The Pelvis and Hip: Function and Anatomy

Anatomy and function of the hip joint from my Strength and Conditioning placement at the Sports Institute of Northern Ireland (SINI). Includes the pelvic girdle, the femoroacetabular joint, common bony landmarks, musculature, range of motion, pelvic tilt, movement tests, associated conditions and more. Athletes names have been replaced with ''Athlete 1'' etc. to maintain confidentiality. Feel free to give some critical feedback.

1. The Hip ANATOMY AND FUNCTION with Jill Costley

2. Overview Summary of the pelvis Hip & thigh anatomy Ligaments Muscles Functions of the structures associated with the hip Movement impairments of the hip/ groin and associated functional tests How can we use this knowledge to inform our practice? Application to athletes

3. The Pelvis Two coxal bones, the sacrum and the coccyx Protects organs Childbirth in females Supports the spine and upper body Supports movement Provides attachment sites for muscles and ligaments of the hip and trunk Coxal bone: ilium, ischium (posterior) & pubis (anterior) Triradiate cartilage - Not fully fused until approximately 18 yrs old Includes the acetabulum (socket) of the hip joint Functions of the Pelvis: Agur & Dalley , 2009

4. The Hip Joint Anatomy

5. The Hip Joint (The Femoroacetabular Joint) Ball-and-socket joint Stable joint due to many factors i.e. osseous/ ligamentous/neuromuscular Large ROM Multi-axial movement  Flexion/ Extension  Rotation: External/ Internal  Abduction/ Adduction Frontera et al., 2014; Diduch & Brunt, 2014 Articulation of the head of the femur with the acetabular socket of the pelvis

6. American College of Sports Medicine, 2014; Swartz, 2014

7. The Acetabulum Depth of the acetabulum is increased through the labrum Articular (lunate surface) Non-articular - acetabular fossa Transverse acetabular ligament crossing the acetabular notch Singh, 2008 The Labrum Fibrocartilaginous rim surrounding the acetabulum Transverse acetabular ligament  acetabular notch Thickest posteriorly Tears common in acetabular dysplasia

8. Reflected tendon of the rectus Anterior lunate cartilage Posterior lunate cartilage Acetabular fossa Acetabular fossa Transverse acetabular ligament Lunate cartilage Ligamentum teres Acetabular labrum Femoral head Obturator foramen Transverse acetabular ligament Byrd, 2013

9. Femur Longest and strongest bone within the human body  supports the load bearing function of the hip Biel, 2004; Madden, 2008 Distal end forms an articulation with the patella and tibia creating the hinge joint of the knee Muscle attachment sites include – Greater trochanter Linea aspera Gluteal tuberosity Adductor tubercle Pectineal line (spiral) Trochanteric fossa Ligament insertion sites include – Intertrochanteric line Intertrochanteric crest Femoral neck

10. Biel, 2004

11. Bony Landmarks – Solo Pass, Iliac Avenue, Tailbone Trail & Hip Hike Biel, 2004

12. Capsular LIGAMENTS The Hip Anatomy

13. Biel, 2004; Torry et al., 2006; Martin et al., 2008; Ito et al., 2008 Iliofemoral Ligament (2 arms)  limit extension in flexion Lateral arm  in flexion: ex. rotation Lateral arm  in extension: in/ex rotation Capsular Ligaments Zona Orbicularis  Hip stability under distraction Ischiofemoral Ligament  internal rotation Pubofemoral Ligament  in extension: external rotation  abduction

14. The Hip & Thigh Anatomy MUSCLES & FUNCTION

15. Categorisation of Muscle Groups Iliopsoas Five main muscle groups: Quadriceps femoris (4) Gluteal (3) Hamstrings (3) Adductors (5) Lateral rotators (6) Tensor Fasciae Latae Sartorius Biel, 2004; Magee, 2014 Pelvic floor

16. Quadriceps Femoris Four muscles: Vastus Lateralis Rectus Femoris ( biarticular ) Vastus Medialis Vastus Intermedius Biel, 2004 All: extend the knee Rectus femoris : flexes the hip Origin: AIIS (rectus femoris )/ along femur (all others) Insertion: Tibial tuberosity

17. Gluteals Three muscles: Hip abductors Gluteus maximus – Upper/ Lower Gluteus medius – Medial/ lateral Gluteus minimus Biel, 2004 Origin: posterior pelvis Insertion: femur/ IT tract Gluteus maximus : hip extension, lateral rotation, hip abduction  Lower fibres : hip adduction Gluteus medius : hip abduction  medial fibres: hip extension, external rotation of thigh  lateral fibres: hip flexion, internal rotation of thigh Gluteus minimus : internal rotation of thigh, hip flexion & hip abduction

18. Hamstrings Biel, 2004 Origin: Ischial tuberosity/ femur (BF SH ) Insertion: fibula (BF)/ tibia (semi’s) Three muscles: Biceps femoris (BF LH & BF SH) Semitendinosus Semimembranosus Semi’s : internally rotates a flexed knee, hip extension, @ Internal rotation of thigh, BF LH : hip extension/ @ external rotation of the thigh ALL: Posterior pelvic tilt, knee flexion

19. Adductor Muscles Five muscles: Adductor longus Adductor brevis Adductor magnus Pectineus Gracilis Adduct the hip Internally rotate the thigh All EXCEPT gracilis : @ hip flexion Gracilis ONLY: Knee flexion Internal rotation of thigh in knee flexion Posterior fibres of adductor magnus : hip flexion Biel, 2004 Origin: On the pelvis  pubic bone  ischium  ischial tuberosity Insertion:  Along the femur  On adductor tubercle (add. magnus )  Tibia ( gracilis ) All:

20. Lateral Rotators All: Externally rotate the thigh Piriformis: Abducts the hip in hip flexion Biel, 2004 Origin: on the pelvis and sacrum Insertion: along the greater trochanter The ‘’deep-6’’ muscles Piriformis Obturator internus Obturator externus Gemellus superior Gemellus inferior Quadratus femoris

21. Gluteus minimus Sciatic nerve Gluteus medius Piriformis Inferior gemellus Quadratus femoris Superior gemellus Internus obturator Byrd, 2013

22. Others Iliopsoas (Iliacus and psoas major) Sartorius Tensor Fasciae Latae (TFL) Perineum

23. Iliopsoas Biel, 2004 Two muscles: Psoas major Iliacus Fixed origin: hip flexion/ external rotation? Origin: Iliac fossa Insertion: Lesser trochanter Fixed insertion: trunk flexion towards thigh/ anterior pelvic tilt Iliacus Psoas major Fixed origin: hip flexion/ external rotation? Fixed insertion: trunk flexion towards thigh/ anterior pelvic tilt Unilateral: @ lateral lumbar flexion Origin: lumbar processes Insertion: lesser trochanter

24. Sartorius Hip: flexion, external rotation, abduction, internally rotates thigh in knee flexion Origin: ASIS Insertion: tibia Biel, 2004 Knee: flexion Longest muscles in the human body

25. Tensor Fasciae Latae Biel, 2004 Stabilisation of knee and hip Iliotibial Tract - Fascia Hip flexion, internal rotation and abduction Origin: Iliac crest Insertion: Iliotibial tract Origin: Gluteal fascia Insertion: Tibial tubercle

26. Perineum & Pelvic Floor Biel, 2004 Perineum Diamond shaped area found inferiorly within pelvis Bordered by the two ischial tuberosities , the pubis symphysis and the coccyx Pelvic floor Supports the abdominal and pelvic viscera  2 levator ani  2 coccygeus  fascia

27. Singh, 2008

28. The Hip & Thigh STABILITY OF THE HIP

29. Contributions to hip stabilization – Osseous Structures Ligamentous Structures Neuromuscular Structures ROM  needs large degree of stability

30. Osseous contributions Femoral (head-neck) offset Acetabular anteversion Acetabular coverage of the femoral head Ligamentous contributions Capsular ligaments – limiting movement Iliofemoral ligaments – Flexion – internal rotation Extension – Internal & external rotation 2. Ischiofemoral ligaments – Flexion & Extension – internal rotation 3. Pubofemoral ligaments – Extension – external rotation Abduction Zona orbicularis – stabilization under distraction* Ligamentum teres – intrinsic stabilization Neuromuscular contributions - Ability to alter muscle stiffness to ensure articular stabilization and articular congruency Torry et al., 2006; Martin et al., 2008; Myers et al., 2011

31. The Hip & Thigh ANTERIOR & POSTERIOR TILT

32. Lippert, 2001; Sahrmann , 2002; Clippinger , 2007 Anterior tilt ASIS moves anteriorly in-front of the pubic symphysis Vertebral hyperextension Hip flexion Posterior tilt ASIS moves posteriorly behind the pubic symphysis Vertebral flexion Hip extension Optimal Position ASIS & pubic symphysis  vertically aligned (as laterally viewed)

33. Force Coupling Abdominals & hamstrings/glutes Spinal erectors and hip flexors Lumbosacral Angle - Horizontal to base of sacrum Narayanan, 2005; Lippert, 2011

34. The Hip & Thigh MOVEMENT TESTS

35. Movement Tests Thomas Test: indicates tightness within the rectus femoris or the iliopsoas - Positive result = testing limb lying above surface of plinth while flexed or extended FABER’s (Patrick) Test: may indicate the presence of hip pathology or SI joint dysfunction - Positive result = pain within the back region of testing side/ restricted movement in testing side above that of the opposite limb  tight hip adductors/ flexors/ joint capsule? Ober Test: indicates tensor fasciae latae (TFL) or iliotibial band (ITB) tightness - Positive result = remaining off the table upon adduction Tightness: Piriformis Test: tests the cause of buttock pain i.e. tight piriformis muscle or as a result of referred pain due to the sciatic nerve - Positive result = gluteal pain or radiating pain from sciatic nerve Palmer et al., 1998; Martin et al., 2010

36. Scouring (Quadrant ) Test: may indicate the presence of a non-specific joint pathology Craig’s Test: Test for femoral anteversion / retroversion Sign of the Buttock: indicates if gluteal pain is localized or being referred from problems within the hip, sciatic nerve or hamstring Trendelenburg Test: a unilateral weight-bearing test that may indicate gluteus maximus weakness   - Positive result = a drop of the pelvis as seen from behind Weakness: Other: Palmer et al., 1998; Martin et al., 2010

37. FADIR Test (Impingement Test) Flexion, ADduction , Internal Rotation High Sensitivity Wilson & Furukawa (2014) Positive test: Pain e.g. hip labral tears, loose material, chondral lesions, femoral acetabular impingements Gold-standard for checking overall hip function Low Specificity

38. The Hip & Thigh HIP PROBLEMS – TO BE AWARE OF

39. Femoroacetabular impingements (FAI) FABER test is most sensitive CAM and PINCHER deformities  causes labral tears Piriformis Syndromes Log roll test is most sensitive Gluteal region pain especially when sitting or walking Tumours Femoral anteversion Craig’s Test Acetabular dysplasia  usually shows hypertrophied labrum  gymnasts Labral tears FADIR test is most sensitive Can occur without FAI Dull or sharp groin pain (may radiate) Cartilage loss wear and tear  hyaline articular Wilson & Furukawa, 2014; Imhoff et al., 2015

40. Case Study 1 – Athlete 1 Cam and pincher deformities – congenital?/genetic? Griffin et al., 2016 Soft tissue damage through: Repetition Abnormal femur/ acetabular shape Excessive movements close to outer range  abnormal contact/ collision Triad of symptoms, clinical signs & imaging findings FADIR Test – sensitive but not specific Limited hip ROM?  internal rotation in flexion FABER Test ? Hip muscles commonly weak in FAI patients

41. UEFA injury study: A prospective study of hip and groin injuries in professional football over seven consecutive seasons FAI’s going to become more common through advancements in improvements of MRI and arthroscopic techniques as well as increased awareness and knowledge of this condition Lavigne et al., 2004; Werner et al., 2009; Khan et al., 2016 Hockey, football, soccer, rugby, martial arts, and tennis Cam-type: men Pincer-type: women Associated with other pathologies such as adductor and hip flexors injuries, ACL injuries etc. Limited ROM may increase stress placed upon other joints e.g knees/ spine

42. Case Study 2 – Gaelic Groin Second most common injury to hamstring strains Werner et al., 2009; Glasgow et al., 2011 Groin – ‘’junction between the anteromedial part of the thigh, including the proximal part of the adductor muscle bellies, and the lower abdomen’’

43. Glasgow et al., 2011

44. Implications for S&C Werner et al., 2009; Glasgow et al., 2011 Field based games: 2 months off-season period  complete strength, flexibility and stability training  Increase ROM, strengthen core and groin/glutes High groin injury rates in: Soccer AFL Rugby League Work with the coach i.e. match play exposure  EASIER SAID THAN DONE Athlete 2 Rehab can be a long process!! Commitment – athlete and therapist/ coach Cooperation between physio’s & S&C.

45. Summary Structure : Acetabulum and femur Muscles : Quadriceps (4), gluteals (3), hamstrings (3), adductors (5), lateral rotators (6) Capsule ligaments  ischiofemoral , iliofemoral , pubofemoral Movement : Hip flexion/ extension, adduction/ abduction, internal/ external rotation Stability : Osseous, ligamentous & neuromuscular factors Tests : FABER, FADIR, Thomas, Ober, Piriformis, Trendelenburg, Craig’s, Scouring, Sign of the Butt. Conditions : FAI, tumours, femoral anteversion, labral tears, cartilage loss…….. FAI – triad of symptoms, signs & radiological feature  increase in cases in future? Gaelic groin – chronic high load  history taking, clinical examination, observation, tests  2 month off-season: strength, flexibility & stability training  Strengthen core and groin/gluteal muscles  Applies to other field sports

46. References Provided via Email

47. Thanks for Listening!!