Lower Extremity Problems Involving the Hip and Pelvis
Overview of the Hip Joint: the hip joint, or the acetabulo-femoral joint,
is the most structurally stable, yet mobile, single joint in the body. In
addition to transmitting large forces between the trunk and the ground, the
hip region is a major component of the locomotor system; in participates in
elevating and lowering the body, as in sitting or standing, and is
important in bringing the foot toward the body or hands, as in putting on a
shoe. (Lehmkuhl and smith, p. 259)
Functional Anatomy and Pertinent Biomechanics
The Pelvis: the pelvis provides support and protection to the abdominal
organs and transmits forces from the head, arms, and trunk to the lower
extremities. (Lehmkuhl and Smith, p. 259) The acetabulum transmits these
forces to the lower extremity.
Acetabulum: the cup-like concave socket of the hip joint located on the
lateral aspect of the pelvis, which articulates with the head of the femur.
The walls of the acetabulum are formed by the three bones of the
innominate: anteriorly by the pubis, posterierly by the body of the
ischium, and superiorly by the ilium. The acetabulum faces laterally,
anteriorly, and inferiorly (Hertling & Kessler, 1996, p.285).
The half-moon shaped acetabulum is deepened by the acetabular labrum,
wedge-shaped fibrocartilage, which along with the transverse acetabular
ligament, holds the femoral head more firmly in the socket.
The Femur: the longest bone in the body, it consists of a number of
important aspects, including the head, the neck, the greater and lesser
trochanters, the shaft, and the two condyles. The alignment and the
angulation of the neck of the femur in the frontal plane and transverse
plane have important biomechanical implications:
Angle of inclination (frontal plane): the angle between the anatomic axis
of the femur (the shaft) and the axis of the femoral neck, determined by
radiographic examination. In the newborn, this angle is approximately 150
degrees, decreasing with weightbearing as the child matures. The average
angle of inclination for adults is 125 degrees (Lehmkuhl & Smith, 1996, p.
Coxa Vara: a decrease in the neck-shaft angle of the femur,
resulting in an angle less than 125 degrees. The greater the
degree of coxa vara (or the closer this angle approaches 90
degrees) the shorter the length of the limb.
Angle of torsion: the angle between the axis of the femoral neck and a line
drawn between the femoral condyles; or the degree of torsion/rotation of
the femoral neck in relation to the shaft of the femur.
Coxa Valga: a neck-shaft angle of the femur that exceeds 125
degrees. The greater the degree of coxa valga, the longer the
resulting limb length.
Unilateral coxa vara or coxa valga will result in a leg
discrepancy, which will influence the level of the pelvis, and
the length of soft tissues surrounding the joint.
Antetorsion: an angle of torsion greater than the upper range of "normal."
Retrotorsion: an angle less than the lower range of "normal."
- The average angle of torsion in children between 4 and 7 years of age
is 23 - 26 degrees (Cusick, 1990, p.94).
- Femoral torsion is complete between 8 and 16 years of age; ie: torsion
angles approach those of an adult (Cusick, 1990, p.94).
- The average angle of torsion in adults is 15 degrees (Hertling &
Kessler, 1996, p. 285). Some authors place "normal" values between 8
and 15 degrees (Magee, 1997, p. 475).
Therapists can determine the angle of torsion using Craig's test, in
which the patient is prone with the knees flexed to 90 degrees. The
therapist positions the lower extremity at the point in which the
greater trochanter is most prominent laterally (determined by
internally or externally rotating the femur). Using a goniometer with
the stationery arm perpendicular to the floor (representative of the
femoral neck axis) and the moving arm in line with the shaft of the
tibia (representative of the line between the femoral condyles) the
therapist can determine the angle of torsion.
Hip Stability: the hip joint is inherently stable, because of its anatomy.
The acetabular socket, deepened by its labrum, serves to tightly enclose
the femoral head; the negative pressure within the thick joint capsule
causes a vacuum effect, which resists distraction forces; and the ligaments
and muscles that cross the joint all serve to tightly hold the femoral head
within the acetabulum. The close-packed position of the hip is maximum
extension, internal rotation, and abduction.
Treatment of these four anomalies from a physical therapy perspective
addresses compensating for the affects of the variations. For
instance, using shoe inserts to compensate for leg length variances.
Of extreme importance is addressing the effects of the pathology on
the surrounding soft tissues: stretching tight musculature and
strengthening lengthened muscles, etc. Some cases of femoral
angulation deviations can only be adequately addressed surgically.
The joint capsule of the hip is strong and dense, and attaches to the
entire periphery of the acetabulum, covering the femoral neck, making the
neck intracapsular, as opposed to the trochanters, which are extracapsular.
The capsule contributes to joint stability, permitting minimal to no
Three extracapsular ligaments reinforce the joint capsule:
Iliofemoral ligament (Y-ligament of Bigelow): located anteriorly,
the strongest ligament in the body. Attaches to the AIIS, inserts
along the intertrochanteric line of the femur. Resists extension
and internal rotation (Hertling & Kessler, 1996, p.288).
Pubofemoral ligament: also located anteriorly. Attaches to the
anterior pubic ramus and to the anterior surface of the
intertrochanteric fossa. Resists primarily abduction and, to a
lesser extent, internal rotation (Hertling & Kessler, 1996, p.
Ischiofemoral ligament: located posteriorly, it attaches
proximally to the ischium and to the acetabulum. It resists
extension and internal rotation (Hertling & Kessler, 1996, p.
Ligamentum Teres (ligament of the head): attaches to the fovea
centralis and the head of the femur, blending with the transverse
acetabular ligament. This is a weaker ligament, which becomes
taut with adduction and slight flexion. Its primary function is
to carry a small artery (a branch of the obturator artery) to the
head of the femur. (Moore, p. 550)
Transverse Acetabular ligament: located inferiorly and medially
along the rim of the acetabulum, this ligament spans the
acetabular notch, which reinforces the labrum in this region.
(Moore, p. 544)
Muscles completely surround the hip, providing three planes of movement.
The actions of the muscles vary depending on joint position. Therapists'
knowledge of muscle testing positions and biomechanics will allow them to
be able to isolate specific pathologies with a hip muscle.
The hip has four significant bursae, the trochanteric bursa (located
lateral and inferior to the greater trochanter), the iliopectineal and
iliopsoas bursae (located anteriorly and medially to the to the neck and
acetabulum), and the ischiogluteal (located posteriorly and inferior to the
Disorders of the Hip and Pelvis
Osteoarthritis / Osteoarthrosis / Degenerative Joint Disease: a disease
process of joint degeneration in response to overuse, trauma, infection,
etc, common to weight bearing joints, such as the hip. Severe degeneration
may require surgical intervention, most commonly arthroplasty.
Primary OA / DJD: wearing down of the articular surfaces of the
joint over time. Although you see primary osteoarthritis mostly
in older adults, it is not a normal part of the aging process.
Clinical findings: onset of symptoms is usually gradual, and the person is
unable to relate it to a specific mechanism of injury. The patient
typically feels the pain in the groin, and as it progresses, into the
anterior thigh and knee. The person may experience morning stiffness, which
decreases as they begin to move around. Many patients experience aching
pain after moderate activity, such as walking. Management: treat
symptomatically; address capsular tightness via joint mobilization and/or
stretching; assess the person's performance of functional activity and
alter or augment as needed, strengthen the muscles around the joint,
consider non weightbearing activities such as bicycling, swimming, or water
Secondary OA / DJD: arthritis that occurs due to previous damage
or mechanical disorders.
Avascular Necrosis of the Femoral Head: a frequent complication following
trauma, most commonly femoral neck fractures or dislocations. May be
insidious in nature, or due to an injury involving the medial circumflex
femoral artery, which supplies most of the blood to the head and neck of
the femur, resulting in necrosis. Clinical findings include unexplained
aching in the hip, soreness with prolonged sitting, and a general "weak"
feeling in the hip. The person may present with an antalgic gait.
Radiographs may not detect it until in the advanced stages of necrosis,
when flattening of the femoral head is noted. Management: if only part of
the head is involved, the person is treated nonoperatively, strengthening
and range of motion exercises, gait training with initially limited
weightbearing. If the entire head is involved, an arthroplasty is usually
Slipped Capital Femoral Epiphysis (SCFE): a disorder affecting a skeletally
immature femur in which the epiphyseal plate of the head is displaced prior
to fusion due to abnormal weakening of the bone. The etiology is unknown,
or pituitary however it appears to be associated with endocrine
dysfunction. SCFE is usually seen in obese boys typically between the ages
of 10 - 15 years. May be due to direct trauma or sudden onset without
trauma. 20-30% of SCFE involve both hips. Clinical findings usually include
a history of trauma or abnormal/excessive exertion, however absence of
trauma is fairly common as well. Pain is sudden in its onset, and is
located in the groin, the anterior medial thigh, and often radiating to the
medial aspect of the knee. Frequently medial knee pain is the only symptom.
The child will present with decreased internal rotation and weakness of the
internal rotators, with the lower extremity occasionally "rolling" into
external rotation when person is supine; gait may be antalgic, with the
involved extremity(s) held in external rotation. Treatment: surgical
fixation of the growth plate is performed using pins or screws.
Rehabilitation usually occurs post operatively, and will include range of
motion and strengthening exercises, gait training, etc.
Legg-Calve-Perthes Disease (LCP): also known as Idiopathic Juvenile
Avascular Necrosis, is found in children, most commonly boys, between four
and eight years old. LCP is characterized by avascular necrosis of the
femoral head, resulting in a flattening of the femoral head with potential
loss of hip range of motion, deformity, and possibly leading to
osteoarthritis. Clinical findings: pain which is of insidious onset and
intermittent, noted at the anterior groin, medial thigh, and/or medial
knee. This pain is more apparent after exertion. There is a noted stiffness
of the hip with restriction in internal rotation, and the adductors may be
in spasm, limiting abduction. Atrophy of the thigh and buttock musculature
may be apparent. LCP is confirmed radiographically. Treatment: the
objective of management of LCP is to preserve the sphericity of the femoral
head and to preserve/enhance function as much as possible. In early stages
of the disease, abduction braces (worn for 6 to 12 months) may achieve
this, in later stages, surgery may be indicated.
Congenital Dysplasia of the Hip: this process, which is of unknown
etiology, is seen in infants and young children, and occurs 6 to 8 times
more frequently in females. Due to a shallowness of the acetabulum, the hip
subluxes and/or dislocates. Clinical findings: hip instability is noted
along with apparent shortening of the limb due to the femoral head being
displaced upward from the acetabulum; in infants, Ortoloni's Sign is
positive (a "clunk" is palpated with the following movements: the hip is
first adducted and the thigh is depressed to subluxate or dislocate the
hip; the thigh is then abducted. The reduction of the displaced hip causes
the "clunk" that is felt). In children who are ambulatory, a limp may be
noted (with unilateral involvement) or a "waddling" gait (with bilateral
involvement). The abductors are usually weakened. Treatment: most neonatal
hip instability resolves spontaneously, others require bracing via Pavlik
Harness or some other orthoses. Physical therapy may be required for joint
approximation exercises and gait training.
Soft Tissue Injuries of the Hip and Pelvis
Bursitis : the bursae are non-contractile/inert structures that normally
elicit pain on passive stretching or compression of the hip, however a
bursa may also be irritated with resisted tests (Hammer, p. 116). An
absolute diagnosis may be difficult to determine without ruling out other
structures. Point tenderness over the location of the involved bursa
assists with diagnosis (Hammer, p. 116).
Trochanteric bursitis: most common hip bursa involved in
bursitis; The trochanteric bursae comprise two major and one
minor bursae. One major bursa is below the gluteus medius muscle,
somewhat posterior and superior to the proximal edge of the
greater trochanter. the subgluteus maximus, the other major
bursa, is beneath the tensor fasciae latae and gluteus maximus as
they converge to form the iliotibial tract over the greater
trochanter. This bursa is palpable on the lateral aspect of the
thigh at the junction of the lower edge of the greater trochanter
with the lateral proximal femur. Trochanteric bursitis may be
associated with ipsilateral hip joint pathology, lumbosacral
strain, and obesity. Iliotibial band tightening (resulting in a
positive Ober's test) is often related to irritation of the bursa
because the band moves forward with hip flexion and backward with
Tendonitis and Muscle Strains: strains usually occur from excessive tension
(force overload) on eccentrically contracted muscle fibers resulting in
muscle tearing. The end result is scar tissue and contractures. When the
tendinous or tendoperiosteal portion becomes involved because of repetitive
overload, tendinitis results. In the lower extremity, muscles spanning two
or more joints are the most frequently injured (Hammer, p. 117). Two of the
more common muscle strains are:
The patient may describe symptoms similar to L-5 radiculopathy,
or the pain could radiate along an L-2 distribution to the knee.
Swelling and tenderness to palpation over the trochanteric bursa
is usually the primary complaint. There may be aching pain after
running due to overuse. SLR or femoral nerve stretch could be
Iliopectineal and Iliopsoas bursitis: Both types of bursitis
present with pain in the groin and anterior thigh, sometimes down
to the knee. The iliopectineal bursa is located between the
iliopsoas muscle and the hip joint at the iliopectineal eminence
(point of union between the ilium and pubis) over the capsule of
the hip. It may be palpated near the head of the femur, one to
two centimeters below the middle third of the inguinal ligament,
and is found on a horizontal line running halfway between the
pubic tubercle and the greater trochanter.
The iliopsoas bursa lies medially near the insertion of the
iliopsoas in the femoral triangle (bounded superiorly by the
inguinal ligament, medially by the adductor longus, and laterally
by the Sartorius). It may be palpated with the patient supine and
the hip flexed to 90 degrees, the examiner palpated over the
lesser trochanter for tenderness just below the inguinal ligament
while passively abducting the hip with the other hand.
There is definite pain with passive and resisted hip flexion, and
probable pain with passive hip extension.
Ischiogluteal bursitis: the ischiogluteal bursa is located over
the ischial tuberosity and may irritate the sciatic nerve. With
this type bursitis, pain is usually acute and very intense.
Sitting aggravates the condition, (more so on a soft surface than
on a hard surface). Palpation of the ischial tuberosity is
tender, and may reveal a "doughy" texture of the bursa. Lumbar
extension is usually painful.
Adductor Strain: most commonly the adductor longus.
Management: with acute strains, rest, anti-inflammatories, and physical
modalities such as ice and pulsed ultrasound; during the subacute phase
(2-3 weeks) begin gentle warm up, stretching, resistive exercise, and
gradual resumption of activity. At four weeks, begin friction massage
followed by resistive exercise emphasizing the injured region of the
muscle. Prevention is an important aspect of treating all strains. Assess
the mechanism of injury, and educate the patient to alter activities as
warranted (Hertling & Kessler, 1996, p. 305).
Hamstring Strain: may be injured at their attachment to the
ischial tuberosity or within the midbellies.
Dislocations and Fractures of the Hip and Pelvis
Dislocations: are almost always traumatic in nature and involve injury to
other soft tissue structures. Posterior hip dislocations occur with hip
flexion, adduction, and internal rotation; anterior dislocations occur with
slight flexion, abduction, and external rotation. Management: patients
usually have some degree of immobilization. During this time you may treat
inflammation, perform functional activities while protecting the hip, and
maintain strength at the knee, foot, and ankle, as well as of the
uninvolved extremity. Depending on the extent of the injury, active
isolated motions may begin as early as the second or third week post
injury, however the patient determines the extent of movement. After four
weeks, the therapist may be more aggressive with exercise and activity
prescription. Typically you do not want the patient to perform the combined
motions that produced the dislocation until six or seven weeks.
Fractures: can be caused from macrotrauma or repetitive microtrauma, or the
fracture may result from a relatively simple movement, as in the case of
Stress Fractures: usually occur in young, active people as a
result of repetitive microtrauma. When the fracture is protected,
it usually will heal without difficulty. Stress fractures are not
common in the hip, but they do occur at the anterior iliac crest
due to faulty running mechanics. Clinical findings : pinpoint
tenderness and pain over area of the stress fracture. Initially
radiographs may be normal. A good history is essential for
diagnosis: activities, changes in activity, and analysis of
movement. The cause must be determined and treated via relative
rest, relief of weight bearing, avoiding stressful positions.
Fractures of the Femoral Neck: occur primarily in elders and are usually
associated with osteoporosis. Forces that produce these fractures are often
small, with fractures being caused by twisting the hip while weight
bearing, stumbles, or a fall from standing height. The actual fall is often
secondary to the fracture. This is the most common hip fracture and occurs
in 1 out of 1,000 women over the age of 70. It is an intracapsular fracture
and thus normal blood supply is disrupted to the head, which often results
in avascular necrosis.
Femoral Shaft Stress Fractures: a partial or complete fracture of
the femur due to the inability to withstand nonviolent stress
that is applied in a rhythmic, repeated, subthreshold manner.
Seen in athletes, soldiers, etc. Clinical findings: initially
symptoms are vague and the location of tenderness is diffuse.
Reid states that 87% complain of anterior groin pain (pg. 645).
No history of trauma however initial symptoms often start after
intense exercise. Reid reports most constant finding is
discomfort at extremes of hip rotation and 2/3 of the athletes he
saw with this injury had TOP anterior inguinal area (pg. 645).
Often misdiagnosed as a muscular problem. Typically found in
runners who train more than 20 miles/week. These occur most
commonly in the proximal 1/3 of the femur. Treatment:
conservative treatment is highly successful. Relative rest, a
program that includes bicycling and swimming during the early
phases of treatment. Sports that involve impact loading are
avoided for 6-8 weeks. If pain with ambulation, a period of
protected weight bearing is advisable. Well-leg and upper body
conditioning exercises are important. The person can usually
return to running in approximately 8 weeks.
Avulsion Fractures: a fracture in which the attachment of a
tendon or ligament is pulled from the bone; mechanism of injury
involves a violent muscle action or tremendous
acceleration/deceleration of the body. Common in teenagers whose
epiphyseal plates are not completely closed. Common sites: the
ASIS, AIIS, Greater trochanter, and Lesser trochanter. Clinical
findings: point tenderness at the avulsion site, therapist may be
able to palpate the bone fragment. Active movement and passive
stretch of the muscle is painful. Radiograph confirms. Treatment:
usually requires internal fixation, unless the avulsion is
incomplete, in which case immobilization is the preferred method
of treatment. Client may ambulate with crutches,
weightbearing/activity altered depending on cause of avulsion: if
muscular, prevent contractions until healing has progressed.
Well-leg and upper body exercise, after cast is removed: active
The Garden Stage classification of femoral neck fractures is based on the
radiographic appearance of the fracture:
In general, the vitality of the person, configuration of the fracture,
quality of the bone, and accuracy of reduction influence the type of
fixation and outcome. Garden Stage I are the only fractures that may not
require surgical fixation. With this fracture, the person is on bed rest
for 3 weeks and should perform only mild hip and knee exercise. After 3
weeks sitting and crutch ambulation is allowed, but full weight bearing
must be avoided for 8 weeks.
- Stage I: incomplete or impacted fracture
- Stage II: complete fracture without displacement
- Stage III: complete fracture with partial displacement
- Stage IV: complete fracture with full displacement, continuity of
fragments is disrupted.
The remaining Garden fractures require surgical intervention if healing is
to occur. Because of the high rates of non-union and development of
avascular necrosis, most surgeons now perform some type of prosthetic
replacement in types III and IV. Type II fractures are typically treated
with closed reduction, if possible, or some type of internal fixation.
Intertrochanteric Fractures: occur along a line between the greater and
lesser trochanters and are more common among elders and almost always is
the result of a fall. Treatment: typically internal fixation via pin and
plate; frequently includes the use of intramedullary rods that run through
the center of the bone to stabilize the fracture fragments. Failure of the
fixation device and mal-union are the most common complications. Weight
bearing status is usually touch down weight bearing.
Subtrochanteric Fractures: the least common and most unstable traumatic
fracture, also the most difficult to treat because of the height mechanical
stresses in this area of the femur. Subtrochanteric fractures are the
result of direct trauma of considerable force, and is the most frequent
femoral fracture in the younger population. Treatment: usually
intramedullary rod or plates, screws, or nails. The Zickle Nail is fairly
commonly used. The person is routinely non weightbearing or toe-touch
weight bearing for four to six weeks. Straight leg raises are absolutely
Additional femur fractures:
Fractures of the Shaft: similar to fractures of other long bones. Shaft
fractures are usually fixated internally via intramedullary (IM) rodding,
or via external fixators, such as Hoffman devices. Ilizarov devices are
commonly utilized to lengthen the femur if a significant amount of bone is
Intercondylar Fractures: usually the result of longitudinal stresses placed
on the femur, such as falls in which the person lands on their feet.
Articular surfaces may be involved, depending on the location of the
fracture within the condyle(s). Nails, pins, screws, etc. may be used. At
times a CPM may be utilized if articular surfaces are involved.
Methods of Stabilization/fracture fixation: The method of internal fixation
depends upon the location and severity of the fracture as well as the age
and physical condition of the person. Various devices are available for
internal fixation, and must be constructed of materials that will be
resistant to corrosion in the tissues. Commonly used materials include:
surgical grade stainless steel, cobalt chrome, and titanium alloys.
Hip Pinning: multiple threaded pins are applied at varying angles across
the fracture site. It may take 3-6 months for the fracture to heal, during
which weight bearing is limited or prohibited. Typically the fracture fully
heals, unless complicated by an injury to the blood supply, then avascular
necrosis or nonunion may result.
Compression Plate: metal plates and screws are used to secure the fracture.
At times the metal plate is removed following fracture healing, because the
plate alters the normal weight bearing pattern of the bone and increases
the potential for future fracture. If the plate is removed, there is a
temporary weakening of the bone where the screws were removed, and weight
bearing must be limited for a few weeks.
Intramedullary Nail: often used for trochanteric fractures. The IM nail is
placed into the endosteal canal of the bone and performs load-sharing
duties: which usually permits weight bearing across the fracture site.
Compression Screw-plate: commonly called the Dynamic Hip Screw. This is
often used for extracapsular fractures of the proximal femur. The screw
grips the femoral head, then slides telescopically into the barrel.
Tightening of a screw in the base of the barrel creates compression across
the bone fragments. Complications are rare, and usually result from failure
of surgical technique rather than failure of the device.
Treatment Guidelines: for people with fractures repaired by internal
fixation, goals are to help the person achieve functional independence in
their various life roles, with adherence to prescribed weight bearing
status, and any precautions associated with the surgery. Gait training is
performed utilizing the most appropriate assistive device. Once there is
radiographic evidence of healing, most patients are allowed to increase
their weight bearing to tolerance.
Pelvic Fractures: are classified as minor or major. Minor fractures involve
avulsions and simple bone disruptions, and are routinely not fixated, due
to the stable nature of these injuries. Major fractures involve more than
one break in the pelvic ring and include displaced sacral injuries, and may
involve internal fixation. Major signifies potential pelvic instability or
serious associated complications. Treatment includes exercise within the
framework of the injury and to patient tolerance, gait training with the
most appropriate assistive device and adherence to appropriate weight
Evaluation of the Hip and Pelvis
For a fairly complete history and physical examination, refer to pages 291
- 298 of Hertling and Kessler (1996).
The evaluation should be reflective of the general orthopedic evaluation,
including a thorough chart review, pertinent history, and physical
examination, proceeding from a general approach to a specific approach.
Although a person's diagnosis may be specific to the pelvis or hip, it is
important that the therapist not be so focused on the pelvis or hip that
other areas of involvement may be missed. Once the general evaluation has
been performed, then tests specific to the hip and pelvis can be
Differential Diagnosis of the Hip and Pelvis include:
- Patrick's/Fabere Test
- Trendelenburg Test
- True Leg Length Test
- Ober's Test
- Craig Test
- Thomas Test
- Modified Thomas Test
- Ely's Test
- Noble Compression Test
Return to Table of Contents