The Pelvis and Thigh

1
Chapter 8

• The Pelvis and Thigh

2
Introduction

• Pelvic girdle forms structural base of support
  between lower extremity and trunk
• Hip articulation strongest and most stable
  joint in the body
• This benefit gained at the expense of ROM

3
Clinical Anatomy

• Bones and Bony Landmarks
• Figures 8-1 and 8-2
• Ilium,
• Ischium
• Pubis
• Sacrum
• Acetabulum
• Labrum

4
Clinical Anatomy

• Bones and Bony Landmarks cont.
• Femoral head and neck
• Angle of inclination
• Head is angled at 125 degrees in frontal plane
• Angle of torsion
• Relationship between head and shaft, 15 degrees
• Figures 8-3, 8-4, 8-5
• Greater trochanter
• Lesser trochanter

5
Clinical Anatomy

• Articulations and Ligamentous Support
• Pubic symphysis
• Fibrocartilaginous interpubic disc
• Small degree of spreading, compression and
  rotation between halves of girdle
• Sacroiliac joint (SI joint)
• Very study, limited ROM

6

• Coxofemoral joint (hip joint)
• Ball-and-socket
• 3 degrees of freedom
• Flexion and extension
• Abduction and adduction
• Internal and external rotation
• Rom supported by depth of acetabulum, strength of
  ligaments, strong muscular support
• Joint capsule
• Dense synovial capsule from acetabular rim to
  distal femoral neck

7

• Iliofemoral ligament (Y ligament of Bigelow)
• Figure 8-6
• AIIS to distal and proximal intertrochanteric
  line
• Reinforces anterior jt capsule and limits
  hyperextension
• Allows us to stand upright with minimal muscular
  activity
• Pubofemoral ligament
• Also reinforces anterior capsule
• Pubis ramus to intertrochanteric fossa

8

• Ligamentum teres (ligament of the head of the
  femur)
• Conduit for medial and lateral circumflex
  arteries
• Little function in stabilizing hip
• Figure 8-7
• Inguinal ligament
• ASIS to pubic symphysis
• Serves to contain soft tissues as they course
  anteriorly from trunk to lower extremity
• Superior border of femoral triangle

9
Muscular Anatomy

• Table 8-1, pages 276-277
• Anterior Musculature
• Quadriceps
• Iliopsoas group
• Psoas major, psoas minor, iliacus
• Primary hip flexors when knee extended
• Figure 8-8
• Medial Musculature
• Adductor group
• Gracilis
• Figure 8-9

10

• Lateral Musculature
• Gluteus medius
• Tensor fascia latae
• Figure 8-10
• Trendelenburgs gait pattern
• Intrinsic muscles form cuff around femoral head
  and externally rotate hip
• Piriformis, quadratus femoris, obturator
  internus, obturator externus, gemellus superior,
  gemellus inferior
• Figure 8-11

11

• Posterior Musculature
• Gluteus maximus
• hamstrings

12
Femoral Triangle

• Figure 8-12
• Formed by
• Inguinal ligament (superiorly)
• Sartorius (laterally)
• Adductor longus (medially)
• Landmark for
• Femoral nerve, artery and vein
• Femoral pulse
• Lymph nodes

13
Bursae

• 3 bursa to decrease friction between gluteus
  maximus and adjacent bony structures
• Trochanteric bursa
• Gluteus max greater trochanter
• Gluteofemoral bursa
• Gluteus max vastus lateralis
• Ischial bursa
• Gluteus max ischial tuberosity

14
Clinical Evaluation of Pelvis and Thigh

• May necessitate evaluation of lower extremity,
  spinal column, and posture
• Patient preparedness
• Clinician preparedness
• Gender issues
• Evaluation Map
• Page 280

15
History

• Location of symptoms
• Table 8-2, page 281
• Onset
• Training techniques
• Mechanism of injury
• Prior medical conditions
• Legg-Calve-Perthes Disease
• Slipped capital femoral epiphysis

16
Inspection

• Most trauma to area cannot be visualized
• Inspection of Hip Angulations
• Angle of inclination
• Relationship of femoral head and shaft
• Coxa valga
• Increase in angle, may lead to genu varum or
  lateral patella
• Coxa vara
• Decrease in angle, may lead to genu valgum or
  squinting patella
• Mechanical advantage of glut medius is reduced

17

• Angle of torsion
• Measured through radiograph
• Box 8-1
• Anteverted hips
• Increases greater than 15 degrees result in
  internal femoral rotation, squinting patellae and
  a toe-in gait
• Retroverted hips
• Angle less than 15 degrees, femur externally
  rotates, resulting in a toe-out position,
  laterally positioned patellae

18

• Inspection of Medial Structures
• Adductor group
• Inspection of Anterior Structures
• Hip flexors
• Inspection of Lateral Structures
• Iliac crest (figure 8-13)
• Nelatons line
• ASIS to ischial tuberosity
• Figure 8-14

19

• Inspection of Posterior Structures
• PSIS
• Gluteus maximus
• Hamstring muscle group (figure 8-15)
• Median sacral crests
• Inspection of Leg Length Discrepancy

20
Palpation

• Refer to list of Clinical Proficiencies
• Utilize pages 283 - 285

21
Range of Motion Testing

• Limited by bony and soft tissue restraints
• Position of knee
• Flexed vs. extended
• Table 8-3, page 286 (Muscle actions)
• Box 8-2, page 287 (Goniometry)

22
Active Range of Motion

• Flexion and Extension
• Figure 8-17
• 130-150 degrees (range, knee flexed)
• Majority occurs during flexion
• Extending knee limits hip flexion
• Adduction and Abduction
• Figure 8-18
• Abduction 45 degrees
• Adduction 20-30 degrees

23
Active Range of Motion

• Internal and External Rotation
• Figure 8-19
• ER 40-50 degrees
• IR 45 degrees
• Hip flexed vs. extended

24
Passive Range of Motion

• Flexion and Extension
• Flexion
• Figure 8-20
• End-feel soft w/knee flexed firm w/knee
  extended
• Thomas Test
• Box 8-3, page 289
• Extension
• Figure 8-21
• End-feel firm w/knee extended and flexed but due
  to different structures

25
Passive Range of Motion

• Adduction and abduction
• Figure 8-22
• End-feel firm
• Adduction due to tension in lateral structures
• Abduction due to tension in medial structures
• Internal and external rotation
• Figure 8-23
• End-feel firm
• IR due to tension in posterior capsule and
  external hip rotators
• ER due to tension in anterior capsule and
  ligament support
• Anteverted vs. retroverted hips

26
Resisted Range of Motion

• Box 8-4, pages 291-292
• Trendelenburgs Test for Gluteus Medius Weakness
• Box 8-5, page 293

27
Ligamentous Testing

• No specific tests for hip ligaments
• Dysfunction is determined through passive testing
  of movement
• Hyperextension places iliofemoral, pubofemoral,
  and ischiofemoral ligaments on stretch

28
Neurologic Testing

• Complete lower quarter screening should be
  performed
• Pathology involving femoral or sciatic nerve
• Piriformis Syndrome
• Impingement of sciatic nerve from spasm of
  piriformis muscle

29
Pathologies and Related Special Tests

• Acute
• Contusions or strains
• Chronic
• Improper biomechanics from poor posture, leg
  length discrepancies, overuse syndromes
• Injury to hip joint is rare
• Potential medical emergency

30
Muscle Strains

• Table 8-4, page 294
• Occur secondary to dynamic overload during
  eccentric muscle contraction
• Commonly injured
• Iliopsoas, quadriceps, adductors, hamstrings
• Signs and Symptoms

31
Bursitis

• Onset related to biomechanical factors,
  congenital influences, or environmental
  conditions, such as prolonged periods of sitting
• Septic infection may be a cause

32
Bursitis

• Trochanteric Bursitis
• Evaluative Findings - Table 8-5, page 295
• May result from a single blow or friction from IT
  band
• History of training changes or increased Q angle
  may be predisposing factors
• Snapping Hip syndrome

33
Bursitis

• Ischial Bursitis
• Evaluative Findings - Table 8-6, page 296
• Movement of buttocks while patient is
  weight-bearing in seated position can irritate
  this bursa
• Also irritated by prolonged sitting
• Need to rule out hamstring strain or avulsion of
  its attachment
• Doughnut padding may help

34
Bursitis

• Iliopsoas Bursitis
• Associated with rheumatoid arthritis or
  osteoarthritis of hip
• Signs and symptoms
• Pain in anterior hip
• Palpable mass in groin or inguinal ligament
• snapping hip syndrome
• Treatment includes strengthening hip rotators

35
Degenerative Hip Changes

• Due to age, repetitive trauma, acute trauma, or
  improper arrangements of hip
• Degeneration of articular surfaces of femur and
  acetabulum
• Arthritis, osteochondritis dissecans, acetabular
  labrum tears, avascular necrosis
• Signs and symptoms
• Pain, referred to low back, anterior thigh, knee
• Loss of motion in all planes, decrease strength
• Hip Scouring, Box 8-6, page 297
• Radiographic evaluation

36
Piriformis Syndrome

• Sciatic nerve passes under or through the
  piriformis muscle as nerve travels across
  posterior pelvis
• Spasm or hypertrophy of muscle places pressure on
  sciatic nerve
• Six times more common in women
• Relatively undefined and confusing
• Mimics lumbar nerve root impingement and
  intervertebral disk disease

37
Piriformis Syndrome

• Evaluative Findings
• Table 8-7, page 298
• Straight leg raise, passive hip internal rotation
  resisted external rotation with patient seated,
  and resisted hip abduction may produce symptoms
• Figure 8-24
• Treatment includes stretching and strengthening
  or surgical release

38
On-Field Evaluation of Pelvis and Thigh Injuries

• Trauma to coxofemoral joint is rare
• Protection from padding
• More commonly, strains, contusions, sprains of SI
  joint
• Note position of athlete
• If leg is moving, rule out dislocation
• Fixed, immobile awkward position may indicate
  dislocation

39
On-Field Evaluation of Pelvis and Thigh Injuries

• After ruling out dislocation or subluxation and
  femoral fracture AROM
• Weight-bearing status
• Removal from field

40
Initial Evaluation and Management of On-Field
Injuries

• Iliac Crest Contusion (hip pointer)
• Evaluative Findings, Table 8-8, page 299
• Disproportionate amount of pain, swelling, and
  loss of function
• Recognition and immediate management of pain
  reduces time lost due to injury
• Treatment
• Ice, padding, reduced activity, crutches, if
  necessary

41
Initial Evaluation and Management of On-Field
Injuries

• Quadriceps Contusion
• As severity of impact increases, so does the
  proportion of muscle fiber death
• Can result in decreased force during knee
  extension
• Associated pain and spasm may limit flexion
• Gross discoloration, painful to touch,
  intramuscular hematoma gives hardened feel,
  increase in girth of muscle
• Overtime, atrophy may occur

42

• Risk of myositis ossificans is increased when
  effusion of knee joint occurs
• Figure 8-25
• First 24 hours following injury are critical
• Pain during AROM, or weakness during MMT
  removal from activity
• Ice applied in flexion
• Maintaining ROM decrease possibility of myositis
  ossificans formation
• Figure 8-26

43

• Hip Dislocation
• Rare
• Medical emergency
• Majority involve posterior displacement of
  femoral head
• Fractures to femoral neck and acetabulum
• Most occur when hip is in flexion and adduction
  and axial force is placed on femur, displacing it
  posteriorly and causing head to be driven through
  posterior capsule

44

• Signs and Symptoms
• Immediate pain within joint and buttocks
• Sensation of giving out
• Femur and lower leg positioned in internal
  rotation and adduction
• Figure 8-27
• AROM is impossible
• No attempt to reduce
• Sensory and vascular check

45

• Immediate immobilization and transportation to
  emergency facility
• Reduction under anesthesia

46
Femoral Fracture

• Torsional or shear force to shaft
• Relatively rare
• weak link principle
• Immediate loss of function, pain, deformity,
  easily recognizable
• Stress fracture
• Shaft and neck, difficult to diagnosis
• Similar s/s to hip flexor strain or tendinitis
• Treatment