Chapter 21: The Thigh, Hip, Groin, and Pelvis

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Chapter 21 The Thigh, Hip, Groin, and Pelvis
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Anatomy of the Thigh
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Nerve 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

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Fascia

• 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

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Functional 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

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• 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

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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
• 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 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

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Palpation Soft Tissue (continued)

• Pectineus
• Iliotibial Band (IT-band)
• Gluteus medius
• Tensor fasciae latae

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• 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

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Prevention of Thigh Injuries

• Thigh must have maximum strength, endurance, and
  extensibility to withstand strain
• In collision sports thigh guards are mandatory to
  prevent injuries

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Recognition 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)

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Quad Contusion
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• 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

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• 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

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• 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)

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• 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

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• 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)

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• 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

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• 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

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• 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

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Anatomy of the Hip, Groin and Pelvic Region
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Functional 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

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Assessment 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?

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• 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

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Palpation 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

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Palpation 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
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Special 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

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Kendalls Test
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Thomas Test
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Femoral 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

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Test 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

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• Gaenslens Test
• Test works to push SI joint into extension
• Test is positive if hyperextension on affected
  side increases pain

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Testing 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

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• 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

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• Obers Test
• Used to determine presence of contracted TFL or
  IT-band
• Thigh will remain in abducted position, not
  falling into adduction

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Trendelenburgs 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)
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• Piriformis Test
• Hip is internally rotated
• Tightness or pain is indicative of piriformis
  tightness

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• 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

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• 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

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Leg Length Discrepancy Measures
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Recognition 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

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• 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

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• 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

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• 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

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• 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

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• 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

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• 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

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Hip 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

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Legg-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

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• 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

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• 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

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Pelvic 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

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• 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

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• 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

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• 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

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• 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

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• 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

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• 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

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• 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

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• 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

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Thigh 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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Mobilization

• 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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Strength

• 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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Neuromuscular 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

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Balance Shoe for Neuromuscular Control
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Functional 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