Hip

Ischiogluteal bursitis: another term for this? (2) where is the pain? what nerve could get irritated?

(Tailor's or Weaver's Bottom): When there is inflammation of the ischiogluteal bursa, pain is experienced around the *ischial tuberosity, especially when sitting*. If the adjacent sciatic nerve is irritated from the swelling, symptoms of sciatica may occur. •Sitting on hard surfaces all the time and not having any support

what muscles are associated with valgus collapse? (3)

*Decreased hip abductor, extensor, and external rotator muscle strength* is associated with valgus collapse at the knee (increased valgus and internal rotation of the femur) during weight-acceptance activities and may contribute to impairments throughout the lower extremity as described in the following examples. Ex: Squat- IR and adductors important to make sure the ER and abductors are strong to prevent that

what has been identified as the possible cause of sciatic nerve compression? what would alleviate the symptoms? (4)

*Hip extensor and abductor weakness* resulting in hip adduction and internal rotation (valgus collapse) during functional activities has been identified as the possible cause of sciatic nerve compression *secondary to piriformis muscle overuse*. *Strengthening and functional retraining and stretching of the gluteus maximus and gluteus medius along with correction of the faulty movement patterns* were reported to alleviate the symptoms and functional improvement. strengthen abductors and ER •compression of the sciatic nerve. •overuse of the piriformis muscle •stretching can help

what has been reported in FAI?

*Muscle flexibility and strength imbalances* have been reported, including *tightness of hip flexors and lumbar extensors and weak, inhibited gluteal and abdominal muscles.*

Repetitive trauma:

*Strength and flexibility imbalances among agonist/antagonist muscle pairs or among synergistic muscles may result in overuse* injuries related to repetitive or high-intensity activities. Common overuse syndromes at the hip may reflect dominance of the tensor fasciae latae and rectus femoris as hip flexors, abductors, and internal rotators with apparent weak gluteus medius and gluteus minimus muscles or dominance of the hamstrings over the gluteus maximus. Overuse of the piriformis muscle with apparent weakness of the gluteus maximus and medius muscles has also been reported. Because of the relationship of these muscles with the pelvis and knee as well as the effect of faulty mechanics on weight-bearing function, patients with these muscle imbalances may also present with low back or knee symptoms.

what are causes of tears in the acetabular labrum and what does it lead to? (5)

*Trauma, acetabular labral impingement, capsular laxity, dysplasia, and degeneration* are causative factors for tears in the acetabular labrum leading to *anterior hip or groin pain.*

Anterior cruciate ligament strain is associated with what? (2)

*Valgus collapse and decreased use of the hip extensors* have been reported to be more common in women than in men who have sustained an anterior cruciate ligament injury. It has been suggested that this is related to *increased anterior shear of the tibia and strain* of the anterior cruciate ligament during loading (*hip-knee flexion when landing following a jump*)

Muscles that Cross the Knee Joint: Posterior (3) Anterior (3) Lateral (2)

- Posteriorly: Semimembranosus, Semitendinosus, Biceps femoris long head - Anteriorly: Rectus femoris, Sartorius, Adductus magnus -IT band connects lateral glutes and TFL

what are the hip muscle imbalances? (5)

- Shortened tensor fasciae latae (TFL) and/or gluteus maximus - Dominance of the TFL over the gluteus medius -Dominance of the two-joint hip flexor muscles over the iliopsoas -Dominance of hamstring muscles over the gluteus maximus -Use of lateral trunk muscles for hip abductors

Cam impingement

- is thought to originate from what is described as a *pistol grip deformity of the femoral neck.* The deformity is likened to a pistolgrip in that the femoral neck fails to taper as the femoral head merges laterally into the femoral neck -This thickening leads to *poor clearance of the femur*, specifically the femoral head-neck junction as the hip joint flexes or abducts (Fig. 10-34B). The abnormal junction or cam causes undersurface wear and tear to the anteriosuperior region of the labrum and the adjacent articular cartilage of the acetabulum

piriformis

-Around 60 degrees of hip flexion it becomes IR -MMT piriformis would be IR; because the pt is sitting and beyond 90 degrees of hip flexion. Stretch it externally! -Tested Prone: ER rotator (Gemelli and obturators)

Hip joint Resting position Capsular Pattern

-Resting position: 30° flexion, 30° abduction, slight lateral rotation. -Capsular pattern: Flexion, abduction, medial rotation (but in some cases, medial rotation is limited) OR medial rotation, flexion, abduction

Dominance of hamstring muscles over the gluteus maximus: over use of the hamstring would cause ? (3)

-With decreased activation of the gluteus maximus, the hamstrings *dominate as hip extensors.* *Overuse* of the hamstring muscles may result in *cramping* of the muscle with high-intensity exercise or may result in *decreased hamstring flexibility and muscle imbalances with the quadriceps femoris* muscles at the knee. -In this muscle imbalance, the hamstrings *dominate* the knee stabilizing function by *increased posterior pulling on the tibia* to extend the knee in closed-chain activities. This alters the mechanics at the knee and may lead to *overuse syndromes in the hamstring tendons or in anterior knee pain* from modified quadriceps forces. oHamstring stronger than glute max could have cramping of that muscle can pull the tibia more.

increased anteversion in the hip leads to what?

-toeing in Anteverted - to compensate will start bring feet out more when they walk which means tibia will be rotated laterally. Affect their patellofemoral mechanics.

Fractures of the Proximal Femur MOI: majority of these pt have? what would cause fx of proximal femur in young adults and kids? stress fx are usually associated with what? (3)

. The *majority of these patients are female and have mild to severe osteoporosis.* *Falls* are the most frequent cause of fracture, although the bone may fracture first, precipitating the fall. *Proximal femur fractures due to trauma are uncommon in children and young adults because of the inherent strength of this bone.* Great force is required to fracture the proximal femur in these age groups, and *motor vehicle accidents* are the usual precipitating mechanism. *Stress fractures in the proximal femur may be seen in young adults*; these are usually associated with *cyclical loading stresses*, as seen in distance *runners, military recruits, and ballet dancers*

Decreased Flexibility at the Hip Joint (3)

1. *Tight hip flexors* cause increased lumbar (lordosis ) extension as the thigh extends. Really important, others are less likely to happen !!! 2. Hip flexion contractures with incomplete hip extension during weight bearing also place added stresses on the knee because the knee cannot lock while the hip is in flexion unless the trunk is bent forward. During weight bearing, *tight adductors* cause *pelvic drop opposite to the side of tightness* and compensatory *side-bending of the trunk toward the side of tightness. * 3. The opposite occurs with tight *abductors.*

Anteversion and retroversion: what is it?

: An increase in the *torsion of the femoral neck* is called anteversion and causes the shaft of the femur to be rotated *medially.* A *decrease in the torsion* is called retroversion and causes the shaft of the femur to be rotated *laterally*.Anteversion often results in genu valgum and pes planus. Unilateral anteversion results in a relatively shorter leg on that side; retroversion causes the opposite effect.

what is coxa valga and coxa vara? Unilateral coxa vara and valga result in what?

A pathologically large angle of inclination *between the femoral neck and shaft* of the femur is called *coxa valga*, and a pathologically smaller angle is called *coxa vara*. Unilateral coxa valga results in a relatively longer leg on that side and associated genu varum. Unilateral coxa vara leads to a relatively shorter leg with associated genu valgum genu varum: knee out Genu valgum: knock knee

Unilateral short leg causes: how would the body compensate? (2) what does it lead to? what causes this? (7)

A unilateral short leg causes *lateral pelvic tilting (drop on the short side) and side-bending of the trunk away from the short side *(convexity of the lateral lumbar curve toward the side of short leg). -This may lead to a functional—or eventually a structural—*scoliosis.* -Causes of a short leg could be unilateral lower extremity faults, such as *(flat foot, genu valgum, coxa vara, tight hip muscles, anteriorly rotated innominate bone, poor standing posture, or asymmetrical bone growth.* (Causes could be structural or functional)

Slipped Capital Femoral Epiphysis Et

A weakening of the physeal plate at the junction of the femoral neck and head allows the head to displace. The etiology of this weakness is unknown but is theorized to be related to an imbalance between growth hormone and the sex hormones, which weaken all physeal plates. The extreme shear and weight-bearing forces inherent to the functioning of the hip joint render the physis vulnerable to displacement. Other etiologies have been implicated, including trauma, obesity, vertical orientation of the physeal plate, retroversion of the proximal femur, renal osteodystrophy, and physical activity.

Acetabular labral pathology is associated with what condition? what do the pt's present with?

Acetabular labral pathology is associated with hip *OA* in older patients. Patients usually present with pain that is activity dependent and describe mechanical symptoms such as *clicking, locking, catching, or giving way.*

Anterior and posterior pelvic tilts are motions of the entire pelvic ring in the _____ plane around a ____ axis

Anterior and posterior pelvic tilts are motions of the entire pelvic ring in the *sagittal *plane around a *coronal axis*

As the head and upper trunk initiate flexion, the pelvis shifts to where?

As the head and upper trunk initiate flexion, the pelvis *shifts posteriorly to maintain the center of gravity over the base of support.*

Avascular Necrosis of the Proximal Femur: what is it? osteochondritis dissecans: when is this seen? epiphyseal ischemic necrosis.

Avascular necrosis (AVN) of the proximal femur is a complicated disease process initiated by an *interruption of blood supply to the femoral head, causing bone tissue death.* AVN can have different presentations. *If an infarction affects a local segment of bone, it is called* osteochondritis dissecans.This is most often seen in *weight-bearing bones*. An infarction that affects an *entire epiphysis in a growing child is* called epiphyseal ischemic necrosis. The proximal femur is the most common location for this occurrence.

what is occurring in the pelvicfemoral motion sidelying and abducting your left leg (3)?

Beyond what your abductors allow you: pelvic hike and lumbar flexion Happens as compensatory mechanism because of tight hip muscles

what occurs when the pelvic force couples are normal?

During hip movement, if the pelvic force-couples are normal, the *pelvis and anterior superior iliac spine (ASIS)/posterior superior iliac spine (PSIS) will not move*. If they do, it may be an indication of muscle imbalance

Femoroacetabular impingement

Femoroacetabular impingement describes a mechanical pathology that results from abutment of the *femoral head with the acetabulum*. The fibrocartilaginous labrum, attached to the acetabular rim, provides some structural resistance to movement of the femoral head within the acetabulum; as such, it is vulnerable to injury when normal joint arthrokinematics are compromised.

Femoroacetabular impingement Etiology

Femoroacetabular impingement is associated with any predisposing factors that alter normal osseous anatomy at the hip. Factors include prior *slipped capital femoral epiphysis, avascular necrosis, altered femoral head-to-neck junction configuration, acetabular retroversion, or developmental hip dysplasias.* The abnormal hip anatomy will lead to painful symptoms when the patient performs activities that require repetitive extreme ranges of motion, or even when the patient performs normal ranges of motion over time Two types of impingement have been described: cam and pincer.Cam impingement occurs when the femoral head- neck junction (Fig 12-67) is offset and the femoral head cannot fully clear the acetabular rim. Pincer impingement is due to "overcoverage" of the femoral head by the acetabulum, due to conditions such as a deep socket (coxa profunda), acetabular protrusion, and acetabular retroversion. Many patients have a combination of both types of impingement.

what occurs in pelvifemoral motion forward flexion? (3)

Flexion of the trunk and pelvis anterior tilting

Force-couple action during a unilateral straight leg raise: Normal activation of muscles during hip flexion

Force-couple action during a unilateral straight leg raise. A, With normal activation of the *rectus abdominis and the hip flexors (psoas and rectus femoris),* the pelvis is stabilized and prevented from anterior tilting by the pull of the hip flexor muscles. -killer six pack, should be able to keep back from arching or hyperlordosis or anterior tilting pelvis - Before lifting you should engage your abs and slightly posteriorly tilt be able to keep legs from lifting or cheating (bilateral leg raise)

what is groin and buttock pain related to?

Groin pain is most often related to an *anterior tear*, and buttock pain is most often related to a *posterior tear.*

Patellofemoral impairment: as a result of what muscle weakness?

Higher valgus moments at the knee as a result of *weak hip abductors* have been associated with patellofemoral impairments, which occur more often in *women* than in men

Hip dislocation

Hip dislocations are due to high-energy trauma such as motor vehicle accidents or falls from heights. The hip can dislocate anteriorly, posteriorly, or centrally through the acetabulum. About 90% of hip dislocations occur posteriorly and are associated with concomitant fractures. Fractures of the acetabulum, femoral head, and patella are most often involved.

Posterior pelvic tilt ACCOMPANYING HIP JOINT MOTION COMPENSATORY LUMBAR SPINE MOTION

Hip extension Lumbar flexion

Common Activity Limitations and Participation Restrictions:

Hip joint impairments interfere with many weight-bearing activities and ADLs. • Early stages. There is progressive pain with continued weight bearing and walking or at the end of the day after repetitive lower extremity activities. The pain may interfere with work or routine household activities that involve prolonged weight bearing. • Progressive degeneration. The individual experiences increased difficulty rising from a chair, walking long distances or on uneven surfaces, climbing stairs, squatting, and other weight-bearing activities and begins to have limitations in routine ADLs, such as bathing, toileting, and dressing (putting on pants, hose, socks). • Bad RA get Total hip replacement

Anterior pelvic tilt ACCOMPANYING HIP JOINT MOTION COMPENSATORY LUMBAR SPINE MOTION

Hip flexion Lumbar extension

what muscle causes lateral pelvic tilt?

Muscles causing lateral pelvic tilting include the *quadratus lumborum* on the side of the elevated crest and reverse muscle pull of the *gluteus medius on the stance side hip.*

Muscles causing pelvic rotation (4)

Muscles causing pelvic rotation are the *hip rotators* working in synergy with the *oblique abdominal muscles, the transversus abdominis, and the multifidus.*

why does patellofemoral impairments occur more often in women?

Occur more in women because they have a wider pelvis (larger Q angle)

On the side that is elevated, there is hip ________; on the side that is lowered, there is hip _______

On the side that is elevated, there is hip *adduction*; on the side that is lowered, there is hip *abduction*

Once all of the vertebral segments are at the end of the range and stabilized by the posterior ligaments and facets what will occur at the pelvis? what controls that motion?

Once all of the vertebral segments are at the end of the range and stabilized by the posterior ligaments and facets, the pelvis begins to rotate forward (*anterior pelvic tilt*), controlled by the *gluteus maximus and hamstring muscles.*

Musculotendinous Factors

Overuse or trauma to any of the musculotendinous units in the hip region *can result from excessive strain during a muscle contraction* or from *repetitive use with inadequate time allowed for the injured tissue to heal between activities.*

Psoas bursitis: where is the pain? what motion aggravates the condition?

Pain is experienced in the *groin or anterior thigh* and possibly into the *patellar area* when there is inflammation of the psoas bursa. Activities requiring excessive, repetitive *hip flexion* aggravate the condition. • Kicking, soccer, dance activities (Repetitive hip flexion activities)

Painful Hip Syndrome caused by what? (4)

Painful symptoms in the hip region other than arthritis may be caused by pathologies involving the *muscles, tendons, bursae, or the acetabular labrum.* Often, symptoms occur as a result of *overuse or repetitive trauma* to the tissues and may have underlying structural or faulty mechanical predisposing factors.

what are used to diagnose labral pathologies?

Radiographic imaging and MRI (using gadolinium contrast) are usually performed to diagnose labral pathology.

why must the knee extension and flexion be performed during resisted isometric movements of the hip?

Resisted isometric flexion and extension of the knee must also be performed, because there are two joint muscles (hamstrings and rectus femoris) that act over the knee as well as the hip.

what is Rheumatoid Arthritis?

Rheumatoid arthritis is a progressive, systemic, autoimmune inflammatory disease primarily affecting synovial joints. Incidence is three times greater in women, and onset is most common in young adulthood.

Lateral pelvic tilt (pelvic hike) ACCOMPANYING HIP JOINT MOTION COMPENSATORY LUMBAR SPINE MOTION

Right hip abduction Left lateral flexion

Lateral pelvic tilt (pelvic drop) ACCOMPANYING HIP JOINT MOTION COMPENSATORY LUMBAR SPINE MOTION

Right hip adduction Right lateral flexion

Backward rotation ACCOMPANYING HIP JOINT MOTION COMPENSATORY LUMBAR SPINE MOTION

Right hip lateral rotation Rotation to the right

Forward rotation ACCOMPANYING HIP JOINT MOTION COMPENSATORY LUMBAR SPINE MOTION

Right hip medial rotation Rotation to the left

Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) is a *posteromedioinferior* displacement of the *proximal femoral epiphysis* that occurs during childhood or adolescence. This condition is the most common disorder of the hip in adolescence.

Tension through the capsuloligamentous structures creates what? how is this accentuated?

Tension through the capsuloligamentous structures creates extreme strain through the anterior labrum. This is accentuated when the hip is moving into positions of abduction and external rotation

Open Chain Motion of the Femur

The *convex femoral head* slides in the direction opposite the physiological motion of the femur. Thus, with hip flexion and internal rotation, the articulating surface slides posteriorly; with extension and external rotation, it slides anteriorly; with abduction, it slides inferiorly; and with adduction, it slides superiorly • Flex: slide posterior IR: posterior • Extension: slide anterior ER: anterior • Abduct: inferiorly • Adduct: superiorly

The acetabulum is deepened what?

The acetabulum is deepened by a ring of *fibrocartilage, the acetabular labrum*

DJD Etiology: Primary Secondary causes?(6)

The etiology of DJD at the hip may be primary, *developing without a clear precursor*, or secondary, directly related to some *predisposing trauma or pathological condition.* Secondary osteoarthritis in the hip may be due to a variety of preexisting conditions, such as *fracture, Paget's disease, epiphyseal disorders, congenital dislocation, avascular necrosis, or other inflammatory arthritides.*

The hip is supported by a strong articular capsule that is reinforced by what? (3)

The hip is supported by a strong articular capsule that is reinforced by the *iliofemoral, pubofemoral, and ischiofemoral ligaments*

Dominance of the TFL over the gluteus medius: TFL would be functioning as what? this results in what? (3) this may lead to pain where? and why?

The imbalance resulting from an apparent weakness of the gluteus medius with compensatory dominance of the TFL functioning as a *hip abductor* results in *increased tension on the IT band, valgus collapse of the knee during weight bearing with hip/knee flexion , and increased dynamic Q-angle.* - This may lead to *lateral knee pain (IT band syndrome) or patellofemoral pain syndrome from increased bowstring effect on the extensor mechanism * • Activity depends if they are in a more flexed position while abduction focus on TFL • Activities more in upright straight position involve abduction strengthen glute min and med. • Should be a balance between them

Fracture of the Pelvis Mechanism of Injury: Majority of fx are a result of? the remainder are caused by? (3)

The majority of pelvic fractures are a result of *motor vehicle accidents.* The remainder are caused by falls or pedestrian or motorcycle accidents.

Final range of motion (ROM) in forward bending is dictated by the flexibility of what?

The pelvis continues to rotate forward until the full length of the muscles is reached. Final range of motion (ROM) in forward bending is dictated by the flexibility of the *various back extensor muscles and fasciae as well as hip extensor muscles* (hamstrings and glutes)

The return to the upright position begins with what?

The return to the upright position begins with the hip extensor muscles rotating the pelvis posteriorly•

Rotator Cuff of the Hip

The shoulder rotator cuff can be used to help understand the function of muscles around the hip. *External rotation of the shoulder is performed by the infraspinatus, teres minor, and suprasinatus* and is compared to the *piriformis, obturator externus and internus, superior and inferior gemelli, as well as the posterior gluteus medius* at the hip. *Internal rotation of the shoulder is performed by the subscapularis compared to the anterior fibers of the gluteus medius and gluteus minimus. Abduction of the shoulder is performed by the supraspinatus and is compared to the gluteus medius of the hip*

Pelvifemoral Motion as the trunk continues to forward bend what muscles controls that motion and until what degree? what ligaments would be taut? and what occurs at the facets?

The trunk continues to forward-bend, controlled by the *extensor muscles* of the spine, until at approximately *45˚. * At this point for an individual with relatively normal flexibility, the *posterior ligaments become taut*, and the facets of the *zygapophyseal joints approximate*. Both of these factors provide stability for the intervertebral joints, and the muscles relax.

With an anterior lesion, positive tests typically include what?

With an anterior lesion, positive tests typically include pain with the *impingement test (combined flexion, adduction, and internal rotation) and with the scour test.* The *log roll test may elicit pain or clicking* when rolling the femur into internal rotation, and there may be restricted mobility and groin pain with the *FABER (flexion, abduction, external rotation) test.*

Trochanteric bursitis: where is pain experienced ? when is discomfort experienced? what aggravate it ? (2) what factors lead to this?

With inflammation of the trochanteric bursa, pain is experienced over the *lateral hip and possibly down the lateral thigh to the knee when the iliotibial band rubs over the greater trochanter.* Discomfort may be experienced after standing asymmetrically for long periods with the affected hip elevated and adducted and the pelvis dropped on the opposite side. Ambulation and climbing stairs aggravate the condition. *Muscle flexibility, strength imbalances, and the resulting faulty pelvic motion* may be the predisposing factors leading to bursal irritation. • IT band can snap and irritate

what occurs when the rectus abdominus is weak and the pt is lying supine?

With reduced activation of the rectus abdominis, contraction of the *hip flexor muscles causes a marked anterior tilt of the pelvis*. Note the increase in lumbar lordosis that accompanies the anterior tilt of the pelvis. - *weak abdominal muscles, (pull reverse muscle action) will anteriorly pelvic tilt* -pelvis should be neutral to posteriorly tilted (a little -Example: tighten up abs and lift your leg or you can bend the other leg because it will posteriorly tilt the pelvis

what are the precautions for the posterolateral total hip?

flexion no more than 80- 90, no ADD beyond neutral, no IR

what muscles control forward flexion?

hamstrings, glutes, and trunk extensors

When the pelvis elevates, it is called

hip hiking

when it lowers, it is called

hip or pelvic drop

Pincer impingement

in femoroacetabular impingement (in contrast to cam impingement) is caused by aberrations of the acetabulum. Patients presenting with pincer-type impingement may demonstrate greater coverage, or overhang, of the acetabulum on the femoral head due to excessive retroversion of the acetabulum, and a deeper acetabular fossa, referred to as coxa profunda(Fig. 10-35A). The excessive coverage of the femoral head causes a compression of the superior labrum between the acetabular rim and the femoral head/neck in abduction. The condition is analogous to primary subacromial impingement of the shoulder

Femoroacetabular impingement (FAI)

is described as the dysfunctional abutment of the proximal femur and the acetabulum. The result of such impingement causes pain and can lead to progressive degenerative changes in the hip joint, specifically the labrum

Degenerative joint disease (DJD),also referred to as

osteoarthritis,is the most common disease affecting the hip joints.

Mechanism of Injury Acetabular fracture: results from what? the configuartion of the fracture depends on what? If the hip is in neutral position, an impaction through the greater trochanter will result in what type of fx? If the hip is flexed, an impaction through the femur will result in what?

results from *impaction of the femoral head into the acetabular cup.* The configuration of the fracture *depends on the position* of the hip at the time of impaction. If the hip is in neutral position, an impaction through the greater trochanter will result in a *transverse fracture* of the acetabulum. If the hip is flexed, an impaction through the femur will result in a *posterior fracture* of the acetabulum.

Retroverted hip

toe out

Dominance of the two-joint hip flexor muscles over the iliopsoas: what muscles are involved? what may the cause?

• Dominance of the *TFL, rectus femoris, and/or sartorius* muscles may cause *faulty hip mechanics or knee pain* from overuse of these muscles as they cross the knee.

Active Movements of the Hip: Flexion Extension Abduction Adduction ER IR

• Flexion (110° to 120°) • Extension (10° to 15°) • Abduction (30° to 50°) • Adduction (30°) • Lateral rotation (40° to 60°) • Medial rotation (30° to 40°)

Passive Movements of the Hip and Normal End Feel Flexion Extension Abduction Adduction IR ER

• Flexion (tissue approximation or tissue stretch) • Extension (tissue stretch) • Abduction (tissue stretch) • Adduction (tissue approximation or tissue stretch) • Medial rotation (tissue stretch) • Lateral rotation (tissue stretch)

Resisted Isometric Movements of the Hip

• Flexion of the hip • Extension of the hip • Abduction of the hip • Adduction of the hip • Medial rotation of the hip • Lateral rotation of the hip • Flexion of the knee • Extension of the knee

Use of lateral trunk muscles for hip abductors: results in what? (2) Someone with not strong abductors will rely on what muscle?

• Relying on the lateral trunk muscles to perform the tasks of the hip abductors results in *excessive trunk motion and increased stress on the lumbar spine.* •Someone with not strong abductors will rely on *quadratus lumborum*

Leg Length Discrepancy

• Shortened tibia - both legs straight left leg shorter than right leg because heel is not at same level as the other one • when you bend knees will notice that one tibia shorter than the other (Front view) • look at the tibia tuberosity from the other side and noticed that they are the same level. Which means the femur is longer not the tibia (Side view) • Shortened femur - knees at the same height but one more posterior than the other

Functional Tests of the Hip (9)

• 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 • Jumping • One-legged hop (time, distance, crossover)

Posterior Pelvic Tilt: what moves closer to the femur? this results in what motions?

• The *posterior superior iliac spines of the pelvis move posteriorly and inferiorly,* thus closer to the posterior aspect of the femur as the pelvis rotates backward around the axis of the hip joints. This results in *hip extension and lumbar spine flexion* • Muscles causing this motion are the hip extensors and trunk flexors. (or abdominals)

Anterior Pelvic Tilt: what moves closer to the femur? This results in what motions?

• The anterior superior iliac spines of the pelvis move *anteriorly and inferiorly *and thus closer to the anterior aspect of the femur as the pelvis rotates forward around the transverse axis of the hip joints. This results in *hip flexion and increased lumbar spine extension* • Muscles causing this motion are the *hip flexors and back extensors.*

Motions of the pelvis (on a stable femur).

• When the lower extremity is stabilized (fixated) distally, as when standing or during the stance phase of gait, *the concave acetabulum moves on the convex femoral head,* so the acetabulum slides in the same direction as the pelvis. The pelvis is a link in a closed chain; therefore, when the pelvis moves, *there is motion at both hip joints as well as at the lumbar spine* • Closed chain: concave on convex (hip hinge and flex trunk)

When the unsupported side of the pelvis moves forward, it is called ____________ of the pelvis. The trunk concurrently rotates in the _________ direction, and the femur on the stabilized side concurrently rotates _______. When the unsupported side of the pelvis moves backward, it is called ______________; the femur on the stabilized side concurrently rotates ______, and the trunk rotates __________

• When the unsupported side of the pelvis moves forward, it is called *forward rotation* of the pelvis. The trunk concurrently rotates in the *opposite* direction, and the femur on the stabilized side concurrently rotates *internally*. When the unsupported side of the pelvis moves backward, it is called *posterior rotation*; the femur on the stabilized side concurrently rotates *externally,* and the trunk rotates *opposite* • If I move my pelvis forward rotation the trunk is rotated the opposite direction

what is the most common area of the labrum that gets torn ? what does the pt complain of?

•Anterior most common area of the labrum that gets torn: complain about pinching during flexion in the front

Tendinopathies and muscle strains in the hip: Commonly strained muscles include the ? what may predispose an individual to a strain? (2)

•Commonly strained muscles include the *hip flexors, adductors, and hamstrings.* *Decreased flexibility and muscle fatigue* may predispose an individual to strains and/or injury during an activity or sporting event; sudden falls, such as slipping on ice, may also cause a muscle strain. • Overuse tendinopathy • Soccer injury: strain

Sciatic Nerve variations in its relationship with the piriformis muscle

•Most people have the sciatic nerve pass below the piriformis muscle •Part of the sciatic nerve split through the piriformis •Others can have it go above and below •Straight through •Piriformis could compress the sciatic nerve •If it gets (hypertrophy) spasticity or goes into spasm it could cause a compression •When you fire or stretch muscle or press on the muscle it will cause pain •Ex: Guarded and inflamed, calm it down then you work on strength •Overly develop it and don't stretch it then that's a problem •Keep the muscle flexible and strong •Can see this with MRI

Hypomobility of the hip would be causes by what? (6)

•Osteoarthritis (OA), rheumatoid arthritis (RA), aseptic necrosis, slipped epiphyses, dislocations, and congenital deformities can lead to degenerative changes in the hip joint •Common impairments and functional limitations are the same •*Pain, lack of motion, weak*

Forces on the Hip: Standing standing on one limb walking walking up stairs Running

•Standing: 0.3 times the body weight •Standing on one limb: 2.4 to 2.6 times the body weight •Walking: 1.3 to 5.8 times the body weight •Walking up stairs: 3 times the body weight •Running: 4.5+ times the body weight

Shortened tensor fasciae latae (TFL) and/or gluteus maximus effects: where does the TFL and gluteus maximus insert? overuse syndromes associated with greater tension of what include what? (2)

•The TFL and approximately *one-third* of the gluteus maximus insert into the *iliotibial (IT) band * •Overuse syndromes associated with greater tension of the IT band include *trochanteric bursitis* in the hip region and *IT band friction syndrome in the knee. * o Lateral patellar femoral ligament: part of the IT band that connects to the patella • Adduction would stretch to go out to the side Decreased flexibility in either of these muscles has an effect on the tension transmitted through the IT band. Postural impairments often associated with a shortened TFL or gluteus maximus include an anterior pelvic tilt posture, slouched posture, or flat back posture

Common Impairments of Structure and Function

■ Pain experienced in the groin and referred along the anterior thigh and knee in the L3 dermatome. ■ Stiffness after rest. ■ Limited motion with a firm capsular end-feel.153 Initially, limitation is only in internal rotation; in advanced stages, the hip is fixed in adduction, has no internal rotation or extension past neutral, and is limited to 90° flexion. ■ Asymmetry in lower extremity weight bearing and an antalgic gait usually with a compensated gluteus medius (abductor) limp and slower speed (related to shorter step length and stance duration). ■ Limited hip extension leading to increased extension forces on the lumbar spine and possible back pain. ■ Limited hip extension preventing full knee extension when standing or during gait, leading to altered knee stresses. ■ Impaired balance and postural control.