Hip Joint

The hip joint is a ball-and-socket joint formed by the head of the femur and the acetabulum of the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis. The hip joint is the most stable joint in the body and is supported by a very strong capsule and several ligaments, allowing the joint to sustain forces that can be multiple times the total body weight. Tolerating these forces is possible thanks to the bony alignment and substantial support from the static and dynamic stabilizers of the hip. Several muscle groups attach to the components of the hip joint, allowing for the joint’s range of motion. The muscles that attach to the hip joint include those of the gluteal region Gluteal region The gluteal region is located posterior to the pelvic girdle and extends distally into the upper leg as the posterior thigh. The gluteal region consists of the gluteal muscles and several clinically important arteries, veins, and nerves. The muscles of the gluteal region help to move the hip joint during walking, running, standing, and sitting. Gluteal Region and thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Bony Structure of the Hip Joint

The hip joint is a multi-axial joint that connects the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis to the lower extremities. As compared with the glenohumeral joint (shoulder), the hip has less range of motion and is designed primarily for weight bearing and stability.

  • Type: ball-and-socket diarthrodial joint
  • Articular surfaces: 
    • Head of the femur
    • Acetabulum of the hip bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones (acetabular labrum: a ring of cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage that increases the depth and stability of the articular surface)
  • Supporting structures:
    • Fibrous capsule
    • Intra-articular and extra-articular ligaments
    • Iliopectineal, trochanteric, and ischial bursae
  • Functions:
    • Connects the axial skeleton to the lower limbs
    • Bears weight during static (i.e. standing) and dynamic (i.e. walking and running) conditions
    • Allows for flexion-extension, lateral-medial rotation, abduction-adduction, and circumduction of the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh
Anterior view of hip joint

Anterior view of the hip joint ( pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis faded), featuring the bony landmarks of the proximal end of the femur

Image by BioDigital, edited by Lecturio.

Supporting Structures of the Hip Joint

Articular capsule

Consists of 2 layers:

  1. Fibrous capsule: 
    • The external layer of the capsule
    • Attaches proximally to the acetabulum, close to the rim
    • Attaches distally around the proximal end of the femur:
      • Anteriorly, to the intertrochanteric line (thickest area)
      • Superiorly, to the base of the femoral neck (thickest area)
      • Posteriorly, about 1 cm from the intertrochanteric crest
      • Inferiorly, on the femoral neck close to the lesser trochanter 
    • Has deep circular fibers that form a collar around the femoral neck, called the zona orbicularis (or annular ligament) 
  2. Synovial membrane:
    • The internal layer of the capsule
    • Produces synovial fluid, a viscous substance that lubricates and circulates nutrients to the joint
    • Originates at the margin of the articular surface of the femoral head, covers a portion of the femoral neck, is reflected on the internal surface of the capsule, reaches the fat tissue contained in the acetabular fossa, and encloses the ligament of the head of the femur
Cross section of the hip joint

Cross-section of the hip joint, featuring the insertions of the articular capsule and supporting ligaments

Image by Lecturio.

Ligaments

Can be divided into 2 groups:

  1. Intra-articular: 
    • Ligament of the femoral head or round ligament of the femur: carries the artery to the femoral head
    • Transverse ligament of the acetabulum
  2. Extra-articular ligaments, which support the capsule: 
    • Iliofemoral or “Y ligament of Bigelow”: strongest ligament of the human body
    • Pubofemoral: prevents over-abduction
    • Ischiofemoral ligaments: prevent over-extension
Table: Intra-articular ligaments
Insertions Functions
Ligament of the femoral head (or round ligament of the femur) Apex of the femoral fovea to either side of the acetabular notch Limits abduction and lateral rotation when the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh is semiflexed; carries the artery to the head of the femur
Transverse ligament of the acetabulum Fibrous structure that converts the acetabular notch into a foramen Allows passage of the neurovasculature into the joint
Table: Extra-articular ligaments
Insertions Functions
Iliofemoral ligament Anterior inferior iliac spine and the acetabular rim to the intertrochanteric line and the greater trochanter
  • Prevents excessive lateral rotation and hyperextension of the hip while standing
  • Reinforces the capsule anteriorly
Pubofemoral ligament Pubic part of the acetabular rim and the superior pubic ramus to the lower part of the femoral neck
  • Limits abduction and extension
  • Reinforces the capsule inferiorly
Ischiofemoral ligament Ischial region of the acetabulum to the neck of the femur medial to the greater trochanter
  • Limits medial rotation and extension
  • Reinforces the capsule posteriorly
Zona orbicularis Annular ligament made of the deep circular fibers of the fibrous capsule, which contains fibers from all extra-articular ligaments Stabilizes the hip

Bursae

Bursae are small, synovial fluid-filled sacs that reduce friction between the bony components of the joint and the surrounding muscles. 

  • Trochanteric bursa: between the greater trochanter and the iliotibial tract
  • Ischial bursa: between the ischial tuberosity and the gluteus maximus 
  • Subgluteus medius bursa: between the superior surface of the greater trochanter and the gluteus medius
  • Subgluteus minimus bursa: between the superior surface of the greater trochanter and the gluteus minimus
  • Iliopectineus or iliopsoas bursa:
    • The largest bursa of the human body
    • Located between the fibrous capsule of the hip and the iliopsoas
Bursae of the hip joint

Bursae of the hip joint

Image by Lecturio.

Flexor Muscles of the Hip Joint

The primary flexor muscles of the hip are the iliopsoas and rectus femoris.

Table: Flexor muscles of the hip joint
Muscle Origin Insertion Innervation
Iliopsoas Iliacus: lateral edge of the sacrum and iliac fossa Iliopsoas tendon: lesser trochanter of the femur Femoral nerve (L2–L4)
Psoas major: transverse processes of vertebrae T12–L5 Lumbar plexus (L1–L3)
Psoas minor: vertebral bodies of T12–L1 Iliopubic ramus Anterior ramus of nerve L1
Rectus femoris (quadriceps) Anterior-inferior iliac spine, superior rim of the femoral acetabulum Base of the patella via the quadriceps tendon Femoral nerve
Tensor fasciae latae Anterior superior iliac spine Iliotibial tract Superior gluteal nerve (L4–L5)
Sartorius Anterior superior iliac spine Upper medial side of the tibia Femoral nerve (L2–L3)

Extensor Muscles of the Hip Joint

The primary extensor muscle of the hip is the gluteus maximus, assisted by the biceps femoris, semitendinosus, and semimembranosus muscles.

Table: Extensor muscles of the hip joint
Muscle Origin Insertion Innervation
Gluteus maximus Ilium, sacrum, coccyx, and the sacrotuberous ligament Gluteal tuberosity of the femur and iliotibial band Inferior gluteal nerve (L4–S1)
Biceps femoris
  • Long head: ischial tuberosity
  • Short head: upper supra-condylar line and linea aspera
  • Lateral tibial condyle
  • Head of the fibula
  • Long head: tibial nerve (L5–S2)
  • Short head: common fibular nerve (L5–S2)
Semitendinosus Ischial tuberosity Superomedial surface of the tibia Tibial nerve (L5–S2)
Semimembranosus Medial condyle of the tibia
Gluteus maximus muscle lateral and posterior view

Gluteus maximus muscle: featuring its origin and insertion in posterior and lateral views

Image by BioDigital, edited by Lecturio.

Abductor Muscles of the Hip Joint

Table: Abductor muscles of the hip joint
Muscle Origin Insertion Innervation
Gluteus medius Outer surface of the ilium, between the iliac crest, and the anterior and posterior gluteal lines Greater trochanter Superior gluteal nerve (L4–S1)
Gluteus minimus Outer surface of the ilium, between the anterior and posterior gluteal lines
Piriformis Anterior surface of the sacrum and sacrotuberous ligament Nerve to the piriformis (L5–S2)
Tensor fascia latae Anterior superior iliac spine, lip of the iliac crest Iliotibial tract Superior gluteal nerve (L4–S1)

Adductor Muscles of the Hip Joint

Table: Adductor muscles of the hip joint
Muscle Origin Insertion Innervation
Pectineus Pectineal line of the pubis and pubic tubercle Pectineal line of the femur Obturator and femoral nerves (L2–L4)
Gracilis Inferior pubic ramus Medial side of the tibial tuberosity Obturator nerve (L2–L4)
Adductor longus Pubic bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones, between the crest and symphysis Linea aspera of the femur
Adductor brevis Body and inferior ramus of the pubis
Adductor magnus Ischial tuberosity and inferior ramus of the pubis Linea aspera and the adductor tubercle Obturator and tibial nerves (L3–S2)

External Rotator Muscles of the Hip Joint

Table: External rotator muscles of the hip joint
Muscle Origin Insertion Innervation
Obturator internus Obturator membrane and ischiopubic rami Greater trochanter Nerve to the obturator internus (L5–S2)
Obturator externus Lateral area of the obturator foramen, outer obturator membrane, and ischiopubic ramus Intertrochanteric fossa of the femur Nerve to the obturator muscles (L3–L4)
Gemelli muscles
  • Superior gemellus: ischial spine
  • Inferior gemellus: ischial tuberosity
  • Superior gemellus: greater trochanter and obturator internus tendon
  • Inferior gemellus: obturator internus tendon
  • Superior gemellus: nerve to the obturator internus (L5–S2)
  • Inferior gemellus: nerve to the quadratus femoris (L4–S1)
Quadratus femoris Ischial tuberosity Intertrochanteric crest of the femur Nerve to the quadratus femoris (L4–S1)
Piriformis Anterior surface of the sacrum and sacrotuberous ligament Greater trochanter Nerve to the piriformis (L5–S2)

Neurovasculature of the Hip

Blood supply

The arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries that supply the hip joint originate from the common iliac artery, which bifurcates into the internal and external iliac arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries.

  • Internal iliac artery—divides into a posterior trunk and the anterior trunk, which has multiple branches:
    • Gluteal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: superior and inferior branches
    • Obturator artery: gives rise to the artery of the head of the femur within the ligament of the head of the femur
  • External iliac artery—becomes the femoral artery after passing under the inguinal ligament:
    • Profunda femoris, a deep branch of the femoral artery, provides blood supply to the hip joint along with its branches: 
      • Medial circumflex femoral artery (MCFA)
      • Lateral circumflex femoral artery (LCFA)
  • The branches of the internal iliac (inferior gluteal) and the external iliac (profunda femoris) arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries form an important connection at the hip: the cruciate anastomosis.

The veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins of the hip joint accompany the arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries in trajectory and name.

Innervation

The femoral and obturator nerves, arising from the lumbar plexus (T12–L4), and multiple smaller nerves arising from the sacral plexus (L4–S4), innervate the hip joint. 

  • Anterior/medial thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh:
    • Femoral nerve (L2–L4): innervates the anterior thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh muscles and anterior aspect of the hip joint 
    • Obturator nerve (L2–L4): primarily innervates the adductor muscles and inferior aspect of the joint
    • Saphenous nerve: the terminal cutaneous branch of the femoral nerve
  • Posterior thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh/ gluteal region Gluteal region The gluteal region is located posterior to the pelvic girdle and extends distally into the upper leg as the posterior thigh. The gluteal region consists of the gluteal muscles and several clinically important arteries, veins, and nerves. The muscles of the gluteal region help to move the hip joint during walking, running, standing, and sitting. Gluteal Region:
    • Sciatic nerve (L4–S3): passes through the greater sciatic foramen to the gluteal region Gluteal region The gluteal region is located posterior to the pelvic girdle and extends distally into the upper leg as the posterior thigh. The gluteal region consists of the gluteal muscles and several clinically important arteries, veins, and nerves. The muscles of the gluteal region help to move the hip joint during walking, running, standing, and sitting. Gluteal Region; the sciatic nerve is the longest and widest nerve in the body
    • Superior gluteal nerve (L4–S1): innervates the gluteus medius, gluteus minimus, and tensor fascia latae muscles, and the superior aspect of the joint
    • Inferior gluteal nerve (L5–S2): innervates the gluteus maximus muscle
    • Quadratus femoris nerve: innervates the posterior aspect of the joint, inferior gemellus muscle, and quadratus femoris muscle

Clinical tip: The knee joint Knee joint The knee joint is made up of the articulations between the femur, tibia, and patella bones, and is one of the largest and most complex joints of the human body. The knee is classified as a synovial hinge joint, which primarily allows for flexion and extension with a more limited degree of translation and rotation. Knee Joint is also innervated by the femoral, obturator, and sciatic nerves, explaining the pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain referral patterns from the knee to the hip.

Clinical Relevance

The following are clinically relevant to the hip joint and region:

  • Legg-Calve-Perthes disease: also known as idiopathic avascular necrosis of the proximal femoral head, characterized by idiopathic avascular necrosis of the femoral head. Legg-Calve-Perthes disease presents as a limp with an insidious onset and associated hip pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain.
  • Slipped capital femoral epiphysis Slipped Capital Femoral Epiphysis Slipped capital femoral epiphysis (SCFE) is an orthopedic disorder of early adolescence characterized by the pathologic "slipping" or displacement of the femoral head, or epiphysis, on the femoral neck. Slipped Capital Femoral Epiphysis: an orthopedic disorder of early adolescence characterized by the pathologic “slipping” or displacement of the femoral head, or epiphysis, on the femoral neck. 
  • Hip fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures: classified according to the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures’s anatomic location as intracapsular or extracapsular. A low-impact fall is the typical mechanism of injury in the elderly, often associated with osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis. Motor vehicle accidents and other high-velocity trauma are common in younger individuals.
  • Fracture and necrosis of the femoral neck: If the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures is secondary to trauma or osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis, the blood supply of the femoral head can be compromised, which may lead to post-traumatic avascular necrosis.
  • Hip dislocation: mostly commonly occurs in cases of high-energy trauma, such as motor vehicle accidents. Posterior dislocation (90%) is the most common, and the extremity generally presents as adducted and internally rotated. Hip dislocations may be associated with avascular necrosis and sciatic nerve injury.
  • Hip dysplasia: an innate or acquired malformation of the hip generally seen in newborns. Characterized by hip instability, resulting in subluxation or dislocation. Early diagnosis is essential because late diagnosis may result in irreversible damage to the joint, which may lead to a painful hip and abnormal gait. 
  • Osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis: characterized by hyaline articular cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage loss but also involves changes to the subchondral bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones, synovium, and surrounding joint structures. Osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis is the most common form of arthritis, and is principally a disease of aging. Patients experience a loss of range of motion and a painful joint.
  • Piriformis syndrome: also called deep gluteal syndrome or wallet neuritis, is characterized by a combination of symptoms involving the hip, buttock, and upper thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh. Described as peripheral neuritis of the sciatic nerve and may be related to irritation of the sciatic nerve at the level of the piriformis muscle. May be caused by trauma, hematoma, excessive sitting, and anatomic variations of the muscle and nerve. 
  • Trendelenburg gait: abnormal gait secondary to weakness of the hip abductors, primarily the gluteus medius and gluteus minimus muscles, which are essential to maintaining the balance of the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis during the gait cycle. Weakness of the hip abductors causes a drop of the contralateral pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis while walking, or Trendelenburg gait.

References

  1. Drake, R.L., Vogl, A.W., & Mitchell, A.W.M. (2014). Gray’s Anatomy for Students (3rd ed.). Philadelphia, PA: Churchill Livingstone.
  2. Gold, M., Munjal, A, & Varacallo, M. (2020). Anatomy, Bony Pelvis and Lower Limb, Hip Joint. In StatPearls. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470555/

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