1. Chapter 14 Injuries to the Hip and Pelvis

2. Hip Motions Ball-and-socket joint Allows for a wide range of motions Musculature surrounding joint aids in stability Hip motions Flexion (0 – 120°) Extension (0 – 20°) Internal rotation (0 – 40°) External rotation (0 – 50°) Abduction (0 – 50°) Adduction (0 – 25°) Cicrumduction

3. Major Bones of the Hip

4. More Bones

5. Anatomy Review Functions of the pelvis include: Attachment of lower extremities. Protection of internal organs. Muscle attachments. Birth process, in females. Joints Femoroacetabular (hip joint) Femur inserts/articulates into/with the acetabulum Sacroiliac Pubic symphysis

6. Anatomy Review Primary hip structures Femur Pelvic bones Ilium Ischium Pubis Sacrum Coccyx

7. Nervous System Major Nerves Femoral Sciatic

9. Hip Flexion Rectus femoris, iliopsoas (made up of the psoas major and iliacus), sartorius These are the major contributors Adductor longus, adductor brevis, pectineus, gracilis, tensor fascia latae These are considered assistors Flexion (0 - 120°)

11. Hip Extension Hamstring muscles Biceps femoris, semitendinosus, semimembranosus Gluteus maximus These are muscles located on the posterior thigh Most of these muscles originate in or around the ischial tuberosity Extension (0 – 20°)

12. Abduction Gluteus maximus, gluteus minimus, gluteus medius, tensor fascia latae The 3 gluteus muscles make up the muscle group known as the gluteals These muscles can be located both posteriorly and laterally Abduction (0 – 50°)

14. Adduction Adductors Adductor magnus, adductor longus, adductor brevis, gracilis These muscles are located on the medial thigh Adduction (0 – 25°)

15. External Rotators Piriformis, gemellus superior, gemellus inferior, obturator externus, obturator internus, quadratus femoris These muscles are located deep External rotation (0 – 50°)

16. Internal Rotation Gluteus medius, gluteus minimus, tensor fascia latae These are muscles located on the lateral thigh Internal rotation (0 – 40°)

18. Common Sports Injuries Sports-related injuries to the skeletal structures (fractures and dislocations) of the hip and pelvis are not common. Injuries to the soft tissues in the region are more common and can be quite debilitating to the athlete. Sports-related injuries to this area commonly involve collision sports or forceful movements. However, overuse injuries are common especially in endurance athletes.

19. Fractures of the Pelvis Pelvic fractures are not common in sports, because it typically takes a great deal of force to fracture the pelvis. Pelvic fractures are devastating injuries. Pelvic fractures in the adolescent can be serious because of open growth plate. This injury may occur in sports such as hockey, pole-vault, or football. No athlete should return to play after a suspected pelvic fracture until being cleared by a physician.

20. Fractures of the Pelvis Signs and symptoms Abnormal pain, swelling, usually accompanied with visual or palpable deformity in pelvic region. Pain elicited when iliac crests are pressed together. Injury to internal organ(s) may be associated with this injury. First Aid Treat for shock and internal bleeding, monitor vital signs. Arrange for transportation to a medical facility on a spine board, elevated at the feet.

21. Other Fractures Femoral Neck Stress Fracture Commonly occurs in amenorrheic athletes involved in endurance sports. Athlete complains of severe anterior thigh or groin pain and experiences pain when walking. This problem can also be a partial result of poor footwear, hard running surface, too much training, or hip deformities. Referral to physician and 6-8 weeks rest is recommended.

22. Hip Dislocation This serious injury is rare in athletics, but it may occur in contact/collision sports. Injury can occur from a violent collision such as seen in tackle football or ice hockey. Typical mechanism of injury is falling on a flexed knee and hip causing force through femur and posterior dislocation.

23. Hip Dislocation Signs and symptoms Pain and loss of movement in affected leg. Hip is flexed and knee of the involved leg is angled toward the opposite leg. Swelling and deformity that is palpable. First Aid Treat for shock. Immobilize the athlete and contact EMS. Monitor blood flow to the lower leg at all times.

24. Avulsion Factures of the Hip In an avulsion fracture, a bone fragment is torn away with tendon attached. Avulsion fractures of the hip are uncommon but can occur—the ischial tuberosity, AIIS, and pubis are likely sites of this injury. Injury likely to occur while sprinting, landing, or jumping.

25. Avulsion Fractures of the Hip Signs and symptoms Snapping or popping sensation upon injury. Pain and swelling at site of injury. Point tenderness and bruising over injury. Inability or pain using the muscle group involved due to avulsion. First Aid Immediately apply ice and limit athlete’s movements. Crutches may be necessary. Refer to a physician for evaluation.

26. Labral Tears Results from trauma, repetitive excessive hip motions (soccer, hockey, dance), and/or femoroacetabular impingement (FAI). Athletes generally complain of anterior hip or groin pain, and some may indicate buttock or leg pain.

27. Hip Pointer Hip Pointer is a common injury, involving a contusion to the anterior/superior portion of the iliac crest (ASIS). Although extremely painful and debilitating, it does not require immediate medical attention. Signs and symptoms include swelling, pain, and discoloration at injury site. Athlete may walk with slight limp (reduced ROM/weakness). Coughing, sneezing, and laughing may also produce pain at the site of injury.

28. Hip Pointer First Aid Apply ice immediately. Athlete should rest and avoid activities involving lower extremities. In severe cases, crutches may be necessary. Permit limited participation within 1 to 2 weeks. Pad for protection upon return to sport.

29. Muscle Strains Most often complain of hearing or feeling a pop, pain at the site of muscle tear, possible palpable deformity and ecchymosis, weakness and loss of ROM compared bilaterally Most common in the adductor muscles and hamstrings First aid Includes ice and compression Rehab to improve ROM and strength should begin in 24 – 48 to prevent muscle atrophy

30. Trochanteric Bursitis “Snapping Hip Syndrome” A result of either acute trauma to the specific area or repeated microtrauma to the tendon attachments with secondary inflammation of the bursae in the area. Iliotibial band, tensor fascia lata, and the gluteus medius often cause. It is a problem seen most often in middle- aged people, especially runners. Stretching, ice, anti-inflammatories, and rest are first line of treatment.

31. Hernias A protrusion of viscera through abdominal wall. Inguinal hernia is more common in males Femoral hernia is more common in females. Athlete should seek the advice of a physician regarding surgical options. In a sports hernia, the posterior inguinal wall is weakened without protrusion of abdominal contents. No palpable hernia is detected, but athlete complains of pain in groin and lower abdominal areas.

32. Sport Hernias Common in kicking and explosive sports. Deep groin pain that does not have a specific onset (or MOI) and gradually gets worse as the days pass. Rarely heals without surgical intervention.

33. Chronic Hip Ailments Sacroiliac (SI) joint can become completely immobile inflamed from an injury or other problems. Requires specific movement techniques to reset. “Snapping Hip” that doesn’t resolve with conservative treatment and/or pain deep in hip joint should be examined by a physician. Rule out microfractures, hip deformities, and labral tears to femoroacetabular joint (hip joint). These will be addresses conservatively but may need surgical intervention.

34. Injuries to Male Genitalia These injuries are usually transient in nature. Scrotal trauma can cause testicular contusion. Medical Emergency Severe trauma can rupture testicle. Severe trauma can cause testicular torsion. Blood supply is compromised to or from the area, causing swelling to occur in the scrotum. Wearing a protective cup is advised in collision/contact sports.

35. Testicular or Scrotal Contusions Signs and symptoms Extreme pain & point tenderness. Assuming fetal position and grasping testicles. Athlete’s report of a blow to the testicles. First Aid Apply ice, and allow athlete to rest lying down. Transport to medical care facility in cases of excessive swelling or lasting pain.

36. Nerve Problems A common complaint is burning or tingling sensation radiating from the hip to buttocks area and going down the leg. This discomfort often results from sciatic nerve irritation. Treatment Continuing to participate in the activity aggravates the irritation. Refer athlete to a physician. Rest, stretching, and strengthening exercises may be helpful.

37. Piriformis Syndrome 2 major causes – Piriformis muscle becomes inflamed or spasms and compresses the sciatic nerve or an anatomical anomaly occurs and the sciatic nerve splits the piriformis muscle compressing the sciatic nerve. Signs and symptoms include: pain in back and leg, numbness and/or tingling in the buttocks, pain when climbing stairs, walking, or running Can be acute due to direct trauma or spontaneous onset Can be difficult to diagnose; treatments can vary from massage, to rest, to stretching and strengthening

38. Prevention Many hip injuries can be prevented through proper conditioning, stretching, and strengthening of the associated musculature. Rest is also important for the body to repair micro damages incurred by the stresses of training. Protective equipment and proper footwear may also help to prevent injuries from occurring.