Chapter 21: The Thigh, Hip, Groin, and Pelvis Jennifer Doherty-Restrepo, MS, LAT, ATC Academic Program Director, Entry-Level ATEP Florida International

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

Jennifer Doherty-Restrepo, MS, LAT, ATCAcademic Program Director, Entry-Level ATEP

Florida International UniversityAcute Care and Injury Prevention

Anatomy of the Thigh

Review

Nerve and Blood Supply

Tibial and common peroneal nerves Arise from the sacral plexus to form the largest

nerve in the body, the sciatic nerve The main arteries of the thigh include:

Deep circumflex, deep femoral, and femoral The two main veins of the thigh include:

Great saphenous and femoral

Muscles

Fascia lata femoris Deep fascia that surrounds thigh musculature Thick anteriorly, laterally, and posteriorly Thin on the medial side

IT-band Attachment site for the tensor fascia lata and

gluteus maximum

Quadriceps

Insertion at proximal patella via common tendon Pre-patellar tendon

Rectus femoris = bi-articulate muscle Only quad muscle that also crosses the hip Extends knee and flexes the hip

Important: distinguish between knee extensors and hip flexors Injury evaluation Treatment and rehabilitation programs

Cross the knee joint posteriorly All hamstrings, except the short of head of the

biceps femoris, are bi-articulate Crosses the hip joint as well Forces dependent upon position of both knee and hip

Important: distinguish between knee flexors and hip extensors Injury evaluation Treatment and rehabilitation programs

Hamstrings

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 the athlete in obvious pain? Is the athlete willing to move the thigh?

Palpation: Bony Tissue

Medial and lateral femoral condyles Greater trochanter Lesser trochanter Anterior superior iliac spine (ASIS)

Palpation: Soft Tissue

Sartorius Rectus femoris Vastus lateralis Vastus medialis Vastus intermedius Semimembranosus Semitendinosus Biceps femoris

Adductor brevis, longus, and magnus

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

Not performed if a fracture is suspected!!! Passive knee flexion

Normal = full, pain-free ROM Injury = swelling or spasm restricting ROM

Active knee extension Muscle strain = strong and painful ROM 3rd degree strain or partial rupture = weak and pain

free ROM Resistive knee extension

Nerve injury = muscle weakness against an isometric resistance

Special Tests

Prevention of Thigh Injuries

Maximum strength Endurance Flexibility In collision sports, thigh guards are

mandatory to prevent injuries

Thigh Injuries: Quadriceps Contusions

Etiology MOI = severe impact, direct blow Extent (depth) of injury depends upon…

Force Degree of thigh relaxation

Signs and Symptoms Pain, transitory loss of function,

immediate effusion (palpable) Graded 1 - 4 = superficial to deep

Increased loss of function 1 - 4 Decreased ROM 1 - 4 Decreased strength 1 - 4

Management RICE NSAID’s and analgesics Crutches, if indicated Aspiration of hematoma Ice post exercise or re-injury Follow-up care

ROM exercises PRE in pain-free ROM

Modalities Heat Massage Ultrasound to prevent

myositis ossificans

Thigh Injuries: Quadriceps Contusions

Etiology Formation of ectopic bone MOI = repeated blunt trauma May be the result of improper thigh contusion

treatment (too aggressive) Signs and Symptoms

X-ray shows Ca++ deposit 2 - 6 weeks post injury Pain, weakness, swelling, tissue tension, point

tenderness, and decreased ROM Management

Treatment must be conservative May require surgical removal

Thigh Injuries: Myositis Ossificans Traumatica

Etiology MOI = over-stretching or too forceful contraction

Signs and Symptoms Pain, point tenderness, spasm, loss of function,

and ecchymosis Superficial strain results in fewer S&S than

deeper strain Complete tear results in deformity

Athlete displays little disability and discomfort

Thigh Injuries: Quadriceps Muscle Strain

Management RICE NSAID’s and analgesics Manage swelling

Compression, crutches Stretching PRE strengthening exercises Neoprene sleeve for added support

Thigh Injuries: Quadriceps Muscle Strain

Etiology: multiple theories of injury Hamstrings and quadriceps contract together Change from hip extender to knee flexor Fatigue Posture Leg length discrepancy Lack of flexibility Strength imbalances

Thigh Injuries: Hamstring Muscle Strains


Signs and Symptoms Pain in muscle belly

or point of attachment

Capillary hemorrhage

Ecchymosis

Grade 1 Pain with movement Point tenderness <20% of fibers torn

Grade 2 Partial tear

<70% of fibers torn Sharp snap or tear Severe pain Loss of function

Grade 3 Rupture of tendinous or

muscular tissue >70% muscle fiber tearing

Severe hemorrhage Disability Edema Loss of function Ecchymosis Palpable mass or gap


Management RICE, NSAID’s and analgesics Modalities PRE exercises When soreness is

eliminated, focus on eccentrics strengthening

Recovery may require months to a full year

Scaring increases risk of injury recurrence of

Grade I Do not resume full

activity until complete function restored

Grade 2 and 3 Should treat

conservatively Gradual return to

stretching and strengthening in later stages of healing

Etiology Fracture in middle third of femoral shaft MOI = great deal of force

Signs and Symptoms Pain, swelling, deformity, muscle guarding Leg with fx positioned in hip adduction and ER Leg with fx may appear shorter

Management Medical emergency! Treat for shock, splint, refer Analgesics and ice

Thigh Injuries: Acute Femoral Fractures

Etiology Overuse (10-25% of all stress fractures) MOI = excessive downhill running or jumping Often seen in endurance athletes

Signs and Symptoms Persistent pain in thigh/groin region X-ray or bone scan will reveal fracture Positive Trendelenburg’s sign

Management Prognosis will vary depending on location

Fx in shaft and medial to femoral neck heal well with conservative management

Fx lateral to femoral neck are more complicated

Thigh Injuries: Femoral Stress Fractures

Anatomy of the Hip, Groin, and Pelvic Region

Review

Functional Anatomy

Hip Joint True ball and socket joint Intrinsic stability Moves in all three planes, particularly during gait

Pelvis Moves in all three planes Anterior tilting

Changes degree of lumbar lordosis Lateral tilting

Changes degree of hip abduction

Assessment of the Hip and Pelvis

Injuries to the hip or pelvis cause major disability in the lower limbs, trunk, or both

Low back may also become involved History

Onset (sudden or slow?) Previous history? Mechanism of injury? Pain description, intensity, quality, duration,

type, and location?

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 to one side Ambulation

Assessment of the Hip and Pelvis

Palpation: Bony Tissue

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 Poster inferior iliac

spine (PIIS)

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, and lymph

nodes

Special Tests

Functional Evaluation PROM, AROM, RROM Hip adduction and abduction Hip flexion and extension Hip internal and external rotation

Special Tests: Hip Flexor Tightness

Kendall test Test for rectus femoris tightness

Special Tests: Hip Flexor Tightness

Thomas test Test for hip contractures

Special Tests: 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

Special Tests: Hip and Sacroiliac Joint

Gaenslen’s Test Test forces SI joint into

extension Hyperextension on the

affected side increases pain

Special Tests: Tensor Fasciae Latae and Iliotibial Band

Renne’s test Athlete stands with knee

bent at 30 - 40 degrees Pain at lateral femoral

condyle indicates tensor fasciae latae tightness


Nobel’s Test Lying supine, knee is

flexed to 90 degrees Pressure is applied to

lateral femoral condyle while knee is extended

Pain at 30 degrees of knee flexion in the area of the lateral femoral condyle indicates IT band irritation

Ober’s Test Used to determine presence of

contracted TFL or IT-band Thigh will remain in abducted position


Special Tests: Tensor Fasciae Latae and Iliotibial Band Trendelenburg’s Test

Stand on one leg and compare level of PSIS and iliac crests bilaterally

Test is positive when affected side is higher

Indicates weak hip abductors (gluteus medius)

Special Tests: Piriformis

Piriformis Test Hip is internally rotated Tightness or pain is

indicative of piriformis tightness

True or anatomical Shortening may be equal throughout limb or

localized in femur or lower leg Measure from ASIS to medial malleolus

Apparent or functional May result due to lateral pelvic tilt, flexion, or

adduction deformity Measure from umbilicus to medial malleolus

Special Tests: Leg Length Discrepancy

Leg Length Discrepancy Measures

Hip and Groin Injuries

Groin Strain Etiology

Injury usually occurs to the adductor longus MOI = running, jumping, or twisting with hip

external rotation; over-stretching; or too forceful contraction

Signs and Symptoms Sudden twinge or tearing during movement Pain, weakness, and internal hemorrhaging

Groin Strain (continued) Management

RICE NSAID’s and analgesics Rest is critical Modalities

Daily whirlpool and cryotherapy Ultrasound

Delay exercise until pain free Restore normal ROM and strength Provide support with elastic wrap


Trochanteric Bursitis Etiology

Inflammation of bursa at greater trochanter Insertion site for gluteus medius and where IT-band

passes over the greater trochanter

Signs and Symptoms Lateral hip pain that may radiate down the leg Point tenderness over greater trochanter IT-band and TFL tests should be performed


Trochanteric Bursitis (continued Management

RICE NSAID’s and analgesics ROM and PRE exercises for hip abductors

and external rotators Phonophoresis Evaluate biomechanics and Q-angle Runners should avoid inclined surfaces


Sprains of the Hip Joint Etiology

Unusual movement exceeding normal ROM MOI = force from opponent/object, or, trunk

forced over planted foot in opposite direction Signs and Symptoms

Pain, which increases with hip rotation Inability to circumduct hip Similar S&S to stress fracture


Sprains of the Hip Joint (continued) Management

RICE NSAID’s and analgesics Depending on severity, crutches may be

required ROM and PRE are delayed until hip is pain-free X-rays or MRI should be performed to rule out

a possible fracture


Dislocated Hip Etiology

Result of traumatic force directed along the long axis of the femur

Posterior dislocation more common Hip flexed, adducted, and internally rotated Knee flexed

Rarely occurs in sport Signs and Symptoms

Flexed, adducted, and internally rotated hip Palpation reveals displaced femoral head Medical emergency

Compications include soft tissue damage, neurological damage, and possible fracture


Dislocated Hip (continued) Management

Immediate medical care Blood and nerve supply may be compromised

Contractures may further complicate reduction 2 weeks immobilization Crutch use for at least one month


Avascular Necrosis Etiology

Temporary or permanent loss of blood supply to the proximal femur

MOI = traumatic conditions (ie: hip dislocation) or non-traumatic conditions (ie: steroids, blood coagulation disorders)

Signs and Symptoms Possibly no S&S in early stages

Develop over the course of months to a year Joint pain with weight bearing, progressing to pain at rest Limited ROM Osteoarthritis may develop


Avascular Necrosis (continued) Management

Must be referred for X-ray, MRI, or CT scan Most cases will ultimately require surgery

Conservative treatment Non-weight bearing;ROM exercises; e-stim for bone

growth; medication to treat pain Limit necrosis

Reduce fatty substances, which react with corticosteroids Limit blood clotting in the presence of clotting disorders


Hip Problems in the Young Athlete

Legg Calve’-Perthes Disease (Coxa Plana) Etiology

Avascular necrosis of the femoral head in child ages 4-10

MOI = trauma (accounts for 25% of cases) Signs and Symptoms

Pain in groin Referred pain to the abdomen or knee

Limping may exhibit limited ROM


Legg Calve’-Perthes Disease (continued) Management

Bed rest to alleviate synovitis Brace to avoid direct weight bearing With early treatment, the femoral head may

re-ossify and revascularize Complications

If not treated early, will result in ill-shaping May develop into osteoarthritis in later life

Slipped Capital Femoral Epiphysis Etiology

Found mostly in tall boys between ages 10-17 May be growth hormone related MOI = trauma (accounts for 25% of cases)

25% of cases are seen in both hips Femoral head slippage on X-ray appears in

posterior and inferior direction


Slipped Capital Femoral Epiphysis (continued)

Signs and Symptoms Pain in groin that progresses over weeks or months Hip and knee pain during passive and active motion

Limitations of hip abduction, flexion, and medial rotation Limp

Management Minor slippage

Rest and non-weight bearing may prevent further slippage Major slippage results in displacement

Requires surgery If condition goes undetected or if surgery fails, severe

problems will result


The Snapping Hip Phenomenon Etiology

Common in young female dancers, gymnasts, and hurdlers

MOI = repetitive movement that leads to muscle imbalance

Related to narrow pelvis, increased hip abduction, and limited lateral rotation

Hip stability is compromised


The Snapping Hip Phenomenon (continued) Signs and Symptoms

Pain while balancing on one leg Possible inflammation

Management ROM exercises to increase flexibility

Flexion and lateral rotation Cryotherapy and ultrasound may be utilized

PRE exercises to strengthen weak muscles


Contusion (hip pointer) Etiology

Contusion of iliac crest or abdominal musculature

MOI = direct blow Signs and Symptoms

Pain, spasm, and transitory paralysis Decreased ROM due to pain

Rotation of trunk, thigh/hip flexion

Pelvic Injuries

Contusion (hip pointer) continued Management

RICE for at least 48 hours NSAID’s, Bed rest 1 - 2 days Referral must be made for X-ray Modailities

Ice massage, ultrasound, occasionally steroid injection

Recovery lasts 1 - 3 weeks

Pelvic Injuries

Osteitis Pubis Etiology

Often seen in distance runners MOI = repetitive stress

Signs and Symptoms Chronic pain and inflammation of groin Point tenderness on pubic tubercle Pain with running, sit-ups, and squats

Management Rest, NSAID’s, and gradual return to activity

Pelvic Injuries

Athletic Pubalgia Etiology

Chronic pubic region pain MOI = repetitive stress to pubic symphysis from

kicking, twisting, or cutting Signs and Symptoms

No presence of hernia Chronic pain during exertion Sharp and burning pain that radiates into

adductors and testicles

Pelvic Injuries

Athletic Pubalgia (continued) Signs and Symptoms (continued)

Point tenderness on pubic tubercle Increased pain with resisted hip flexion, internal

rotation, abdominal contraction, and hip adduction Management

Conservative treatment (rarely effective): rest, ROM exercises, and PRE exercises

Aggressive treatment: cortisone injection or surgical tightening of pelvic wall

Pelvic Injuries

Stress Fractures Etiology

Seen in distance runners – more common in women than men

MOI = repetitive cyclical forces from ground reaction forces

Common sites include inferior pubic ramus, femoral neck, and subtrochanteric area of the femur

Signs and Symptoms Groin pain

Aching sensation in thigh that increases with activity and decreases with rest

Standing on one leg may be impossible Deep palpation results in point tenderness

Pelvic Injuries

Stress Fractures (continued) Management

Rest for 2 - 5 months Crutch walking

Especially for ischium and pubis stress fractures X-rays are usually normal for 6 -10 weeks,

therefore a bone scan will be required to detect the stress fracture

Swimming can be used to maintain CV fitness Breast stroke should be avoided

Pelvic Injuries

Avulsion Fractures and Apophysitis Etiology

Common sites include ischial tuberosity, AIIS, and ASIS

MOI = sudden accelerations and decelerations Signs and Symptoms

Sudden localized pain Limited ROM Pain, swelling, point tenderness Muscle testing increases pain

Pelvic Injuries

Avulsion Fractures and Apophysitis (continued)

Management X-ray required for diagnosis RICE, NSAID’s, crutch “toe-touch” walking ROM exercises PRE exercises

When 80 degrees of ROM have been regained Return to play when full ROM and strength are

restored

Pelvic Injuries

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


Strength Progression from isometric exercises to isotonic

strengthening PREs Isokinetic exercises may be utilized PNF strengthening could be incorporated to enhance

functional activity Active exercise should occur in pain free ranges

Avoid re-aggravating the injury Exercises for the core must also be included

Develop functional strength and dynamic stabilization


Neuromuscular Control Established through 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

Functional Progression and Return to Activity Begin in pool, non-weight bearing Progression of walking, to jogging, to running,

and to more difficult agility tasks Before returning to play, athlete should

demonstrate pain free function, full ROM, strength, balance, and agility

Documents

Chapter 21: The Thigh, Hip, Groin, and Pelvis Jennifer Doherty-Restrepo, MS, LAT, ATC Academic Program Director, Entry-Level ATEP Florida International