Pelvis/hip/thigh injuries

Hip Pointers Mechanism – direct blow to the iliac crest Occurs most often in contact/collision sports like football because of improperly fitting (or absent) hip pads One of the most handicapping injuries in sports

Hip Pointers Signs and symptoms include… Point tenderness, swelling, ecchymosis Antalgic gain with shortened swing phase Immediate pain Muscle spasms Transitory paralysis of the soft tissue structures - Athlete may not be able to rotate trunk or flex their thigh without pain

Hip Pointers Management/Care and treatment by the ATC Immediate application of ice and compression (as tolerated by the athlete) In severe cases, bed rest may be necessary for 24-48 hours after injury Referral to a physician if you suspect a fracture Ice massage and ultrasound after the acute phase Protective, hard-shell padding upon return to activity in 1-3 weeks

Thigh Contusion (Quadriceps) Mechanism – Direct Blow, usually develop as the result of being hit by someone or something, while thigh muscles were relaxed forcing the soft tissues against the hard surface of the femur – helmets, pads, elbows The extent of the force and the degree of thigh relaxation usually determines the depth of the injury and amount of structural and functional disruption that occurs

Thigh Contusion Early detection is essential to a quick recovery for the athlete Signs and Symptoms weakness with muscle testing Transitory paralysis or loss of function (dead leg) A circular, swollen area at the location of the injury with point tenderness Limited AROM due to pain;

Thigh Contusion Care and treatment for contusions by the ATC includes management in 3 stages… Stage 1 Application of ice, compression, and elevation Isometric quad contractions Crutches for 2nd and 3rd degree cases Gentle passive stretching w/cold application Stage 2 Recovery of ROM through the use of warm whirlpool or moist heat packs, ultrasound, ice, and stretching Stage 3 Recovering full function through PRE’s and gradual return to activity

Thigh contusions Care and rehabilitation of thigh contusions should be handled relatively conservatively Exercises should not be used if pain is present Never use deep, penetrating therapies and manual therapies until you are convinced swelling and bleeding have stopped Once an athlete has suffered an injury like this, care should be taken to insure that the athlete is not re-injured by providing protective padding, etc.

Myositis Ossificans What is it : Mechanism of Injury: An inflammation of muscle leading to bone formation Mechanism of Injury: Severe and repeated blows to the same area of the thigh can result in ECTOPIC BONE FORMATION Usually occurs after bleeding into the quadriceps/thigh and formation of a hematoma (blood tumor) This causes a disruption in the tissues, which may result in inflammation This irritation, in turn, cause tissue formation resembling cartilage or bone

Myositis Ossificans

Myositis Ossificans S/S Warm, firm, swollen thigh; 2-4 cm larger Hard lump in muscle tissue Limited ROM - Palpable, painful mass may limit passive knee flexion to 20 – 30 degrees Previous quadriceps contusion

Myositis Ossificans Management The most common cause of this condition is improper care of a thigh contusion The following are classic ways in which this condition can be caused or aggravated… or Attempting to “run off” the quad contusion Management Limit the swelling and bleeding – compression wrap Preserve elasticity – gentle stretching Physical therapy Donut padding to prevent repeated blows to the area Referral to physician: In most cases the bony growth will have to be surgically removed, after which a recovery of up to one year can be expected

Myositis Ossificans Examples of ossified tissues removed from patients suffering from Myositis Ossificans

Thigh Strains - Quadriceps Quadriceps muscle strains Mechanism of Injury The quad is often strained with a sudden contraction or stretching of the muscle A tear of the rectus femoris muscle (the most commonly torn muscle) may cause partial or complete disruption of the muscle fibers These tears can occur in the belly of the muscle or at the ends of the muscle, most typically towards the distal aspects at the muscle-tendon junction

Thigh Strains - Quadriceps Quadriceps muscle strains S/S swelling Pain when muscle is used or the inability to use the muscle Bruising Popping Indentation in the muscle

Thigh Strains - Quadriceps Quad contusion

Thigh Strains – Quadriceps Care & Treatment of Quad Strains Immediately application of ice, compression, and elevation Crutches (if necessary) After swelling and inflammation have ended, whirlpool and/or ultrasound may be used Isometric muscle contraction as tolerated, progressing to PRE’s to restore muscle strength Gentle stretching as tolerated Elastic wrapping for support

https://www.youtube.com/watch?v=aFKALofVRpg https://www.youtube.com/watch?v=ReYVJ_k7j2Q https://www.youtube.com/watch?v=6-5Ay-Z4Wsw

Thigh Strains - Hamstring Hamstring strains Hamstrings are the muscles most likely to be injured in the thigh Mechanism of Injury The exact cause of hamstring strains is unknown It is believed that it most often has to do with a quick change in the functions of the muscle from that of a knee stabilizer to a hip flexor This thought stems from the fact that most hamstring injuries are the result of “explosive starts” Hamstrings should be 60-70% as strong as the quadriceps muscles A greater difference may also play a role in causing hamstring injury

Thigh Strains - Hamstring Hamstring strains As with the quads, strains about the hamstring can occur in the belly of the muscle or more distally towards the muscle attachments or muscle-tendon junctions The extent of the injury can very from a simple tearing of a few muscle fibers to a complete rupture of the muscle or tendons General signs and symptoms include… Bleeding or bruising Pain and point tenderness Immediate loss of function All of these will vary depending on severity

Thigh Strains - Hamstring

Thigh strains – hamstring Degrees of hamstring strains 1st Degree Muscle soreness with movement Point tenderness Sometimes difficult to detect because symptoms often do not appear until well after the athlete has cooled down 2nd Degree Partial tearing of the muscle fibers Identified by a sudden snap or tear accompanied by severe pain and loss of strength with knee flexion 3rd Degree A complete rupture of the tendon or muscle Major disability and bleeding

Thigh strains - hamstring Care and Treatment by the ATC… Immediate application of ice, compression, and elevation Decreased or stopped activity until soreness subsides NO ballistic stretching or explosive sprinting Whirlpools, ultrasound, e-stim, massage, etc, after inflammation and bleeding have subsided Gentle stretching, either passive or active Isometric muscle exercise progressing to PRE’s as tolerated Gradual return to activity with jogging, etc. Elastic wrapping for support

Thigh strains - hamstring Remember… Hamstring strains often recur in athletes Care must be taken in instructing the athlete about daily warm-ups and stretching to prevent recurring injury The psychological factors of this injury must also be considered by the ATC Often athletes who suffer hamstring strains develop concerns and “worries” about re-injury which may affect their future performance

Hip sprains/strains Mechanism of Injury Usually seen as a result of a violent twisting of the hip Involves the various ligaments that hold the hip in place Professional athletes with this injury: Derek Jeter, Kobe Bryant, Greg Norman

Hip Sprains/Strains S/S Management Pain Swelling Decrease ROM Ecchymosis –discoloration Felt/heard pop inability to circumduct the thigh Management RICE Crutches Gentle stretching Physical therapy – for electrical stim, ultrasound, etc Referral to physician if symptoms do not resolve

https://www.youtube.com/watch?v=TLPc1pM9458 https://www.youtube.com/watch?v=nzrHvkiCMeU

Hip strains - groin Mechanism of injury Usually caused by an overstretching of the muscles within the groin area Activities such as running, jumping, and twisting with external rotation can cause these types of injuries Runners, jumpers (soccer, football)

Hip strains - groin These injuries are often some of the most difficult to care for in athletics They can occur suddenly or appear gradually over time Signs & symptoms include… Pain Weakness Popping or snapping felt Decrease in motion – adduction, external rotation Internal hemorrhage (discoloration)

Hip strains - groin Care and treatment by the ATC should include… Ice, compression, elevation, and rest for the first 48-72 hours after the injury is discovered Warm whirlpools, moist heat packs, and/or ultrasound (after initial 2-3 days) Reduced participation until athlete is pain free Rehab should emphasize flexibility with graduated stretching and range of motion exercises Groin should be wrapped for support using a hip spica

Hip strains - groin Special Note… Care should be taken if a distance runner presents in the athletic training room complaining of severe groin pain Pelvic stress fractures often first appear as groin strains and exhibit similar signs and symptoms If there is no logical cause or explanation for their injury and pain, they should be referred to a physician for evaluation

Bursitis Iliopsoas Ischial bursitis Pain medial and anterior to joint; cannot be easily palpated Increase pain with passive hip rotation; resisted hip flexion, abduction, adduction and external rotation Ischial bursitis Pain aggravated by prolonged sitting and uphill running Point tenderness directly over ischial tuberosity Increase pain with passive and resisted hip extension Management: Standard acute; deep friction massage, NSAIDS, stretching program for involved muscles, ongoing prevention, biomechanical analysis

Trochanteric bursitis Relatively common condition involving the greater trochanter of the femur, surrounding muscles, and ligaments Most commonly seen in female runners

Trochanteric bursitis Trochanteric Bursitis, continued… Care and treatment by the ATC should include… Elimination of running on inclined surfaces Correction of leg-length discrepancies and faulty running form Cold packs/ice massage in combination with rest Anti-inflammatory medications with physician approval or direction

Hip Stress fracture MOI Once most commonly affected military personnel who marched and ran all day after day. Now hip stress fx are more common in athletes. Esp distance runners. a) Femoral neck stress fracture primarily in endurance athletes, overuse injury

Hip stress fracture S/S Management: RICE, Referral to Physician Plain radiographs taken early may be negative- Further imaging may be required- (i.e.) MRI/ Bone Scan.  If suspected, keep on crutches nonweight bearing until diagnosis confirmed nondisplaced fracture on the compression (inferior) side consists of non-weightbearing/modified bed rest until the patient is completely pain free displaced fractures and nondisplaced tension  side fractures - ORIF S/S presence with groin or anterior thigh pain, often a deep ache relived with cessation of activity. antalgic gait, painful ROM, especially with internal and external rotation

Fractures - femur Femoral Fractures In athletics, most often occur in the shaft of the femur Usually caused by an outside force like falling from a height, being hit, etc Shock generally accompanies a femur fracture as a result of the extreme pain and bleeding associated with the injury This is a TRUE medical emergency There will usually be deformity and displacement of the bone ends as a result of the quad muscles contracting This can also cause internal lacerations to muscle tissues

Fracture - femur

Fractures - femur Signs and Symptoms of Femoral Fractures include… Deformity with the thigh turned inward Shortening of the thigh Loss of function Severe pain and point tenderness Swelling of the soft tissues

Fractures - femur Care & Treatment by the ATC… Immediate application of manual traction Activation of EMS system Splinting with a TRACTION SPLINT If a traction splint is not available, then manual traction should be maintained until EMS arrives Application of ice to the area of fracture Treatment for shock Monitoring of vital signs

Hip dislocations Mechanism: Rarely seen in athletics When they do occur, it is usually the result of massive traumatic forces along the long axis of the femur Generally hip dislocations occur with the knee in a flexed position Displacement will occur posteriorly with the femoral shaft adducted and in a flexed position This is a very serious injury, requiring emergency care, because of the severe damage that can be caused to surrounding soft tissues in the hip

Hip dislocations Dislocation of the Hip Joint, continued… Bi-lateral hip dislocation with x-ray image

Hip dislocations Managment S/S Intense pain Inability to move hip Immediate request for EMS assistance Monitor vital signs especially distal vascular integrity treat for shock Stabilization of the hip and athlete in the position found. Best way to splint this type of injury is by placing the athlete on a backboard and then stabilizing the hip in the position found with pillows, blankets, etc. S/S Intense pain Inability to move hip

Hip dislocations After reduction the athlete will usually be confined to bed rest for approximately 2 weeks, followed by 1-2 months of assisted ambulation with a crutch or cane Also during this time the athlete will probably receive physical therapy to restore the hip to normal function Complications that can arise from this injury include… Muscle paralysis as a result of damage to various nerves including the sciatic nerve Osteoarthritis in the hip joint

Legg- Calve’-Perthes Disease Legg-Perthes Disease (Coxa Plana) Definition: An avascular necrosis of the femoral head Caused by a loss or disruption of blood flow to femoral head Osteochondrosis of femoral head Occurs more often in boys than in girls and is generally seen between the ages of 3 and 12

Legg-Perthes Disease Management S/S Gradual onset of limp and mild hip or knee pain of several months in duration Pain is activity related Decrease ROM in hip abduction, extension, and external rotation due to spasm in hip flexors and adductors Pain in the groin area, often referred to the abdomen Management Complete bed rest Special bracing to avoid direct weight bearing on the hip Complications related to this condition include… Improper formation of the femur leading to osteoarthritis later in life

http://www.youtube.com/watch?v=BpuMRphcxCo

Avascular Necrosis Avascular Necrosis of the Femoral Head Rarely seen in athletics but can occur as the result of a severe blow to the hip joint Lack of blood flow to the femoral head, causing bone death Most famous case was that of Bo Jackson Usually results in hip replacement surgery

Snapping Hip Snapping Hip Phenomenon Commonly seen among dancers, gymnasts, and hurdlers Caused by habitual movements which cause certain muscles surrounding the hip to become unbalanced in terms of strength Usually occurs when the athlete laterally rotates and flexes the hip

Snapping hip Snapping Hip Phenomenon The athlete will complain of snapping, mainly when balancing on one leg Care and treatment by the ATC should include…. Encouraging the athlete to avoid activities that cause the snapping Stretching Muscle strengthening If there is associated pain, the athlete may need to be referred to a physician for evaluation

Osteitis pubis Osteitis Pubis Most often seen in long distance runners, but can also be seen in football, soccer, and wrestling athletes

Osteitis pubis Osteitis Pubis, continued… Chronic inflammatory condition of the pubic symphysis as a result of muscle pulling and repetitive stress on the bony structures of the pelvis

Osteitis pubis Osteitis Pubis, continued… Signs and symptoms include… Pain in the groin area and over the pubic symphysis Pain with movements such as running, sit-ups, and squats Care and treatment by the ATC includes… Rest and anti-inflammatory medications per physician orders Gradual return to activity as tolerated

Thrombosis Other thigh conditions Thrombosis Blood clot in a vein or artery in the thigh Disrupts blood flow to the leg Needs to be referred to the emergency room or a physician for immediate treatment Signs & Symptoms may include… Swelling Pain Loss of function Loss of sensation

Thrombosis Deep thrombosis to the thigh

Thrombosis of the thigh Other thigh conditions Very similar to compartment syndrome in the lower leg Swelling in the thigh compartment that leads to loss of sensation, loss of blood flow, etc. Signs and Symptoms include thigh swelling, severe pain, loss of function, loss of sensation, etc. This condition needs to be referred to a physician for evaluation and treatment, which may involve surgical intervention

Thigh compartment syndrome

Done with injuries