Chapter 11 The Hip
Figure 11.25 Active movement testing of flexion.
Figure 11.26 Active movement testing of extension.
Medial (Internal) Rotation
The patient, in the supine position, is instructed to roll the extended lower extremity inward without lifting the buttock off the table (Figure 11.29).
Lateral (External) Rotation
The patient, in the supine position, is instructed to roll the lower extremity outward (Figure 11.30).
Passive Movement Testing
Passive movement testing can be divided into two areas: physiological movements (cardinal plane), which are the same as the active movements, and mobility testing of the accessory (joint play, component) movements. You can determine whether the noncontractile (inert) elements can be incriminated by using these tests.
The Hip Chapter 11
Figure 11.27 Active movement testing of abduction.
Figure 11.28 Active movement testing of adduction.
These structures (ligaments, joint capsule, fascia, bursa, dura mater, and nerve root) (Cyriax, 1979) are stretched or stressed when the joint is taken to the end of the available range. At the end of each passive physiological movement, you should sense the end feel and determine whether it is normal or pathological. Assess the limitation of movement and see if it fits into a capsular pattern. The capsular pattern of the hip is medial
rotation, extension from 0 degrees, abduction, and lateral rotation (Kaltenborn, 1999). If you find that the patient has limited motion, experiences pain during hip flexion with the knee extended or with the knee flexed, and presents with a noncapsular pattern, you should consider that the patient has the sign of the buttock (Cyriax, 1979). This is indicative of a serious lesion such as neoplasm, fracture of the sacrum, or ischiorectal abscess.
Chapter 11 The Hip
Figure 11.29 Active movement testing of medial (internal) rotation.
Figure 11.30 Active movement testing of lateral (external) rotation.
Physiological Movements
Assess the amount of motion available in all directions. Each motion is measured from the anatomical starting position which is 0 degrees of flexion–extension, abduction–adduction, and medial–lateral rotation. Patients will substitute for tightness in the joint or surrounding muscles with trunk or pelvic movement.
Therefore it is important to monitor where the movement is taking place while stabilizing the pelvis.
Flexion
The patient is placed in a supine position with the hip in the anatomical position. Place your hand over the patient’s knee and ankle and create flexion in the
The Hip Chapter 11
Figure 11.31 Passive movement testing of flexion.
hip and knee joint. Increased motion can be achieved by posteriorly tilting the pelvis; therefore, stabilization of the pelvis is important for the accurate determination of hip movement. Hip flexion is normally blocked by the approximation of the anterior part of the thigh and the abdomen. If the patient is obese, range of motion can be limited by early contact with the abdominal area. The normal end feel is considered to be soft (tissue approximation) (Kaltenborn, 1999; Magee, 1997). Normal range of motion is 0–120 degrees (Figure 11.31) (American Academy of Orthopedic Surgeons, 1965).
Extension
The patient is placed prone with the hip in the anatomical position. The knee must be extended to put the rectus femoris on slack and so that it does not decrease the available range. Place your hand under the anterior distal aspect of the thigh and lift the lower extremity toward the ceiling. Increased motion can be created by increasing the lumbar lordosis and by anterior tilting of the pelvis. Stabilization of the pelvis is important to obtain accurate measurements. The normal end feel is firm (ligamentous) due to tension from the anterior capsular ligaments (Kaltenborn, 1999; Magee, 1997). Tight anterior muscles can also
contribute to the limitation of motion. Normal range of motion is 0–30 degrees (Figure 11.32) (American Academy of Orthopedic Surgeons, 1965).
Abduction
The patient is placed supine with the hip in the anatomical position. Place your hand on the medial distal aspect of the leg and move the lower extremity laterally. Increased motion can be created by laterally rotating the lower extremity and hiking the pelvis. Stabilization of the pelvis is important to obtain accurate measurements. Normal end feel is firm (ligamentous) due to tension from the medial capsular ligaments (Kaltenborn, 1999; Magee, 1997). Motion can also be limited by tightness in the adductor muscles. Normal range of motion is 0–45 degrees (Figure 11.33) (American Academy of Orthopedic Surgeons, 1965).
Adduction
Place the patient supine with the hip in the anatomical position. Abduct the contralateral hip to allow enough room for movement. Place your hand on the lateral distal aspect of the leg and move the lower extremity medially. Increased motion can be created by laterally tilting the pelvis. Stabilization of the pelvis is important
Figure 11.32 Passive movement testing of extension.
Figure 11.33 Passive movement testing of abduction.
The Hip Chapter 11
Figure 11.34 Passive movement testing of adduction.
to obtain accurate measurements. Normal end feel is firm (ligamentous) due to tension from the lateral capsule and superior band of the iliofemoral ligament. Motion can also be limited by tightness in the abductor muscles. Normal range of motion is 0–30 degrees (Kaltenborn, 1999; Magee, 1997) (Figure 11.34) (American Academy of Orthopedic Surgeons, 1965).
Medial (Internal) Rotation
Medial rotation can be assessed with the hip in either flexion or extension. To assess movement with the hip in extension, place the patient prone with the hip in the anatomical position and the knee flexed to 90 degrees. Place your hand on the medial distal aspect
Figure 11.35 Passive movement testing of medial (internal) rotation with the hip extended.
of the leg and rotate the leg outward. Increased motion can be created by rotating the pelvis. Stabilization of the pelvis is important for accurate measurement. Motion can also be limited by tightness in the external rotator muscles. The normal end feel is firm (ligamentous) due to tension from the posterior capsule and the ischiofemoral ligament (Kaltenborn, 1999; Magee, 1997) (Figure 11.35).
To assess medial rotation with the hip in flexion, have the patient sit with the hip and knee flexed to 90 degrees. Place your hand on the medial distal aspect of the leg and rotate the leg outward. Increased motion can be created by rotating the pelvis and laterally flexing the spine. Stabilization of the pelvis is important for accurate measurement. The normal end feel is firm (ligamentous) due to tension from the posterior capsule and the ischiofemoral ligament (Kaltenborn, 1999; Magee, 1997). Motion can also be limited by tightness in the external rotator muscles. Normal range of motion is 0–45 degrees (Figure 11.36) (American Academy of Orthopedic Surgeons, 1965).
Lateral (External) Rotation
Lateral rotation is performed in flexion and extension using the same positions as for medial rotation. Place your hand on the lateral distal aspect of the leg and rotate the leg inward. Increased motion can be created by further abducting the hip and laterally flexing the spine. Stabilization of the pelvis is important for accurate measurement. The normal end feel is firm (ligamentous) due to tension in the anterior capsule
Chapter 11 The Hip
Figure 11.36 Passive movement testing of medial (internal) rotation with the hip flexed.
and iliofemoral and pubofemoral ligaments. Motion can also be limited by tightness in the medial rotator muscles. Normal range of motion is 0–45 degrees (Kaltenborn, 1999; Magee, 1997) (Figure 11.37) (American Academy of Orthopedic Surgeons, 1965).
Figure 11.37 Passive movement testing of lateral (external) rotation with the hip extended.
The Hip Chapter 11
stabilizing strap
Figure 11.38 Mobility testing of hip traction (longitudinal distraction).
Mobility Testing of Accessory
Movements
Mobility testing of accessory movements will give you information about the degree of laxity present in the joint. The patient must be totally relaxed and comfortable to allow you to move the joint and obtain the most accurate information. The joint should be placed in the maximal loose packed (resting) position to allow for the greatest degree of joint movement. The resting position of the hip is 30 degrees of flexion, 30 degrees of abduction, and slight lateral rotation (Kaltenborn, 1999).
Traction (Longitudinal Distraction)
Place the patient in the supine position with the hip in the resting position and the knee in flexion. Stand on the side of the table so that your body is turned toward the patient. The pelvis should be stabilized so that all the movement takes place at the hip joint. Place your hands on the medial and lateral inferior aspects of the thigh. Pull along the axis of the femur in a longitudinal direction until the slack is taken up. This technique provides an inferior separation of the femoral head from the acetabulum (Figure 11.38). This technique can also be performed with the knee in extension. You would place your hands around the patient’s malleoli and pull in the same direction as previously described. Recognize that additional stress is placed on the knee joint. This technique should not
be used with patients who have increased laxity in the knee (Figure 11.39).
Lateral Distraction or Glide
Place the patient in the supine position with the hip in the resting position and the knee in flexion. Stand on the side of the table so that your body is turned toward the side of the patient. The pelvis should be stabilized so that all the movement takes place at the hip joint. Place your hands on the proximal medial aspect of the thigh as close to the inguinal crease as possible. Pull laterally at a 90 degree angle from the femur until the slack is taken up. This movement will separate the femoral head from the acetabulum (Figure 11.40).
Ventral Glide of the Femoral Head
Place the patient in the prone position so that the pelvis is resting on the table and the remainder of the lower extremity is unsupported. Stand at the end of the table so that your body is turned toward the medial side of the patient’s thigh. The pelvis is stabilized by the treatment table. Place your hands so you support the lower extremity by holding the distal part of the leg and allowing the knee to flex. Your other hand should be at the proximal posterior aspect of the thigh as close to the gluteal crease as possible. Push anteriorly with your proximal hand until the slack is taken up. This movement will create an anterior glide of the femoral head (Figure 11.41).
Chapter 11 The Hip
stabilizing strap
Figure 11.39 Mobility testing of hip distraction through the knee.
Figure 11.40 Mobility testing of lateral distraction (glide).
Resistive Testing
There are six motions of the hip to be examined: flexion, extension, abduction, adduction, external (lateral) rotation, and internal (medial) rotation. Although a single action is usually ascribed to each muscle in the hip region, it should be remembered that most of the muscles perform more than one action simultaneously. The position of the leg at the time of muscle contraction is an important determinant of the muscle’s function. For
example, the adductor longus muscle is a hip flexor up to 50 degrees of hip flexion. Beyond 50 degrees of hip flexion, the adductor longus functions as an extensor. This is an example of inversion of muscular action.
Flexion
The most powerful flexors of the hips are the psoas and the iliacus, which share a common tendon (Figure 11.42). The iliopsoas is assisted by the rectus femoris, sartorius, and tensor fascia lata, which cross both the hip and the knee joints.
Figure 11.41 Mobility testing of ventral glide of the femoral head.
Psoas major
Iliacus
Figure 11.42 The flexors of the hip.
Figure 11.43 Testing hip flexion.
