Hip Surface Anatomy Lab Outline 2024 PDF

**[Clinical Conference I]** **Lower Extremity: The Hip Complex** - **Palpate the PSIS and sacral hiatus.** - start laterally and a bit cranially; palpate inferiorly to ID the iliac crest - palpate bilaterally along the superior aspect of the iliac crest coming from...

**[Clinical Conference I]** **Lower Extremity: The Hip Complex** - **Palpate the PSIS and sacral hiatus.** - start laterally and a bit cranially; palpate inferiorly to ID the iliac crest - palpate bilaterally along the superior aspect of the iliac crest coming from lateral to posterior medial - as palpation continues posteriorly the iliac crest curves downward to end at a bony step called the **PSIS** (Posterior Superior Iliac Spine) - use your thumb perpendicular to the underside of the PSIS - from the inferior part of the PSIS's, draw a dashed helper's line connecting these two points; this line represents the level of **S2** - the S2 SP is variable in size - from S2 continue palpation along the midline until your finger falls into a small step, the **sacral hiatus** - from this point palpate slightly laterally in both directions and you will feel a bony prominence, the **sacral horns** (cornua sacralis) - draw a line from the midpoint of the PSIS to the sacral hiatus; this is **[line A]**; divide this into 1/3's - **Palpate the greater trochanter** - place your fingers at the midpoint of the lateral aspect of the iliac crest - palpate caudally until you come in contact with a bony prominence the greater trochanter - confirm by passively flexing the knee to 90 degrees and producing passive internal and external rotation of the femur - if you are on the greater trochanter you will feel the bone moving under your palpating hand - this is a large bony structure which is about 2 inches wide - draw a line from the midpoint of the cranial aspect of the greater trochanter to the midpoint of the PSIS; this is **[line B]**, divide this into 1/3's - draw a line from the cranial aspect of the greater trochanter to lowest part of the cranial 2/3 of line A; this is **[line C],** divide this line into 1/3's - the triangle created by the top 2/3 of line A, line B, and line C represents the location of the **piriformis** muscle - Piriformis (personal notes from lecture) - Locate PSIS (lower part) - Find lateral edge of Sacrum, then move laterally towards coccyx - Piriformis attaches to anterior aspect and inserts at greater trochanter (Superior Border) so it creates a T shape - Rotate leg in and out of external rotation to find greater trochanter - This outlines where you should palpate for the piriformis - Have patient perform bent leg hip external rotation - in the region of the medial aspect of the gluteal fold palpate the **ischial tuberosity**; note the relationship to the greater trochanter - mark point at level of bone - the **hamstring muscle group** with the exception of the short head of the biceps femoris muscle have their attachment on the proximal lateral border of the ischial tuberosity - this can be confirmed by asking for gentle knee flexion and following the hamstrings proximally toward their insertion Find Gluteal fold to feel ischial tuberosity Go back to greater trochanter - draw a line from the ischial tuberosity to the midpoint of the cranial aspect of the greater trochanter; this is **[line D]**, divide this in ½ - **Course of the sciatic nerve.** - the sciatic nerve exits the sciatic notch at a point corresponding to the line dividing the medial and middle 1/3 of line C - draw a line connecting this point with the midpoint of line D - then direct your line distally toward the popliteal fossa of the knee - this is the general course of the sciatic nerve C:\\Users\\hjonely\\AppData\\Local\\Microsoft\\Windows\\Temporary Internet Files\\Content.Word\\FullSizeRender (5).jpg **II. Medial Femoral Triangle -- [Supine] (slight flexion and abd of hip)** **Borders:** **base = inguinal ligament** **lateral = sartorius** **medial = add longus** - palpate the **iliac crest** and locate the **ASIS** (Anterior Superior Iliac Spine) - **ASIS**- palpate from posterior lateral to anterior medial along the iliac crest until you fall off a prominent bony edge, this is the **ASIS** - palpate from the umbilicus caudally until you locate the **pubic tubercle** (start at belly button and work down) - **Inguinal ligament** - between the pubic tubercle and the ASIS runs the fibers IMPORTANT - represents the base of the medial femoral triangle - thicker at ASIS and thinner towards pubic tubercle - Origin pubic tubercle - Insertion ASIS - **Sartorious muscle** - this can be located by having the patient perform slight flexion and external rotation of the hip - ASIS to proximal tibia - is the lateral leg of the triangle - Captain Morgan Rum - Provide some resistance in hip flexion to identify the lateral border - **Adductor longus** - have the patient rest with the hip in slight flexion, neutral rotation and slight flexion of the knee - the muscle and tendon can be palpated at their attachment on the pubic tubercle as the patient performs an isometric hip adduction contraction - has a big tendon - is the medial leg of the triangle - can be followed to about mid-thigh - Pretty thick tendon at the tubercle but it disappears mid thigh. So you might have to have your partner resist adduction and relax a few times - **Gracilis tendon and muscle belly** - at the attachment on the inferior ramus of the pubis just medial to adductor longus - differentiate between adductor longus and the gracilis, by asking the patient to perform and isometric hip abduction (to not activate other adductors) while also performing isometric knee flexion (Dig heel into the bed) - You can feel the adductor longus above and gracilis below in the medial of the thigh. Once they dig their heel, youlll feel the gracilis tighten up more - Inserts into tibia with sartorius at pes anserinus The contents of the medial femoral triangle include: - **femoral artery** - located in the region which is midway between the pubic tubercle and ASIS - feel for a pulsating structure with the pads of your fingers (can't feel through clothing, For the practical you can just state it and feel it over clothing) - **femoral nerve** - lateral to the femoral artery - **femoral vein** - medial to the femoral artery - **Iliopsoas** - between the femoral artery and the sartorius - this can be confirmed by palpation over this area while the patient performs slight hip flexion - The sartorius and iliopsoas join together at the lesser trochanter  Reichert B. **III. Lateral Femoral Triangle -- [Supine]** **Borders:** **base = rectus femoris** **lateral = TFL** **medial = sartorius** - **Sartorious** - previously located - this is the medial leg of the triangle - **Tensor fascia lata (TFL)** - this is the lateral leg of the triangle - First find ASIS - ask the patient to perform flexion, abduction, and internal rotation of the hip - the attachment of this muscle is about 5 cm wide on the iliac crest, posterior to the ASIS - When they turn their foot in, you should feel a muscle pop out - Book shows it in supine, but can do it in sidelying doing all three things again - Either option works for the practical - **Rectus femoris** - this is the floor of the triangle - ask the patient to gently extend the knee - You can put your knee under the patient's knee to offer support as they extend the knee - this can be followed to its attachment at the **AIIS** (Anterior Inferior Iliac Spine) - the AIIS can be palpated in the region which is about 5cm distal to ASIS between the tensor fascia lata and sartorius muscle, a bit under sartorius - will no longer feel a contraction of knee extension - hard to find C:\\Users\\hjonely\\Downloads\\FullSizeRender (4).jpg Reichert B. **IV. Lateral Hip -- Supine or sidelying** - locate the **greater trochanter** - the most superior aspect of the greater trochanter is attachment of **gluteus minimus**, whereas the **gluteus medius** is in the region of the posterior/superior aspect - Find TFL and come posterior to that to find glute medius - the **gluteus maximus**, is from the posterior/superior aspect of the greater trochanter and extends below the gluteal fold; runs obliquely toward the distal femur into its attachment on the iliotibial tract (Glute max goes diagonally toward femur whereas medius doesn't) - Can be done sidelying or prone but definitely not supine [References:] Reichert B. Palpation Techniques Surface Anatomy for Physical Therapists. Stuttgart, Germany: Thieme; 2011.