Title: Chapter 21: The Thigh, Hip, Groin, and Pelvis
1Chapter 21 The Thigh, Hip, Groin, and Pelvis
2Anatomy of the Thigh
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5Nerve and Blood Supply
- Tibial and common peroneal are given rise from
the sacral plexus which form the largest nerve in
the body the sciatic nerve complex - The main arteries of the thigh are the deep
circumflex femoral, deep femoral, and femoral
artery - The two main veins are the superficial great
saphenous and the femoral vein
6Fascia
- The fascia lata femoris is part of the deep
fascia that invests the thigh musculature - Thick anteriorly, laterally and posteriorly but
thin on the medial side - Iliotibial track (IT-band) is located laterally
serving as the attachment for the tensor fascia
lata and greater aspect of the gluteus maximum
7Functional Anatomy of the Thigh
- Quadriceps insert in a common tendon to the
proximal patella - Rectus femoris is the only quad muscle that
crosses the hip - Extends knee and flexes the hip
- Important to distinguish between hip flexors
relative to injury for both treatment and rehab
programs
8- Hamstrings cross the knee joint posteriorly and
all except the short of head of the biceps
crosses the hip - Bi-articulate muscles produce forces dependent
upon position of both knee and hip joints - Position of the knee and hip during movement and
MOI play important roles and provide information
to utilize w/ rehab and prevention of hamstring
injuries
9Assessment of the Thigh
- History
- Onset (sudden or slow?)
- Previous history?
- Mechanism of injury?
- Pain description, intensity, quality, duration,
type and location? - Observation
- Symmetry?
- Size, deformity, swelling, discoloration?
- Skin color and texture?
- Is athlete in obvious pain?
- Is the athlete willing to move the thigh?
10Palpation Bony and Soft Tissue
- Medial and lateral femoral condyles
- Greater trochanter
- Lesser trochanter
- Anterior superior iliac spine (ASIS)
- Sartorius
- Rectus femoris
- Vastus lateralis
- Vastus medialis
- Vastus intermedius
- Semimembranosis
- Semitendinosis
- Biceps femoris
- Adductor brevis, longus and magnus
- Gracilis
- Sartorius
11Palpation Soft Tissue (continued)
- Pectineus
- Iliotibial Band (IT-band)
- Gluteus medius
- Tensor fasciae latae
12- Special Tests
- If a fracture is suspected the following tests
are not performed - Beginning in extension, the knee is passively
flexed - A normal muscle will elicit full range of motion
pain free (one w/ swelling or spasm will have
restricted motion) - Active movement from flexion to extension
- Strong and painful may indicate muscle strain
- Weak and pain free may indicate 3rd degree or
partial rupture - Muscle weakness against an isometric resistance
may indicate nerve injury
13Prevention of Thigh Injuries
- Thigh must have maximum strength, endurance, and
extensibility to withstand strain - In collision sports thigh guards are mandatory to
prevent injuries
14Recognition and Management of Thigh Injuries
- Quadriceps Contusions
- Etiology
- Constantly exposed to traumatic blunt blow
- Contusions usually develop as a result of severe
impact - Extent of force and degree of thigh relaxation
determine depth and functional disruption that
occurs - Signs and Symptoms
- Pain, transitory loss of function, immediate
effusion with palpable swollen area - Graded 1-4 superficial to deep with increasing
loss of function (decreased ROM, strength)
15Quad Contusion
16- Management
- RICE, NSAIDs and analgesics
- Crutches for more severe cases
- Aspiration of hematoma is possible
- Following exercise or re-injury, continued use of
ice - Follow-up care consists of ROM, and PRE w/in pain
free range - Heat, massage and ultrasound to prevent myositis
ossificans
17- General rehab should be conservative
- Ice w/ gentle stretching w/ a gradual transition
to heat following acute stages - Elastic wrap should be used for support
- Exercises should be graduated from stretching to
swimming and then jogging and running - Restrict exercise if pain occurs
- May require surgery of herniated muscle or
aspiration - Once an athlete has sustained a severe contusion,
great care must be taken to avoid another
18- Myositis Ossificans Traumatica
- Etiology
- Formation of ectopic bone following repeated
blunt trauma (disruption of muscle fibers,
capillaries, fibrous connective tissue, and
periosteum) - Gradual deposit of calcium and bone formation
- May be the result of improper thigh contusion
treatment (too aggressive) - Signs and Symptoms
- X-ray shows calcium deposit 2-6 weeks following
injury - Pain, weakness, swelling, decreased ROM
- Tissue tension and point tenderness w/
- Management
- 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)
19- Quadriceps Muscle Strain
- Etiology
- Sudden stretch when athlete falls on bent knee or
experiences sudden contraction - Associated with weakened or over constricted
muscle - Signs and Symptoms
- Peripheral tear causes fewer symptoms than deeper
tear - Pain, point tenderness, spasm, loss of function
and little discoloration - Complete tear may live athlete w/ little
disability and discomfort but with some deformity - Management
- RICE, NSAIDs and analgesics
- Manage swelling, compression, crutches
- Move into isometrics and stretching as healing
progresses - Neoprene sleeve may provide some added support
20- Hamstring Muscle Strains
- (second most common thigh injury)
- Etiology
- 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 and Symptoms
- Muscle belly or point of attachment pain
- Capillary hemorrhage, pain, loss of function and
possible discoloration - Grade 1 - soreness during movement and point
tenderness (lt20 of fibers torn( - Grade 2 - partial tear, identified by sharp snap
or tear, severe pain, and loss of function (lt70
of fiber torn)
21- Signs and Symptoms (continued)
- Grade 3 - Rupturing of tendinous or muscular
tissue, involving major hemorrhage and
disability, edema, loss of function, ecchymosis,
palpable mass or gap - gt70 muscle fiber tearing
- Management
- RICE, NSAIDs and analgesics
- Grade I - dont resume full activity until
complete function restored - Grade 2 and 3 should be treated conservatively w/
gradual return to stretching and strengthening in
later stages of healing (modalities and
isometrics) - When soreness is eliminated, isotonic leg curls
can be introduced (focus on eccentrics) - Recovery may require months to a full year
- Greater scaring greater recurrence of injury
22- Acute Femoral Fractures
- Etiology
- Generally involving shaft and requiring great
force - Occurs in middle third due to structure and point
of contact - Signs and Symptoms
- Pain, swelling, deformity
- Management
- Treat for shock, verify neurovascular status,
splint before moving, reduce following X-ray - Analgesics and ice
- Extensive soft tissue damage will also occur as
bones will displace due to muscle force
23- Femoral Stress Fractures
- Etiology
- Overuse (10-25 of all stress fractures)
- Excessive downhill running or jumping activities
- Compression or distraction fracture generally
occur - Signs and Symptoms
- Persistent pain in thigh
- X-ray or bone scan will reveal fracture
- Commonly seen in femoral neck
- Management
- Analgesics, NSAIDs RICE
- ROM and PRE exercises are carried out w/ pain
free ROM - Rest, limited weight bearing
- Complete stress fracture may require pins
24Anatomy of the Hip, Groin and Pelvic Region
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31Functional Anatomy
- Pelvis moves in three planes through muscle
function - Anterior tilting changes degree of lumbar
lordosis, lateral tilting changes degree of hip
abduction - Hip is a true ball and socket joint w/ intrinsic
stability - Hip also moves in all three planes, particularly
during gait (bodys relative center of gravity) - Tremendous forces occur at the hip during varying
degrees of locomotion - Muscles are most commonly injured in this region
- Numerous injuries attach in this region and
therefore injury to one can be very disabling and
difficult to distinguish
32Assessment of the Hip and Pelvis
- Bodys center of gravity is located just anterior
to the sacrum - Injuries to the hip or pelvis cause major
disability in the lower limbs, trunk or both - Low back may also become involved due to
proximity - History
- Onset (sudden or slow?)
- Previous history?
- Mechanism of injury?
- Pain description, intensity, quality, duration,
type and location?
33- Observation
- Symmetry- hips, pelvis tilt (anterior/posterior)
- Lordosis or flat back
- Lower limb alignment
- Knees, patella, feet
- Pelvic landmarks (ASIS, PSIS, iliac crest)
- Standing on one leg
- Pubic symphysis pain or drop on one side
- Ambulation
- Walking, sitting - pain will result in movement
distortion
34Palpation Bony
- Iliac crest
- Anterior superior iliac spine (ASIS)
- Anterior inferior iliac spin (AIIS)
- Posterior superior iliac spine (PSIS)
- Pubic symphysis
- Ischial tuberosity
- Greater trochanter
- Femoral neck
-
35Palpation Soft Tissue
- Rectus femoris
- Sartorius
- Iliopsoas
- Inguinal ligament
- Gracilis
- Adductor magnus, longus brevis
- Pectineus
- Gluteus maximus, medius minimus
- Piriformis
- Hamstrings
- Tensor fasciae latae
- Iliotibial Band
- Major regions of concern are the groin, femoral
triangle, sciatic nerve, lymph nodes
36Special Tests
- Functional Evaluation
- ROM, strength tests
- Hip adduction, abduction, flexion, extension,
internal and external rotation - Tests for Hip Flexor Tightness
- Kendall test
- Test for rectus femoris tightness
- Thomas test
- Test for hip contractures
37Kendalls Test
38Thomas Test
39Femoral Anteversion (A) and Retroversion (B)
- Relationship between neck and shaft of femur
- Normal angle is 15 degrees anterior to the long
axis of the femur and condyles - Internal rotation in excess of 35 degrees is
indicative of anteversion, 45 degrees of external
rotation is an indicator of retroversion
40Test for Hip and Sacroiliac Joint
- Patrick Test (FABER)
- Detects pathological conditions of the hip and SI
joint - Pain may be felt in the hip or SI joint
41- Gaenslens Test
- Test works to push SI joint into extension
- Test is positive if hyperextension on affected
side increases pain
42Testing the Tensor Fasciae Latae and Iliotibial
Band
- Rennes test
- Athlete stands w/ knee bent at 30-40 degrees
- Positive response of TFL tightness occurs when
pain is felt at lateral femoral condyle
43- Nobels Test
- Lying supine the athletes knee is flexed to 90
degrees - Pressure is applied to lateral femoral condyle
while knee is extended - Pain at 30 degrees at lateral femoral condyle
indicates a positive test
44- Obers Test
- Used to determine presence of contracted TFL or
IT-band - Thigh will remain in abducted position, not
falling into adduction
45Trendelenburgs Test- Iliac crest on unaffected
side should be higher when standing on one leg-
Test is positive when affected side is higher
indicating weak abductors (glut medius)
46- Piriformis Test
- Hip is internally rotated
- Tightness or pain is indicative of piriformis
tightness
47- Elys Test
- Used to assess tightness of rectus femoris
- Athlete is prone, w/ pelvis stabilized and knee
on the affected side is flexed - If hip on that side extends as the knee is
flexed, rectus femoris is tight - Measuring Leg Length Discrepancy
- With inactive individual, difference of more
that 1 may produce symptoms - Active individuals may experience problems w/ as
little 3mm (1/8) difference - Can cause cumulative stresses to lower limbs,
hips, pelvis or low back
48- True or anatomical
- Shortening may be equal throughout limb or
localized w/in femur or lower leg - Measurement taken from medial malleolus to ASIS
- Apparent or functional
- Result of lateral pelvic tilt or from a flexion
or adduction deformity - Measurement is taken from umbilicus to medial
malleolus
49Leg Length Discrepancy Measures
50Recognition and Management of Specific Hip,
Groin, and Pelvic Injuries
- Groin Strain
- Etiology
- One of the more difficult problems to diagnose
- Injury to one of the muscles in the regions
(generally adductor longus) - Occurs from running , jumping, twisting w/ hip
external rotation or severe stretch - Signs and Symptoms
- Sudden twinge or tearing during active movement
- Produce pain, weakness, and internal hemorrhaging
51- Groin Strain (continued)
- Management
- RICE, NSAIDs and analgesics for 48-72 hours
- Determine exact muscle or muscles involved
- Rest is critical daily whirlpool and
cryotherapy, moving into ultrasound - Delay exercise until pain free
- Restore normal ROM and strength -- provide
support w/ wrap
52- Trochanteric Bursitis
- Etiology
- Inflammation at the site where the gluteus medius
ties into the IT-band - Signs and Symptoms
- Complaint of lateral hip pain that may radiate
down the leg - Palpation reveals tenderness over lateral aspect
of greater trochanter - IT-band and TFL tests should be performed
- Management
- RICE, NSAIDs and analgesics
- ROM and PRE directed toward hip abductors and
external rotators - Phonophoresis if pain doesnt respond in 3-4 days
- Look at biomechanics and Q-angle
- Avoid inclined surfaces
53- Sprains of the Hip Joint
- Etiology
- Due to substantial support, any unusual movement
exceeding normal ROM may result in damage - Force from opponent/object or trunk forced over
planted foot in opposite direction - Signs and Symptoms
- Signs of acute injury and inability to circumduct
hip - Similar S S to stress fracture
- Pain in hip region, w/ hip rotation increasing
pain - Management
- X-rays or MRI should be performed to rule out fx
- RICE, NSAIDs and analgesics
- Depending on severity, crutches may be required
- ROM and PRE are delayed until hip is pain free
54- Dislocated Hip
- Etiology
- Rarely occurs in sport
- Result of traumatic force directed along the long
axis of the femur (posterior dislocation w/ hip
flexed and adducted and knee flexed) - Signs and Symptoms
- Flexed, adducted and internally rotated hip
- Palpation reveals displaced femoral head,
posteriorly - Serious pathology
- Soft tissue, neurological damage and possible fx
- Management
- 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
55- Avascular Necrosis
- Etiology
- Result of temporary or permanent loss of blood
supply to proximal femur - Can be caused by traumatic conditions (hip
dislocation), or non-traumatic circumstances
(steroids, blood coagulation disorders, excessive
alcohol use compromising blood vessels) - Signs and Symptoms
- Early stages - possibly no SS
- Joint pain w/ weight bearing progressing to at
times of rest - Pain gradually increases (mild to severe)
particularly as bone collapse occurs - May limit ROM
- Osteoarthritis may develop
- Progression of SS can develop over the course of
months to a year
56- Avascular Necrosis (continued)
- Management
- Must be referred for X-ray, MRI or CT scan
- Must work to improve use of joint, stop further
damage and ensure survival of bone and joint - Most cases will ultimately require surgery to
repair joint permanently - Conservative treatment involves ROM exercises to
maintain ROM electric stim for bone growth
non-weight bearing if caught early - Medication to treat pain, reduce fatty substances
reacting w/ corticosteroids or limit blood
clotting in the presence of clotting disorders
may limit necrosis
57Hip Problems in the Young Athlete
- Legg Calve-Perthes Disease (Coxa Plana)
- Etiology
- Avascular necrosis of the femoral head in child
ages 4-10 - Trauma accounts for 25 of cases
- Articular cartilage becomes necrotic and flattens
- Signs and Symptoms
- Pain in groin that can be referred to the abdomen
or knee - Limping is also typical
- Varying onsets and may exhibit limited ROM
58Legg-Calve-Perthes Disease (continued)
- Management
- Bed rest to alleviate synovitis
- 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
59- Slipped Capital Femoral Epiphysis
- Etiology
- Found mostly in boys ages 10-17 who are
characteristically tall and thin or obese - May be growth hormone related
- 25 of cases are seen in both hips, trauma
accounts for 25 - Head slippage on X-ray appears posterior and
inferior - Signs and Symptoms
- 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
60- The Snapping Hip Phenomenon
- Etiology
- Common in young female dancers, gymnasts,
hurdlers - Habitual movement predispose muscles around hip
to become imbalanced (lateral rotation and
flexion) - Related to structurally narrow pelvis, increased
hip abduction and limited lateral rotation - Hip stability is compromised
- Signs and Symptoms
- Pain w/ balancing on one leg, possible
inflammation - Management
- Focus on cryotherapy and ultrasound to stretch
musculature and strengthen weak musculature in
hip region
61Pelvic Conditions
- Athletes can suffer serious acute and chronic
injuries to the pelvic region - Pelvis rotates along longitudinal axis when
running, proportionate to the amount of arm swing - Also tilts as legs engage support and nonsupport
- Combination of motion causes shearing and changes
in lordosis throughout activity
62- Contusion (hip pointer)
- Etiology
- Contusion of iliac crest or abdominal musculature
- Result of direct blow (same MOI for iliac crest
fx and epiphyseal separation - Signs and Symptoms
- Pain, spasm, and transitory paralysis of soft
structures - Decreased rotation of trunk or thigh/hip flexion
due to pain - Management
- RICE for at least 48 hours, NSAIDs,
- Bed rest 1-2 days
- Referral must be made, X-ray
- Ice massage, ultrasound, occasionally steroid
injectionRecovery lasts 1-3 weeks
63- Osteitis Pubis
- Etiology
- Seen in distance runners
- Repetitive stress on pubic symphysis and adjacent
muscles - Signs and Symptoms
- Chronic pain and inflammation of groin
- Point tenderness on pubic tubercle
- Pain w/ running, sit-ups and squats
- Acute case may be the result of bicycle seat
- Management
- Rest, NSAIDs and gradual return to activity
64- Athletic Pubalgia
- Etiology
- Chronic pubic region pain caused by repetitive
stress to pubic symphysis from kicking, twisting,
or cutting - Forced adduction, from hyperextended position,
creates shearing forces that are transmitted
through pubic symphysis to insertion of rectus
abdominus, hip adductors and conjoined tendon - Result in microtears of tranversalis abdominis
fascia, aponeurosis of obliques, or conjoined
tightness - Create weakening of anterior wall and inguinal
canal - Signs and Symptoms
- No presence of hernia
- Chronic pain during exertion, sharp and burning
that later radiates into adductors and testicles
65- Signs and Symptoms (continued)
- Point tenderness on pubic tubercle
- Pain increased w/ resisted hip flexion, internal
rotation, abdominal contraction, resisted hip
adduction (adductors not painful adductor
strain) - Management
- Conservative treatment (even though rarely
effective) - Massage, stretching after 1 week of surrounding
musculature - 2 weeks, strengthening of abs and hip flexors and
adductors - 3-4 weeks begin running progression
- Aggressive treatment involves cortisone injection
or tightening of pelvic wall surgically
66- Stress Fractures
- Etiology
- Seen in distance runners - repetitive cyclical
forces from ground reaction force - More common in women than men
- Common site include inferior pubic ramus, femoral
neck and subtrochanteric area of femur - Signs and Symptoms
- Groin pain, w/ aching sensation in thigh that
increases w/ activity and decreases w/ rest - Standing on one leg may be impossible
- Deep palpation results in point tenderness
- Intense interval or competitive racing may cause
67- Stress Fractures (continued)
- Management
- Rest for 2-5 months
- Crutch walking for ischium and pubis fractures
- X-ray normal 6-10 weeks and bone scan will be
required - Swimming can be used -- breast stroke avoided
68- Avulsion Fractures and Apophysitis
- Etiology
- Traction epiphysis (bone outgrowth)
- Common sites include ischial tuberosity, AIIS,
and ASIS - Avulsions seen in sports w/ sudden accelerations
and decelerations - Signs and Symptoms
- Sudden localized pain w/ limited movement
- Pain, swelling, point tenderness
- Muscle testing increases pain
69- Avulsion Fractures and Apophysitis
- Management
- X-ray
- If uncomplicated, RICE, NSAIDs, crutch toe-touch
walking - After control pain and inflammation, 2-3 weeks of
gradual stretching - When 80 degrees of ROM have been regained,
athlete can return to competition
70Thigh and Hip Rehabilitation Techniques
- General Body Conditioning
- Must maintain cardiovascular fitness, muscle
endurance and strength of total body - Avoid weight bearing activities if painful
- Flexibility
- Regaining pain free ROM is a primary concern
- Progress from passive to PNF stretching
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72Mobilization
- Will be necessary if injury and subsequent
limitation is caused by tightness of ligaments
and capsule surrounding the joint - Use to re-establish appropriate arthrokinematics
- Series of glides (anterior and posterior) and
rotations can be used to restore motion
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74Strength
- Progression should move from isometric exercises
until muscle can be fully contracted to isotonic
strengthening PREs into isokinetics - PNF strengthening should then be incorporated to
enhance functional activity - Active exercise should occur in pain free ranges
-- in an effort not to aggravate condition - Exercises for the core must also be included
- Develop optimal levels of functional strength and
dynamic stabilization
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77Neuromuscular Control
- Establish through combination of appropriate
postural alignment and stability strength - As neuromuscular control is enhanced, the ability
of the kinetic chain to maintain appropriate
forces and dynamic stabilization increases - Focus on balance and closed kinetic chain
activities
78Balance Shoe for Neuromuscular Control
79Functional Progression and Return to Activity
- Begin in pool, non-weight bearing
- Depending on activity, progression of walking, to
jogging, to running and more difficult agility
tasks can occur - Before returning to play, athlete should
demonstrate pain free function, full ROM,
strength, balance and agility