hello and welcome to your online lecture for the hip I can't believe we made it here we started in August and now we're here we started with the foot the toes moved to the ankle lower limb went to the knee and now we're at the hip our last stop is the pelvis you guys so we're almost there so I guess that's kind of my encouragement to you guys is we're almost through the lower extremity I hope by now that you have a really good grasp on what it means to assess the joints that we've already covered we're moving into the hip joint and so we'll break this lecture into two parts the first part of this lecture which we'll cover currently is really just focusing on the hip Anatomy historical questions that you might ask and inspection of of the hip or observation in the second part of this lecture series we will dive deep into special tests that can be used to um assess pathologies and obviously we're going to talk about the pathologies in that second part of the lecture so I'm really looking forward to these to hip lectures uh did you guys know that the hip is the largest joint and one of the most stable joints in the body so it's large and it's stable and you combine those two together it's the largest most stable joint in the body and one of the great things about the hip that we we see most often in the clinical setting is that um if it's injured um or if it exhibits pathology then typically it's going to be immediately perceptible in other words you're going to see it either in the patient's gug when they're walking or when they're running or when they uh sit to stand or stand to sit so it's one of those joints where the injury is most often extremely obvious to the clinician so I think that kind of makes us less anxious about learning about the hip hopefully so our first stop is going to be in the anatomy of the hip joint what we know about the hip joint and I'm sure you all know this is that the hip joint is a multi- aial ball and socket joint um that has crazy amounts of of stability because of its deep articulation do you hear me its deep articulation with this anatomical structure here this is the acetabulum of the pelvis um and we're going to talk about its unique relationship to the actual femoral head so when we think about it the ball and a ball and socket joint essentially there has to be a convex structure and a concave structure right a concave structure to receive that rounded structure our human head is going to be the conve convex structure and then our acetabulum is going to be that concave structure so you can see that that ball is going to fit relatively well into that socket and if it doesn't fit relatively well then we have massive amounts of muscle surrounding that joint which will then kind of a create a suction cup and keep that feral head uh in that acetabulum of the pelvis okay so if we think about the um hip joint a lot of clinicians would call it the femoral acetabular joint right they don't just typically call it the hip joint uh they sometimes will call it the coxo coxofemoral joint right so it has a name like the tibio femoral joint right for the exam you can put the hip joint and I will accept that but again what's important on this slide is that you're really seeing this convex structure that has an articulation with this concave structure and that's what creates the ball and socket joint and creates a lot of the stability that we talk about within the actual hip joint itself so when we think about this maximum stability this is an actual gross anatomy model so we can see this femoral head right which is extremely convex we can also see the acetabular labrum and we're going to talk about that on the next slide I believe so I'll save that for then but we can see how that femoral head is just going to fit really snug within the acetabulum right okay so as we progress we kind of can't talk about the hip joint without talking about the pelvis itself right the the good thing is we have a whole entire lecture series dedicated to the pelvis but I do want to spend a little bit of time here because the acetabulum which is the concave structure which receives that femoral head sits on or lives or exists on the actual ilum or pelvis of the patient right and so what we know about the acetabulum is that superiorly it's formed by the ilum posteriorly it's formed by the isum right which remember that isal tuberosity is going to be the proximal attachment site to the actual hamstring muscles and then anteriorly it's going to be formed by that pubis bone right so again for recap we have this acetabulum which is made up of three bones of the pelvis right so we kind of can't talk about the hip without talking about the pelvis for at least a quick few seconds so again just to review super torly it's formed by the ilium posteriorly it's going to be formed by the isum and then anteriorly it's going to be um it's going to be made up of the pubic bone right but all in all this C shaped structure is what we call the acetabulum and it's extremely important in terms of creating hip stability um for the hip joint as we progress we can really spend more time talking about the acetabulum but we already know that it's this concave structure one of the interesting things to me about the acetabulum is that the the cavity is actually deepened by this fibrocartilagenous collar which is known as the labram you guys clinically okay so the laum is an extension of the acetabulum which deepens that articulation right does that sound familiar does it sound like other anatomical structures that we've already talked about like the meniscus for example which Also Serve to deepen the articulation between two different bones yes good okay the head of the femur is hemispherical um and fits completely into the concavity of that acetabulum and again it's covered by that articular cartilage so let's just go there right when we think about the labrum or the articular cartilage it's not your traditional laum uh most often when we think about L Broms you're going to see that kind of labrum lay down within the ring but in this particular case the the acetabulum is going to be covered by um a Highland cartilage um and this is very proactionary right just think about the tibio femoral joint and those condil and how they get or suffer from arthritis right it's that Highland cartilage wearing away so what we know about the acetabulum is that it's lined with this highland cartilage which is which is great it's proactionary it's going to prevent friction and rubbing of the formal head against the acetabulum but then the beautiful thing to me is the way in which this laum do you see it here this labrum creates a crazy lip over the acetabulum and so imagine that femoral head sitting within that acetabulum and then that lip just suctioning it in or sucking it in right so it's almost like it's a suction cup it's one of the major resources that creates that maximum stability about the hip joint itself and I really like this gross anatomy model because you can see how it looks like a lip and now does that laborum kind of extend into the acetabulum most certainly but again I want to show you guys something here and we'll get to it in pathologies but I think it's important to point out is I don't know if you can see this articular defect here so remember I said that acetabulum is line by Highland cartilage and we can see that Highland cartilage here but do you see how we can actually see the bottom of the acetabulum so this is a patient who probably has some sort of arthritic or degenerative changes happening right but again back to that laborum you guys I I don't know if you guys can appreciate this at all but it suctions the femoral head and creates the stability so a tear to the acetabulum could lead to increased instability at the hip joint so bony wise we've already talked about the distal part of the femur right we did that when we talked about the KN joint in particular when we talked about the tibial femoral joint so I'm not going to spend time there I'm going to spend time a little bit talking about the shaft of the femur the what we know about the femur in general you guys is it's the largest bone in the human body you all know that I think I said it the summer in our lecture series but it's the largest bone in the human body one of the the cool things that we know about the shaft is it begins to change its shape about mid shaft and so a lot of the stress fractures or or full fractures that we'll see will most hap most often happen in the mid shaft of the femur because it's where the bone is weakest again we don't really most often see stress fractures or complete fractures but if we do see a complete fracture it is a medical emergency and we'll talk about that in in class and how to care for that in in a lab situation but as we progress more proximally we want to talk about important anatomical structures so we have the greater Cho Canter which is certainly p bowl and we'll do that in lab and then on the medial aspect of the femur we have the Lesser Cho caner and they get their names based on their size and also their position so example the greater choke Canter is larger and it's more Superior when we look at it comparatively to the Lesser choke Canter which is extremely small and inferior so those two bones will become important but but palpable wise you'll need to know how to palpate that greater choke cancer next we have the neck of the femur the neck of the femur is um one of the most commonly fractured sites when we look at elderly patients and when we look at um those patients that are malnourished or suffer from some type of disordered eating or eating disorders right most often this bone becomes extremely weak because it's changing its shape um and it's it's it's becoming the head of the femur right so often times we'll see stress fractures in our cross country runners in our gymnasts uh most often or in in our elderly patients so those above the age of 50 or or greater right and so if you're a physical therapist when you have that slip and fall most often with an elderly patient most often what fractures is the neck of the femur and then finally what we have is the head of the femur and the head of the femur is extremely important again because it's going to articulate with the acetabulum and it's what's responsible for creating those Osteo kinematic motions right those large gross movement motions at the hip joint so as we progress let's go ahead and talk a little bit more about the Bony nature of of the hip uh in general we have the pubic symphysis which it represents the articulation of both pubic Bones on each side of the pelvis so we have a right ilium we have a left ilium where those two bones come together anteriorly we call that the pubic symphysis and we'll spend more time on this in the pelvis so if I feel like I'm blowing through this it's okay for the purpose of the exam you won't need to know pubic symphysis at least for the hi uh or the sacral iliac joint but the sacral iliac joint is the point in which the pelvis comes together the two the two pelvi come together and articulate posteriorly then we have the coxo for moral joint another name for hip joint probably what you see in your textbook I think some spell it coxo and some spell it coxa so you may see both forms or or spellings for for the hip joint right and then we have um the the Ramis But ultimately you guys what I'm saying for now in this particular lecture in this particular section we need to focus on the following um the we need to focus on the acetabulum which again is comprised of three different bones of the ilum um or the pelvis it's the isum posterior superiorly it's the ilam and then anteriorly it's the pelvis so we're going to focus on that and we're going to focus on the femur for now in terms of the clinical Anatomy uh and and ligamentous support there are three major ligaments that help to support the femoral head into the acetabulum or its articulation right uh and those are the ilal ligament the pubal ligament and the isop fal ligament so let me see if I can find all of those here so we have the ILO moral ligament here which you guys all can see we have the pubil femoral ligament and I don't think we're going to see the isal femoral ligament on here but it's okay it has its own slide so as we progress um and we really start thinking about the ligaments of the hip and their role we know that number the number one role of a ligament is to connect a bone to a bone so in this particular case these ligaments are going to be connecting the femur to to the pelvis in some way shape or form right so so far so good we also know that they create stability about a joint right so in this particular case these ligaments are going to be creating stability about the coxofemoral joint or the hip joint right and we can see these three ligaments here in this image and the reason we couldn't see the issal for moral ligament in the other um image is because it's a posteriorly driven ligament so we can see that it has an attachment to um the isum hence its name and then the femur right we can see here that this is going to have um an attachment to the ilium in the pubis the ILO fural ligament as the name implies has an attachment to the ilium uh and then to guess what the femur and then last but not least would be our pubal fural ligament which has an attachment to the pubis anteriorly and then attaches to the femur so if you think about this as a a critical thinking component of this lecture each of these ligaments has an attachment to the femur that makes sense right but then each of these ligament ligaments independ ly attached to each of the bones that make up the acetabulum are you guys tracking with me here like right now are you having a aha moment right we said the isum is comprised or the acetabulum is comprised of which three bones we said it's comprised of the pubic bone anteriorly so we have the pubofemoral ligament right we said superiorly sorry I got excited guys we said superiorly we said that it is is the it is comprised of the ilium so we have the ILO foral ligament right uh and then posteriorly what did we say we said it was the isum so we have the isop foral ligament here you guys so we have these three ligaments which attach to the three different bones that make up the acetabulum and then all of those have a distal attachment to the femur who would have thought right you guys so what we can say is that each of these ligaments provide stability but they also connect a specific joint the pubil femoral joint the ILO femoral joint um or the isal femoral joint I hope you guys got that I got excited a little bit okay and hand away from the clicker from now on okay so the ILO femoral ligament you guys do need to know this it is called the ligament of Y um and it's because it has a y-shaped appearance which we can certainly see in this image um as we're looking at it so here um are the different bundles of the um iloom moral ligament but it pretty much is known as the the Y ligament the cool thing about the iloom moral ligament okay think about this it's connecting the ilium to the femur right we know this so if that's the case we have to think about its anatomical alignment its major role is to prevent hyperextension of the hip okay why do I talk about this ligament first it's because it's the strongest of the three ligaments and we'll see why in just a second but it has to do with the way that its fibers are laying what we can also see is that it's made up of three strong bands right um so that should tell you something number one it prevents hyperextension of the HIP number two what we know is it's the strongest of the three ligaments if you're trying to think well how do I remember that it prevents hyperextension of the hip it's an anteriorly positioned ligament right so just think it wouldn't it wouldn't limit hip flexion it's going to resist the motion opposite that so it's going to limit hip hyperextension next we have the pubo fal ligament the pubo foral ligament is here you guys can see it uh it's going to attach the pubic bone to the femur uh it is its responsibility okay so think about this it's kind of a medial anterior ligament so it's going to prevent massive amounts of abduction and also Aid in preventing hip extension but its major role is to prevent hip abduction so when we go into Abduction the reason we're limited in our amount of abduction you can kind of blame that on the hip adductor muscle group but you can also blame that on the pubil femoral ligament as well our isal femoral ligament as you can kind of see it here right here it's going to connect the isum to the femur posteriorly um and you would obviously you would assume that oh it's going to prevent hip flexion but but the reality is one of the cool things about the issue for moral ligament is it wraps onto the anterior aspect of the femur and so it also prevents um hip hyperextension the other thing that this ligament does that the other two do not is it actually helps to stabilize the head in the acetabulum so it kind of is is like a spiral muscle in essence you can kind of see it ringing around it's that ringing around or that spiral nature that tucks the femoral head into the acetabulum so again we can see how these three ligaments all of them prevent hyper extension right of the hip um but then each of these ligaments do something unique and distinct which is why they serve a function at the hip it's these three ligaments that provide massive amounts of joint stability to the coxofemoral Joint the next anatomical structure that we'll spend a little bit of time uh with is the ligamentum terries uh the ligamentum terries as you guys can kind of see here and somewhat here um is is a triangular band um most often it's it's made up of three different bundles um and its major role quite honestly in the hip is to serve as a connection piece between the acetabulum um and the the fal head most specifically it um has an attachment to the the phobia of of the femur uh and then again has that attachment to the acetabulum in terms of its role um there were some purported roles such as like the ligament um created um some form of blood supply through an indirect arterial affiliation but that has been debunked um so what they really typically say is that the role of the ligamentum terries is just to provide stability in particular to provide stability in flexion um a deduction moments so again it's another stabilizing structure that doesn't really have much of a role but what we know about the ligamentum terries is that it's most often injured or can become injured most often um in Hip dislocations uh in particular inferior hip dislocations of the coxal for moral joint our next stop is going to be uh the muscular anatomy and I am not spending a whole bunch of time here because I feel like we have this down but on the anterior aspect of the hip we have the rectus Fus which has a proximal attachment to the anterior inferior iliac spine we have the Sartorius which has an attachment to the pelvis right and attaches to the anterior superior iliac spine and then we have the ilos soaz group I'm really going to refer to the the soaz major which has a proximal attachment um starting at T12 right um and each of these muscles if we think about what they do at the hip they're going to serve to uh Flex the hip most certainly I think uh concentrically in terms of its contraction their major role as a group is hip flexion but we certainly know that the Sartorius does much more than that right it's a major hip abductor as well um so we can see and an internal Rotator of the hip so we can see that ultimately the anterior compartment of the hip is going to serve uh uh or assist with hip fun flexion the medial aspect of the hip uh is mainly comprised of the adductor muscle group and the the gillus as a whole they are concentrically going to contract to cause the hip to ad duct um we also know that secondarily they aid in Hip internal rotation um so you have this this muscle group on the medial aspect of the limb working to adduct or to slow down the rate at which we a b duct the hip and here they are you can kind of see them we I hope that you got to see them in Gross Anatomy but I really love this image I really like the way that it shows how unique and distinct each of the adductor muscles are I think a lot of times as clinicians we group them all together which is completely okay but noting where each of these muscles are going to attach on the femur and on the pelvis as you can see that there becomes extremely important in your rehab approach right um if we have let's say an injury to the longest right the way that we lunge might look different than then if we have an injury to the ptinus right um so those are just things to think about now that you're in an advanced lower extremity course is okay they're they're certainly a group but then independently where do they attach distally right where do they attach distally and how does that change my evaluation how does that change my rehab how does that change my treatment right those are questions that you're asking yourself as you start to think about the adductor muscle group on the last L Al side of the of the hip we have several muscles which we'll kind of talk about um those are highlighted in yellow for a reason and we'll talk about them on another slide but we have the the glute medius most certainly misspelled I um so we have the glute we have the glute medius um which is deep to the glute Max and we'll talk about the role of the glute medius but at the hip we know it's a hip AB ductor but it certainly does other things in the transverse plane we have the tensor fascia lat right which disly becomes the IT band and we talked about the IT band uh in the knee online lectures but now what we're referring to is its most proximal muscular component right which is a major hip abductor and then posteriorly we have the glute Max which is a hip extender and the hamstring muscle group right and we've talked a little bit about the hamstring muscle group and manual muscle testing at the knee they're knee flexors but they are also hip extenders as well so we'll test them differently in the next few weeks in in our lab class so the muscles that I skipped on the other page are now here the they are the six internal muscles of the hip and I'm sure you had a fun time looking at these during gross anatomy right probably the most difficult thing to look at but let's get an appreciation for these muscles so play golf or go on Quaaludes that's kind of how I remember them P play is going to be performas golf GIS Superior um or opat internis the other G is going to be GIS inferior your opterus exteris and your quadratus Fus and these are kind of listed in the order in which they lie so from most superficial to deep right so if we look at this here uh we can see the piriformis right here right and then the next muscle that we would expect to see would be the gis Superior um and so we'll piriformis Superior GIS or GIS Superior depending on who you ask your opter internis is going to be next the gis inferior right here so we can kind of see that and then your quadrate is for moris which is way deep um looks easy on this image but as a whole one of the things that we know about these intrinsics is that they're going to control hip internal rotation during gate so they're going to slow the rate at which we internally rotate during gate and that will become important because if we don't slow that rate just think as we're moving from the swing phase and we're getting touching back down to contact phase right um one of the concerns is we'll slam into internal rotation maybe vus moment or moments at the knee and it could lead to injury so these muscles play a major role in controlling internal rotation during gate which is huge right any injury to them and we don't have control and internal rotation which leads to changes up the kinetic chain so the glut medius remember that I said we would talk about the glut medius a little bit deeper right so what we know about the gluten medius is it certainly is a hip AB ductor there is no question about that but as we dive deeper into the literature and dissection what we can see um with the glut medius in particular is that it has bundles and so the first bundle is the anterior bundle and we can see its fibrous orientation so the anterior fibers and then we have the posterior fibers and we can see that their fibrous orientation is in the opposite direction of each other so our anterior fibers not only do they abduct the hip but they are also responsible for causing hip flexion and internal rotation our posterior fibers then also hip abduct but drive hip extension and external rotation so you need to know that the glute medius is more than just a frontal plane mover right I just told you that it works in the sagittal plane and the transverse plane so what am I saying it's a multipler muscle whose major role is to certainly stabilize the pelvis on the femur but it certainly does more than just AB duct the hip right and again if we're thinking about rehab if we're thinking about treatment if we're thinking about assessment this changes the way that I assess glute mes right not only do I manually muscle test in hip abduction guys but I'm also going to a uh manually muscle test with the hip inflection in abduction or extension in abduction right so you can see how this changes what we do clinically um when we're assessing a patient who walks in with a glut media strain it also changes our reab right if we have a muscle strain of the anterior fibers of the glute medius not only should we be working in the frontal plane but we certainly should be doing sagittal plane exercises and transverse plane exercises right because the glut does all three or Works in all three planes of movement okay so clinical Anatomy uh first and foremost is the femoral triangle and this is important because if we have a hip dislocation it's a dislocation it's one of the major reasons that a a patient can lose their limb and it's a medical emergency but we have the femoral triangle and it's a triangle because it's formed by the inguinal ligament um superiorly it's formed by the sartorious laterally and then the adductor longus medially and within that formal triangle our our what we would call our our van right so we have have the femoral vein we have the fal artery and then last but not least we have the femoral nerve it's also a site that we can certainly assess a pulse but most importantly when we think about the femoral triangle and its role we're extremely worried when we have a patient take an anterior blow to the hip we're worried about the Integrity of our neurovascular system right and if we have a hip dislocation we're certainly worried about the patient losing their actual hip right so the femoral triangle and knowing what it's made up of is extremely important next um we have B of the hip just like we had in the knee joint we know that the hip remember it's it's extremely stable but certainly a mobile structure right and so we want to reduce friction wherever we can so first and foremost we have the tro canic Bersa the trochanteric Bersa as you can see is located over that greater Cho Canter at the distal sight or attachment to the the the glute medius because there's going to be friction and rubbing of that tendon when but listen to me when there's flection extension moments right and so there's a baa there and that the role of the Bersa as you guys already know is to reduce friction over a bone right so we have the choic Bersa probably the one that's injured most often we have the ilos soaz Bersa um the isal Glu Bersa and then last but not least the uh glutitis medius Bersa uh what am I saying to you guys the one that's most common is going to be the trochanteric Bersa in terms of neurovascular anatomy um the first neurovascular structure that we really need to know and own is the formal nerve um but you certainly um we have branches off of that foral nerve anteriorly we have the opter nerve which is going to serve the adductor adductor muscle group right so we have that operator nerve uh we have the femoral nerve and then um posteriorly we have the sciatic nerve right the sciatic nerve is going to supply most of the posterior musculature so again the froral nerve the operator nerve and then you have the sciatic nerve all of those become important in our lower quarter screen right remember that L1 through S2 assessment of your patient neurovascular Integrity as we progress I think um I haven't talked about vascular Anatomy so if I'm talking about it then I'm hoping that you're understanding that this is actually an important component to HP pathology so we have an array of vascular um arteries that Supply the F the femur and keep it keep that bone alive so the two that are most common are the medial femoral circumflex arteries and the lateral um femoral circumflex article um arteries but I think to me the most important is this medial circumflex femoral artery its major role is to supply the femoral head are you listening to me to supply the femoral head with blood flow so that the femoral head doesn't die now I want you to put this in your back pocket so that when we get to injuries we're going to talk about some where the femoral head starts to die because there's a lack of blood supply and the major compromise is to that medial femoral circumflex artery right okay what we know about the the neck I guess of the femur um is that it's supplied by the lateral femoral circumflex artery so a lot of times if we don't have healing um after a femoral neck dress fracture most often there's compromise to the lateral femoral circumflex arteries and then we also have the um operator artery I don't think it's pictured here at least I'm not seeing it but the opter raater um artery will supply create direct supply to the fal head so you have two blood supplies really aiding to serve that FAL head and supply it so it can stay rich in blood supply and that's the medial femoral circumflex arteries and the opter artery okay so features of the joint uh what's the primary function of the hip have you started asking yourself that what do you think okay so what we know about um forces on the hip so if we look at this where when is the force greatest about the hip I think none of us would be surprised that most often running is going to increase the amount of forces going across cross the hip right and standing will have very little forces going through the hip so you can look at this from a ascending perspective starting with the lowest going to to the highest but what do you think the function of the hip is okay um so if you said the following to transfer force from the lower extremity to the spine you would be correct right it is the Midway point you guys are you guys excited yet the hip and the pelvis represent the Midway point so we're now at a place where we're ready to take all of the forces that have been distributed through the lower extremity and transfer those to the spine so that they can then be transferred to the skull right so the hips primary function is really Force transference from the lower lower extremity to the spine I don't know if that gets you excited but I'm getting excited about that okay so this is for you to use to study and I'm not going to go through all of these because you have to own these right but let me just briefly walk you through this table these are motions at the hip flexion hip abduction hip internal rotation hip extension hip a deduction external rotation and then these are all of the muscles that are driving that motion right so hint hint flash card time right for my exam but then also for the board of certification exam and then I'll take it even deeper for you to be good clinicians you need to know what's driving hip flexion right this would be rectus femoris this would be biceps femoris I'm assuming you guys know this is glute Max glute me right these all become important for you to understand because as you're manually muscle testing as you're assessing for a strain of a muscle you need to know which muscles are driving that particular movement so maybe screenshot this and study it um whatever would be helpful I can tell you for our exam you will be asked certain questions like which muscles Drive hip abduction and you should be able to say more than just glute me this concludes this portion of the online lecture series uh I I'm actually thinking that I'm going to break it into three parts as I went through this lecture so the next part of this series will be on um the in observation and inspection portion of the hip thank you for listening to this online lecture