Musculoskeletal examination of the hip and groin
- Margot Putukian, MD, FACSM
Margot Putukian, MD, FACSM
- Director of Athletic Medicine
- Princeton University
- Associate Clinical Professor
- Robert Wood Johnson Medical School - University of Medicine & Dentistry of New Jersey
- Megan Groh Miller, MD
Megan Groh Miller, MD
- Primary Care Sports Medicine Specialist
- Tri-Rivers Musculoskeletal Centers
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Hip and groin pain are common complaints among active adults and pose a diagnostic challenge to clinicians due to the complex anatomy and biomechanics of the region. Effective evaluation of the hip depends upon an understanding of local anatomy and function and the proper performance of a focused physical examination. This topic will review the clinical anatomy and examination of the hip and groin. Specific injuries of structures in the hip or groin are discussed separately in the program.
ANATOMY AND BIOMECHANICS
The pelvis is a bony ring-like structure that provides postural support when stationary and during movement (figure 1 and figure 2) . In addition, the pelvis provides a stable platform for the hip, a ball and socket joint positioned at each inferolateral aspect of the pelvis that enables rotation, flexion, extension, abduction, adduction, and rotation of each lower extremity. The bones forming the hip include the ilium, pubis, and ischium bones. The hip joint consists of the femoral head (ball) and the acetabulum (socket), a cavity created by the hips bones. The depth of the acetabulum is increased by a triangular fibrocartilage structure called the labrum that attaches along its outer rim.
Posteriorly the ilium articulates with the sacrum. This sacroiliac joint provides a stable connection between the pelvis and the lower spine. This allows force transmitted down the spine to be transferred in part to the pelvis. Conversely, forces absorbed during impact with the ground and transmitted up the lower extremities, during such activities as running and jumping, can be dissipated through the pelvis and spine. The sacroiliac joint is diarthrodial, involving bony surfaces of the ilium and sacrum. The ilial surface is slightly convex and the sacral surface slightly concave, which increases stability and limits motion. Motion is only approximately 3 degrees in both the longitudinal and transverse planes but appears important for normal rotation of the hemipelvis and for flexion and extension of the hip. Below the sacrum, the coccyx forms the distal portion of the spine .
The pelvis must support the entire torso and upper extremities, and support of the bony articulations is provided by powerful ligaments (figure 3 and figure 4). At the same time, pelvic motion is a critical aspect of normal walking and running so the left and right hemipelvis have articulations at the sacroiliac joint that allow some rotation and both flexion and extension of the trunk. The sacroiliac ligaments, as well as the sacrotuberous and sacrospinal ligaments, prevent anterior translation of the hemi-pelvis and help to stabilize the joint during motion. The iliolumbar ligament assists in stabilizing the posterior pelvis. The sacroiliac joint is a stress point during motion and thus a frequent location for injury. Anteriorly, the pelvis has a strong ligament that encompasses a disk lying between the superior pubic rami and forms the symphysis pubis. Together the symphysis pubis and sacroiliac joint allow a small degree of anterior translation of the hemipelvis. Combined with posterior translation of the opposite hemipelvis, this motion is sufficient to allow for pelvic rotation in an anteroposterior plane, thereby enabling efficient walking and running.
Key muscular attachments to the hip and pelvis include those for muscles that stabilize and move the hip joint (figure 5). On the anterior surface of the hip, the iliacus and psoas descend from the ilium and lumbar vertebrae respectively and fuse to form the iliopsoas muscle, a major hip flexor. The iliopsoas tendon attaches to the lesser trochanter of the proximal femur. Just medial to the iliopsoas on the anterior surface is the pectineus muscle that arises from the anterior aspect of the superior pubic ramus. The pectineus inserts on the superior femur along the pectineal line. The rectus femoris is part of the quadriceps complex but also an important hip flexor. Its major tendinous attachment is found at the antero-inferior iliac spine. Superficial anterior hip muscles include the Sartorius, which arises from the antero-superior iliac spine and crosses the thigh to attach at the pes anserine area. The sartorius is a weak hip flexor and assists with external rotation of the thigh. The tensor fascia lata muscle lies just superior and anterior to the hip and attaches to the iliotibial band .
- Betti L, von Cramon-Taubadel N, Manica A, Lycett SJ. Global geometric morphometric analyses of the human pelvis reveal substantial neutral population history effects, even across sexes. PLoS One 2013; 8:e55909.
- Foley BS, Buschbacher RM. Sacroiliac joint pain: anatomy, biomechanics, diagnosis, and treatment. Am J Phys Med Rehabil 2006; 85:997.
- Bianchi S, Martinoli C. Hip. In: Ultrasound of the Musculoskeletal System, Springer, New York 2007. p.551.
- Heiderscheit B, McClinton S. Evaluation and Management of Hip and Pelvis Injuries. Phys Med Rehabil Clin N Am 2016; 27:1.
- Suarez JC, Ely EE, Mutnal AB, et al. Comprehensive approach to the evaluation of groin pain. J Am Acad Orthop Surg 2013; 21:558.
- Byrd JW. Evaluation of the hip: history and physical examination. N Am J Sports Phys Ther 2007; 2:231.
- Hölmich P. Long-standing groin pain in sportspeople falls into three primary patterns, a "clinical entity" approach: a prospective study of 207 patients. Br J Sports Med 2007; 41:247.
- Zelle BA, Gruen GS, Brown S, George S. Sacroiliac joint dysfunction: evaluation and management. Clin J Pain 2005; 21:446.
- Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med 2001; 29:521.
- Broadhurst NA, Bond MJ. Pain provocation tests for the assessment of sacroiliac joint dysfunction. J Spinal Disord 1998; 11:341.
- Levangie PK. Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain. Phys Ther 1999; 79:1043.
- ANATOMY AND BIOMECHANICS
- TIPS FOR A PRODUCTIVE EXAMINATION
- NEUROVASCULAR ASSESSMENT
- PHYSICAL EXAMINATION
- Assessment of gait and the standing patient
- Examination with the patient supine
- Examination with patient lying on their side
- Examination with the patient prone
- SPECIAL TESTS FOR SPECIFIC CONDITIONS
- Tests of hip abductors
- Tests of hip adductors
- Tests of hip flexors
- Tests for acetabular pathology
- Tests of sacroiliac region
- Tests for lateral hip pain
- Tests for stress fractures and minor pelvic fractures
- SUMMARY AND RECOMMENDATIONS