Chapter 11 The Hip
Figure 11.44 Testing hip flexion with gravity eliminated.
•Position of patient: Sitting upright with knees bent over the edge of the table, with hands holding onto the edge of the table for support and to prevent substitution.
•Resisted test: Ask the patient to raise the thigh off the table while you resist this movement by applying pressure downward on the thigh just above the knee (Figure 11.43).
Testing hip flexion with gravity eliminated is
performed with the patient in a side-lying position (Figure 11.44). The upper part of the leg is elevated slightly, and the patient is asked to flex the hip.
Inguinal pain during resisted hip flexion may be due to iliopsoas bursitis or abdominal pathology.
Weakness of hip flexion results in difficulty getting out of a chair, walking up an incline, and climbing stairs.
Extension
The extensors of the hip are the glutei and hamstrings (Figure 11.45). The gluteal muscles attach to the femur and iliotibial band (gluteus maximus only), and the hamstrings attach to the proximal part of
Gluteus maximus
|
Long head of |
|
Biceps femoris |
|
Semi - |
Semi - |
membranosus |
tendinosus |
|
Figure 11.45 The extensors of the hip.
A
B
Figure 11.46 (A) Testing hip extension. (B) Isolating the gluteus maximus by testing hip extension with the knee flexed.
Chapter 11 The Hip
Figure 11.47 Testing hip extension with gravity eliminated.
the tibia. The gluteus maximus is the strongest of all the hip extensors. The strength of the hamstrings in hip extension is dependent on the position of the knee. With the knee flexed, the hamstrings are at a disadvantage and are relatively weaker. As the knee is extended, the hamstrings are stretched more and become stronger extensors of the hip.
•Position of patient: Lying prone on the table with the knee extended. The test can also be performed with the knee flexed to isolate the gluteus maximus (Figure 11.46).
•Resisted test: Stabilize the pelvis with one hand with downward pressure, and apply downward resistance above the knee posteriorly on the thigh. Ask the patient to elevate the leg and thigh off the table.
Testing hip extension with gravity eliminated is
performed by having the patient lie on the opposite side with the hip flexed and the knee extended (Figure 11.47). Elevate the upper part of the leg (test leg), which is flexed at the hip, and support the weight of the leg as the patient attempts to extend the hip toward you. The gluteus maximus is isolated by performing this test with the patient’s knee flexed (Figure 11.46B).
Painful resisted hip extension can be due to spasm of the gluteus maximus or hamstring muscles. Pain
can also be caused by ischial bursitis at the ischial tuberosity. Pain may be referred to the hip extensors from spondylolisthesis or a herniated lumbosacral disc.
Weakness of the hip extensors results in difficulty with ambulation and return to erect posture. Stair climbing and walking up an incline are also restricted.
Abduction
The main abductor muscle is the gluteus medius. It is assisted by the gluteus maximus and piriformis (Figure 11.48). The efficiency of the gluteus medius muscle is increased because of the presence of the femoral neck. The more lateral attachment of the muscle increases its resultant torque (Figure 11.49). The primary function of the hip abductors, rather than moving the thigh away from the midline, is to prevent the pelvis from adducting on the thigh (dropping) during unilateral stance.
•Position of patient: Lying on the side with the lower leg slightly flexed at the hip and the knee. The upper leg is in neutral position at the hip and extended at the knee (Figure 11.50).
•Resisted test: Stabilize the pelvis with one hand to prevent the patient from rolling forward or backward. As the patient attempts to elevate the
The Hip Chapter 11
Short lever |
Longer lever |
arm of adductors |
arm due to presence |
without femoral neck |
of femoral neck |
Gluteus medius
Femoral neck
Tensor fasciae latae
Figure 11.49 The presence of the femoral neck increases the efficiency of the hip abductors.
Figure 11.48 The abductors of the hip.
leg from the table, put downward pressure on the inferior distal aspect of the leg.
Testing abduction with gravity eliminated is performed by having the patient lie supine with the knees
extended (Figure 11.51). The patient tries to move the leg into abduction so as to separate the legs. Be careful not to allow the patient to externally rotate the hip (substitution).
Lateral hip pain during resisted abduction can be due to trochanteric bursitis. This can result from an excessively tight gluteus medius or minimus.
Figure 11.50 Testing hip abduction.
Chapter 11 The Hip
Figure 11.51 Testing hip abduction with gravity eliminated.
Weakness of hip abduction results in an abnormal gait pattern, known as a Trendelenburg gait.
Adduction
The strongest hip adductor is the adductor magnus (Figure 11.52). Along with the adductor longus, adductor brevis, and gracilis, the adductor muscles also function to stabilize the pelvis. The hamstrings, gluteus maximus, pectineus, and some of the short rotators also assist in adduction. The hip adductors prevent the lower extremity from sliding into abduction during ambulation (Figure 11.53).
•Position of patient: Lying on the side, with the spine, hip, and knee in neutral position (Figure 11.54).
•Resisted test: Lift the upper leg and support it with one hand while pressing down on the lower limb just above the knee with the
other hand. Ask the patient to raise the lower extremity off the examining table against your resistance.
Testing hip adduction with gravity eliminated is per-
formed with the patient lying supine (Figure 11.55). The hip is passively or actively abducted, and the
patient attempts to bring the limb back toward the midline.
Painful resisted adduction can be due to tendinitis or a tear in the adductor longus, which is the most commonly “pulled groin muscle.” Pain in the region of the pubic ramus can be due to osteitis pubis. Pain below the knee can be due to a pes anserinus bursitis irritated by the contracting gracilis muscle at its distal attachment.
External (Lateral) Rotation
The external rotators of the hip include the piriformis, obturator internus, obturator externus, and the two gemelli. The quadratus femoris and pectineus also assist in external rotation (Figure 11.56).
•Position of patient: Sitting with both knees flexed over the edge of the table (Figure 11.57).
•Resisted test: Hold the patient’s leg at the medial aspect above the ankle. The patient then attempts to rotate the leg upward so as to reach the opposite knee.
Testing external rotation with gravity eliminated is
performed with the patient lying supine with the knee and hip in neutral position (Figure 11.58). The patient
The Hip Chapter 11
|
Gracilis |
|
Adductor brevis |
Pectineus |
Adductor longus |
|
Adductor magnus
Figure 11.52 The adductors of the hip.
Hip adductors
Figure 11.53 During the stance phase of gait, there is a tendency for the weight-bearing limb to slide into abduction. Powerful hip adductors prevent this from occurring, especially during running.
Figure 11.54 Testing hip adduction.
Figure 11.55 Testing hip adduction with gravity eliminated.
The Hip Chapter 11
|
Piriformis |
Obturator externus |
Gemellus superior |
|
|
Quadratus femoris |
Obturator internus
Gemellus inferior
Figure 11.56 The lateral (external) rotators of the hip.
attempts to rotate the lower extremity away from the midline so that the lateral malleolus is in contact with the table.
Painful resisted external rotation can be caused by dysfunction in the piriformis muscle. This can be confirmed by performing the piriformis test.
Piriformis Test
This test is used to isolate the piriformis muscle in external rotation of the hip (Figure 11.59).
• Position of patient: Lying supine with the affected hip and knee flexed.
• Resisted test: Push the patient’s thigh and knee into adduction and then ask the patient to push them back toward your chest.
A complaint of pain on attempted external rotation in this position against resistance is considered a positive finding on the piriformis test. This maneuver may elicit tingling or pain in the distribution of the sciatic nerve due to its proximity to the piriformis muscle.
Internal (Medial) Rotation
Figure 11.57 Testing hip lateral (external) rotation.
The internal rotators of the hip are less than half as strong as the external rotators. The gluteus medius,
Chapter 11 The Hip
Figure 11.58 Testing hip lateral (external) rotation with gravity eliminated.
Figure 11.59 The piriformis test isolates this muscle as a cause of buttock pain. Reproduction of symptoms of sciatica, such as tingling or radiating pain down the posterolateral aspect of the thigh and leg, confirms the diagnosis of piriformis syndrome.
gluteus minimus, and tensor fasciae latae are the primary internal rotators of the hip (Figure 11.60). Accessory muscles include the semitendinosus and semimembranosus.
Gluteus minimus
Tensor fasciae latae
Figure 11.60 The medial (internal) rotators of the hip.
•Position of patient: Sitting at the edge of the table with the knees bent over the table (Figure 11.61).
•Resisted test: Place your hand on the distal lateral aspect of the leg proximal to the ankle. The patient attempts to rotate the leg laterally away from the opposite leg.
Testing internal rotation with gravity eliminated
is performed with the patient lying supine with the
The Hip Chapter 11
Painful resisted internal rotation can be seen in arthritic conditions of the hip.
Figure 11.61 Testing hip medial (internal) rotation.
hip and knee in neutral position (Figure 11.62). The patient then attempts to roll the lower extremity inward so as to bring the medial aspect of the foot in contact with the table.
Neurological Examination
Motor
The innervation and spinal levels of the muscles that function across the hip joint are listed in Table 11.1 (p. 325).
Reflexes
There are no reflexes that can be elicited at the hip.
Sensation
Light touch and pinprick sensation should be examined following the motor examination. The dermatomes for the anterolateral aspect of the hip are L1 and L2. Refer to Figure 11.63 for the exact locations of the key sensory areas in these dermatomes. We have intentionally included dermatome drawings from different sources in this text to emphasize that patients as well as anatomists vary significantly with respect to sensory nerve root innervation of the extremities. The peripheral nerves
Figure 11.62 Testing hip medial (internal) rotation with gravity eliminated.
