APTA’s Current Concepts of the Hip

Nathaniel Yomogida PT, DPT

2025-10-30

¹

Resources

Clinical Practice Guidelines

• AOPT Nonarthritic Hip Joint Pain²
• AOPT Hip Pain and Mobility Deficits-Hip Osteoarthritis: Revision 2017³
• Pelvic PT: Pelvic Girdle Pain in the Antepartum Population⁴
• Screening hip: Low back pain cpg

Related structures

• SIJ / Pelvic dysfunction

Muscles

Deep Hip Stabilizers

Table 1: Deep Stabilizers of the hip

Muscle	Origin	Insertion	Innervation	Action
Inferior Gemellus	Ischial tuberosity	Medial surface of greater trochanter via obturator internus tendon	Nerve to Quadratus femoris L5 - S1	Hip: ER, Extension, Abduction
Obturator externus	Outer surface of Obturator membrane Adjacent bony boundaries	Trochanteric Fossa	Obturator n. L3 - L4	Hip: Adduction, ER Pelvis: Sagittal Stabilization
Obturator Internus	Obturator membrane and its bony boundaries	Medial surface of Greater Trochanter	Nerve to Obturator internus L5 - S1	Hip: ER, Extension, Abduction, Stabilization
Piriformis	Anterior Sacrum	Apex of the Greater Trochanter	Sacral Plexus Direct Br. S1 - S2	Hip (at <60° flexion): ER Hip: Abduction, Extension, Stabilization Hip (at ≥60° flexion): IR
Quadratus femoris	Lateral border of Ischial tuberosity	Intertrochanteric crest	Nerve to Quadratus femoris L5 - S1	Hip: ER
Superior gemellus	Ischial spine	Medial surface of greater trochanter via obturator internus tendon	Nerve to Obturator internus L5 - S1	Hip: ER, Extension, Abduction

Guarded Deep hip Stabilizers

• Femoral head will be pushed forward and be passively resting on hip flexor tendons anteriorly

The long muscles will attempt to perform the job of stabilization. Long muscles such as sartorius, TFL, rectus femoris, hip flexors, and hamtrings. I think of this similar to dysfunctional deep neck flexors that result in overactive scalenes, upper trapezius, and levator scapulae.

Biomechanics

Function

Red Flags

“Medical concerns related to traumatic onset injuries include but are not limited to fractures, dislocations, tendon avulsions, and lower abdominal organ injury. Traumatic injuries that are accompanied by inability to bear weight, intolerance to joint movement, obvious disfigurement, extreme swelling, non-musculoskeletal symptoms, or extreme patient apprehension should be considered indicators for medical referral before initiating physical therapy intervention and even potentially before performing a comprehensive examination”¹.

Pharmeceutical considerations

• Corticosteroids associated with AVN and Hip fx
• Fluoroquinolone is associated with hip tendinopathies

Evaluation

Subjective

• Nature
• Severity

Screening

• Connective tissue disorders

Screening for Medical referral

• systemic or septic related inflammation
• table 5

Lumbopelvic

SIJ

Pelvic Floor

Functional Testing

GAIT

• Trendelendberg Sign

Diagnosis

Start generally

Is it Intra- or Extra-articular?

Intraarticular

If it is intraarticular, is the condition nonarthritic or OA

Intraarticular non-arthritic

Divided into 2 categories based on MOI: FAI or microinstability

Note

hip joint microinstability can coexist with FAI and hip

Note

AOPT hip OA CPG17 for a detailed description of hip OA characteristics that will assist in differentiating the condition from FAIS¹

ddx: Other differential diagnoses include femoral neck and pubic ramus stress fractures and iliopsoas muscle complex and bursa involvement¹

Hip Osteoarthritis

Updated Cluster

• Moderate anterior or lateral hip pain with weight bearing activities
• Morning stiffness lasting less than 1 hour in duration
• Hip internal rotation ROM <24° or hip internal rotation and flexion 15° less than the contralateral hip
• Increased pain with passive hip IR

Note

Hip internal rotation <15° was modified to <24°

Treatment

B Project

• Are they deep hip stabilizers or external rotators?
• Prone Hip IR/ER arthrokinematic test
  • Symmetry
  • End feel
  • ROM
• Palpate each deep hip stabilizer distal belly during rotation
• deep hip stabilizer release
• Functional test?
• FAddER contract-relax
  • Therapist assisted
  • Self-stretch

Modalities

• BFR

HEP

SmartPhrase

OA Cluster

OA Cluster

• Moderate anterior or lateral hip pain with weight bearing activities
• Morning stiffness lasting less than 1 hour in duration
• Hip internal rotation ROM <24° or hip internal rotation and flexion 15° less than the contralateral hip
• Increased pain with passive hip IR

Adductor Injuries

Hamstring Injuries

Key points

• Prognosis
• Prevention
  • Future hamstring injuries
  • Secondary Complications

Prognosis

Palpation test

Prevention of future injuries

Preventing Secondary Complications

• Active SLUMP

Greater Trochanteric Pain Syndrome

Greater Trochanteric Pain Syndrome: lateral hip pain that may originate from numerous sources surrounding the greater trochanter¹.

• Gluteus minimus and medius tendons¹
• Trochanteric bursa¹
• Proximal ITB¹

Piriformis Syndrome

Piriformis Syndrome:

References

1.

APTA. Current Concepts of Orthopaedic Physical Therapy. 5th ed.; 2024.

2.

Enseki KR, Bloom NJ, Harris-Hayes M, et al. Hip Pain and Movement Dysfunction Associated With Nonarthritic Hip Joint Pain: A Revision. The Journal of Orthopaedic and Sports Physical Therapy. 2023;53(7):CPG1-CPG70. doi:10.2519/jospt.2023.0302

3.

Cibulka MT, Bloom NJ, Enseki KR, Macdonald CW, Woehrle J, McDonough CM. Hip Pain and Mobility Deficits-Hip Osteoarthritis: Revision 2017. The Journal of Orthopaedic and Sports Physical Therapy. 2017;47(6):A1-A37. doi:10.2519/jospt.2017.0301

4.

Clinton SC, Newell A, Downey PA, Ferreira K. Pelvic Girdle Pain in the Antepartum Population: Physical Therapy Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Section on Women’s Health and the Orthopaedic Section of the American Physical Therapy Association. Journal of Women’s Health Physical Therapy. 2017;41(2):102-125. doi:10.1097/JWH.0000000000000081