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The Pelvis and Hip: Function and Anatomy
- 1. The Hip ANATOMY ANDFUNCTION with Jill Costley
- 2. Overview Summary ofthe pelvis Hip & thigh anatomy Ligaments Muscles Functions of the structures associated with the hip Movement impairments of the hip/ groin and associated functional tests How can we use this knowledge to inform our practice? Application to athletes
- 3. The Pelvis Two coxalbones, the sacrum and the coccyx • Protects organs • Childbirth in females • Supports the spine and upper body • Supports movement • Provides attachment sites for muscles and ligaments of the hip and trunk Coxal bone: ilium, ischium (posterior) & pubis (anterior) Triradiate cartilage - Not fully fused until approximately 18 yrs old Includes the acetabulum (socket) of the hip joint Functions of the Pelvis: Agur & Dalley, 2009
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- 5. The Hip Joint (TheFemoroacetabular Joint) Ball-and-socket joint Stable joint due to many factors i.e. osseous/ ligamentous/neuromuscular Large ROM Multi-axial movement Flexion/ Extension Rotation: External/ Internal Abduction/ Adduction Frontera et al., 2014; Diduch & Brunt, 2014 Articulation of the head of the femur with the acetabular socket of the pelvis
- 6. American College ofSports Medicine, 2014; Swartz, 2014
- 7. The Acetabulum Depth ofthe acetabulum is increased through the labrum Articular (lunate surface) Non-articular - acetabular fossa Transverse acetabular ligament crossing the acetabular notch Singh, 2008 The Labrum • Fibrocartilaginous rim surrounding the acetabulum • Transverse acetabular ligament acetabular notch • Thickest posteriorly • Tears common in acetabular dysplasia
- 8. Reflected tendon of the rectus Anteriorlunate cartilage Posterior lunate cartilage Acetabular fossa Acetabular fossa Transverse acetabular ligament Lunate cartilage Ligamentum teres Acetabular labrum Femoral headObturator foramen Transverse acetabular ligament Byrd, 2013
- 9. Femur Longest and strongestbone within the human body supports the load bearing function of the hip Biel, 2004; Madden, 2008 Distal end forms an articulation with the patella and tibia creating the hinge joint of the knee Muscle attachment sites include – Greater trochanter Linea aspera Gluteal tuberosity Adductor tubercle Pectineal line (spiral) Trochanteric fossa Ligament insertion sites include – Intertrochanteric line Intertrochanteric crest Femoral neck
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- 11. Bony Landmarks –Solo Pass, Iliac Avenue, Tailbone Trail & Hip Hike Biel, 2004
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- 13. Biel, 2004; Torryet al., 2006; Martin et al., 2008; Ito et al., 2008 Iliofemoral Ligament (2 arms) limit extension in flexion Lateral arm in flexion: ex. rotation Lateral arm in extension: in/ex rotation Capsular Ligaments Zona Orbicularis Hip stability under distraction Ischiofemoral Ligament internal rotation Pubofemoral Ligament in extension: external rotation abduction
- 14. The Hip &Thigh Anatomy MUSCLES & FUNCTION
- 15. Categorisation of MuscleGroups Iliopsoas Five main muscle groups: 1. Quadriceps femoris (4) 2. Gluteal (3) 3. Hamstrings (3) 4. Adductors (5) 5. Lateral rotators (6) Tensor Fasciae Latae Sartorius Biel, 2004; Magee, 2014 Pelvic floor
- 16. Quadriceps Femoris Four muscles: 1.Vastus Lateralis 2. Rectus Femoris (biarticular) 3. Vastus Medialis 4. Vastus Intermedius Biel, 2004 All: extend the knee Rectus femoris: flexes the hip Origin: AIIS (rectus femoris)/ along femur (all others) Insertion: Tibial tuberosity
- 17. Gluteals Three muscles: Hipabductors 1. Gluteus maximus – Upper/ Lower 2. Gluteus medius – Medial/ lateral 3. Gluteus minimus Biel, 2004 Origin: posterior pelvis Insertion: femur/ IT tract Gluteus maximus: hip extension, lateral rotation, hip abduction Lower fibres: hip adduction Gluteus medius: hip abduction medial fibres: hip extension, external rotation of thigh lateral fibres: hip flexion, internal rotation of thigh Gluteus minimus: internal rotation of thigh, hip flexion & hip abduction
- 18. Hamstrings Biel, 2004 Origin: Ischialtuberosity/ femur (BFSH) Insertion: fibula (BF)/ tibia (semi’s) Three muscles: 1. Biceps femoris (BFLH & BFSH) 2. Semitendinosus 3. Semimembranosus Semi’s: internally rotates a flexed knee, hip extension, @ Internal rotation of thigh, BFLH: hip extension/ @ external rotation of the thigh ALL: Posterior pelvic tilt, knee flexion
- 19. Adductor Muscles Five muscles: 1.Adductor longus 2. Adductor brevis 3. Adductor magnus 4. Pectineus 5. Gracilis • Adduct the hip • Internally rotate the thigh All EXCEPT gracilis: @ hip flexion Gracilis ONLY: • Knee flexion • Internal rotation of thigh in knee flexion Posterior fibres of adductor magnus: hip flexion Biel, 2004 Origin: On the pelvis pubic bone ischium ischial tuberosity Insertion: Along the femur On adductor tubercle (add. magnus) Tibia (gracilis) All:
- 20. Lateral Rotators All: Externallyrotate the thigh Piriformis: Abducts the hip in hip flexion Biel, 2004 Origin: on the pelvis and sacrum Insertion: along the greater trochanter The ‘’deep-6’’ muscles 1. Piriformis 2. Obturator internus 3. Obturator externus 4. Gemellus superior 5. Gemellus inferior 6. Quadratus femoris
- 21. Gluteus minimus Sciatic nerve Gluteusmedius Piriformis Inferior gemellus Quadratus femoris Superior gemellus Internus obturator Byrd, 2013
- 22. Others 1. Iliopsoas (Iliacusand psoas major) 2. Sartorius 3. Tensor Fasciae Latae (TFL) 4. Perineum
- 23. Iliopsoas Biel, 2004 Two muscles: 1.Psoas major 2. Iliacus Fixed origin: hip flexion/ external rotation? Origin: Iliac fossa Insertion: Lesser trochanter Fixed insertion: trunk flexion towards thigh/ anterior pelvic tilt Iliacus Psoas major Fixed origin: hip flexion/ external rotation? Fixed insertion: trunk flexion towards thigh/ anterior pelvic tilt Unilateral: @ lateral lumbar flexion Origin: lumbar processes Insertion: lesser trochanter
- 24. Sartorius Hip: flexion, external rotation, abduction,internally rotates thigh in knee flexion Origin: ASIS Insertion: tibia Biel, 2004 Knee: flexion Longest muscles in the human body
- 25. Tensor Fasciae Latae Biel,2004 Stabilisation of knee and hip Iliotibial Tract - Fascia Hip flexion, internal rotation and abduction Origin: Iliac crest Insertion: Iliotibial tract Origin: Gluteal fascia Insertion: Tibial tubercle
- 26. Perineum & Pelvic Floor Biel,2004 Perineum Diamond shaped area found inferiorly within pelvis Bordered by the two ischial tuberosities, the pubis symphysis and the coccyx Pelvic floor Supports the abdominal and pelvic viscera 2 levator ani 2 coccygeus fascia
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- 28. The Hip &Thigh STABILITY OF THE HIP
- 29. Contributions to hipstabilization – Osseous Structures Ligamentous Structures Neuromuscular Structures ROM needs large degree of stability
- 30. Osseous contributions 1. Femoral(head-neck) offset 2. Acetabular anteversion 3. Acetabular coverage of the femoral head Ligamentous contributions • Capsular ligaments – limiting movement 1. Iliofemoral ligaments – Flexion – internal rotation Extension – Internal & external rotation 2. Ischiofemoral ligaments – Flexion & Extension – internal rotation 3. Pubofemoral ligaments – Extension – external rotation Abduction • Zona orbicularis – stabilization under distraction* • Ligamentum teres – intrinsic stabilization Neuromuscular contributions - Ability to alter muscle stiffness to ensure articular stabilization and articular congruency Torry et al., 2006; Martin et al., 2008; Myers et al., 2011
- 31. The Hip &Thigh ANTERIOR & POSTERIOR TILT
- 32. Lippert, 2001; Sahrmann,2002; Clippinger, 2007 Anterior tilt - ASIS moves anteriorly in-front of the pubic symphysis - Vertebral hyperextension - Hip flexion Posterior tilt - ASIS moves posteriorly behind the pubic symphysis - Vertebral flexion - Hip extension Optimal Position ASIS & pubic symphysis vertically aligned (as laterally viewed)
- 33. Force Coupling - Abdominals& hamstrings/glutes - Spinal erectors and hip flexors Lumbosacral Angle - Horizontal to base of sacrum Narayanan, 2005; Lippert, 2011
- 34. The Hip &Thigh MOVEMENT TESTS
- 35. Movement Tests Thomas Test:indicates tightness within the rectus femoris or the iliopsoas - Positive result = testing limb lying above surface of plinth while flexed or extended FABER’s (Patrick) Test: may indicate the presence of hip pathology or SI joint dysfunction - Positive result = pain within the back region of testing side/ restricted movement in testing side above that of the opposite limb tight hip adductors/ flexors/ joint capsule? Ober Test: indicates tensor fasciae latae (TFL) or iliotibial band (ITB) tightness - Positive result = remaining off the table upon adduction Tightness: Piriformis Test: tests the cause of buttock pain i.e. tight piriformis muscle or as a result of referred pain due to the sciatic nerve - Positive result = gluteal pain or radiating pain from sciatic nerve Palmer et al., 1998; Martin et al., 2010
- 36. Scouring (Quadrant) Test:may indicate the presence of a non-specific joint pathology Craig’s Test: Test for femoral anteversion/ retroversion Sign of the Buttock: indicates if gluteal pain is localized or being referred from problems within the hip, sciatic nerve or hamstring Trendelenburg Test: a unilateral weight-bearing test that may indicate gluteus maximus weakness - Positive result = a drop of the pelvis as seen from behind Weakness: Other: Palmer et al., 1998; Martin et al., 2010
- 37. FADIR Test (Impingement Test) Flexion,ADduction, Internal Rotation High Sensitivity Wilson & Furukawa (2014) Positive test: Pain e.g. hip labral tears, loose material, chondral lesions, femoral acetabular impingements Gold-standard for checking overall hip function Low Specificity
- 38. The Hip &Thigh HIP PROBLEMS – TO BE AWARE OF
- 39. 1. Femoroacetabular impingements(FAI) FABER test is most sensitive CAM and PINCHER deformities causes labral tears 2. Piriformis Syndromes Log roll test is most sensitive Gluteal region pain especially when sitting or walking 3. Tumours 4. Femoral anteversion Craig’s Test Acetabular dysplasia usually shows hypertrophied labrum gymnasts 5. Labral tears FADIR test is most sensitive Can occur without FAI Dull or sharp groin pain (may radiate) 6. Cartilage loss wear and tear hyaline articular Wilson & Furukawa, 2014; Imhoff et al., 2015
- 40. Case Study 1– Athlete 1 Cam and pincher deformities – congenital?/genetic? Griffin et al., 2016 Soft tissue damage through: • Repetition • Abnormal femur/ acetabular shape • Excessive movements close to outer range abnormal contact/ collision Triad of symptoms, clinical signs & imaging findings 1. FADIR Test – sensitive but not specific 2. Limited hip ROM? internal rotation in flexion 3. FABER Test ? 4. Hip muscles commonly weak in FAI patients
- 41. UEFA injury study:A prospective study of hip and groin injuries in professional football over seven consecutive seasons FAI’s going to become more common through advancements in improvements of MRI and arthroscopic techniques as well as increased awareness and knowledge of this condition Lavigne et al., 2004; Werner et al., 2009; Khan et al., 2016 Hockey, football, soccer, rugby, martial arts, and tennis Cam-type: men Pincer-type: women Associated with other pathologies such as adductor and hip flexors injuries, ACL injuries etc. Limited ROM may increase stress placed upon other joints e.g knees/ spine
- 42. Case Study 2– Gaelic Groin Second most common injury to hamstring strains Werner et al., 2009; Glasgow et al., 2011 Groin – ‘’junction between the anteromedial part of the thigh, including the proximal part of the adductor muscle bellies, and the lower abdomen’’
- 43. Glasgow et al.,2011
- 44. Implications for S&C Werneret al., 2009; Glasgow et al., 2011 Field based games: 2 months off-season period complete strength, flexibility and stability training Increase ROM, strengthen core and groin/glutes High groin injury rates in: • Soccer • AFL • Rugby League Work with the coach i.e. match play exposure EASIER SAID THAN DONE Athlete 2 1) Rehab can be a long process!! 2) Commitment – athlete and therapist/ coach 3) Cooperation between physio’s & S&C.
- 45. Summary • Structure: Acetabulumand femur • Muscles: Quadriceps (4), gluteals (3), hamstrings (3), adductors (5), lateral rotators (6) • Capsule ligaments ischiofemoral, iliofemoral, pubofemoral • Movement: Hip flexion/ extension, adduction/ abduction, internal/ external rotation • Stability: Osseous, ligamentous & neuromuscular factors • Tests: FABER, FADIR, Thomas, Ober, Piriformis, Trendelenburg, Craig’s, Scouring, Sign of the Butt. • Conditions: FAI, tumours, femoral anteversion, labral tears, cartilage loss…….. • FAI – triad of symptoms, signs & radiological feature increase in cases in future? • Gaelic groin – chronic high load history taking, clinical examination, observation, tests 2 month off-season: strength, flexibility & stability training Strengthen core and groin/gluteal muscles Applies to other field sports
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Editor's Notes
- #4 The pelvic consists of two coxal bones, the sacrum (which is situated between the two coxal bones) and the coccyx (which projects inferiorly from the sacrum)
- #8 TAL helps prevent widening of acetabulum (anteroposteriorly)
- #9 Reflected tendon of the rectus
- #11 Acetabulum and femoral head
- #12 Iliac crest ASIS PSIS AIIS Sacrum Greater trochanter Gluteal tuberosity Coccyx
- #14 Iliofemoral ligament AIIS & acetabular rim intertrochanteric line Pubofemoral superior pubic ramis and acetabular rim intertrochanteric crest Ischiofemoral acetabular rim femoral neck
- #17 Hip pointer rect fem pulling from pelvis All insertion: tibial tuberosity Origin – rect fem – AIIS - vast lat. – greater trochanter, gluteal tuberosity, linea aspera - vast med. – linea aspera - vast int. – femur (like lateralis)
- #18 Max – coccyx, sacrum, posterior iliac crest & pelvic lig ITB & gluteal tuberosity Med – gluteal surface greater trochanter Min – gluteal surface greater trochanter (anteriorly)
- #19 ALL: posterior pelvic tilt, knee flexion & hip extension (except BFSH) BF’s: (external rot of flexed knee) BFLH: ischial tuberosity fibular head BFSH: linea aspera fibular head (Semi’s: @ internal rotation of thigh extended and with flexed knee) ST: ischial tuberosity per anserinus tendon (tibia) (anteriolateral) SM: ischial tuberosity tibia (posterior)
- #20 All: hip adduction WITHOUT GRACILIS: @ hip flexion Gracilis: knee flexion (with internal rotation) Mag: posterior fibres: hip extension Pectineus, Longus, Brevis: pubic bone to pectineal line/ linea aspera Mag: inferior pubic ramus + ischium linea aspera + adductor tubercle Gracilis: inferior pubic ramus per anserinus tendon
- #21 ALL: externally rotate Piriformis: anterior sacrum greater trochanter (abducts in hip flexion) All others pelvis to region around greater trochanter
- #22 Muscles run into each other with fibres into each muscle
- #24 SAME FUNCTION Fixed origin: hip flexion/ external rotation Fised insertion: trunk flexion towards thigh + anterior pelvic tilt Psoas major: Unilateral: lateral trunk flexion Lumbar spine lesser trochanter Iliacus: Iliac fossa lesser trochanter
- #25 Flexion, abduction, external rotation, internal rotation with flexed knee knee flexion ASIS per anserinus tendon
- #26 TFL - hip adductor, flexor and internal rotator TFL to ITB fascia running from glutealfascia to tibial tubercle
- #31 Shoulder position impacts how muscle works same with hip leads on to anterior and posterior tilt Congruency argreement/ harmony
- #33 Force couples dynamic ensure fibres are in correct position to run Optimal lumbosacral angle is @ 30*
- #34 Lordosis, kyphosis
- #36 Ober: lateral leg to table Piriformis stretch lasenge’s manoeuvre
- #37 Scouring flexed knee adductors in pressure through to abduction pain? Sign of buttock straight leg raise flex knee if limited & check
- #41 Footballers 12-13 yrs old FAI’s Suspect FAI – examine gait , single leg control, muscle tenderness around the hip and hip ROM including internal rotation in flexion and FABER distance. Impingement test and must reproduce pain similar to patients to be positive examine the groin to ensure that pain is not coming from other structure
- #42 B reduced femoral head and neck offset C excessive over coverage of the femoral head by the acetabulum D B and C together
- #43 Groin can involve the trunk, pelvis & lower limbs so large range of symptoms 1) dec. hip internal rotation 2) dec. hip stabilty 3) dec. rnage of short hip adductors 4) dec. hip adductor strength 5) altered muscle recruitment First while able to struggle on but symptoms become worse and then harder to treat Strategies for gaelic groin need a mutli-factoral approach which treats all impairments/dysfunctions relationship between contra & ipslatral hip adductors and abdominal musculature Adductor longus, rectus abdominis, obliquus interis, transverse abdominis strength important for the stability and force transmission through groin therefore deficiencies should involve and multi-factorial approach Overuse force imbalance over the pubis symphysis chronic changes affects ofther surrounding musculature
- #44 Treatment – high occurrence rate! 1 out of every 6 Footballers – adductor injuruies (64%) hip flexor/iliopsoas injuries 8% reinjury takes longer to recover!
- #45 Common in soccer – uefa injury study – a prospective study of hip and groin injureies in professional football over seven consecutive seasons Work with the coach: Consider match play exposure I.e. months were match play is high low-intensity training
- #48 Hip distraction Tests what to do to fix these… What is the impact of interventions that you put into