Anatomi dan Kinesiologi Hip 3.pptx

MODUL HIP 3
Anatomy, Physical Exam,
Special Test

Hip Bursae
Hip bursae are synovial fluid-filled sacs
around the hip region, including the
greater trochanter of the femur.
Bursae often facilitate movement and
reduce friction where tendons or muscles
pass over bony structures. Hip bursae can
be either communicating or non-
communicating with the hip joint itself.
Most are only evident on imaging if
distended.

Hip Bursae
•anterior
• iliopsoas bursa (iliopectineal bursa)
•lateral
• subgluteal bursae
• greater trochanteric
bursa (subgluteus maximus bursa)
• superficial subgluteus
maximus bursa
• deep subgluteus maximus
bursa
• subgluteus medius bursa
• subgluteus minimus bursa
• secondary subgluteus minimus
bursa
• gluteofemoral bursa

Hip Bursae
•posteroinferior
• obturator externus bursa
• obturator internus bursa
• ischiogluteal bursa
•piriformis bursa

Trabecular Pattern of Femur
Trabecular pattern of proximal femur refers to the five groups of
trabeculae that are demonstrable within the femoral head and neck
Trabecula is a supportive and connective tissue element which form in
cancellous bone.
The trabecular pattern of growth follows the course of stress lines along
the bone and maximum trabeculae develop along the lines of maximum
stress.

WOLFF’S LAW
• Wolff's law suggests that there are dynamic internal forces as well as static
and dynamic external forces acting on the bone.
• These static forces are imposed by gravity and the dynamic forces by weight
bearing.
• Wolff's Law implies a reaction of a living bone to the mechanical forces on a
bone segment
• If the loading on a particular bone increases, then the bone will remodel itself
over time to become stronger and resist the loading in that particular bone
segment and for that particular force of loading.
• Both tensile and compressive forces are present and correspond to the
lines of forces.

Types of trabeculae
1.principal tensile trabeculae
2.principal compressive/medial compressive trabeculae
3.secondary compressive/lateral compressive trabeculae
4.secondary tensile trabeculae
5.greater trochanteric trabeculae

Principal tensile trabeculae
•it is in the form of an arc
•extends from the lateral margin of the greater trochanter to the inferior aspect
below the fovea
•the arc traverses through the superior cortex of the neck and the femoral head
Principal compressive /medial compressive trabeculae
•it is vertically oriented and has a triangular configuration
•extends from the medial cortex of the head into the femoral neck
Secondary compressive/lateral compressive trabeculae
•it has a fan-like configuration
•extends from the calcar and lesser trochanter to the greater trochanter
A central area bounded by the three trabecular patterns is referred to as the Ward
triangle

Importance of Trabecular Pattern
As per the Garden classification of subcapital femoral fractures, the
displacement is graded as per the position of the medial
compressive trabecular.
• stage I: medial trabeculae form an angle greater than 180°
• stage II: medial trabeculae of head form an angle of approximately
160° with femoral neck
• stage III: medial trabeculae are out of alignment with those of
pelvis
• stage IV: medial trabeculae are in alignment with those of pelvis

Shape of The Proximal Femur
∙ Angle of inclination
o Angle within the frontal plane between the femoral neck &
the medial side of the femoral shift
o 1250
o Coxa vara (Latin coxa, hip, + vara, to bend inward) describes
an angle of inclination markedly < 125o
o Coxa valga (Latin valga, to bend outward) describes an angle
of inclination markedly > 125o

Coxa Vara
The normal femoral neck–shaft angle is 160 degrees at birth,
decreasing to 125 degrees in adult life.
An angle of less than 120 degrees is called coxa vara.
The deformity may be either congenital or acquired.

Femoral Torsion
∙ Femoral torsion
o Relative rotation (twist) between the bone’s shaft & neck
o Normal anteversion ⭢ about 15o anterior to a medial-lateral
axis through the femoral condyles
o Normal angle of inclination (15o) ⭢ optimal alignment and
joint congruence
o Excessive anteversion ⭢ > 15o
o Retroversion ⭢ < 15o

Inspection
● Particular attention should be paid to his gait → many hip problems
manifest themselves most clearly during ambulation
● Check the hip and pelvic area for : arasions, discolorations, birth
marks, blebls, open sinus drainage, and particularly for abnormal
swellings, bulges, or skin folds
● Observe patient’s stance → checking to see if the ASIS are in the
same horizontal plane → if they are not, there may be some
pelvic obliquity (tilted pelvis) secondary to leg length discrepancy
Physical Examination

● Observed from the side, lumbar portion of the spine normally exhibits a
slight lordosis (anterior curvature of the spine) → if the spine exhibits an
exaggerated curve, the anterior abdominal muscles may be weak → if
increased lumbar lordosis may also be caused by a fixed flexion deformity
of the hip
● Observing posterior aspect → notice that the lower orders of the buttocks
are marked by the gluteael folds (lateral and slightly inferior to the
approximate midline of the thigh) → asymmetrical folds may be due to a
congenital dislocation of the hip, muscular atrophy, pelvic obliquity, or a
leg length discrepancy
● Observe the two discerbible dimples which overlie the posterior superior
iliac spine directly above the buttock → should lie along te same
horizontal plane → if the do not, there is evidence of pelvic obliquity
Physical Examination

Greater Trochanter
● With your patient in supine, place your thumbs
on the ASIS’s and move your fingers about 3”
posteriorly along the iliac crest to the widest
part of the pelvis known as the iliac tubercles.
● Now, move your fingers caudally from the iliac
tubercles until you can palpate the greater
trochanters.
● The posterior edge of the trochanter is most
palpable.
● The examiner can also passively internally
and externally rotate the femur to
facilitate identification of this landmark.
Anterior Aspect

The Femoral Triangle Borders
● Superior Border = Inguinal Crease
● Medial Border = Adductor Longus
● Lateral Border = Sartorius
*To facilitate palpation of
these structures, place your patient in
hip flexion, abduction and ER, with
their heel resting on the opposite knee
Soft Tissue Palpation

Adductor Longus
● The adductor longus is the
most superficial adductor muscle and
the only one accessible for palpation.
● It is palpable as a cordlike
structure proximally near the pubic
symphysis and can be felt running
toward the middle of the thigh.
● It is often strained during sports or
activity.

● Inguinal Ligament
● Femoral Artery
● Femoral Nerve & Vein (not palpable)
*To facilitate palpation of these
structures, place your patient in hip
flexion, abduction and ER, with their
heel resting on the opposite knee
The Femoral Triangle
Interior Structures

Inguinal Ligament
● This ligament is palpable between
the ASIS and the pubic tubercle.
● Any unusual bulges along this
ligament may be indicative of an
inguinal hernia.

Femoral Artery
● The femoral artery passes under
the inguinal ligament
at it’s midpoint. Palpate the pulse
of this artery just inferior to the
ligament at it’s midpoint.

Trochanteric Bursae
● The trochanteric bursae covers
the posterior portion of the
greater trochanter.
● This structure is not distinctly
palpable unless it is distended or
inflamed, in which case it will
feel boggy and be tender to
palpation.

Gluteus Medius Muscle
● This muscle is most easily
palpated with the patient
in sidelying and with the
leg actively raised into a few
degrees of abduction. It is
palpable just below the iliac crest
and also at it’s insertion, on the
anterior and lateral aspects of
the greater trochanter.

Sciatic Nerve
● When the hip is extended, the
sciatic nerve is covered by the
gluteus maximus, but is exposed
during hip flexion. Place your
patient sidelying with the hip
flexed. In some individuals the sciatic
nerve is palpable midway between the
greater trochanter and the ischial
tuberosity.

Rectus Femoris
● The rectus femoris is the only two-
joint muscle of the quadriceps muscles.
● Except in individuals with very
developed musculature, it is not distinctly
palpable from the other three heads of
the quadriceps, however tenderness
over the area of it’s origin at the AIIS
can indicate avulsion.
● The quadriceps muscle group covers the
vast area on the anterior aspect of the
femur. Palpate the vicinity of this muscle.

Gluteus Maximus
It is difficult to palpate the origin and insertion
of this massive muscle, but palpation the
muscle belly of the gluteus maximus is
facilitated with the patient prone, with the
buttocks squeezed together. It’s outline can
also be estimated by the following imaginary
lines:
1. Line between the PSIS to just above
the greater trochanter
2. Line between the coccyx and the
ischial tuberosity

Hamstring Muscles
● The common origin of the
hamstring muscles is palpable at the
ischial tuberosity.
● Palpation is facilitated by having the
patient in sidelying with their knees
flexed to the chest.
● Tenderness to palpation in this
region may be indicative of
tendonitis or ischial bursitis.

The Femoral Triangle Borders
● Superior Border = Inguinal Crease
● Medial Border = Adductor Longus
● Lateral Border = Sartorius
*To facilitate palpation of
these structures, place your patient in
hip flexion, abduction and ER, with
their heel resting on the opposite knee
Anterior Aspect

ACTIVE RANGE OF MOTION TEST
Abduction
• Ask the patient to stand and to spread his legs apart as far as he
can.
• He should be able to abduct catch leg at least 45o from the midline.
Adduction
• Instruct the patient to bring his legs together from the abduct
position, ad alternately cross them, first with the right leg in front,
then with the left.
He should be able to achieve at least 20o of adduction.
Range of Motion

Flexion
• Instruct the patient to draw each knee toward his chest as far as he can
withput bending his back.
• He should be able to brong his knees almost to his chest (approcimately
135o of flexion).
Flexion and Adduction
• Have the patient sit in a chair and ask him to cross one thigh over the other.
Flexion, Abduction, and External Rotation
• Then, instruct the patient to uncross his thighs and place the lateral side of
his foot upon the opposite knee.
Range of Motion

Extension
• Have the patient sit in a chair and ask him to cross one thigh over
the other.
Internal and External Rotation
• There are no specific, quick active test for range of internal and
external rotation of the femur; however, these functions have been
adequately tested in conjuction with the previous tests.
Range of Motion

PASSIVE RANGE OF MOTION
TESTS
Flexion – 120o
• Flex the hip as far as possible.
• Normal flexion limits allow the
anterior portion of the thigh to rest
against the abdomen, almost
touching the chest wall.
Range of Motion

Extension – 30o
• Ask the patient to lie prone upon
the examining table, and stabilize
the pelvis by placing your arm over
the iliac crest and lower lumbar
spine.
• Habe the patient then bend his
knees slightly to relax the
hamstring muscles so that they will
not be active in hip extension.
• Now, place your other hand under
the thigh and lift his leg upward.
Range of Motion

Abduction – 45-50o
• With the patient supine and his
legs in the neutral position,
stabilize the pelvis by placing your
forearm across the abdomen and
your hand upon the opposite
anterior superior iliac spine.
• Then, hold one ankle and gently
abduct the leg as far as it will go.
Range of Motion

Adduction – 20-30o
• With the patient still supine,
continue to stabilize the pelvis and,
by holding one angle, guide the leg
across the midline of the body and
over the opposite extremety.
• You can feel the pelvis begin to
move at the end point of hip
adduction. Measure the range af
adduction and repeat the
procedure for the opposite hip.
Range of Motion

Internal Rotation – 35o
External Rotation – 45o
• Have the patient assume a supine
position, with his legs extended.
• Stand at the foot of the table, hold
his feet just above the malleoli,
and rotate the legs externally and
internally, using the proximal end
of the patella as a guidline to
evaluate range of rotation
Range of Motion

Internal Rotation – 35o
External Rotation – 45o
• Ask the patient to sit up on the end
of the table so that both hips and
knees are in 90o of flexion.
• Stabilize the femur so that it
cannot move from side to side
during the test.
• Them grasp the lower end of the
tibia and rotate the leg, externally
and internally using the tibia and
fibula as levers, as in the previous
test
Range of Motion

Articular Tests Muscles and
Tendon Tests
Other Tests
FAIR test
McCarthy test
FABER test
Torque test
Active SLR test
Thomas’s test
Modified Ober’s test
Tredelenburg test
Craig’s test
Sign of the butock

FAIR (Flexion, Adduction,
Internal Rotation Test
Aka
Impingement test
Posterior labral tear test
Apprehension sign
Piriformis test
Psoas test
Purpose
To reproduce pain and/or apprehension and increase the likelihood
of detecting a range of conditions such as articular pathology (e.g.
femoro-acetabular impingement (FAI), labral and hip joint pathology
and instability), piriformis syndrome and psoas bursitis.

Technique
• Patient position
Lying supine.
• Clinician position
Standing on the affected side.
• Action
The hip and knee are taken into 90 ° of flexion and then full internal
rotation is added by applying a stabilizing pressure on the outside at
the knee with the cephalic hand and drawing the lower leg outwards
by using the heel as a lever with the caudal hand. The final component
is adduction, achieved by passively moving the knee towards
the opposite hip.

Variations
The scour/quadrant/flexion adduction test
• is a modification where the hip is passively flexed to 90 ° and adducted. The
clinician’s hands are interlocked and placed over the patient’s flexed knee.
Leaning over the knee so that the examiner’s body weight can be used to
good effect, a compressive force is applied through the longitudinal axis of
the femur. Small passive movements are made into flexion and extension in
order to ‘ scour ’ the joint.
• A positive test is indicated by reproduction of the patient’s symptoms.

McCarthy Test
Purpose
To reproduce pain and/or a ‘ click ’ in order to detect an acetabular
labral tear.
Technique
Lying supine with the hips and knees flexed and both feet resting
on the couch.
The affected hip is taken into full passive flexion, with one hand
supporting the flexed knee and the other supporting the foot.

McCarthy Test
• Action
External rotation is then added as the affected hip is gradually
taken down towards extension (see Fig. 5.4 ). If this does not elicit
a positive response, the manoeuvre is repeated with the addition of
internal rotation instead.
• Positive test
Reproduction of the patient’s hip pain or click.

FABER (Flexion, Abduction,
External Rotation Test
Aka
The ‘ 4 ’ test
Patrick’s test
Jansen’s test
Purpose
To test primarily for articular pathology in the hip joint. Also stresses
the sacro-iliac joint (SIJ), iliopsoas tendon and the lumbar spine.

Technique
The patient lies supine and the affected leg is flexed and externally
rotated so that the lateral aspect of the ankle is positioned just above
the opposite knee joint. If this starting position is uncomfortable for
the patient, the knee can be brought more into the midline to reduce
hip abduction.
Standing at the patient’s affected side, the pelvis is stabilized by applying
gentle pressure over the opposite anterior superior iliac spine.
• Action
The patient is asked to lower the knee towards the couch and if full
range is achieved, gentle overpressure can be applied to the medial

• Positive test
A positive test is indicated by the reproduction of the patient’s pain
or reduced range of movement. If the knee lowers to a point which
is level to the opposite knee or the range is equivalent to the
contralateral side, range is considered to be normal.

Torque Test
Purpose
To test the capsular ligaments and passive stability of the hip joint.
Technique
Lying supine to one side of the treatment couch with the buttock
just off the edge.

Torque Test
• Clinician position and action
The clinician stands between the couch and the patient’s affected leg
with the cephalic hand placed over the anterior aspect of the thigh.
The caudal hand supports the lower limb at the ankle. With the knee
extended, the hip is taken to end-range extension over the edge of the
couch until the pelvis just starts to rotate anteriorly. The hip is then
taken to end-range internal rotation using the ankle to supply the leverage
while simultaneously applying a strong posterolateral pressure
over the anterior aspect of the upper thigh for 20 seconds.
• Positive test
Reproduction of the patient’s pain suggests hip instability.

Active Straight Leg Raise
(SLR) Test
Aka
Stinchfield resisted hip flexion test
Mens test
Purpose
To test for intra-articular hip pain (e.g. OA, labral tear, femoroacetabular
impingement), fracture, pain stemming from a hip prosthesis
and contractile lesions of the hip flexors.
Technique
Lying supine.

(SLR) Test
Standing on the affected side.
• Action
Keeping the knee extended, the patient performs a straight leg raise
(SLR) to approximately 20 – 30 ° . The clinician then steadily resists the
SLR by applying pressure to the lower aspect of the anterior thigh.
• Positive test
Reproduction of the patient’s hip pain, which is usually in the groin
or anterior aspect of the thigh.

(SLR) Test

Thomas’s Test
Aka
Hugh Owen Thomas (HOT) test
Thompson test
Rectus femoris contracture test
Purpose
To test for a fixed flexion deformity at the hip and assess muscle
length of the rectus femoris, iliacus, tensor fascia lata (TFL) and the
iliotibial band (ITB).
Technique
Patient position
Lying supine.

Thomas’s Test
Firstly , the clinician checks that the patient is able to maintain their
normal lumbar lordosis with the legs comfortably resting on the
couch. In patients with soft tissue tightness or flexion contracture,
the affected hip(s) will be held in a degree of flexion (this may also
present as an increased lumbar lordosis). One hand is then placed
under the patient’s lumbar spine in order to assess the degree of
lumbar movement during the test.
• Action
The patient flexes the unaffected hip and knee towards the chest
until the lumbar spine is flattened as assessed by the clinician’s hand.
The patient then grasps the knee with both hands and maintains the
hip in this position. Attention is then turned to the affected leg where
the position of the thigh in relation to the couch is determined.

Thomas’s Test
• Positive test
In a normal hip, the affected thigh is able to remain extended,
resting on the couch. In the presence of soft tissue tightness or a
fixed flexion deformity, the affected hip will be drawn into a degree
of flexion bringing the thigh away from the couch. If the clinician
attempts to passively extend the hip by pushing the thigh in a
downwards direction, the patient will report a stretching sensation
over the anterior hip and thigh and an attempt to increase their
lumbar lordosis will be noted. If the hip gravitates more towards
abduction than flexion during the test (the J sign), shortening of the
ITB is likely.

Ely’s Test
Purpose
Detecting a contracture of the rectus femoris.
Technique
The patient lies prone and the knee is passively flexed to
approximately 90 ° . If there is shortening or contracture of the
muscle, the hip on the same side will endeavour to flex as
flexion is added at the knee.

Modified Ober’s Test
Purpose
To assess ITB and tensor fascia lata (TFL) extensibility.
Technique
Lying on the unaffected side with the hip and knee flexed to provide
a stable base. The affected hip is uppermost and in a neutral position.
Standing behind the patient, the caudal hand crosses over the top
of the uppermost leg and cups the medial aspect of the thigh just
above the knee. The cephalic forearm stabilizes the pelvis by applying
a firm downward and forward pressure onto the iliac crest. The
affected hip is then drawn into an extended and abducted starting
position ensuring that neutral femoral rotation is maintained.

Action
The pelvis must be prevented from tilting backwards by maintaining
the downward and forwards pressure with the stabilizing
arm. Maintaining the affected hip in extension the thigh is lowered
towards an adducted position. The end-point of the test is either
cessation of hip adduction as the leg reaches a resting position on
the couch or the clinician detecting movement of the pelvis.
Positive test
A positive test is either reproduction of the patient’s lateral hip pain
or reduced range of movement. The normal range of hip adduction
in the modified Ober’s test position is 10 ° beyond neutral and an
inability to reach this range is therefore considered abnormal.

Variations
The original Ober’s test (Fig. 5.12) was described for use
with patients suffering from low back pain and sciatica. The position
of both clinician and patient is as described above. The affected knee
is then flexed to 90 ° and the hip lowered into the adducted position.
A reduced range (normal range 0 ° adduction) is anticipated when
compared with the modified Ober’s test

Tredelenburg Test
Purpose
To test for stability of the pelvic/hip complex and strength of the
hip abductors.
Technique
Standing .
Standing facing the patient in order to observe the outcome of the
test and provide some support to the patient with the hands if
required.

Tredelenburg Test
• Action
The patient is asked to transfer their weight onto the affected leg
and lift the unaffected foot off the ground by flexing both the hip
and knee. The clinician observes the movement as the weight is
transferred onto the symptomatic side.
• Positive test
A positive/abnormal test is recorded if the pelvis on the non-weightbearing
side drops because the gluteal muscles on the weight-bearing
side cannot maintain the pelvis in a neutral position. Normally
the glutei will produce a slight uplift of the pelvis on the nonweight-
bearing side as weight is borne on the opposite leg. In a
study of normal volunteers the change in position of the pelvis on the
femur was measured at a barely detectable 4 ° and, that being the case,
normal abductor performance could be assumed.

Craig’s Test
Aka
Ryder method for measuring femoral anteversion
Purpose
To ascertain the degree of femoral anteversion.
Technique
Lying prone with the thighs and knees approximated and
the
affected knee flexed to 90 °.

Craig’s Test
Using one hand, the lateral aspect of the greater trochanter on the
affected side is palpated. The other hand uses the patient’s foot as
a lever and passively internally rotates the hip until the greater trochanter
reaches its most prominent point laterally. The angle that
the line of the tibia makes with the vertical equates to the degree of
femoral anteversion.
• Positive test
The normal angle of femoral anteversion in the adult is between
8 ° and 15 ° . An angle greater than 15 ° indicates increased femoral
anteversion; less than 8 ° indicates femoral retroversion.

Sign of The Buttock Test
Purpose
To test for a serious lesion in the buttock or hip region, e.g. fracture,
neoplasm or infection.
Technique
Lying supine.

Purpose
To test for a serious lesion in the buttock or hip region, e.g. fracture,
neoplasm or infection.
Technique
Patient position
Lying supine.
Clinician position and action
Standing adjacent to the side being tested the clinician performs a
straight leg raise (SLR) on the affected leg and the angle achieved is
noted (see Fig. 5.16A ). At the point where increased pain is reported
by the patient, the tension in the posterior thigh, buttock and sciatic
nerve is removed by flexing the knee while maintaining the
hip at the same angle (see Fig. 5.16B ). Further hip flexion is then attempted.
Under normal circumstances, it should then be possible
to move the hip into further flexion.

Standing adjacent to the side being tested the clinician performs a
straight leg raise (SLR) on the affected leg and the angle achieved
is
noted (see Fig. 5.16A ). At the point where increased pain is
reported by the patient, the tension in the posterior thigh, buttock
and sciatic nerve is removed by flexing the knee while maintaining
the hip at the same angle (see Fig. 5.16B ). Further hip flexion is
then attempted. Under normal circumstances, it should then be
possible to move the hip into further flexion.

• Positive test
Once the knee is flexed, further hip flexion would be expected but
in fact none is possible as this increases the patient’s buttock pain.
This may be accompanied by voluntary muscle spasm and the
patient stopping further movement taking place.

Anatomi dan Kinesiologi Hip 3.pptx

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