Body weight from above is transmitted downward through the lower extremity in the upright position, and this force is greatly multiplied in locomotion. A priority in examining disorders of the lower extremity is to determine whether the primary lesion is local. While it is true that nerve contusions or entrapment syndromes will produce pain, weakness, paresthesias, and other neurologic symptoms locally, such symptoms can also mean a vascular disturbance or a neurologic lesion in the brain or spinal cord. It is also well to note that, at times, pelvic or retroperitoneal disease will mimic a nerve root impingement syndrome manifesting solely in one or both lower extremities.

Hip Pain

The common causes of hip pain are shown in Table 1.

Table 1.   Common Causes of Hip Pain

Soderberg points out that, regardless of etiology, pain is a symptom common of most hip diseases.

"In such a circumstance, patients assume postures that diminish the force through the hip joint. During normal standing, the magnitude of the forces is low and usually tolerable. However, single limb stance during gait significantly increases the joint force due to the abductor muscle force required to keep the pelvis from dropping on the opposite side."

Thus, overstressed fatigued muscles from an adductor lurch are a common cause of hip pain, and it should be recognized that this soft-tissue stress and the pain associated are almost always a secondary condition.

Another initial concern during physical examination when hip pain is the primary complaint is to determine if joint motion is restricted and if certain passive motions conducted in a nonweight-bearing position aggravate or initiate the pain. Early evaluation should include internal and external rotation, abduction and adduction, and flexion and extension. Branch reports that the loss of normal internal rotation is the most sensitive sign of hip disease.

Hip joint dysfunctions often refer pain more distally in the ipsilateral lower extremity, and while the lumbosacral region may refer pain to the area of the hip, rarely does a diseased hip joint refer pain to the lower back. Sciatic pain and tenderness clearly confined to the distribution of the sciatic nerve can usually be traced to lumbar or sacroiliac subluxation, strain, or looseness; spondylitis; and neuritis. Some pathologies that often refer to the hip area are prostatitis, prostatic abscess or neoplasm, and pelvic tumors or abscesses, including psoas abscess.


Thigh Trauma

Sports injuries and related disorders of the thigh include contusions, abrasions, strains, contractures, vascular abnormalities, and infrequent femoral fractures. Pain can be referred from above (eg, lumbar spine, pelvis, hip) or from below (eg, knee, ankle, foot). Minor mat, court, or turf abrasions of the thigh are seen in sports that do not require protection. These are usually easily managed if precaution is taken against secondary infection. Lacerations are rarely seen excepting vehicular and cycle sports, but muscle contusions and strains are common.


      SCREENING TESTS FOR THE LOWER EXTREMITY

Gillet found that when extra-vertebral articulations are fixated, they have a tendency to produce and reproduce spinal subluxations. Thus, the analysis and elimination of articular causes must consider every segment in the kinematic chain from foot to occiput.

Background

Most primary injuries involving the lower extremities are of a musculotendinous unit. For accurate physical diagnosis, inspection, thorough palpation of bone and soft tissues, comprehensive evaluation of joint motion, and testing reflexes and active muscle action against resistance will usually point out the effects. Chronic weakness or shortening of muscles and ligaments often underlies a sprain or strain initiated by abrupt trauma or prolonged overstress.

Pioneer chiropractors considered most subluxations the effect of trauma. We now realize that this is not the case and that many subluxations can be the effect of intrinsic stresses (eg, mechanical, chemical, emotional). In general, it is believed that these subluxations will continually recur if the reasons for their existence are not also eliminated. In general, any fixated subluxation that has been effectively mobilized yet tends to recur should be considered as secondary to another cause.

During the evaluation of lower-extremity neuromusculoskeletal disorders, it is well to initially seek signs of atrophy, hypertrophy, fibrillation, and abnormal movements such as tremors, myoclonus, chorea, athetosis, tics, etc. Gross postural defects, structural attitude, and deformities should also be noted. The range of joint motion at each area can be measured with a goniometer during the orthopedic part of the examination. Then voluntary power of each group of muscles can be tested against resistance and compared bilaterally. Abnormal muscle tone and texture can be determined by palpation during passive movements.


Paralysis

True paralysis is usually pathologic rather than the effect of local malfunction (eg, transient circulatory insufficiency), and common clues aid the gross differentiation of paralyses. For example, in spastic paraplegia of any type, the legs are stiff, the reflexes are increased, but sensation and the sphincters are normal. There is no atrophy. Hysteria, however, is not uncommon in youth. It may take on almost any type of paralysis and deceive even the experienced examiner. As a rule, other evidence of hysteria will guide the diagnosis.


      PHYSICAL SIGNS OF HIP LESIONS

Following are some clinical tests designed to bring out a hip lesion or pathology affecting the hip. Although the originators of these tests often claimed the procedures to be specific and diagnostic, analysis of the biomechanics involved during the maneuvers usually disprove inflated claims. They are all helpful, however, when used as one tool in the diagnostician's kit that must be thoroughly substantiated.

Remark's Sign.   This sign results when for any reason the conducting pathways of the spinal cord are interrupted. When the upper third of the anterior surface of the thigh is mildly stimulated by stroking, the reflex consists of extension of the knee with plantar flexion of the first three toes in which the foot may also participate plantarly.

Patrick's F-AB-ER-E Test.   This general test helps to confirm a suspicion of hip joint pathology. The patient lies supine, and the examiner grasps the ankle and the flexed knee. The thigh is flexed (F), abducted (AB), externally rotated (ER), and extended (E). Hip pain during the maneuvers, particularly on abduction and external rotation, is said to be a sign of a hip lesion.

Hibb's Test.   The patient is placed in the prone position, and the examiner stands next to the patient on the side of involvement. The examiner stabilizes the patient's contralateral uninvolved hip, flexes the patient's knee on the involved side toward the buttock, and then slowly adducts the leg, which externally rotates the femur. Pain initiated in the hip joint indicates a hip lesion; pain rising in the sacroiliac joint, but not the hip, points to a sacroiliac lesion.

Lasegue's Differential Sign.   This test is used to rule out hip disease, but it is not reliable without further confirmation. A patient with sciatic symptoms is placed supine. If pain is elicited on flexing the thigh on the trunk with the knee extended but not produced when the thigh is flexed on the trunk with the knee relaxed (flexed), coxa pathology can be ruled out.

Trendelenburg's Hip Test.   If the hip and its muscles are normal, the iliac crest and sacral dimple will be slightly low on the weight-bearing side and high on the leg-elevated side when one leg is lifted. In testing, have the patient with suspected hip involvement stand on one foot on the side of involvement and raise the other foot and leg in hip and knee flexion. If there is hip joint involvement with muscle weakness, the iliac crest and sacral dimple will be markedly high on the standing side and low on the side the leg is elevated. A positive sign suggests the gluteus medius and minimus muscles on the supported side are weak. The gait exhibits a characteristic lurch to counteract the imbalance caused by the descended hip. This sign is also commonly positive in epiphyseal separation, pathology of the superior gluteal nerve, coxa ankylosis, hip dislocation, fracture, or chronic subluxations of L4--S1. Pathology to rule out includes Perthe's disease, poliomyelitis, muscular dystrophy, coxa vara, and Otto's pelvis.

Gauvain's Sign.   With the patient in the sidelying position, the examiner stabilizes the patient's uppermost iliac crest with the heel of the hand and the fingerpads are fixed against the patient's lower abdomen. With the patient's uppermost knee extended, the examiner grasps the patient's upper ankle with the other hand, moderately abducts the limb, and firmly rotates it internally and externally. With the patient's knee locked in extension, these rotary maneuvers will affect the entire limb, as far superiorly as the head of the femur. A positive sign is seen when a strong abdominal contraction occurs, indicating a somatosomatic reflex spasm that is usually traced to hip disease.

Hip Adduction Deformity Sign.   When a patient with hip disease walks or stands, it may be noted that the iliac crest is elevated on the affected side, the heel is elevated, and the patient walks on the toes of affected side. The sign is positive if measurement from umbilicus to each medial malleolus shows one leg short but measurements from the right ASIS to the right medial malleolus and from the left ASIS to the left medial malleolus shows limbs to be the same length. This is significant of adduction deformity of the hip of the apparently short limb and suspicious of tuberculosis. This stage often precedes the actual shortening of the involved limb by destruction of the femur head or joint cup.

Meralgia Paresthetica.   This is the presence of a patch of anesthesia, paresthesia, or hyperesthesia, with or without pain, on the anterior and upper surface of one or both thighs (the area of the external cutaneous nerve).

Radiologic Signs of Hip Disease

Epiphysitis.   Epiphysitis is more common in youth than any other serious lesion of the thigh except fracture. The diagnosis of acute cases depends chiefly on roentgenographic evidence, WBC count, and excluding arthritis of any type. Solicitous examination with testing of joint motions will usually demonstrate that the pain and tenderness are in the bone and not in the joint. Monarticular arthritis, the only variety likely to be considered in such a diagnosis, is rare in youth, when most cases of acute epiphysitis occur. Whether a disease starts in the shaft of the bone or in the epiphysis is determined by the seat of pain, tenderness, and x-ray findings.

Necrosis of the Femoral Head.   The examiner should recognize the possibility of post-ischemic changes in the head of the femur during roentgenography of a hip or pelvic fracture. Subchondral collapse, related sclerosis, and irregularity on the weight-bearing anterolateral and superior aspect of the femoral head are characteristic of ischemic necrosis. Signs are best shown in the "frog-leg" abduction, lateral, and partially flexed-hip A-P views. It is an important consideration in traumatology because it often is an effect of cortisone therapy, so often used by allopathic team physicians and trainers to subdue inflammation. Aseptic necrosis may also result from hip dislocation without fracture. The examiner should take special care not to confuse a radiodense femoral head with that of necrosis. After bone or vascular injury, bone ischemia may exist without film evidence. Most of the density noted on film following bony ischemia is attributed to the reparative sclerosis of new bone laid on necrotic trabeculae (ie, creeping substitution). The relative increased density can also be contributed by osteoporosis in the nonischemic zone or by minute trabeculae collapse attenuating the x-ray beam.

Abscesses.   Psoas abscess or hip-joint abscess may burrow downward to the lateral thigh. Psoas abscess presents the ordinary signs of infection and is commonly associated with vertebral tuberculosis (dorsal or lumbar). It would be embarrassing to treat an acute hip disorder for several visits and then see an MD withdraw a cup of pus from just below the patient's hip.

      POSTURAL PATTERNS INVOLVING THE HIP

Underlying most all physical activity is the maintenance of upright posture, which is essentially a continuous challenge between the individual and gravity. In opposing gravity to achieve and maintain posture, approximately 40% of total energy is consumed in the physically fit. If only a slight neuromuscular problem exists, even more energy is used just to maintain balance. When many sports events are won or lost by a fraction of a second, the importance of alert chiropractic care in athletics is underscored.


Plumb-Line Analysis

During good postural balance when viewed from the side, the gravity line passes slightly anterior to the S2 segment, behind the axis of the hip joint, slightly anterior to the transverse axis of rotation of the knee (slightly posterior to the patella), crosses anterior to the lateral malleolus, and through the cuboid-calcaneal junction to pass between the heel and metatarsal heads. When viewed from the back, the lateral line of gravity passes through the spinous of L5 and the coccyx and bisects the knees and ankles. When viewed from the front, a line dropped from the anterior-superior iliac spine (ASIS) should bisect the patella and the web space between the 1st and 2nd toes.


Adaptation to Hip Abductor Weakness

When one foot is removed from the floor (eg, in walking), the center of mass of above body weight plus the weight of the lifted limb sits on the supporting hip medial to the femoral head. This force, which tends to force the pelvis downward on the unsupported side, is counteracted by contraction of the hip abductors on the supported side so that the pelvis is relatively stabilized in the frontal plane. These two forces are opposed by the force of the femoral head acting upward. However, if the hip abductors are weak, the patient must laterally abduct the trunk from the supporting side so that the gravity line falls laterally over the supporting femoral head to stabilize the hip in the frontal plane. This gross shifting moves the center of mass of the supported weight closer to the femoral fulcrum to reduce the moment of superimposed weight on the supporting hip and thus reduce the need for abductor stabilization. The resulting limp is often attributed to gluteus medius weakness, but the gluteus minimus, upper gluteus maximus, and tensor fascia lata are also important considerations.


Pelvic Muscle Effects on the Hip

Attention to hip biomechanics is important to achieve maximum performance. Secondary spinal curves depend to a large extent on the inclination of the pelvis below, and this plane relies greatly on the posture of the hip joints. Thus, hip muscles are strategically involved in determining pelvic inclination.

In the upright position, the thighs are fixed points from which these muscles act. Contraction or shortening of the extensors (glutei, hamstrings) decreases pelvic inclination, and contractions or shortening of the flexors (iliopsoas, rectus femoris) increases inclination. Weakness of antagonists has the same effect. Thus, rehabilitation is directed to relax muscles shortened by spasm or contracture (eg, abnormal reflex patterns) and strengthen counterparts weakened by inactivity, a nerve lesion, or constitutional factors. Restoration of agonist/antagonist integrity need not be a dual activity as a muscle relaxes as its antagonist contracts against resistance.


Weak Agonist or Spastic Antagonist?

Chiropractic studies of bilateral muscle checking during posture analysis suggest that the overwhelming majority of patients presenting chronic postural defects have relative muscle weakness rather than primary muscle spasm. It appears to be this weakness that causes contralateral muscles to contract into an apparent spasm. Therefore, the weakness is said to be primary by applied kinesiologists and the spasm is secondary and thought to be the result of the prime-mover/antagonist reciprocal relationship. For example, an elevated iliac crest on the right relative to the left may be due to weakness on the right of the psoas, gluteals, and tensor fascia lata or weakness on the left of the adductors, quadratus lumborum, rectus or transverse abdominis, or the sacrospinalis muscles.


Direction of Muscle Therapy in Postural Hip Distortions

During the correction of almost all postural distortions, certain muscles must be strengthened and certain muscles will require stretching. The hip is no exception to this rule. The common muscles to be strengthened in postural distortions of the hip are the lateral and medial hip rotators, hip adductors, knee extensors and flexors, foot invertors, metatarsophalangeal flexors, and the abductors, flexors, and extensors of the toes. The common muscles to be stretched in lower extremity postural distortions are the flexors, medial rotators, and adductors of the thigh; the ankle plantar flexors; and the foot evertors and invertors. Specific muscle dysfunction in individual patients varies somewhat from those listed above depending on occupation, age, gender, trauma history, and other variables, but those described should be given priority consideration.


      RULING OUT HIP AND FEMUR FRACTURES

Hip pain directs physical and roentgenographic evaluation of the soft tissues on the lateral and medial aspects of the hip. A hip dislocation with or without fracture should be considered a major injury and referred immediately without attempts of reduction. Radiographs will never indicate all soft-tissue damage present. Severe pain on mild motion is typical in both hip dislocations and fractures, but this may be subdued initially by shock and the patient's fear (denial).

The possibility of nonunion and of absorption of the femur neck must be kept in mind when forming a prognosis in hip fracture. The vitality of the femur head can be inferred from its density; ie, a viable head becomes decalcified to the same degree as surrounding bone. If it is dead, density will be equal to or greater than that of healthy bone.

Adult diaphyseal fractures require more severe trauma than that usually seen in sports, excepting vehicular or parachuting accidents. Extensive connective tissue, vascular, and possibly nerve damages are associated. Fat embolism is always a danger, and severe shock is typical. Diagnosis is usually not difficult, and immediate orthopedic care is required. Incidence of isolated shaft fracture is high in children and the elderly and usually oblique from rotational stress. If fracture is suspected, special care must be made to avoid soft-tissue damage during movement and transportation.


Clinical Tests for the Hip

Following are a number of clinical tests that have shown to be helpful in screening for possible fracture. A positive sign in any one or two of the below tests is rarely conclusive in itself, however. Some are often found to be positive in functional disorders. Their importance is in their relationship with the patient's history, complaints, and physical, roentgenographic, and laboratory findings.

Allis' Hip Sign.   This sign features relaxation of the fascia between the crest of the ilium and the greater trochanter. It suggests a fracture of the neck of the femur.

Allis' Knee Sign.   With the patient supine, knees flexed, and soles of feet flat on the table, the examiner observes the heights of knees superiorly from the foot of the table. If the top of one knee is lower than the other, it points to a unilateral hip dislocation, a severe coxa disorder, or a short femur.

Langoria's Sign.   Relaxation of the extensor muscles of the thigh is an indication of intracapsular fracture of the femur.

Hannequin's Sign.   The patient is placed supine with the knees extended. A positive sign is found if deep palpation just inferior to Poupart's ligament and lateral to the large inguinal vessels produces deep tenderness, pain, and crepitation --features of femoral neck fracture.

Anvil Test.   If an uncomplicated fracture of the leg or femur is suspected, the patient is placed supine and the examiner holds the ankle of the involved side in one hand and mildly strikes the patient's heel with the fist of the other hand, sending a shock wave up the extremity. The result may be localized pain that will help forecast the site of fracture or pathologic focus.

Roentgenographic Signs

The most common hip injuries viewed on film are dislocations and fractures, both of which may lead to avascular necrosis of the femoral head. Femur fractures occurring above the intertrochanteric line are within the joint capsule. They heal, as a rule, without the formation of visible callus.

Shenton's line.   is frequently disturbed in hip fracture. A gracefully arching line is drawn connecting the inferior margin of the superior pubic ramus with the medial margin of the neck of the femur. With minimal hip displacement, normal landmarks will be altered unilaterally.

Impactions.   Following an impaction injury, it is often difficult to locate a fracture of the margin of the head of the femur. It is shown by slight contour changes and unusual densities. Comparative views, oblique and stereoscopic, tomography, or arthrography are frequently necessary to identify small fracture fragments.

Avulsions.   The trochanteric areas should be checked for possible injury of the gluteal insertion at the greater trochanter or avulsion of the iliopsoas insertion at the lesser trochanter. Any type of hip pain encourages evaluation of the soft-tissue structures in the area of the obturator internus.

Epiphyseal Slippage.   It is common for athletes in later years to exhibit degenerative disease of the hip suggesting evidence of an old slipped capital femoral epiphysis. Even in minimal slip of this epiphysis, a chronic "tilt deformity" may result that shows the femoral head sitting eccentrically on the neck in a drooped or tipped position. When swelling and ecchymosis appear at the base of Scarpa's triangle and the patient is unable to raise the thigh while in the sitting position, traumatic separation at the epiphysis of the lesser trochanter is indicated (Ludloff's sign).

Evidence is clear that there is an association of certain forms of degenerative hip disease, often with osteophytic flanges on the femoral head, secondary to a rearranged femoral-acetabular articulation. Thus, recognition during the early years is most helpful. Slips of the femoral capital epiphysis often occur 1 or 2 years earlier in females because the most rapid growth in that area comes earlier.

Fractures of the Proximal Femur

Femoral neck fractures are rare in the young; usually a degree of osteoporosis is predisposing. However, in contact athletics, a stress fracture of the femoral neck may become a complete fracture following later torsional stress. Repetitive trauma may result in comminuted femoral head fractures.


      HIP DISLOCATIONS

Posterior Dislocations.   The most common luxation is posterior dislocation of the femoral head, exhibiting thigh adduction and internal rotation at the hip and leg shortening on the affected side. When dislocation occurs, the head of the femur is driven into the posterior or central acetabulum creating comminuted acetabular fragments. The inferior aspect of the head may fracture. But posterior displacement may also be seen without fracture, with a single major posterior acetabular fragment, or with femoral head fracture. The cause is usually a force against the flexed knee with the hip in flexion and slight adduction. Complications include sciatic nerve stretching causing foot drop and numbness of the lateral calf.

Central Dislocations.   These may be seen with displacement toward the inner wall only, with partial dome fractures or with central displacement with comminution of the dome. This type of dislocation-fracture commonly results from a severe force to the lateral trochanter and pelvis directed through the femoral head (eg, baseball slide). Occasionally, they are produced by a force on the long axis of the femur when the hip is abducted.

Anterior Dislocations.   Anterior dislocation is relatively rare because Bigelow's ligament offers considerable protection. The limb will be externally rotated, abducted, without leg shortening. Obturator, iliac, and pubic displacements may be seen, as well as those associated with femoral head fractures. A shear fracture of the superior aspect of the femoral head is usually associated. The limb will usually be externally rotated without leg shortening. Anterior dislocations usually occur from a blow to the back while squatting, a fall where forced abduction occurs (eg, vaulting), or forced abduction of the extended hip.

Gait Clues

When observing the stance phase of the patient's gait, the dynamics of heel strike, foot flat, midstance, and toe push-off of each extremity should be noted. Failure of the knee to extend during heel strike is a sign of weak quadriceps or a flexion fusion of the knee. Weak quadriceps will display themselves in excessive flexion and poor knee stability during midstance. A midstance forward lurch of the hip is a typical sign of a weak gluteus medius, while a midstance backward lurch suggests a weak gluteus maximus.

During the swing phase, note acceleration, midswing, and deceleration of each extremity. If the patient must rotate the pelvis severely anterior to provide a thrust for the leg, the cause is likely weak quadriceps. A harsh heel strike, usually associated with knee hyperextension, is a common sign of weak hamstrings.


Leg-Length Discrepancy Observations

Bilateral differences because of anatomical discrepancies can arise from growth irregularities, effects of severe fractures, or pathology causing bone loss. Apparent discrepancies are usually due to unilateral rotatory misalignment of an ilium on the sacrum, adductor spasm causing pelvic tilt, knee distortion, or a fallen arch. Anatomical (true) leg lengths are bilaterally measured from the ASIS to a point on the medial malleolus of the respective tibia. It is usually preferred that the patient be in the nonweight-bearing supine position. In contrast, functional (apparent) leg lengths are measured bilaterally from the umbilicus to the respective medial malleolus when the patient is in the standing position.

A pelvic sag sideward (short-leg syndrome) when viewed from the front or back can be caused by several abnormalities. The most common are muscle shortening or weakness, a unilateral lower extremity deficiency, sacroiliac dysfunction, and hip or lower extremity alignment problems. Muscle fixation from lack of stretch is a common cause, second only to the common unilateral leg-length deficiency.

An anatomical or functional short leg, or both, will show that:

1. On fully extending the legs of a supine patient with a leg deficiency, the extremity on the side of involvement will be shorter than its mate on the opposite side because posterior innominate rotation causes the acetabulum to be carried superiorly and anteriorly: the superior position producing the retraction of the limb. However, on bringing the extremities upward to a position of right angles to the body, the short leg will appear to be the longest because the acetabulum of the posterior innominate has been carried superiorly and anteriorly, and the anterior position now produces the added length.

2. If a standing patient with a short leg seeks to rest his back by shifting from one foot to the other, he will come to rest by bearing most weight on the side on which the leg is short, the sacrum has gravitated anteriorly and inferiorly, and the low iliac crest has rotated posteriorly and inferiorly. Using dual weight scales, the patient habitually carries most weight on the side of the short leg. When posterior iliac rotation, sacral inferiority, or weight dominance is on the side of the long leg, a biomechanical or antalgic complication is likely,

3. Two other basic points must be considered: (a) The pelvis normally tends to rotate as a whole anteriorly on the low side during stance. (b) With the patient flexed in the Adams position, the pelvis slants anteriorly and inferiorly on the side of extremity deficiency. The lumbar spine gravitates into scoliotic deviation to the low sacral side, which establishes a state of reverse rotation between L5 and the sacrum. If the pelvis rotates horizontally backward on the low side during stance or the lumbar curve is toward the high extremity in the Adams position, a biomechanical complication is involved. A common exception to this is an acutely inflamed sacroiliac lesion on the low side where the patient attempts to maintain weight on the high side to relieve pain. This would cause the lumbar scoliosis to straighten or possibly reverse to the high side. If the lower lumbar region is fixated, adaptation will not occur until the first freely movable segment is reached (eg, T12) and then the shift will be made sharply.

Stableness of the Hip

Stability of the hip joint is provided by its structural design and ligaments. The shaft of the femur attaches to the pelvis near a 130° angle by way of its superomedially-slanted neck. The neck ends in the large globe-like head of the femur, which articulates within the deep acetabulum, while the shaft proper ends cephally in the greater trochanter.

The articulating surface of the head of the femur is more than half a sphere, and a fibrocartilaginous labrum surrounds the acetabulum to further deepen the articular cavity. The femoral shaft bows inferiorly and twists obliquely anteriorly and medially to bring the knee joint in plumb with the hip joint. This spiral of the shaft of the femur gives it increased resistance to bending forces and shear stress.


Hip Ligaments

The capsule of the hip, unlike the shoulder, is quite strong and closely associated with four ligaments: the iliofemoral, ischiofemoral, pubofemoral, and interarticular. The strong triangular iliofemoral ligament covers the front of the joint capsule and connects with the ilium below the AIIS. It attaches to the femur at two insertions (the inverted Y ligament of Bigelow) on the anterior aspects of the greater and lesser trochanters, and thus is able to restrict excessive extension of the joint imposed by body weight in the erect posture.

The ischiofemoral ligament covers the posterior aspect of the capsule. It spans relatively horizontal between the ischial rim of the acetabulum and the greater trochanter. The spiral design of its fibers gives extra stability to the joint during extension.

The pubofemoral ligament spans from the pubic aspect of the acetabulum to the medial aspect of the femoral neck, thus covering the medial aspect of the capsule. This position allows the pubofemoral ligament to strap excessive abduction of the femur and helps to check severe extension.

These three ligaments described above tend to tighten on internal rotation and relax on external rotation and flexion. This forces the hip muscles to provide stability during external rotation and flexion.

The flat interarticular band of the hip is frequently referred to as the ligament of the femur head, ligamentum teres, or the round ligament of the hip. It courses from the pit of the femur head, through the capsule, to the nonarticular surface of the acetabulum.


Hip Joint Motion

The prime movers and accessory muscles involved in hip motion are shown in Table 2.

Table 2.   Hip Motion

Joint Motion	Prime Movers	Accessories
Flexion	Iliopsoas	Tensor fascia latae
	Sartorius	Pectineus
	Rectus femoris	Adductor brevis and longus
		Adductor magnus, oblique fibers
		Gluteus medius, anterior fibers
		Gluteus minimus
Extension	Gluteus maximus	Gluteus medius, dorsal fibers
	Hamstrings	Adductor magnus, vertical fibers
Abduction	Gluteus medius	Sartorius
	Gluteus minimus
	Tensor fascia latae
Adduction	Adductor longus
	Adductor brevis
	Adductor magnus
	Pectineus
	Gracilis
External rotation	Obturator internus	Gluteus maximus
	Obturator externus	Gluteus medius, dorsal fibers
	Gemelli	Sartorius
	Quadratus femoris
	Piriformis
Medial rotation	Gluteus medius, anterior   fibers	Adductor magnus, vertical fibers
	Gluteus minimus
	Tensor fascia latae

Flexion

To test passive joint flexion, the supine patient is placed in a straight line with the trunk square to the pelvis so that a line drawn between the ASISs strikes the midline at right angles. The examiner places a stabilizing hand under the patient's lumbar spine and flexes the patient's hips by bringing both thighs toward the abdomen as far as possible with the knees flexed. The thighs should normally rest against the patient's abdomen and almost touch the chest.

Rotation in Flexion.   To test passive hip rotation in hip flexion, the patient sits upright with knees hanging from the edge of the table. The examiner stabilizes the patient's thigh with one hand while his active hand, placed just above the ankle, moves the limb laterally and medially in an arc to test hip internal and external rotation.

Extension

Extension is judged with the patient prone with ankles on a small roll to relax the hamstrings. The examiner stabilizes the pelvis by placing an arm horizontally across the upper pelvic area about the level of the iliac crests. The examiner's active hand is placed under the patient's thigh above the knee and an upward lifting motion is made to extend the hip with the patient's knee kept extended. The hip should normally extend about 30°; if not, a flexion contracture should be the first suspicion.

Rotation in Extension.   To test passive internal and external rotation in extension, place the patient supine in the neutral position and make a dot with a marking pencil in the center of each patella. The examiner stands at the foot of the examining table and grasps each leg just above the ankle. The legs are rotated internally and externally, noting the movement of the dot on each patella to judge the range of motion. Excessive rotation can usually be traced to anteversion or retroversion of the femoral neck. Anteversion results in excessive toe-in, while retroversion has the opposite effect. In young children, excessive external rotation and restricted internal rotation may be the result of a slipped capital upper femoral epiphysis that has moved inferiorly and posteriorly.

Abduction

To test hip abduction passively, place the supine patient in the neutral position and stand at the patient's side. The examiner places his stabilizing forearm across the patient's pelvis. The examiner's active hand grasps one leg of the patient and slowly abducts the limb as far as possible (normally about 45°). At the end of abduction, the pelvis under the stabilizing arm begins to move.


Adduction

The range of hip adduction is tested in the same manner, by bringing the patient's limb horizontally across the other limb (normally about 20°-30°). Upper thighs that are quite muscular or fat will restrict the degree of adduction.



Kinesiology

The major muscles of the hip and thigh and their innervation are shown in Table 3.

Table 3.   Major Muscles of the Hip and Thigh

Note:   Spinal innervation varies somewhat in different people. The spinal nerves listed here are averages and may differ in a particular patient; thus, an allowance of a segment above and below those listed should be considered.

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Evaluation should be made of muscle groups controlling flexion, extension, abduction, and adduction to judge the integrity of the muscles and their nerve supply. All muscles should be compared bilaterally. Only in unusual situations is it necessary to thoroughly test internal and external rotators.

Flexion.   Hip flexion is provided by the iliopsoas, innervated by the femoral nerve (L1–L5), with assistance from the rectus femoris, and sartorius. To test active hip flexion, ask the sitting or supine patient to draw each knee to the chest as far as possible without bending the back. The knee should normally come near the thorax (about 1––5°).

Extension.   Extension of the hip is primarily offered by the gluteus maximus supplied by the inferior gluteal (L5––S2), with secondary effort by the hamstrings. Active extension can be tested roughly in the sitting position by having the patient fold his arms across his chest and keep his as back straight as possible while he arises from the chair.

Abduction.   Hip abduction is provided in the most part by the gluteus medius, innervated by the superior gluteal nerve (L4––S1), with assistance by the gluteus minimus and tensor fascia lata. For a quick test, the standing patient in the neutral position is asked to spread his legs as far apart as possible. Each leg should normally be able to be actively abducted at least 45° from the midline. A more useful test is to place the patient in the side position. The examiner's stabilizing hand is placed on the iliac crest to fix the pelvis. The patient is asked to abduct his uppermost thigh while the doctor applies increasing resistance to the lateral knee area. The fingers of the examiner's stabilizing hand can be used to palpate the origin of the gluteus medius muscle.

Adduction.   Adduction is primarily made by the adductor longus supplied by the obturator nerve (L3––L4), with help from the adductor brevis, adductor magnus, pectineus, and gracilis. To test active motion in the standing position, the patient in the neutral position is requested to alternately cross the left leg in front of the right and then the right leg in front of the left. At least a 20° active adduction from the midline should normally be achieved.

An alternative method to test adduction strength is for the examiner to slip his active hand under the medial aspect of the patient's knee and apply increasing resistance as the patient adducts his thigh toward the midline.

A third method to test hip abduction and adduction strength is to place the patient supine with his legs abducted about 20°. The examiner, at the foot of the table, grasps the patient's legs above the ankles and applies increasing resistance as the patient attempts first to abduct his legs laterally and then to adduct his lower limbs medially.

1. Stage of Acute Inflammation and Active Congestion

The major goals are to control pain and reduce swelling by vasoconstriction, compression, and elevation; to prevent further irritation, inflammation, and secondary infection by disinfection, protection, and rest; and to enhance healing mechanisms. Common electives include:

Disinfection of open skin (eg, scratches, abrasions, etc)
Cryotherapy
  Cold packs
  Cold immersions
  Ice massage
  Vapocoolant spray
Pressure bandage
Protection (padding)
Indirect therapy (reflex therapy)
Iontophoresis/phonophoresis
Auriculotherapy
Meridian therapy
Spondylotherapy
Mild pulsed ultrasound
Pulsed alternating current
Rest
  Bedrest
  Cane
  Crutches
  Foam/padded appliance
  Shoe orthotic
  Shoelift
Immobilization
  Brace
  Rigid appliance
  Plaster cast
Indicated diet modification and nutritional supplementation.

2. Stage of Passive Congestion

The major goals are to control residual pain and swelling, provide rest and protection, prevent stasis, disperse coagulates and gels, enhance circulation and drainage, maintain muscle tone, and discourage adhesion formation. Common electives include:

Indirect articular therapy (reflex therapy)
Alternating superficial heat and cold
Pressure bandage
Protect lesion (padding)
Light nonpercussion vibrotherapy
Passive exercise of adjacent joints
Mild surging alternating current
Mild pulsed ultrasound
Phonophoresis
Cryokinetics (passive exercise)
Meridian therapy
Spondylotherapy
Rest
  Bedrest
  Cane
  Crutches
  Foam/padded appliance
  Shoe orthotic
  Shoelift
Immobilization
  Brace
  Rigid appliance
  Plaster cast
Indicated diet modification and nutritional supplementation.

3. Stage of Consolidation and/or Formation of Fibrinous Coagulant

The major goals are the same as in Stage 2 plus enhancing muscle tone and involved tissue integrity and stimulating healing processes. Common electives include:\

Mild articular adjustment technics
Moist superficial heat
Thermowraps
Spray-and-stretch
Cryokinetics (active exercise)
Moderate active range-of-motion exercises
Meridian therapy
Alternating traction
Sinusoidal current
Ultrasound, continuous
Phonophoresis
Microwave
Vibromassage
High-volt therapy
Interferential current
Spondylotherapy
Mild transverse friction massage
Mild proprioceptive neuromuscular facilitation techniques
Rest
  Bedrest
  Cane
  Crutches
  Foam/padded appliance
  Shoe orthotic
  Shoelift
Immobilization
  Brace
  Semirigid appliance
Indicated diet modification and nutritional supplementation.

4. Stage of Fibroblastic Activity and Potential Fibrosis

At this stage, causes for pain should be corrected but some local tenderness likely exists. The major goals are to defeat any tendency for the formation of adhesions, taut scar tissue, and area fibrosis and to prevent atrophy. Common electives are:

Deep heat
Articular adjustment technics
Spondylotherapy
Local vigorous vibromassage
Transverse friction massage
Spray-and-stretch
Active range-of-motion exercises without weight bearing
Motorized alternating traction
Negative galvanism
Ultrasound, continuous
Phonophoresis
Sinusoidal and pulsed muscle stimulation
Microwave
High-volt therapy
Interferential current
Meridian therapy
Proprioceptive neuromuscular facilitation techniques
Rest
  Bedrest
  Cane
  Crutches
  Foam/padded appliance
  Shoe orthotic
  Shoelift
Immobilization
  Brace
  Semirigid appliance
Indicated diet modification and nutritional supplementation.

5. Stage of Reconditioning

Direct articular therapy for chronic fixations
Progressive remedial exercise
Passive stretching
Isometric static resistance
Isotonics with static resistance
Isotonics with varied resistance
Plyometrics
Aerobics
Indicated diet modification and nutritional supplementation.

A hip "pointer" is an injury of the superior iliac crest and overlying tissues that occurs in many sports and some industrial accidents. It is very painful and slow to heal. The easily irritated epiphysis of the iliac crest does not close until about 24 years of age and is easily injured by a shoulder, helmet, knee, or shoe blow. In addition, ilioinguinal and iliohypogastric nerve contusion, painful avulsion of the iliolumbar ligament from the ilium and/or sprain at its L4––L5 attachment, and/or crushing of the muscle bulge overlapping the crest may be involved. Muscles are richly innervated.

Clinical Features.   Symptoms often mimic fracture; ie, acute, steadily increasing pain, and severe progressing disability. On onset, a moderate injury will present tenderness below the iliac wing and at the overlapping muscle bulge but not on the crest itself. This indicates a bone bruise with nerve contusion. An impact to the anterior spine may actually strip attachments along the crest. Thus, severe injury presents extreme tenderness throughout and above the crest, indicating torn attachments. The pain is agonizing, easily aggravated, and often requires hospitalization. If examination is delayed, bleeding, spasm, and swelling obscure localization of diagnostic signs.

Management.   Initial care requires cold packs to stop the bleeding, swelling, and spasm, and careful strapping to tilt the trunk toward the ipsilateral pelvis to prevent further spasm. Disability and swelling must be monitored daily during the early stage. In minor strains with minimal bleeding and swelling, cold may be discontinued after 24 hours. Active motion without heat may begin at this time. Ultrasound and interferential therapy have been found especially helpful in resolution. Active motion with support and padding are beneficial, but heat is usually contraindicated. Activity of an athlete may be resumed in 3––10 days, depending on the extent of injury. In severe strains with extensive swelling, cold must be continued for 48––72 hours.

Posttraumatic Hip Spasm

Two forms of postinjury spasm are common in the hip joint: (1) spasm due to irritation of the psoas alone, and (2) spasm in which all muscles moving the hip are contracted to some degree. The normal range of hip flexion is 120°. Limited motion from muscle spasm is also seen with special frequency in joint disease and spinal dysarthrias, but it may occur in almost any form of joint trouble, particularly the larger joints. General spasm of the hip muscles is tested via Patrick's test.

Screening.   Once the possibility of fracture, dislocation or gross pathology has been eliminated, general spasm of the hip muscles can be tested with the patient supine on a table, bench, or bed and the involved leg flexed at a right angle, both at the knee and at the hip. A child may be tested on its parent's lap. Using the uninvolved limb as a standard of comparison, draw the knee away from the midline (abduction), toward and then past the midline (adduction) and toward the patient's chest (flexion). Rotation can be tested by holding the knee still and moving the foot away from the median line of the body or toward and across it.

Management.   To relieve muscle spasm, heat is helpful, but cold and vapocoolant sprays may be more effective. Mild passive stretch is an excellent method of reducing spasm in the long muscles, but heavy passive stretch destroys beneficial reflexes. Quadriceps spasm can usually be relaxed by passive hip and knee flexion. Peripheral inhibitory afferent impulses can be generated to partially close the theoretical presynaptic gate by acupressure, acupuncture, or transcutaneous nerve stimulation.

Snapping Hip

This diagnostic sign refers to an audible or palpable "click" heard or felt on the lateral surface of the upper thigh near the head of the femur. The cause is thought to be a taut fascial band that slips over the greater trochanter as the hip is rotated internally while being partially flexed. This band is often found on surgery to be either a thickened posterior border of the iliotibial band or the anterior tendon of the gluteus maximus muscle. Besides the crepitation, local tenderness will manifest during hip motion, especially internal rotation.

Management.   The first priority after pain relief is to relieve any fixations found within the pelvis, hip, and knee. Adjunctive care generally includes the common procedures for acute sprain during the early stage (eg, cold, rest); later, the common procedures for chronic sprain such as massage, ultrasound, diathermy, and graded exercise are used. With the poorly nourished, manganese, vitamin C, and vitamin A may be helpful.

Trigger Points of the Hip and Thigh

Trigger points of the pelvis are commonly located (1) over the greater sciatic notch through the gluteal muscles, (2) over the crest of the ilium, (3) over the belly of the tensor fascia lata, (4) in the ischiorectal fossa apex, and (5) at the sciatic outlet onto the back of the thigh from under the gluteus maximus.


      HIP SPRAINS AND STRAINS

The hip articulation sits deeply beneath heavy muscles, fascia, ligaments, and fat that protect the joint but often obscure physical signs. Fortunately, severe injury is rare. One should always consider the possibility of hip pain being referred from pelvic, intra-abdominal, or retroperitoneal disease or a biomechanical fault in the lumbar, pelvic, knee, or ankle joints. The symptoms of hip strains and sprains should always be differentiated from mimicking contusions (eg, hip pointer), abscess, arthritis, bursitis, and fatigue fractures.

Sprains of the hip in the young frequently injure the upper femoral epiphysis. In adults, trauma usually damages the muscles about the hip rather than to harm the joint itself.

Around the hip, two forms of spasm are common: (1) those due to irritation of the psoas alone, and (2) those in which all muscles moving the joint are more or less contracted. General spasm of hip muscles can be evaluated by Patrick's test.


Clinical Features

Motion is restricted and pain is often referred to the medial aspect of the knee. A limp is invariably present. Laguere's, Ely's, Patrick's F–AB–ER–E, and Ober's tests are used to support the diagnosis. Thomas' sign is positive in hip contracture; Trendelenburg's sign in hip dislocation; and Allis' knee sign in hip fracture. In hip sprain, the mechanism is usually a twisting or wrenching motion. Occasionally, a stubborn case will show pus on aspiration.

Laguere's Test.   With the patient supine, the thigh and knee are flexed and the thigh is abducted and rotated outward. This forces the head of the femur against the anterior portion of the coxa capsule. Increased groin pain and spasm are positive signs of a hip lesion, iliopsoas muscle spasm, or a sacroiliac lesion. It differentiates from a lumbosacral disorder.

Hip Abduction Stress Test.   The patient is placed in the sidelying position with the underneath lower limb flexed acutely at the hip and knee. While the patient's upper limb is held straight and extended at the knee, ask the patient to try to abduct the upper limb while you apply resistance. Pain initiated in the area of the uppermost sacroiliac joint or the hip joint suggests an inflammatory process of the respective joint.

Other Kinematic Tests.   Ely's, Patrick's, and Ober's tests support the diagnosis. Thomas' sign is positive in hip contracture; Trendelenburg's sign in hip dislocation; and Allis' knee sign in hip fracture. Increased groin pain and spasm during Laguere's test are usually positive signs of a lesion of the hip joint, iliopsoas muscle spasm, or a sacroiliac lesion. This latter test can also help to differentiate a hip disorder from a lumbar lesion.

Management.   When symptoms of joint involvement are present, functional rest is indicated until signs of irritation disappear. Treat as any joint sprain in accord with the stage in progress. Strapping should be provided as well as crutches during the acute stage. The patient should be carefully monitored for at least a month.

      BURSITIS IN THE HIP AREA

It was reviewed in the previous monograph that a bursa lies between the lateral capsule of the proximal femur and the gluteus maximus muscle's tendon as it courses over the greater trochanter to insert into the iliotibial tract. Inflammation from an external blow on this bursa is not unusual.

Another bursa is formed at the internal obturator tendon and the superior and inferior gemelli. It runs under the piriformis and courses posteriorly to round the sciatic notch, largely filling the lesser sciatic foramen. A clue to inflammation of this bursa is gained by testing thigh external rotation against resistance and signs of tenderness on deep palpation. An attempt to elicit a buttock sign should be attempted unless contraindicated by other features.


Buttock Sign

The involved lower extremity of a supine patient is passively flexed at the hip with the knee extended as in an SLR test. If flexion of the limb on the trunk is restricted by local or radiating buttock pain (rather than pain in the hip or lower back), it signifies an inflammatory pelvic lesion such as ischiorectal abscess, coxa bursitis, or sacroiliac septic arthritis. It may also signal osteomyelitis of or near the hip joint or an advanced pelvic neoplasm.


Trochanteric Bursitis

Trochanteric bursitis is often associated with tendinitis of the gluteus medius. It is characterized by pain radiating laterally downward along the iliotibial band. Thus, it must be differentiated from an iliotibial or low-back lesion. Point tenderness will be found over the head of the femur, and this is a helpful sign in differential diagnosis.

Management.   Treat as any bursitis: cold and rest initially; later with deep heat, interferential therapy, and stretching exercises. Special care should be made to rule out pelvic and femur fatigue fractures; hamstring, piriformis, and iliopsoas strains; and hip joint contractures. Dr. John Palo adds the following comment: "My experience has been that many cases of trochanteric bursitis come from a longer lower limb. The longer limb forces its greater trochanter to protrude more. The tensor fascia lata or iliotibial tract is then forced to override or snap over the protruding greater trochanter. This irritating action can produce trochanteric bursitis. Solution? A heel lift placed under the contralateral (shorter) lower limb." See the previous monograph for the application of shoe lifts.

Iliopectinal Bursitis

Iliopectinal bursitis closely resembles and is often confused with signs of iliopsoas abscess. It is characterized by abrupt hip pain (mild--severe) that is aggravated by hip flexion and adduction. A deep ache may radiate along the course of the femoral nerve down the anterior thigh and possibly to the leg. Palpation reveals tenderness deep within Scarpa's triangle, the inguinal groove may be swollen, and Thomas' test is invariably positive.

Management.   The primary objectives following pain relief are to release any fixations found within the lumbar spine, pelvis, and lower extremities, and treat the swelling. During the acute stage, treat locally as an acute sprain with cold and rest. Later, apply stretching exercises to the patient's tolerance, active exercise within a painless range, and physiotherapy to reduce the inflammatory process and prevent posttraumatic complications.

      OSTEOARTHRITIS OF THE HIP

Osteoarthritis of the hip is a common noninflammatory disorder that afflicts about 200,000 Americans over 65 years of age. As in osteoarthritis elsewhere, the cause is thought at this writing to be a posttrauma reaction. There are signs of deteriorated articular cartilage, diminished joint lubrication, new bone formation at joint margins, loss of soft-tissue elasticity, and a reduced range of joint motion. Morning stiffness is common. Overstress produces pain in the anterolateral thigh that may extend to the knee.

Management.   Free all fixations found in the lumbar spine, pelvis, upper cervicals, and lower extremities. Moist heat, interferential therapy, massage, diathermy, ultrasound, stretching exercises, hydrotherapy, and nutritional supplementation are commonly used. Obesity is often a complicating factor.

      QUADRICEPS DYSFUNCTION

The quadriceps group forms the anterior muscles of the thigh; viz, the rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius.


Quadriceps Contusions

A common bruise of the thigh results from an anterior blunt blow. The effect may be a minor but disabling "charley horse" if the muscles are contracted during the injury. A severe rupture of the rectus femoris or vastus intermedius can result, producing extensive intramuscular bleeding leading to myositis ossificans if not treated quickly and adequately.

Clinical Features.   A quadriceps contusion can be one of the most crippling of all contusions. Even when carefully fitted padding is provided in contact sports, it is not always adequate for the impacts received. Hemorrhage may extend from knee to groin. If the mass tenses the overlying tensor fascia lata, signs of circulatory impairment will be noted in the toes requiring immediate fasciotomy. Such "ballooning" of the thigh occurring many hours after injury is typical of a massive "charley horse." It sometimes results from what was initially thought a trivial injury.

The tendency for bleeding to recur may remain for a week after injury. The time for resorption of the mass extends from several weeks to months. In the "low Charley" contusion of the vastus medialis, a complication may occur with hemarthrosis of the knee joint, which offers false signs of joint injury. In such cases, delayed diagnosis allows fibrosis to become extensive. This may require many weeks to overcome.

Management.   Bleeding is the first problem. Cold packs, a pressure bandage, and elevation should be started immediately. This therapy must be continued up to 72 hours or more if a mass can be felt and flexion is limited. Heat should not be applied for 5 days, and even then there is a risk for a few days. When bleeding has been controlled and other acute signs subside, walking can begin and slowly progress to jogging if symptoms do not return. Premature postinjury activity may easily lead to greater disability. Running should always be preceded by slow stretching exercises (eg, pulling heel toward buttocks).

Quadriceps Strains

Clinical Features.   Symptoms of quadriceps strain may be exaggerated at either the hip or the knee, and may not appear for several hours in mild strains. Pain is aggravated by movement, especially going down stairs. Swelling is usually mild, but spasm is always present to some degree depending on the extent of injury. Normal quadriceps action reveals a distinct degree of limitation. Note that it is almost impossible to have a strong knee and weak quadriceps, and the quadriceps group is the first to show atrophy after knee injury.

Management.   Treat as any long, bulky muscle strain, keeping in mind that the quadriceps is the largest muscle group in the body. In comparison to moderate strains, even mild tears (highly disabling) are more difficult to manage. Bleeding is always a concern, thus heat should not be applied for 3––5 days. Support consists of criss-crossed adhesive straps up the anterior thigh. This requires 10––14 diagonal strips anchored by overlapping semicircular horizontal strips extending from the medial to the lateral aspects of the thigh. Any taping procedure for the quadriceps is helpful but never fully adequate for full activity. Special care must be used to avoid posttraumatic contracture.

Quadriceps Contracture

The quadriceps flexion test and Nachlas' test will aid the diagnosis of quadriceps contracture.

Quadriceps Flexion Test.   Posttraumatic scars in a muscle always limit the working length of all muscles in the group. Quadriceps contracture is tested simply by placing the patient prone, flexing the leg toward the buttock to tolerance, and measuring the distance from the heel to the buttock. Once the point of tolerance is reached, the lumbosacral spine will arch and the buttocks will rise to prevent further stretch. This test may prove a lesion too deep to palpate as well as evaluate progress during treatment. Activity should be restricted until flexion exceeds 90°. Squatting activities must be avoided until full healing is demonstrated. Premature postinjury activity may easily tear a weakened muscle. Ely's test may also be helpful.

Nachlas' Test.   After placing the patient in the prone position, flex the patient's knee to a right angle. Then, with pressure against the anterior surface of the ankle, slowly direct the heel straight toward the patient's ipsilateral buttock. The contralateral ilium should be stabilized by your other hand. If a sharp pain arises in the ipsilateral buttock or sacral area, a sacroiliac disorder should be suspected. If pain occurs in the lower back area or is sciatica-like in nature, a lumbar disorder (especially L3 or L4) is suggested. If pain occurs in the upper lumbar area, groin, or anterior thigh, quadriceps spasticity/contracture or a femoral nerve lesion should be suspected.

      HAMSTRING DYSFUNCTION

The hamstring group forms the posterior muscles of the thigh; viz, the semimembranosus, semitendinosus, and the biceps femoris. The semimembranosus arises from the ischial tuberosity and inserts at the medial condyle of the femur and the medial condyle and border of the tibia. The semitendinosus originates at the ischial tuberosity and inserts on the upper part of the medial surface of the tibia. The long head of the biceps femoris arises from the ischial tuberosity and the short head from the linea aspera of the femur. Both divisions of the biceps femoris insert by a common tendon at the head of the fibula and lateral condyle of the femur.


Hamstring Strains

Hamstring strains are usually the result of weakness plus poor warm-up before exertion. The pain involved is rarely referred to the leg as in sciatica. Gross hamstring weakness is tested by simultaneously extending the thigh and flexing the knee against resistance.

Clinical Features.   Symptoms develop slowly with progressive disability. The characteristics of severe hamstring strain include acute pain (generally at the origin of the short head of the biceps femoris), restricted motion, hamstring dyskinesia, loss of strength exhibited by poor coordination, and an altered gait. Bleeding is usually mild, and general spasm is common. Tenderness is found at the ischial origins and attachments at the musculotendinous junctions. A palpable, compensatory, fibrous thickening may manifest. Special care must be taken to differentiate strain of the lower biceps femoris from sprain of the lateral ligaments or lateral meniscus tear.

Management.   Treat as a strain of any large muscle group with emphasis initially on the control of bleeding and pain. Provide support (eg, taping) and later on flexibility and strengthening exercises. Check lower lumbar and the sacroiliac joints for fixations. Because bleeding may be a problem in soft-tissue overstress, light compression by an elastic bandage can be used. Heat should not be applied for 3––5 days when the fear of inducing bleeding fades. Once bleeding has been controlled, walking is the first exercise, followed by "high knee" exercises and graduated jogging. The latter is necessary only if the patient is involved in demanding athletic activities. During rehabilitation, ultrasound, high-volt therapy, or interferential therapy are often applied to encourage healing. Magnesium and vitamin C may be helpful.

Taping.   The patient should stand with his weight on the uninjured leg. A series of 3–inch overlapping strips is firmly applied vertically from just above the popliteal space to just below the rib line. A single strip is run diagonally from the PSIS, around the hip, and then to the anterolateral thigh. All strips are anchored with semicircular strips applied at the waist and from the inferior aspect of the buttocks to the popliteal fossa.

Special Concerns.   Return to full activity should not be rushed, and any attempt by the patient to "work out" the discomfort should be discouraged. Reinjury readily leads to severe tear and scar formation. To prevent a chronic problem, rehabilitation with emphasis on stretching exercises (eg, knee flexion when erect) should continue until complete recovery. If the patient is returning to athletic activity, races and hill running should be avoided until full strength and flexibility have returned. The optimal balance between quadriceps and hamstring strength is in the ratio of 60:40. Management should also consider rehabilitation of the gluteus maximus.

Hamstring Ruptures

In contrast to a severe stretch, a hamstring tear features a history of bursting pain during activity and a highly tender mass at the site of hemorrhage. The size of the mass can vary from that of a walnut to that of a melon, and it parallels the degree of spasm and weight-bearing disability. During recovery, a startling ecchymosis usually appears in the popliteal fossa and slowly extends caudally. Bicipital tendinitis is a frequent complication of distal bicipital strain. Symptoms may be exaggerated at either the hip or the knee. Roentgenographs may show avulsion fracture at the head of the fibula.


Hamstring Spasm

Besides direct trauma, hamstring spasm may be the result of any lower motor irritation located between the midthoracic spine and the lower sacrum. The clinical procedures listed below have proved helpful in differentiating hamstring spasm from mimicking disorders.

Tripod Sign.   The patient is placed prone with the knees flexed over the edge of the table. Active and passive muscle strength and range of motion of knee extension are then evaluated. If the patient must pull backward (extend the trunk on the pelvis) and grasp the table to support body weight on the arms when the knees are bilaterally extended, hamstring spasm is indicated.

Lewin's Knee Sign.   If quick extension of a knee in the standing position produces pain and a sharp flexion response, hamstring spasm should be suspected.

Neri's Bowing Sign.   This general sign is positive when a standing patient can flex the trunk further without low-back discomfort when the ipsilateral leg is flexed than when both knees are held in extension. The sign suggests hamstring spasm, contractures of the posterior thigh and/or leg muscles, sciatic neuritis, a lumbar IVD lesion, or a sacroiliac subluxation syndrome.

Hamstring Contracture

Tight, often scarred, hamstrings are customarily the result of improperly treated strains and tears. Contracture is a common cause of prolonged immobility. In some cases, etiology can be traced to excessive exercise producing a horizontal tear across the belly of the muscle. Recurring episodes are typical. A program of carefully graduated activity must be undertaken quickly because prolonged rest encourages tightening and functional disability.

Berry's Sign.   This sign is positive if a patient with a history of lower trunk discomfort and fatigue is fairly comfortable when sitting with the knees flexed but experiences discomfort in the standing position. It is typically seen in spasticity or contractures of the posterior thigh and/or leg muscles.

Hamstring Reflexes

Two normal hamstring reflexes have significance: (1) Internal: With the patient recumbent, knee slightly flexed, leg abducted and partially externally rotated, the examiner's fingers are placed on the medial aspect of the leg below the knee, over the muscles and tendons, and the fingers are percussed. A reflex supplied by L4–S2 results in increased flexion of the leg on the thigh. (2) External: Similar to above, the examiner's fingers are placed over the tendon of the biceps femoris muscle just above its insertion on the lateral side of the head of the fibula and lateral tibia condyle, and the fingers are percussed. A reflex supplied by L5–S3 results in flexion of the leg on the thigh and moderate external rotation of the leg.


      GROIN STRAINS

Groin strains are frequently caused by slips on a slick surface where severe hip abduction or adduction overstress might occur. A wrenching-type disability arises slowly rather than suddenly (as in a quickly torn muscle). Also refer to this topic in the previous monograph.

Management.   The management of severe groin strain sometimes requires great patience on the part of both doctor and patient, especially if it is associated with the sedentary patient with muscle shortening in the groin. Standard physiotherapy relieves attending muscle spasm due to the irritation from the inflammatory reaction. Despite extensive ecchymosis, there is usually immediate relief after correcting attending sacroiliac and pubic subluxations if avulsion has not taken place. Cold, compression, pressure by an elastic figure–8 bandage to inhibit hyperextension, and rest will rapidly control the swelling. Carefully monitored graduated exercises must be initiated as soon as possible to avoid posttraumatic contractures that will produce recurrent disability.

Adductor Strains

Painful groin strains may involve the gracilis, abductor longus, or iliopsoas muscles, but precise differentiation is usually not necessary in management. Interfiber bleeding is always a problem. Healing is slow (eg, 2––3 months). Low adductor strains, contusions, and bone bruises near the medial femoral epicondyle often mimic knee joint injury. Such strains usually result from a fall on the adducted knee producing overadduction and avulsion of the adductor tendon leading to periosteal calcification (Pellegrini-Stieda disease). Fortunately, severe posttraumatic disability is rarely a factor except with the aged and severely unconditioned patient.

Phelp's Test.   Place the patient in the prone position with both lower limbs extended in the relaxed position. Abduct the patient's thighs just short of the patient's threshold of pain, and then flex the patient's knees to 90° angles with the thighs. If this flexion allows greater abduction of a thigh on the hip without undue discomfort, a contracture of the gracilis muscle is suggested.

An adductor strain referring pain to the pelvis is frequently suffered by athletes. The presenting complaint includes stiffness, tenderness, and pain high in the groin during abduction. Besides regular strain therapy, treatment should include progressive adductor tendon stretching that does not exceed patient tolerance.

Soccer Syndrome.   A severe "scissors" kick, common in soccer, frequently leads to instability of the sacroiliac and symphysis pubis joints. Groin pain is aggravated during running and jumping, and in the stretching motion of kicking with power. Roentgenography may show a periosteal reaction at the origin of the adductor muscles (gracilis syndrome).

Rider's Strain.   An adductor strain is frequently suffered by horsemen, cyclists, runners, and fast bowlers. The patient's complaint includes stiffness, tenderness, and pain high in the groin during abduction.

Management.   Treat as any strain; however, a first-aid analgesic pack added to the regimen is often beneficial. The pack consists of spreading a balm such as menthol salicylate, about a half an inch thick, over the site of injury and covering it with an 8 X 10–inch or larger cotton pad. Secure the pack with tape, and cover it with an elastic bandage. In strapping, the final strips should be applied so that medial traction is maintained (ie, around the contralateral hip and posteriorly). Rehabilitation should emphasize stretching and massage to avoid posttraumatic contractures.

Sartorius Strain and Tears

Sartorius strains are usually mild but present with a persistent disability that is often seen with activities requiring excessive and unaccustomed "squatting" or rowing positions. The associated discomfort is aggravated by abduction and extension of the thigh, and eased after a mild warm-up.


      ILIOTIBIAL DYSFUNCTION

The tensor fascia lata muscle arises from the iliac crest and inserts into the iliotibial band (ITB). The ITB is neither a muscle nor a tendon or is it a ligament. It is the long distal extension of the thick lateral fascia of the thigh, and as such, it serves as a supplemental support of the knee laterally. The ITB arises proximally from the fascia lata and gluteus maximus and inserts distally into Gerdy's tubercle on the lateral tibial condyle.

During flexion, the knee depends primarily on muscular support rather than on ligamentous straps. This is performed laterally by the ITB and biceps femoris; medially by the combined action of the semitendinosus, semimembranosus, gracilis, and sartorius; anteriorly by the quadriceps femoris; and posteriorly by the action of the popliteus. Because the ITB crosses the knee joint, its effect on the knee varies according to the position of the hip. Evans, reports Hazel, believes that the ITB greatly assists rest during standing.


The ITB Syndrome

The Iliotibial band syndrome, an overuse symptom complex common in runners, is the result of excessive friction between the iliotibial band and the lateral femoral epicondyle during prolonged flexion-extension activity of the knee. The bursa overlying the lateral femoral epicondyle becomes inflamed, and periostitis at the attachment of the iliotibial band is usually associated. Knee flexion-extension (eg, climbing stairs) aggravates the pain (a stinging sensation). Crepitus and tenderness around the lateral epicondyle can be found, but lax ligaments and para-articular effusion are absent.

The importance of the ITB syndrome within athletics has been pointed out in a paper by John Nash of Texas Chiropractic College. It has also been described by R. H. Hazel who feels it is essentially limited to long distance runners. A summary of their findings is described below.

During the walking cycle, the knee is normally in full extension at heel strike --and this is the only time in the cycle when this occurs. At other phases of the cycle, the knee is in various degrees of flexion. When running on flat terrain, the knee does not accomplish full extension at heel strike. However, it is close enough that lateral stability is satisfactorily accomplished by the ligament straps. This situation changes when running on hills, particularly during an up-hill phase where flexion of the knee reduces the support contributed by the ligaments and places more emphasis on dynamic muscle tissue.

Etiologic Considerations.   Three factors can and will alter the ITB system sufficiently to produce symptoms:

1. The first factor occurs during semiflexion of the knee. During this action, as mentioned above, the dynamic muscle groups must stabilize the knee. When done repetitively, this can hasten trigger-point development in the overstressed muscles, especially when (even slight) biomechanical faults are associated. Thus, during strenuous physical activity, the ITB is easily victimized because it has such a high connective-tissue content. The resulting trigger points can produce aberrant control of the leg during performance and produce pain.

2. The second factor involves contracture and inelasticity of the hamstrings. This is a common finding among the general population as well as in athletics. Hamstring shortening prevents complete extension of the knee at heel strike, which precipitates the same negative situation that is seen in up-hill running.

3. The third factor is related to contracture of the triceps surae. This alters normal gait by producing push-off before the full stride is accomplished, thus producing the characteristic knee posture and semiflexion at heel strike. The result is the same as in Factors 1 and 2 described above.

Athletes, either serious or the weekend variety, can fall victim to this problem when they alter their activity suddenly, either by an increase in duration or intensity. A change in terrain or footwear can also be a causative or precipitate factor. Other contributing situations include novice runners with tibia vera and pronated ankles, excessive length in stride, and/or excessive wear on the outer sole of a running shoe.

Clinical Features.   An afflicted individual reports pain during or immediately following a workout, but there is usually no sign of effusion. Tests for ligament or meniscus faults in the knee prove negative. The ITB can be palpated distally by locating the tendon of the biceps femoris, moving anteriorly into the groove that separates it from the ITB. Palpation of the lateral thigh distally invariably shows evidence of single or multiple trigger-point development. The usual sites are across the ITB, at or just above the joint line. Gerdy's tubercle will be surprisingly pain free. Gross ITB weakness can be judged by testing thigh flexion and medial rotation against resistance.

Hazel recommends three tests that he believes are a must in the accurate diagnosis of an ITB syndrome: (1) Have the patient jog to (but not beyond) the point of pain. This will help localize the focal point of stressed tissues. Running beyond the threshold of pain causes it to become diffuse, and point tenderness will then be lost. (2) The sitting patient should flex and extend the involved leg while the examiner applies pressure to the lateral femoral epicondyle. (3) The patient is placed in the lateral recumbent position and instructed to rapidly abduct the leg (to about 20°) several times. This puts considerable tension on the tensor fascia lata and gluteus maximus, helping to bring out a subtle lesion.

Management.   After relaxing (eg, stripping) the tensor fascia lata muscle, the lower extremity should be checked for articular fixations at the hip or knee. Treat as an acute sprain. Initial cryotherapy and adequate rest are vital to rapid recovery. Nash recommends that the treatment of associated trigger points incorporate transverse friction over the reactive points for 3--4 minutes on alternate days for 1--2 weeks, depending on the severity and the responsive nature of the patient. Each treatment is followed by negative pole high-volt therapy, which may be preceded by ice massage for 15-20 minutes for anesthetic purposes. Stretching exercises to tolerance are emphasized early and continued until recovery is full. Shoe orthoses, reduced activity, moist heat, interferential therapy, and/or phonophoresis with some type of anti-inflammatory agent are the common adjunctive procedures used.

A regimen of bilateral passive and then active stretching exercises for the tensor fascia lata, ITB, quadriceps, and hamstrings should be prescribed, but exercises designed to strengthen the quadriceps should be avoided. Activity is modified according to the signs at hand, and consideration is given to nontraumatic activities such as swimming or mild bicycling in the interim period. Ice massage can be applied to the involved area after each workout. If conservative measures fail, one alternative is referral for surgical release of the ITB or removal of the lateral epicondyle.

Recurrence Prevention.   To prevent return, close evaluation of the patient, environment, and activity situation must be made. This might include footwear, foot mechanics, knee mechanics, pelvic motion, and even the terrain on which the workout is performed. Walking upstairs can be especially aggravating, but walking on level ground may have no ill effects. As with most posttraumatic problems, clinical success can only be achieved through careful analysis of all factors involved.

Iliotibial-Band Contracture

Ober calls attention to the frequency of a negative roentgenogram in the presence of clinical signs and symptoms of irritation of the sacroiliac or lumbosacral joints. He refers to the importance of the iliotibial band as a factor in the occurrence of lame backs, with or without associated sciatica. To differentiate, he believes that pain on extension and abduction points to a sacroiliac lesion; pain when the knee is released suggests lumbosacral strain; and contraction of the iliotibial band is indicated when the thigh does not return to the table on being released. Ely's test helps to pinpoint femoral nerve (L3--L4) involvement, and Lasegue's SLR test aids differentiating lumbosacral from upper lumbar involvement.

Ober's Test.   This is the classic test for iliotibial band contractures. The patient is placed directly on his side with the unaffected side next to the table. The examiner places one hand on the pelvis or under the thigh to steady it and grasps the patient's ankle with the other hand, holding the knee flexed near a right angle. The thigh is abducted and extended in the coronal plane of the body. In the presence of iliotibial band contracture, the leg remains abducted --the degree of abduction depending on the amount of contracture present.

The hip is the most proximal joint of the lower extremity and is a near-perfect ball-and-socket joint. It provides stability for the body above and gross control for the extremity segments below. From a biomechanical and kinesiologic viewpoint, the hip joint is one of the most complex joints of the body in its role of providing both large ranges of motion and large muscle torques in attempting to meet the requirements of imposed body weight during static and dynamic postures in the upright position.

Considerations Prior to Adjustive Therapy

It has been the author's experience that almost any technic designed to release a soft-tissue fixation or reduce a subluxation within a synovial joint should incorporate procedures (eg, manual axial traction) to assure slight physiologic distraction and biomechanical tissue adaptation before a corrective maneuver. If not, there is a possibility (likely, a probability) of injuring the cartilage of the articular surfaces and thus add to the development of further fixation. Obviously, distracted articular surfaces are much easier to move. Forcing motion on jammed articular surfaces will likely injure the apposed structures and set up an imposed inflammatory process leading to fibrosis, cartilage sclerosis, adhesion development, pain from excited mechanoreceptors and effected splinting, etc. Any clinical procedure should be uniquely patient-oriented, not prescripted by doctrine.

As with any clinical program, this procedure to assure articular distraction can be overdone. If too much distraction is used, the articular surfaces might become so separated (eg, in an unstable joint) as to dislocate during a poorly controlled adjustment. Another consideration is that stretched arteriosclerotic vessels are disposed to rupture when a strong longitudinal or rotational force is applied because structural plasticity is already at its limit. Even if bleeding may be minute, a degree of contribution to an adverse situation has been initiated. Knowing just how much joint distraction to apply and how much force, velocity, and depth to bestow during the adjustment in an individual situation is part of the art of chiropractic and just one factor that differentiates the chiropractic physician from the therapist or technician.

These principles are just as applicable to adjustive technics involving spinal and other extraspinal joints. In many extremity joints and the cervical vertebrae (C1--C6), it is fairly easy to dislocate an overly distracted joint that is unstable or normally very "loose." This is infrequently found, however, with thoracic, lumbar, sacroiliac, or the extraspinal axial articulations that have strong short ligaments. Typical exceptions would be with acrobats, contortionists, gymnasts accustomed to performing "somersaults and backflips," and others whose occupations require extremely unusual postural distortions. In these people, the ligament restraints may be lengthened through prolonged conditioning to such a degree that dislocation (and spontaneous reduction) is commonplace.


Special Clinical Considerations

Because the head of the femur articulates deeply within the acetabulum, the joint is highly stable. Unfortunately, this asset excludes the advantages of direct palpation during examination. Most of the physical clues of joint dysfunction must therefore be analyzed indirectly from the effects expressed in the thigh as a whole during passive motion studies in the nonweight-bearing position, gait and upright postural analyses, muscle strength testing, subjective symptoms (eg, pain, tenderness), superficial signs (eg, skin characteristics and temperature changes), reflexes, etc.

Degenerative changes and fractures predisposed by structural changes (eg, osteoporosis, biomechanical failure) in the hip are common. This is likely because the hip is frequently subjected to heavy repetitive loading that must be tolerated during function. Cortisone therapy, especially, appears to attack the hip (necrosis) more than other joints.

Muscle and ligament shortening affecting the hip is prevalent in the nonathletic individual, frequently producing complicating secondary effects in musculoskeletal architecture above and below. Overstress imposed on such fixations (added to the large muscle torques required for hip function) appears to encourage the development of acute and chronic subluxation syndromes. While chronic hip subluxations may exhibit themselves locally, they can express remotely anywhere in the kinematic chain (eg, lumbosacral area, feet, upper cervical spine).


Common Differentiation Clues

In testing hip flexion with the knee locked (straight-leg test), sciatic neuritis would be aggravated. In testing full hip flexion with the knee relaxed, a sacroiliac lesion may be aggravated. However, testing internal and external rotation of the hip with the hip and knee flexed to 90° should not normally ignite low-back or sacroiliac pain unless there is complicating psoas or piriformis spasm.


      HIP FIXATIONS

Mennell considers long-axis (downward) joint play to be the most important motion of the hip joint. The gross degree of distraction available can easily be judged by placing the patient supine in a position of rest, stabilizing one foot against your thigh and then applying traction on the thigh to be examined.

Many types of hip dysfunction are associated with a limitation in joint distraction. In osteoarthritic hip disease and certain adhesions, forced flexion of the thigh on the involved side toward the abdomen causes the contralateral thigh to raise from the table. This occurs because the motion limitation in the involved socket forces the pelvis as a whole to rotate upward. It suggests a restriction in hip flexion and points to a posterior adhesion or shortened tissues posteriorly (eg, hamstrings).

The same procedure can be used when testing forced extension with the patient in the prone position. If the contralateral thigh rises before normal extension is reached, the examiner should suspect an anterior joint fixation or shortening of the quadriceps.

Note: The maneuvers described below must be applied gently and not beyond patient tolerance, with special caution used with the elderly and very young. Too forceful an application, especially during forced extension, can cause a torsion fracture of the neck of the femur in the elderly or dislocate the head of the femur in a youngster. At the same time, it must be kept in mind that the hip joint is much more stable than the shoulder and requires a greater force to overcome larger muscle and ligament restrictions.


Releasing Inferior Distraction Fixations

Soft-tissue distraction (separation of intra-articular space) restrictions can be released simply by axial traction (manual or mechanical). Some type of belt or harness to stabilize the patient's pelvis is helpful. Once long-axis joint play is restored, at least to a modest degree, attention can be given to flexion, extension, abduction, and adduction fixations.

Straight distraction inferiorly is achieved by holding the supine patient's leg distally with one hand and the proximal aspect of the leg with your other hand and applying a pulling force, thus directing a distraction force to the hip via the knee. If the patient has a knee problem, contact must be taken on the distal thigh.


Releasing Flexion Fixations

To improve posterior glide with the patient supine, stand perpendicular to the involved thigh. Place your cephalad palm firmly on the most superior aspect of the anterior surface of the patient's thigh as possible, and grasp the underside of the patient's proximal thigh with your caudad hand. In this position, apply a slow pushing force directed to the floor with your cephalad hand (elbow locked) and a slight upward pull with your caudad hand.

To further improve flexion range of motion, stand on the opposite side of involvement perpendicular to the supine patient and approximately centered to the patient's knees. Flex the uninvolved knee and hip toward the patient's abdomen. Place your contact (cephalad) hand over the knee of the uninvolved side, and reach over the patient with your caudad hand and stabilize the distal aspect of the patient's thigh on the involved side. Flex the uninvolved limb toward the patient's abdomen just to the point where the contralateral (involved) femur begins to rise from the table. At this point, apply firm pressure against the involved limb as you continue to apply flexion pressure to the uninvolved hip.

Another technic is to place the patient supine with the hip and knee flexed at a right angle. Stand obliquely to the involved thigh, and grasp the patient's kneecap with your cephalad hand. Reach under the patient's leg with your caudad hand and place that hand on top of your other hand, thus supporting the patient's leg in the angle of your caudal arm and forearm. In this position, apply pressure toward the floor (through the vertical axis of the femur).

Also with the supine patient, specific posteroinferior distraction of the hip can be applied in hip flexion and slight abduction by facing the patient, placing the patient's flexed knee over your medial shoulder, grasping the upper thigh of the patient anteriorly with both hands and fingers interlaced, and applying a pulling force directed to your chin.


Releasing Extension Fixations

To improve anterior glide with the patient prone, stand perpendicular to the involved thigh. Place your cephalad palm firmly on the most superior aspect of the posterior surface of the patient's thigh as possible, and grasp the patient's flexed knee with your caudad hand. In this position, apply a slow pushing force directed to the floor with your cephalad hand (elbow locked) and a mild upward pull with your caudad hand.

To further improve extension range of motion, stand on the opposite side of involvement perpendicular to the prone patient --approximately centered to the patient's knee. Grasp under the uninvolved extended knee, and start to lift the limb upward. Reach over the patient with your caudad hand and stabilize the distal aspect of the patient's thigh on the involved side. Extend the uninvolved limb just to the point where the contralateral (involved) hip begins to rise from the table. At this point, apply firm pressure against the involved limb as you continue to apply extension pressure to the uninvolved hip.


Releasing Lateral Hip Fixations

A lateral fixation within the hip joint is not an uncommon finding. On the involved side, abduction and internal rotation will be restricted and the psoas muscle will usually test weak.

Psoas Strength.   Psoas strength can be tested by the supine patient lifting the extended limb to 45°, externally rotating the foot, and resisting your attempt to move the patient's foot laterally and toward the floor. Stand at the foot of the table so that your inactive hand can stabilize the patient's contralateral pelvis.

Adjustment.   Place the patient supine with the involved hip and knee flexed so that the foot rests flat on the table without strain. Stand at the foot of the table, and face the patient. Interlock your fingers over the patient's flexed knee, and lean forward so your sternum is almost above the knee. With the medial aspect of your forearm, press the patient's leg laterally to internally rotate the femur approximately 25°. While holding this pressure, make a gentle thrust through the longitudinal axis of the femur. Check if the fixation has been freed by evaluating bilateral internal rotation of the hip and psoas strength.

Active Exercise.   In chronic cases, the following bed exercise is recommended. Have the patient assume the sidelying position with the involved side upward. The patient's body should be positioned near the edge of the bed, with the patient facing away from the near edge. A small pillow should be placed between the upper thighs. The underlying uninvolved hip and knee should be moderately flexed. The patient then slightly extends the limb and allows the leg to drop over the edge of the bed, thus producing hip adduction in mild extension. The patient should then actively abduct the limb a few inches and let it drop by its own weight several times. This will stretch soft-tissue restrictions to external rotation and inferior distraction.

      HIP SUBLUXATIONS

Internally Subluxated Femur

An internally subluxated femur is commonly associated with restricted femoral external rotation, anterior pelvic tilting, external tibia rotation, and subtalar pronation. Some genu valgum and hip pain are usually associated.

Adjustment.   Place the patient supine with flexed knees so that the buttocks are near the end of the table. Stand medially, facing perpendicular to the thigh of the involved hip. Contact the medial aspect of the upper thigh. While your stabilizing hand grasps the patient's upper calf, externally rotate the femur, apply traction with your stabilizing hand, and make a gentle thrust with your contact hand, directed toward further external rotation.

Externally Subluxated Femur

An externally subluxated femur is related to restricted femoral internal rotation, internal tibia rotation, and subtalar pronation. A degree of genu varum and hip pain are usually related.

Adjustment.   With the patient supine, stand lateral to the patient on the side of involvement, facing obliquely medial. Contact the superolateral aspect of the femur at midshaft with your cephalad hand, while your stabilizing hand is wrapped over the patient's leg so that your palm supports the patient's upper calf. Internally rotate the femur, apply caudal traction with your stabilizing hand, and make a gentle thrust with your contact hand that is directed toward further internal rotation.

Superiorly Subluxated Femur

A superiorly subluxated femur is usually found when nagging hip pain complicates low back pain. A degree of fixed internal or external rotation is often involved.

Adjustment.   With the patient supine, stand at the foot of the table and face the patient. Grasp the lower leg of the involved limb just above the ankle, and stabilize the patient's contralateral foot against your thigh. Apply traction, and make a gentle pull --taking into consideration any internal or external rotation involved by rotating your hands accordingly.

Anteriorly Subluxated Femur

Occasionally one comes upon a lesser degree of an anterior (obturator) dislocation. The cause is usually a severe fall or being forced backward against an obstacle. On the involved side of an anteriorly subluxated femur, the patient exhibits hip pain and an externally rotated limb that is lengthened. The head of the femur lies nearer the obturator foramen than normal.

Adjustment.   With the patient supine, stand at the foot of the table, near the side of involvement, and face the patient. With your lateral hand, grasp the patient's posterior-distal aspect of the leg just above the ankle. With your medial hand, reach across the patient's foot and grasp the heel. Both hands should be on the lateral aspect of the patient's ankle area. Apply gentle traction and medial rotation to the limb. Adduct the patient's involved limb across the patient's other leg, maintaining control. Constant traction, medial rotation, and adduction should reset the displaced femoral head.

Posteriorly Subluxated Femur

When the femur is subluxated backward, the patient has difficulty in extending the thigh. Measurement will indicate limb shortening. The mechanism of injury is usually a fall, long jump, or severe upper-thigh blow directed from the anterior.

Adjustment.   Place the patient supine. Stand on the side of involvement at a level near the patient's flexed knee, and face obliquely medial to the patient. Bring the patient's knee laterally so that it is firm against your upper abdomen. With your cephalad hand, stabilize the patient's contralateral ilium. With your caudad contact hand, grasp the patient's ankle from the anterior. Apply abduction to the flexed knee with your body weight, and simultaneously use superior pressure with your contact hand to increase hip flexion and carry the patient's lower leg medially. This hip flexion, abduction, and external rotation should realign the displaced femoral head.

Sciatic Displacement

Sciatic displacement of the head of the femur is a chronic postural disorder associated with pelvic tilt where weight balance is decidedly unilateral on the involved side. The head of the femur is found near the lesser sciatic notch --thus its name. Acute trauma is rarely involved, but injury may be in the patient's history. The patient presents with hip pain, internal limb rotation, and a shortened limb.

Adjustment.   This maneuver is essentially the opposite of adjusting an anteriorly subluxated femur. Place the patient supine, stand at the foot of the table near the side of involvement, and face the patient. With your lateral hand, grasp the patient's posterodistal aspect of the leg just above the ankle. With your medial hand, reach across the patient's foot and grasp the heel. Both hands should be on the lateral aspect of the patient's ankle area. Apply gentle traction and lateral rotation to the limb. Abduct the patient's involved limb. In this position, constant traction, lateral rotation, and abduction should reset the displaced femoral head.

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