The Thigh, Hip, Groin, and Pelvis © 2007 McGraw-Hill Higher Education. All rights reserved.

Anatomy:

Assessment of the Thigh History Onset (sudden or slow?) Previous history? Mechanism of injury? Pain description, intensity, quality, duration, type and location? Observation Postural symmetry? Size, deformity, swelling, discoloration? Skin color and texture? Is athlete in obvious pain? Is the athlete willing to move the thigh?

Palpation Soft tissue of the thigh (anterior, posterior, medial, lateral) should be palpated for pain and tenderness Bony palpation should also be performed to locate areas of pain/discomfort Utilize palpation to assess body symmetry (compare bilaterally)

Special Tests Thomas test Straight Leg Raise Test for hip contractures -Permanent fixation of the hip in primary positions, with limited passive or active motion at the hip joint. Locomotion is difficult and pain is sometimes present when the hip is in motion. It may be caused by trauma, infection, or poliomyelitis.  Straight Leg Raise Test for hip extensor tightness Can also be used to assess low back or SI joint dysfunction

Prevention of Thigh Injuries Thigh must have maximum strength, endurance, and extensibility to withstand strain Dynamic stretching programs may aid in muscle preparation for activity Strengthen programs can also help in preventing injuries Squats, lunges, leg press Core strengthening

Recognition and Management of Thigh Injuries Quadriceps Contusions Cause of Injury Direct blow to the Thigh Constantly exposed to traumatic blows Signs of Injury Pain, transitory loss of function, immediate bleeding of affected muscles Ecchymosis Swelling Palpable knot Early detection and avoidance of internal bleeding are vital – increases recovery rate and prevents muscle scarring

Care RICE and NSAID’s Crutches for more severe cases Isometric quadriceps contractions should begin as soon as tolerated Ice on a stretch Padding, heat, massage and ultrasound to prevent myositis ossificans Padding may be worn for additional protection upon return to play

Myositis Ossificans Cause of Injury Signs of Injury Care Formation of ectopic bone following repeated blunt trauma Signs of Injury X-ray shows calcium deposit 2-6 weeks following injury Pain, weakness, swelling, decreased ROM Tissue tension and point tenderness Care 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) If condition is recurrent it may indicate problem with blood clotting

Quadriceps Muscle Strain Cause of Injury Sudden stretch when athlete falls on bent knee or experiences sudden contraction Associated with weakened or over constricted muscle Signs of Injury Superficial tear causes fewer symptoms than deeper tear Pain, point tenderness, spasm, loss of function and little discoloration Complete tear may leave athlete w/ little disability and discomfort but with some deformity Palpable divot or lump/‘ball of muscle’ Care Rest, ice and compression to control internal bleeding Determine extent of injury early Neoprene sleeve may provide some added support

Hamstring Muscle Strains Cause of Injury 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, etc Signs of Injury Muscle belly or point of attachment pain Hemorrhage, pain, loss of function and possible discoloration Grade 1 - soreness during movement and point tenderness Grade 2 - partial tear, identified by sharp snap or tear, severe pain, and loss of function

Signs of Injury (continued) Grade 3 - Rupturing of tendinous or muscular tissue, involving major hemorrhage and disability, edema, loss of function, ecchymosis, palpable mass or gap Care RICE Rehab Restrict activity until soreness has subsided Ballistic stretching and explosive sprinting should be avoided Lengthy return to play 6-8 weeks

Acute Femoral Fractures Cause of Injury Generally involving shaft and requiring great force Occurs in middle third due to structure and point of contact Signs of Injury Shock, pain, swelling, deformity Must be aware of bone displacement and gross deformity Loss of function Care Treat for shock, verify neurovascular status, splint before moving, reduce following X-ray Secure immediate emergency assistance and medical referral

Femoral Stress Fractures Cause of Injury Overuse Females who are amenorrheic are more vulnerable to stress fx Signs of Injury Persistent pain in thigh X-ray or bone scan will reveal fracture Commonly seen in the femoral neck Management Analgesics, NSAID’s RICE ROM exercises are carried out w/ pain free ROM Rest, limited weight bearing 4-6 respectively

Recognition and Management of Specific Hip, Groin, and Pelvic Injuries Groin Strain Cause of Injury One of the more difficult problems to diagnose Often seen early in the season due to poor strength and flexibility Occurs from running , jumping, twisting w/ hip external rotation or severe stretch Signs of Injury Sudden twinge or tearing during active movement Produce pain, weakness, and internal hemorrhaging Point tenderness

Groin Strain (continued) Care RICE, NSAID’s and analgesics for 48-72 hours Determine exact muscle or muscles involved Rest is critical Restore normal ROM and strength -- provide support w/ wrap Refer to physician if severe groin pain is experienced

Sprains of the Hip Joint Cause of Injury Result of violent twist due to forceful contact Force from opponent/object or trunk forced over planted foot in opposite direction Signs of Injury Signs of acute injury and inability to circumduct hip Pain in hip region, w/ hip rotation increasing pain Care 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 PRE are delayed until hip is pain free

Piriformis Syndrome Cause of Condition Signs of Injury Care Compression of sciatic nerve; irritation due to tightness or spasm of muscle May mimic sciatica Signs of Injury Pain, numbness and tingling in butt – may extend below knee and into foot Pain may increase following periods of sitting, climbing stairs, walking or running Care Stretching and massage NSAID’s may be prescribed Cessation of aggravating activities will be prescribed Corticosteroid injection may also be suggested Surgery is sometimes an option as well

Dislocated Hip Cause of Injury Signs of Injury Care Rarely occurs in sport Result of traumatic force directed along the long axis of the femur Signs of Injury Flexed, adducted and internally rotated hip Palpation reveals displaced femoral head, posteriorly Serious pathology Soft tissue, neurological damage and possible fx Care 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

Hip Problems in Adolescent Athletes Legg Calve’-Perthes Disease (Coxa Plana) Cause of Condition Avascular necrosis of the femoral head in child ages 4-10 Articular cartilage becomes necrotic and flattens Signs of Condition Pain in groin that can be referred to the abdomen or knee Limping is also typical Varying onsets and may exhibit limited ROM

Legg-Calve’-Perthes Disease Care Bed rest to reduce chance of chronic condition Brace to avoid direct weight bearing Early treatment and head may re-ossify and re-vascularize Complication If not treated early, will result in ill-shaping and osteoarthritis in later life

Slipped Capital Femoral Epiphysis Cause of Condition May be growth hormone related 25% of cases are seen in both hips Epiphysis slips from femoral head in backwards direction due to weakness in growth plate May occur during periods of elevated growth Signs of Condition 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

Iliac Crest Contusion (hip pointer) Cause of Injury Contusion of iliac crest or abdominal musculature Result of direct blow Signs of Injury Pain, spasm, and transitory paralysis of soft structures Decreased rotation of trunk or thigh/hip flexion due to pain Care RICE for at least 48 hours, NSAID’s, Bed rest 1-2 days in severe cases Referral must be made, X-ray Padding should be used upon return to minimize chance of added injury

Osteitis Pubis Cause of Injury Signs of Injury Management Seen in distance runners Repetitive stress on pubic symphysis and adjacent muscles Signs of Injury Chronic pain and inflammation of groin Point tenderness on pubic tubercle Pain w/ running, sit-ups and squats Management Rest, NSAID’s and gradual return to activity

Acute Fracture of Pelvis Cause of Injury Signs of Injury Care Result of direct blow or blunt trauma Signs of Injury Severe pain, loss of function, shock Care Immediately treat for shock Refer to physician Seriousness of injury dependent on extent of shock and possibility of internal injury

Stress Fractures Cause of injury Signs of Injury Care Repetitive abnormal overused forces Signs of Injury Groin pain, w/ aching sensation in thigh that increases w/ activity and decreases w/ rest Discomfort increases with activity and subsides during rest Care Refer to physician for assessment and X-ray Rest for 2-5 months

Avulsion Fractures Cause of Injury Signs of Injury Care Avulsions seen in sports w/ sudden accelerations and decelerations Pulling of tendon away and off of bony insertion Common sites include ASIS (sartorius), AIIS (rectus femoris attachment), ischial tuberosity (hamstring Signs of Injury Sudden localized pain w/ limited movement Pain, swelling, point tenderness Care Rest, limited activity and graduated exercise

Pelvic Avulsion Fracture