The Hip Joint
• “coxofemoral joint”
• articulation of the acetabulum of the
pelvis and the head of the femur
• diarthrodial ball-and-socket joint with
three degrees of freedom:
➢flexion/ extension in the
sagittal plane
➢abduction/adduction in the
frontal plane
➢medial/lateral rotation in the
transverse plane
• support the weight of the head, arms,
and trunk (HAT) both in static erect
posture and in dynamic postures
Proximal Articular Surface
• acetabulum”
• lateral aspect of the pelvic bone
(innominate or os coxa):
➢ilium
➢ischium
➢pubis
• ischium forms 2/5, ilium forms 2/5, pubis
forms 1/5 of the acetabulum
• periphery (lunate surface) is covered
with hyaline cartilage (horseshoe-
shaped
• inferior aspect of the lunate surface (the
base of the horseshoe) is interrupted by
a deep Notch called the acetabular
notch
• the acetabular notch is spanned by the
transverse acetabular ligament that
connects the Two ends of the horseshoe
• forms a fibro-osseous tunnel through
which blood vessels pass into the
deepest portion of The acetabulum
called the acetabular fossa
• The acetabulum is deepened by the
fibrocartilaginous acetabular labrum,
which surrounds The periphery of the
acetabulum
Acetabulum
>domaera
• Positioned laterally with an inferior
and anterior tilt
• laterally inclined 50°; anteriorly
rotated (anteversion) 20°; and
anteriorly tilted 20°
• normal functioning of the hip
requires optimal femoral head
coverage by the acetabulum;
Femoral head coverage is largely
determined by acetabular depth
• Acetabular depth can be measured
as the center edge/angle of Wiberg
o formed by a line connecting
the lateral rim of the
acetabulum and the center
of the femoral Head and a
vertical line from the center
of the femoral head
• acetabular dysplasia is an
abnormally shallow acetabulum that
results in a lack of femoral Head
coverage classified as follows:
o normal = >25°
o definite dysplasia = <16°
o possible dysplasia = 16° to
25°
o may indicate excessive
acetabular overcoverage =
>40°
• coxa profunda an acetabular
protrusio are conditions in which the
acetabulum Excessively covers the
femoral head
o limited range of motion
(ROM) and internal
impingement between the
femoral head-neck junction
And acetabulum
• anteversion of the acetabulum is
when the acetabulum is positioned
too far anteriorly in The transverse
plane
o acetabulum that is
positioned with less
inclination
o can lead to instability
• retroversion of the acetabulum is
when the acetabulum is positioned
too far posteriorly in The transverse
plane
o acetabulum that is
positioned with more
inclination
o can lead to overcoverage
and impingement between
the acetabulum femoral-
head neck junction
Acetabular Labrum
• a ring of wedge-shaped fibrocartilage
that rims the entire periphery of the
acetabulum
• functions of the acetabular labrum:
1. deepens the acetabulum
2. acts as a seal to maintain negative
intra-articular pressure
3. decreases force transmitted to the
articular cartilage
4. provides proprioceptive feedback
• an abnormally shallow acetabulum will
increase stress on the surrounding
capsule and Labrum
• transverse acetabular ligament is
considered to be part of the acetabular
labrum
Distal Articular Surface
• “head of the femur”
➢ attached to the femoral neck; the
femoral neck is attached to the shaft
of the femur between the Greater
and lesser trochanters
➢ angulated so that the femoral head
faces medially, superiorly, and
anteriorly
➢ articular area of the femoral head
forms approximately 2/3 of a sphere
and is more circular than the
Acetabulum
• inferior to the most medial point on the
femoral head is a small, roughened pit
called the Fovea or fovea capitis
 • not covered with articular cartilage
and is the point at which the
ligament of the head of the
femur(ligamentum teres) is attached
Angulation of the Femur
• 2 angulations made by the head and
neck of the femur in relation to the
shaft:
1. angle of inclination occurs in the
frontal plane between an axis
through the femoral head and
neck and the longitudinal axis of
the femoral shaft
2. angle of torsion occurs in the
transverse plane between an
axis through the femoral head
and neck and an axis through
the distal femoral condyles
Angle of Inclination of the Femur
• in a normal angle of inclination, the
greater trochanter lies at the level of the
center of the Femoral heat
• normal range = 110° to 144°
(approximates 125°)
• angle of inclination of the femur changes
across the life span
➢ it approximates 150° at birth
➢ gradually declines to about 125°
at skeletal maturity
➢ continue to decline again in the
elderly
• pathological increase in the angulation
between the neck and shaft is called
coxa valga
• pathological decrease in the angulation
between the neck and shaft is called
coxa vara
Coxa Valga
• angle of inclination in the femur is
greater than 125°
• brings the vertical weight-bearing line
closer to the shaft of the femur,
diminishing the shear, Or bending, force
across the femoral neck
>domaera
• decreases the length of the moment
arm of the hip abductor muscles
• abductor muscles will be unable to
meet the increased demand and will be
functionally Weakened
• reduction in force is actually reflected in
a reduction indensity of the lateral
trabecular system
• decreases the amount of femoral
articular surface in contact with the
dome of the Acetabulum
• decreases the stability of the hip and
predisposes the hip to dislocation
Coxa Vara
• gives the advantage of improved hip
joint stability
• decreased angle between the neck and
shaft of the femur will turn the femoral
head deeper Into the acetabulum
• increase the length of the moment arm
of the hip abductor muscles by
increasing the Distance between the
femoral head and the greater trochanter
• seen by the increased density of
trabeculae laterally in the femur, caused
by the increase in Tensile stresses
• The increased shear force along the
femoral neck will increase the
predisposition toward Femoral neck
fracture
• Slipped capital femoral epiphysis/SCFE
results when weight-bearing forces slide
the Femoral head inferiorly on the
cartilaginous epiphysis of the head of
the femur
➢ The epiphyseal obliquity makes the
plate more vulnerable to shear
forces at a time when the plate is
Already weakened
➢ most common adolescent hip
disorder occurring when the femoral
head displaces posteriorly on the
Femoral neck at the level of the
growth plate (physis)
Angle of Torsion of the Femur
• best be viewed by looking down the
length of the femur superiorly
• axis through the femoral head and neck
in the transverse plane will lie at an
angle to an axis Through the femoral
condyles, with the head and neck
torsioned anteriorly (laterally) with
Regard to an angle through the femoral
condyle
• angle of anterior torsion decreases with
age
o In the newborn, 30° to 40° on
average
o This angle decreases of
approximately 1.5° per year until
skeletal maturity
o In the adult, 10° to 20° (15° for
males and 18° for females)
Femoral Anteversion
• angle of anterior torsion is greater than
15° to 20°
• associated with increased medial
rotation ROM and concurrent decreased
lateral rotation so That the total
excursion of hip rotation motion remains
the same
• femoral anteversion and coxa valga are
commonly found together (but each may
occur Independently of the other)
• reduces hip joint stability because the
femoral articular surface is more
exposed anteriorly
• line of the hip abductors may fall more
posterior to the joint, reducing the
moment arm for Abduction resulting
need for additional abductor muscle
force
• The abnormal position of the knee joint
axis is commonly labeled medial femoral
torsion
o medial femoral torsion and
femoral anteversion are the
same abnormal condition of the
femur
 o whether the exaggerated twist
in the femur is altering the
mechanics at the hip joint
(femoral anteversion) or at the
knee joint (medial femoral
torsion)
• when femoral head is anteverted, the
anterior capsuloligamentous structures
and Musculature may push the femoral
head back into the acetabulum, causing
the entire femur Torotate medially with
toe-in
o however, the toe-in position of
the foot may appear to diminish
over time because it is common
to See a compensatory lateral
tibial torsion develop
o although the foot placement
looks better, the underlying hip
problem generally remains
Femoral Retroversion
• angle of anterior torsion is less than 15°
to 20°
• femoral retroversion is the opposite of
anteversion and creates problems
opposite those of Femoral anteversion
Articular Congruence
• there is more articular surface on the
head of the femur than there is on the
acetabulum
• in neutral or standing position, the
articular surface of the femoral head
remains exposed Anteriorly and
somewhat superiorly
o the acetabulum does not fully
cover the head superiorly, and
the anterior torsion of the
femoral head Exposes a
substantial amount of the
femoral head’s articular surface
anteriorly
• incongruent joint in non-weightbearing,
given the larger femoral head; in weight-
bearing, The elastic deformation of the
>domaera
acetabulum increases contact with the
femoral head
• articular contact between the femur and
the acetabulum can be increased in the
normal non weight-bearing hip joint by a
combination of flexion, abduction, and
slight lateral rotation(frog-leg position)
• an additional contribution to articular
congruence of joint surfaces by the
acetabular fossa
o may be important in setting up a
partial vacuum in the joint so
that atmospheric pressure
contributes To stability by
helping maintain contact
between the femoral head and
the acetabulum
o stronger role in stabilization than
capsuloligamentous structures
• the labrum enhances joint stability not
only by deepening the acetabulum but
also by acting As a seal to maintain
negative intra-articular pressure
Hip Joint Capsule
• an irregular, dense fibrous structure with
longitudinal and oblique fibers and with
three Thickened regions that constitute
the capsular ligaments
• capsule covers the femoral head and
neck like a cylindrical sleeve and
attaches to the base of The femoral
neck the
o femoral neck is intracapsular
o both greater and lesser
trochanters are extracapsular
• unlike the relatively weak articular
capsule of the shoulder, the hip joint
capsule is a Substantial contributor to
joint stability
• capsule is attached proximally to the
entire periphery of the acetabulum
beyond the Acetabular labrum
• fibers near the proximal attachment are
aligned in a somewhat circumferential
manner and a tight ring called the zona
orbicularis
o stability of the hip joint during
distractive forces
• thickened anterosuperiorly, where the
predominant stresses occur; it is
relatively thin and Loosely attached
posteroinferiorly
• superior and inferior gluteal arteries
supply the hip capsule more proximally
• medial and lateral circumflex arteries
supply the capsule more distally
• gluteal contributions dominate the
posterior portions of the joint capsule
• circumflex branches supply the anterior
capsule
• femoral head was supplied through the
medial femoral circumflex artery
• Legg-Calvé-Perthes Disease is noted
by collapse of the femoral head,
resulting in flattening Of the head from
loss of blood supp
Hip Joint Ligaments
• Ligamentum teres
o is an intra-articular accessory
joint structure encased in a
flattened sleeve Of synovial
membrane so that it does not
communicate with the synovial
cavity of the joint
- is a triangular band that
attaches to the
peripheral edge of the
acetabular notch.
- passes under the
transverse acetabular
ligament to attach at its
other end to the fovea
of the femur
- called the “ligament of
the head of the femur”
- tighten with lateral
rotation when the hip is
flexed 10°.
 - because of its laxity,
pinching between the
femoral head and
acetabulum can occur,
causing Complaints of
pain and clicking
• 2 anterior capsular ligaments
1. Iliofemoral ligament
- is referred to as the Y
ligament of Bigelow
- apex of the ligament is
attached to the AIIS,
and the 2 arms of the Y
fan out to attach along
the Intertrochanteric line
of the femur
- band of the iliofemoral
ligament is the strongest
and thickest of the hip
joint ligaments
- primary stabilizing
component of the
anterior hip joint
2. Pubofemoral ligament
- arising from the anterior
aspect of the pubic
ramus and passing to
the anterior surface of
the Intertrochanteric
fossa
- controls lateral rotation
in an extended position
• the bands of the iliofemoral and the
pubofemoral ligaments form a Z on the
anterior capsule
• 1 posterior capsular ligament
1. Ischiofemoral ligament Capsuloligamentous Tension
- attaches to the posterior
surface of the
acetabular rim and the
acetabulum labrum
- primary restraint to
medial rotation of the
hip regardless of hip
>domaera
position in flexion or
extension
• each of the hip joint motions will be
checked by at least one portion of one of
the hip joint Ligaments and that the
forces transmitted by the ligaments (and
capsule) are dependent on Orientation
of the femur in relation to the
acetabulum
• hip joint capsule and the majority of its
ligaments are quite strong and that each
tightens with Full hip extension
(hyperextension)
• lateral branch of the iliofemoral limited
medial rotation, especially when the hip
was in Extension; also the most
significant restraint to lateral rotation
when the hip was in neutral Position and
when the hip was flexed
• hip joint, its capsule, and ligaments
routinely support two thirds of the body
weight (the Weight of HAT)
• in bilateral stance, the hip joint is
typically in neutral position or slight
extension
• in this position, the capsule and
ligaments are under some tension
• the normal line of gravity in bilateral
stance falls behind the hip joint axis,
creating a gravitational Extension
moment
• further hip joint extension creates
additional passive tension in the
capsuloligamentous Complex that is
sufficient to offset the gravitation
extension moment
• hip extension with slight abduction and
medial rotation, is the close-packed
position for the Hip joint
• in contrast to most other joints in the
body, the close-packed and stable
position for the hip Joint is not the
position of optimal articular contact
(congruence)
o as already noted, optimal
articular contact occurs with
combined flexion, abduction,
and lateral Rotation
• a position of vulnerability occurs when
the hip joint is flexed and adducted (as
it is when Sitting with the thighs
crossed)
o in this position, a strong force
up the femoral shaft toward the
hip joint (as when the knee hits
the Dashboard in a car
accident) may push the femoral
head out of the acetabulum
• capsuloligamentous tension at the hip
joint is least when the hip is in moderate
flexion, slight Abduction, and
midrotation.
o in this position, the normal
intra-articular pressure is
minimized, and the capacity of
the synovial Capsule to
accommodate abnormal
amounts of fluid is greatest
o position assumed by the hip
when there is pain arising from
capsuloligamentous problems
or from Excessive intra-articular
pressure caused by extra fluid
(blood or synovial fluid) in the
joint
• minimizing intra-articular pressure not
only decreases pain in the joint but also
prevents the Excessive pressure from
compressing the intra-articular blood
vessels and interfering with the Blood
supply to the femoral head
Structural Adaptations to Weight-Bearing
• the trabeculae (calcified plates of
tissue within the cancellous bone)
line up along lines of stress and
form systems that normally adapt to
stress requirements
• in standing or upright weightbearing
activities, at least half the weight of
 the hat (the gravitational force)
passes down through the pelvis to
the femoral head; whereas the
ground reaction force (grf) travels up
the shaft
1. these two forces, nearly
parallel and in create a force
couple with a moment arm
equal to the distance
between the superimposed
body weight on the femoral
head and the grf up the
shaft
2. these forces create a
bending moment (or set of
shear forces) across the
femoral neck
3. the bending stress creates a
tensile force on the superior
aspect of the femoral neck
and a compressive stress
on the inferior aspect
• a complex set of forces prevents the
rotation and resists the shear forces
that the force Couple causes;
among these forces are the
structural resistance of two major
and three Minor trabecular systems
1. the medial (or principal
compressive) trabecular
system
➢ arises from the medial
cortex of the upper
Femoral shaft and
radiates through the
cancellous bone to the
cortical bone of the
superior aspect of The
femoral head. The
medial system of
trabeculae is oriented
along the vertical
compressive forces
Passing through the hip
joint
>domaera
2. lateral (or principal
tensile) trabecular system
of the femur
➢ arises from the lateral
cortex of the upper
Femoral shaft and, after
crossing the medial
system, terminates in
the cortical bone on the
inferior Aspect of the
head of the femur. The
lateral trabecular
system is oblique and
may develop in
response To parallel
(shear) forces of the
weight of hat and the
ground reaction force.
3. Two accessory (or
secondary) trabecular
systems,
➢ one is considered
compressive and the
Other is considered
tensile. Another
secondary trabecular
system is confined to
the trochanteric area Of
the femur
• Areas in which the trabecular systems
cross each other at right angles are
areas that offer The greatest resistance
to stress and strain. There is an area in
the femoral neck in which The
trabeculae are relatively thin and do not
cross each others is the zone of
weakness
• The primary weight-bearing surface of
the acetabulum, or dome of the
acetabulum, is located on the superior
Portion of the lunate surface/shows the
greatest prevalence of degenerative
changes in the acetabulum which
Corresponds to the area of greatest
pressure
• primary weightbearing area of the
femoral head is, correspondingly, its
superior portion. Degenerative changes
In the femoral head include loss of the
regular “ball” shape with flattening of the
superior portion. DegenerativeChanges
are also consistently noted near the
attachment of the ligamentum teres
• superior femoral head receives
compression not only from the dome in
standing but also from the posterior
Acetabulum in sitting and the anterior
acetabulum in extension.
• More frequent and complete
compression of the cartilage of the
superior femoral head, according to this
Premise, leads to better nutrition within
the cartilage.
• Persisting incongruence in the dome of
the acetabulum in the moderately
loaded hip (especially in young Adults)
could result in incomplete compression
of the dome cartilage and, therefore,
inadequate fluid exchange To maintain
cartilage nutrition
• The forces of HAT and the ground
reaction force that act on the articular
surfaces of the hip Joint and on the
femoral head and neck also act on the
femoral shaft
o the shaft of the femur is not
vertical however, the vertical
loading on the oblique femur
results in bending stresses in
the shaft
o the medial cortical bone in the
shaft (diaphysis) must resist
compressive stresses; whereas
the lateral Cortical bone must
resist tensile stresses
Motion of the Femur on the Acetabulum
• convex femoral head within the
concavity of the acetabulum as the
femur moves through its Three degrees
of freedom:
 flexion/extension,abduction/adductio
n, and medial/lateral Rotation
• normal gait on level ground requires at
least the following hip joint ranges:
▪ 30° flexion
▪ 10°Hyperextension,
▪ 5° of both abduction
and adduction,
▪ 5° of both medial and
lateral Rotation.
o walking on uneven terrain or
stairs will increase the need for
joint range beyond that required
for level Ground, as will
activities such as sitting in a
chair or sitting cross-legged
• flexion of the hip is generally about 90°
with the knee extended and 120° when
the knee is Flexed and passive tension
in the two-joint hamstrings muscle group
is released
• hip extension is considered to have a
range of 10° to 30°
o when hip extension is combined
with knee flexion, passive
tension in the two-joint rectus
femoris Muscle may limit the
movement
• The femur can be abducted 45° to 50°
and adducted 20° to 30°
o abduction can be limited by the
two-joint gracilis muscle
o adduction limited by the TFL
muscle and ITB
• medial and lateral rotations of the hip
are usually measured with the hip joint
in 90° of Flexion; the typical range is 42°
to 50
Motion of the Pelvis on the Femur
• When the hip joint is weight-bearing
and the femur is relatively fixed,
motion of the hip joint is Produced by
movement of the pelvis on the femur
>domaera
• aligned pelvis, the ASIS of the pelvis lie
on a horizontal line with the PSIS and on
a vertical line With the symphysis pubis
• anterior and posterior pelvic tilts are
motions of the entire pelvic ring in the
sagittal plane Around a coronal axis
o hip joint extension through
posterior tilting of the pelvis
brings the symphysis pubis up
and the Sacrum of the pelvis
closer to the femur, rather than
moving the femur posteriorly on
the pelvis
o hip flexion through anterior
tilting of the pelvis moves the
anterior superior iliac spines
anteriorly and Inferiorly; the
inferior sacrum moves farther
from the femur, rather than
moving the femur away from
The sacrum
• lateral pelvic tilt is a frontal plane
motion of the entire pelvis around an
anteroposterior axis
• lateral tilt of the pelvis in unilateral
stance, one hip joint (e.g., the left hip
joint) is the pivot Point or axis for motion
of the opposite side of the pelvis (e.g.,
the right side) as that side of The pelvis
elevates (pelvic hike) or drops (pelvic
drop)
• if a person stands on the left limb and
hikes the pelvis, the left hip joint is being
abducted Because the medial angle
between the femur and a line through
the anterior superior iliac Spines
increases
• if a person stands on the left leg and
drops the pelvis, the left hip joint will
adduct because medial angle formed by
the femur and a line through the anterior
superior iliac spines Will decrease
• With pelvic shift, the pelvis cannot
hike; it can only drop because there is a
closed chain
Between the two weight-bearing feet
and the pelvis,
o both hip joints will move in the
frontal plane in a predictable
way as the pelvic tilt (or pelvic
shift) Occurs
• pelvis is shifted to the right in bilateral
stance, the left side of the pelvis will
drop, the right hip joint will be adducted,
and the left hip joint will be abducted
• pelvic rotation is motion of the entire
pelvic ring in the transverse plane
around a vertical axis
o more importantly occurs in
single-limb support around the
axis of the supporting or weight-
bearing Hip joint
• forward (anterior) rotation of the pelvis
occurs in unilateral stance when the side
of the pelvis
• Opposite to the weight-bearing hip joint
moves anteriorly
o forward rotation of the pelvis
produces medial rotation of the
weight-bearing hip joint
• backward (posterior) rotation of the
pelvis occurs when the side of the pelvis
opposite the Weight-bearing hip moves
posteriorly
o backward rotation of the pelvis
produces lateral rotation of the
supporting hip joint
Coordinated Motions of the Femur, Pelvis,
And Lumbar Spine
• when the pelvis moves on a relatively
fixed femur, there are two possible
outcomes to Consider.
1. Either the head and trunk will
follow the motion of the pelvis
(moving the head through
Space)
2. Head will continue to remain
relatively upright and vertical
despite the pelvic motions
 • these are open- and closed-chain
responses, respectively
Pelvifemoral Motion
• “pelvifemoral rhythm”
• when the femur, pelvis, and spine move
in a coordinated manner to produce a
larger ROM Than is available to one
segment alone predominantly (but not
exclusively) be an open-chain Motion
• can be considered analogous to
scapulohumeral motion
• in the case of scapulohumeral motion,
the joints are serving the hand. In the
case of Pelvifemoral motion, the joints
may serve either end of the chain: the
foot or head
• if the goal is to bend forward to bring the
hands (and head) toward the floor,
isolated flexion at the hip joints
(anteriorly tilting the pelvis on femurs) is
generally insufficient to reach the
ground. if the knees remain extended,
the hips will typically flex no more than
90° (and often less, depending on
extensibility of the hamstrings). the
addition of flexion of the lumbar spine
(and, perhaps, flexion of the thoracic
spine) will add to the total ROM. the
combination of hip and trunk flexion is
generally sufficient for the hands to
reach the ground—as long as the
hamstrings and lumbar extensors allow
sufficient lengthening. The combination
of hip motion and lumbar motion to
achieve a greater rom for the hands and
head is an example of a largely open-
chain response in the hips and trunk.
• Moving the foot through space
• when a person is lying on the right side,
the left foot may be moved through an
arc of motion Approaching 90° this is
clearly not all from the left hip joint,
which can typically abduct only to 45°;
motion of the foot through space also
includes lateral tilting of the pelvis
>domaera
(hiking around The right hip joint) and • A true open-chain response to isolated
lateral flexion of the lumbar spine to the hip flexion would displace the head and
left. The abducting limb is in An open trunk forward, with the line of Gravity
chain; the lumbar spine (and thoracic falling in front of the supporting feet.
spine) is constrained by the body weight • In a functional closed chain, motion at
and Contact with the ground. the hip (one link in the chain) is
Closed-Chain Hip Joint Function accompanied by an essentially
• A true closed chain is formed because mandatory Lumbar extension to
both ends of the chain (both feet in this maintain the head over the sacrum/ In
example) are “fixed” and Movement at contrast, hip flexion in open-chain
any one joint in the chain invariably pelvifemoral Motion is accompanied by
involves movement. at one or more lumbar flexion because the goal is to
other links in the chain achieve more range for the head in
• true closed chain when both lower limbs space
are weightbearing and the chain is
defined as all the segments
Between the right foot, up through the
pelvis, and down through the left foot
• For the hips (and other lower limb joints)
to be in a closed chain in standing, both
ends of the chain (the head And the
feet) must be fixed. The feet are, in fact,
fixed by weight-bearing. The head,
however, is often (but not Necessarily)
functionally “fixed.”
• When the head (one end of the chain)
is held upright and over the feet (the
other end of the chain), all the Segments
in the axial skeleton and lower limbs
function as part of a closed chain
• our functional closed-chain premise, hip
flexion does not occur independently
(which would move the head Forward in
space) but is accompanied by
mandatory motion in one or more
interposed segments to ensure that The
head remains upright over the base of
support and that the body does not
become unstable
• common example of closed-chain
(versus open-chain) function is seen
when the hip flexor musculature is
• Tight and the hip joint is maintained in
flexion.