Chapter 18: Hip Joint

 Introduction
o The lower extremity includes the pelvis, thigh, leg, and foot.
o Bones of the pelvis are the two innominate bones (hip bones), the sacrum, and the coccyx
o Hip bone = innominate bone
 Consists of three bones: ilium, ischium, and pubis
o The leg includes the tibia and fibula
o The foot includes 7 tarsal bones, 5 metatarsals and 14 phalanges

 Joint Structure and Motions

o The hip joint is the most proximal of the lower extremity joints
o It is very important in weight-bearing and walking activities
o It is a ball-and-socket joint
 The rounded, or convex-shaped, femoral head fits into and articulates with the concave-
shaped acetabulum
 The convex femoral head slides in the direction opposite the movement of the thigh
o The hip is a very stable joint and therefore sacrifices some range of motion
o The hip is a triaxial joint
 Flexion, extension, and hyperextension occur in the sagittal plane with approximately 120º of
flexion/extension and 15º of hyperextension
 Abduction and Adduction occur in the frontal plane with about 45º of abduction.
 Adduction is usually thought of as the return to anatomical position, though there is
approximately an additional 25º of motion possible beyond the anatomical position
 In the transverse plane, medial and lateral rotations (internal and external rotations) there is
approximately 45º of rotation possible in each direction from the anatomical position
o The end feel of all hip joint motions, except flexion are firm because the tension in the capsule,
ligaments, and muscles.
 For hip flexion, the end feel is soft because of contact between the anterior thigh and the
abdomen.

 Arthrokinematics
o The hip is in the open-packed position when it is in 30º of flexion, 30º of abduction, and a small
degree of lateral rotation.
 This is the position where maximal joint surface movement is possible
o The hip joint is a convex-on-concave articulation where the head of the femur glides in the opposite
direction from the distal end of the bone.
 For example, when the femur (distal end of the bone) moves laterally in hip abduction, the
femoral head (articular surface) glides medially. In other words, they move in opposite
directions
 During hip adduction, the femur moves medially while the femoral head glides laterally
 The same movement pattern occurs for hip flexion/extension and medial-lateral rotation.
o When these accessory motions of the femoral head are limited, a mobilizing force that moves the
head of the femur into the direction of restriction can help restore motion
 A posterior glide of the head of the femur will promote stretching of the posterior capsule
and increased flexion and medial rotation.
 An anterior glide will stretch the anterior capsule and increase extension and lateral rotation

 Bones and Landmarks

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 o The innominate bone is irregularly shaped and actually consists of three bones: the ilium, the
ischium, and the pubis. By adulthood, these bones fuse together
 Bony Landmarks: Ilium
o Iliac fossa
 Large, smooth, concave area on the internal surface to which the iliac portion of the iliopsoas
muscle attaches
o Iliac Crest
 Bony part that your hands rest on when you put your hands on your hips
 Its borders are the anterior superior iliac spine and the posterior superior iliac spine
o Anterior Superior Iliac Spine
 The projection on the anterior end of the iliac crest
 The tensor fascia lata and the sartorius muscles and the inguinal ligament attach here
o Anterior Inferior Iliac Spine
 The projection to which the rectus femoris attaches is on the AIIS
o Posterior Superior Iliac Spine
 It is the posterior projection on the iliac crest
o Posterior Inferior Iliac Spine
 Located just below the PSIS

 Bony Landmarks of the Ischium

 The posterior inferior portion of the innominate bone
o Ischial Body
 Makes up about two-fifths of the acetabulum
o Ischial Ramus
 Extends medially from the body to connect with the inferior ramus of the pubis.
 The adductor magnus, obturator externus, and obturator internus muscles attach here
o Ischial Tuberosity
 Rough, blunt projection of the inferior part of the body, which is weight-bearing when you
are sitting
 It provides attachment for the hamstring and adductor magnus muscles
o Ischial Spine
 Located on the posterior portion of the body between the greater and lesser sciatic notches
 It provides attachment for the sacrospinous ligament

 Bony Landmarks of the Pubis

o Pubic Body
 Externally forms about one-fifth of the acetabulum
 Internally provides attachment for the obturator internus muscle
o Superior Ramus
 Lies superiorly between the acetabulum and the body
 Provides attachment for the pectineus muscle
o Inferior Ramus
 Lies posterior, inferior, and lateral to the body
 Provides attachment for the adductor magnus and brevis and gracilis muscles
o Symphysis Pubis
 A cartilaginous joint connecting the bodies of the two pubic bones at the anterior midline
o Pubic Tubercle
 Projects anteriorly on the superior ramus near the symphysis pubis
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  Provides attachment for the inguinal ligament

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 Important Bony Landmarks of a Combination of the Innominate Bones
o Acetabulum
 A deep, cup-shaped cavity that articulates with the femur
 It is made up of nearly equal portions of the ilium, ischium, and pubis
o Obturator Foramen
 A large opening surrounded by the bodies and rami of the ischium and pubis and through
which pass blood vessels and nerves
o Greater Sciatic Notch
 Large notch just below the PIIS that is actually made into a foramen by the sacrospinous and
sacrotuberous ligaments
 The sciatic nerve, piriformis muscle, and other structures pass through this opening

 Bony Landmarks of the Femur

o The femur is the longest, strongest, and heavy bone in the body. A person’s height can roughly be
estimated to be four times the length of the femur It articulates with the innominate bone to form the
hip joint and has significant landmarks
o Head
 The rounded portion covered with articulating with the acetabulum
o Neck
 The narrower portion located between the head and the trochanters
o Greater Trochanter
 Large projection located laterally between the neck and the body of the femur
 Provides attachment for the gluteus medius and minumus and for the deep rotator muscles
o Lesser Trochanter
 A smaller projection located medially and posteriorly just distal to the greater trochanter
 Providing attachment for the iliopsoas muscles
o Trochanteric Fossa
 Medial surface of the greater trochanter
o Intertrochanteric Crest
 The smooth ridge between greater and trochanters
 Serves as an attachment for quadratus femoris
o Body
 The long, cylindrical portion between the bone ends
 Also called the shaft
 It is bowed slightly anteriorly
o Medial Condyle
 Distal medial end
o Lateral Condyle
 Distal to lateral end
o Lateral Epicondyle
 Projection proximal to the lateral condyle
o Medial Epicondyle
 Projection proximal to the medial condyle
o Adductor Tubercle
 Small projection proximal to the medial epicondyle to which a portion of the femur to which
many muscles attach
o Pectineal Line
 Runs from below the lesser trochanter diagonally toward the linea aspera
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  It provides attachment for the adductor brevis

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 o Patellar Surface
 Located between the medial and lateral condyle anterior
 It articulates with the posterior surface of the patella

 Ligaments and Other Structures

o The hip has a fibrous joint capsule
 It is strong and thick, and it covers the hip joint in a cylindrical fashion
 It attaches proximally around the lip of the acetabulum
o Three ligaments reinforce the capsule:
 Iliofemoral ligament
 It reinforces the capsule anteriorly by attaching proximally to the AIIS and crossing
the joint anteriorly
 It splits in two parts distally to attach to the intertrochanteric line of the femur
 It is often referred as the Y ligament due to its introverted Y resemblance
 Known as the ligament of Bigelow
 Its main function is to limit hyperextension
 Pubofemoral Ligament
 Spans the hip joint medially and inferiorly
 It attaches from the medial part of the acetabular rim and superior ramus of the pubis
and runs down the back to attach on the neck of the femur
 Limits hyperextension and abduction
 Ischiofemoral Ligament
 Covers the capsule posteriorly
 It attached on the ischial portion of the acetabulum, crosses the joint in a lateral and
superior direction, and attaches on the femoral neck
 Its fibers limit hyperextension and medial rotation
 All three of these ligaments attach along the rim of the acetabulum and cross the hip joint in a
spiral fashion to attach on the femoral neck
 The combined effect of this spiral attachment is to limit motion in one direction
(hyperextension) while allowing full motion (flexion) in the other direction
 Therefore, these ligaments are slack in flexion and become taut as the hip joint moves
into hyperextension
 If you thrust your hips forward so that they are in front of your shoulders and knees, you
cause the line of gravity to pass posterior to the axis of the rotation for the hip joint
 This allows you to stand in the upright position without using any muscles by
essentially resting or hanging on the iliofemoral ligament
 This is the basis for the standing posture of an individual with paralysis following
spinal cord injury
o The depth of the acetabulum is increased by the fibrocartilaginous acetabular labrum
 Located around the rim
 The free end of the labrum surrounds the femoral head and helps to hold the head in the
acetabulum

o The inguinal ligament

 Has no function at the hip joint
 It should be identified because of its presence
 It runs from the ASIS to the pubic tubercle and is the landmark that separates the anterior
abdominal wall from the thigh
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  When the external iliac artery and vein pass under the inguinal ligament, their names change
to the femoral artery and vein
o The iliotibial band and tract
 The very long, tendinous portion of the tensor fascia lata muscle
 It attaches to the anterior portion of the iliac crest and runs superficially down the lateral side
of the thigh to attach to the tibia
 Both the gluteus maximus and tensor fascia lata muscles have fibers attaching to the iliotibial
band
o The end feel as all hip joint motions, except flexion is firm because of tension in the capsule,
ligaments, and muscles
 for hip flexion, the end feel is soft because of contact between the anterior thigh and the
abdomen

o Adductor Hiatus
 The adductor hiatus is the gap or opening in the distal attachment of the adductor magnus
between the linea aspera and the adductor tubercle
 It is significant because the femoral artery and vein pass through this opening to reach the
posterior surface of the knee, where their name changes to popliteal artery and vein

 Muscles of the Hip

o There are many similarities between the shoulder and hip joints.
o Like the shoulder, the hip has a group of one-joint muscles that provide most of the control, and
it has a group of longer, two-joint muscles that provide the range of motion.
o These muscles can also be grouped according to their location and somewhat by their function.
 The anterior muscles with a vertical line of pull tend to be flexors
 Lateral muscles tend to be abductors
 Posterior muscles tend to be extensors
 Medial muscles tend to be adductors.
o Muscles that have a more horizontal line of pull and cross the anterior side of the hip are medial
rotators
 Those that cross the posterior side of the hip are lateral rotators.
o Several of the hip prime movers are two-joint muscles that also cross the knee.
 Those muscles that cross the anterior side of the knee are knee extensors, whereas the
posterior muscles are knee flexors.
o Iliopsoas Muscle
 Is two muscles with separate proximal attachments and a common distal attachment.
 The iliacus muscle portion arises from the iliac fossa
 Psoas major muscle portion comes from the transverse processes, bodies, and
intervertebral disks of the T12 through L5 vertebrae.
 These muscles blend together to attach on the lesser trochanter of the femur. T
 he iliopsoas muscle is a prime mover in hip flexion.
 Because of its attachment on the vertebrae, the psoas muscle portion contributes to
trunk flexion when the femur is stabilized.
o Rectus Femoris Muscle
 Is part of the quadriceps muscle group and is the only one of that group to cross the hip joint
 Its proximal attachment is on the AIIS.
 It runs almost straight down the thigh, where it is joined by the three vasti muscles to
blend into the quadriceps tendon (also called the patellar tendon).

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  This tendon encases the patella, crosses the knee joint, and attaches to the tibial
tuberosity.
 The rectus femoris muscle is a prime mover in hip flexion and knee extension.

o Sartorius Muscle
 The longest muscle in the body
 This straplike muscle arises from the ASIS.
 It runs diagonally across the thigh from lateral to medial and proximal to distal to cross the
medial knee joint posteriorly.
 Because of its line of pull, it is capable of flexing, abducting, and laterally rotating the hip
and flexing the knee.
 However, it is not considered a prime mover in any one of these motions.
 It is most efficient when doing all four motions at the same time.
 An example of this motion is when you cross your legs by putting one foot on the
opposite knee.

o Pectineus Muscle
 Located medial to the iliopsoas muscle and lateral to the adductor longus muscle
 Its origin is on the superior ramus of the pubis
 Its insertion is on the pectineal line of the femur
 Because it spans the hip joint anteriorly and medially, it provides hip flexion and adduction.

o Three One-Joint Hip Adductors

 There are three other one-joint hip adductors, all with the same first name

 Adductor Longus Muscle

 The most superficial of the three
 It originates from the anterior surface of the pubis near the tubercle
 It inserts on the middle third of the linea aspera of the femur.
 Because it is superficial, its tendon can easily be felt in the anteromedial groin.
 Being able to palpate this tendon is important when checking for correct fit of the
quadrilateral socket of an above-knee prosthesis.
 It is a prime mover in hip adduction.

 Adductor Brevis Muscle

 Implies by its name that it is shorter than the other adductor muscles.
 It lies deep to the adductor longus muscle but superficial to the adductor magnus
muscle.
 It arises from the inferior ramus of the pubis
 It inserts on the pectineal line and proximal linea aspera above the adductor longus
muscle.
 It is a prime mover in hip adduction.

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  Adductor Magnus Muscle
 The largest and deepest of the adductors
 It arises from the ischial tuberosity and ramus of the ischium and inferior ramus of the
pubis.
 It makes up most of the bulk on the medial thigh.
 Its fibers fan out in a downward and lateral direction to insert along the entire linea
aspera and on the adductor tubercle.
 There is an interruption called the adductor hiatus, in the distal attachment between
the linea aspera and adductor tubercle.
 The femoral artery and vein pass through this opening.
o After these structures have passed through to the posterior surface,
their names become the popliteal artery and vein, respectively.
o Because of its size, the adductor magnus muscle is a very strong hip adductor.
o Because the lower fibers have a near vertical line of pull, it can assist in hip
extension.
 Gracilis Muscle
 The only hip adductor that is a two-joint muscle.
 It arises from the symphysis and inferior ramus of the pubis and descends the thigh
medially and superficially.
 It crosses the knee joint posteriorly and curves around the medial condyle to attach
distally on the anteromedial surface of the proximal tibia.
 It assists with knee flexion.

o Gluteus Maximus Muscle

 Can be described as a large, thick, one-joint, quadrilateral muscle located superficially on the
posterior buttock
 It arises from the general area of the posterior sacrum, coccyx, and ilium, and it runs in a
diagonal direction distally and laterally to the posterior femur, inferior to the greater
trochanter.
 Some fibers also attach to the iliotibial band.
 Because it spans the hip joint posteriorly in this diagonal direction, it is very strong in hip
extension, hyperextension, and lateral rotation.

o Deep Rotator Muscles

 There are six small, deep, mostly posterior muscles that span the hip joint in a horizontal
direction, and they all laterally rotate the hip.
 Because they all work together to produce the same motion, their individual attachments are
not functionally important; therefore, they can be grouped together as the deep rotator
muscles 
 However, the piriformis is the best known of this group, perhaps because of its close
relationship to the sciatic nerve
 Tightness of the piriformis can compress the sciatic nerve resulting in radiating pain down
the back of the leg

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 o Hamstring Muscles
 Three muscles that cover the posterior thigh.
 They consist of the semimembranosus, the semitendinosus, and the biceps femoris muscles
They have a common site of origin on the ischial tuberosity.

 Semimembranosus Muscle 
 Runs down the medial side of the thigh, deep to the semitendinosus muscle
 Inserts on the posterior surface of the medial condyle of the tibia.

 Semitendinosus Muscle
 The semitendinosus muscle has a much longer and narrower distal tendon that spans
the knee joint posteriorly and then moves anteriorly to attach to the anteromedial
surface of the tibia with the gracilis and sartorius muscles.

 Biceps Femoris Muscle 

 Has two heads and runs down the thigh laterally on the posterior side.
o The long head arises with the other two hamstring muscles on the ischial
tuberosity
o The short head arises from the lateral lip of the linea aspera of the femur.
o Both heads join together, spanning the knee posteriorly to attach laterally on
the head of the fibula and, by a small slip, to the lateral condyle of the tibia.
 Because they span the knee posteriorly, they flex the knee.
 The long head, because it spans the hip joint posteriorly, extends the hip.

 Gluteus Medius Muscle

 Are more laterally located.
 Triangular, much like the deltoid muscle of the shoulder.
 It attaches proximally to the outer surface of the ilium and distally to the lateral
surface of the greater trochanter.
 Because it spans the hip joint laterally, the gluteus medius muscle can abduct the hip.
 Its anterior fibers are able to assist the gluteus minimus muscle in medially rotating
the hip.

 Gluteus Minimus Muscle

 The smallest and deepest of the three gluteal muscles
 Lies deep and inferior to the gluteus medius muscle on the lateral ilium
 Its broad proximal attachment extends from near the greater sciatic notch to almost as
far forward as the anterior border, near the ASIS.
 The distal attachment is on the anterior aspect of the greater trochanter.
 This gives the gluteus minimus muscle a somewhat diagonal line of pull, making it
able to medially rotate the hip.
 Because it spans the hip joint laterally, it also abducts the hip.

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  Attaching to the ilium and the femur and spanning the hip joint laterally, these two gluteal
muscles have another very important function.
 When you stand on one leg, the gluteus medius and minimus muscles contract to keep the
pelvis fairly level and to prevent the opposite side of the pelvis from dropping too much
(lateral tilt) when you stand on one leg
 This occurs every time you pick up one leg, as when walking.
 Weakness or loss of these muscles results in a “Trendelenburg gait.”
 For example, because the pelvis moves as a whole, if your right hip abductors are
weak, the left side of your pelvis will drop significantly when you stand on your right
leg and lift your left leg off the ground.

o Tensor Fascia Lata Muscle

 A very short muscle with a very long tendinous attachment
 It arises from the ASIS, crosses the hip joint laterally and slightly anteriorly, and then
attaches to the long fascial band called the iliotibial band, which proceeds down the lateral
thigh and attaches to the lateral condyle of the tibia.
 It is a hip abductor, but due to its slight anterior position, it is perhaps strongest when
performing a combination of flexion and abduction.
 Stated another way, it is most efficient when abducting in a slightly anterior direction.

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 Common Hip Pathologies
o The hip joint is the site of many orthopedic conditions that occur throughout life and can affect
lower extremity alignment
o Congenital Hip Dislocation, or dysphasia
 Occurs when an unsually shallow acetabulum causes the femoral head to slide upward
 The joint capsule remains intact, though stretched
o Legg-Calve-Perthes Disease, or coxa plana
 A condition in which the femoral head undergoes necrosis
 It is usually seen in children between the ages of 5 and 10 years
 During the course of the disease, it may take about 2 to 4 years for the head to die,
revascularize, and then remodel
o Slipped Capital Femoral Epiphysis
 Seen in children during the growth-spurt years
 Proximal epiphysis slips from its normal position on the femoral head
o Angle of Inclinations
 The angle between the shaft and the neck of the femur in the frontal plane
 Normally 125 degrees
 This angle varies from birth to adulthood
 At birth, the angle may be as great as 170 degrees, but by adulthood the angle
decreases significantly
 Factors such as congentital deformity, trauma, and disease may affect the angle
o Coxa Valga
 Characterized by a neck-shaft angle greater than 125 degrees
 Because the angle is “straighter,” it tends to make the limb longer, thus placing the hip in an
adducted position during weight-bearing
o Coxa Vara
 A deformity in which the neck-shaft angle is less than the normal 125 degrees
 Because it is “more bent,” it tends to make the involved limb shorter, dropping the pelvis on
that side during weight-bearing
o Angle of Torsion
 The angle between the shaft and the neck of the femur in the transverse plane
 Normally has the head and neck rotated outward from the shaft approximately 15 to 25
degrees
 Looking down on the femur, you can see the femoral head and neck superimposed on
the shaft
 The shaft is best shown here by a line through the femoral condyles, which attach to
the shaft distally
 As the shaft rotates, so do the condyles
o Anteversion
 Is an increase in the angle of torsion
 Forces the hip joint into a more medially rotated position
 This causes a person to walk more “toed in”
o Retroversion
 A decrease in the angle of torsion
 This forces the hip joint into a more laterally rotated position
 This causes the person to walk more “toed out”
o Osteoarthritis
 A degeneration of the articular cartilage of the joint

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  It may result from trauma or wear and tear and typically seen later in life
 Commonly treated with a total joint replacement
o Hip Fractures
 Tend to be of two types: Intertrochanteric and Femoral Neck
 These are very common among elderly people, usually resulting from falls
 High-impact trauma such as motor vehicle accidents may cause hip fractures in younger
individuals
o Iliotibial Band Syndrome
 Is an overuse injury causing lateral knee pain
 Commonly seen in runners and bicyclists
 This syndrome is believed to result from repeated friction of the band that slides over the
lateral femoral epicondyle during knee motion
 Caused by factors such as muscle tightness, worn-down shoes, and running on uneven
surfaces
 Because many muscles insert at the greater trochanter, there are many bursae providing a
friction-reducing cushion between the muscles and the bones
o Trochanteric Bursitis
 The result of either acute trauma or overuse
 It can be seen in runners or bicyclists or in someone with a leg length discrepancy, or it can
be caused by other factors that put repeated stress on the greater trochanter

o Hamstring Strain
 Also called a pulled hamstring
 Is probably the most common muscle problem in the body
 Often recurrent
 May result from an overload of the muscle or trying to move the muscle too fast
 Therefore is a common injury among sprinters in sports that require bursts of speed or
rapid acceleration, such as soccer, track and field, football, baseball, and rugby
 Hamstring strains can occur at one of the attachment sites or at any point along the length of
the muscle
o Hip Pointer
 A misnomer because it occurs at the pelvis, not the hip joint
 It is a severe bruise caused by direct trauma to the iliac crest of the pelvis
 It is most commonly associated with football but can be seen in almost any contact sport
 Spearing the hip and pelvis with a helmet while tacking may be the most common
cause

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