The document outlines the anatomy, functionality, and common pathologies of the hip joint, including key ligaments, muscles, nerves, and orthopedic tests. It discusses conditions such as congenital hip dysplasia, hip fractures, osteoarthritis, and avascular necrosis, along with their clinical signs, symptoms, and testing methods. Postoperative management strategies following total hip arthroplasty (THA) are also covered, emphasizing the importance of early movement and weight-bearing considerations.

1. Examination, evaluation & Assessment
of Hip
Dr. Abid Ullah PT
Lecturer FIMS
Abbottabad
Email:
dr.abidullahpt@yahoo.com

2. Anatomy
 Ball and socket joint of synovial joint.
 Connects the pelvic girdle to the lower limb
 Made up of femoral head and acetabulum
 Designed for stability and wide range of movement
 Covered with a thin layer of hyaline cartilage

4. More Anatomy
 The articular surface of is horse-shoe shaped and is
deficient inferiorly- acetabular notch
 Has a labrum
- is a circular layer of cartilage which surrounds the
outer part of the acetabulum making the socket deeper
and so helping provide more stability
- Acetabular labral tears are a common injury from
major or repeated minor trauma

6. Iliofemoral Ligament
 This is a strong ligament
which connects the pelvis to
the femur
 at the front of the joint
 It resembles a Y in shape
 Stabilises the hip by limiting
hyperextension

7. Ligaments
 Pubofemoral ligament
 The pubofemoral ligament attaches the part of the pelvis
known as the pubis (most forward part, either side of the
pubic symphysis) to the femur.
 Ischiofemoral ligament:
 This is a ligament which reinforces the posterior aspect of the
capsule
 attaches the ischium to the two trochanters of the femur.
 Transverse acetabular Ligament:
 Bridges acetabular notch.
 Ligament of head of femur: flat and triangular in shape
 Lies within joint, ensheathed by synovium

8. Muscles
 Gluteals:
 Gluteus Maximus, Gluteus
Minimus and Gluteus Medius
 Attach to the Ilium and travel
laterally to insert into the greater
trochanter of the femur
 Medius and Minimus abduct and
medially rotate the hip joint, as well
as stabilising the pelvis
 Gluteus maximus extends and
laterally rotates the hip joint

9. More Muscles
 Quadriceps
 The four Quadricep muscles are
Vastus lateralis, medialis,
intermedius and Rectus femoris
 All attach inferiorly to the tibial
tuberosity
 Rectus femoris originates at the
Anterior Inferior Iliac Spine and acts
to flex the hip
 The 3 other Quad muscles do not
cross the hip joint, and attach
around the greater trochanter and
just below it.

10. Muscles
 Iliopsoas:
 The is the primary hip flexor
muscle which consists of 2
parts
 Attaches superiorly to the
lower part of the spine and
the inside of the ilium
 Cross the hip joint and insert
to the lesser trochanter of the
femur

11. Muscles
 Hamstrings:
 The hamstrings are three
muscles which form the
back of the thigh
 Attach superiorly to the
ischial tuberosity
 Cause hip extension

12. Functional Group of Muscles
Acting on the Hip
Flexors:
 Iliopsoas, sartorius, tensor fascia lata, rectus femorus, pectineus,
adductor longus, brevis, and magnus, gracilis
Extensors:
- hamstrings, addcutor magnus, gluteus maximus
Adductors:
- adductor longus, brevis, and magnus, gracilis, pectineus
Abductors:
- gluteus medius, minimus, tensor fascia lata
External rotators:
- obturator externus, internus, piriformis, quadratus femoris, gluteus
maximus
Internal Rotators:
- gluteus medius, minimus, tensor fascia lata.

13. Nerves
 Femoral (L2,3,4)
 Obturator (L2, 3, 4)
 Sciatic (L4,5, S1, 2,)
 WHY ARE THESE
IMPORTANT???
- Referred pain to the
knee can hide hip
pathology and vis
versa

14. Blood Supply

15. Clinical features of Hip Pathology
 Pain.
 Stiffness.
 Loss of function.
 Crepitations.
 Leg length discrepancy.

16. Gait
 Antalgic gait: painful, short stance phase
 Ataxic: uncoordinated walk, with a wide base &
 Double-step-gait: in which there is a noticeable
difference in the length or timing of alternate step
 Trendelenburg (abductor lurch) gait: weak abductors
 Waddling gait: bilateral weak abductors, bilateral
DDH
 Steppage gait: foot drop
 Toe-walking
 In-toeing vs out-toeing
 Others: scissoring, etc.

17. Hip Joint Orthopedic Tests
 Congenital Hip Dysplasia
 Congenital hip dysplasia is a condition in which the
femoral head is displaced out of the acetabular cavity.
 Often bilateral. Girls affected more often than boys.
 The acetabular cavity is shallow or more vertical than
normal.

18. Congenital Hip Dysplasia
 Clinical Signs and Symptoms
 Decreased hip flexibility
 Limited hip abduction
 Painless limp
 Hip pain
 Shortened extremity

19. Allis Test
 Procedure: Infant supine, flex the knees, Feet
should approximate one another on the table.
 Positive Test: A difference in the height of the knees
is a positive test.
 Short knee on the affected side – posterior displacement
of the femoral head or a short tibia.
 Long knee on the affected side – anterior displacement
of the femoral head or increase in tibia length.

20. Allis Test

21. Ortalani’s Click Test
 Procedure: Infant supine. Grasp both thighs with
thumbs on the lesser trochanters. Flex and abduct the
thighs b/l.
 Positive Test: Palpable or audible click is a positive
sign. The click signifies displacement of the femoral
head in or out of the acetabular cavity.

22. Ortalani’s Click Test

23. Hip Fractures
 Hip fractures occur most frequently in the elderly
population.
 Most common types are intertrochanteric and
intracapsular.
 Intertrochanteric and femoral head fractures typically
do NOT disrupt the blood supply.
 Intracapsular fractures disrupt the blood supply to the
femoral head and can lead to avascular necrosis

24. Hip Fractures
 Clinical Signs and Symptoms
 Hip pain
 Shortened extremity
 Externally rotated extremity
 Referred pain to medial thigh

25. Anvil Test
 Procedure: Patient supine. Tap the inferior
calcaneous with your fist.
 Positive Test: Local pain in the hip joint may
indicate a femoral head fracture or joint pathology.
 Pain in the thigh or leg secondary to trauma may
indicate a femoral, tibial, or fibula fracture.
 Pain local to the calcaneous may indicate a calcaneal
fracture.

26. Anvil Test

27. Hip Contracture
 A hip joint contracture is a condition of soft tissue
stiffness that restricts joint motion.
 This can be caused by immobility due to spasticity,
paralysis, ossification, bone trauma, or joint trauma.
 A frequently moved joint is unlikely to develop a
contracture deformity.
 The joint capsule, ligaments, or muscle tendon units
can be involved.

28. Hip Contracture
 Clinical Signs and Symptoms
 Stiff hip joint
 Limited hip range of motion
 Inability to position joint in the neutral position
 Hip joint pain on range of motion

29. Thomas Test Procedure: A test to determine if a patient has tightness of hip flexors
i.e rectus femoris or iliopsoas muscles.
 The patient is positioned supine on the table. The subject is then asked
to bring both knees to their chest and to hold the untested limb with
their hands. The examiner then passively lowers the test limb to the
table. If the limb remains up off the table, a hip flexor contracture is
suspected. To differentiate muscles, the examiner then passively
extends the knee placing the rectus femoris on slack. If the test limb
lowers to the table the rectus femoris is shortened. If the test limb
remains off the table with the knee flexed the iliopsoas is shortened.
 Positive Test:
 No tightness – suspect restriction at the hip joint structure or joint
capsule.
If tightness is palpated on the side of the involuntary flexed knee –
hip flexure contraction is suspected.

30. Thomas Test

31. Ely’s Test
 Structure : iliopsoas & rectusfemorus
 Procedure: Patient prone. Grasp ankle and
passively flex the knee to the buttock.
 Positive Test: If the patient has a tight rectus
femoris or hip flexion contracture, the hip on the same
side will flex, raising the buttock off the table.

32. Ely’s Test

33. General Hip Joint Lesions
 Common problems associated with the hip joint
include the following:
 Osteoarthritis, sprains, fractures, dislocations, bursitis,
tendinitis, synovitis, and avascular necrosis of the
femoral head.
 The following tests determine whether a general lesion
of the hip is present. Further diagnostic imaging can
determine the exact pathology.

34. General Hip Joint Lesions
 Clinical Signs and Symptoms
 Hip pain
 Shortened extremity
 Externally rotated extremity
 Referred pain to medial thigh

35.  Trochanteric Bursitis
• Pain over the lateral hip and possibly
• down the lateral thigh to the knee
• Discomfort after standing
• hip elevated and adducted and the pelvis dropped on
• the opposite side.
• climbing stairs aggravate the condition.
 Psoas Bursitis
• Pain in the groin or anterior thigh
• Aggravated during excessive hip flexion
 Ischiogluteal Bursitis
• Pain is around the ischial tuberosities,
• increase when sitting

36. Patrick Test (Faber)
 Procedure: Patient supine. Flex leg and place foot flat
on table. Grasp femur and press it into the acetabular
cavity. Cross leg to opposite knee. Stabilize ASIS opposite
and press down on knee of side tested.
 Positive Test:
 Pain in the hip – inflammatory process in the hip joint
 Pain secondary to trauma – may indicate fracture
 Pain may indicate avascular necrosis of femoral head
 Faber – Flexion, abduction, & external rotation
 If pain is elicited on the ipsilateral side anteriorly, it is
suggestive of a hip joint disorder on the same side. If pain is
elicited on the contralateral side posteriorly around the
sacroiliac join

37. Patrick Test (Faber)

38. Trendelenburg Test
 Procedure: Patient standing. Grasp waist.
Thumbs on PSIS . Instruct patient to flex one leg at a
time.
 Positive Test:
 If the patient cannot stand on one leg because of pain
 If the opposite pelvis falls or fails to rise
 This tests the integrity of the hip joint opposite the side
of hip flexion

39. Trendelenburg Test

40. Laguerre’s Test
 Procedure: Patient supine. Flex the hip and knee
to 90 degrees. Rotate the thigh outward and the knee
medially. Press down on the knee with one hand and
pull up on the ankle with the other.
 Positive Test: This test externally forces the head
of the femur into the acetabular cavity.
 May indicate an inflammatory process in the joint such
as osteoarthritis.
 Pain secondary to trauma – suspect fracture of the
acetabular cavity or rim.

41. Laguerre’s Test

43. Avascular necrosis (AVN) of the hip
(osteonecrosis)

44. Osteonecrosis
 also called avascular necrosis or aseptic necrosis.
 is a painful condition that occurs when the blood
supply to the bone is disrupted
 Because bone cells die without a blood supply,
osteonecrosis can ultimately lead to destruction of the
hip joint and arthritis.
 The pain localized to the groin area, but it may in the
ipsilateral buttock, knee, or greater trochanteric
region.
 Painful symptoms exacerbated with weight bearing
but are relieved by rest.

45.  Causes
 Atraumatic
 Excessive corticosteroid
 Alcoholism
 Other medical conditions — sickle cell disease, SLE, arterial
embolism, thombosis, and vasculitis
 traumatic
 Femoral neck fractures
 Hip dislocation, subluxation, displaced femoral neck fracture
can damage the fragile retinacular vessels, which supply the
femoral head and result in femoral head necrosis.

46.  Symptoms
 Osteonecrosis develops in stages. Hip pain is typically the
first symptom. This may lead to a dull ache or throbbing
pain in the groin or buttock area. As the disease progresses,
it will become more difficult to stand and put weight on the
affected hip, and moving the hip joint will be painful.
 How long it takes for the disease to progress through these
stages varies from several months to over a year. It is
important to diagnose this disease early, because some
studies show that early treatment is associated with better
outcomes.

47.  Passive range of motion of the hip is limited and
painful, especially forced internal rotation.
 A distinct limitation of passive abduction is usually
noted.
 A straight-leg raise against resistance provokes pain in
most symptomatic cases.
 Passive internal and external rotation of the extended
leg ("log roll test") may elicit pain that is consistent
with an active capsular synovitis.

48. Postoperative Management
 Immobilization
 After THA there is no need for immobilization of the
operated hip
 postoperative rehabilitation emphasizes early
movement
 the operated limb may need to remain in a position of
slight abduction and neutral rotation
 An abduction pillow or wedge typically is sufficient to
maintain the position.

49.  Weight-Bearing Considerations
 After cemented THA, typically patients are permitted
to bear as much weight as tolerated almost
immediately after surgery
 Cementless or hybrid THA, it is often necessary to
limit weight bearing on the operated limb for the first
few weeks or up to 3 months
 Exercise and Functional Training