1. Assessment of the Hip and Pelvis

2. 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?

3. 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

4. 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

5. 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

6. Special Tests Functional Evaluation Tests for Hip Flexor Tightness
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

7. Kendall’s Test

8. Thomas Test

9. Femoral Anteversion (A) and Retroversion (B)
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

10. 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

11. Gaenslen’s Test Test works to push SI joint into extension
Test is positive if hyperextension on affected side increases pain

12. Testing the Tensor Fasciae Latae and Iliotibial Band
Renne’s test
Athlete stands w/ knee bent at degrees
Positive response of TFL tightness occurs when pain is felt at lateral femoral condyle

13. 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

14. Ober’s Test Used to determine presence of contracted TFL or IT-band
Thigh will remain in abducted position, not falling into adduction

15. 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)

16. Piriformis Test Hip is internally rotated
Tightness or pain is indicative of piriformis tightness

17. Measuring Leg Length Discrepancy
Ely’s Test
Used to assess tightness of rectus femoris
Athlete 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 that 1” may produce symptoms
Active individuals may experience problems w/ as little 3mm (1/8”) difference
Can cause cumulative stresses to lower limbs, hips, pelvis or low back

18. Apparent or functional
True or anatomical
Shortening may be equal throughout limb or localized w/in femur or lower leg
Measurement taken from medial malleolus to ASIS
Apparent or functional
Result of lateral pelvic tilt or from a flexion or adduction deformity
Measurement is taken from umbilicus to medial malleolus

19. Leg Length Discrepancy Measures

20. Recognition and Management of Specific Hip, Groin, and Pelvic Injuries
Groin Strain
Etiology
One of the more difficult problems to diagnose
Injury to one of the muscles in the regions (generally adductor longus)
Occurs from running , jumping, twisting w/ hip external rotation or severe stretch
Signs and Symptoms
Sudden twinge or tearing during active movement
Produce pain, weakness, and internal hemorrhaging

21. 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

22. 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

23. 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 and Q-angle
Runners should avoid inclined surfaces

24. 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 & S to stress fracture
Pain in hip region, w/ hip rotation increasing pain

25. 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 PRE are delayed until hip is pain free

26. Dislocated Hip Etiology Signs and Symptoms Management
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

27. Avascular Necrosis Etiology Signs and Symptoms
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

28. 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

29. Hip Problems in the Young Athlete
Legg Calve’-Perthes Disease (Coxa Plana)
Etiology
Avascular necrosis of the femoral head in child ages 4-10
Trauma accounts for 25% of cases
Articular cartilage becomes necrotic and flattens
Signs and Symptoms
Pain in groin that can be referred to the abdomen or knee
Limping is also typical
Varying onsets and may exhibit limited ROM

30. Legg-Calve’-Perthes Disease (continued)
Management
Bed rest to alleviate synovitis
Brace to avoid direct weight bearing
With early treatment and the head may re-ossify and revascularize
Complication
If not treated early, will result in ill-shaping and develop into osteoarthritis in later life

31. 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

32. Signs and Symptoms Management
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

33. The Snapping Hip Phenomenon
Etiology
Common in young female dancers, gymnasts, hurdlers
Habitual movement predispose muscles around hip to become imbalanced (lateral rotation and flexion)
Related to structurally narrow pelvis, increased hip abduction and limited lateral rotation
Hip stability is compromised
Signs and Symptoms
Pain w/ balancing on one leg, possible inflammation
Management
Focus on cryotherapy and ultrasound to stretch musculature and strengthen weak musculature in hip region

34. Pelvic Conditions
Athletes can suffer serious, acute and chronic injuries to the pelvic region
Pelvis rotates along longitudinal axis when running, proportionate to the amount of arm swing
Also tilts as legs engage support and nonsupport
Combination of motion causes shearing and changes in lordosis throughout activity

35. 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, and transitory paralysis of soft structures
Decreased rotation of trunk or thigh/hip flexion due to pain
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

36. Osteitis Pubis Etiology Signs and Symptoms Management
Seen in distance runners
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

37. Athletic Pubalgia Etiology Signs and Symptoms
Chronic pubic region pain caused by repetitive stress to pubic symphysis from kicking, twisting, or cutting
Forced adduction, from hyperextended position, creates shearing forces that are transmitted through pubic symphysis to insertion of rectus abdominus, hip adductors and conjoined tendon
Result in microtears of tranversalis abdominis fascia, aponeurosis of obliques, or conjoined tightness
Create weakening of anterior wall and inguinal canal
Signs and Symptoms
No presence of hernia
Chronic pain during exertion, sharp and burning that laterally radiates into adductors and testicles

38. 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

39. Stress Fractures Etiology Signs and Symptoms
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 or competitive racing

40. 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

41. Avulsion Fractures and Apophysitis
Etiology
Traction epiphysis (bone outgrowth)
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

42. Avulsion Fractures and Apophysitis
Management
X-ray
If uncomplicated, RICE, NSAID’s, crutch toe-touch walking
After control pain and inflammation, 2-3 weeks of gradual stretching
When 80 degrees of ROM have been regained a PRE program should be instituted.
With full return of ROM and strength athlete can return to play