Chapter 17: The Thigh, Hip, Groin, and Pelvis

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Chapter 17 The Thigh, Hip, Groin, and Pelvis
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Anatomy of the Pelvis, Thigh, and Hip
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Assessment of the Thigh

• History
• Onset (sudden or slow?)
• Previous history?
• Mechanism of injury?
• Pain description, intensity, quality, duration,
  type and location?
• Observation
• Postural symmetry?
• Size, deformity, swelling, discoloration?
• Skin color and texture?
• Is athlete in obvious pain?
• Is the athlete willing to move the thigh?

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• Palpation
• Soft tissue of the thigh (anterior, posterior,
  medial, lateral) should be palpated for pain and
  tenderness
• Bony palpation should also be performed to locate
  areas of pain/discomfort
• Utilize palpation to assess body symmetry

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• Special Tests
• Thomas test
• Test for hip contractures
• Straight Leg Raise
• Test for hip extensor tightness
• Can also be used to assess low back or SI joint
  dysfunction

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Prevention of Thigh Injuries

• Thigh must have maximum strength, endurance, and
  extensibility to withstand strain
• Dynamic stretching programs may aid in muscle
  preparation for activity
• Strengthen programs can also help in preventing
  injuries
• Squats, lunges, leg press
• Core strengthening

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Recognition and Management of Thigh Injuries

• Quadriceps Contusions
• Cause of Injury
• Constantly exposed to traumatic blows
• Signs of Injury
• Pain, transitory loss of function, immediate
  bleeding of affected muscles
• Early detection and avoidance of internal
  bleeding are vital increases recovery rate and
  prevents muscle scarring

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• Care
• RICE and NSAIDs
• Crutches for more severe cases
• Isometric quadriceps contractions should begin as
  soon as tolerated
• Heat, massage and ultrasound to prevent myositis
  ossificans
• Padding may be worn for additional protection
  upon return to play

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• Myositis Ossificans
• Cause of Injury
• Formation of ectopic bone following repeated
  blunt trauma
• Signs of Injury
• X-ray shows calcium deposit 2-6 weeks following
  injury
• Pain, weakness, swelling, decreased ROM
• Tissue tension and point tenderness
• Care
• Treatment must be conservative
• May require surgical removal if too painful and
  restricts motion (after one year - remove too
  early and it may come back)
• If condition is recurrent it may indicate problem
  with blood clotting

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• Quadriceps Muscle Strain
• Cause of Injury
• Sudden stretch when athlete falls on bent knee or
  experiences sudden contraction
• Associated with weakened or over constricted
  muscle
• Signs of Injury
• Peripheral tear causes fewer symptoms than deeper
  tear
• Pain, point tenderness, spasm, loss of function
  and little discoloration
• Complete tear may leave athlete w/ little
  disability and discomfort but with some deformity
• Care
• Rest, ice and compression to control internal
  bleeding
• Determine extent of injury early
• Neoprene sleeve may provide some added support

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• Hamstring Muscle Strains
• Cause of Injury
• Multiple theories of injury
• Hamstring and quad contract together
• Change in role from hip extender to knee flexor
• Fatigue, posture, leg length discrepancy, lack of
  flexibility, strength imbalances,
• Signs of Injury
• Muscle belly or point of attachment pain
• Capillary hemorrhage, pain, loss of function and
  possible discoloration
• Grade 1 - soreness during movement and point
  tenderness
• Grade 2 - partial tear, identified by sharp snap
  or tear, severe pain, and loss of function

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• Signs of Injury (continued)
• Grade 3 - Rupturing of tendinous or muscular
  tissue, involving major hemorrhage and
  disability, edema, loss of function, ecchymosis,
  palpable mass or gap
• Care
• RICE
• Restrict activity until soreness has subsided
• Ballistic stretching and explosive sprinting
  should be avoided initially

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• Acute Femoral Fractures
• Cause of Injury
• Generally involving shaft and requiring great
  force
• Occurs in middle third due to structure and point
  of contact
• Signs of Injury
• Shock, pain, swelling, deformity
• Must be aware of bone displacement and gross
  deformity
• Loss of function
• Care
• Treat for shock, verify neurovascular status,
  splint before moving, reduce following X-ray
• Secure immediate emergency assistance and medical
  referral

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• Femoral Stress Fractures
• Cause of Injury
• Overuse
• Uncommon injury tends to occur in endurance
  athletes
• Females gt Males
• Signs of Injury
• Pain occurs weeks after increasing workout
  intensity
• Persistent pain in thigh, groin, especially after
  activity
• Referred pain to knee
• X-ray or bone scan will reveal fracture
• Commonly seen in femoral neck
• Management
• Initial treatment involves rest
• While most head with conservative management,
  fracture may result
• May require surgical repair

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Recognition and Management of Specific Hip,
Groin, and Pelvic Injuries

• Groin Strain
• Cause of Injury
• One of the more difficult problems to diagnose
• Often seen in early part of season due to poor
  strength and flexibility
• Occurs from running , jumping, twisting w/ hip
  external rotation or severe stretch
• Signs of Injury
• Sudden twinge or tearing during active movement
• Produce pain, weakness, and internal hemorrhaging

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• Groin Strain (continued)
• Care
• RICE, NSAIDs and analgesics for 48-72 hours
• Determine exact muscle or muscles involved
• Rest is critical
• Restore normal ROM and strength -- provide
  support w/ wrap
• Refer to physician if severe groin pain is
  experienced

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• Sprains of the Hip Joint
• Cause of Injury
• Result of violent twist due to forceful contact
• Force from opponent/object or trunk forced over
  planted foot in opposite direction
• Signs of Injury
• Signs of acute injury and inability to circumduct
  hip
• Pain in hip region, w/ hip rotation increasing
  pain
• Care
• X-rays or MRI should be performed to rule out
  fracture
• RICE, NSAIDs and analgesics
• Depending on severity, crutches may be required
• ROM and PRE are delayed until hip is pain free

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• Dislocated Hip
• Cause of Injury
• Rarely occurs in sport
• Result of traumatic force directed along the long
  axis of the femur
• Signs of Injury
• Flexed, adducted and internally rotated hip
• Palpation reveals displaced femoral head,
  posteriorly
• Serious pathology
• Soft tissue, neurological damage and possible
  fracture

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• Care
• Immediate medical care (blood and nerve supply
  may be compromised)
• Contractures may further complicate reduction
• 2 weeks immobilization and crutch use for at
  least one month

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• Hip Labral Tears
• Cause of Condition
• Result of repetitive overuse (i.e. running or
  pivoting)
• May occur due to acute trauma (i.e. dislocation)
• Signs of Injury
• Often present as asymptomatic
• Causes clicking, locking, or catching
• Pain in the groin stiffness limited motion
• Care
• Exercises to maintain ROM, strength stability
• Avoid aggravating activities
• NSAIDs, corticosteroids
• Surgical repair

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• Result of traumatic force directed along the long
  axis of the femur
• Signs of Injury
• Flexed, adducted and internally rotated hip
• Palpation reveals displaced femoral head,
  posteriorly
• Serious pathology
• Soft tissue, neurological damage and possible
  fracture
• Care
• Immediate medical care (blood and nerve supply
  may be compromised)
• Contractures may further complicate reduction
• 2 weeks immobilization and crutch use for at
  least one month

Piriformis Syndrome

• Cause of Condition
• Compression of sciatic nerve irritation due to
  tightness or spasm of muscle
• May mimic sciatica
• Signs of Injury
• Pain, numbness and tingling in butt may extend
  below knee and into foot
• Pain may increase following periods of sitting,
  climbing stairs, walking or running

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Piriformis Syndrome cont

• Care
• Stretching and massage
• NSAIDs may be prescribed
• Cessation of aggravating activities will be
  prescribed
• Corticosteroid injection may also be suggested
• Surgery is sometimes an option as well

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Hip Problems in Adolescent Athletes

• Legg Calve-Perthes Disease (Coxa Plana)
• Cause of Condition
• Avascular necrosis of the femoral head in child
  ages 4-10
• Articular cartilage becomes necrotic and flattens
• Signs of Condition
• Pain in groin that can be referred to the abdomen
  or knee
• Limping is also typical
• Varying onsets and may exhibit limited ROM

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Legg-Calve-Perthes Disease (continued)

• Care
• Bed rest to reduce chance of chronic condition
• Brace to avoid direct weight bearing
• Early treatment and head may reossify and
  revascularize
• Complication
• If not treated early, will result in ill-shaping
  and osteoarthritis in later life

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• Slipped Capital Femoral Epiphysis
• Cause of Condition
• May be growth hormone related
• 25 of cases are seen in both hips
• Epiphysis slips from femoral head in backwards
  direction due to weakness in growth plate
• May occur during periods of elevated growth
• Signs of Condition
• Pain in groin that comes on over weeks or months
• Hip and knee pain during passive and active
  motion limitations of abduction, flexion, medial
  rotation and a limp
• Management
• W/ minor slippage, rest and non-weight bearing
  may prevent further slippage
• Major displacement requires surgery
• If undetected or surgery fails severe problems
  will result

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• Iliac Crest Contusion (hip pointer)
• Cause of Injury
• Contusion of iliac crest or abdominal musculature
• Result of direct blow
• Signs of Injury
• Pain, spasm, and transitory paralysis of soft
  structures
• Decreased rotation of trunk or thigh/hip flexion
  due to pain
• Care
• RICE for at least 48 hours, NSAIDs,
• Bed rest 1-2 days in severe cases
• Referral must be made, X-ray
• Padding should be used upon return to minimize
  chance of added injury

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• Osteitis Pubis
• Cause of Injury
• Seen in distance runners
• Repetitive stress on pubic symphysis and adjacent
  muscles
• Signs of Injury
• Chronic pain and inflammation of groin
• Point tenderness on pubic tubercle
• Pain w/ running, sit-ups and squats
• Management
• Rest, NSAIDs and gradual return to activity

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• Acute Fracture of Pelvis
• Cause of Injury
• Result of direct blow or blunt trauma
• Signs of Injury
• Severe pain, loss of function, shock
• Care
• Immediately treat for shock
• Refer to physician
• Seriousness of injury dependent on extent of
  shock and possibility of internal injury

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• Stress Fractures
• Cause of injury
• Repetitive abnormal overused forces
• Signs of Injury
• Groin pain, w/ aching sensation in thigh that
  increases w/ activity and decreases w/ rest
• Discomfort increases with activity and subsides
  during rest
• Care
• Refer to physician for assessment and X-ray
• Rest for 2-5 months

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• Avulsion Fractures
• Cause of Injury
• Avulsions seen in sports w/ sudden accelerations
  and decelerations
• Pulling of tendon away and off of bony insertion
• Common sites include ASIS (sartorius), AIIS
  (rectus femoris attachment), ischial tuberosity
  (hamstring
• Signs of Injury
• Sudden localized pain w/ limited movement
• Pain, swelling, point tenderness
• Care
• Rest, limited activity and graduated exercise