Psoas major lliacus
Origin: Ventral surfaces of the transverse processes of all lumbar vertebrae, sides of the bodies and corresponding intervertebral disks of the last thoracic and all lumbar vertebrae, and the membranous arches that extend over the sides of the bodies of the lumbar vertebrae.
Insertion: Lesser trochanter of the femur.
Origin: Superior h of the iliac fossa, internal lip of the iliac crest, iliolumbar and ventral sacroiliac ligaments, and ala of the sacrum.
Insertion: Lateral side of the tendon of the psoas major and just distal to the lesser trochanter.
Action: With the origin fixed, flexes the hip joint by flexing the femur on the trunk, as in supine alternate-leg raising, and may assist in lateral rotation and abduction of the hip joint. With the insertion fixed and acting bilaterally, flexes the hip joint by flexing the bunk on the femur, as in a sit-up from the supine position. The psoas major, acting bilaterally with the insertion fixed, will increase the lumbar lordosis; when acting unilaterally, it will assist in lateral flexion of the trunk toward the same side.
ILIOPSOAS (WITH EMPHASIS ON PSOAS MAJOR)
Fixation: The examiner stabilizes the opposite iliac crest. The quadriceps stabilize the knee in extension.
Test: Hip flexion in a position of slight abduction and slight lateral rotation. The muscle is not seen in the photograph above because it lies deep beneath the sartorius, the femoral nerve, and the blood vessels contained in the femoral sheath.
Pressure: Against the anteromedial aspect of the leg, in the direction of extension and slight abduction, directly opposite the line of pull of the psoas major from the origin of the lumbar spine to the insertion on the lesser trochanter of the femur.
Weakness and Contracture: See the discussion of hip flexors on facing page. Weakness tends to be bilateral in cases of lumbar kyphosis and sway-back posture and unilateral in cases of lumbar scoliosis.
This muscle is not a lower extremity muscle, because it does not cross the hip joint It is relatively unimportant and not always present.
Origin: Sides of the bodies of the 12th thoracic and first lumbar vertebrae and from the intervertebral disk between them.
Insertion: Iliopectineal eminence, arcuate line of the ilium, and iliac fascia.
Action: Flexion of pelvis on lumbar spine, and vice versa. Nerve: Lumbar plexus, LI, 2.
Origin: Anterosuperior iliac spine and superior half of the notch just distal to the spine.
Insertion: Proximal part of the medial surface of the tibia near the anterior border.
Action: Flexes, laterally rotates, and abducts the hip joint. Flexes and assists in medial rotation of the knee joint
Fixation: None necessary by the examiner. The patient may hold on to the table.
Test: Lateral rotation, abduction, and flexion of the thigh, with flexion of the knee.
Pressure: Against the anterolateral surface of the lower thigh, in the direction of hip extension, adduction, and medial rotation, and against the leg, in the direction of knee extension. The examiner's hands are in a position to resist the lateral rotation of the hip joint by pressure and counterpressure (as described for the hip lateral rotator test, p. 431).
Weakness: Decreases the strength of hip flexion, abduction and lateral rotation. Contributes to anteromedial instability of the knee joint.
Contracture: Flexion, abduction and lateral rotation deformity of the hip, with flexion of the knee.
The position of the leg, as illustrated in the accompanying photograph, resembles the sartorius test position in its flexion, abduction, and lateral rotation. The ability to hold this position is essentially a function of the hip adductors, however, and requires little assistance from the sartorius.
Fixation: The patient may hold on to the table. Quadriceps action is necessary to hold the knee extended. Usually, no fixation is necessary by the examiner, but if there is instability and the patient has difficulty in maintaining the pelvis firmly on the table, one of the examiner's hands should support the pelvis anteriorly, on the opposite side.
Test: Abduction, flexion, and medial rotation of the hip, with the knee extended.
Pressure: Against the leg, in the direction of extension and adduction. Do not apply pressure against the rotation component.
Weakness: Moderate weakness is evident immediately by failure to maintain the medially rotated test position. In standing, there is a thrust in the direction of a bowleg position, and the extremity tends to rotate laterally from the hip.
Contracture: Hip flexion and knock-knee position. In a supine or standing position, the pelvis will be anteriorly tilted if the legs are brought into adduction.
position of the patella.
TENSOR FASCIAE LATAE
Origin: Anterior part of the external lip of the iliac crest, outer surface of the anterosuperior iliac spine and deep surface of the fascia lata.
Insertion: Into the iliotibial tract of the fascia lata at the junction of the proximal and middle thirds of the thigh.
Action: Flexes, medially rotates, and abducts the hip joint. Tenses the fascia lata. May assist in knee extension. (See p. 437.)
Nerve: Superior gluteal, L4, 5, SI.
Shortness: The effect of shortness of the tensor fasciae latae in standing depends on whether the tightness is bilateral or unilateral. If bilateral, there is an anterior pelvic tilt and, sometimes, bilateral knock-knees. If unilateral, the abductors of the hip and fascia lata are tight, along with the tensor fasciae latae, and there is an associated lateral pelvic tilt, low on the side of tightness. The knee on that side will tend toward a knock-knee position. If the tensor fasciae latae and other hip flexor muscles are tight, there is an anterior pelvic tilt and a medial rotation of the femur, as indicated by the longus Gracilis
Semitendinosus Sartorius longus Gracilis
Add. longus Gracilis
Stippled lines in the figures above indicate muscle attachments located on the posterior surface of the femur.
Origin: Surface of the superior ramus of the pubis, ventral to the pecten, between the iliopectineal eminence and the pubic tubercle.
Insertion: Pectineal line of the femur.
Nerve: Femoral and Obturator, L2, 3, 4.
Origin: Inferior pubis ramus, ramus of the ischium (anterior fibers), and ischial tuberosity (posterior fibers).
Insertion: Medial to the gluteal tuberosity, middle of the linea aspera, medial supracondylar line, and adductor tubercle of the medial condyle of the femur.
Nerve: Obturator, L2, 3, 4, and Sciatic, L4, 5, SI. GRACILIS
Origin: Inferior half of the symphysis pubis and medial margin of the inferior ramus of the pubic bone.
Insertion: Medial surface of the body of the tibia, distal to the condyle, proximal to the insertion of the semi-tendinosus, and lateral to the insertion of the sartorius.
Origin: Outer surface of the inferior ramus of the pubis.
Insertion: Distal h of the pectineal line and proximal half of the medial lip of the linea aspera.
Origin: Anterior surface of the pubis at the junction of the crest and the symphysis.
Insertion: Middle '/? of the medial lip of the linea aspera.
Nerve: Obturator, L2, 3, 4. HIP ADDUCTORS
Action: All the muscles cited on this page adduct the hip joint. In addition, the pectineus, adductor brevis and adductor longus flex the hip joint. The anterior fibers of the adductor magnus, which arise from the rami of the pubis and the ischium, may assist in flexion, whereas the posterior fibers that arise from the ischial tuberosity may assist in extension. The gracilis, in addition to adducting the hip joint, flexes and medially rotates the knee joint. (See p. 428 for discussion of rotation action on the hip joint.)
Patient: Lying on the right side to test the right (and vice versa), with the body in a straight line and the lower extremities and lumbar spine straight.
Fixation: The examiner holds the upper leg in abduction. The patient should hold on to the table for stability.
Test: Adduction of the underneath extremity upward from the table, without rotation, flexion, or extension of the hip or tilting of the pelvis.
Pressure: Against the medial aspect of the distal end of the thigh, in the direction of abduction (i.e., downward toward the table). Pressure is applied at a point above the knee to avoid strain of the tibial collateral ligament.
Note: Forward rotation of the pelvis with extension of the hip joint shows an attempt to hold with the lower fibers of the gluteus maximus. Anterior tilting of the pelvis, or flexion of the hip joint (with backward rotation of the pelvis on upper side), allows substitution by the hip flexors.
The adductor longus, adductor brevis, and pectineus aid in hip flexion. If the side-lying position is maintained and the hip tends to flex as the thigh is adducted during the test, it is not necessarily evidence of substitution but, rather, is merely evidence that the adductors that flex the hip are doing more than the rest of the adductors that assist in this movement. Alternatively, it may be evidence that hip extensors are not helping to maintain the thigh in a neutral position.
Contracture: Hip adduction deformity. In standing, the position is one of lateral pelvic tilt, with the pelvis so high on the side of contracture that it becomes necessary to plantar flex the foot on the same side, holding it in equinus so the toes can touch the floor. As an alternative, if the foot is placed flat on the floor, the opposite extremity must be either flexed at the hip and knee or abducted to compensate for the apparent shortness on the adducted side.
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