Chapter 8 The Pelvis and Thigh

Introduction Pelvic girdle forms structural base of support between lower extremity and trunk Hip articulation – strongest and most stable joint in the body This benefit gained at the expense of ROM

Clinical Anatomy Bones and Bony Landmarks Figures 8-1 and 8-2 Ilium, Ischium Pubis Sacrum Acetabulum Labrum

Clinical Anatomy Bones and Bony Landmarks cont. Femoral head and neck Angle of inclination Head is angled at 125 degrees in frontal plane Angle of torsion Relationship between head and shaft, 15 degrees Figures 8-3, 8-4, 8-5 Greater trochanter Lesser trochanter

Clinical Anatomy Articulations and Ligamentous Support Pubic symphysis Fibrocartilaginous interpubic disc Small degree of spreading, compression and rotation between halves of girdle Sacroiliac joint (SI joint) Very study, limited ROM

Coxofemoral joint (hip joint) Ball-and-socket 3 degrees of freedom Flexion and extension Abduction and adduction Internal and external rotation Rom supported by depth of acetabulum, strength of ligaments, strong muscular support Joint capsule Dense synovial capsule from acetabular rim to distal femoral neck

Iliofemoral ligament (Y ligament of Bigelow) Figure 8-6 AIIS to distal and proximal intertrochanteric line Reinforces anterior jt capsule and limits hyperextension Allows us to stand upright with minimal muscular activity Pubofemoral ligament Also reinforces anterior capsule Pubis ramus to intertrochanteric fossa

Ligamentum teres (ligament of the head of the femur) Conduit for medial and lateral circumflex arteries Little function in stabilizing hip Figure 8-7 Inguinal ligament ASIS to pubic symphysis Serves to contain soft tissues as they course anteriorly from trunk to lower extremity Superior border of femoral triangle

Muscular Anatomy Table 8-1, pages 276-277 Anterior Musculature Quadriceps Iliopsoas group Psoas major, psoas minor, iliacus Primary hip flexors when knee extended Figure 8-8 Medial Musculature Adductor group Gracilis Figure 8-9

Lateral Musculature Gluteus medius Tensor fascia latae Figure 8-10 Trendelenburg’s gait pattern Intrinsic muscles form cuff around femoral head and externally rotate hip Piriformis, quadratus femoris, obturator internus, obturator externus, gemellus superior, gemellus inferior Figure 8-11

Posterior Musculature Gluteus maximus hamstrings

Femoral Triangle Figure 8-12 Formed by: Landmark for: Inguinal ligament (superiorly) Sartorius (laterally) Adductor longus (medially) Landmark for: Femoral nerve, artery and vein Femoral pulse Lymph nodes

Bursae 3 bursa to decrease friction between gluteus maximus and adjacent bony structures Trochanteric bursa Gluteus max – greater trochanter Gluteofemoral bursa Gluteus max – vastus lateralis Ischial bursa Gluteus max – ischial tuberosity

Clinical Evaluation of Pelvis and Thigh May necessitate evaluation of lower extremity, spinal column, and posture Patient preparedness Clinician preparedness Gender issues Evaluation Map Page 280

History Location of symptoms Onset Training techniques Table 8-2, page 281 Onset Training techniques Mechanism of injury Prior medical conditions Legg-Calve-Perthes Disease Slipped capital femoral epiphysis

Inspection Most trauma to area cannot be visualized Inspection of Hip Angulations Angle of inclination Relationship of femoral head and shaft Coxa valga Increase in angle, may lead to genu varum or lateral patella Coxa vara Decrease in angle, may lead to genu valgum or squinting patella Mechanical advantage of glut medius is reduced

Angle of torsion Measured through radiograph Box 8-1 Anteverted hips Increases greater than 15 degrees result in internal femoral rotation, squinting patellae and a toe-in gait Retroverted hips Angle less than 15 degrees, femur externally rotates, resulting in a toe-out position, laterally positioned patellae

Inspection of Medial Structures Inspection of Anterior Structures Adductor group Inspection of Anterior Structures Hip flexors Inspection of Lateral Structures Iliac crest (figure 8-13) Nelaton’s line ASIS to ischial tuberosity Figure 8-14

Inspection of Posterior Structures PSIS Gluteus maximus Hamstring muscle group (figure 8-15) Median sacral crests Inspection of Leg Length Discrepancy

Palpation Refer to list of Clinical Proficiencies Utilize pages 283 - 285

Range of Motion Testing Limited by bony and soft tissue restraints Position of knee Flexed vs. extended Table 8-3, page 286 (Muscle actions) Box 8-2, page 287 (Goniometry)

Active Range of Motion Flexion and Extension Adduction and Abduction Figure 8-17 130-150 degrees (range, knee flexed) Majority occurs during flexion Extending knee limits hip flexion Adduction and Abduction Figure 8-18 Abduction – 45 degrees Adduction – 20-30 degrees

Active Range of Motion Internal and External Rotation Figure 8-19 ER – 40-50 degrees IR – 45 degrees Hip flexed vs. extended

Passive Range of Motion Flexion and Extension Flexion Figure 8-20 End-feel: soft w/knee flexed; firm w/knee extended Thomas Test Box 8-3, page 289 Extension Figure 8-21 End-feel: firm w/knee extended and flexed but due to different structures

Passive Range of Motion Adduction and abduction Figure 8-22 End-feel: firm Adduction – due to tension in lateral structures Abduction – due to tension in medial structures Internal and external rotation Figure 8-23 IR – due to tension in posterior capsule and external hip rotators ER – due to tension in anterior capsule and ligament support Anteverted vs. retroverted hips

Resisted Range of Motion Box 8-4, pages 291-292 Trendelenburg’s Test for Gluteus Medius Weakness Box 8-5, page 293

Ligamentous Testing No specific tests for hip ligaments Dysfunction is determined through passive testing of movement Hyperextension places iliofemoral, pubofemoral, and ischiofemoral ligaments on stretch

Neurologic Testing Complete lower quarter screening should be performed Pathology involving femoral or sciatic nerve Piriformis Syndrome Impingement of sciatic nerve from spasm of piriformis muscle

Pathologies and Related Special Tests Acute Contusions or strains Chronic Improper biomechanics from poor posture, leg length discrepancies, overuse syndromes Injury to hip joint is rare Potential medical emergency

Muscle Strains Table 8-4, page 294 Occur secondary to dynamic overload during eccentric muscle contraction Commonly injured Iliopsoas, quadriceps, adductors, hamstrings Signs and Symptoms

Bursitis Onset related to biomechanical factors, congenital influences, or environmental conditions, such as prolonged periods of sitting Septic infection may be a cause

Bursitis Trochanteric Bursitis Evaluative Findings - Table 8-5, page 295 May result from a single blow or friction from IT band History of training changes or increased Q angle may be predisposing factors “Snapping Hip” syndrome

Bursitis Ischial Bursitis Evaluative Findings - Table 8-6, page 296 Movement of buttocks while patient is weight-bearing in seated position can irritate this bursa Also irritated by prolonged sitting Need to rule out hamstring strain or avulsion of its attachment Doughnut padding may help

Bursitis Iliopsoas Bursitis Associated with rheumatoid arthritis or osteoarthritis of hip Signs and symptoms Pain in anterior hip Palpable mass in groin or inguinal ligament “snapping hip” syndrome Treatment includes strengthening hip rotators

Degenerative Hip Changes Due to age, repetitive trauma, acute trauma, or improper arrangements of hip Degeneration of articular surfaces of femur and acetabulum Arthritis, osteochondritis dissecans, acetabular labrum tears, avascular necrosis Signs and symptoms Pain, referred to low back, anterior thigh, knee Loss of motion in all planes, decrease strength Hip Scouring, Box 8-6, page 297 Radiographic evaluation

Piriformis Syndrome Sciatic nerve passes under or through the piriformis muscle as nerve travels across posterior pelvis Spasm or hypertrophy of muscle places pressure on sciatic nerve Six times more common in women Relatively undefined and confusing Mimics lumbar nerve root impingement and intervertebral disk disease

Piriformis Syndrome Evaluative Findings Table 8-7, page 298 Straight leg raise, passive hip internal rotation resisted external rotation with patient seated, and resisted hip abduction may produce symptoms Figure 8-24 Treatment includes stretching and strengthening or surgical release

On-Field Evaluation of Pelvis and Thigh Injuries Trauma to coxofemoral joint is rare Protection from padding More commonly, strains, contusions, sprains of SI joint Note position of athlete If leg is moving, rule out dislocation Fixed, immobile awkward position may indicate dislocation

On-Field Evaluation of Pelvis and Thigh Injuries After ruling out dislocation or subluxation and femoral fracture – AROM Weight-bearing status Removal from field

Initial Evaluation and Management of On-Field Injuries Iliac Crest Contusion (hip pointer) Evaluative Findings, Table 8-8, page 299 Disproportionate amount of pain, swelling, and loss of function Recognition and immediate management of pain reduces time lost due to injury Treatment Ice, padding, reduced activity, crutches, if necessary

Initial Evaluation and Management of On-Field Injuries Quadriceps Contusion As severity of impact increases, so does the proportion of muscle fiber death Can result in decreased force during knee extension Associated pain and spasm may limit flexion Gross discoloration, painful to touch, intramuscular hematoma gives hardened feel, increase in girth of muscle Overtime, atrophy may occur

First 24 hours following injury are critical Risk of myositis ossificans is increased when effusion of knee joint occurs Figure 8-25 First 24 hours following injury are critical Pain during AROM, or weakness during MMT = removal from activity Ice applied in flexion Maintaining ROM decrease possibility of myositis ossificans formation Figure 8-26

Hip Dislocation Rare Medical emergency Majority involve posterior displacement of femoral head Fractures to femoral neck and acetabulum Most occur when hip is in flexion and adduction and axial force is placed on femur, displacing it posteriorly and causing head to be driven through posterior capsule

Signs and Symptoms Immediate pain within joint and buttocks Sensation of “giving out” Femur and lower leg positioned in internal rotation and adduction Figure 8-27 AROM is impossible No attempt to reduce Sensory and vascular check

Immediate immobilization and transportation to emergency facility Reduction under anesthesia

Femoral Fracture Torsional or shear force to shaft Relatively rare “weak link” principle Immediate loss of function, pain, deformity, easily recognizable Stress fracture Shaft and neck, difficult to diagnosis Similar s/s to hip flexor strain or tendinitis Treatment