Hip and Pelvis - Clinical Tree

Clinical Summary and Recommendations

Patient History
Complaints	Several complaints appear to be useful in identifying specific hip pathologic conditions. A subjective complaint of “clicking in the hip” is strongly associated with acetabular labral tears. Reports of “constant low back/buttock pain” and “ipsilateral groin pain” are moderately helpful in diagnosing osteoarthritis (OA) of the hip.
Physical Examination
Range-of-Motion Measurements	Measuring hip range of motion has consistently been shown to be highly reliable and when limited in three planes can be fairly useful in identifying hip OA (+LR [likelihood ratio] = 4.5 to 4.7). Assessing pain during range-of-motion measurements can be helpful in identifying both OA and lateral tendon pathologic conditions. Lateral hip pain during passive abduction is strongly suggestive of lateral tendon pathologic disorders (+LR = 8.3), whereas groin pain during active hip abduction or adduction is moderately suggestive of OA (+LR = 5.7). Limited hip abduction in infants can also be very helpful in identifying hip dysplasia or instability.
Strength Assessment	Assessment of hip muscle strength has been shown to be fairly reliable, but it appears to be less helpful in identifying lateral tendon pathologic conditions than reports of pain during resisted tests, especially of the gluteus minimus and medius muscles (+LR = 3.27). Similarly, a report of posterior pain with a squat is also fairly useful in identifying hip OA (+LR = 6.1). Although less reliable than strength tests, the Trendelenburg test is also moderately useful in identifying both lateral tendon pathologic conditions and gluteus medius tears (+LR = 3.2 to 3.6).
Special Tests	The FABER test in identifying the presence of hip instability (+LR = 5.4). The patellar-pubic-percussion test is useful at detecting and ruling out hip fractures (+LR = 6.7 to 21.6, −LR = .07 to .14). The ligamentum teres test has been found to be valuable in identifying tears of the ligamentum teres (+LR = 6, −LR = .12) Additionally, the long-stride walking test (+LR = 6.12 and −LR = .07) and ischiofemoral impingement test (+LR = 5.35 and −LR = .21) may be useful for identifying the presence of ischiofemoral impingement. However, the wide confidence intervals should be considered.
Combinations of Findings	Patients with at least four of five signs and symptoms (squatting aggravates symptoms, lateral pain with active hip flexion, scour test with adduction causes lateral hip or groin pain, pain with active hip extension, and passive internal rotation of 25 degrees or less) are highly likely to have hip OA.

Anatomy

Osteology

Arthrology

Joint	Type and Classification	Closed Packed Position	Capsular Pattern
Femoroacetabular	Synovial: Spheroidal	Full extension, some internal rotation, and abduction	Internal rotation and abduction greater than flexion and extension
Pubic symphysis	Amphiarthrodial	Not applicable	Not applicable
Sacroiliac	Synovial: Plane	Not documented	Not documented

Ligaments

Hip Ligaments	Attachments	Function
Iliofemoral	Anterior inferior iliac spine to intertrochanteric line of femur	Limits hip extension
Ischiofemoral	Posterior inferior acetabulum to apex of greater tubercle	Limits internal rotation, external rotation, and extension
Pubofemoral	Obturator crest of pubic bone to blend with capsule of hip and iliofemoral ligament	Limits hip hyperabduction
Ligament of head of femur	Margin of acetabular notch and transverse acetabular ligament to head of femur	Carries blood supply to head of femur

Pubic Symphysis Ligaments	Attachments	Function
Superior pubic ligament	Connects superior aspects of right and left pubic crests	Reinforces superior aspect of joint
Inferior pubic ligament	Connects inferior aspects of right and left pubic crests	Reinforces inferior aspect of joint
Posterior pubic ligament	Connects posterior aspects of right and left pubic crests	Reinforces inferior aspect of joint

Muscles

Posterior Muscles of Hip and Thigh

Muscle	Proximal Attachment	Distal Attachment	Nerve and Segmental Level	Action
Gluteus maximus	Posterior border of ilium, dorsal aspect of sacrum and coccyx, and sacrotuberous ligament	Iliotibial tract of fascia lata and gluteal tuberosity of femur	Inferior gluteal nerve (L5, S1, S2)	Extension, external rotation, and some abduction of the hip joint
Gluteus medius	External superior border of ilium and gluteal aponeurosis	Lateral aspect of greater trochanter of femur	Superior gluteal nerve (L5, S1)	Hip abduction and internal rotation; maintains level pelvis in single-limb stance
Gluteus minimus	External surface of ilium and margin of greater sciatic notch	Anterior aspect of greater trochanter of femur	Superior gluteal nerve (L5, S1)
Piriformis	Anterior aspect of sacrum and sacrotuberous ligament	Superior greater trochanter of femur	Ventral rami of S1, S2	External rotation of extended hip, abduction of flexed hip; steadies femoral head in acetabulum
Superior gemellus	Ischial spine	Trochanteric fossa of femur	Nerve to obturator internus (L5, S1)
Inferior gemellus	Ischial tuberosity		Nerve to quadratus femoris (L5, S1)
Obturator internus	Internal surface of obturator membrane, border of obturator foramen		Nerve to obturator internus (L5, S1)
Quadratus femoris	Lateral border of ischial tuberosity	Quadrate tubercle of femur	Nerve to quadratus femoris (L5, S1)	Lateral rotation of hip; steadies femoral head in acetabulum
Semitendinosus (hamstring)	Ischial tuberosity	Superomedial aspect of tibia	Tibial division of sciatic nerve (L5, S1, S2)	Hip extension, knee flexion, medial rotation of knee in knee flexion
Semimembranosus (hamstring)	Ischial tuberosity	Posterior aspect of medial condyle of tibia	Tibial division of sciatic nerve (L5, S1, S2)
Biceps femoris (hamstring)	Long head: ischial tuberosity Short head: linea aspera and lateral supracondylar line of femur	Lateral aspect of head of fibula, lateral condyle of tibia	Long head: tibial division of sciatic nerve (L5, S1, S2) Short head: common fibular division of sciatic nerve (L5, S1, S2)	Knee flexion, hip extension, and knee external rotation when knee is flexed

Figure 6-5, Muscles of hip and thigh: posterior views.

Anterior Muscles of Hip and Thigh

Muscle	Proximal Attachment	Distal Attachment	Nerve and Segmental Level	Action
Obturator externus	Margin of obturator foramen and obturator membrane	Trochanteric fossa of femur	Obturator nerve (L3, L4)	Hip external rotation; steadies head of femur in acetabulum
Hip Flexors
Psoas major	Lumbar transverse processes	Lesser trochanter of femur	L1-L4	Flexes the hip, assists with external rotation and abduction
Psoas minor	Lateral bodies of T12-L1	Iliopectineal eminence and arcuate line of ileum	L1-L2	Flexion of pelvis on lumbar spine
Iliacus	Superior iliac fossa, iliac crest and ala of sacrum	Lateral tendon of psoas major and distal to lesser trochanter	Femoral nerve (L1-L4)	Flexes the hip, assists with external rotation and abduction
Tensor fasciae latae	Anterior superior iliac spine and anterior aspect of iliac crest	Iliotibial tract that attaches to lateral condyle of tibia	Superior gluteal nerve (L4, L5)	Hip abduction, internal rotation and flexion; aids in maintaining knee extension
Rectus femoris	Anterior inferior iliac spine	Base of patella and through patellar ligament to tibial tuberosity	Femoral nerve (L2, L3, L4)	Hip flexion and knee extension
Sartorius	Anterior superior iliac spine and notch just inferior	Superomedial aspect of tibia	Femoral nerve (L2, L3)	Flexes, abducts, and externally rotates hip; flexes knee
Adductors
Longus	Inferior to pubic crest	Middle third of linea aspera of femur	Obturator nerve (L2, L3, L4)	Hip adduction
Brevis	Inferior ramus of pubis	Pectineal line and proximal linea aspera of femur	Obturator nerve (L2, L3, L4)	Hip adduction and assists with hip extension
Magnus	Adductor part: inferior pubic ramus, ramus of ischium Hamstring part: ischial tuberosity	Adductor part: gluteal tuberosity, linea aspera, medial supracondylar line Hamstring part: adductor tubercle of femur	Adductor part: obturator nerve (L2, L3, L4) Hamstring part: tibial part of sciatic nerve (L4)	Hip adduction Adductor part: hip flexion Hamstring part: hip extension
Gracilis	Inferior ramus of pubis	Superomedial aspect of tibia	Obturator nerve (L2, L3)	Hip adduction and flexion; assists with hip internal rotation
Pectineus	Superior ramus of pubis	Pectineal line of femur	Femoral nerve and obturator nerve (L2, L3, L4)	Hip adduction and flexion; assists with hip internal rotation

Figure 6-6, Muscles of thigh: anterior view.

Nerves

Nerve	Segmental Level	Sensory	Motor
Obturator	L2, L3, L4	Medial thigh	Adductor longus, adductor brevis, adductor magnus (adductor part), gracilis, obturator externus
Saphenous	Femoral nerve	Medial leg and foot	No motor
Femoral	L2, L3, L4	Thigh via cutaneous nerves	Iliacus, sartorius, quadriceps femoris, articularis genu, pectineus
Lateral cutaneous of thigh	L2, L3	Lateral thigh	No motor
Posterior cutaneous of thigh	S2, S3	Posterior thigh	No motor
Inferior cluneal	Dorsal rami L1, L2, L3	Buttock region	No motor
Sciatic	L4, L5, S1, S2, S3	Hip joint	Knee flexors and all muscles of lower leg and foot
Superior gluteal	L4, L5, S1	No sensory	Tensor fasciae latae, gluteus medius, gluteus minimus
Inferior gluteal	L5, S1, S2	No sensory	Gluteus maximus
Nerve to quadratus femoris	L5, S1, S2	No sensory	Quadratus femoris, inferior gemellus
Pudendal	S2, S3, S4	Genitals	Perineal muscles, external urethral sphincter, external anal sphincter

Figure 6-8, Nerves and arteries of thigh: anterior views.

Patient History

Initial Hypotheses Based on Historical Findings

History	Initial Hypothesis
Reports of pain at the lateral thigh. Pain exacerbated when transferring from sitting to standing	Greater trochanteric bursitis Muscle strain
Age over 60 years. Reports of pain and stiffness in the hip with possible radiation into the groin	OA
Reports of clicking or catching in the hip joint. Pain exacerbated by full flexion or extension	Labral tear
Reports of a repetitive or an overuse injury	Muscle sprain/strain
Deep aching throb in the hip or groin. Possible history of prolonged steroid use	Avascular necrosis
Sharp pain in groin. Often misdiagnosed by multiple providers	Femoroacetabular (anterior) impingement
Pain in the gluteal region with occasional radiation into the posterior thigh and calf	Piriformis syndrome Hamstring strain ^, Ischial bursitis

Diagnostic Utility: Hip Pain, Osteoarthritis, and Acetabular Labral Tears

Patient Complaint and Study Quality	Population	Reference Standard	Sens	Spec	+LR	−LR
Constant low back/buttock pain	78 patients with unilateral pain in the buttock, groin, or anterior thigh	Hip OA on radiographs using the Kellgren and Lawrence grading scale	.52 (.30, .74)	.92 (.80, .97)	6.4 (2.4, 17.4)	.52 (.33, .81)
Ipsilateral groin pain			.29 (.12, .52)	.92 (.80, .97)	3.6 (1.2, 11.0)	.78 (.59, 1.00)
Squatting aggravates symptoms			.76 (.52, .91)	.57 (.42, .70)	1.8 (1.2, 2.6)	.42 (.19, .93)
No lateral thigh pain	49 potential surgical patients with hip pain	Intraarticular hip pain as defined by relief of more than 50% with intraarticular anesthetic-steroid injection	.78 (.59, .89)	.36 (.2, .57)	1.2 (.84, 1.8)	.61 (.25, 1.5)
Groin pain ⁷			.59 (.41, .75)	.14 (.05, .33)	.67 (.48, .98)	3.0 (.95, 9.4)
Catching			.63 (.44, .78)	.54 (.35, .73)	1.39 (.81, 2.4)	.68 (.36, 1.3)
Pinching pain when sitting			.48 (.31, .66)	.54 (.35, .73)	1.1 (.58, 1.9)	.95 (.56, 1.6)
Patient complains of clicking in the hip	18 patients with hip pain	Acetabular labral tear as determined by magnetic resonance arthrography	1.0 (.48, 1.0)	.85 (.55, .98)	6.7	.00

Physical Examination Tests

Range-of-Motion Measurements

Reliability of Range-of-Motion Measurements

Measurements and Study Quality	Instrumentation	Population	Interexaminer Reliability
External rotation (sitting) Internal rotation (sitting) External rotation (supine) Internal rotation (supine) Flexion Abduction Adduction Extension	Goniometer	6 patients with hip OA	Prestandardization/poststandardization: ICC = .55/.80 ICC = .95/.94 ICC = .87/.80 ICC = .87/.94 ICC = .91/.91 ICC = .91/.88 ICC = .72/.56 ICC = NA/.66
Passive hip flexion	Gravity inclinometer	22 patients with knee OA and 17 asymptomatic subjects	ICC = .94 (.89 to .97)
Internal rotation	Digital inclinometer	25 healthy subjects	ICC = .93 (.84, .97)
Internal rotation External rotation Flexion Abduction Extension (knee flexed) Extension (knee unconstrained)	Goniometer (except rotation with inclinometer)	22 patients with hip OA	ICC = .93 (.83, .97) ICC = .96 (.91, .99) ICC = .97 (.93, .99) ICC = .94 (.86, .98) ICC = .86 (.67, .94) ICC = .89 (.72, .95)
Flexion Abduction Adduction External rotation Internal rotation Extension	Inclinometer	78 patients with unilateral pain in the buttock, groin, or anterior thigh	ICC = .85 (.64 to .93) ICC = .85 (.68 to .93) ICC = .54 (−.19 to .81) ICC = .77 (.53 to .89) ICC = .88 (.74 to .94) ICC = .68 (.32 to .85)
Flexion Extension Abduction Adduction External rotation Internal rotation Total hip motion	Goniometer	25 subjects with radiologically verified OA of the hip	ICC = .82 ICC = .94 ICC = .86 ICC = .50 ICC = .90 ICC = .90 ICC = .85
Flexion Internal rotation External rotation Abduction Extension Adduction	Goniometer	167 patients, 50 with no hip OA, 77 with unilateral hip OA, 40 with bilateral hip OA based on radiologic reports	ICC = .92 ICC = .90 ICC = .58 ICC = .78 ICC = .56 ICC = .62
Hip flexion, right Hip flexion, left	Goniometer	106 patients with OA of the hip or knee confirmed by a rheumatologist or an orthopaedic surgeon	ICC = .82 (.26, .95) ICC = .83 (.33, .96)

ICC, Intraclass correlation coefficient; NA, not applicable.

Figure 6-9, Measurement of passive range of motion.

Reliability of Determining Capsular and Noncapsular End Feels

Measurements and Study Quality	Description and Positive Finding	Population	Intraexaminer Reliability
Flexion test	Maximal passive range of motion was assessed. End feels were dichotomized into “capsular” (early capsular, spasm, bone-to-bone) and “noncapsular” (soft tissue approximation, springy block, and empty) as defined by Cyriax	78 patients with unilateral pain in the buttock, groin, or anterior thigh	κ =.21 (−.22, .64)
Internal rotation test			κ = .51 (.19, .83)
Scour test			κ = .52 (.08, .96)
Patrick (FABER) test			κ = .47 (.12, .81)
Hip flexion test			κ = .52 (.09, .96)

Diagnostic Utility of Cyriax’s Capsular Pattern for Detecting Osteoarthritis

A few studies ^, have investigated the diagnostic utility of Cyriax’s capsular pattern (greater limitation of flexion and internal rotation than of abduction, little if any limitation of adduction and external rotation) in detecting the presence of OA of the hip. Bijl and associates demonstrated that hip joints with OA had significantly lower range-of-motion values in all planes when compared with hip joints without OA. However, the magnitude of the range limitations did not follow Cyriax’s capsular pattern. Similarly, Klässbo and colleagues did not detect a correlation between hip OA and Cyriax’s capsular pattern. In fact, they identified 138 patterns of passive range-of-motion restrictions depending on the established norms used (either the mean for symptom-free hips or Kaltenborn’s published norms).

Figure 6-10, Hip joint involvement in osteoarthritis.

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