The Thigh, Hip, Groin, and Pelvis

Hip/pelvis/thigh Low Back Mid back/neck

Anatomy Review https://www.youtube.com/watch?v=qlCvKEOZtpo

Anatomy of the Thigh Review

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

Hamstrings 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

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

Thigh Injuries: Quadriceps Contusions 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: Myositis Ossificans Traumatica 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: Quadriceps Muscle Strain 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: Hamstring Muscle Strains 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 Ecchymosis Palpable mass or gap

Thigh Injuries: Hamstring Muscle Strains 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

Thigh Injuries: Acute Femoral Fractures 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: Femoral Stress 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

Anatomy of the Hip, Groin, and Pelvic Region Review

Functional Anatomy Hip Joint Pelvis 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?

Assessment of the Hip and Pelvis 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

Special Tests: Leg Length Discrepancy 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

Leg Length Discrepancy Measures

Hip and Groin Injuries Groin Strain Etiology Signs and Symptoms 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

Hip and Groin Injuries 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

Hip and Groin Injuries 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

Hip and Groin Injuries 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

Hip and Groin Injuries 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

Hip and Groin Injuries 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

Hip and Groin Injuries Dislocated Hip Etiology Signs and Symptoms 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

Hip and Groin Injuries 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

Hip and Groin Injuries Avascular Necrosis Etiology Signs and Symptoms 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

Hip and Groin Injuries 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

Hip Problems in the Young Athlete 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

Hip Problems in the Young Athlete 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

Hip Problems in the Young Athlete 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

Hip Problems in the Young Athlete 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

Hip Problems in the Young Athlete 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

Pelvic Injuries Contusion (hip pointer) Etiology Signs and Symptoms 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 Stress Fractures Etiology Signs and Symptoms 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

Palpations THE HIP

Greater Trochanter PSIS https://www.youtube.com/watch?v=o7ui31QEaRk

ASIS Iliac Crest

Palpations Low to mid back

Lumbar Spine Thoracic Spine

Palpations Chest and neck

Ribs 1-12 Cervical Spine

Occipital protuberance

ROM - HIP

Hip Flexion Hip Extension

Hip ABD Hip ADD

ROM - TRUNK

Trunk SB, Flex., Ext

Trunk rotation

ROM –Head and neck

Head and neck rom Flexion Extension Rotation Lateral Side Bending

Special Tests https://www.youtube.com/watch?v=MZuPBL_rTns Trendelenburg's Test Steps Athlete stands with the feet evenly distributed (i.e. approximately shoulder–width apart from each other) Examiner sits or kneels behind the athlete Examiner slightly lowers the athlete's shorts so that the examiner may palpate the right & left PSIS and/or iliac crests Examiner instructs the athlete to flex the hip thereby lifting the right (and then the left knee) while observing the pelvis Positive Test The PSIS or iliac crest on the same side as the leg lifted will drop in relation to the contralateral side Positive Test Implications Contralateral (i.e., stance leg) gluteus medius weakness https://www.youtube.com/watch?v=MZuPBL_rTns

Glute Med.

https://www.youtube.com/watch?v=vPPp1wEEQFQ Gaenslen's Test Steps Athlete is supine, lying close to the side of the table Examiner allows the near leg to hang over the side edge of the table Examiner instructs the athlete to actively flex the other leg to his/her chest & hold Examiner stabilizes the athlete & applies pressure to the near leg, forcing it into hyperextension Positive Test Pain in the SI region Positive Test Implications SI joint dysfunction https://www.youtube.com/watch?v=vPPp1wEEQFQ

SI JOINT

Piriformis Tightness Test Steps Athlete is side–lying with the test leg being the uppermost leg Athlete's test leg is flexed at the hip to about 60° & the knee flexed Examiner stabilizes the hip with one hand & applies a downward pressure to the knee Positive Test Piriformis muscle pain; buttock pain; sciatica pain Positive Test Implications Piriformis tightness (piriformis muscle pain); piriformis muscle pinching the sciatic nerve (buttock pain and sciatica pain) https://www.youtube.com/watch?v=QzFng74fueY https://www.youtube.com/watch?v=sEu4jhBnIAs

piriformis

Babinski Test Steps Run metal edge of neurlogic hammer, or fingernail along the tplantar surface of the foot from the calcaneus, along the lateral border of the foot to the forefoot Positive Test Great toe extension with flexion and splaying of the lateral four toes Positive Test Implications Upper motor neuron lesion (SPINAL CORD INJURY) https://www.youtube.com/watch?v=kOq5Np0eZ6A

90–90 Straight Leg Raising Test Steps Athlete lies supine with the hips and knees flexed to 90° Athlete grasps behind both of his/her thighs to stabilize the hip joints Athlete actively extends each knee in turn Positive Test Unable to extend the knee to within 20° of full knee extension Positive Test Implications Hamstring muscle tightness https://www.youtube.com/watch?v=A5yl1r2sTxw https://www.youtube.com/watch?v=ChfnY2ZMR0I

Hamstrings

Thomas Test Steps Athlete is supine with his/her knees bent at the end of the table Examiner places one hand between the lumbar lordotic curve & the tabletop Examiner passively flexes one of the athlete's legs to his/her chest, allowing the knee to flex during the movement Examiner observes the involved leg for movement Positive Test The knee of the leg on the table cannot flex past 90° (i.e. the knee of the leg on the table will extend as the examiner flexes the contralateral hip); the involved leg (i.e. the leg on the table) rises up off the table (i.e. the contralateral hip to the one being moved will flex) Positive Test Implications Rectus femoris tightness (the knee extends as the examiner flexes the hip); iliopsoas tightness (the leg on the table will rise off of the table) https://www.youtube.com/watch?v=NbRXi-nZVJs

Hip Flexors

Pelvis Anatomy https://www.youtube.com/watch?v=PJOT1cQHFqA