pelvis and hip

Figure 9.1

The pelvis and hips

Introduction

Hip injury causing pain is common both in general and in sports, especially when there are elements of twisting and sharp movements. The definition of hip pain is soreness and/or restriction of range of movement in the hip joint. Differential diagnosis of hip and groin pain can be difficult because of the complex interactions of forces through the hip and pelvis, the wide-ranging pathological processes that can occur within this area, and the crossover of signs and symptoms presenting on physical examination (Omar et al 2008).

Manual therapy of the hip has been proven to be an effective treatment mode for hip pain; this can be in the form of either articulation or traction/distraction of the joint (Herding & Kessler 1990, Cibulka & Delitto 1993). Hoeksma et al (2004) and Brantingham et al (2009) found that articulation of the hip joint plus exercise advice was far more effective than exercise advice alone. The NICE Osteoarthritis: National Clinical Guideline for Care and Management in Adults (2008) recommends articulation and stretching for use as one of the core treatments in osteoarthritis of the hip. Similarly, the American Physical Therapy Association’s (Orthopaedic Section) guidelines on hip pain and mobility deficits make the recommendation of manual therapy for pain relief and improvement of range of mobility within the hip for mild osteoarthritis (Cibulka et al 2009). In addition, manual therapy is recommended in the treatment of osteoarthritis focusing on addressing restriction of movement and the adaptations caused by this (Delarue et al 2007, Hunter & Lo 2008, Zhang et al 2008).

As discussed in Chapter 1 articulation of the hip joint is thought to help in the reduction of pain through the activation of large fiber afferent nerves or by assisting in the lubrication of the synovial joint (Yoder 1990, Makofsky et al 2007, Coelho 2008, Schmid et al 2008). It is also believed to improve the range of movement in the joint post treatment (Makofsky et al 2007, Schwellnus 2008).

Cibulka and Delitto (1993) found that treating the sacroiliac joint reduced pain levels in patients and that rhythmical articulation of the joint, initially with grade 2 and then with grade 4, caused an improvement in range of movement. They also observed that the changes after treatment were not immediate and postulated that this may be because of slower reaction changes to the synovial cartilage or capsule.

Although studies have found that articulation of the sacroiliac joint does not affect the position of the joint, it may still affect the muscular tension in the surrounding muscles (Cibulka et al 1986, Tullberg et al 1998, Foley & Buschbacher 2006). In a study by Kirkaldy-Willis and Cassidy (1985), 71% of patients reported a decrease in pain following articulation of the sacroiliac joint 2 weeks post treatment. However, there is still a great deal of contention about the effects of manual therapy and the sacroiliac joint, and more research into this is needed (Cohen et al 2013).

Bony anatomy

The hip is the name given to the anatomical region formed between the lateral parts of the pelvis and the superior part of the femur. The hipbones, also known as the coxal bones or os coxae, are two identical mirror-image bones that are strongly united to one another. They form a bony ring called the pelvic girdle (hip girdle), joining each other anteriorly and the sacrum posteriorly (Mader 2004). Each coxal bone results from the fusion of three bones – the ilium, the ischium and the pubis – and is firmly attached to the axial skeleton because of its articulation with the sacrum (McCann & Wise 2014). The coxal bones are largely immobile, weight-bearing structures. They also help transfer the weight of the body to the mobile lower limbs, thus providing more stability to the upper extremities (OpenStax 2013).

The bony pelvis is interposed between the lower spinal column and the lower extremities; it includes the pelvic girdle (the two coxal bones), the sacrum and the coccyx. It is divided into the false and true pelvis by an oblique line known as the pelvic brim (Gray 1958). The pelvis functions as the site of attachment for the lower limbs. It also protects the internal reproductive organs, the urinary bladder and a portion of the large intestine. In addition, a woman’s pelvis helps protect the developing fetus during pregnancy and forms the pelvic ring through which the fetus passes during normal vaginal delivery (Tate 2009).

Ilium

The ilium is the largest part of the coxal bone that spreads slightly outward to provide the hip prominence. It is fan-shaped and forms the superior portion of the acetabulum. Each ilium attaches posteriorly to the sacrum at the largely immobile sacroiliac joint. The curved, top ridge of the ilium is known as the iliac crest (Mader 2004). The iliac crest terminates anteriorly as the anterior superior iliac spine (ASIS); inferior to this is a rounded protuberance called the anterior inferior iliac spine (AIIS). The crest ends posteriorly as the posterior superior iliac spine; more inferior to this is called the posterior inferior iliac spine (PIIS) (Tate 2009).

Medially, the upper ilium has a large, shallow depression on the internal surface known as the iliac fossa. The fossa is bounded below by the arcuate line and above by the iliac crest. Posteriorly, the ilium has an auricular surface on its medial aspect. This auricular surface is a large, roughened area that articulates with the sacrum’s auricular surface to form the sacroiliac joint (OpenStax 2013).

Ischium

The ischium is the most inferior portion of each coxal bone. It forms the posteroinferior portion of a coxal bone and is located inferior to the ilium and behind the pubis. It is the strongest of the three bones that fuse to form the coxa and is itself made up of three portions: the superior ramus, the inferior ramus and the body (Moore & Dalley 1999).

The inferior ramus of the ischium unites with the inferior ramus of the pubis to form a compound structure known as the ischiopubic ramus. The body of the ischium joins with the ilium and pubis, and forms the posterolateral portion of the acetabulum. The posterior region of the inferior ischium has a large, roughened area called the ischial tuberosity, which bears the weight of the body while a person is sitting. Near the junction of the ilium and ischium is a bony projection known as the ischial spine, which projects into the pelvic cavity. The ischial spine separates the lesser sciatic notch and the greater sciatic notch; the space between the ischial spines thus helps determine the pelvic cavity size (OpenStax 2013).

Pubis

The pubis forms the anteromedial part of each coxal bone and constitutes the anterior portion of the acetabulum. The two pubic bones of the hip join with each other at a specialized joint known as the pubic symphysis. The pubic symphysis is a unique structure and is classed as a secondary cartilaginous joint (Standring 2008) because it has a fibrocartilaginous disc which separates the articular surfaces of the pubic bones (Li et al 2006). This allows a small quantity of movement through the joint to aid in the transmission of tensile, shearing and compressive forces placed through it mainly during locomotion and movement (Becker et al 2010). Similar to the ischium, the pubis is made up of three parts: the flat body and the two rami (superior and inferior) (Gray 1958).

The pubic body is the medial and flat portion of the pubis, which unite with the body of the opposite pubic bone at the pubic symphysis. The small bump located superiorly on the pubic body is the pubic tubercle. The superior ramus of the pubis is the portion of the pubic bone that extends laterally from the pubic body to unite with the ilium. The inferior ramus of the pubis is the segment of bone that passes laterally and downward from the medial end of the superior pubic ramus to articulate with the ischial ramus (Thompson 2002).

Acetabulum

The acetabulum is a shallow depression where the three parts – ilium, ischium, and pubis – of each coxal bone meet. It is a cup-shaped socket and is located on the lateral surface of the pelvis. The acetabulum serves as an articulation point between the lower limb and the pelvic girdle. It articulates with the femur head to make up the hip joint. Inferior to the acetabulum is the large obturator foramen (Mader 2004).

Range of motion

The hip muscles exert 3° of freedom on three mutually perpendicular axes. These include the transverse axis (flexion and extension), the longitudinal axis (lateral and medial rotation), and the sagittal axis (abduction and adduction) (Schünke et al 2006).

The normal range of motion of the hip has been estimated by a variety of studies (see Table 9.1). Although these have shown similar results in their estimates of normal hip flexion, abduction, and lateral and medial rotation, the estimates for hip extension varied widely (Roach & Miles 1991). It is known that the movement of the hip may vary with age, sex, race, and positioning during measurement, but there have been limited studies on the influence of these factors on range of motion. In addition, the active versus passive range of motion has still not been well documented (Prather et al 2010).

The amount of movement at the sacroiliac joint has been the subject of many arguments over the years among manual therapists, although it is basically agreed that some movement does occur at the joint as it transfers loading between the legs and torso (Vleeming et al 2013) and that the movement decreases from childhood to adulthood as our bodies grow and increase in weight-bearing through the joint (Kampen & Tillmann 1998). Most of the current research on the sacroiliac joint suggests that there is between 1.3° and 3.6° of movement at the joint, with an average of 2° (Tullberg et al 1998, Sturesson et al 2000a, 2000b, Kibsgård et al 2012).

Movement type	Range of motion (°)
Flexion	115–125
Extension	15–30
Abduction	30–50
Adduction	30
Lateral (external) rotation	30–45
Medial (internal) rotation	40–60

Table 9.1
Estimated normal range of motion of the hip

Data from Daniels & Worthingharn 1972, Kendall et al 1973, Hoppenfeld 1976, Mohr 1989, Roach & Miles 1991, Seidenberg & Childress 2005

In the pubic symphysis there is also a small amount of movement that allows for forces to travel through the area. It is believed that, in normal physiological conditions, there is approximately 2 mm (approximately 1/12 inch) of movement at the pubic symphysis and approximately 1° of rotation (Becker et al 2010). During pregnancy this range of movement increases due to the effects of relaxin on collagen fibers within the pelvic ligaments (Samuel et al 1996). This increase in movement can be between 32–68% (Mens et al 2009).

Epidemiology

Hip and pelvis injuries are common in all populations, male and female, the young and the old, and athletes of numerous sports. However, the incidence and etiology of these injuries vary considerably depending on age, sex and sports type in which athletes participate (Larkin 2010). The sacroiliac joint is believed to be the source of pain in 15–30% of the population with low back pain (Dreyfuss et al 2004, Cohen et al 2013).

The prevalence of hip and pelvis injury and pain is highest in adolescents and older adults. Boyd et al (1997) suggest that 10–24% of injuries reported during recreational activities or athletics in children are associated with the hip. However, a significant acute injury to the hip and pelvis is very rare in young children. The most common hip disorder that affects children and adolescents is transient synovitis. Other notable disorders include developmental hip dysplasia, Legg–Calvé–Perthes disease (LCPD) and slipped capital femoral epiphysis (Spahn et al 2005).

In adults, the prevalence of hip and pelvis pain increases with age; the risk of pain from hip osteoarthritis also increases substantially (Larkin 2010). In addition, older adults are more prone to hip fractures. According to NICE (2011), hip fracture accounted for approximately 60,000 emergency hospital admissions in the UK in the year 2010–2011 in adults (age ³ 18 years). Among those patients, 54,000 were reported to have undergone a hip fracture procedure, 73% of whom were female and 92% were aged 65 or over. An estimated 103 per 100,000 standard population adults aged 18 or over undergo hip fracture procedures annually (NICE 2011).

The overall prevalence of sports injuries to the pelvis and hip is relatively low. According to Braly et al (2006), only 5–6% of sports injuries originate in this region. However, those who participate in explosive and contact sports have the maximum risk of developing a hip or pelvis problem (Watkins & Peabody 1996). Some studies have found that athletic hip injuries can relate to 2–8% of injuries and 13% in footballers (Ekstrand & Gillquist 1983, Ekstrand & Hilding 1999, Emery & Meeuwisse 2001). One study found that football (soccer) players had a historical presentation of 58% of hip/groin pain (Harris & Murray 1974). In other studies they found the incidence rate was on average 10–18 per hundred football patients (Hölmich & Amager 2014).

Condition	Description	Reference
Hip dislocation	Usually results from a traumatic injury, a high energy directed along the axis of the femur Can be anterior, posterior or central May present with associated injuries, such as fractures of the femoral head or neck Often occurs because of motor vehicle accidents (about 70% of cases) Occurs predominantly in the posterior region (about 90% of cases)	Seidenberg (2010), Kovacevic et al (2011)
Osteitis pubis	A chronic inflammatory condition that affects the pubic symphysis and surrounding muscle insertions May occur as an inflammatory process in athletes Often reported in athletic sports requiring excessive side-to-side motion, cutting, twisting and pivoting on one leg, or multidirectional motions with frequent acceleration and deceleration Occurs most commonly in males aged 30–50 years	Sing et al (1995), Byrd (1996), Choi et al (2008)
Symphysis pubis dysfunction	During pregnancy Commonly associated with pain on weight-bearing activities such as walking and climbing stairs May hear or feel a grinding or clicking feeling in the joint Due to high levels of relaxin and increase in weight during pregnancy	Maclennan & Maclennan (1997), Jain et al (2006), Becker et al (2010)
Athletic pubalgia (sports hernia, Gilmore’s groin)	Chronic groin pain Pain induced with sports, predominantly extension and twisting Pain can radiate into medial thigh and occasionally testicles in males Can be caused by tearing of external oblique aponeurosis, conjoint tendon (inguinal aponeurotic falx) or abdominal internal oblique, or by abnormality within the rectus abdominis	Larson et al (2011), Meyers et al (2012), Hegedus et al (2013)
Avascular necrosis of the femoral head (Perthes, Legg–Calvé–Perthes disease)	A pathological process that results from disturbance in blood supply to the bone This condition causes a softening and breaking down of the femoral head Results in bone death and osteophyte formation Causes progressive arthritis of the hip joint in relatively young adults Mean age of incidence: 38 years Possible causes include hip dislocation, fractures of the femoral neck, chronic corticosteroid use, heavy alcohol intake, blood clots and damage to the arteries	Steinberg (1997), Lavernia et al (1999)
Osteoarthritis of the hip	Causes pain and swelling in the hip joint Results in anterior hip pain in most patients aged 50 years or over Often develops as people get older Symptoms include increased pain and stiffness, tenderness in joints, reduced range of movement in the joints, and weakness and muscle wasting	Idjadi & Meislin (2004), Seidenberg (2010)
Transient synovitis	A self-limited unilateral inflammatory synovitis in which an inflammation of the synovium occurs at the capsule of the hip joint The most common reason for hip pain in children aged 3–10 years Affects boys twice as often as girls	Illingworth (1978), Fabry (2010)

Table 9.2
Common disorders of the pelvis and hip

Hip and pelvis pain is more widespread in women than men. Regardless of age or sport, most studies note that women are twice as likely as men to suffer from hip pain (Tüchsen et al 2003).

The most common disorders of the pelvis and hip are summarized in Table 9.2.

Pelvis and hip examination

Medical history

Taking a detailed medical history of the patient is the most important part for the pelvis and hip examination. In most cases, the narrative provided by the patient presenting with hip pathology helps characterize the severity of the pain and facilitate the physical examination. Apart from characterizing the pain as constant or intermittent, sharp or dull, severe or mild, the examiner should ask the patient about the onset, behavior since onset, exacerbating and relieving factors, quality, radiation, severity, and timing (duration) of symptoms. The primary goal of the history taking should be to determine whether the injury or pain is acute, chronic, or acute-on-chronic in nature.

Red flags

Table 9.3 lists red flag conditions for the therapist to note.

Physical examination

Physical examinations of the pelvis and hip should be done in a systematic manner to confirm initial findings and fully explore the nature and extent of the problem. A general evaluation of the pelvis and hips usually involves inspection, palpation, range of motion and a variety of special tests.

Inspection

The physical examination process should start with a careful visual inspection of the how the patient is affected, and their posture and gait pattern. For this, the patient should be asked to sit and rise from the chair in a characteristic manner. While standing, the clinician should examine the patient from the anterior, posterior and lateral aspects. Any postural abnormalities observed, such as pelvic obliquity, muscular atrophy or weakness, and abnormal scoliotic or lordotic curves, should be noted carefully. It is also important to ascertain the presence or absence of shortening during visual inspection of the patient’s hip and pelvis. In true shortening, the affected limb is shorter than the other; in apparent shortening, the limb is not shorter in length than the other, but appears shorter due to a contracture of the hip.

Condition	Signs and symptoms
Pathological fractures of the femoral neck	Older females over 70 years of age Severe, constant hip, groin or knee pain Past history of trauma, such as a fall from a standing position
Avascular necrosis (AVN) of the femoral head	Prolonged corticosteroid use History of excessive alcohol use History of slipped capital femoral epiphysis Gradual onset of pain Groin, thigh or medial knee pain – worse with weight-bearing
Cancer	Previous history of cancer (e.g. prostate, breast or any reproductive cancer) Unexpected loss of weight Constant, progressive pain unchanged by positions or movement
Colon cancer	Age > 50 years Family history of colon cancer Bowel disturbances (e.g. rectal bleeding, black stools)
Infection	Fever, chills Recent urinary tract or skin infection Burning sensation with urination Unrelenting night pain or pain at rest No improvement after 6 weeks of conventional treatment

Table 9.3
Red flags for serious pathology in the hip and pelvis region

Data from Meyers et al (2000), Henschke et al (2007), Gabbe et al (2009), Van den Bruel et al (2010), Reiman & Thorborg (2014)

Palpation

While examining the pelvis and hips, several important bony and soft-tissue structures need to be palpated to determine areas of pathology. Palpation should include the musculature, bony prominences, sacroiliac joint, pubic symphysis, tendinous origins and insertions, bursae and apophyses.

Range of motion

Range of motion of the hip should be assessed in three ways: active, passive and resisted isometric. The examiner may use a goniometer to assess the range of motion (McRae 2010). The movements to be tested include flexion, extension, abduction, adduction, lateral rotation and medial rotation. Special attention should be paid to abduction and internal rotation, as these two are the most frequently compromised motions, involved in many pathological conditions of the hip. After measuring the range of motion of the hip, the examiner should compare the collected data with a reliable standard (see Table 9.2).

Special tests

See Table 9.4.

Test	Procedure	Positive sign	Interpretation
Trendelenburg’s sign	The patient stands on both feet. The examiner asks the patient to slowly raise one foot off the ground, without taking any additional support. The patient keeps an upright posture without significant tilt of the upper trunk.	A compensatory tilt of the torso or a drop of the contralateral iliac crest	Presence of a muscular dysfunction Subluxation or dislocation of the hip
Faber’s test	The patient lies supine and the tested leg is placed in a flexed, abducted, externally rotated position.	Pain elicited on the ipsilateral side anteriorly Pain elicited on the contralateral side posteriorly	Hip joint disorder Sacroiliac joint dysfunction
Ober’s test	The patient is placed in a lateral decubitus position. The affected knee is then flexed to 90° while the pelvis is stabilized. The examiner passively abducts and pulls the patient’s upper leg posteriorly until the thigh is in line with the torso.	Leg remains abducted and does not fall to the table	Excessive tightness of the iliotibial band
Thomas test	The patient is placed in a supine position with their back flat on the table. The patient is then instructed to flex one leg and pull it to the chest with their hands.	Straight leg lifting off the exam table	Flexion contracture of the hip
Log roll test	The patient lies supine with both hip and knee extended. The examiner passively rotates both fully extended legs internally and externally.	Pain in the anterior hip or groin	Piriformis syndrome Slipped capital femoral epiphysis
Ely’s test	The patient lies prone with their legs fully extended. The examiner passively flexes the knee, making the heel touch the buttock. The examiner then observes the ipsilateral hip for vertical separation from the exam table.	Hip is forced to lift off the exam table	Rectus femoris contracture

Table 9.4
Special tests for pelvis and hip examination

Data from Baxter (2003), McFadden & Seidenberg (2010), McRae (2010)

Pelvis and hip muscles

Name	Origin	Insertion	Action	Nerve supply
Ischiocavernosus	Ischial ramus and tuberosity	Crus of penis or clitoris	Maintains the erection of the penis or clitoris via vasocompression of the veins	Deep branch of perineal nerve (branch of pudendal nerve S2–S4)
Superficial transverse perineal	Ischial tuberosity	Perineal body	Reinforces the action of the deep transverse perineal muscle to stabilize the perineal body	Deep branch of perineal nerve (branch of pudendal nerve S2–S4)
Sphincter urethrae	Inferior aspect of pubic ramus and ischial tuberosity	Surrounds urethra; in females, some fibers also enclose vagina	Controls the flow of urine through the urethra; also compresses the vagina in females	Deep branch of perineal nerve (branch of pudendal nerve S2–S4)
Deep transverse perineal	Inner aspect of ischiopubic ramus	Median raphe (male), perineal body and external anal sphincter	Supports the function of the levator ani and sphincter urethra	Deep branch of perineal nerve (branch of pudendal nerve S2–S4)
Levator ani	Dorsal surface of pubis and fascia of obturator internus	Coccyx, opposite levator ani	Supports the pelvic viscera and structures that pass through it	Nerve to levator ani (branches of S4), inferior rectal nerve (from pudendal nerve S3–S4)
Coccygeus (ischiococcygeus)	Ischial spine	Lower two sacral and upper two coccygeal spinal segments, blends with sacrospinous ligament	Supports the pelvic viscera, flexion of the coccyx, stabilizes the sacroiliac joint	Anterior rami of S4–S5
Gluteus maximus	Outer surface of ilium, iliolumbar fascia, sacrum and sacrotuberous ligament	Gluteal tuberosity of femur and iliotibial tract	Abducts, laterally (externally rotates) and extends the thigh	Inferior gluteal nerve (L5–S2)
Gluteus medius	Outer surface of ilium	Lateral part of greater trochanter of femur	Abducts and medially rotates the thigh	Superior gluteal nerve (L4–S1)
Gluteus minimus	Outer surface of ilium	Anterior part of greater trochanter of femur	Abducts and medially rotates the thigh	Superior gluteal nerve (L4–S1)
Piriformis	Pelvic surface of sacrum, passes through greater sciatic foramen	Superior border of the greater trochanter of femur	Hip external rotation, assists with hip abduction if the hip is flexed	Anterior rami of S1–S2
Obturator internus	Internal obturator foramen	Medial part of the greater trochanter of femur	Hip external rotation, assists with hip abduction if the hip is flexed	Sacral plexus (L5–S2)
Obturator externus	Outer surface of inferior and superior rami of pubis and ramus of ischium	Trochanteric fossa of femur	Laterally (externally) rotates the femur	Obturator nerve (L3–L4)
Quadratus femoris	Lateral portion of ischial tuberosity	Inferior to intertrochanteric crest	Laterally (externally) rotates the femur	Sacral plexus (L5–S1)
Gemellus superior	Spine of ischium	Greater trochanter via tendon of obturator internus	Laterally (externally) rotates the femur	Sacral plexus (L5–S1)
Gemellus inferior	Superior surface of ischial tuberosity	Greater trochanter via tendon of obturator internus	Laterally (externally) rotates the femur	Sacral plexus (L5–S1)
Psoas major	Transverse processes and bodies of T12–L5	Lesser trochanter of femur	Flexion and laterally (externally) rotates the thigh	Lumbar plexus via anterior branches of L1–L4
Psoas minor	Body of T12–L1	Pectineal line and iliopectineal eminence	Weak trunk flexor	L1
Illiacus	Iliac fossa, ala of sacrum and anterior inferior iliac spine	Lesser trochanter of femur	Flexion of the hip	Femoral nerve (L2–L3)
Tensor fasciae latae	External anterior surface of iliac crest	Iliotibial tract (band)	Flexion and abduction of the hip	Superior gluteal nerve (L4–S1)
Sartorius	Anterior superior iliac spine	Superior medial surface of tibia (pes anserinus conjoined tendon of sartorius, gracilis and semitendinosus)	Flexion, abduction and laterally (externally) rotates the thigh	Femoral nerve (L2–L3)
Rectus femoris	Anterior head: anterior inferior iliac spine Posterior head: ilium superior to acetabulum	Quadriceps tendon to patella, via ligamentum patellae on to tubercle of tibia	Extension of the knee and flexion of the hip	Femoral nerve (L2–L4)
Gracilis	Ischiopubic ramus	Superior medial surface of tibia (pes anserinus conjoined tendon of sartorius, gracilis and semitendinosus)	Flexion, medially (internally) rotates, and adduction of the thigh	Obturator nerve (L3–L4)
Adductor magnus	Inferior pubic ramus, ramus and tuberosity of ischium	Linea aspera and adductor tubercle of femur	Adduction, extension and medial (internally) rotates the thigh	Obturator nerve (L3–L4)
Semimembranosus	Tuberosity of ischium	Medial condyle of tibia	Flexion of the knee and extension of the hip	Tibial portion of sciatic nerve (L5–S2)
Semitendinosus	Tuberosity of ischium	Superior medial surface of tibia (pes anserinus conjoined tendon of sartorius, gracilis and semitendinosus)	Flexion of the knee and extension of the hip	Tibial portion of sciatic nerve (L5–S2)
Biceps femoris	Long head: ischial tuberosity and sacrotuberous ligament Short head: linea aspera and lateral supracondylar ridge	Lateral (external) portion of fibular head and lateral condyle of tibia	Flexion of the knee and long head assists in extension of the thigh	Long head: tibial portion of sciatic nerve (S1–S3) Short head: common peroneal (fibula) portion of sciatic nerve (L5–S2)