The Hip Complex

Dr. Steven Lester

CMCC
Hip Joint

 Also known as the Coxofemoral joint.

– Formed by the acetabulum and head of femur.

 Diarthrodial ball-and-socket with 3 D of F.

– Flexion/Extension in the sagittal plane.
– Abduction/Adduction in the frontal plane.
– Medial/Lateral Rotation in the transverse plane.

 The primary function of the hip:

– To support the head, arms, and trunk (HAT) in both
static and dynamic postures.
Proximal Articular Surface

 Acetabulum: Cuplike concave socket of hip

– Located in pelvic bone (innominate)

 Formed by ilium, ischium, pubis.

– Each bone contributes to the structure of the
acetabulum.

 Horseshoe-shaped portion of the periphery of the

acetabulum is covered by hyaline cartilage (The
Lunate Surface) and articulates with the femoral
head. No contact with the inferior or central portion.
Proximal Articular Surface

 Acetabular Notch: The inferior aspect of the lunate

surface.

 Connecting the two ends of the horseshoe is a

fibrous ligament.
– Transverse acetabular ligament (TAL)
 Centre Edge (CE) Angle of the Acetabulum***
EXAM
 Normal position of the acetabulum
– Laterally, with inferior and anterior rotation to it
 Assessing inferior orientation of the acetabulum is
done using the centre edge (CE) angle or angle of
Wiberg.
– A line connecting the lateral rim of the acetabulum and
the centre of the femoral head forms an angle with the
vertical.
 Range of 22 – 42o
 Significance of this measurement:
– CE angle decreases, causes increased risk of superior
dislocation.
– CE increases with age in adults, therefore less stability
in kids.
Question 1: EXAM

A decrease in the Centre Edge angle of the

acetabulum increases the risk of:
A) Anterior Dislocation
B) Superior Dislocation
C) Posterior Dislocation
D) Inferior Dislocation
Acetabular Anteversion

 The magnitude of acetabular anterior orientation.

– Angle of acetabular anteversion.

 18.5o in men, 21.5o in women.

 Some cite up to 40o.

 Pathologic increases of anteversion: EXAM

– Decreased joint stability
– Increased chance of anterior dislocation.
Acetabular Labrum

 Due to the need for stability at the hip joint.

– The entire periphery is rimmed by a ring of
wedge-shaped fibrocartilage.
– This deepens the socket and increases the
concavity of the acetabulum.
 Triangle shape grasps the head.
 The transverse acetabular ligament is part of the
labrum and spans the gap at the base of the
horseshoe but contains no cartilage cells.
Distal Articular Surface

 Head of femur:
– Rounded and covered with hyaline cartilage.
 The radius of curvature is smaller in women.
 Fovea (fovea capitis) is just inferior to the most
medial part of the head and is not covered with
articular cartilage.
– Attached to the ligament of the head of the femur.
Distal Articular Surface

 Femoral neck orientation:

– Medially, superiorly, anteriorly.
Angulation of the Femur

 Angle of Inclination: Occurs in the frontal plane

between the axis of the femoral neck and the axis of
the femoral shaft.
 Average angle decreases with age: EXAM**
– 150o during infancy
– 125o in adulthood
– 120o in elderly population
Angulation of the Femur

 Gender Differences
– Somewhat smaller in women.
 Due to increased width of the female pelvis.
 Normal Angle
– Causes the Greater Trochanter to lie at the center of
the femoral head.
 Pathological Variation
– Increased angle: Coxa Valga (>135 Degrees)
– Decreased angle: Coxa Vara (<120 Degrees)
Question 2

Is the torque through the femoral neck greater with

an angle of inclination of 125 degrees or 90
degrees.

A) 125 Degrees
B) 90 Degrees: because more forces go
through at perpendicular angle
Avg: 125°
Coxa Valga: 135-150 degrees

 Reflects persistence of the normal neonatal

alignment of the proximal femur and usually results
from weakness of the abductor muscles and lack
of normal weight-bearing forces.
 It is most commonly associated with neuromuscular
disorders such as cerebral palsy and polio, as well
as, skeletal dysplasias and juvenile idiopathic
arthritis.
 If coxa valga is severe there may be associated
lateral subluxation or even dislocation of the
femoral head  Due to spastic hip flexors.
Coxa Vara: less than 120 degrees

 Causes a leg to be shortened.

 Commonly caused by injury such as fracture.
 Bone softening disorders
– Osteomalacia and Pagets
 Shephards Crook Deformity
– Angle less than 90 Degrees
– Osteogenesis Imperfecta, Pagets, Osteomyelitis
Angulation of the Femur

 Angle of Torsion: (Anteversion) occurs in the

transverse plane between the axis of the femoral
neck and the axis of the femoral condyles.
 Average angle of torsion:
– 40o in newborns
 1.5o decrease/year to skeletal maturity
– 8o – 30o (avg 15o) in adult
Angulation of the Femur

 Pathological Variation
– Increase: Anteversion
– Decrease: Retroversion
Angulation of the Femur
Angulation of the Femur
Femoral Anteversion

 Excessive femoral anteversion (medial femoral

torsion) is most common cause of in-toeing that
first presents in early childhood.
– Twice as common in girls as in boys, it is nearly
always symmetrical, and it is often familial.
– Tripping as a result of crossing the feet may occur,
pigeon-toed gait and the awkward running pattern
most likely will persist.
 If it is NOT pathological, femoral anteversion will
correct itself.
 Pathological causes:
– Cerebral Palsy (Muscle Spasticity)
Femoral Retroversion

 Causes out-toeing.
 Less common than anteversion.
 When there is pain and Retroversion.
– Slipped Capital Femoral Epiphysis (SCFE) can
result.
 More prevalent with obese children.
Femoral Version

Anteversion  internal femoral torsion are

SAME thing
Retroversion  external femoral torsion
SAME thing
Angulation of the Femur

 Changes in angles can cause numerous

biomechanical changes:
– Compensatory hip changes
– Hip Stability
– Weight bearing biomechanics
– Muscle biomechanics
 Think glute med weaknesses
Articular Congruence of the Hip Joint

 The femoral head is larger than the acetabulum.

– In the neutral or standing position, the femoral head
is exposed anteriorly and superiorly.
– Structural deviations:
 Femoral anteversion, coxa valga, or decreased
center edge angle can increase the articular
exposure.
 Therefore, decreasing stability and leading to
dislocations
Articular Congruence of the Hip Joint

 To increase articular contact between the femoral

head and acetabulum.
– Use a combination of flexion, abduction, and slight
lateral rotation. (Frog Leg Position).
 Frog-leg position
– Is the true physiologic position.
– This position is commonly used during hip
immobilization when the goal is to improve joint
congruence such as in a congenital dislocation of the
hip.
Articular Congruence of the Hip Joint

 Researchers have found under light loads that the

femoral head does not contact the superior aspect
of the acetabulum.

 When subjected to running (5xBW), the flattening of

the articular cartilage and subchondral bone causes
maximum surface contact.
Articular Congruence of the Hip Joint
Hip Joint Capsule and Ligaments

 The articular capsule is dense and attaches to the

entire periphery of the acetabulum, covers the
femoral neck (sleeve) and attaches to the base of
the neck.
 The superficial longitudinal fibres and deeper
circular fibres make up the capsule.
 Circular fibres form a collar called the zona
orbicularis.
 The capsule is thickened anterosuperiorly where
the forces are the greatest.
Iliofemoral (Y Ligament of Bigelow)

 The base of the “Y” runs from the AIIS and fans out
to attach along the intertrochanter line.
 Becomes taught during hyperextension.
 Superior and inferior fibres may become tense with
adduction and abduction, respectively.
Pubofemoral Ligament

 Arising from the anterior pubic ramus passing to the

anterior intertrochanteric fossa.
 Becomes taut in hip abduction and in extension.
 Together with the iliofemoral ligament forms the “Z”
on the anterior capsule.
Ischiofemoral Ligament

 Attaches to the posterior femoral neck and blend with the

fibres of the zona orbicularis.
 These spiral fibres tighten during extension and
unwind with flexion.
Hip Joint Capsule and Ligaments

 All ligaments spiral as they pass from the pelvis to

the femur in the neutral position.
 Hip extension causes the ligaments to tighten
making this the closed pack position.
– Extension, Abduction, and Medial Rotation
 Most stable since the joint surfaces are pulled
together and prevents further extension.
Hip Joint Capsule and Ligaments

 The hip is one of the few joints where closed packed

is not the position of maximal congruency.
– Closed packed vs. True physiological.
– True physiological is just maxima congruency of
the bony surfaces
 Sitting with the thighs crossed is the least stable
where a strong force up the femur can lead to
dislocation.
– Not maximally congruent or closed packed.
– Decreased capsuloligamentous tension.
Weight-Bearing Structure of the Hip Joint

 The internal architecture of the pelvis and femur

accommodates to the mechanical stresses.
 3 stress highways of trabeculae
– 1. Pelvis through to the acetabulum
 Load from/to pelvis and the femur.
– 2. Along the pubic ramus
 Prevents separation/compression of the ilia.
– 3. To the ischial tuberosity
 Sitting.
Weight-Bearing Structure of the Hip Joint

 Pelvis through to the acetabulum highway has two

major systems.
– Medial trabecular system
 Arises from the medial cortex of the superior
aspect of the femoral shaft and radiates outward
to the cortical bone of the superior aspect of the
femoral head.
 Transmits vertical weight-bearing compressive
forces though the hip (superior portion).
 Coincides with a thickened area of cortical bone on
the medial shaft of femur.
Medial Trabecular
System
Weight-Bearing Structure of the Hip Joint

 Pelvis through to the acetabulum highway has two

major systems.
– Lateral trabecular system
 Arises from the lateral cortex of the upper femoral
shaft, crosses the medial system, and terminates
on the cortical bone of the inferior aspect of head
of femur.
 May develop in response to shear forces.
 From contraction of the hip abductors and
tensile stresses from the head/neck bending on the
shaft as the body weight arrives on the head of
femur.
Lateral Trabecular
System
Weight-Bearing Structure of the Hip Joint

 Two minor (accessory) trabecular systems.

– At the trochanteric and neck areas.
– Medial accessory system
 Arises from the medial aspect of the upper
femoral shaft, crosses the lateral trabecular system
and fans out to the greater trochanter.
– Lateral accessory system
 Runs parallel to the greater trochanter .
Lateral
Accessory

Medial Accessory
Weight-Bearing Structure of the Hip Joint

 Greatest resistance to stress is at the

intersections.
 Zone of weakness has less reinforcement and is
more prone to injury.
– Susceptible to bending forces.
– Injury will occur when force is excessive or when the
tissue is no longer able to resist normal force.
Lateral
Accessory

Medial Accessory

Lateral Trabecular
Medial Trabecular
System
System
Question 4

The Medial Tracecular system transmits what type

of forces

A) Compressive
B) Tensile
C) Torsional
Weight-Bearing Structure of the Hip Joint

 The primary weight bearing surface:

– 1. Dome of the acetabulum
 Superior portion of the lunate surface.
– 2. Superior portion of the femoral head
 Degenerative changes:
– Occur at the dome
– Inferior portion of the femoral head. Distal to the
fovea.
Weight-Bearing Structure of the Hip Joint

 Proposed reason to inconsistencies:

– Creep characteristics and thickness differences in
response to articular cartilage.
– Thicker pieces require more intense compression etc
for nutrition
 Cartilage Nutrition
– Incomplete compression of the dome cartilage.
– The femoral head receives compression during
standing.
– The posterior acetabulum during sitting and the
anterior acetabulum in hip extension.
Function of the Hip Joint

 Motion of the Femur at the Hip Joint

– ROM is influenced by Two joint vs. Single joint
muscles.
 Passive hip range is 90o of hip flexion with the knee
extended and 120o-135o with the knee flexed (due to
passive hamstring tension released with knee
flexed)
Function of the Hip Joint

 Hip extension ranges from 10o to 30o depending if

the knee is extended to release passive tension in
the rectus femoris.
 Femoral abduction ranges from 30o to 50o and can
be limited by gracilis.
 Femoral adduction ranges from 10o to 30o and can
be limited by TFL and the ITB.
Function of the Hip Joint

 Lateral femoral rotation ranges from 45o to 60o (hip

flexed to 90o) - decreased by anteversion.
 Medial femoral rotation ranges from 30o to 45o (hip
flexed to 90o) – increased by anteversion.
Question 5

What is meant by passive tension?

A) Contracting the muscle ↑ tension

B) Stretching the muscle ↑ tension
C) Someone else ↑ the tension for you
Motion of the Pelvis at the Hip Joint –
Anterior Posterior Pelvic Tilt
 Normal Position: The ASIS’ lie on a horizontal line
with the PSISs and on a vertical line with the
symphysis pubis.
 Posterior and anterior tilting of the pelvis on the
fixed femur produce hip extension and flexion,
respectively.
 Anterior and posterior tilting can occur around both
hip joints simultaneously or one hip joint in a single-
leg support.
Anterior and Posterior Pelvic Tilt
Lateral Pelvic Tilt

 Normal Position: A line through the iliac crests is

horizontal.
 Lateral Tilt of the pelvis: One hip joint serves as
the pivot point and the opposite iliac crest
elevates (hip hiking) or drops (hip drop).
Lateral Pelvic Tilt
Lateral Pelvic Tilt

 Right hip hiking on Left limb stance =

– Left hip abduction.
 Right hip drop on Left limb stance =
– Left hip adduction.
Question 6

Describe the pelvic tilt, if the patient is standing on

their Right Leg.

A) Right Hip Drop R

B) Left Hip Drop
C) Left Hip Hike, with right hip abduction
L
Pelvic Rotation

 Occurs in the transverse plane around a vertical

axis most commonly around the axis of the
supporting hip joint.
 Forward rotation: When the side of the pelvis
opposite to the supporting hip joint moves anteriorly.
 This produces medial rotation of the supporting
hip joint.
Pelvic Rotation

 Backward rotation: When the side of the pelvis

opposite to the supporting hip joint moves
posteriorly.
 This produces lateral rotation of the supporting
hip joint.
Pelvic Rotation
Coordinated Motion of the Femur, Pelvis,
and Lumbar Spine
 Open Kinematic Chain: The head and trunk will
follow the motion of the pelvis (moving the head
through space). Touching toes
 Closed Kinematic Chain: The head will continue to
remain relatively upright and vertical in spite of the
pelvic motions.
– E.g.
Lumbar-Pelvic Rhythm

 The open-chain phenomenon in the hip joint,

pelvis, and lumbar spine where coordinated activity
of the segments produced a larger ROM than might
be available to one segment alone.
– Hip, pelvis, and lumbar spine move
 The chance of reaching the floor is greatly increased
when one flexes the lumbar spine (+45 o) as
apposed to just flexing the hips (anteriorly tilting the
pelvis on femur).
Lumbar-Pelvic Rhythm

 An attempt at maximal abduction of the top leg will

bring the leg through ~90o.
 This is clearly not all from hip joint abduction (~45 o)
but includes lateral tilting of the pelvis and
lumbar spine.
Closed-Chain Responses to Motions of the
Pelvis and Hip Joint
 Compensatory movements are required to ensure
the COG remains within the base of support.
 We thus spend much time ensuring that our head is
upright and vertical, regardless of what is occurring
at the pelvis.
 In a Closed Kinematic Chain, motion at one
segment within the chain requires compensatory
motion at least at one other segment in the chain.
Closed-Chain Responses to Motions of the
Pelvis and Hip Joint
 The relationship between the hip joint, pelvis and
lumbar spine is generally the opposite to those
seen in lumbar-pelvic rhythm.
 If the pelvis is anteriorly tilted (hip flexion), the head
and trunk will be displaced forward and you may fall.
Thus, by extending the lumbar spine you keep
the head up and over the sacrum.
 If there is too much lumbar extension, further
cervical and/or thoracic flexion compensation may
be required.
EXAM**
Question 7: EXAM

You have a patient standing on her Right Leg. Lateral

pelvic tilting is normal; however, you noticed that
anterior or forward rotation of the pelvis has occurred.
What accompanying hip joint motion and compensatory
lumbar spine motion has occurred.
A) Right hip medial rotation / Rotation of the spine to the
left
B) Left hip lateral rotation / Rotation of the spine to the left
C) Right hip lateral rotation / Rotation of the spine to the right
D) Left hip medial rotation / Rotation of the spine to the right
E) Nothing accompanied the forward rotation
Closed-Chain Responses to Motions of the
Pelvis and Hip Joint
 The lumbar spine tends to be the “first line of
defense” when compensation is required for varying
pelvic motions to maintain the head upright and
LOG over the base of support.
Hip Joint Musculature

 The hip muscles work best in the middle of their

contraction range or on a slight stretch (optimal
length-tension).
 Moment generation is best with eccentric, followed
by isometric, followed by concentric contractions.
Flexors

 Primary Function of flexors:

– Ambulation
 Secondary Function:
– Resists hip extension
 Major Contributors of Hip Flexion:
– **Iliopsoas**, rectus femoris, tensor fascia lata and
sartorius.
– Increases lumbar lordosis?
Flexors

 Rectus Femoris
– Only portion of the quadriceps that crosses the hip
joint (to the AIIS).
 Flexes the hip and extends the knee.
 Active insufficiency occurs with the knee
extended and the hip flexed. No more space for
this muscle to shorten and produce force
 Optimal potential for force generation is when the
hip and knee are flexed.
Flexors

 Sartorius
– Runs from ASIS to upper portion of the medial aspect
of tibia.
– A hip flexor and abductor.
– A knee flexor and medial rotator.
– Strength output not significantly affected by the
position of the knee given the relatively small
proportional length change.
Flexors

 Tensor fascia lata

– Runs from the anterolateral lip of the iliac crest to the
iliotibial band.
– A hip flexor, abductor and medial rotator.
– ***Maintains tension in the iliotibial band. This in
turn may assist in relieving the femur of some of the
tensile stresses imposes on the shaft by weight-
bearing forces.
– Recall tensile forces run along the lateral femur.
– Tensile forces are less tolerated than compressive.
Adductors

 Pectineus, adductor brevis, adductor longus,

adductor magnus, gracilis.
 Maximum isometric torque of adduction is greater
than that of abduction.
Extensors

 One-joint gluteus maximus and two-joint

hamstrings.
 Assistance from posterior fibres of the gluteus
medius, superior fibres of adductor magnus and
from piriformis.
– Moment arm (MA) of gluteus maximus is greater
than that of the hamstrings or adductor magnus and
greatest in neutral hip joint position.
 MA of the gluteus maximus decreases with any hip
flexion beyond neutral.
Extensors

 The three 2-joint extensors are long head of

biceps femoris, semitendinosus and
semimembranosus (i.e the hamstrings)
 Extends the hip and flexes the knee.
 Compared to Extensors: MA is larger for the gluteus
maximus at all hip ranges.
Abductors

 Predominantly by gluteus medius and minimus.

 May be assisted by superior fibres of gluteus
maximus and TFL.
Lateral Rotators

 6 Short muscles
 Obturator internus, obturator externus, gemellus
superior and inferior, quadratus femoris and
piriformis.
 Their positioning would make them ideal tonic
stabilizers of the hip joint during most weight and
non weight bearing activities.
Medial Rotators

 There are no muscles with the primary function of

medial hip rotation.
 Muscles with lines of pull anterior to the hip joint axis
at some point in the ROM may contribute.
 Anterior portion of gluteus medius and tensor
fascia lata and perhaps the adductor muscles.
Thank you for your time and attention