Therapeutic Kinesiology:Musculoskeletal Systems, Palpation, and Body Mechanics

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