HIP FLEXION. Evaluation and Measurement. By Isabelle Devreux

Transcription

1 HIP FLEXION Evaluation and Measurement By Isabelle Devreux 1

2 Hip Flexion ROM : 0 to Muscles : Psoas Major Iliacus 2

3 Psoas Major Origin: Ventral surface of transverse processes of all lumbar vertebrae. Sides of the bodies and corresponding intervertebral discs of the last thoracic and all lumbar vertebrae and membranous arches. Insertion: Lesser trochanter of femur. Nerve supply: L1,L2, L3,L4 Lumbar Plexus. Action : Flexion of the hip joint 3

4 Iliacus Muscle Origin: 2/3 of iliac fossa; Internal lip of iliac crest Iliolumbar and ventral sacroiliac ligament. Insertion: Lateral tendon of Psoas Major, and just distal to the lesser trochanter. Nerve Supply: L2, L3,L4 Femoral Nerve. Action: Flex. of the hip joint 4

5 Acessory muscles for Hip Flexion Rectus Femoris Sartorius. Tensor of the Fascia Lata. Pectineus ROM: with knee flexion: to ROM can be limited by: The contact of the thigh on the abdomen when knee flexed. The tension of the hamstring muscles when movement is performed with knee extension 5

6 Testing Procedure Grade 3 Fair strength Pt. starting position: sitting with legs over the edge of table + grasps the edge of table to stabilize pelvis. Therapist position: at the foot of the table; proximal hand is pressing the iliac crest down. Command: Raise your leg up vertically «in the midline» towards your chest. relax. 6

7 Hip Flexion- Grade 4 ( Good Strength) Pt. Position:Same as grade 3. Therapist position: same as grade 3 + hand proximal to the knee joint to give resistance. Resistance: moderate opposing line of raising. Command : Lift your leg. 7

8 Hip Flexion: Grade 5 ( Normal Strength) Position of therapist and patient is the same as for gr.4. Resistance is applied opposite the line of raising + hold at the end of range of motion. Command : same + hold at the end of ROM. 8

9 Hip Flexion: Grade 2 ( Poor strength) Pt. position: sidelying, trunk, pelvis and back are straight. Upper leg is supported & is the leg to be tested. Therapist pos.: behind the pt. with the distal hand supporting the limb. ( knee is allowed to be flexed). Command: move your knee towards your chest through full ROM---relax. 9

10 Hip Flexion: Grade 1 & 0 ( Trace & Zero strength) Pt. back lying, supine with both legs extended. Affected leg near the edge of the table. Distal hand supports the affected leg, proximal hand palpates the psoas major distal to the inguinal ligament. Command: pull your leg towards your chest -relax. 10

11 Substitutions: By Sartorius in hip flexion causes lateral rotation and abduction of the thigh. By Tensor of the Fascia Latae in hip flexion causes medial rotation and abduction of the thigh. 11

12 Effects of weakness of the flexor muscles Stair climbing. Walking up or down the incline. Getting up from a reclined position. Bring the trunk forward in the sitting position prelimirary to raising from chair. In marked weakness, walking is difficult and is brought foreward by pelvice motion, produced by ant. & lat. abd. muscle action. 12

13 Main types of contracture of hip flexor m. & effect on posture: Bilateral hip flexion deformity combined with increased lumbar lordosis. Unilateral hip flexion contracture will be often combined with hip abduction and external rotation. 13

14 HIP Extension Evaluation and Measurement I. Devreux 14

15 Hip Extension ROM : to 0. Hyper extension: 0 to Muscles: Gluteus Maximus. Semitendinosus. Semimemebranosus. Biceps Femoris ( long head) 15

16 Guteus Maximus: Origin: Post. gluteal line of ilium & portion of bone sup. & post. to it. Post. surface of lower part of sacrum, side of coccyx, aponeurosis of erector spinae, sacrotuberous lig.& gluteal aponeurosis. Insertion: Larger proximal portion & superficial fibers of distal portion of m. into tract of fascia latae. Deeper fibers into gluteal tuberosity of femur. Nerve: L5, S1, S2. Action: Extends + laterally rotates the hip joint. Assists in add. of the hip. Helps to stabilize the knee in extension. 16

17 Semitendinous: Origin: Tuberosity of ischium. Insertion: proximal part of medial surface of body of tibia. Deep fascia of the leg. Action : extends the hip joint & assist in hip medial ( int.) rotation. Flex. & int. rotate the knee joint. Nerve: sciatic nerve: L4, L5, S1, S2 Semimembranosus Origin: Tuberosisty of ischium proximal and lateral to biceps femoris and semtendinosus. Insertion: posteromedial aspect of condyle of tibia. 17

18 Biceps Femoris: Origin: Distal part of sacrotuberous lig. Post. part of tuberosity of ischium. Insertion: lat. side of head of fibula, lat. condyle of tibia, deep fascia on lat. side of the leg. Nerve : L5, S1, S2, S3. Action: Extends the hip + assists in lat. rotation. Long head & short heads flex. & lat. rotate the knee joint. Tension in the iliofemoral ligament & tension of the hip flexor muscles will limit hip extension. 18

19 Testing Grade 3 Fair Strength Position: half prone with flexed knee, affected leg away from th., sound leg on stool. Therapist stands beside the table facing the pat. with proximal hand stabilizing the pelvis. Command : raise your leg through full ROM--- relax. 19

20 Hip Extension: Grade 4 & 5 ( good normal) Position of therapist and patient is same as for gr. 3. A belt can be placed to stabilize the pelvis. Resistance: moderate ( grade 4) or maximal ( gr. 5) by pressing down on knee directly opposing the line of raising + hold for gr

21 Modified test position for hip flexor tightness. Modified test in supine 21

22 Hip Extension: Grade 2 Poor Strength Pt. Is in sidelying, affected leg w.hip flexed, knee extended with uppermost leg supported. Therapist is behind & stabilizes with prox. Hand the pelvis, distal hand supports the upper leg. Command: move your leg backwards through full ROM ---relax. 22

23 Hip extension: grade 1 and 0 ( trace and 0) Patient position as in gr. 3,4 or 5. Therapist palpates with his two hands the upper and lower portion of the muscle narrowing of the gluteal crease. Command: Press your buttock together ---relax. 23

24 Special considerations: To isolate the gluteus max. m., all the tests should be performed with knee flexion. Weakness of hip extensors: makes the walking extremely difficult ( crutches); Raising the trunk from a forward bend position will need, in case of extreme weakness to push themselves up by using their arms. 24

25 HIP Abduction Evaluation and Measurement By Isabelle Devreux 25

26 Hip Abduction ROM: 0 to 45 Gluteus Minimus: Origin: Surface of ilium between ant. & inf. gluteal lines. Margin of greater sciatic notch. Insertion: ant. border of greater trochanter, hip joint capsule. Nerve supply: sup. gluteal nerve; L4,L5,S1. Action: abd. + medial rot. the hip joint.& assists in flex. of the hip. 26

27 Hip abduction Gluteus medius: Origin: External surface of the ilium between iliac crest and posterior gluteal line & ant. gluteal line. Insertion: oblique ridge on lat. surface of greater trochanter of femur. Nerve: L4,L5,S1. Action: Add. Hip, Ant fibers :medially rotates + assist in hip flex. Post fibers: lat. rotate + may assist in extension of the hip joint. 27

28 Hip abd. can be of 45 but is limited by : a: tension of the distal band of iliofemoral ligament and of pubocapsular ligament. b: tension of the hip adductor muscles Test: grade 3 Fair : Pt. is in sidelying, with affected leg is upper. Lower knee is flexed for balance. Therapist stands behind pt. and stabilzes the pelvis. Command: raise up your leg to full ROM without lat. rot. of the hip---relax 28

29 Hip Abd.: grade 4 and 5 Pt. and therapist position as for grade 3; distal hand is placed proximal to knee to give moderate ( gr. 4) or maximal resistance + hold (gr. 5). Command : as gr. 3 lift your leg up to full ROM (without lat. rot.) + hold at end of ROM. 29

30 Hip Add. : Grade 2 - Poor Strength Pt. Position: back lying with legs extended; affected leg away from therapist. Ph.Th.: stands beside, prox. hand stabilizes the pelvis, distal hand around the ankle to fix non tested leg on table. Command: move your leg outward trough full ROM without lateral rotation. 30

31 Hip Abduction: Grade 1-0 Pt. lies in supine. The therapist grasps the non affected ankle & proximal hand is placed on lateral aspect of ilium above greater trochanter to palpate contraction. Command: try to move th leg outward through full ROM without lat. rotation. 31

32 Note: Stabilization by the examiner s proximal hand will prevent the tendency to roll anteriorly or posteriorly. Any shift may result from trunk weakness or indicate an attempt to substitute by anterior or posterior hip m. or lateral abdominals in the mov. of hip abd. 32

33 HIP ADDUCTION Evaluation and Measurement By Isabelle Devreux 33

34 Hip Adduction ROM: Muscles tested: 1. Adductor magnus 2. Adductor brevis 3. Adductor longus 4. Pectineus 5. Gracilis 34

35 Hip Adduction 1. Pectineus: Add.+ Flex. Origin: surface of sup. ramus of pubis ventral ( in front) between iliopectineal eminence and pubic tubercle. Insertion/ pectineal line of femur. Nerves: femoral and obturator nerves: L2, L3, L4. 35

36 Adductor magnus: Add. + flex. +ext Origin:inf. pubic ramus, ramus of ischium and ischial tuberosity. Insertion: medial to gluteal tuberosity, adductor tubercule of medial condyle. Nerve: Obturator & Sciatic nerve: L2, L3, L4, S1. Gracilis: Add. + flex. + medial rot. Origin: inferior ½ of symphysis pubis and medial margin of inf ramus of pubic bone. Insert.: prox. Part of medial surface of body of tibia distal to condyle. Nerve: Obturator: L2,L3, L4. 36

37 Adductor Brevis: Add. + Flex Origin: outer surface of inf. ramus of pubis. Insertion: distal 2/3 of pectineal line, & proximal half of medial lip of linea aspera. Nerve: L2, L3, L4. Adductor Longus: Add. + Flex. Origin: Ant. Pubis at junction of crest and symphesis. Insertion: middle 1/3 of medial lip of liea aspera. Nerve: L2,L3,L4 37

38 Restriction of ROM Limitation of hip adductions to 45 may be limited by: Contact with the other leg. When the hip is flexed, tension of the ischio-femoral ligament. 38

39 Hip Add.: grade 3 = Fair Strength Pt. Position: sidelying with leg resting on table, affected leg down. upper leg supported in 25 abd. Th.stands behind and support the upper leg. Command: raise up your leg until it contacts the upper ---relax. 39

40 Hip add.: grade 4-5 ( Good-normal) Pt. position: as in gr. 3. Grasp of therapist as in gr.3 + resistance to knee ( gr.4) and to leg + hold (gr.5). Command: lift your lower leg up. 40

41 Hip Add. Grade 2 = Poor Strength. Position of pt. of supine lying. Leg away from th. Is abducted 45. Therapist stabilizes the pelvis of the affected leg. «Move your leg towards th other without rotation of the hip» 41

42 Hip Add. Grade Trace and Zero = 1 & 2 Position as in gr. 2 (Supine) Therapist grasps around the ankle and proximal hand palpates the contraction of m. on medial aspect of thigh. Command:» try to move your leg towards the other without rot. of hip» 42

43 Substitutions: Anterior tilting of the pelvis or flexion of the hip allows substitutions by hip flexors. Forward rotation of the pelvis with extension of the hip shows to hold with lower fibers of gluteus Maximus. 43

44 Thank You THANK YOU 44