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Hip Adduction BONES AND JOINTS OF THE LOWER LIMBS Yasser Moh. Aneis, PhD, MSc., PT. Lecturer of Physical Therapy Basic Sciences Department BONES AND JOINTS OF THE LOWER LIMBS The Pelvis The top portion of the femur with its head in the acetabulum Bones of the right thigh, anterior and posterior view Bones of the lower leg Bones of the foot PELVIC ELEVATION (Hip Hiking) oThe Primary muscle •Quadratus Lumborum Origin: -Iliac crest. -Iliolumber ligament. Insertion: -Inferior border of 12th rib. -Apices of transverse processes of L1- 4. - Iliolumber ligament. Nerve supply: -Anterior primary rami (T12, L1, L2, L3) Range of Motion: -In standing position pelvis may be raised on one side until foot is well clear of floor. Action: -Elevates the pelvis laterally by producing a lateral flexion of the lumber spine. -Depress the last rib and fixes the last two ribs during forced expiration. Action of Quadratus Lumborum Muscle •Factors Limiting Motion: -Tension of spinal ligaments on opposite side. -Contact of iliac crest with thorax. Testing procedure oGrades 4-5. "Good and Normal strength" -Back lying with lumbar area of spine in moderate extension. -Patient grasps edge of table to stabilize thorax. -Therapist stands at the foot of the table, both hands grasping the lower limb above or proximal to the ankle joint. •Command: -Pull up your pelvis toward the thorax on one side ----Relax. •Resistance: -resistance is given in a form of traction on the extremity directly opposing the line of pull. oGrade 3 and Grade 2 (Fair and Poor Strength) -Patient starting position :Same as for Grade 4&5. -Therapist stands at the foot of the table, both hands grasping the lower limb above or proximal to the ankle joint. •Resistance: -Grade 3: Slight resistance is given in a form of traction on the extremity directly opposing the line of pull. -Grade 2:No resistance but complete range of motion. oGrade 3 Fair Strength (Alternative) -Patient Starting Position is Standing. -Therapist stride standing behind the patient stabilizes the patient thorax with both hands. •Command: -pull up your pelvis toward the thorax on one side through full ROM ----Relax. oGrades 1 and 0. "Trace and Zero strength" -The patient is Back lying with leg completely extension. -The therapist stands at the side of the table and support the thigh with his arm (proximal to the knee ) as his proximal hands deeply palpates in the lumber area under lateral edge of erector spine. Muscle Testing of Hip Flexion oThe Primary muscles -Psoas major. -Iliacus. oThe Accessory muscles -Rectus Femoris. -Tensor fasciae late. -Sartorius. -Pectineus. Psoas Major Muscle Origin: -Transverse processes of all lumber vertebrae L1-5. -Bodies and intervertebral disks of the last thoracic and all lumbar vertebraeInsertion: -Middle surface of lesser trochanter of femur. Action: -Flexes and laterally rotates hip Nerve: Anterior primary rami of L1,2,3,4 Iliacus Muscle Origin: -The inner border of the iliac crest. Insertion: -Lowermost surface of lesser trochanter of femur. Action: -Flexes and laterally rotates hip Nerve: Anterior primary rami of L1,2,3,4. Range of Motion: -The hip flexion with the knee flexed will permit a range of motion approximately 115 to 125. •Factors Limiting Motion: -Contact of thigh on abdomen. -Tension of the hamstring muscles Action of Iliopsoas Muscle Testing procedure oGrade 3 "fair strength" -Patient is sitting with legs over edge of table, grasping the edge of table to stabilize pelvis or arms may be folded on the chest if patient is stable enough. -The therapist stand at the foot of the table, with one hand against the anterior shoulder area gives counter pressure. -while the other hand applies pressure against the thigh, in the direction of hip extension. •Command: -Raise up your leg vertically “in the mid line” towards your chest through full range of motion then-relax. oGrades 4-5. "Good and Normal strength" -Same as for Grade 3. with one hand against the anterior shoulder area gives counter pressure, while the other hand applies pressure against the thigh, in the direction of hip extension. -Grade 4: Moderate leading resistance is given directly opposing the line of motion. -Grade 5: Maximum leading resistance is given throughout the range plus a "hold" at the end of the range. oGrade 2. "poor strength" •Patient Starting Position is Side lying, -with the affected leg down. -Trunk, pelvis, legs are straight. -Upper leg is supported. •Therapist stands behind the patient with the proximal hand stabilizing the pelvis “the side of the affected leg and the distal hand supporting the upper leg. •Note: Patient is allowed to flex the knee to prevent tension brought by the hamstring muscles. •Command: -With flexed knee move your leg toward your chest through full range of motion.----relax. oGrades 1 and 0. "Trace and Zero strength" -The patient is Back lying, both legs are extended, with affected leg near the edge of the table. -Therapist stands beside the table, distal hand supporting the affected leg, the proximal hand palpating contraction of psoas major muscle just distal to the inguinal ligament. Substitutions -Substitution by Sartorius in hip flexion causes lateral rotation and abduction of thigh. Hip Flexion, Abduction & External Rotation by Sartorius Muscle -Substitution by tensor fasciae latae in hip flexion causes medial rotation and abduction of thigh. Hip Flexion, Abduction & internal Rotation by tensor fasciae latae Muscle Effects of weakness of the hip flexor muscles •Weakness of the hip flexor muscles decreases the ability to flex the hip joint and results in marked disability in: -Stair climbing. -Walking up or down the incline. -Getting up from a reclined position. -Bringing the trunk forward in the sitting position preliminary to rising from a chair. •In marked weakness, walking is difficult because the leg must be brought forward by pelvic motion (produced by anterior or lateral abdominal muscle action) rather than by hip flexion. Contracture of Hip Flexor Muscles, and Their Effect on Posture -Bilateral hip flexion deformity will be combined with increased lumber lordosis. Iliopsoas Muscle Bilateral Hip Flexion Compensatory Kypho-Lordosis -Unilateral hip flexion contracture will be often combined with hip abduction and external rotation. Muscle Testing of Hip Extension oThe Primary muscles -Gluteus Maximus -Biceps Femoris -Semimembranosus -Semitendinosus Gluteus Maximus Muscle Origin -Outer surface of ilium behind posterior gluteal line -posterior third of iliac crest -lumbar fascia -lateral mass of sacrum & coccyx Insertion -Gluteal tuberosity of femur -Iliotibial tract Nerve supply -Inferior gluteal nerve (L5, S1,2) Action -Extends and laterally rotates hip. -Maintains knee extended via iliotibial tract Biceps Femoris Origin -Long head: posterior surface of ischial tuberosity -Short head: middle third of linea aspera, lateral supracondylar ridge of femur Insertion -Head of fibula -Lateral collateral ligament -Lateral tibial condyle Nerve supply -Sciatic nerve Action -Flexes and laterally rotates knee -Long head extends hip Semimembranosus Origin -Posterior surface of ischial tuberosity Insertion -Medial condyle of tibia below articular margin Nerve supply -Sciatic nerve (L5, S1) Action -Extends hip -Flexes and medially rotates knee Semitendinosus Origin -Posterior surface of ischial tuberosity Insertion -Upper medial shaft of tibia Nerve supply -Sciatic nerve (L5, S1) Action -Extends hip -Flexes and medially rotates knee Range of Motion: -Extension: 115º – 125º to 0º. -Extension beyond midline 0º to 10º - 15º. •Factors Limiting Motion: -Tension of iliofemoral ligament. -Tension of hip flexor muscles Testing procedure oGrade 3 "fair strength" -Patient Starting Position is Prone lying with legs extended. -Therapist stands beside the table with the proximal hand stabilizing the pelvis. •Command: -Raise up your leg through full range of motion---- relax oGrades 4-5. "Good and Normal strength" -Same as for Grade 3. with one hand stabilizing the pelvis. While the distal hand is placed proximal to the knee joint to give resistance. Resistance -Resistance is given in a form of pressing down directly opposing the line of raising. oGrade 2. "poor strength" -The patient is side lying with affected legs on the table, hip flexed, and knee extended. -Therapist stands behind the patient with the proximal hand stabilizing the pelvis & the distal hand supporting the uppermost leg. oGrades 1 and 0. "Trace and Zero strength" -Patient Starting Position is prone lying with legs extended. -Therapist stands behind the patient with his hands palpates the upper and lower portion of the muscles. -A contraction of the gluteus maximus muscle will result in a narrowing of the gluteal crease. -Command: Squeeze or press your buttock together --- -- relax. Test for isolation of Gluteus Maximus Muscle -Patient Starting position is prone with knee flexed. -The therapist proximal hand stabilizing the pelvis -The distal hand is placed proximal to the knee joint to give resistance. •Command: -Extends your hip, keeping knee flexed to decrease action of hamstrings. Effects of weakness of the hip extensor muscles -Bilateral marked weakness of the Gluteus maximus muscle makes walking extremely difficult, and necessitates the aid of crutches. -Raising the trunk from a forward-bent position requires action of the gluteus maximus, and in cases of weakness, patients must push themselves to an upright position using their arms. -when gluteus maximus is weak, trunk lurches backward (maximus lurch) at heel-strike on weakened
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