The Thigh, Hip, Groin, and Pelvis © 2011 McGraw-Hill Higher Education. All rights reserved.

Anatomy of the Thigh © 2011 McGraw-Hill Higher Education. All rights reserved.

Nerve and Blood Supply the largest nerve in the body - the sciatic nerve The main arteries of the thigh are the deep femoral circumflex, deep femoral, and femoral artery The two main veins are the superficial great saphenous and the femoral vein © 2011 McGraw-Hill Higher Education. All rights reserved.

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 © 2011 McGraw-Hill Higher Education. All rights reserved.

Hamstrings cross the knee joint posteriorly and cross the hip Bi-articulate muscles produce forces dependent upon position of both knee and hip 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

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 Semimembranosus Semitendinosus Biceps femoris Adductor brevis, longus and magnus Gracilis Sartorius © 2011 McGraw-Hill Higher Education. All rights reserved.

Palpation: Soft Tissue (continued) Pectineus Iliotibial Band (IT-band) Gluteus medius Tensor fasciae latae © 2011 McGraw-Hill Higher Education. All rights reserved.

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) © 2011 McGraw-Hill Higher Education. All rights reserved.

Quad Contusion © 2011 McGraw-Hill Higher Education. All rights reserved.

Management –RICE, NSAID’s 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 resistance exercises w/in pain free range –Heat, massage and ultrasound to prevent myositis ossificans © 2011 McGraw-Hill Higher Education. All rights reserved.

–General rehab should be conservative –Ice w/ 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 a patient has sustained a severe contusion, great care must be taken to avoid another © 2011 McGraw-Hill Higher Education. All rights reserved.

Myositis Ossificans –Etiology Formation of 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 –Management Treatment must be conservative May require surgical removal due to pain and decreased ROM © 2011 McGraw-Hill Higher Education. All rights reserved.

Myositis Ossificans Traumatica –Management Treatment must be conservative May require surgical removal due to pain and decreased ROM

Quadriceps Muscle Strain –Etiology Sudden stretch, violent forceful contraction of hip and knee into flexion Overstretching of quadriceps –Signs and Symptoms Peripheral tear causes fewer symptoms than deeper tear Pain, point tenderness, spasm, loss of function and little discoloration Complete tear may leave patient w/ disability, discomfort and some deformity © 2011 McGraw-Hill Higher Education. All rights reserved.

–Signs & Symptoms Grade 1: Complain of tightness in front of thigh; near normal ambulation; swelling may be limited; mild discomfort during palpation Grade 2: Abnormal gait cycle; may be splinted in extension; swelling may be noticeable with pain on palpation; possible defect in muscle; resistive knee extension will reproduce pain Grade 3: Possibly unable to ambulate; pain with palpation; may be unable to perform knee extension; isometric contractions may produce defect or bulging in muscle belly © 2011 McGraw-Hill Higher Education. All rights reserved.

–Management RICE, NSAID’s and analgesics Manage swelling, compression, crutches With increased healing, progress to isometrics and stretching Grade 1: Neoprene sleeve may provide some added support Grade 2: Ice and compression for 3-5 days with gradual increase in isometric exercises and pain free knee ROM exercises –Limit passive stretching until later phases Grade 3: Crutch use for 7-14 days; restore normal gait; compression for support; may require 12 weeks until returning to full activity © 2011 McGraw-Hill Higher Education. All rights reserved.

Hamstring Muscle Strains (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 (<20% of fibers torn) Grade 2 - partial tear, identified by sharp snap or tear, severe pain, and loss of function (<70% of fiber torn) © 2011 McGraw-Hill Higher Education. All rights reserved.

–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 >70% muscle fiber tearing –Management RICE, NSAID’s and analgesics Grade I - don’t 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

–Management (continued) Modalities and strengthening need to gradually be introduced during healing process When soreness is eliminated, leg curls can be introduced (focus on eccentrics) Recovery may require months to a full year Greater scaring = greater recurrence of injury © 2011 McGraw-Hill Higher Education. All rights reserved.

Acute Femoral Fractures –Etiology Generally involving shaft and requiring a great deal of force Occurs in middle third due to structure and point of contact –Signs and Symptoms Pain, swelling, deformity Muscle guarding, hip is adducted and ER Leg with fx may also be shorter –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 © 2011 McGraw-Hill Higher Education. All rights reserved.

Femoral Stress Fractures –Etiology Overuse (10-25% of all stress fractures) Excessive downhill running or jumping activities Often seen in endurance athletes –Signs and Symptoms Persistent pain in thigh/groin X-ray or bone scan will reveal fracture Positive Trendelenburg’s sign –Management Fx lateral to femoral neck tend to be more complicated Shaft and medially located fractures tend to heal well with conservative management © 2011 McGraw-Hill Higher Education. All rights reserved.

Anatomy of the Hip, Groin and Pelvic Region © 2011 McGraw-Hill Higher Education. All rights reserved.

Functional Anatomy Pelvis moves in three planes through muscle function Hip is a true ball and socket joint Hip also moves in all three planes © 2011 McGraw-Hill Higher Education. All rights reserved.

Tremendous forces occur at the hip during varying degrees of locomotion Muscles are most commonly injured in this region Numerous muscles attach in this region and therefore injury to one can be very disabling and difficult to distinguish © 2011 McGraw-Hill Higher Education. All rights reserved.

Assessment of the Hip and Pelvis © 2011 McGraw-Hill Higher Education. All rights reserved.

Body’s 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? © 2011 McGraw-Hill Higher Education. All rights reserved.

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 © 2011 McGraw-Hill Higher Education. All rights reserved.

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 Poster inferior iliac spine © 2011 McGraw-Hill Higher Education. All rights reserved.

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 © 2011 McGraw-Hill Higher Education. All rights reserved.

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 © 2011 McGraw-Hill Higher Education. All rights reserved.

Kendall’s Test © 2011 McGraw-Hill Higher Education. All rights reserved.

Thomas Test © 2011 McGraw-Hill Higher Education. All rights reserved.

Femoral Anteversion and Retroversion –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 © 2011 McGraw-Hill Higher Education. All rights reserved.

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 © 2011 McGraw-Hill Higher Education. All rights reserved.

Gaenslen’s Test –Test works to push SI joint into extension –Test is positive if hyperextension on affected side increases pain © 2011 McGraw-Hill Higher Education. All rights reserved.

Testing the Tensor Fasciae Latae and Iliotibial Band Renne’s test –Athlete stands w/ knee bent at degrees –Positive response if TFL tightness occurs when pain is felt at lateral femoral condyle © 2011 McGraw-Hill Higher Education. All rights reserved.

Nobel’s Test –Lying supine the athlete’s 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

Ober’s Test –Used to determine presence of tight TFL or IT-band –Patient’s leg is extended and abducted –Thigh will remain in abducted position when released, not falling into adduction © 2011 McGraw-Hill Higher Education. All rights reserved.

Trendelenburg’s 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) © 2011 McGraw-Hill Higher Education. All rights reserved.

Piriformis Test –Hip is internally rotated –Tightness or pain is indicative of piriformis tightness © 2011 McGraw-Hill Higher Education. All rights reserved.

Ely’s Test –Used to assess tightness of rectus femoris –Patient 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 than 1” may produce symptoms –Active individuals may experience problems w/ as little as 3mm (1/8”) difference © 2011 McGraw-Hill Higher Education. All rights reserved.

–Anatomical Discrepancy Shortening may be equal throughout limb or localized w/in femur or lower leg Measurement taken from medial malleolus to ASIS –Apparent Discrepancy Result of lateral pelvic tilt or from a flexion or adduction deformity –Functional Discrepancy Difference due to deformity (i.e. valgus knee) that cannot be “fixed” Measurement is taken from umbilicus to medial malleolus © 2011 McGraw-Hill Higher Education. All rights reserved.

Leg Length Discrepancy Measures © 2011 McGraw-Hill Higher Education. All rights reserved.

Recognition and Management of Specific Hip, Groin, and Pelvic Injuries Adductor/Hip Flexor (Groin) Strain –Etiology One of the more difficult problems to diagnose Injury to one of the muscles in the regions Occurs from running, jumping, twisting w/ hip external rotation or severe stretch –Signs and Symptoms Sudden twinge or tearing during active movement Produces pain, weakness, and internal hemorrhaging © 2011 McGraw-Hill Higher Education. All rights reserved.

Groin Strain (continued) –Management RICE, NSAID’s and analgesics for 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

Trochanteric Bursitis –Etiology Inflammation at the site where the gluteus medius inserts or the IT-band passes over the trochanter –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 © 2011 McGraw-Hill Higher Education. All rights reserved.

–Management RICE, NSAID’s and analgesics ROM and PRE directed toward hip abductors and external rotators Phonophoresis if pain doesn’t respond in 3-4 days Must look at biomechanics Runners should avoid inclined surfaces © 2011 McGraw-Hill Higher Education. All rights reserved.

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 & Sx of stress fracture Pain in hip region, w/ hip rotation increasing pain © 2011 McGraw-Hill Higher Education. All rights reserved.

–Management X-rays or MRI should be performed to rule out fx RICE, NSAID’s and analgesics Depending on severity, crutches may be required ROM and resistance exercises are delayed until hip is pain free © 2011 McGraw-Hill Higher Education. All rights reserved.

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 © 2011 McGraw-Hill Higher Education. All rights reserved.

Dislocated Hip –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 © 2011 McGraw-Hill Higher Education. All rights reserved.

Avascular Necrosis –Etiology Result of temporary or permanent loss of blood supply to proximal femur Can be caused by traumatic conditions (hip dislocation – disruption of circumflex artery), or non-traumatic circumstances (steroids, blood coagulation disorders, excessive alcohol use compromising blood vessels) –Signs and Symptoms Early stages - possibly no S&S Joint pain w/ weight bearing progressing to pain at times of rest Pain gradually increases (mild to severe) particularly as bone collapse occurs May limit ROM Osteoarthritis may develop Progression of S&S can develop over the course of months to a year © 2011 McGraw-Hill Higher Education. All rights reserved.

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 © 2011 McGraw-Hill Higher Education. All rights reserved.

Hip Labral Tear –Etiology Often occurs due to repetitive movements such as running or pivoting, resulting in degeneration or breakdown of the labrum Can also occur acutely due to a hip dislocation –Signs and Symptoms Often asymptomatic May present with clicking, locking, stiffness, limited ROM Pain in through the groin and hip © 2011 McGraw-Hill Higher Education. All rights reserved.

Hip Labral Tear –Management Focus on hip ROM, strength & stability Avoid painful movements Medication for pain management; corticosteroids Failure to resolve in ~4 weeks may warrant surgery for removal of torn piece of labrum or sutures to repair tear © 2011 McGraw-Hill Higher Education. All rights reserved.

Hip Problems in the Young Athlete Legg Calve’-Perthes Disease (Coxa Plana) –Etiology Avascular necrosis of the femoral head in child ages Articular cartilage becomes necrotic and flattens –Signs and Symptoms Pain in groin that can be referred to the abdomen or knee Limping © 2011 McGraw-Hill Higher Education. All rights reserved.

Management –Bed rest to alleviate inflammation –Brace to avoid direct weight bearing –With early treatment the head may re-ossify and revascularize Complication –If not treated early, will result in ill-shaped head and develop into osteoarthritis later life © 2011 McGraw-Hill Higher Education. All rights reserved.

Slipped Capital Femoral Epiphysis –Etiology Found mostly in boys ages 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

–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 presents with 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

The Snapping Hip –Etiology Common in young female dancers, gymnasts, hurdlers Habitual movement predispose muscles around hip to become imbalanced External –IT-band moves over greater trochanter resulting in trochanteric bursitis –Iliopsoas tendon moving over iliopectineal eminence –Iliofemoral ligament moving over femoral head –Long head of biceps femoris moving over ischial tuberosity Related to structurally narrow pelvis, increased hip abduction and limited lateral rotation Internal causes –Loose bodies, labral tears, joint subluxations © 2011 McGraw-Hill Higher Education. All rights reserved.

–Signs and Symptoms Patient complains of snapping with severe pain and disability upon each snap –Management Decrease pain and inflammation –Ice, NSAID’s, ultrasound Move on to stretch and strengthen weak musculature in hip region © 2011 McGraw-Hill Higher Education. All rights reserved.

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, transitory paralysis of soft structures Decreased rotation of trunk or thigh/hip flexion © 2011 McGraw-Hill Higher Education. All rights reserved. Figures 21-34

© 2011 McGraw-Hill Higher Education. All rights reserved. Pelvic Conditions

Contusion (hip pointer) –Management RICE for at least 48 hours, NSAID’s, Bed rest 1-2 days Referral must be made, X-ray Ice massage, ultrasound, occasionally steroid injection Recovery lasts 1-3 weeks © 2011 McGraw-Hill Higher Education. All rights reserved.

Osteitis Pubis –Etiology Seen in distance runners and also in soccer, football, and wrestling 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, NSAID’s and gradual return to activity © 2011 McGraw-Hill Higher Education. All rights reserved.

Athletic Pubalgia –Etiology Chronic pubic region pain caused by repetitive stress to pubic symphysis from kicking, twisting, or cutting –Signs and Symptoms No presence of hernia Chronic pain during exertion, sharp and burning that laterally radiates into adductors and testicles © 2011 McGraw-Hill Higher Education. All rights reserved.

–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 © 2011 McGraw-Hill Higher Education. All rights reserved.

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 May be caused by intense interval training or competitive racing © 2011 McGraw-Hill Higher Education. All rights reserved.

Stress Fractures (continued) –Management Rest for 2-5 months Crutch walking for ischium and pubis fractures X-ray are usually normal for 6-10 weeks and bone scan will be required Swimming can be used for training -- breast stroke should be avoided © 2011 McGraw-Hill Higher Education. All rights reserved.

Avulsion Fractures and Apophysitis –Etiology 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

Avulsion Fractures and Apophysitis –Management X-ray If uncomplicated, RICE, NSAID’s, crutch toe- touch walking After controlling pain and inflammation, 2-3 weeks of gradual stretching When 80 degrees of ROM have been regained a resistance program should be instituted. With full return of ROM and strength athlete can return to play © 2011 McGraw-Hill Higher Education. All rights reserved.

Thigh and Hip Rehabilitation Techniques General Body Conditioning Flexibility Strength Proprioception © 2011 McGraw-Hill Higher Education. All rights reserved.