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Chapter 13 Notes
Transcript
Therapeutic Kinesiology Instructor Manual: Ch13 p.1
TK INSTRUCTOR MANUAL: CHAPTER 13
The Hip and Pelvis
Chapter manuals include:
Objectives
Lecture Notes
Suggested Classroom and Student Development Activities
For other chapter-by-chapter resources, see:
Key Term Quizzes
Muscle Origin and Insertion Worksheets
Muscle OIAs List by Chapter
MyTest Test Bank
For additional resources see “Teaching Tips and Tools”:
7 research-based learning principles for kinesiology courses in massage
5-step self-directed learning cycle for body mechanics courses
Tools that build metacognitive skills: e.g., concept (mind) maps, grading rubrics, and self-assessments inventories
OBJECTIVES
Name the four bones of the hips and pelvis.
List and demonstrate the palpation of 14 bony landmarks of the hips and pelvis.
Describe the coxofemoral joint, its range of motion, and its supporting ligaments.
Describe the two femoral inclinations and how the shape of the femur creates each one.
Describe six ways the hip can move at the pelvis and the pelvis can move on the femur.
Name three pelvic joints, their functions and classifications, and their ranges of motion.
Name and discuss four common hip problems.
Define the lumbar pelvic rhythm and describe efficient and inefficient rhythms.
Identify the origins, insertions, and actions of the muscles of the hips and pelvis.
Identify the trigger points and pain referral patterns of the muscles of the hips and pelvis.
Demonstrate the active movement and palpation of each muscle of the hips and pelvis.
Identify three perineal muscles and describe their general locations and functions.
Discuss the postural patterns that occur with chronically tight hamstrings or quadriceps.
LECTURE OUTLINE
BONES OF THE HIPS AND PELVIS
Features of the hips and pelvis
A well-balanced weight-supporting structure
Hips and pelvis allow
Limb and trunk mobility in three directions
Bidirectional force transmission between legs and trunk
Bones
Coxal bones (innominate)
Three separate bones at birth: ilium, ischium, pubis
Fuse into a single bone by age 25
Sacrum
Triangular-shaped bone
The keystone of the pelvic girdle
Coccyx
A small vestigial tail
Five separate bones that fuse by birth
Bony landmarks of hip
Greater trochanter
Neck of femur
Lesser trochanter
Head of femur
Linea aspera
Bony landmarks of ilium
Iliac crest
Iliac fossa
Anterior superior iliac spine (ASIS)
Anterior inferior iliac spine (AIIS)
Posterior superior iliac spine (PSIS)
Posterior inferior iliac spine (PIIS)
Bony landmarks of ischium and pubis
Ischial ramus
Ischial tuberosity
Obturator foramen
Pubic crest
Pubic rami
Pubic tubercles
Bony landmarks of sacrum
Sacral foramen
Median sacral crest
Sacral hiatus
Coccyx
Pelvic girdle
Made up of coxal bones and sacrum
Circular structure also called pelvic ring
Wider in females than males
Stability depends on integrity of pelvic joints
Coxofemoral joint: Ball-and-socket joint
between femoral and acetabulum
Acetabular labrum: Cartilaginous band that deepens socket
Covered by largest ligaments in the body
Deep hip socket is rarely dislocated
Stable in extended position because ligaments are taut
LIGAMENTS OF THE HIPS AND PELVIS
Coxofemoral ligaments
IIiofemoral ligament: Y ligament
Binds ASIS to neck of femur
Limits hyperextension, abduction, lateral rotation
Pubofemoral ligament
Binds anterior pubic ramus to anterior intertrochanteric fossa
Limits hyperextension, abduction, lateral rotation
Ischiofemoral ligament
Binds posterior acetabular labrum to greater trochanter
Limits adduction, medial rotation, hyperextension
Hyperextension twists its fibers into taut position
Femoral angulations
Angle of inclination: Between neck and shaft of femur
Averages 135 degrees
Abnormal angle of inclination
Coxa valga: Decrease in angle, is less stable
Coxa vara: Increase in angle, is less mobile
Angle of torsion: Between femoral neck and femoral axis
Averages 15 degrees
Greater/lesser angles cause pathological variances
Affects biomechanics and stability of hip
Leads to muscular pain and compensations
Compensations: Toed-in or toed-out patterns
Six movements of femur at pelvis
Flexion: soft end-feel
125 degrees with knee extension
140 degrees with knee flexion
Hyperextension: 1015 degrees
Abduction: 45 degrees
Adduction: 10 degrees
Lateral rotation: 45 degrees
Medial rotation: 45 degrees
Six movements of pelvis at femur
Posterior tilt
Anterior tilt
Right lateral tilt
Left lateral tilt
Forward rotation
Backward rotation
Lumbar pelvic rhythm
Coordinated ratio of motion between hips/lumbar spine
Allows person to bend farther forward
Normal rhythm: lumbar spine flexes, then hips flex
To assess, observe forward-bending motion and notice:
Which moves first, lumbar spine or hips?
How far does each joint move?
Observe reverse motion and ask same questions
Abnormal lumbar pelvic rhythms
Abnormal rhythms affect efficiency of forward bending
Restricted lumbar flexion causes hyperflexion in hips
Restricted hip flexion causes hyperflexion in lumbars
NM patterning can improve rhythm
Joints of pelvis
Pubic symphysis: fibrocartilage joint
Between pubic bones along anterior pelvic ring
Semimovable: Moves primarily during childbirth
Sacroiliac joints (SIJs): Synovial in top portion, fibrous in bottom portion
Between sacrum and ilia
Oriented in the sagittal plane
Sacrococcygeal joint: small fibrous joint
Between distal sacrum and coccyx
No active range of motion
Passive motion during defecation and labor
Sacral Ligaments
Sacroiliac ligament: Has anterior and posterior layers
Binds front/back of sacrum to ilium
Strong ligament covering most of sacrum
Sacrotuberous ligament
Anchors sacrum to ischial tuberosity
Sacral torsions? one side slack, other side taut
Sacrospinous ligament
Anchors sacrum to ischial spine
Ligamentous hammock suspends lower sacrum
Sacrococcygeal ligament
Tethers coccyx to sacrum
Attaches anterior coccyx to anterior sacrum
Sacroiliac joint stabilization
Stabilization occurs three ways:
Ligamentous support
Form closure: Sacrum wedged between ilium
Forced closure: Transversus abdominis contraction pulls ASIS together
Sacroiliac joint dysfunction
Common SIJ dysfunction
Destabilized on one side, hypermobile on other
Upslip or downslip in coxal bone on one side
SIJ dysfunctions are caused by:
Mechanical stresses (compression, torsion, etc.)
Sudden force that damages ligaments
Leg-length discrepancies and postural asymmetries
Muscle dysfunctions:
Weak gluteus maximus
Inhibited transversus abdominis and abdominal distension
Piriformis spasm
Quadratus lumborum spasm that hikes hip on one side
Sacroiliac joint motion
SIJ has small range of uniaxial nodding motion in sagittal plane called:
Nutation: Top of sacrum rocks forward
Counternutation: Top of sacrum rocks backward
Common hip problems
Arthritis
Painful in weight-bearing
Can degenerate joint, require hip replacement
Osteoporosis
Common in seniors
Makes hips susceptible to fracture
Bursitis
Inflammation causes pain during movement
Can be trochanteric or psoatic bursitis
Labral tear
Causes deep pain with flexion and adduction
Can heal or may need surgical repair
MUSCLES OF PELVIS AND HIP
Introduction
Both biarticular and uniarticular muscles
Functions vary according to position of pelvis
Abductors
Tensor fascia latae
O: Iliac crest and posterior side of ASIS
I: Lateral condyle of tibia via iliotibial band
A: Abducts and medially rotates hip, assists hip flexion
Sartorius: "Tailor's muscle"
O: Anterior superior iliac spine (ASIS)
I: Proximal medial tibia, superior tendon of pes anserinus
A: Flexes, abducts, and laterally rotates hip; flexes and medially rotates knee
Gluteus medius: "Deltoid of hip"
Adductors
Pectineus
O: Superior pubic ramus
I: Pectineal line of femur
A: Flexes and adducts hip, assists medial and lateral rotation (depending on position of hip)
Adductor longus: Most superficial, prominent proximal tendon
O: Anterior pubic ramus, lateral to pubic tubercle
I: Middle third of linea aspera
A: Adducts hip, assists hip flexion and medial rotation
Adductor brevis: Smallest adductor
O: Anterior pubic ramus, inferior to pubic tubercle
I: Medial lip of linea aspera
A: Adducts hip, assists hip flexion and medial rotation
Adductor magnus
O: Inferior pubic ramus
I: Linea aspera, adductor tubercle
A: Flexes, extends, and medially rotates hip; adducts hip during resisted adduction
Gracilis: Only two joint adductors
O: Inferior pubic ramus
I: Proximal medial tibia, middle tendon of pes anserinus
A: Adducts hip, assists hip flexion and knee flexion
Gluteals
Gluteus maximus: Bulk of buttock's mass, often weak
O: Lateral, posterior ilium, lateral sacrum and coccyx, sacrotuberous ligament
I: Gluteal tuberosity of femur and iliotibial band
A: Extends and laterally rotates hip, lateral fibers abduct hip, medial fibers adduct hip
Gluteus medius
O: Outer surface of ilium
I: Lateral surface of greater trochanter
A: Abducts hip, posterior fibers laterally rotate and extend hip, anterior fibers medially rotate and flex hip
Gluteus minimus
O: Lateral ilium
I: Anterior surface of greater trochanter
A: Abducts and medially rotates hip, assists hip flexion
Iliopsoas
Iliacus
O: Iliac fossa
I: Lesser trochanter
A: Flexes and laterally rotates hip
Psoas major
O: Bodies and transverse processes of L-1 to L-4
I: Lesser trochanter
A: Stabilizes anterior lumbar spine, flexes and laterally rotates hip
Psoas minor: Absent in 50% of population
O: Body of 1st lumbar vertebra
I: Superior pubic ramus
A: Supports and levels front of pelvic rim
"Deep six" lateral hip rotators
Piriformis
O: Anterior surface of the sacrum
I: Superior surface of the greater trochanter
A: Laterally rotates hip, abducts thigh
Gemellus inferior
O: Upper aspect of ischial tuberosity
I: Upper surface of greater trochanter
A: Laterally rotates hip
Gemellus superior
O: Ischial spine
I: Upper surface of greater trochanter
A: Laterally rotates hip
Obturator externus
O: Obturator membrane and anterior side of obturator foramen
I: Under medial lip of greater trochanter
A: Laterally rotates hip
Obturator internus
O: Obturator membrane and posterior side of obturator foramen
I: Under medial lip of greater trochanter
A: Laterally rotates hip
Quadratus femoris: Most inferior rotator, often tight and tender
O: Ischial tuberosity
I: Lower surface of greater trochanter
A: Laterally rotates hip
Piriformis syndrome
NM disorder from muscle spasm
Piriformis muscle compresses sciatic nerve
Causes pain, tingling, and numbness
Often leads to combination of three conditions:
Nerve and vascular entrapment
Myofascial pain from piriformis TrPs
Sacroiliac joint dysfunction
Perineal muscles and "pelvic floor"
Diamond-shaped muscular sling, floor of pelvis
Between pubic bone, coccyx, ischial tuberosities
Coccygeus (pubococcygeus and iliococcygeus)
O: Sacrospinous ligament and ischial spine
I: Lateral sides of coccyx and sacrum
A: Aids defection by pulling coccyx forward, supports pelvic viscera, draws back of perineum in
Levator ani
O: Inner posterior surface of ramus of pubis, obturator fascia, spine of ischium
I: Pelvic fascia, sides of distal rectum, sides of distal vagina, last two segments of coccyx
A: Supports pelvic viscera, draws perineum in
Contains anal orifice and vaginal opening
Under constant load, supports pelvic organs
Part of postural stabilizing system
Co-contracts with transversus abdominis
Toned with slow-motion Kegal
Rectus femoris and hamstring balance
Works as opposing pairs to level pelvis
Can become adaptively shortened and stretch-weakened
Short rectus abdominis and weak hamstrings ? posterior pelvic tilt
Short hamstrings and weak rectus abdominis ? anterior pelvic tilt
SUGGESTED CLASSROOM AND STUDENT DEVELOPMENT ACTIVITIES
PROVIDE AN OVERVIEW OF THE CLASS
Before class, write a short schematic overview of the class on the board, then go over it at the beginning of class. For example:
Today's class covers:
Bones of hip and pelvis
Joints and ligaments
Muscles
Activities: Review, lecture and assessments, palpation exercises, recap
STRUCTURAL OBSERVATION EXERCISE: The hip and pelvis: Have several volunteers stand in a line and have the rest of the class observe and study the position of the hips and pelvis. As they do, ask these questions or discuss these elements.
Front view
What is alignment of femur in relation to joint neutral?
Is either hip laterally or medially rotated?
Is either hip abducted or adducted?
Which side carries weight? Is one hip higher than the other?
What is the Q-angle and the angle of inclination? It should be 57 degrees in a position.
Is there a chronic toed-out pattern or chronic toed-in pattern?
In each pattern, which hip muscles are adapatively shortened and which hip muscles are stretch-weakened? What kind of mechanical stress does each pattern put on the hip joint?
Compare the individual patterns.
Discuss which muscles might be adaptively shortened, which muscles might be stretch-weakened, and how to address this in bodywork.
Side view
Where is center of gravity in the pelvis? Is it behind, on, or in front of the center of gravity in the thorax? Is it over the center, behind, or in front of the center of the knee and foot?
Is the pelvis level, anteriorly tilted, or posteriorly tilted?
Ask the volunteers to explore tilting the pelvis forward and back and notice the effect on spinal alignment. Notice the effect of the tilt on the knee, ankle, and foot alignment. What happens to the spine in each tilt? What happens to the balance of the pelvis over the leg in each tilt?
Compare the individual patterns.
Discuss which muscles might be adaptively shortened, which muscles might be stretch-weakened, and how to address this in bodywork.
GAIT OBSERVATION EXERCISE: The hips and pelvis
Do legs swing in sagittal plane?
Is there a lateral weight shift with clear motion between right, center, and left?
Does the pelvis rotate as block or is there a nutation moment in the sacrum?
Does the gluteus maximus fire during hip extension?
Where is weight on feet and how does this affect hips and trunk?
Examples: feet on heels, PPT in pelvis, swayback spine (UB carried behind LB)
EXPLORING TECHNIQUE EXERCISES
Passive range of motion for the hip (p. 391)
Stretching the iliotibial band (p. 401)
Quadriceps length assessment and stretch (p. 429)
Hamstring length assessment and stretch (p. 430)
PALPATION EXERCISES
Hips and pelvis (p. 381))
Sacral ligaments and sacral motion (p. 397)
Sartorius and tensor fascia latae (p. 403)
Adductor longus, adductor brevis, pectineus, gracilis, and adductor magnus (p. 408)
Gluteus maximus, gluteus medius, and gluteus minimus (p. 414)
Iliacus and psoas major (p. 418)
“Deep six” lateral hip rotators (p. 424)
SELF-CARE EXERCISES
Seated pelvic rock (p. 379)
Stretching the lateral hip rotators (p. 423)
Exercises for the perineal muscles (p. 427)
Stretching the hip muscles (p. 431)
© 2013 by Education, Inc. Foster, Instructor Resources for Therapeutic Kinesiology
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