Stanbridge - T6 - Ortho2 - W1 - Hip

• The presentation covers PTA 1016 Orthopedic Interventions II with a focus on the Hip Joint in Week 1.

Hip Objectives

• Students should accurately describe and palpate bony landmarks and musculature of the hip.
• Students should describe the biomechanics of gross movement and the joint, including surface arthrokinematics.
• Students should describe the relationship between muscle imbalance and functional performance of the hip.
• Key causes of hip dysfunction should be summarized.
• Intervention strategies and techniques should be described and demonstrated based on clinical findings and established goals.
• Students will be able to evaluate intervention effectiveness to determine progress and modify interventions.
• Home programs for addressing hip pathology should be effectively taught.

Hip Anatomy

• The hip requires a balance between mobility and stability
• The innominate bones include the ilium, ischium, and pubis
• The two innominate bones form an anatomic ring with the pelvis

Acetabulum

• The ilium, ischium, and pubis come together at the acetabulum.
• The acetabulum encloses the head of the femur.
• The superior surface is lined with heavy cartilage, where the head of the femur contacts the acetabulum.

Acetabular Labrum

• The acetabular labrum is a ring of cartilage surrounding the acetabulum
• The transverse ligament forms a 360-degree ring
• It increases the articular congruence.
• The acetabular labrum creates a partial vacuum.

Pubic Symphysis - Anatomic Ring

• The superior and inferior rami converge into two pubic bodies
• There is a symphyseal fibrocartilage disc in between
• Fissure is lined with synovial membrane, making it prone to inflammation.
• The anterior pubic ramus connects to L2-4 spinal levels, which causes groin pain when irritated.
• The posterior pubic ramus connects too S3-5 spinal levels and causes genital pain when irritated.

Vascular Supply

• Proximal femur includes the head, neck, and shaft.
• The proximal shaft of the femur and neck have a lot of blood supply.
• The femoral head has poor vascular supply.
• The head receives blood from medial and lateral circumflex femoral arteries and the artery of the ligament of the head of the femur.
• Displaced femoral neck fractures affect these arteries, leading to poor healing or avascular necrosis.

Muscles of the Hip

• Table 23-1 has a muscles chart
• Hip flexors include the iliacus, psoas major, rectus femoris, tensor fascia latae, sartorius, adductor longus, adductor brevis, adductor magnus (anterior part), gluteus minimus, and gluteus medius (anterior part).
• Hip extensors include the gluteus maximus, piriformis, adductor magnus (extensor head), gluteus medius (posterior part), semimembranosus, semitendinosus, and biceps femoris (long head).
• Hip abductors include the gluteus medius, gluteus minimus, psoas major, iliacus, sartorius, tensor fascia latae, gemellus inferior and superior, gluteus maximus (upper part), and obturator internus.
• Hip external rotators include the piriformis, gemellus superior, obturator internus and externus, gemellus inferior, quadratus femoris, psoas major, iliacus, sartorius, tensor fascia latae, gluteus maximus, and biceps femoris (long head).
• Hip adductors include the pectineus, adductor brevis, adductor longus and magnus, gracilis, the obturator externus, and the gluteus maximus (low).
• Hip internal rotators include the adductor longus and brevis, tensor fascia latae, gluteus minimus and medius (anterior), semimembranosus and semitendinosus.

Hip Joint Capsule

• The hip capsule extends from the femoral neck base to the acetabular labrum
• The 3 fiber systems are:
  • Longitudinal fibers: from proximal to distal, creating tensile constraint.
  • Transverse fibers: around the femoral head, narrowing around the neck of the femur.
  • Arcuate fibers loops around the labrum reinforcing the insertion reinforcing the insertion.
• Because the internal capsule is lined with synovium, swelling can constrict blood flow to the femoral head.

Hip Joints

• Five ligaments hold the femur in place:
  • The Iliofemoral Ligament runs from the anterior inferior iliac spine to intertrochanteric line of the femur
    • This limits ER, adduction,extension and reduces hip extensor contraction.
  • The Pubofemoral ligament runs from the superior ramus of the pubis to the intertrochanteric line
    • This limits ER, extension and abduction and reinforces the joint capsule medially
  • The Ischio-femoral ligament connects the ischium to the greater trochanter of the femur.
    • This limits internal rotation, is the most injured and limits hip adduction when hip is flexed
  • Transverse acetabular ligament: is the labrum covering the notch
• The Femoral head ligament (ligamentum teres/fovea) joins the femoral head with the transverse ligament and acetabular notch
  • It maintains reduction of the femoral head and it acts a conduit for neurovascular supply.

Hip Sensorimotor System

• The anterior joint is innervated through the sensory branches of what? -femoral N -obturator N

  • this can elicit groin pain, if irritated

• The posterior joint is innervated by?

  • sacral plexus
  • this can elicit buttock & trochanteric pain if irritated

Hip Kinesiology

• The hip is a ball and socket joint with a convex femoral head
• The hip has 3 planes of motion
• Extreme motions require motion at the pelvis
  • End range hip flexion is associated with posterior rotation of the ilium
  • End range hip extension is associated with anterior rotation of the ilium
  • Hip abduction and adduction are associated with lateral tilt of the pelvis
• The most stable hip position is standing.
• The close-packed position hip extension with abduction with internal rotation.
• The open-packed one is with: 30 deg. Flex; 30 deg abd; 5 deg ER
• Capsular pattern:
  • IR greatest loss
  • Loss of ABD, Flex, Ext varies in the literature
  • Add, ER are rarely lost
• The hip joint has:
  • A synovial capsule is sealed
  • Is anchored firmly with strong ligaments
  • A tight, reciprocal-shaped limits translation with traditional joint mobilizations
  • Joint mobilizations can be enhanced with MWM

Moblization with Movement MWM

• Sustained accessory moblization is applied by a PTA and an active physiological movement to end the range of the patient. Followed up by passive end of range overpressure with stretching, in-case its pain free Injuries might result in a "positional fault", this cases restrictions with movement

• MWM has techniques that help joint tracking issues of positonal fault where there is subtle biomechanical dysfuction

• With the aggravating Movement that the patient experiences, an appropriate glide has to be chosen

• Decision to use weight bearing or non-weight bearing is based on the condition of the patient.

  • Use weight beearing for subacute/chronic stages, where there IS a slight tissue/irratiability / capsular movement

• Sustained glide and pain free movement is applied to chosen glide unitil pain fee motion increases Mobilations are always preformed with tissue resistamce, without pain. Expect immadate pain relive with improved ROM.

• With Mobilization with movement, consider these factors:

  1. Line of force
  2. Angle of Mobilization
  3. Reps and Sets

• Hip Joint Force

  • Peak force during gait: 1.8-3.8 times an individual's bodyweight (BW)
    • Force increased with femoral anteversion( forward twisting of the thighbone)
    • More than three times BW increases joint's risk of early degeneration
    • Reduced functions result woth greater 4x compression of cartilage
    • Consider an assesive divce to reileve weight. Lumbopelvic Rhythm: Hip Kinesiology: Forqard Bend/Weigt Bearing
  • As Head and trunk shift/shift forward: pelvis shifts posteriorly to maitain COG over BOS (base of support)
    1. 45deg: posterior ligaments are taut
    2. pelvis starts to rotate forward
    3. zygapophyseal joints are full flexion (full opening) facit joint flexion is complete.
       • The whole event is: ECCENTRICALLY controlled until muscle flexibility is reached. (Lumbar Extensors, Glute, Hamstrings)

• lumbopelvic rythm is reversed for the position. Forward bend to return to an upright position.

  1. Lumbar extensors initiate spinal rythm. (recoil) 2. Hip extensors rotate the pelvis posteriorly 3. 45 degree mark: forward lean (back extensors extend spine)

• WHOLE event is: CONCENTRICALLy controlled by Lumbar Extensors / Glutes & H. Asessment at LPM will point to limitiations such as strenght and control/flexibility.. Collum/Incilination Angle: (Frontal Plane): What should I know? - What’s Normal 125 degree - FRONTal angle @ shaft/neck femur - Less than 120: COXA VARA [lesser angle} (More medially) > Mechanics Short Person - increases shear force @ artic - increases medial compressive force - Lengthens moments arm abd - - Decreases overall extremities - Cases Genu VaLGum . - Greater than 130 COXA VALGA: Greater] (Greater to Acetbulum.) • Higher angle is “VaLGa” - Mechanics - TalLer person

• Shifts joints reactions forces switch from vertical-> parallel (femoral shaft/)

• Shortens moment arm @ abducations

• Increases length of overall. Exts

• GENU VARUM

Transverseplane

Hip Kinesiology : ante version and retroversion

    1. What do In need to understand
        - alignment
    2. Anteversino : Anterior positions axis of femur to Codvyles
        35 Degree : is ante (increase intern: (w sittting) and toe-in) - MORE COMMON

• Can Impacts Tendononphaties/Cartaliage - Retroversion : parallel or posterior position

• Pt will excessive more ER (out-toe-out) 5 deg is retro.

• Impacts -Degeration of AC ( superior Labrum ) Hip Exam End feels ->6

• abnormal. ->abduct,ext,ir

• The hip has: sofe tissue injuries and affect lumbar/ pelvis/exremities

• always include the chain MYOFASCIAL LINES

• Clinical partners and how they approach them as a supplemental info Mio fascia meridians: Myo+Facia + nature muscular tissue - continuity- connection between/along/adjacent/alighment “Lines of pull" inter connects the fascia.

• *Body Has 3 Whole Body Communications Networks:

  • NEural net : BRAIN/spinal cord, nerves
  • fluid: heat Arteries/Veins
  • fibers: FASICA .

• Nutriennts- >to cells ->determ by Density fibers matrices+visocity the substanxe • Test My Know

• • Superfical Lines:

• Anterior : mastoid process and more

Intervention

• General Activities

  1. Protection for injury-> assistive device
  2. Promotion to pain free> mobs to help with stretch.
  3. Decrease inflammation- pricemen
  4. Cardiac help
  5. Atrophy muscle - Open and pack positinons
  • progress once sub-acute + pain-free movement. Subacute Phase

1. FULL ROM (stretch/moblize
2. Improve/ neuromusul control/weight Normal Gaits Mech

• tilt of pelvis- >limb Flex and DF Anter- First THEN->unitaerql
• • Chronic/ Phase - Endurance :ADL :activty Compensate • Hip flex : low

Contractures

• Lack->flex/and hip -position and sitting ->exxtensor->muscle help to retain compensate
• Low/ hyper extensions. : kyphosis thoraic
• knee Flex : based off acuteness : low and stretches tfl Retain position- prone/lying and strength/stretch
• *osteoarhtis ->synolvotis
• disease /trauma:
• more then 20 years / hyperextion (reitive. . Test Your Knowledge"

Osteoa

• squarts Agrava Flex pain AD (Lateral/Groin.) Passir irl <25
• • Labral Pathology! Test Your Knowledge"

Osteotra

• squarts Agrava -Flex pain **AD (Lateral/Groin.)

• Passir irl less-than25 ** Lab Pathology

• *UmbrellA. inflamation. @ but, groin knee pattern loss

• loss Rec

• severe Night

• IR loss -loss Abd. Flex ractice ->dditions /ER

• 2 -type impoingement • Cam- head /more radius -impingence labrum • Pincher (lab is caught between structures/coverage Test Your Knowledge"

• osteo

Impingmence (

• head /more radius impingence labrum

-Primary

hip: degeneration -radiographic

• more/synovolits -may geneticadvancem age