* The Hip Joint

-Aishwarya Panchal (TYBPTH)

* Ball and socket variety of multiaxial synovial
joint
* Formed by articulation between Head of Femur
and Acetabulum
* Has high degree of stability and mobility

*Anatomy
* The fibrous capsule
* The iliofemoral ligament
* The pubofemoral ligament
* The ischiofemoral ligament
* Ligamentum teres
* The acetabular labrum
* The transverse acetabular ligament

*Ligaments
* Flexors
- Psoas major and iliacus
* Extensors
- Gluteus maximus and hamstrings
* Adduction
- Adductor longus, brevis and magnus
* Abduction
- Glutei medius and minimus
* Medial rotation
- Tensor fascia lata and anterior fibres of glutei medius and minimus
* Lateral rotation
- Two obturators, two gemelli and the quadratus femoris

* Muscles acting on hip joint

*What is the age of the patient ?
Different disease occur in different age groups
and ROM decreases with age.
For example, congenital hip dysplasia is seen in
infancy, primarily in girls; Legg-Calvé-Perthes
disease is more common in boys 3 to 12 yers old;
and elderly women are more prone to
osteoporotic femoral neck fractures.

*Patient History
* Did the patient land on the outside of hip joint (eg.
Trochanteric bursitis) or landed on or hit the knee,
thus jarring the hip (eg.subluxation, acetabular labral
tear)
* Was the patient involved in any repititive loading
activity (eg. femoral stress fracture) or osteoporotic
(insufficiency injury)
* Sitting is uncomfortable, getting up from sitting
position may cause a catch, difficulty in ascending and
descending stairs, difficulty in putting on shoes or
socks

*If any trauma was involved what

was the mechanism of injury
* Site
* Anterior hip pain : arthritis, hip flexor strain, iliopsoas bursitis,
labral tear
* Lateral hip pain : greater trochanteric bursitis, gluteal medial
tear, iliotibial band syndrome(athletes), meralgia parasthetica(i.e.
an entrapment syndrome of lateral femoral cutaneous nerve)
* Posterior hip pain : hip extensor and external rotator pathology,
degenerative disc disease, spinal stenosis
* Referred pain
* Onset
* Character
* Radiation

* Details of present pain and

other symptoms
* Clicking is common with labral tears
* Snapping in and around the hip(coxa saltans)
has many causes

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* Site
* Onset
* Duration
* Association with pain
* Progression over time

*Swelling
* Onset
* Duration
* Association with pain
* Progression
* Ambulatory status

*Limp
* Is the condition improving? Worsening? Staying the same?
* Does any type of activity ease the pain or make it worse?
* Are there any movements that the patient feels are
weak or abnormal?
* What is the patient’s usual activity or pastime?
* Is there any past medical and/or surgical history, such as
developmental disorders (eg. Hip dysplasia, legg-calvé-
perthes disease), systemic illness, metabolic, or
inflammatory disorders?
* Posture
* Gait
* Whether the patient can or will stand on both the legs
* Balance – Stork standing test
* Whether limb positions are equal and symmetric
* Any obvious shortening of a leg
* Colour and texture of skin
* Any scars or sinuses
* The patient’s willingness to move

*Observation
* Active movements
* Flexion (110-120°)
* Extension (10-15°)
* Abduction (30-50°)
* Adduction (30°)
* Lateral rotation (40-60°)
* Medial rotation (30-40°)

*Examination
* These are performed if the ROM was not full
and the examiner was unable to test end feel
during active movements

*Passive Movements
*Resisted Isometric
Movements
* Squatting
* Going up and down stairs one at a time
* Crossing the legs so that the ankle of one foot rests on the
knee of the opposite leg
* Going up and down stairs two or more at a time
* Running straight ahead
* Running and decelerating
* Running and twisting
* One legged hop (time, distance, crossover)
* Jumping

*Functional
assessment
*Special Tests
* The Thomas test is used to assess a fixed
flexion flexion contracture

*Thomas test
* This test assesses the stability of the hip and the ability of the hip
abductors to stabilize the pelvis
* The patient is asked to stand on one lower limb
* Normally, the pelvis on the opposite side should rise, this indicates
a negative test
* If the pelvis on the opposite side drops when the patient stands on
the affected leg, a positive test is indicated
* The pelvis drop on the opposite side indicates a weak gluteus
medius or an unstable hip (eg. as a result of hip dislocation) on the
affected or stance side
* To add difficulty to test and to test overall stability of the hip and
pelvis, the patient may be asked to do a single leg squat. The
normal result should be the same as negative trendelenburg test.

*Trendelenburg Test
* This test is used for assessing
unilateral
developmental dysplasia of hip (DDH) and may
be used in children from 3 to 18 months of age
* The child lies supine with the knees flexed and
the hip flexed to 90°
* A positive test is indicated if one knee is higher
than the other

*Galeazzi Test (Allis

test)
* True Leg Length
Apparent length – From umbilicus to
medial malleolus
True length – From ASIS to medial
malleolus
* The telescoping sign is evident in a child with a dislocated
hip
* The child lies in supine position
* The examiner flexes the knee and hip to 90°
* The femur is pushed down onto the examining table
* The femur and leg are then lifted up and away from the
table
* With the normal hip, little movement occurs with this action
* With the dislocated hip, however, there is a lot of relative
movement
* This excessive movement is called telescoping, or pistoning

*Telescoping Sign
 * This test can determine whether the infant has a congenital dislocation of
hip (CDH)
* With the infant supine, the examiner flexes the hips and grasps the legs so
that the examiner’s thumbs are against the insides of the knees and thighs,
and the fingers are placed along the outsides of the thighs to the buttocks
* With gentle traction, the thighs are abducted and pressure is applied
against the greater trochanters of the femora
* Resistance to abduction and lateral rotation begins to be felt at
approximately 30-40°
* The examiner may feel a click, clunk, or jerk, which indicates a positive
test and that the hip has reduced; in addition, increased abduction of the
hip is obtained
* The femoral head has slipped over the acetabular ridge into the
acetabulum, and normal abduction of 70-90° can be obtained

*Ortolani’s Test
Barlow_Ortolani_test_Congenital_Hip_Dislocation_Everything_You_Need_To_Know_Dr_Nabil_Ebraheim.mp4
* This test is a modification of ortolani’s test used for DDH
* The infant lies supine with legs facing the examiner
* The hips are flexed to 90°, and the knees are fully flexed
* Each hip is evaluated individually while the examiner’s other hand steadies the opposite femur
and pelvis
* The examiner’s middle finger of each hand is placed over the greater trochanter, and the
thumb is placed adjacent to the inner side of the knee and thigh opposite the lesser
trochanter
* The hip is taken into abduction while the examiner’s middle finger applies forward pressure
behind the greater trochanter
* If the femoral head slips forward into the acetabulum with a click, clunk, or jerk, the test is
positive, indicating that the hip was dislocated
* This part of the test is identical to ortolani’s test
* The examiner then uses the thumb to apply pressure backward and outward on the inner thigh
* If the femoral head slips out over the posterior lip of acetabulum and then reduces again when
pressure is removed, this hip is classified as unstable
* The hip is not dislocated but is dislocatable. The same procedure is repeated for the other
hip.

*Barlow’s Test
* This a test for femoral anterversion.
* Patient is in position prone on the bed with knee bent
to 90°.
* The greater trochanter is palpated and then the test
leg is internally and externally rotated until the
greater trochanter is positioned parallel to the table
or feels to be protruding the greatest.
* The greater trochanter is then allowed to return to its
normal position and the angle created is measured.
* A positive test is an angle > 15°.

*Craig’s Test
* This test assesses the tensor fascia lata (iliotibial band) for
contracture
* The subject is positioned sidelying with the test limb on top. The
hip and knee of the limb closest to the bed should both be flexed
to stabilize the patient.
* The uppermost limb is passively positioned into abduction and
extension so the ITB passes over the greater trochanter.
* The knee may be either flexed or extended, but a greater stretch
will be felt in extension.
* The examiner stabilizes the pelvis to prevent substitution and then
allows the test limb to slowly adduct towards the table.
* A positive test is indicated by the test limb remaining off the table.

*Ober’s Test
* The patient is in side lying position with the test leg
uppermost
* The patient flexes the test hip to 60° with the knee
flexed
* The examiner stabilizes the hip with one hand and
applies a downward pressure to the knee
* If the piriformis is tight, pain is elicited in the muscle
* If the piriformis muscle is pinching the sciatic nerve,
pain results in the buttock and sciatica may be
experienced by the patient

*Piriformis Test
* This Is a test for non-specific joint pathology.
* The examiner takes the test extremity and
passively brings it into flexion and adduction
* While applying an axial load the examiner then
moves the extremity in quadrants.
* A positive test is indicated by clicking, crepitus
or pain.

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*Hip Scour Test
(Quadrant)
* This is a test for hip dysplasia, slipped capital
epiphysis, and femoroacetabular impingement
* The patient lies supine with hip flexed to 90°
* The examiner then medially rotates and
adducts the hip which leads to impingement of
femoral neck against the acetabular rim
* Pain is a positive sign

*Anteroposterior
Impingement Test
* This test is a test for global over coverage, global femoral
neck offset abnormalities, and posterior acetabular cartilage
damage
* This test is also positive in people who place the hip in
extremes of ROM (eg. ballet dancers, martial artists, hockey
goal tenders, mountain climbers, yoga practitioners, long
striding runners)
* The patient lies supine with the legs hanging free over the
edge of the bed to ensure maximum hip extension
* The examiner then laterally rotates the hip quickly
* Deep seated groin or buttock pain is an indication of
posteroinferior impingement

*Posteroinferior
Impingement Test
* The patient sits knees bent over the end of the bed with
feet dangling
* The examiner places an arm under the patient’s thigh to
act a fulcrum
* The fulcrum arm is moved from distal to proximal along
the thigh as gentle pressure is applied to the dorsum of
the knee with the examiner’s opposite hand
* If a stress fracture is present, the patient complains of a
sharp pain and expresses apprehension when the fulcrum
arm is under the fracture site
* A bone scan then confirms the diagnosis

*Fulcrum Test
* Patient lies supine and then actively elevates the
straight leg to about 20-30° while the examiner
applies gentle resistance
* In a positive test pain may be referred into the
sensory distribution of the femoral, obturator or
sciatic nerves
* A positive test indicates intra-articular pathology,
which may include a labral tear, synovitis, arthritis,
occult femoral neck fractures, iliopsoas
tendinitis/bursitis, and prosthetic failure or loosening

*Stinchfield resisted
hip flexion
• Test for anterior-superior impingement syndrome,
anterior labial tear, and iliopsoas tendinitis
• The patient is placed in supine position
• The examiner takes hip into full flexion, lateral rotation
and full abduction as a starting position
• The examiner then extends the hip combined with
medial rotation and adduction
• A positive test is indicted by the production of pain, the
reproduction of the patient’s symptoms with or without a
click, or apprehension

* Anterior labral tear test

(Anterior apprehension test)
* The patient is placed in supine position
* The examiner takes the hip into full flexion, adduction,
and medial rotation as a starting position
* The examiner then takes the hip into extension
combined with abduction and lateral rotaion
* A positive test is indicated by the production of groin
pain, patient apprehension, or the reproduction of the
patient’s symptoms, with or without a click
* A positive test is an indication of a labral tear, anterior
hip instability, or posterior-inferior impingement

* Posterior labral test

(Posterior apprehension test)
* Reflexes and cutaneous
distribution
* Sciatic nerve (L4 to S3)
* Superior Gluteal nerve (L4 to S1)
* Femoral nerve (L2 to L4)
* Obturator nerve (L2 to L4)

* Peripheral neve injuries

above the hip
*Long Leg traction
*Compression
*Lateral distraction

* Joint Play Movements of the

hip
* Anterior aspect
* Iliac crest, greater trochanter, and anterior
superior iliac spine
* Inguinal ligament, femoral triangle, hip joint,
pubic symphisis
* Posterior aspect
* Iliac crest, posterior superior iliac spine, ischial
tuberosity, and greater trochanter
* Sacroiliac, lumbosacral and sacrococcygeal joints

*Palpation
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