Podcast
Questions and Answers
What is coxa valga primarily associated with?
What is coxa valga primarily associated with?
What degree is considered normal for the femoral anteversion angle?
What degree is considered normal for the femoral anteversion angle?
What gait pattern may excessively anteverted femoral heads lead to?
What gait pattern may excessively anteverted femoral heads lead to?
Which of the following conditions describes a reduction in the femoral neck-shaft angle?
Which of the following conditions describes a reduction in the femoral neck-shaft angle?
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What is a potential consequence of abnormal femoral angulations?
What is a potential consequence of abnormal femoral angulations?
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How is excessive anteversion defined in terms of degrees?
How is excessive anteversion defined in terms of degrees?
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Which muscle originates from the anterior and medial aspect of the femur?
Which muscle originates from the anterior and medial aspect of the femur?
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Which of the following muscles inserts into the femur?
Which of the following muscles inserts into the femur?
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Which condition is often related to compensatory ipsilateral genu valgum?
Which condition is often related to compensatory ipsilateral genu valgum?
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At birth, what is the average femoral anteversion angle?
At birth, what is the average femoral anteversion angle?
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What is one of the muscles that originates from the superior and posterior aspect of the femur?
What is one of the muscles that originates from the superior and posterior aspect of the femur?
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Which muscle is NOT associated with the anterior aspect of the femur?
Which muscle is NOT associated with the anterior aspect of the femur?
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The gracilis is primarily involved in which movement of the femur?
The gracilis is primarily involved in which movement of the femur?
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Which muscle is found to insert alongside the iliopsoas?
Which muscle is found to insert alongside the iliopsoas?
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Which of the following muscles inserts into the hip area?
Which of the following muscles inserts into the hip area?
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Which muscle originates from the area associated with the gluteus minimus?
Which muscle originates from the area associated with the gluteus minimus?
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What does the weight-bearing line of the head, arms, and trunk primarily impact?
What does the weight-bearing line of the head, arms, and trunk primarily impact?
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What type of stress does the bending moment create on the inferior aspect of the femoral neck?
What type of stress does the bending moment create on the inferior aspect of the femoral neck?
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Which of the following structures are primarily involved in the primary trabecular systems?
Which of the following structures are primarily involved in the primary trabecular systems?
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Ward's triangle is best described as what?
Ward's triangle is best described as what?
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What is the primary function of trabeculae in cancellous bone?
What is the primary function of trabeculae in cancellous bone?
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Which angle describes the orientation of the acetabulum?
Which angle describes the orientation of the acetabulum?
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What type of forces do the secondary compressive and tensile systems reinforce?
What type of forces do the secondary compressive and tensile systems reinforce?
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What is primarily transmitted through the medial compressive trabecular system?
What is primarily transmitted through the medial compressive trabecular system?
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What primary muscle is responsible for external rotation of the hip?
What primary muscle is responsible for external rotation of the hip?
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Which muscle has a secondary action in both hip rotation and control of alignment during adduction?
Which muscle has a secondary action in both hip rotation and control of alignment during adduction?
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During rapid adduction, which muscle group is primarily activated to help decelerate the limb?
During rapid adduction, which muscle group is primarily activated to help decelerate the limb?
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What action do the gluteus minimus and gluteus medius anterior fibers share when the hip is flexed greater than 60 degrees?
What action do the gluteus minimus and gluteus medius anterior fibers share when the hip is flexed greater than 60 degrees?
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Which of the following muscles does NOT have a primary role in internal rotation of the hip?
Which of the following muscles does NOT have a primary role in internal rotation of the hip?
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Which hip muscle is categorized as having only secondary actions in abduction and external rotation?
Which hip muscle is categorized as having only secondary actions in abduction and external rotation?
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What is the common action associated with hip external rotator muscles?
What is the common action associated with hip external rotator muscles?
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Which muscle functions as an internal rotator of the hip primarily?
Which muscle functions as an internal rotator of the hip primarily?
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What is the joint reaction force magnitude on each femoral head during bilateral stance relative to body weight?
What is the joint reaction force magnitude on each femoral head during bilateral stance relative to body weight?
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Which muscles are identified as the main stabilizers during weight-bearing activities for the hip joint?
Which muscles are identified as the main stabilizers during weight-bearing activities for the hip joint?
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How does the dislocating action of the adductors change with hip movements?
How does the dislocating action of the adductors change with hip movements?
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What happens to the line of gravity during unilateral stance?
What happens to the line of gravity during unilateral stance?
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What is the joint compression force during a body weight of 82.5 kg?
What is the joint compression force during a body weight of 82.5 kg?
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What is the primary role of the pelvitrochanteric lateral rotator muscles?
What is the primary role of the pelvitrochanteric lateral rotator muscles?
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What role do internal rotators play during the stance phase of locomotion?
What role do internal rotators play during the stance phase of locomotion?
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Which of the following correctly describes the force on each lower extremity during bilateral stance?
Which of the following correctly describes the force on each lower extremity during bilateral stance?
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What role do the iliopsoas muscles play according to the stability mechanisms described?
What role do the iliopsoas muscles play according to the stability mechanisms described?
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Which muscle acts as an internal rotator while also contributing to hip abduction?
Which muscle acts as an internal rotator while also contributing to hip abduction?
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How do most adductor muscles contribute in terms of rotational movement?
How do most adductor muscles contribute in terms of rotational movement?
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What effect does coxa vara have on the hip abductor force?
What effect does coxa vara have on the hip abductor force?
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What is one of the biomechanical advantages of coxa vara?
What is one of the biomechanical advantages of coxa vara?
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Which condition may improve stability of the hip joint through alignment?
Which condition may improve stability of the hip joint through alignment?
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What is a consequence of the anterior bowing of the femoral shaft?
What is a consequence of the anterior bowing of the femoral shaft?
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What action is primarily performed by the tensor fasciae latae during the gait cycle?
What action is primarily performed by the tensor fasciae latae during the gait cycle?
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Study Notes
Lower Extremities - Functional B
- Lecturer: Beáta Seregély, assistant lecturer
- Email: [email protected]
- Affiliation: Semmelweis University Faculty of Health Sciences, Department of Physiotherapy
The Hip - Theory
- Lecturer: Beáta Seregély, assistant lecturer
- Email: [email protected]
- Affiliation: Semmelweis University Faculty of Health Sciences, Department of Physiotherapy
The Lower Limb
- Quadrupedal evolution to bipedal resulted in the hip joint becoming the proximal joint of the lower limb, replacing the posterior limb's joint.
- The upper limb's supportive and locomotor functions were lost in favor of prehensile hand use.
- The lower limb retained locomotor function, becoming the sole responsible for body support and movement.
- The hip's role as a base and basilar joint for the lower extremities and entire pelvis/trunk led to structural adaptations.
The Hip
- The hip, a single joint, ensures both orientation and support of the lower limb, with a broader range of motion and greater stability than the shoulder.
- "Stance phase" (walking and standing) involves the entire foot or a specific portion of the foot contacting the ground.
- This closed kinetic chain movement during functional activities is primarily focused on maintaining postural balance.
- Eccentric work of muscles with controlled elongation is crucial during this process.
Considerations for Examining Hip Motion
- The hip joint (coxofemoral joint) is the articulation of the acetabulum of the pelvis and the head of the femur.
- Hip joint motion includes flexion/extension, abduction/adduction, and medial/lateral rotation, along with simultaneous movement in multiple axes, which is called circumduction.
- Though the hip and shoulder have similarities, their structural and functional adaptations are substantial.
Considerations for Examining Hip Motion
- The primary role of the hip joint is supporting the weight of the head, arms, and trunk during both static and dynamic postures, such as walking, running, and climbing stairs.
- The hip joint's structure directly relates to its weight-bearing function.
- Understanding the interactions with other joints, like the spine, is crucial to grasping full hip function.
What Moves in Relation to What?
- Femur on Acetabulum: The free-moving femur's movement in relation to the relatively stationary acetabulum.
- Pelvis on Femur: The pelvis's movement over the relatively stationary femur during weight-bearing actions.
What Moves in Relation to What?
- The head and trunk follow the pelvis's movement in open kinematic chain motions, controlled mainly by eccentric muscle actions.
What Moves in Relation to What?
- The head and trunk remain in generally a vertical, upright posture despite pelvic motions in closed kinematic chains.
- Movement at one joint in a closed kinematic chain influences movement in other joints of the chain.
The Pelvic Bones
- The innominate (hip) bones comprise the ilium, ischium, and pubis.
- These bones connect anteriorly at the pubic symphysis and posteriorly meeting the sacrum to form a complete osteoligamentous ring (pelvis).
The Acetabulum
- Shaped like a socket in the pelvis, it is formed by the union of the three pelvic bones, though only the upper lunate surface is articular and covered in hyaline cartilage.
- The acetabular fossa, a unique depression, lies below it.
- The acetabular labrum surrounds the circumference of the socket.
- The labrum contributes to the socket's depth and security.
Anterior Aspect of the Pelvis
- This section lists the muscles that originate from the anterior aspect of the pelvis, articulating prominently on the femur. Many of these are also listed as having attachment on the femur.
Anterior Aspect of the Pelvis
- This section lists muscles originating from the anterior aspect of the pelvis, attaching to the femur.
Posterior Aspect of the Pelvis
- Describes the muscles that originate on the posterior aspect of the pelvis.
Posterior Aspect of the Pelvis
- Lists muscles originating and inserting on the posterior aspect of the pelvis. Important to notice is that some attach to the femur.
Posterior Aspect of the Pelvis
- Includes the muscles that originate and insert on the posterior aspect of the pelvis.
Lateral Aspect of the Pelvis
- Describes the muscles originating from the lateral aspect of the pelvis.
Anterior and Medial Aspect of the Femur
- Includes muscles that originate in the anterior and medial aspects of the femur.
Superior and Posterior Aspect of the Femur
- Includes muscles originating in the superior and posterior aspects of the femur.
Structural Adaptations to Weight-Bearing
- The weight-bearing line of the head, arms, and trunk (HAT) influences femoral loading, bending, and tensile stresses on the superior femoral neck accompanied by compressive and shear stresses on the inferior section.
- Interactions between the femur and pelvis involve trabecular systems (calcified bone plates) adapting along stress lines.
Trabecular Systems
- Medial and lateral trabecular systems are prominent for transmitting forces within the femoral head and neck.
- The Ward's triangle in the neck is a zone vulnerable to weakness in bone.
Most Characteristic Angulations
- In reference to an adult human, the acetabulum faces slightly anterior and inferior.
- The center-edge angle (CE angle)/angle of Wiberg is a measurement of how much the acetabulum covers the femoral head, typically declining with age.
- Significant variations in the CE angle pose risk for dislocation.
Most Characteristic Angulations
- Acetabular anteversion angle: This reflects how much the acetabulum faces anteriorly, measured on a CT scan of the pelvis.
- Normal values vary between sexes (male and female).
Most Characteristic Angulations
- Femoral inclination describes the angle between the femoral neck and the femoral shaft's axis.
- It decreases naturally as a person ages, with variations associated with conditions like coxa vara/valga.
Deviations of the Angle of Inclination
- Coxa valga involves an increased angle of inclination, associated with shallow acetabula and genu varum (bow-leggedness).
- Coxa vara involves a decreased angle of inclination, linked to compensatory genu valgum (knock-knees).
Most Characteristic Angulations
- Femoral torsion: This reflects the relative rotation (twist) between the femoral shaft and neck.
- Normal ranges are around 15° and abnormal variations are considered excessive anteversion or retroversion.
Deviations of the Torsional Angle
- Excessive anteversion is accompanied by a gait pattern called “in-toeing,” which is common in individuals with cerebral palsy.
- Abnormal anteversion can impact hip joint stability and biomechanics.
The Capsule and Ligaments
- The hip joint capsule is a complex structure of dense tissue important for hip stability.
- Three ligaments—iliofemoral, pubofemoral, ischiofemoral—strengthen the outside of the capsule.
- A deep layer ("zona orbicularis") of the capsule and bursae contribute to additional stability and protection.
The Capsule and Ligaments
- Iliofemoral ligament is the strongest and stiffest and has a Y-shape.
- Pubofemoral ligament's fibers blend with those of the iliofemoral and become more taut in abduction and extension.
- Ischiofemoral ligamenmt blends with adjacent capsule fibers and is most taut in internal rotation paired with abduction.
The Capsule and Ligaments
- Ischiofemoral ligament: It originates at the posterior and inferior acetabulum and then spirals towards the greater trochanter of the femur, particularly taut in internal rotation accompanied by abduction.
- Deeper components of this ligament blend with other capsule fibers.
Function of the Ligaments
- Flexion/extension of the hip: Iliofemoral and pubofemoral ligaments are taut during standing and fully extended hip positions, while lax during flexion.
- Lateral/medial rotation: The iliofemoral and pubofemoral ligaments are taut during external hip rotation, but slack during internal rotation.
- Abduction/adduction: The iliofemoral and pubofemoral ligaments are taut during abduction, while the inferior band is more taut in adduction.
The Ligamentum Teres
- An intra-articular and extrasynovial structure, it covers the femoral head.
- In infants, it carries the femoral head's primary blood supply.
- The ligament later loses its role in blood supply in adult humans.
- The circumflex arteries are important for blood supply to the femoral head and neck; the ligament plays a supporting role in the fetus while this is active in adults.
Close- and Open-Packed Position
- The close-packed position of the hip is attained by maximal stretch of most of the capsule fibres with slight internal rotation and abduction coupled with full hip extension.
- This position is not the one of maximal joint congruence for the hip as it is for many other joints. Hip joints optimal contact to each other is at 90° flexion with some adduction and external rotation.
- The open-packed position of the hip involves a slackening of the majority of the hip capsule ligaments.
Articular Congruence
- In neutral or standing position, the femoral head is partially exposed anteriorly and superiorly.
- Maximum articular contact occurs with hip flexion, abduction, and lateral rotation.
- Hip flexion or crossing of the legs may lead to instability; therefore the applied force can easily result in dislocation.
Dysplastic Hip
- Variations in femoral anteversion, coxa valga, and acetabulum can lead to increased exposure of the femoral head, decreased congruence, and joint instability.
- Management often involves positioning to encourage hip joint normalization and contact (frog-leg positions, Pavlik harness).
Movements - Osteokinematics
- Femoral-on-pelvic hip osteokinematics: The femur's motion relative to the pelvis in open kinetic chain.
- Pelvic-on-femoral hip osteokinematics: Pelvis moving over the fixed femur, such as in lumbopelvic rhythm where they move together or in opposite ways to facilitate reaching or gait.
Lumbopelvic (Pelvifemoral) Rhythm
- LR is a coordinated motion of the femur, pelvis, and lumbar spine, with concepts applied to the sagittal, frontal, and horizontal planes.
- Contralateral foot motion approaches 90 degrees, though hip motion is limited to approximately 45 degrees of abduction.
- Lumbar spine motion is constrained by body weight and ground contact.
Movements - Osteokinematics
- Pelvic-on-femoral: The pelvis's motion over a relatively stationary femur, crucial to hip function and movement (e.g., "gait").
- Flexion/extension: Anterior/posterior pelvic tilting.
- Abduction/adduction: Side-to-side iliac crest movement (related to nonsupporting hip).
- Internal/external rotation: Forward/backward iliac crest movement (related to nonsupporting hip).
Stability in the Frontal Plane
- In bilateral stance, the lower extremity's reaction force is one-sixth of the upper body's total weight, effectively distributed among the two supporting hips.
- Abductor muscle forces counteract the gravitational torque, leading to a higher joint reaction force.
- The abductors' actions in unilateral stance are crucial to counteract gravity.
Stability in the Frontal Plane
- Muscles parallel to the femoral neck—particularly the pelvitrochanteric lateral rotator muscles—are critical in stabilizing the hip by compressing the femoral head against the acetabulum.
- The gluteal muscles (medius and minimus) are essential during weight-bearing activities to ensure coaptation (contact and fitting).
Stability in the Frontal Plane
- Lateral shifting of the trunk's center of gravity during unilateral stance influences hip stability.
- The body's weight shift in parallel with shifting abductor muscle lines of force.
- The weight shift causes changes in hip abduction forces that impact hip stability, such as in walking, running, or climbing.
Reduction of Compression Forces
- Excessive hip joint pain from osteoarthritis requires reducing these forces to minimize pain.
- Compensatory lateral trunk lean, a seemingly counterintuitive strategy, transfers the gravity impact more directly onto the hip joint.
- Using a cane correctly on the unsupported side during walking can effectively alter this balance of forces, thus reducing stress.
Reduction of Compression Forces
- When a load is carried on the same side as the painful hip, it exacerbates hip joint compression and pain, impacting hip joint stability.
- Carrying the load on the opposite side effectively counteracts the harmful shift in the body's center of mass and can lead to improved joint function.
Stability in the Sagittal Plane
- The line of gravity (LoG) falls behind the flexion-extension axis of the hip, creating an extension moment.
- This is counteracted by passive tension in the capsule and ligaments, as well as intermittent iliopsoas activity.
- The interplay between hip flexors (primarily iliopsoas) and low back extensors control the pelvic tilt (in sagittal plane).
Stability in the Sagittal Plane
- Excessively tilted anterior pelvis can overload bony tissues over prolonged periods.
- Maintaining a healthy lumbar lordosis helps ensure proper alignment and minimize excess stress on the bones and surrounding tissues.
- Hip extensors and abdominal muscles act synergistically to counteract anterior pelvic tilt.
Stability in the Sagittal Plane
- Forward bending posture during standing often relies on hamstring muscle activation.
- The hamstrings' position and their involvement in controlling pelvic motion are important in stabilizing posture.
- Excessive forward bending combined with weakened hip muscles can lead to lumbar spine stress and lordosis.
Muscles of the Hip Joint
- This section provides a comprehensive overview of the hip's muscles, categorized based on their primary functions (flexors, extensors, abductors, adductors, and rotators).
Innervation of the Muscles of the Hip Joint - Femoral Nerve
- This section details the muscles innervated by the femoral nerve, excluding the psoas major and minor ones.
Innervation of the Muscles of the Hip Joint - Obturator Nerve
- These muscles originate from the hip but are innervated by the obturator nerve.
Innervation of the Muscles of the Hip Joint - Sacral Plexus
- This section identifies the muscles innervated by the sacral plexus.
Innervation of the Muscles of the Hip Joint - Sciatic Nerve
- This section lists the muscles innervated by the sciatic nerve.
Sensory Innervation of the Hip
- The hip's capsule, ligaments, and labrum typically receive sensory input from the femoral and obturator nerves anteriorly.
- Posterior regions receive input from nerve roots associated with the sacral plexus (primarily sciatic and superior gluteal nerves).
- The nerve to quadratus femoris also provides sensory input to the medial section.
Ligamentous and Muscular Tissues Limiting Hip Extremes
- These structures provide constraints to the extent of hip motion, ensuring stability and preventing excessive movement.
Table 12.3: Muscles of the Hip
- Categorizes hip muscles into primary and secondary functional groups.
Hip Joint Musculature
- Emphasizes the weight-bearing functions of the hip joint's muscles adapting to optimize their function and range of motion.
Flexors and Extensors
- This section provides primary and secondary function categorization for both hip flexor and extensor muscles.
Flexors - Iliopsoas
- The function of the iliopsoas, a primary hip flexor, is crucial for walking and running.
- Their actions influence spinal posture.
Flexors - Rectus Femoris
- This two-joint muscle acts as a hip flexor but is also a knee extensor.
- Its effectiveness as a hip flexor is reliant on the knee's position.
Flexors - Sartorius
- A two-joint muscle with a minor role in hip flexion and significant contribution to abduction and external hip rotation.
Flexors - Tensor Fasciae Latae
- The IT band is an important structure stabilized by the tensor fasciae latae, aiding in hip flexion, internal rotation, and abduction.
The Secondary Flexors
- Adductor muscles also function as hip flexors, with their effectiveness dependent on the position of the hip and knee.
- The gracilis's role in hip flexion is contingent on the knee's position.
Flexors
- The hip flexors effectively influence pelvic positioning, primarily through interacting with abdominal muscles, and are crucial for movement.
Extensors - Gluteus Maximus
- The gluteus maximus is a powerful hip extensor with a significant moment arm, but its effectiveness is most notable at 70°of hip flexion.
Extensors - Hamstrings - Biceps Femoris
- The biceps femoris is a crucial muscle for hip extension and external rotation.
Extensors - Hamstrings - Semitendinosus
- The semitendinosus is a key hip extensor and internal rotator.
Extensors - Hamstrings - Semimembranosus
- The semimembranosus plays a considerable role in hip extension and internal rotation.
Extensors
- The gluteus maximus is a major contributor to hip extension and external rotation.
- The three hamstring muscles (biceps femoris, semitendinosus, and semimembranosus) function as extensors as well as assisting in knee flexion.
Extensors
- The hip extensor group, acting as a whole, is vital for generating powerful movements, especially in gait and various other functional activities.
Flexors and Extensors
- Understanding the balance between agonist and antagonist muscles (hip flexors and extensors) is critical to maintaining upright posture.
- The hip's functional stability involves a delicate equilibrium between multiple forces and muscle coordination.
The Functional Interdependence Among the Muscles of the Lower Extremity
- The various muscles interrelate to provide sufficient torque for tasks like climbing; disruptions in this interaction can lead to movement issues.
Adductors and Abductors
- This section details the primary and secondary adductor groups of the hip, classifying muscles by their prominent roles in adduction.
Abductors - Gluteus Medius
- The gluteus medius and minimus functions in abduction and stabilization of the pelvis during unilateral stance.
- Their anterior, middle, and posterior portions differ in their primary function according to the position of the hip joint.
Abductors - Gluteus Minimus
- Gluteus minimus assists in hip abduction and internal/external rotation.
- Its functional role is contingent on position, as its fibres switch function when the position of the hip changes.
Adductors
- Adductor muscles, arranged in three layers, generate significant hip adduction torques and contribute significantly to the overall muscle mass of the lower extremity.
Adductors - Pectineus
- The pectineus plays a role in hip flexion, adduction, external rotation, and internal rotation.
Adductors - Adductor Brevis
- The adductor brevis function is primarily in adduction, external rotation, and providing weak flexion.
Adductors - Adductor Longus
- Adductor longus contributes to internal rotation and adduction at the hip, and its function changes depending on its position with respect to the axis of rotation.
Adductors - Adductor Magnus
- The adductor magnus features two heads, each with distinctive roles, one as an adductor and the other as an extensor.
Adductors - Gracilis
- Originating from the pubic bone, the gracilis plays a role in hip adduction, internal hip rotation, and weak hip flexion.
Adductors
- Adductor muscle function changes in relation to the axis of rotation, acting as either flexors or extensors at the hip.
Rotators
- Differentiates between primary and secondary internal/external hip rotators.
Hip External Rotator Muscles
- The obturator externus and quadratus femoris are the key external hip rotators that notably do not change their moment arm with changes in hip position.
Hip External Rotator Muscles
- The piriformis, with a large moment arm for external rotation in the neutral position, shifts to internal rotation as hip flexion increases.
- The sciatic nerve's proximity to the piriformis can present a potential for compression.
External Rotators
- External Rotator muscles (Obturator internus, superior and inferior gemelli, quadratus femoris, and piriformis) are vital for activities requiring hip rotation or rapid changes in direction.
Internal Rotators
- Internal rotator muscles are less prominently positioned for internal rotation in neutral/extended hip positions; their functions significantly increase as the hip approaches and moves beyond 90° of flexion.
Internal Rotators
- Internal rotators play a unique role in locomotion, primarily during the stance phase and assisting the swing phase of gait.
- The tensor fasciae latae and gluteus medius and minimus help stabilize the pelvis.
Biomechanics of the Adductor Muscles as Internal Rotators
- Most hip adductors generate modest internal rotation torques when the body is near its anatomical position.
- The anterior positioning of the adductor longus’s force of action with respect to the axis of rotation enhances the internal rotation effect and changes to extension as it approaches near 100 degrees of hip flexion.
Biomechanical Consequences of Coxa Vara and Coxa Valga
- Coxa vara (decreased angle of inclination) often results in a larger moment arm for hip abductors, potential improvements in joint stability, but also heightened risk of shear force and femoral neck fracture.
- Coxa valga (increased angle of inclination) leads to a reduced moment arm, potentially lowering joint stability and increasing the risk of hip dislocation.
Biomechanical Consequences of Coxa Vara and Coxa Valga
- Coxa vara can lead to improved hip joint alignment but may lessen the effectiveness of abductor muscles, possibly resulting in instability issues.
- Coxa valga poses a higher risk of dislocation, primarily due to an altered moment arm for abductor muscles.
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Test your knowledge on femoral angulations and associated conditions with this quiz. Explore concepts such as coxa valga, femoral anteversion, and relevant muscle attachments. Perfect for anatomy students and medical professionals!
