The hip joint sits deep beneath layers of muscle, making it one of the more challenging joints to reach whether for surgery, imaging, physical examination, or hands-on therapy. How the hip is accessed depends entirely on the goal: surgeons choose from several well-defined approaches based on the procedure, clinicians use bony landmarks to locate the joint through the skin, and physical therapists apply specific mobilization techniques to restore movement. Here’s how each method works and what it involves.
Bony Landmarks for Locating the Hip
The hip joint itself can’t be seen or directly felt through the skin, so clinicians rely on surrounding bony landmarks to pinpoint its location. The greater trochanter, the bony bump on the outer side of your upper thigh, is the most prominent and easiest to feel. Its edges can be traced upward to a tip that serves as a reference point for nearly every procedure involving the hip. Higher up, the iliac crest (the rim of your pelvis) and the anterior superior iliac spine, or ASIS (the bony point at the front of your pelvis), provide additional orientation.
A straight line drawn from the ASIS down to the center of the kneecap marks the inner boundary for safe surgical and needle access. Going past this line toward the inner thigh increases the risk of hitting the femoral nerve and major blood vessels. On the back side, the ischial tuberosity (the “sit bone”) serves as the landmark for locating the hamstring tendons. Together, these reference points create a map that guides everything from ultrasound exams to surgical incisions.
Surgical Approaches to the Hip
Surgeons access the hip through three main routes: anterior (from the front), posterior (from the back), and lateral (from the side). Each involves different muscles, carries different risks, and suits different clinical situations.
Anterior Approach
The direct anterior approach reaches the hip from the front of the thigh. Its main advantage is that it works between muscles rather than cutting through them. The surgeon passes through the natural gap between the tensor fasciae latae (on the outside) and the sartorius and rectus femoris (on the inside). Because no major muscle groups are detached, recovery tends to be faster and the hip is more stable immediately after surgery.
In a study comparing the two most common approaches, zero dislocations occurred in 139 hips done through the anterior route over a five-year follow-up, compared to a 4% dislocation rate in 177 hips done from the back. Larger studies have reported anterior dislocation rates between 0.6% and 1.5%. Cleveland Clinic reports that most anterior hip replacement patients leave the hospital after one night, with a growing number going home the same day. One patient drove himself to a follow-up appointment just over two weeks after surgery and returned to golf and tennis within three weeks.
The tradeoff is a small risk of injury to the lateral femoral cutaneous nerve, a sensory nerve that supplies feeling to the outer thigh. In one registry of over 8,000 anterior hip replacements, about 0.36% of patients developed a confirmed nerve injury. Most cases involve temporary numbness or tingling, though some patients experience persistent sensitivity changes in the skin of the outer thigh.
Posterior Approach
The posterior approach is the most widely used route to the hip. The incision starts about 5 centimeters below the greater trochanter, runs up along its back edge, and curves toward the pelvis for another 5 to 7 centimeters. The surgeon splits the fibers of the gluteus maximus (the large buttock muscle) and then works through the deeper layer of short external rotator muscles, including the piriformis, to reach the joint capsule.
This approach gives the surgeon excellent visibility of the socket (acetabulum) and is familiar to most orthopedic surgeons. The main disadvantage is a higher dislocation risk in the early recovery period, because the rotator muscles that stabilize the back of the hip are cut during the procedure. Recovery from a conventional posterior hip replacement typically takes six to eight weeks.
Lateral Approach
The lateral approach accesses the hip from the side. The surgeon incises the fascia just in front of the tip of the greater trochanter and splits the gluteus medius muscle along the direction of its fibers. The split is limited to 3 to 5 centimeters above the trochanter to protect the superior gluteal nerve, which runs through the muscle higher up. Below the trochanter, the vastus lateralis (the outer quadricep muscle) is split longitudinally and connected to the gluteus medius split to create a single window down to the hip capsule.
This route provides good access to both the femoral head and the socket while keeping the posterior stabilizing muscles intact. The risk of dislocation is lower than the posterior approach, but splitting the gluteus medius can cause a temporary limp if the muscle doesn’t heal fully, since it’s the primary muscle that keeps your pelvis level when you stand on one leg.
Hip Arthroscopy Portals
Arthroscopic surgery uses small incisions called portals rather than one large opening. For the hip, three main portals are placed using the greater trochanter as the central reference point while the patient lies with the leg in traction to open up the joint space.
The anterolateral portal goes in first, positioned 1 centimeter above and 1 centimeter in front of the tip of the greater trochanter. The posterolateral portal mirrors this position on the back side of the trochanter. The anterior portal sits at the intersection of a horizontal line through the first two portals and a vertical line dropped straight down from the ASIS. That vertical ASIS line also serves as the safety boundary: placing instruments closer to the midline risks the femoral nerve and blood vessels.
Imaging the Hip Joint
Plain X-rays remain the first step for evaluating the hip. A standard anteroposterior (front-to-back) view of the pelvis provides a surprising amount of information: leg length, the angle of the femoral neck, how well the socket covers the femoral head, socket depth and tilt, the roundness of the femoral head, and the width of the joint space. Joint space width, measured as the smallest gap between the top of the femoral head and the bottom of the socket on a standing X-ray, is one of the key indicators of cartilage loss in arthritis.
Lateral views add a second angle. The frog-leg lateral, taken with the knee bent and the leg rotated outward, is useful for evaluating the roundness of the femoral head and the shape of the head-neck junction. The cross-table lateral, shot with the opposite hip flexed out of the way, defines the front of the head-neck junction clearly, though image quality drops in patients with a larger body habitus. A third option, the false-profile view, is taken with the pelvis rotated 65 degrees and specifically shows how well the front of the socket covers the femoral head, which is important for diagnosing hip dysplasia or impingement.
Physical Therapy Mobilization
Physical therapists access the hip joint non-surgically through manual mobilization, applying controlled forces to stretch the joint capsule and restore range of motion. The techniques are graded by intensity: grade II mobilizations, the most commonly used at the hip, involve large, rhythmic movements performed within the pain-free portion of available range.
The four primary techniques are long-axis distraction (pulling the leg straight away from the socket), lateral distraction (pulling the thigh outward away from the body), posterior-to-anterior mobilization (pressing from back to front while the patient lies on their side), and contract-relax stretching where the patient actively pushes against the therapist’s resistance before relaxing into a deeper stretch. Long-axis distraction is often performed at multiple angles of hip abduction (with the leg at neutral, 15 degrees out, and 30 degrees out) to target different parts of the joint capsule. These techniques are gentle enough that family members can be trained to perform basic long-axis distraction at home between therapy sessions.
When Specialist Referral Makes Sense
Not all hip problems need advanced access. But certain conditions have consistently good surgical outcomes, making early referral to a hip specialist worthwhile rather than prolonging conservative treatment. Femoroacetabular impingement (where the ball and socket pinch against each other), labral tears (damage to the cartilage ring lining the socket), and significant tears of the gluteus medius tendon all fall into this category. For large partial or complete gluteus medius tears in particular, surgery typically produces good results, and delaying referral can allow the tear to progress.