve fascial planes

Obturator Nerve

Howship Rhomberg SignMOB TCD

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• Pressure on obturator nerve• Pain on inner aspect of thigh

relieved by flexion of hip• Increased by extension,

adduction and medial rotation

Howship Rhomberg Sign


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Obturator Nerve

Psoas MuscleMOB TCD

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Psoas Muscle

Sacral PlexusMOB TCD

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Sacral Plexus

Pudendal NerveMOB TCD

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Pudendal Nerve

Pudendal NerveMOB TCD

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• Compression of pudendal nervein cyclists due to saddle

• History of change of saddle• Compressing dorsal nerve of

penis

Pudendal Nerve

Psoas MuscleMOB TCD

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Psoas Muscle

IliacusMOB TCD

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• Iliac fossa and iliac crest• Inserts into psoas• Major • Nerve L23

• Psoas bursa

Iliacus

Rectus Femoris MuscleMOB TCD

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• Upper half of anterior inferior iliac spine• Area above actetabulum• Inserted into quadriceps tendon• Flexes hip

• Extends knee• Femoral nerve

Rectus Femoris Muscle

Hip JointMOB TCD

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• Synovial ball and socket joint• Multiaxial• Three degrees of freedom• Movement in three planes

• Close pack extension andmedial rotation• Least pack semiflexion

Hip Joint

Hip JointMOB TCD

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• One of most stable joints in thebody

• Articular surface of hip joint arereciprocally curved

• Superior surface of femur andacetabulum sustain greatestpressure

p Jo t

AcetabulumMOB TCD

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• Y shaped epiphyseal cartilage• Start to ossify at 12• Fuse 16-17• Acetabular notch is inferior

• Nonarticular fossa, thin relatedmedially to obturator internus• Pad of fat, proprioceptive nerves

Articular Surface of Hip JointMOB TCD

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• Semilunar articular surfacecovered with hyaline cartilage

• Deepened by labrumacetabulare

• Wedge shaped fibrocartilage

p

Articular SurfaceMOB TCD

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• Head of femur 2/3 rd of sphere• Pit for ligamentum teres• Covered with articular cartilage• Cartilage thicker posterior superior •

Epiphyseal line for headintracapsular

Femur MOB TCD

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• Trabeculae develop along lines of stress

• Calcar femorale is the corticalbone on inferior aspect of neck

• Neck is cancellous bone

Capsule of HipMOB TCD

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• Proximally attached• Margins of the acetabular fossa• Base of labrum• Distally, anterior to the

intertrochanteric line• Inferiorly, femoral neck close to

lesser trochanter

p p


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• Posterior • Free border, finger’s breadth

from trochanteric crest due toinsertion of obturator externus

• Into trochanteric fossa and• Root greater trochanter

p p


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• Strongest superiorly• Anteromedially, deep fibres

reflected head of rectus femoris• Iliopsoas is anterior • Lateral deep fibres of gluteus

minimus

p p

Retinacular FibresMOB TCD

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• Fibres of capsule reflectedalong neck to articular margincalled retinacular fibres

• Blood supply to head run under retinacular fibres

Ligaments of HipMOB TCD

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• Labrum acetabulare

• Transverse ligament• Ligament of head• Iliofemoral ligament• Pubofemoral ligament• Ischiofemoral ligament• Zona orbicularis

g p

Ligaments of HipMOB TCD

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• Transverse ligament is part of thelabrum

• Ligamentum teres is triangular • Its base is attached to transverse

ligament and the apex to the piton the head of femur

• Blood supply to epiphysis fromobturator artery

• Only supplies a flake of bone inelderly

g p

Iliofemoral LigamentsMOB TCD

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• Thickening of capsule

• Lower half of anterior inferior iliac spine and adjoiningacetabulum

• Distally

• Upper and lower parts of inter trochanteric line

Iliofemoral LigamentsMOB TCD

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• One of strongest ligaments in

body• Tightens in extension• Helps maintain erect posture• Facet on anterior aspect of

neck• Prevents hyperextension• Fulcrum reducing hip

Pubofemoral LigamentMOB TCD

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• Superior pubic ramus• Inferior part of inter trochanteric

line and upturned part• Relatively weak• Prevents abduction• Bursa between it and iliofemoral

Ischiofemoral LigamentMOB TCD

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• Ischium to posterior part of joint (weak)

• Circular fibres called zonaorbicularis

• Centre of gravity in front of head

• Synovial under obturator externus

Synovial MembraneMOB TCD

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• Lines inner portion of capsule

and nonarticular structures• Ligament of head• Fat in acetabular fossa• May communicate with psoas

bursa• Bursa under obturator externus

Bursa Under Glueus MaximusMOB TCD

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• Trochanteric bursa• Posterolateral aspect of

greater trochanter gluteofemoral

• Vastus lateralis ischial bursa• Ischial tuberosity

Blood Supply to Head of Femur MOB TCD

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• Child: obturator artery vialigamentum teres suppliesepiphysis

• Elderly: main supply viaretinacular vessels from

trochanteric and cruciateanastamoses

• Medial and lateral circumflexfemoral vessels

Blood SupplyMOB TCD

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• Superior gluteal supplies the upper part of the acetabulum

• Inferior gluteal supplies the inferior and posterior and the capsule

• Transverse and ascendingbranches of lateral circumflexfemoral artery

• Transverse and ascending branchof medial circumflex femoral

• Cruciate and trochantericanastomosis

Blood SupplyMOB TCD

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• Fractures of neck may cause

avascular necrosis, extracapsular arteries enter thetrochanter at the base of neck

• Medial and lateral circumflex

femoral vessels and superior gluteal

Nerve SupplyMOB TCD

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• Femoral nerve• Obturator nerve• Superior gluteal nerve• Nerve to quadratus femoris• Posterior dislocation may

damage sciatic• Pain in hip referred to knee

Stability of HipMOB TCD

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• One of the most stable joints• Congenital dislocations is

common• 1.5 per 1000 live births• Female : Male = 8:1• Ultrasound best method of

detecting

Anterior RelationsMOB TCD

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• Rectus femoris• Adductor longus• Pectineus• Psoas, iliacus•

Femoral sheath• Femoral nerve

Inferior and Posterior RelationsMOB TCD

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• Obturator externus• Passes inferior and then posterior to

joint• Superior gluteal nerve• Inferior gluteal nerve• Sciatic nerve• Posterior cutaneous nerve thigh• Nerves to obturator internus and

quadratus femoris• Pudendal nerve

Lateral RelationsMOB TCD

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• Gluteus minimus• Gluteus medius• Superior gluteal vessels and nerves

between• Iliotibial tract• Superficial three quarters of gluteus

maximus

Posterior RelationsMOB TCD

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• Piriformis• Superior gemellus• Obturator internus• Inferior gemellus•

Quadratus femoris• Adductor magnus• Obturator externus• Gluteus maximus

Movements: FlexionMOB TCD

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• Limited by anterior abdominal wall• Psoas• Iliacus• Pectineus•

Adductor longus and brevis• Rectus femoris

Movements: ExtensionMOB TCD

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• Hamstrings first 10°1. Long head of biceps2. Semitendinosus3. Semimembranosus

• 123, extended knee ++

• Adductor magnus• Gluteus maximus most efficient when hip is

flexed 45 °

Movements: AdductionMOB TCD

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• Obturator nerve• Adductor longus• Adductor brevis• Adductor magnus• Can flex or extend depending on

position of hip

Movements: AbductionMOB TCD

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• Gluteus medius• Gluteus minimus• Standing on leg, gluteus medius

and minimus abduction

• By preventing adduction

Movements: Medial RotationMOB TCD

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• Iliopsoas• Adductors• Anterior fibres of gluteus medius

Movements: Lateral RotationMOB TCD

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• Obturator internus• Piriformis• Superior gemmelus• Obturator internus• Inferior gemmelus• Quadratus femoris

Trendelenburg TestsMOB TCD

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Fractured Neck of Femur MOB TCD

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Hip Problems in ChildrenMOB TCD

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• Apophysitis• Avulsion fractures• After 13 years• 11-40% of all hip and

pelvic fracturesBoyd et al., 1997

• Anterior superior iliacspine

• Anterior inferior iliacspine

• Ischial tuberositycommonest

Hip ProblemsMOB TCD

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Pain in a ChildMOB TCD

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• 5-10 year old child

• Aching pain in hip• Limp• Limitation of movement• Perthe’s• Osteochondritis of head of femur

Stability of HipMOB TCD

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• One of the most stable joints

• Congenital dislocations iscommon

• 1.5 per 1000 live births• Female : Male = 8:1• Ultrasound best method of

detecting

Femoral AnteversionMOB TCD

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• Femoral version is the

angular differencebetween axis of femoralneck and transcondylar axis of the knee

• Femoral anteversionranges from 30º - 40º atbirth

• Decreases progressively

15º at skeletalmaturation

• Adults

• Anteversion• Average of 8º in men and

14º in women• Most common cause of

in-toeing• If associated with internal

tibial torsion may lead topatellofemoralsubluxation due to anincrease in the Q-angle

Tumors and NeoplasmsMOB TCD

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• Young, healthy athletesdo get cancer!

• Fortunately most tumorsare benign!

• Bone pain at night

• Tumor till provedotherwise

Renstrom, 2008

Hip Joint Labral Tear MOB TCD

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• Chronic

• Secondary to acetabular dysplasia• Part of ‘rim lesion’ complexRenstrom, 2008

•

Labrum Tears and Cartilage LossMOB TCD

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• Labrum tears and cartilage loss arecommon in patients with mechanicalsymptoms in the hip

• In young, active patients with acomplaint of groin pain

• The diagnosis of a labrum tear shouldbe suspected and investigated asradiographs and the history may benonspecific for this diagnosis

Burnett et al., 2006

MR – Arthrography (MRA)MOB TCD

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• MR arthrogram has an accuracyof 91% for labral tears

Chan et al., 2005

• Sensitivity labral tear

• MR 25%,

• MRA 92%Toomayan et al., 2006

Pincer ImpingementMOB TCD

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• The acetabulum covers too much of the

femoral head• Secondary to ‘retroversion’ of the socket• Or a ‘profunda’ socket that is too deep• Most of the time, the cam and pincer forms

exist together • Female, 30-40 yearsRenstrom, 2008

Cam ImpingementMOB TCD

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• Loss of roundness contributes toabnormal contact between the head andsocket

• Male, 20-30 yearsRenström, 2008

Cam ImpingementMOB TCD

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Renström, 2008

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