hip joint

Chapter 1 The hip joint



ANATOMY 1
Bony landmarks to be palpated 2

Ligaments 2

Muscles 3
Extensors 3

Flexors 4

Abductors 5

Adductors 6

Lateral rotators 7

Medial rotators 8

MEASUREMENT 8
Range of movement 9
Extension 9

Flexion 10

Abduction 11

Adduction 12

Lateral (external) rotation 13

Medial (internal) rotation 14

Observational/reflective checklist 16

Muscle bulk 17
Limb girth: thigh 17

Observational/reflective checklist 19

Muscle strength: Oxford muscle grading 20
Extensors 20

Flexors 22

Abductors 25

Adductors 27

Lateral (external) rotators 30

Medial (internal) rotators 32

Leg length 36
True length of limb 38

Site of true shortening 38

Apparent shortening 38


Anatomy



1. The hip joint is a synovial ball and socket joint.

2. It is an articulation between the head of the femur and the acetabulum of the innominate (hip) bone.

3. It has a strong joint capsule, attaching to the articular margins of the acetabulum and the femoral neck.

4. It has very strong capsular ligaments – the iliofemoral, pubofemoral and ischiofemoral ligaments.

5. The acetabular labrum deepens the acetabulum.

6. The movements that take place at the hip joint are: flexion, extension, abduction, adduction, lateral (external) rotation and medial (internal) rotation.


Bony Landmarks to be Palpated


The innominate (hip) bone – iliac crest, anterior superior iliac spine (ASIS), posterior superior iliac spine (PSIS), pubic tubercle, ischial tuberosity.


The femur – greater trochanter.



Ligaments




Table 1.1The ligaments

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Muscles



Extensors




Table 1.2The extensors of the hip

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Flexors




Table 1.3The flexors of the hip

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Abductors




Table 1.4The abductors of the hip

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Adductors




Table 1.5The adductors of the hip

image



Lateral rotators




Table 1.6The lateral rotators of the hip

image



Medial rotators




Table 1.7The medial rotators of the hip

image


Measurement




Clinical tip


Palpation. The centre of the hip joint lies in a horizontal plane, passing through the top of the greater trochanter. The joint centre lies 1 cm below the middle third of the inguinal ligament (this goes from the anterior superior iliac spine (ASIS) to the pubic tubercle).




Range of Movement



Extension



Starting position



image

Fig 1.1 Goniometric measurement of hip extension.


The patient is positioned in prone lying on a plinth. Their hip is in neutral and knee in extension. Their feet must be over the end of the plinth.



Goniometer axis


The axis of the goniometer is placed over the greater trochanter of the femur.



Stationary arm


This is parallel to the mid-axillary line of the trunk.



Moveable arm


This is parallel to the longitudinal axis of the femur, pointing towards the lateral epicondyle of the femur.



Command to patient


‘Lift your leg backwards as far as you can.’



End position


The hip is extended to the limit of motion.



Trick movement


Extension of the lumbar spine.



Clinical tip


The greater trochanter can be found by palpating the iliac crest – at its mid-point, one hand span down should get you to the area of the greater trochanter. You will feel movement at the greater trochanter on medial and lateral rotation of the leg.




Flexion



Starting position



image

Fig 1.2 Goniometric measurement of hip flexion.


The patient is positioned in supine lying on the plinth. Their hip is in neutral and the knee is in extension.



Goniometer axis


The goniometer axis is placed over the greater trochanter of the femur.



Stationary arm


This is parallel to the mid-axillary line of the trunk.



Moveable arm


This is parallel to the longitudinal axis of the femur, pointing towards the lateral epicondyle of the femur.



Command to patient


‘Bend your knee up towards your chest as far as you can, sliding your heel up the plinth.’



End position


The hip is flexed to the limit of motion. The heel is moved towards the buttock to the limit of hip flexion.



Trick movement


Flexion of the lumbar spine.



NB: It may be necessary to reposition the stationary and moveable arms of the goniometer prior to taking the reading, as they may have moved when the patient flexed their hip.




Abduction



Starting position



image

Fig 1.3 Goniometric measurement of hip abduction.


The patient is positioned in supine lying on the plinth. Their hip is in neutral and their knee is in extension. Ensure the pelvis is level.



Goniometer axis


The goniometer axis is placed over the anterior superior iliac spine (ASIS) of the innominate bone, on the side of the hip being measured.



Stationary arm


This is placed along a line between the two ASISs.



Moveable arm:


This is parallel to the longitudinal axis of the femur, pointing to the middle of the patella.



Command to patient


‘Take your leg out sideways as far as you can. Keep your great toe pointing towards the ceiling.’



End position


The hip is abducted to the limit of motion.



Trick movement


Lateral (external) rotation of the hip.



Adduction



Starting position



image

Fig 1.4 Goniometric measurement of adduction of the hip.


The patient is positioned in supine lying on the plinth. Their hip is in neutral and their knee is in extension. Ensure the pelvis is level. The opposite leg is abducted over the side of the plinth and the foot is resting on a stool.



Goniometer axis


The goniometer axis is placed over the anterior superior iliac spine (ASIS) of the innominate bone, on the side of the hip being measured.



Stationary arm


This is placed along a line between the two ASISs.



Moveable arm


This is parallel to the longitudinal axis of the femur, pointing to the middle of the patella.



Command to patient


‘Bring your leg in towards your opposite leg as far as you can. Keep your great toe pointing towards the ceiling.’



End position


The hip is adducted to the limit of motion.



Trick movement


Medial (internal) rotation of the hip.



Lateral (external) rotation



Starting position



image

Fig 1.5 Goniometric measurement of lateral rotation of the hip.


The patient is positioned in sitting on a raised plinth. Their hip is in 90° of flexion and neutral rotation, with the knee flexed to 90°.The opposite hip is abducted and the foot is supported on a stool.



Goniometer axis


The axis of the goniometer is placed over the mid-point of the patella.



Stationary arm


This is perpendicular to the floor.



Moveable arm


This is parallel to the anterior border of the tibia.



Command to patient


‘Turn your leg and foot in as far as you can.’



End position


The hip is laterally (externally) rotated to the limit of motion, so that the leg and foot move in a medial direction.



Clinical tip


This may seem a confusing movement: turning the foot in produces lateral (external) rotation at the hip and turning the foot out produces medial (internal) rotation. It may help if you think what would happen if a nail was inserted anteriorly into the femoral shaft – it would move laterally when the foot was turned in and medially when the foot was turned out.




Medial (internal) rotation



Starting position



image

Fig 1.6 Goniometric measurement of medial rotation of the hip.


The patient is positioned in sitting on a raised plinth. Their hip is in 90° of flexion and neutral rotation, with the knee flexed to 90°.The opposite hip is abducted and the foot is supported on a stool.



Goniometer axis


The axis of the goniometer is placed over the mid-point of the patella.



Stationary arm


This is perpendicular to the floor.



Moveable arm


This is parallel to the anterior border of the tibia.



Command to patient


‘Turn your leg and foot out as far as you can.’



End position


The hip is medially (internally) rotated to the limit of motion, so that the leg and foot move in a lateral direction.



Clinical tip


This may seem a confusing movement: turning the foot in produces lateral (external) rotation at the hip and turning the foot out produces medial (internal) rotation. It may help if you think what would happen if a nail was inserted anteriorly into the femoral shaft – it would move laterally when the foot was turned in and medially when the foot was turned out.




Notes



Treatment record




Observational/reflective checklist




image



Muscle Bulk



Limb girth: thigh



Patient’s position



image

Fig 1.7 Measurement of the girth of the thigh.


The patient is positioned in long sitting/half lying on a plinth, well supported. The knees are in passive extension so that the thigh and calf muscles are relaxed.



Method


Three points are marked – 15 cm (6 inches), 20 cm (8 inches) and 25 cm (10 inches) from the distal end of the tibial tuberosity. The limb is encircled with a tape measure at each marked point. The circumferential measurements are then recorded.


Repeat three times and produce an average reading, then repeat the procedure on the other limb to compare the measurements.



Points to note:


The state of the tape measure – is it stretched?

The muscles must be relaxed.

Keep the tape measure straight (not twisted).

Measure consistently – at the top/bottom of the tape, and either in centimetres or in inches.



Notes



Treatment record




Observational/reflective checklist




image



Muscle Strength: Oxford Muscle Grading



Extensors



Grade 0 – ‘No contraction’ and Grade 1 – ‘Flicker of a contraction’


Patient’s position


image

Fig 1.8 Oxford muscle grading for the hip extensors – Grades 0 and 1.


The patient is positioned in prone lying on the plinth.



Clinician’s position

The clinician is standing by the patient, with both hands palpating the gluteus maximus muscle.



Command to patient

‘Try and tighten your seat muscles.’



Clinical tip

Closely observing and feeling the muscle is essential in enabling the clinician to pick up on even the smallest flicker of a contraction.



Grade 2 – ‘Full range of movement (ROM) with the effects of gravity eliminated’

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Jun 4, 2016 | Posted by in MANUAL THERAPIST | Comments Off on hip joint

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