Hip, Pelvis and Thigh Problems

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Hip, Pelvis and Thigh Problems

• Kevin deWeber, MD, FAAFP
• LTC(P), US Army
• Director, Military Sports Medicine Fellowship

Military Sports Medicine Fellowship
Every Warrior an Athlete
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Objectives for Hip, Pelvis and Thigh Problems

• Define relevant anatomy, physiology, and
  radiographic features
• Recognize the history, presenting signs and
  pertinent exam findings
• Demonstrate common rehabilitative exercises
• Demonstrate proper injection techniques, to
  include indications and contraindications

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Name the muscle(s) used to flex the hip.

• Iliopsoas
• Sartorius
• Rectus femoris
• All of the above

Q
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Practical Anatomy

• Practical vs. Surgical vs. Gross Anatomy
• Bones
• Cartilage
• Ligaments
• Nerves
• Blood Vessels
• Muscles

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Bones of the Hip and Pelvis

• Pelvis
• Ilium
• Anterior Superior Iliac Spine
• Anterior Inferior Iliac Spine
• Posterior Inferior Iliac Spine
• Ischium
• Ischial Spine
• Ischial Tuberosity
• Pubis
• Pubic Symphysis
• Inferior and Superior Rami
• Acetabulum

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Pelvis Details
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Femur

• Head
• Neck
• Greater Trochanter
• Lesser Trochanter
• Shaft

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Hip Cartilage

• Articular Cartilage
• Hyaline
• Caps Joints
• Labrum
• Fibrocartilage
• Stability and cushioning

• Articular Cartilage
• Hyaline
• Caps Joints
• Labrum
• Fibrocartilage
• Stability and cushioning

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Ligaments of the HipSurgical, not Practical

• Joint Capsule
• Name two bones and connect them
• Pubofemoral
• Iliofemoral
• Ischiofemoral
• Ligamentum teres

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Nerves of Hip, Pelvis and Thigh

• Sciatic Nerve
• L4-S3
• Articular and Muscular
• Sensation
• External rotation and posterior thigh, foot
• Femoral Nerve
• L2-4
• Anterior thigh compartment
• Lateral Femoral Cutaneous
• L3-4
• Sensory

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Blood Supply

• Femoral Artery
• Profunda femoris
• Circumflex
• Artery of ligamentum teres
• Posterior division of the obturator artery
• Femoral head

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Hip, Pelvis and Thigh Muscles
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The iliopsoas bursa can be indirectly palpated
over the

• Lateral hip
• Anterior hip/groin
• 3. Over the lower buttocks
• 4. Only with a chaperone

Q
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Hip Bursae

• Trochanteric
• Greater trochanter and Iliotibia band
• Ischial
• Ischial tuberosity and gluteus muscles
• Iliopsoas
• Iliopsoas tendon and lesser trochanter extending
  upward into the iliac fossa beneath the iliacus
  muscle

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Hip Pelvis Problemskinda like surfing!
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Physical Exam Approach

• Inspection
• Palpation
• Range of motion
• Strength testing
• Neurovascular exam
• Special tests

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6 Planes of MotionTest each to elicit pain and
determine location of the problem

• Flexion??Extension
• Abduction??Adduction
• Internal Rotation??External Rotation

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Flexion /Extension

• Flexion
• Anterior Muscles
• Iliopsoas, rectus femoris, sartorius, pectineus
• Extension
• 0-15 deg
• Posterior muscles
• Gluteus maximus
• Hamstrings, adductor magnus

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Abduction/Adduction

• Abduction
• 0-50 degrees
• Gluteus medius, gluteus minimus, tensor fascia
  lata
• Adduction
• 0-30 degrees
• Adductor longus/brevis/magnus
• Gracilis, pectineus, obturator externus

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Internal/External Rotation

• Internal Rotation
• Gluteus medius/minimus, tensor fascia lata
• External Rotation
• Obturator externus/internus, superior/inferior
  gemelli, piriformis, quadratus femoris, gluteus
  maximus

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The Trendelenberg test looks for weakness of
primarily what muscle?

• Bulbus cavernosus
• Gluteus medius
• Iliopsoas
• Rectus abdominus

Q
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Hip Special Tests
FAbER
Obers Test
Modified Thomas Test
Trendelenberg Test
Popliteal angle
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Hip Special Tests

• Leg Length
• ASIS to Medial Malleolus
• Labrum Test FAdAxL
• Flexion, Adduction, Axial Load (add some rotation
  too!)

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Hip Imaging

• X-rays
• WEIGHT-BEARING AP
• Frog leg
• Bone Scan (Flex, ExRot)
• CT
• MRI
• MRI Arthrogram

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Case 1

• 32 yo female recreational runner
• Previous dancer
• Gradual increase in distance and abdominal
  workouts
• Pain and popping in groin and anterior hip with
  hip flexion and crunches
• Tender anterior groin

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Iliopsoas Bursitis/Tendinosis

• Evaluation
• Consider X-ray or MRI to r/o other dx
• Treatment
• Relative rest, stretch, consider NSAIDs
• Physical therapy
• Injection (US guided)
• Surgical rare

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Case 2

• 28 yo male skier
• Hip pain with deep click that persists 2 months
  after a fall
• Catching sensation
• Worse with deep flexion
• Decreased ROM, pain with FAdAxL maneuver

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Acetabular Labrum Tear

• Evaluation
• FAdAxL hip Flexion, ADduction and AXial Loading)
• Imaging x-rays (neg)? MRI arthrogram
• Treatment
• Physical Therapy to maximize ROM and strength
• Corticosteroid injection?
• Surgical referral?

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Hip MRI MRI-arthrogram
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Case 3

• 52 yo woman with left lateral hip pain after a
  vacation at the beach
• Gradual onset
• No trauma or previous hx
• Painful laying on left side
• TTP over greater trochanter
• Ober test bilat

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What is your leading diagnosis?

• Femoral neck stress fracture
• Acetabular labrum injury
• Trochanteric bursitis
• Meralgia paresthetica

Q
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Trochanteric Bursitis

• Evaluation
• No imaging needed
• Treatment
• Ice, brief NSAIDs
• PT stretch ITB, strengthen hip muscles
• Evaluate biomechanics leg length and gait
• Corticosteroid injection early (proven)

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Trochanteric Bursa Injection
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Case 4

• Retired Navy CPO with progressive right hip and
  groin pain
• Associated decreased ROM
• Bowling game suffering
• No trauma, no other joint complaints
• Painful internal rotation

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Osteoarthritis of the Hip

• Evaluation
• X-rays
• Weight-bearing most sensitive early on
• Treatment
• Physical therapy to improve ROM
• Aquatic aerobic exercise
• Glucosamine, APAP gt NSAIDs
• Hip injection (US guided)
• Corticosteroid or viscosupplement
• Surgical referral if disabling

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Case 5

• 13 yo female gymnast with increasing groin pain
  over the past 2 months
• Increased pain with increased activity
• No acute trauma
• FROM w/o pain, good strength

• Vague anterior groin tenderness
• Positive Hop Test

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Femoral Neck Stress Fracture

• Evaluation
• Imaging
• X-ray (prob neg)
• Bone scan or MRI
• Treatment
• Relative rest, NON-painful activity only
• slow increase
• Address other factors

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What other factors are important?

• Menstrual history
• Exercise and activity history
• Dietary history
• All of the above

Q
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Stress Fractures of Femoral Neck

• High index of suspicion
• CRUTCHES pending imaging
• Tx
• Inferior side NON-painful activity, gradual
  protected return to activity
• Superior side Ortho referral
• High risk for complete fracture
• Address causation
• Diet, activity level, maturity

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Other pelvic stress fractures to LOOK FOR

• Sacrum
• Superior pubic ramus
• Inferior pubic ramus

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Case 6

• 25 yo male soccer player with chronic right lower
  abdominal/groin pain for the past several weeks
• Increased training in the past month
• Worse with right footed kicking and resisted
  adduction
• Mild TTP at adductor tendon
• Pain w/ resisted hip adduction

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Adductor Tendinopathy

• Evaluation
• Females r/o inferior pubic ramus stress fx
• Treatment
• Relative rest, ice
• PT isometric and eccentric strengthening

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Case 7

• 22 yo college hockey player with left groin/lower
  abdomen pain
• Progressive over past month
• Worse with sprint skating
• No specific trauma
• Pain w/ crunch, cough
• TTP above inguinal ligament
• No hernias

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Athletic Pubalgia/Sports Hernia

• Evaluation
• Possible dilated superficial ring
• MRI to r/o other problems, but doesnt confirm dx
• Etiology NOT a hernia
• Injury to conjoined tendon, internal oblique,
  external oblique, transversalis fascia, inguinal
  ligament, etc.
• Surgical referral
• Find the rare surgeon that does these!

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Case 7 Differential Diagnosis

• Osteitis Pubis
• Adductor tendinopathy
• Pelvis stress fracture
• Nerve injury/entrapment
• Ilioinguinal
• Iliohypogastric
• Obturator
• Hernia

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Case 8

• 19 yo female rugby player struck in the right
  thigh with a knee
• Localized pain, swelling, bruising, no muscle
  defect
• Decreased ROM and strength

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What is your leading diagnosis?

• Thigh contusion
• Femur fracture
• Vastis medialis strain
• Thigh splint

Q
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Thigh Contusion

• Evaluation and grading
• X-rays (prob neg)
• Treatment
• RICE
• Splint in knee flexion 24hr
• Gradual stretch, strength ex, return to
  activities
• NSAIDs to ? prevent heterotopic ossification

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Muscle Strains and Contusions

• Patients generally recall injury
• Swelling, ecchymosis, decreased ROM
• Palpate for muscle defect although rare
• MRI if suspect avulsion or complete tear
• Refer to Ortho if ruptured
• Consider image with X-ray
• Protect, Rest, Ice, Compression, pain med
• Gradual protected return to activity
• Physical Therapy to restore strength/agility

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Think outside the pelvis

• Low Back Pain
• Knee Pain
• Pelvic Pathology
• Intra-abdominal Pathology
• Obturator and Iliopsoas signs

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Hip Pain Evaluation
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Case 9

• 41 yo female retired pro soccer player, chronic
  left buttocks pain
• Pain to sit a long time
• Increases after run
• Pain numbness radiating into calf

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Questions to ask?

• Back history
• Trauma
• Recent
• Remote
• Low back red flags
• Fever, weight loss, h/o cancer, saddle
  anesthesia, loss of bowel or bladder control, IV
  drug use, unrelenting night pain

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Case 9 History and Physical

• History
• Previous back aches
• No specific trauma
• Points to left lower back and buttocks
• Some radiation of pain to calf
• No red flags

• Physical
• Normal gait and appearance
• TTP left upper/outer buttocks
• Painful resisted ExtRot
• Painful passive IntRot
• Normal sensory and strength

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Piriformis Strain vs Syndrome

• Variable muscle and nerve relationship
• Strain no sciatica
• Syndrome sciatica
• Treatment
• Rule out other things
• Brief NSAIDs
• Stretch/strengthen
• PT Core strength program
• Steroid injection

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Surfing causes fatigue of which muscles first?

• Quadriceps
• Gluteus maximus
• External oblique
• Erector spinae

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