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    Cadera Neuman

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    Cadera Neuman

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    Cadera Neuman

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    Section IV Lower Extremity Cuarren 12 Hip, 465 Cuarrer 15 Knee, s20 Cuarren 14 Ankle and Foot, 573 Cuarren ts Kinesiology of Walking, 627 Avrenpix IV Reference Materials for Muscle Attachments and Innervation of the Lower Extremity, 682 SecTION IV is divided into four chapters. Chapters 12 to 14 describe the kinesiology of the major articular regions within the lower extremity; Chapter 15 describes the kinesiology of walking, an ultimate functional expression of the kinesiology of the lower extremity. For cach limb, about 60% of the walking cycle is involved in the “stance phase,” in which the distal end of the extremity is fixed to the ground. During the “swing phase”—the remaining. 4046 of the walking cycle—the distal end of the extremity is unconstrained and free to move. Chapters 12 to 14 describe the function of the muscles and joints from two perspectives: when the distal end of the extremity is fixed, and when itis fee. An understanding of both types of actions greatly increases the ability to appreciate the beauty and complexity of human ‘movement, as well as to diagnose, treat, and prevent related impairments of the musculosk- eletal system. | | Additional Clinical Connections Additional Clinical Connections are included at the end of each chapter. This feature is intended to highlight or expand on a particular clinical concept associated with the kinesiology covered in the chapter. Study Questions Study Questions are also included at the end of each chapter. These questions are designed to challenge the reader to review or reinforce some of the main concepts contained within the chapter. The answers to the questions are included on the Evolve website.) DONALD A. NEUMANN, PT, PhD, FAPTA Pyvae swt POT ‘osTEoLoGy, 465 DOstookinematies, 476 Innominate, 465 Femora-on-Pelvc Osteokinematcs, 473 Hum, 467, Pelvic-on-Femoal Osteckiematic, 473 Pubis, 468 ‘Atrokinematics, 481 Ischium, 468 ‘Acetabulum, 468, (MUSCLE AND JOINT INTERACTION, 481 Femur, 468. Innervation of the Muscles and Joint, 481, ‘Shape of the Proximal Femur, 470 Internal Structure of the Proximal Innervation of Muscles, Sensory Innervation othe Hi, 482 ‘EXAMPLES OF HIP DISEASE: RATIONALE FOR SELECTED THERAPEUTIC AND ‘SURGICAL INTERVENTIONS, 500, Fracture of the Kip, 500 Osteoarthritis ofthe Hi, 601 ‘Therapeute Intervention fora Painful ‘or Mechanically Unstable Hip, 501 Using Cane and Proper Methods for Carving External Loads, 501 481 Femur, 472 Muscular Function atthe Hip, 484 ‘Surgical Intervention after Fracture Hip Flexor Musces, 484 or Osteoarthritis, 504 ARTHROLOGY, 472 Hip Adductor Muscis, 487 Biomechanical Consequences of Coxa Vara Functional Anatomy ofthe Hip Joint, 472 Hip Internal Rotator Muscles, 490, and Cova Valga, 504 Femoral Head, 472 Hip Extensor Muscles, 491 Aectabulum, 473, Hip Abductor Muscles, 494 SYNOPSIS, 505 ‘Acetabular Labrum, 473 Hip Etoral Rotator Muses, 408 [ADDITIONAL CLINICAL CONNECTIONS, 507 ‘Acetabular Aignment. 473 Maximal Torque Produced by the Hip ‘REFERENCES, 515 Muscles, 499 ‘STUDY QUESTIONS, 519 Capsule and Ligamens of the Hip, 474 he hip is the articulation between the large spherical head of the femur and the deep socket provided by the icetabulum of the pelvis (Figure 12-1). Because of the joints’ central location within the body, the logical question, arises: do the hips serve as “base” joints for the lower extremi- ties, or basilar joints for the entite superimposed pelvis and trunk? As this chapter unfolds, it will become clear that the hips serve both roles. For this reason the hips play a dominant Kinesiologic role in movements across 2 large part of the body. Pathology or trauma affecting the hips typically causes a wide range of functional imitations, including difficulty in walking, dressing, driving a car, lifting and carrying loads, and climbing stairs The hip joint has many anatomic features that are well suited for stability during standing, walking, and running, The femoral head is stabilized by a deep socket that is surrounded and sealed by an extensive set of connective tissues. Many large and forceful muscles generate the necessary torques needed to accelerate the body upward and forward, or decel- crate the body in a controlled fashion. Weakness in these muscles can have a profound impact on the mobility and stability of the body as a whole. Hip disease and injury are relatively common, particularly in the very young and in the elderly. An abnormally formed hip in an infant may be prone to dislocation, The hip in the aged adults vulnerable to degenerative joint disease. Increased osteoporosis coupled with increased risk of falling also pre- disposes the elderly to a higher incidence of hip fracture. ‘his chapter describes the structure of the hip, its ass ated capsule and ligaments, and the actions of the surroun: ing musculature, This information is the basis for treatment and diagnosis of musculoskeletal problems in this important region of the body. OSTEOLOGY Innominate Each innominate (from the Latin nmominatum, meaning name- less) is the union of three bones: the illum, pubis, and ischinm (see Figures 12-1 and 12-2). The right and left innominates connect with each other anteriorly at the pubic symphysis and posteriorly at the sacrum. These connections form a 465 466, Section IV Lower Extremity uscratue timber Anietorsuperar ise sine Amterorinteron ise sine FIGURE 12-1. ‘The antesior pect ofthe pelvis, scrum, and sight proximal fem Proximal atachments ae indicated au in red, distal attachments in gray. A section of the left side Ocular Othe sacram is removed to expose the auricular surface of the sacroiliac joint. The pelvic attachments of the capsule rmedils around the sarong joi ae indicated by dashed lines (Glueae maximus Postere:-supetir Artrsierer “ise sine Posterior gata ne Postar: Tce sine rragnus Yemore FIGURE 12-2. A lateral view of the right innominate bone. Proximal attachments of muscle are indicated in red, distal attachments in gray. Chapter 12 Hip 467 complete osteoligamentous ring, referred to a the pelos from the Latin, meaning basin or bow). The pelvis i associated with three important and very difierent functions. First, the pelvis serves as a common attachment point for many large muscles of the lower extremity and the trunk, The pelvis also transmits the weight of the upper body and trunk either to the ischial tuberosities during sitting or to the lower extremi- ties during standing and walking. Last, with the aid of the muscles and connective tissues of the pelvic floor, the pelvis supports the organs involved with bowel, bladder, and repro- ductive functions ‘The external surface of the pelvis has three striking fea- tures. The large fan-shaped wing (or ala) of the ilium forms the superior half of the innominate. Just below the wing is the deep, cup-shaped acetabulum. Just inferior and slightly medial to the acetabulum is the obturator foramen—the largest foramen in the body. This foramen is covered by an obturator, membrane (see Figure 12-1), ‘While a person stands, the pelvis is normally oriented so that when viewed laterally a vertical line passes between the anterior-superior iliac spine and the pubic tubercle (see Figure 122), IuuM ‘The external surface of the ilium is marked by rather faint posterior, anterior, and inferior gluteal lines (see Figure 12-2). ‘These lines help to identify attachment sites of the gluteal muscles. At the most anterior extent of the ilium is the easily palpable anterir-superior iliac spine (see Figures 12-1 and 12-2). Below this spine is the anterio-inferior iliac spine. The promi- nent iliac crest, the most superior rim of the ium, continues Pasatorftr Poster suparer Postetor vin ‘Osteologic Features of the Hium ternal Surface * Posterior, anterior, and inferior gluteal lines + Anteriorsuperior iliac spine Anteriorinterioriliae spine Iliac exes Posteior-superior lac spine Posteriorinteriorilae spine Greater sciatic notch Greater static foramen Saetotuberous and sacrospinous ligaments Internal Surf * Tia fossa + Auicula surface + Tae tuberosity posteriorly and ends at the posterior superior iliac spine (Figure 12.3). The sof tissue superficial to the posterior superior iliac spine is often marked by a dimple in the skin, The less promi- nent postrir-inferor ita spine marks the superior rim of the greater sciatic notch, The opening of this notch is converted to the greater sciatic foramen by the sacrotuberous and sacrospinous samen. ‘The internal aspect of the ilium has three notable features (see Figure 12-1), Anteriorly, the smooth concave ilia fossa is filled by the iliacus muscle. Posterionly, the auricular suyface articulates with the sacrum at the sacroiliac joint. Just poste- rior to the auricular surface is the large, rough diac tuberosity, which marks the attachments of sacroiliac ligaments Siew acne FIGURE 12-3, The posterior aspect of the pelvis, scrum, and right proximal femur Proximal atachments of ‘muscles are indicated in ted, distal atachments in gray. 468 Section IV Lower Extremity + Pubic tubercle + Pubic symphysis and dise * Inferior pubie ramus Superior pubic rams * Boy + Crest + Pete line joint PUBIS ‘The superior pubic ramus extends anteriorly from the anterior vwall ofthe acetabulum to the large flattened body of the pubis (see Figure 12-1), The upper border of the body of the pubis is the pubic crest, serving as an attachment for the rectus abdominus muscle. On the upper surface of the superior ramus is the pectineal line, masking the attachment of the pectineus muscle, The pubic iuberde projects anteriorly from the superior pubic ramus, serving as an attachment for the inguinal ligament. The inferior pubic ramus extends from the body of the pubis posteriorly to the junction of the ischium. ‘The two pubic bones articulate in the midline by way of the pubic symphysis joint (see Figure 12-1). This relatively immmo- bile joint is typically classified as a synarthrosis. Hyaline carti- lage lines the opposing surfaces ofthe articulation; the surfaces are not completely flat but possess small raised ridges, likely designed to resist shear."” The joint is firmly bound by a fibrocartilaginous interpubic disc and ligaments. The interpubie disc is strengthened by an interlacing of collagen fibers, com- bined with distal attachments made by the rectus abdominis muscles."° Up to 2 mm of translation and very slight rotation ‘oveur at the pubic symphysis joint."* The pubic symphysis provides stress relief throughout the anterior ring of the pelvis during walking and, in women, during childbinth Symphysis pubis dysfunction can occur in some women during pregnancy or just after birth. This painful condition is associated with increased instability in the symphysis pubis caused by the physiologic relaxation of the joint’ supposting ligaments.” IscHIUM ‘The sharp ischial spine projects from the posterior side of the ischium, just inferior to the greater sciatic notch (see Figure 12-3). The lesser sciatic noth is located just inferior to the spine. The sacrotuberous and sacrospinows ligaments convert the lesser sciatic notch into a lesser sciatic foramen. Projecting posteriorly and inferiorly from the acetabulum is the large, stout sichial tuberosity (see Figure 12-3). This pale pable structure serves as the proximal attachment for many. muscles of the lower extremity, most notably the hamstrings and part of the adductor magnus. The ischial ramus extends anteriorly from the ischial tuberosity, ending at the junction with the inferior pubic ramus (see Figure 12-1) ‘ACETABULUM Located just above the obturator foramen is the large cup- shaped acetabulum (see Figure 12-2). The acetabulum forms the socket of the hip. All three bones of the pelvis contribute to the formation of the acetabulum: the ilium and ischium contribute about 75%, and the pubis contributes the remain- ‘agenet! FIGURE 12-4, The anterior aspect of the right femur, Proximal atachments of muscles ate indicated in red, distal attachments i ‘gay, The femoral attachments ofthe hip joint caprule and the knee joint capsule are indicated by dashed lines Osteologic Features of the Ischium + lechil spine + lichial tuberosity + Ischial ramus + Lesser sciatic notch * Lesser sciatic foramen ing approximately 254%. The specific features of the acetabu- Jum are discussed in the section on arthrology. Femur ‘The femur is the longest and strongest bone of the human body (Figure 124), Its shape and robust stature reflect the powerful action of muscles and contribute to the long stride length during walking. At its proximal end, the femoral head projects medially and slightly anteriorly for an articulation with the acetabulum, ‘The femoral neck connects the femoral head to the shaft, The neck serves to displace the proximal shaft of the femur laterally away from the joint, thereby reducing the likelihood of bony impingement against the pelvis. Distal to the neck, the shaft of the femur courses slightly medially, effectively placing the knees and feet closer to the midline of the body. Chapter 12 Hip 489 Phtomis roves -Ghe meatus ‘and gers Obtrator estrus in ‘roche tones Hiopsoas on Varta mesa ctor invemesiue i pastor Toros Aesutor magnus Pesto vow laeus meds Ko, ge Ierrchaie cost users ectnea (pir ne So oneeun teal woereety Autor revi Vast intomede Biceps tema (shor hese) Adductor magnus on real supracondar be Aaducor magnus on and aaduetor bere ‘prcondat ie and auctor oercle Medal peony at econ Gastonens ee fuses tease esrerantr ‘aan A 8 ch FIGURE 12-5, The medial (A) and posterior (B) surfaces of the right femur, Proximal atachments of muscles ate indicated in red, distal axtachments in gray. The femoral attachments of the hip joint capsule and the knee joint capsule ae indicated by dashed lines. ‘Osteologic Features of the Femur Femoral head + Lewer trochanter Femoral neck + Lines aspera Tatertzochanteic ine * ‘ectincal (itl) ine + luteal aberosiy + Lateral and medial supracondylar lines ‘Trochanteric fossa Intertrochanteric crest + Greater trochanter + Quadtate tubercle + Adductor tubercle The shaft of the femur displays a slight anterior convexity (Figure 12-5, 4), As a long, eccentrically loaded column, the femur bows very slightly when subjected to the weight of the body. Consequently, stress along the bone is dissipated through compression along its posterior shaft and through tension along its anterior shaft. Ultimately this bowing allows the femur to bear a greater load than if the femur were per fectly steaight ‘Anteriorly, the intetrochanteric line marks the distal attach- ment of the capsular ligaments (see Figure 12-4). The greater, trochanter extends laterally and posteriorly from the junction of the femoral neck and shaft (se Figure 125, 8). This promi- Ssuperr view Cauteus minimus Pitormie obturator extern ‘rosrantere fossa Wopsoas Quacratus Guteus modus ‘emer FIGURE 12-6. The superior aspect of the sight femur. Distal attach- ‘ments of muscles are shown in gray. nent and easily palpable structure serves as the distal attach- ment for many muscles. On the medial surface of the greater trochanter isa small pit called the trochanteric fossa (see Figures 12-5, A and 12-6). This fossa marks the distal attachment of the obturator extermus muscle 470 Section IV Lower Extremity Posteriorly, the femoral neck joins the femoral shaft at the raised sntertrocbanteric crest (see Figure 12-5, B). The quadrate tubercle, the distal attachment of the quadratas femoris muscle, isa slightly raised area on the crest just inferior to the tro- chanteric fossa, The lesser trochanter projects sharply from the inferior end of the crest in a posterior-medial direction. The lesser trochanter serves as the distal attachment for the ilior psoas muscle, an important hip flexor and vertical stabilizer of the lumbar spine ‘The middle third of the posterior side of the femoral shaft is clearly marked by a vertical sidge called the linea aspera (Latin words linea, line + aspera, rough). This raised line serves as an attachment site for the vasti muscles of the quadriceps ‘group, many of the adductor muscles, and the intermuscular fascia of the thigh, Proximally, the linea aspera splits into the ectineal (pial line medially and the gluteal tuberosity laterally (see Figure 12-5, B), At the distal end of the femur, the linea aspera divides into the lateral and. medial supracondslar lines, ‘The adductor tubercle is located at the extreme distal end of the medial supracondylar line SHAPE OF THE PROXIMAL FEMUR The ultimate shape and configuration of the developing proximal femur are determined by several factors, including ditferential growth of the bone’s ossification centers, the force ‘of muscle activation and weight bearing, and circulation," Abnormal growth and development resulting in a misshaped proximal femur is referred to generically as femoral dysplasia {fiom the Greek ds, ill or bad, + plasia, growth). Trauma or ‘other acquired factors can also affect the shape of the prox- rmal femur. The shape and configuration of the proximal femur have important implications on the congruity and stability of the joint, as well as the stress placed on the joint structures. This topic willbe revisited throughout this chapter. ‘Two specific angulations of the proximal femur help define its shape: the angle of inclination and the torsional angle Angle of inclination ‘The angle of inclination of the proximal fernur describes the angle within the frontal plane between the femoral neck and the medial side of the femoral shaft (Figure 12-7). At birth this angle measures about 140 to 150 degrees. Primarily because of the loading across the femoral neck during walking, this angle usualy reduces to its normal adulthood value of about 125 degrees." As depicted by the pair of red dots in Figure 12. this angle optimizes the alignment of the joint surfaces. FIGURE 12-7, The proximal femur is shown: A, normal angle of inclination; B, coxa vata; and C, coxa valga. The pair of red dots in each figure indicates the different aligaments of the hip joint surfaces. Optimal alignment is shown in A. A Normal A change in the normal angle of inclination is referred to as either coxa vara of coxa valpa. Coxa vara (Latin coxa, bip, + vara, to bend inward) describes an angle of inclination ‘markedly dss than 125 degrees; coxa valga (Latin culge, to bend outward) describes an angle of inclination markedly greater ‘han 125 degrees (see Figure 12-7, B and C). These abnormal angles can significantly alter the articulation between the femoral head and the acetabulum, thereby affecting hip bio- mechanics. Severe malalignment may lead to dislocation or stress-induced degeneration of the joint. Femoral Torsion Femoral torsion describes the relative rotation (twist) between the bone’s shaft and neck. Normally, as viewed from above, the femoral neck projects about 15 degrees anterior to 2 mediatlateral axis through the femoral condyles.” This degree of torsion is called normal anteversion (Figure 12-8, A), In conjunction with the normal angle of inclination, an approximate IS-degree angle of anteversion affords optimal alignment and joint congruence (see alignment of red dots in Figure 12-8, 4) Femoral torsion that is markedly different from 15 degrees is considered abnormal. Torsion significantly greater than 15 degrees is called excessive anteversion (see Figure 12-8, B). In contrast, torsion significantly less than 15 degrees (ie., approaching 0 degrees) is called rtroverion (see Figure 12-8, C) ‘Typically a healthy infant is born with about 40 degrees of femoral anteversion.” With continued bone growth, increased weight bearing, and muscle activity, this angle usually decreases to about 15 degrees by 16 years of age. Excessive anteversion that persists into adulthood can increase the likelihood of hip dislocation, articular incongruence, increased joint contact force, and increased wear on the articular cartilage.” These factors may lead to secondary osteoarthritis ofthe hip." Excessive anteversion in children may be associated with an abnormal gait pattem called “intocing.” In-tocing is a walking pattern with exaggerated posturing of hip internal rotation. The amount of intocing is generally related to the amount of femoral anteversion. This gait pattem appar ‘ently is a compensatory mechanism sed to guide the exces sively anteverted femoral head more directly into the acetabulum (Figure 12-8). In addition, Amold and colleagues have shown that the exaggerated intemally rotated position during walking serves to increase the moment arm of the important hip abductor muscles—leverage that is substantially reduced with excessive femoral anteversion.” Regardless of the reason for the intemal rotated position, children may, ‘Angle of inclination hos hos: Aso B Coxavara © coxa valga Chapter 12 Hip a over time, develop shortening of the internal rotator muscles and various ligaments, thereby reducing extemal rotation range of motion. Fortunately, most children with in-tocing eventually walk normally.” The gait pattem typically improves with time because of a natural normalization of the anteversion or a combined structural compensation in other parts of the lower extremity, most commonly the tibia” There is no evidence that nonoperative treatment can reduce excessive femoral anteversion, Excessive femoral anteversion of 25 to 45. degrees is common in persons with cerebral palsy, and even anteversion as high as 60 to 80 degrees has been reported.” In-tocing typically persists in children with cerebral palsy who are ambulatory and usually does not resolve.” Natural Anteversion of the Femur: a Reflection of the Prenatal Development of the Lower Limb turing prenatal development, the upper and lower extremi ties both undergo significant axial rotaton. By about 54 days after conception, the lower limbs have rotated internally {imedially) about 90 degrees." Ths rotation turns the kneecap ‘egion to its final anterior postion. In essence, the lower limbs hhave become permanently ‘pronated.” This helps to explain why the “extensor’ muscles—such as the quadriceps and tiialis anterior—face anteriorly, and the “flexor” muscles—such as the hamstrings and gastrocnemius—face posterior aftr birth. The torsion angle between the shaft and the neck ofthe femur at birth partially reflects the degree of this medial rotation. The functional consequence of the medial rotation of the lower imbs is that the plantar surfaces of the feet assume a plantigrade position suitable for walking. The fixed pronated position is evidenced by the medial position of the great toe of the lower limb, similar to the thumb in the fully pronated forearm. Additional anatomic features that may reflect this developmental medial rotation include the spiraled path of the lower extremity dermatomes (see Appencix W, Part C), the ‘wisted or spiraled ligaments of the hip (described aheac), and the oblique course ofthe sartorius muscle. c Retroversion FIGURE 12-8. The angle of torsion is shown between the neck and shaft of the femur: A, normal anteversion; B, excessive anteversion; and G, retroversion. The pair of red dots in each figure indicates the Sffercot alignments of the hip joint surfaces. Optimal alignment is shown in A. FIGURE 12-9, Two situations show the same individual with excessive anteversion of the proximal femur. A, Offset red dots indicate fhalalignment of the hip while a subject stands in the anatomic position. B, As evie enced by the alignment of the red dots, standing with the hip internally rotated ("in tosing”) improves the joint congruity. B Excessive anteversion wit “in-oeing” an Section IV Lower Extremity ee /'vone cei rabecular FIGURE 12-10. A frontal plane cross-section showi architecture of the proximal femur, Note the thicker areas of compact, bone around the shaft, and the eancellose bone occupying most of the medullary Gntemal) egion. Two trabecular networks within the cancellous bone are also indicated. (Fsom Neumann DA: An arthritis Thome study course. The synovial joint anatomy, function, and dysfunction, LaCrosse, Wise, 1998, Orthopedic Section ofthe American Physical ‘Therapy Association) INTERNAL STRUCTURE OF THE PROXIMAL FEMUR ‘Compact and Cancellous Bone ‘Walking produces tension, compression, bending, shear, and torsion on the proximal femur. Many of these forces are large, exceeding one's body weight. Throughout a lifetime, the proximal femur typically resists and absorbs these repetitive forces without incurring injury. This is accomplished by two strikingly different compositions of bone, Compact bone is very dense and unyielding, with an ability to withstand large loads. This type of bone is particularly thick in the cortex, or outer shell, ofthe lower femoral neck and entie shaft (Figure 12-10), These regions are subjected to large shear and torsion forces. Cancellous bone, in contast, is relatively porous, cone sisting of a spongy, three-dimensional trabecular lattice, as shown in Figure 12-10, The relative elasticity of cancellous bone is ideal for repeatedly absorbing external forces. Cancel lous bone tends to concentrate along lines of stress, forming trabecular networks. K medial trabecular and an arcuate trabecular network axe visible within the femur shown in Figure 12-10. The overall pattem of the trabecular network changes when the proximal femur is subjected to abnormal forces over an extended time ARTHROLOGY Functional Anatomy of the Hip Joint ‘The hip isthe classic bal-and-socket joint of the body, secured within the acetabulum by an extensive set of connective tissues and muscles. Thick layers of articular cartilage, muscle, lechiofemoral Wotemoral ligament Hotere Ligamentum Acetabular th : tabrum ral es (et ligament Les! ‘Lunate surface Acetabular fossa Ligamentum teres (eu) Lesser rochster Trantverse ‘acetabular ligament FIGURE 12-11, The sight hip joint is opened to expose ite internal components. The regions of thickest cartilage are highlighted (in blue) on the articular surfaces of the femoral head and acetabulum, and cancellous bone in the proximal femur help dampen the large forees that routinely cross the hip. Failure of any of these protective mechanisms because of disease, congenital or developmental malalignment or malformation, or trauma often leads to a deterioration of the joint structure, FEMORAL HEAD The femoral head is located just inferior to the middle one third of the inguinal ligament. On average, the centers of the two adult femoral heads are 17.5 em (6.9 inches) apart from each other.” The head of the femur forms about two thieds of a nearly perfect sphere (Figure 12-11). Located slightly posterior to the center of the head isa prominent pit, or fovea (see Figure 12-5, 4). The entire surface of the femoral head is covered by articular cartilage, except for the tegion of the fovea. The cartilage is thickest (about 3.5 mm) in a broad region above and slightly anterior to the fovea (sce high- lighted region in Figure 12-11)." ‘The ligamentum teres(also known asthe ligament to the head of the femus) is a tubular sheath of synovialined connective tissue that runs between the transverse acetabularligament and the fovea ofthe femoral head (see Figure 12-11). Although the ligament is stretched during flexion and adduction, it likely contributes only a small amount of stability to the articula- tion.” Interestingly, the ligament functions primarily as a protective conduit, or sheath, for the passage of the small acetabular artery (2 branch from the obturator attery) to the femoral head. The small and inconstant acetabular artery provides only a minor source of blood to the femur." The primary blood supply to the head and neck of the femur is through the medial and lateral circumflex arteries, which pierce the capsule of the joint adjacent to the femoral neck. Chapter 12 Hip 473 ACETABULUM The acetabulum (fiom Latin, meaning “vinegar cup") is a deep, hemispheric cuplike socket that accepts the femoral head, About 60 to 70 degrees of the rim of the acetabulum are incomplete near its inferior pole, creating the acetabular not (see Figure 12-2) The femoral head contacts the acetabulum only along its horseshoe-shaped lunatesuafae (see Figure 12-11). This surface is covered with articular cartilage, thickest along the superior anterior region of its dome."™* The region of thickest cartilage (about 3.5 mm) corresponds to approximately the same region of highest joint force during walking,’ During walking, hip forces fluctuate from 13% of body weight during mid- swing phase to over 300% of body weight during the mid- stance phase. During the stance phase—when forces are the agreatest-the lunate surface flattens slightly as the acetabular notch widens slightly, thereby increasing contact area as a means to reduce peak pressure (Figure 12-12).™” This natural dampening mechanism represents yet another design that strives to keep the stress on the subchondral bone within physiologic tolerable levels “The acetabular fossa is a depression located deep within the floor of the acetabulum. Because the fossa does not normally contact the femoral head, it is devoid of cartilage. Instead, the fossa contains the teres ligament, fat, synovial membrane, and blood vessels. ‘Anatomic Features of the Hip Joint Femoral Head + Foves + Ligamentum teres Accum Acetabular notch + Lunate surface + Acctabular fossa + Labrum + Transverse acetabular ligament ACETABULAR LABRUM ‘The acetabular labrum is a flexible ring of primary fibrocarti- lage that surrounds the outer circumference (rim) of the acetabulum (see Figure 12-11). Adjacent to the acetabular notch, the labrum widens as it is transformed into the trans- verse acetabular ligament © The acetabular labrum is neatly triangular in cross-section, with its apex projecting outward about 5 mm toward the femoral head." The base of the labrum attaches along the internal and extemal surfaces of the acetabulum rim. The part of the labrum that attaches to the intemal surface gradually fuses with the articular cartilage within the acetabulum. ‘The acetabular labrum provides significant stability to the hip by “gripping” the femoral head and by deepening the volume of the socket by approximately 30%."" The seal formed around the joint by the labrum helps maintain a negative intraarticular pressure, thereby creating a modest suction that resists distraction of the joint surfaces. The cit- cumferential seal also holds the synovial fluid within the joint; therefore the labrum indirectly enhances the lubrica- tion and load dissipation functions of the articular cartilage The labrum directly protects the articular cartilage by reduc- [il conisct area [[] Norcontact @ WO] @ “ul ‘Stanee re ee 7% 8 100 Ineal Foot ld Heat Toe of Heel Percent of gait eyele FIGURE 12-12, Graph shows a computer model's estimate ofthe hip joint compression force a a multiple of body weight duting the ga cydle, The stance phate is between 05» and 608 of the gait cycle, tnd the swing phase is betmeen 60% and 100% of the gait cycle (ertical stippied line separates these major divisions of the gait cycle) The images above the graph indicate the approximate area of acetabular contact at three selected magnitudes of hip joint force, estimated by data published in the literature." The area of joint Contact increase: from about 20% of the lunate surface during sing phate to about 983% during mid stance phase ing contact stress (force/atea) by increasing the surface area of the acetabulum.“ Consisting primarily of fibrocantlage, the labrum is poorly vascularized, receiving only modest blood supply to its outer cone third." For this reason, a tom labrum has a very limited ability to heal. In contrast to its poor vascular the labrum is well supplied by afferent nerves capable of providing proprioceptive feedback and, when the labrum is acutely injured, the sensation of pain.” ACETABULAR ALIGNMENT In the anatomic position the acetabulum typically projects Jaterally from the pelvis with a varying amount of inferior and anterior tilt. Congenital or developmental conditions may cause an abnormally shaped acetabulum. A malshaped, dypla- ticacdabulum that does not adequately cover the femoral head may lead to chronic dislocation and increased stress, often leading to degeneration or osteoarthritis. Two measurements are commonly used to describe the extent to which the acetabu- Jum naturally covers and helps secure the femoral head: the centeredge angle and the acetabular anteversion angle Center-Edge Angle ‘The center-edge ange is highly variable but on average measures about 35 degrees in radiographs trom adults (Figure 12-13, A). As described in the legend of Figure 12-13, a significantly lower central-edge angle reduces the acetabular coverage of 474 Section IV Lower Extremity ‘Conter-eage" angle ‘Acetabular anteversion angle ‘Superior view FIGURE 12-13. A"The centered angle eases the fixed orientation athe acetabulum within the font plane, fcativ tothe pelvis, This ncaturetent defines the extent fo which te acetabulum cover the lp ofthe femoral head. The center-edge angle is measured as the intersection of a vertical, fixed reference line (stippled) with the Aecainlar fered ling hat connects the upper Intra edge ofthe actabuem withthe center of the femoral head, A more vertical acetabular reference line results in. a smaller center-edge angle, providing less superior coverage of the femoral head By The alabularenrerson angle eases the fed oatation ofthe acctabulum within the horizontal plane, relative to the pels. Th meanivement indeates the extent to which the acetabulum covers te fon ofthe femoral head. The angle i formed bythe intersection of xed anton poseorrerencline pled wth a etter eee ld bid ie) hat cont he aero nd posterior fim ofthe accabulus A lager accabular antcretion angle teats fo acetabular containment ofthe asi ‘ideo the femoral head. (A normal femoral anteversion of 18 degrees alo shown) the femoral head. This reduced coverage increases the rk of TE RRC ET dislocation and, equally important, ceduces the contact area (SAVE Sanna a a Oa tin the joint A centahedge angle of only 15 degres, ERAS for example, reduces normal contact area by as mich 36 Busing the igletinnppon paso ang, fr stane, this reduced surface area would theoretically inceae joint yu gexion Qnee Hamtin pressure (force/ates) by about 50%. Over many years of iP fexion ines Hamstrings talking, thie scenario may ead to premature hip otcoarthit, yy vac aac. leior and povterior eapele ates Sienstartingwithdegencationoftheacetabulalabram "=" Mipfeon Gee Teor snd poeror ape ea ‘Acetabular Anteversion Angie ended ter ofthe publetord sad “The acetabular anteversion angle measures the extent to which FR pean ieiniseed the acetabulum projects antenorh within the horizontal plane, ps xenon (hace Recah tenes telative to the pelvis. Such a perspective can be measured Hpewenvion (knee Recs through computed tomography. Observed fiom above, the Abduction Pabofemoral ligament; adductor acetabular anteversion angle is normally about 20 degrees ule (Figure 12-13, B)!"* Even when normal, this orientation tio 7 + of ischiofemo ‘exposes part of the anterior side of the femoral head. The “#uston Sere bal Coord thick anterior capsular ligament of the hip and the iliopsoas abductor maces such a5 the tensor tendon naturally cover and support this vulnerable side of fascia latae and gluteus medius the joint. A hip demonstrating excessive acetabular anteversion taternal rotation _ichiofemora ligament; external is more exposed anteriorly: when anteversion is severe, the otator museles, such asthe hip is mote prone to anterior dislocation and associated pinformis or gluteus maximus lesions of the anterior labrum, especially at the extremes of Extemal rotation _Iiofémoral and pubofemoral extemal rotation, The likelihood of these associated patholo- ligaments internal rotator muscles, gies increases when acetabular anteversion is combined with such asthe tensor fasciae atae o ‘excessive femoral anteversion.” luteus minims ‘An acetabulum that projects directly laterally, or even slightly posteriorlaterlly, within the horizontal plane is described as being abnormally retroveried. games enforce the extemal suri of the eaprule (Fuses 12-14 and 12-15). Passive tension in stretched ligaments, the CAPSULE AND LIGAMENTS OF THE HIP adjacent capsule, and the surrounding muscles help define A gnovial membrane lines the internal surface of the hip joint the end-range of movements of the hip (Table 12-1)" Increas ‘apsule. The iliofemoral, pubofemoral, and ischiofemoral ing the flexibility in various parts of the capsule is an impor Chapter 12 Hip 475 Anterior viow Hiotemoral ligament Exposed head ol femur Pubotemors ligament obturator oxtmus Isehiofemoral ligament FIGURE 12-14, ‘The anterior capsule and ligaments of the right hip. The iliopsoas is cut to expose the anterior side of the joint. Note that part ofthe femoral head protradee just medial tothe ihofemoral ligament, This region may be covered by a bursa, tant component of manual physical therapy for restricted motion of the hip." ‘The iliofemoral ligament (or Y-ligament) is a thick and strong sheet of connective tissue, resembling an inverted Y. Pros mally, the iliofemoral ligament attaches near the anterior inferior iliac spine and along the adjacent margin of the acetabulum, Fibers form distinct medial and lateral fascicul, cach attaching to either end of the intertrochanteric line of the femur (see Figure 12-14). Full hip extension stretches the iliofemoral ligament and anterior capsule, Full external rota: tion also elongates fibers of the iliofemoral ligament, espe- cially those within the lateral fasciculus." The iliofemoral ligament is the strongest and stiflestliga- ment of the hip." The mean maximal force required to disrupt cither fasciculus is approximately 330 N (75 Ib). When a person stands with the hip fully extended, the ante- rior surface of the femoral head presses firmly against the iliofemoral ligament and superimposed iliopsoas muscle." From 2 position of standing, passive tension in these struc- tures forms an important stabilizing force that resists further hip elenion. Persons with paraplegia often rely on the passive tension in an elongated and taut iliofemoral ligament to assist with standing (Figure 12-16). Although thinner and more circular than the fibers of the iliofemoral ligament, the pubofemoral and ischiofemoral liga- ments blend with and strengthen adjacent aspects of the capsule, The pubofemoral ligament attaches along the anterior and inferior fim of the acetabulum and adjacent parts of the superior pubic ramus and obturator membrane (see Figure 12-14), The fibers blend with the medial fasciculus of the Posterior view Ischiofomoral ligament Protrsion of ‘synovial membrane FIGURE 12-15. The posterior capsule and ligaments ofthe right hip. Medial-ateral axis of rotation atthe hip Body weight FIGURE 12-16. A person with paraplegia is shown standing with the aid of braces at the knees and anes. Leaning the pelvis and trunk posteriorly ovients the body weight vector (red arrow) posterior to the hip joints (mall geen cic thereby stetching the sofemoral gx ments. This stctch provides a passive flexion torque at the hip, which helps to balance the extension torque generated by gravity ‘Once counterbalanced, these opposing torques can stabilize the pelvis and trunk, relative to the femur, dunng standing. (Modified fiom Somers ME: Spinal cord inguy:anctonal ebaitation, Nonwalk, 1992, Appleton a Lange) 416 Section IV Lower Extremity Posterior tata te wos Anterior otarir view ‘Superior view | tautpubctemoraligament A from extension and abduction “Tautitotemeraligament trom extension FIGURE 12-17, A, The hip ic shown in a nevtral position, with all three capsular Kigaments identified B, Superior view ofthe hip in its close-packed positon (ie, fully extended with sight abduction and internal rotation). This position elongates at least some component of al three capsular ligaments iliofemoral ligament, becoming taut in hip abduction and extension and, to a lesser degree, external rotation. ‘The ivbiofemoral ligament attaches trom the posterior and inferior aspects of the acetabulum, primarily from the adjacent ischium (see Figure 12-15). Fibers from this ligament join circular fbers located deeper within the posterior and inferior capsule. Other more superficial fibers spiral super orly and laterally across the posterior neck of the femur to attach near the apex of the greater trochanter (see Figure 12-14). These superficial fibers become taut in full internal rotation and extension”; other more superior fibers become taut in full adduction, Close-Packed Position of the Hip Full extension of the hip (Le., about 20 degrees beyond the ‘neutral position) in conjunction with slight internal rotation and slight abduction twists or “spirals” most of the fibers within the capsular ligaments to their most taut position (Eigure 12-17). This position is useful therapeutically during. attempts to stretch the entirety ofthe hip’s capsular ligaments Because the position of full extension, slight internal rotation and abduction elongates most of the capsule, itis considered the close packed postion atthe hip. The passive tension gener- ated especially by full extension lends stability to the joint and reduces passive accessory movement or “joint play.” The hip is one of a very few joints in the body in which the close- packed position is nor also associated with the position of ‘maximal joint congruency. The hip joint susfaces fit most congruently in about 90 degrees of flexion with moderate abduction and external rotation. In this position, most of the ‘capsule and associated ligaments have “unraveled” to a more slackened state, adding only litle passive tension to the joint. Osteokinematics ‘This section describes the range of motion allowed by the adult hip, including the factors that permit and restrict this motion. Reduced hip motion may be an early indicator of disease or trauma, either a the hip or elsewhere in the body." Limited hip motion can impose significant functional limit tions in activities such as walking, standing upright comfort- ably, or picking up objects off the floor. “Two terms are used to describe the kinematics at the hip. Femorat-on-peloic hip osteokinematics describes the rotation of the femur about a relatively fixed pelvis. Pelvicon femoral bip osteokinematics, in contrast, describes the rotation of the pelvis, and often the superimposed trank, over relatively. fixed femurs. Regardless of whether the femur or the pelvis is the ‘moving segment, the osteokinematics are described from the anatomic position. The names of the movements are as follows: flexion and extension in the sagittal plane, abduction and adduction in the frontal plane, and internal and external rotation in the horizontal plane (Figure 12-19). Reporting the range of motion at the hip uses the anatomic position as the O-degree or neutral reference point. Within the sagittal plane, for example, femoral-on-pelvic (hip) flexion occurs a5 the femur rotates anteriorly beyond the O-degree reference position. Extension, the reverse movement, occurs as the femur rotates posterionly toward and beyond the Oategree reference position. The term hyperextension is no! used to describe normal range of motion at the hip. ‘As depicted in Figure 12-19, each plane of motion is assoc- ated with a unique aris of rotation. The axis of rotation for internal and extemal rotation is often referred to as a “longi tudinal” or vertical axis. (The vertical description assumes the subject is standing with the hip in the anatomic position.) ‘This longitudinal axis of rotation extends as a straight line between the center of the femoral head and the center of the knee joint, Because of the angle of inclination of the proximal femur and the anterior bowing of the femoral shaft, most of the longitudinal axis of rotation lies outside the femur itself (ee Figure 12-19, 4 and B), The extramedullary axis has implications on some of the actions of hip muscles, a point discussed later in this chapter. Chapter 12 Hip an re Intracapsular Pressure within the Hip + described earlier, the intracapsular pressure within the healthy hip is normally less than atmospheric pressure. This telatively low pressure creates a partial suction tat provides some stabilty tothe hip. Wingstrand and colleagues studied the effect of jointpostion and capsular sweling on the intracapsular pressure within cadaveric, hips.” Except inthe extremes of motion, pressures remained rla- tively low throughout mostf flexion and extension. When uid was injected into the joint simulate capsular sweling, pressures rose ‘dramatically throughout a greater portion of the range of motion (Figure 12-18). Regardless ofthe amount of injected fluid, however, Dressures always remained lowest in the middle of the range of ‘motion, These data help to explain why persons with capsults and sweling within the hip tend to feel most comfortable holding the hip in partial flexion, Reduced intracapsular pressure decreases. distension ofthe inflamed capsule. Unfortunately, overtime, the flexed postion may lead to contracture caused by the adaptive shortening of the hip flexor muscles and capsular ligaments Persons with an inflamed synovium, capsule, of bursa of the hip are susceptible to flexion contracture. Its important to reduce the inflammation through medicine and physical therapy so that activities that favor the extended postion can be tolerated, When tolerated, exercises should be devised that strengthen hip & sor muscles while also stretching the hip flexor muscles and anterior capsular structures. pm 2 oo a E eco £ 3 S00" 36 mL 24mL z 4007 Bmb Eo i aw om. B 100- ° 3h iG 0 1a ilo Wo 10 ip texion (degrees) FIGURE 12-18. The intacpslar presure the hip joins of cadaver: ar a function of hip flexion angle. The four curved lines indicate the pressure-angle relationships after the injection of different volumes of fluid into the capsule of the hip.” ‘Sagital plane rotation -Posttor Anton pewite SS pat eatorsion { exon \ FIGURE 12-19. ‘The osteokinematics of the right hip joint, Femoralon-pelvic and pelvic Hotizontal pane rotaton Frontal plane rotation ‘Abduction: femoral rotations occur in three planes. The axis of rotation for each plane of movement is shown a: a colored dot, located at the center of the femoral head. A, Side view shows saital Plane rotations atousd + medial-aterl ais of rotation, B, Front view shows jronal plane rotations axound an anterior posterior axis of rotation, {G,Top view shows horizontal plane rotations around a longitudinal, or vertical, axis of rotation 478 Section IV Lower Extremity Flexion ‘Shek ilotomeoal ligament hip rotation Extension iotemoral ligament Rectus femoris ene ‘luteus meds, Ischicfemoral ligamen (superior bers) Tensor fascne latae ‘and ital band Internal rotation Ikchiofomoral ligament tteroral and pubotemeraliarents FAGURE 12-20, The near maximal range of fmoratom pele (ip) motion is depicted in the sagital plane (A), frontal plane (B), and horizontal plane (Q). Tissues that ate elongated or pulled taut are indicated by straight black of dathed Black arrows, Slackened Gesu i indicated by a wavy black aro. Chapter 12 Hip 479 Unless otherwise specified, the following discussions include passive ranges of motion. The connective tissues and selected muscles that limit motion are also described and are summarized in Table 12-1, The muscles used to produce and control hip motion are discussed later in this chapter, Although femoral-on-pelvic and pelvic-on-femoral move- ‘ments often occur simultaneously, they are presented here separately, FEMORAL-ON-PELVIC OSTEOKINEMATICS Rotation of the Femur in the Sagital Pane On average, with the knee flexed, the hip flexes to about 120 degrees (Figure 12-20, 4)" Tasks such as comfortably squatting oF tying a shoelace typically requite this amount of hip flexion.” Full hip flexion slackens the three primary cap- sular ligaments but stretches the inferior capsule and muscles such as the gluteus maximus, With the knee fally extended, hip flexion is typically limited to 70 to 80 degrees by increased tension in the hamstring muscles. Considerable variability can be expected in this movement because of high inter subject variability in hamstring muscle flexibility ‘The hip normally extends about 20 degrees beyond the neutral position.” Full hip extension increases the passive tension throughout the capsular ligaments—especially the ilio- femoral ligament and the hip flexor muscles. When the knee is fully flexed during hip extension, passive tension in the stretched rectus femoris, which crosses both the hip and the inee, reduces hip extension to about the neutral position. Rotation of the Femur in the Frontal Plane The hip abducts on average about 40 degrees, limited primar ily by the pubofemoral ligament and the adductor muscles (see Figure 12-20, B)." The hip adducts about 25 degrees beyond the neutral position.” In addition to interference with the contralateral limb, passive tension in stretched hip abductor muscles, iiotibial band, and superior fibers of the ischiofemoral ligament limits full adduction, Rotation of the Femur in the Horizontal Plane ‘The magnitude of internal and external rotation of the hip is particularly variable among subjects. On average, the hip intemaily rotates about 35 degrees from the neutral position (Gee Figure 12-20, ©). With the hip in extension, maximal internal rotation elongates the extemal rotator muscles, such as the piriformis, and parts of the ischiofemoral ligament. The extended hip externally rotates on average about 45 degrees. Excessive tension in the lateral fasciculus of the iliofemoral ligament can limit full external rotation. In addition, extemal rotation can be limited by excessive tension in any intemal rotator muscle. PELVIC-ON-FEMORAL OSTEOKINEMATICS Lumbopeivic Rhythm ‘The caudal end of the axial skeleton is firmly attached to the pelvis by way of the sacroiliac joints. As a consequence, rotation of the pelvis over the femoral heads typicaly changes the configuration of the lumbar spine. This important kine- matic relationship is known as lumbopeloic rhythm, introduced in Chapter 9. This concept is revisited in this chapter with a focus on the kinesiology at the hip. Figure 12-21 shows two contrasting types of lumbopelvic rhythms frequently used during pelvic-on-temoral (hip) flexion. Although the kinematics depicted ate limited to the sagittal plane, the concepts can also be applied to pelvic rota tions in frontal and horizontal planes. Figure 12-21, A shows an example of an ipsidiecional lumbopeloc rhythm, in. which the pelvis and lumbar spine rotate in the same direction.”® The effect of this movement is to maximize the angular displace- ment of the entre trunk relative to the lower extremitiesan effective strategy for increasing reach of the upper extremities, The kinematics of the ipsiditectional lumbopelvic thythm are discussed in detail in Chapter 9. In contrast, during contradi- rectional lumbopelvc rythm, the pelvis rotates in one direction ‘while the lumbar spine simultaneously rotates in the opposite direction (see Figure 12-21, B). The important consequence of this movement is that the supralumbar trunk (ve, that part of the body located above the first lumbar vertebra) can remain nearly stationary as the pelvis rotates over the femurs, This type of rhythm is used during walking, for example, when the position of the supralumbar trunk~inchuding th head and eyes-needs to be held relatively fixed in space, independent of the rotation of the pelvis. In this manner the Iumbar spine funetions as a mechanical “decouple,” allowing the pelvis and the supralumbar trunk to move indepen- dently. A person with a fused lumbar spine, therefore, is ‘Contradtectional™ lumbopelvic rythm “Ipsdirectional lumbopeti rhytam FIGURE 12-21. Two contrasting types of lumbopelvicshythms used tozotate the pelvis over fixed fermurs. A, An “ipsdirectional” shytim

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