Let us take a slightly eccentric look at the mighty array of muscles around the hip joint. For those who want to refresh or deepen their visual grasp of this material, we include references to Frank Netter’s Atlas of Human Anatomy, published by CIBA-Geigy, although you can follow along with any good anatomy atlas.
Because of the deeply cupped way this ball-and-socket joint fits together, and the strength of the muscles around it, the effects of trauma or injury to this part of the body often get pushed into the knee or the lower back, rather then showing up directly in the hip. Likewise, postural imbalances in the hip tend to force problems or pain to occur either north or south of this super-strong joint. Ida Rolf calls the hip “the joint that determines symmetry,” because small tilts, twists or body “attitudes” here can lead to painful compensations almost anywhere else. The lesson for us? We need to look at the functional health of the hip joint in all our clients, not just those who complain about that area.
The joint is also subject to slow wear and tear, as the number of late-in-life hip replacements attests. Does this indicate a widespread misuse of the hip joint in the Western world-when our hip joint does not last as long as we do? Or is it just our lot as humans for having stood up and put more of our weight on the hip, where four-legged creatures put more of their weight on the shoulder girdle? Should we be sitting less and squatting more? Exercising more or exercising less? Getting more massages maybe, so that tight muscles are not pulling the irreplaceable cartilaginous surfaces so firmly together? (Both sedentary and overactive folks often seem in our experience to be candidates for hip replacements. Is there a movement re patterning or preventative exercise regime that would save these hips?)
“Ida Rolf calls the hip “the joint that determines symmetry,” because small tilts, twists or body “attitudes” here can lead to painful compensations almost anywhere else.”
Our thesis in this article is this: No matter what the activity level of the hip you are working on, the working life of that hip depends on an even balance of tone in the 30 or so “myofascial units” (muscles) arranged around the femur and the hip bone. In school we tend to study the hip muscles as individuals or in small groups like the gluteals or lateral rotators. But who can remember all their Latin names, exact attachments and multiple functions when we are out there actually working on someone’s tight butt? And yet we want to be specifically helpful.
There is a solution. Here we will zoom above these individual trees for a look at the forest: the hip muscles are (in fact, as opposed to in school) arranged around the joint in three large, sweeping and interconnected fans-and we can balance the hip joint by balancing within and among these fans. Our goal in this article is to corral this seemingly incomprehensible gaggle of muscles, through this metaphor of a fan, into an easily understood continuum.
We will first examine briefly the structure of the joint itself, and then take on the part we hands-on therapists can play with to enhance hip health and balance: the musculature around the hip. So, fans of the hip joint, let’s go look at the fans of the hip joint.
FIRST, THE BONES
The hip joint is the classic ball and socket joint. The shaft of the femur sweeps up from the knee to the two knobbly trochanters, the greater provides attachment for the gluteals, the lesser for the iliopsoas. From the top of the shaft, the neck of the femur angles gracefully in toward the hip, giving the femur its characteristic “seven” shape, with the nearly perfect ball-peen hammer of the head on its end. The socket or acetabulum (it comes from the Latin meaning “vinegar cup”) is formed at the intersection of three bones: the ilium, which constitutes the whole superior portion of the hip bone; the ischium, which includes our sitting bones; and the pubis (you know where that is). These three bones have fused into one by the time a baby starts to walk, but because they begin as three separate bones, their names persist in the adult body e.g. iliac crest, ischial tuberosity, pubic symphysis. Although the formal name for the fused bones is “os inominata,” we are sticking with “hip bone” here (Netter plate 457).
The hip bone is a difficult one to visualize in three dimensions. It is worthwhile to find a skeleton and hold the hip bone in your hands for a while to get a true sense of its shape. Since we are trapped in two dimensions between the pages of this magazine, we commend the idea to you that each hip bone is like a twisted figure-eight, or a two-blade propeller.
The mid-point or axis of the propeller is right where the femur sits into the acetabulum. One blade reaches up that is the iliac portion, with the iliac crest as the tip of the blade. The other reaches down from the acetabulum to the ischial and pubic ramus, the tip of the second blade. These blades, as we will see, provide the attachment points for all these muscles that cross and move the hip.
In addition to having two blades and an axis, the blades are also twisted like a propeller’s. Look down from the top on a single hip bone. The iliac crest is angled at 45 degrees moving out from the spine and widening at the front. The ramus at the bottom of the pelvis is wide at the back, coming medially as it comes forward until it meets its opposite number at the pubic symphysis. Though the resemblance is intriguing, it is not being suggested here that the hip bone acts like a propeller; we offer this image only as an easy way to help visualize the three-dimensional complexity of the two hip bones.
Besides being joined by a fibrocartilage disc at the pubic symphysis, each hip is joined to the sacrum at the left and right sacroiliac joint. The majority of muscles we will discuss cross only the hip joint.
THEN, THE LIGAMENTS
The femur is joined to the hip bone by a set of ligaments that wind around the neck of the femur like a twisted towel. The towel is twisted in such a way that it is unwound as we flex the joint, and wound tighter as we try to hyperextend the joint. Thus, if you lean back to look at the sky with your knees straight, or lift the front of your pelvis away from the leg, you soon find that your attempt to go backward is stopped by these ligaments (and maybe the hip flexors too; have you been doing your stretching?).
Likewise, if you stand on one leg and put the other foot way back behind you in a lunge or warrior pose, you will find that you are stretching the groin: the muscles, and eventually the ligaments, that run right in front of the hip joint. If we take a very large step, we are likely to have to arch the lower back into a swayback or lordosis to achieve this long stride, again because hip hyperextension is limited by these ligaments. In full extension, these ligaments also limit lateral rotation, which saves us from dislocating the ball out of the relatively shallow front of the socket (Netter plate 458).
AND FINALLY ,THE MUSCLES
In spite of the ligamentous restrictions, the hip joint is quite mobile through many degrees of circumduction and rotation. Because of the balland-socket arrangement with its slick cartilage and synovial lubricant, it is also very slippery and easily moveable. Thus it is necessary to have muscles coming from every direction to provide the stability and control necessary to balance the entire upper body, as well as the precision of movement to this all-important joint. And we would further expect these muscles to be triangular in shape, as triangular muscles provide precise control across a wide set of angles. (Look at how many triangular muscles surround the highly movable shoulder: traps, lats, pects, and delts, for instance.)
In fact, the hip sports not only a preponderance of triangular muscles, but these muscles are further arranged in a series of triangular fans, which interconnect with and counterbalance each other. It is simple once you see it: understand these fans and you understand how to balance the hip joint. Each of these fans has an axis, or a hub, where several muscles insert close together. Each has an outer edge, or a rim, where the same muscles attach along a longer line. Each of the fans has an “apex” muscle-a muscle about in the middle of each fan that goes “farther” than the other ones in terms of joints crossed.
Each of these muscular fans performs a variety of functions-flexion, abduction, rotation, etc., but they all work cooperatively together, or should, at least, to achieve both mobility and stability. Getting this complex in balance is part of our job, and the goal of any good stretching, exercise or rehabilitation program. Taken altogether, the three fans comprise about 20 muscles, depending on how you count them, so we will try to break them down into digestible mouthfuls.
THE TROCHANTERIC FAN
This fan includes:
Tensor Fasciae Latae
Gluteus maximus, superior fibers
Transition: Quadratus femoris
The fans are named for their hub or axis, and the axis of the first fan is the greater trochanter, the large knob of bone on the outside of the thigh a couple of inches below the hip. The rim is the iliac crest, running from the Anterior Superior Iliac Spine (ASIS) around to the lateral edge of the sacrum, down the sacrotuberous ligament and onto the ischial tuberosity (IT) (Netter plate 461).
You are familiar with the muscles of this fan as the abductor group and the lateral rotators, but we are going to try to persuade you to see these as parts of an integrated whole that play a dual role: they all help move the femur in the socket when that is what is required.
For instance, when we stroke off a skate or a Rollerblade, these muscles are used in a smooth continuum (which is why these sports are so good at toning our buns). They stabilize the hip bone (and thus the whole upper body) on the leg when we are standing or sitting, or whenever we are in a posture that requires the lower body to be a stationary platform for movements of the upper body.
The functional role is perhaps more important to sports massage and rehabilitative therapists. The postural role-the habitual tone of these muscles in standing or sitting-is of great interest to structural body workers.
To trace this first fan, begin with the front of the abductor group: the tensor fasciae latae (TFL), which joins the outside edge of the ASIS to the front face of the greater trochanter (and of course to the iliotibial band). Because of its forward position the TFL can function as a flexor and medial rotator, as well as an abductor (Netter plates 464-465).
Continue with the gluteus medius and minimus that go to the outside of the top of the trochanter, and act to abduct and to medially or laterally rotate, depending on which part of the muscle is used (just like the deltoid in the shoulder).
We can include the upper fibers of the gluteus maximus in this fan, as they travel from the posterior portion of the iliac crest to the back outside of the trochanter, but the lower fibers, from the sacrum and sacrotuberous ligament, go so far down the shaft of the femur that they really cannot be thought of as part of the trochanteric fan, but more as a separate extensor muscle for running.
Right next to the, posterior edge of the gluteus medius, and deep to the gluteus maximus, comes the next muscle in our fan series-usually thought of as a member of another group, but in actual function part of this trochanteric fan continuum: the piriformis.
The piriformis comes from the anterior surface of the sacrum, deep within the body, and, coming out through the same opening as the sciatic nerve, goes to the very inside top of the greater trochanter. It is usually listed as one of the lateral rotators, but this is so far from its real function (Netter plates 473, 466).
For now, we will content ourselves by noting that the piriformis, located about halfway through this first fan, is the apex muscle of this fan. Even though the piriformis is not that long if measured by a ruler, it is “longer” than the other muscles because it crosses not only the hip joint but also the sacroiliac joint.
With this slight bow to the most holy piriformis, we keep going around our fan to the obturator internus and its two friends, gemellus superior and inferior. Since the tendons of these three often cluster together into one, we can consider them together. Of the three, the obturator is by far the strongest, and also the most important because, as we will learn in more detail next time around, it goes around the comer of the ischium into the inside of the pelvis and has a strong connection to the pelvic floor. For now, we note that these three are tied to the inside back of the trochanter and thus very much part of our fan.
The next muscle is the last of this first fan and the first muscle of the next fan, a transitional point of fixation between the one fan and the other. The quadratus femoris is a small square of muscle covering the small distance from the outside of the ischial tuberosity to the back side of the trochanter. God uses square muscles where She needs stability.
Although this muscle is listed in the group of lateral rotators, once again its main function is not to turn the femur, but to stabilize the pelvis on the femur, preventing the hip from falling into flexion-and preventing the joint between these two fans from being too loose.
In fact, this whole fan around the greater trochanter provides great stability against the tendency of the hip to adduct and flex from the fully extended position required by upright standing. Although the so called lateral rotators are capable of laterally rotating the femur, they actually function much more as extensors of the hip. They keep the pelvis (and thus the spine and head) from falling forward into a four legged position. Balance in this fan is thus a hallmark of easy upright posture.
There is one other muscle usually included in the lateral rotator group. The obturator externus lies deep to the quadratus femoris, starting from the deep back of the trochanter and passing under the neck of the femur to the outside face of the lower “propeller blade” of the hip bone. It is very hard to feel directly. Having ignored this muscle for many years, this practitioner is now very hot on its functional importance. It is not really part of this fan, nor is it primarily a lateral rotator, but it connects inside to outside through the complicated obturator membrane. The gory details are beyond the scope of this article, but think of this muscle as a kind of trampoline for the upper body’s weight on the hip joint (Netter 463 & 465).
“The hip bone is a difficult one to visualize in three dimensions.”
THE RAMIC FAN
This fan includes:
Transition: Quadratus femoris
Adductor magnus, middle part
Adductor magnus, lower part
The second fan is a little harder to see, it has a confusing set of functions, and it lies in an area with a degree of taboo about it. So listen up, because understanding this fan could radically simplify and clarify your work on the inner thigh.
The second fan is called the Ramic fan because its hub or axis is the bone that runs along the bottom of the pelvis from the IT to the pubic symphysis, known as the ischial and pubic ramus-but let us just call it the ramus (meaning “branch”) for short.
If the hub is the ramus, the rim of this fan is the linea aspera, the rough line that sweeps down the posterior shaft of the femur from below the trochanters to the medial epicondyle above the knee. The rest of the shaft of the femur-the outside, anterior and medial portions-is taken up by the strong and greedy quadriceps, leaving all the adductors and the short head of the biceps to scramble for attachment space along this fairly thin line that is (remember!) on the back of the femur, not the medial edge (Netter p. 461).
“Wait a minute,” you may be saying, “the first fan looked like a fan, with a hub and a sweeping rim. The linea aspera does not sweep around like the rim of a fan.”
“Ah,” I will tell you, “this sneaky little fan sweeps down one side of the linea aspera and up the other. Maybe it looks a little more like a feather than a fan, or like a folded-up fan, but it keeps with the idea of these three fans that stabilize the hip joint. Watch. From the greater trochanter, we will go down the back side (literally the lateral side) of the linea aspera, and up the front (or medial) side to the lesser trochanter.”
The second fan begins right where the first fan left off: the quadratus femoris. The distal attachment of the quadratus defines the beginning of the linea aspera, which continues downward from the greater trochanter to the distal attachment of adductor minimus. The adductor minimus is a part of the adductor magnus, which is a muscle as huge as its name. This anatomist would prefer that it be broken down into three muscles to define its differing parts and functions, but for now let us just call them the top, middle and bottom parts. The adductor minimus, when it is separated from the rest of the muscle, is the top part. (Netter p. 463)
All three parts originate from the underside (OK, OK, the inferior aspect) of the IT, as opposed to the hamstrings which attach to the back side of the IT. Thus the adductor magnus is as far posterior on the ramus as we can get, and we will be working our way forward from here.
The middle part of the adductor magnus inserts farther down the linea aspera from the adductor minimus part, and forms a living functional continuity with the short head of the biceps femoris (see Body3, “The Knee and Thigh,” Massage Magazine, Issue #70, Sept./Oct.1997). Below this middle part, there is a hiatus (or hole) through the adductor magnus to allow the neurovascular bundle to pass from the front to the back of the leg, and then we get to the lowest section of the adductor magnus, which attaches very strongly to the medial femoral epicondyle. You can feel this lump and the attaching tendon very clearly on the inside of your knee about an inch above the joint.
The next muscle, the gracilis, is the apex muscle of this second fan, and like the others of its kind it goes farther than the rest of its fan-mates. The gracilis (literally, “thin”) originates on the ramus just a little in front of the adductor magnus, and runs on top of the magnus straight down across the knee and into the pes anserinus on the inside of the tibia. (Again, for a discussion of the pes, see Body3, “The Knee and Thigh,” Massage Magazine, Issue #70, Sept./ Oct. 1997) The gracilis thus crosses two joints, both the hip and knee. (Netter p. 462)
Having come down one side of the linea aspera with the adductor magnus complex, and beyond the linea altogether with the gracilis, let us go up the other (more medial or frontal portion of the linea, though remember it is still on the back side of the femur) toward the groin and the lesser trochanter.
The adductor longus has its distal attachment about halfway down the femur, parallel to but in front of the middle part of adductor magnus. The proximal attachment is more forward on the pubic ramus than that of gracilis. You can always feel this one: it is the big, hunky tendon that you can feel on everyone on the front inside of the leg, and the one readily visible in most people when they sit cross-legged in a bathing suit.
Deep to adductor longus, but still on the “front” side of this adductor fan, is the adductor brevis, another triangular muscle that can be divided into separate parts like the adductor magnus on the “back” side of the fan.
This muscle breaks up the fan a little bit, because although it is clearly the next muscle along the rim of this fan as we come up the front of the linea aspera, adductor brevis has its ramic attachment a little bit posterior and inferior to the adductor longus, between gracilis and longus. Noting this little “fudge factor,” we carry on to the transitional muscle to the next fan.
Before we do, we need to say something about adductor function and adductor fact. Sadly, our beautifully laid-out scheme is rarely what you find when you put your hand on the leg. The adductors are very often a confused and tightly bunched up set of muscles, which is why we have been offering these palpatory clues for finding the muscles with confidence. They are not as easily delineated as the quadriceps or hamstrings. Why is this? There are three reasons that make sense to us:
The inside of the leg is a charged area due to the proximity of sexuality. A lot of emotions can get stored as chronic tension in the adductors, especially sexual fears and impotent rage. Proceed with caution, tenderness and awareness.
Like the abductors, the adductors are primarily used posturally to keep the body steady while other actions are going on. One only has to do the occasional horse ride to discover how sore the adductors get when they are really actively used. So postural difficulties in the spine, upper body or pelvis get shifted down onto the adductors (because the other thigh muscles have to be free to move us in walking, kicking, swimming or whatever).
The adductors are pinch hitters-they are capable of substituting for or augmenting the actions of the other muscles of the thigh. The adductor magnus can pinch hit as an extensor, the brevis and longus can aid in flexion. Furthermore, depending on the position of the hip joint, the adductors can assist in medial or lateral rotation. The adductors are especially active in returning the femur to a normal position from an extreme-i.e., the longus and brevis work best as flexors when returning the femur from a fully extended or hyper extended position.
For all these reasons or combinations, these muscles and their fasciae can get bound up with each other, and especially the insertions on the linea aspera can be tied in together like so much tangled hair. As with your daughter’s tangled hair, it is best just to take a small bit each time and brush and comb it out, rather than taking on the whole inside of the leg at once.
OK, hip joint fans, we have made it to the last of the hip joint fans, and our transitional muscle is (May I have the envelope, please?) the pectineus! Yes, the pectineus, like the quadratus femoris that won the last award as a transition between two fans, is a squarish kind of muscle, but with a very hip function. It hails from a band of tendon that defines the top edge of the inner part of the linea aspera, bringing that part of the line to the lesser trochanter just as the quadratus insertion defined the transition between the linea aspera and the greater trochanter (Netter plate 462).
The upper attachment of pectineus goes beyond the ramus to that top branch of bone just beside the pubic symphysis. You can find your own pectineus by sitting cross-legged and putting your fingers right up against the fold of your leg, finding the big, obvious tendon of adductor longus. Put your fingers into the hole just in front of and lateral to the tendon, staying very close to the fold between your leg and your trunk. Since pectineus is both a flexor and abductor, if you lift your knee up and in, you should feel the pectineus pushing out against your fingers. It is a touchy area to go for in clients if you have never done it before, but it is rewarding to get used to it (and get them used to it) because the pectineus can be so involved in the anterior pelvic tilts that form the basis of so much bad posture.
But let us get the whole picture, because pectineus may be the transition muscle, but it is also very much involved in the third and last fan of the hip joint, which should, by our own rules, be called the lesser trochanter fan. We have dubbed it “The Inguinal Fan” instead. In our even less-formal-than-usual moments we call it the “leg pit,” for these next set of muscles define the armpit of the leg.
THE INGUINAL FAN
This fan includes:
The hub of our last fan is the lesser trochanter, that little nub of bone tucked on the inside corner of the “seven” of the femur. The first muscle, pectineus, has a band of tendon that comes up to the lesser trochanter from below, then the psoas and the iliacus both have attachments right into the knob of the trochanter itself.
The rim of this fan is not as easy to define as a single line, but it covers the front of the pelvis from the pubic bone to the ASIS. The pectineus has a wide, flat origin that stretches along the pelvic rim from the pubic symphysis out about an inch toward the ASIS. The psoas covers the next area, but, being the apex muscle of this fan, stretches beyond the single joint to cover the sacroiliac and lower lumbar joints as well. The iliopectineal bursa makes sure that the psoas slides over this part of the pelvis rather than attaching here. The iliacus, the third and last muscle of this fan, fills the inside of the iliac bone, essentially attaching along the rim of the pelvis from the sacral promontory all the way over to the ASIS (Netter plates 246, 462, 466).
All three of these muscles flex the hip, and although there are arguments to the contrary, we find them all to be lateral rotators as well. They are all located in the “leg pit”-more formally, the femoral triangle: a space defined by the inguinal ligament on the superior side, the adductor longus on the medial side, and the sartorius on the lateral side. They can all be palpated and worked on in this area, and they can all affect pelvic tilt and resulting curvature in the spine.
Everybody bows down before the psoas, and this anatomist is no exception. We will devote our next column to the psoas almost exclusively. In the matter of anterior pelvic tilt, however, do not neglect the pectineus and iliacus, which, being one-joint muscles, are single-minded about pulling the femur into flexion toward the pelvis. When one is standing up and the femur is fixed, they can be just as single-minded about pulling the pelvis down in the front toward the femur. The iliacus needs to be considered with the muscle that continues from it up to the 12th rib, the quadratus lumborum.
We have come full circle around the “propeller” of the hip bone, from the tensor fasciae latae on the outside tip of the ASIS to the iliacus on the inside tip of the ASIS. To get there, we had to travel out and back and down on the iliac crest, around the ischial tuberosity and along the ramus to the pubic bone, and out along the superior ramus to the ASIS.
Thus it becomes evident that the musculature around the hip acts in a sweeping continuum, which can be conveniently divided into the three fans we have described. Generally speaking, we look for a consistency o tension among all these guy wires, like the cables on a suspension bridge.
Isolated pockets of higher or lower tension lead to imbalance in the affected hip (which leads eventually to joint degeneration of some kind) o imbalance between the hips, which can manifest at the sacroiliac joint or farther a field.
The special muscles within the fans call for a little extra attention. The transitional muscles, the quadratus femoris and the pectineus, generally clamp down when there is a severe postural distortion. The quadratus will work very hard in cases of posterior pelvic tilt or in postural lateral rotation of the femur; the pectineus gets slam-dunked in anterior tilt and medial femoral rotation.
The apex muscles-the psoas, piriformis, and gracilis-are more delicately poised, fall into imbalance more easily, and require patient care and feeding. The balance of the gracilis relates to the balance of tendon pull at the pes anserinus, but the ramifications of the psoas and piriformis are so profound to our upright balance that we will bring our discussion to a close here.
THE PIRIFORMIS, OBTURATOR INTERNUS, QUADRATUS FEMORIS
Most of the muscles in this first trochanteric fan are familiar and easily found by most massage therapists. In our teaching experience, the last three muscles named above are often not worked on specifically, because, since they are under the gluteus maximus, they are not always easy to feel clearly. This is a shame, because each of these muscles is so important to the structural balance of the pelvis. So here are fail-safe instructions on how to find these three muscles and be sure you are working on them, even if you cannot feel any guitar string twang under your fingers (all these can best be found with the client lying face-down).
Piriformis: First, find the top of the trochanter as specifically as you can. Press in a bit, sometimes the amount of flesh around the hip can fool you. Leave one finger there, pressed down against the superior aspect. With your other hand, put a thumb and index finger along the body’s midline at the top and bottom of the sacrum (for reasons of client privacy, do not include the tail bone). The best place to find the piriformis is in the center of the triangle made by your three fingers. Too close to the sacrum (medial) and you will not feel it, for the muscle runs deep to the sacrum. Too close to the trochanter (lateral) and the little stringy tendon disappears with all the others headed for the trochanter. If you strum across the fibers of the muscle, you will often feel it twanging, and even if you do not, you can be sure you are working on it through the gluteus.
Obturator internus: Find the bottom of the ischial tuberosity (IT). With your fingers firmly touching the bone, walk your fingers up the bone straight towards the head. You will go up the “mountain” of the IT and down into a “valley” on the superior side of the IT. The softer part in this shallow valley is the obturator internus as it turns the corner from the internal part of the pelvis around the back of the IT headed for the trochanteric fossa of the femur. As you go straight out laterally from here, you can often follow the tendon by twanging up and down over the fibers, again through the gluteus maximus. You may or may not be able to distinguish one or two other separate tendons, which would be the gemellus superior and inferior accompanying the obturator.
Quadratus femoris: Again, find the IT. Go just lateral to the lower aspect of the IT onto the back lower part of the trochanter. Strum up and down, but do not expect a twang-in most people this quadrate muscle feels like a little mound on the back side of the trochanter. Do not go lower than the lower aspect of the IT, or you will find yourself palpating the attachment of gluteus maximus instead.
In finding your way around the confusing territory of the inner thigh, try this mnemonic: First have your client lie on their side with the topside hip flexed so that the inner side of the lying-on-the-table leg is accessible. Now put your same hand on that thigh (i.e. your left hand on their left thigh or vice versa) with your middle finger running about straight up and down the axis of their leg, and your fingers lightly spread. With allowances for large thighs and small hands or the reverse, you will find that your thumb falls on the line of the sartorius, that thin little muscle that covers the sulcus between the quadriceps and adductors.Your index finger can easily find the tendonous bulk of the adductor longus. Your middle finger will then lie on the thin vertical line of the gracilis, your ring finger on the adductor magnus, and your little finger makes it all the way over to the hamstrings.