1. The Thigh, Hip, Groin, and Pelvis

2. Anatomy of the Thigh
Review

5. Quadriceps Insertion at proximal patella via common tendon
Pre-patellar tendon
Rectus femoris = bi-articulate muscle
Only quad muscle that also crosses the hip
Extends knee and flexes the hip
Important: distinguish between knee extensors and hip flexors
Injury evaluation
Treatment and rehabilitation programs

6. Hamstrings Cross the knee joint posteriorly
All hamstrings, except the short of head of the biceps femoris, are bi-articulate
Crosses the hip joint as well
Forces dependent upon position of both knee and hip
Important: distinguish between knee flexors and hip extensors
Injury evaluation
Treatment and rehabilitation programs

7. Thigh Injuries: Quadriceps Contusions
Etiology
MOI = severe impact, direct blow
Extent (depth) of injury depends upon…
Force
Degree of thigh relaxation
Signs and Symptoms
Pain, transitory loss of function, immediate effusion (palpable)
Graded = superficial to deep
Increased loss of function 1 - 4
Decreased ROM 1 - 4
Decreased strength 1 - 4

8. Thigh Injuries: Quadriceps Contusions
Management
RICE
NSAID’s and analgesics
Crutches, if indicated
Aspiration of hematoma
Ice post exercise or re-injury
Follow-up care
ROM exercises
PRE in pain-free ROM
Modalities
Heat
Massage
Ultrasound to prevent myositis ossificans

9. Thigh Injuries: Myositis Ossificans Traumatica
Etiology
Formation of ectopic bone
MOI = repeated blunt trauma
May be the result of improper thigh contusion treatment (too aggressive)
Signs and Symptoms
X-ray shows Ca++ deposit weeks post injury
Pain, weakness, swelling, tissue tension, point tenderness, and decreased ROM
Management
Treatment must be conservative
May require surgical removal

10. Thigh Injuries: Quadriceps Muscle Strain
Etiology
MOI = over-stretching or too forceful contraction
Signs and Symptoms
Pain, point tenderness, spasm, loss of function, and ecchymosis
Superficial strain results in fewer S&S than deeper strain
Complete tear results in deformity
Athlete displays little disability and discomfort

11. Thigh Injuries: Quadriceps Muscle Strain
Management
RICE
NSAID’s and analgesics
Manage swelling
Compression, crutches
Stretching
PRE strengthening exercises
Neoprene sleeve for added support

12. Thigh Injuries: Hamstring Muscle Strains
Etiology: multiple theories of injury
Hamstrings and quadriceps contract together
Change from hip extender to knee flexor
Fatigue
Posture
Leg length discrepancy
Lack of flexibility
Strength imbalances

13. Thigh Injuries: Hamstring Muscle Strains
Signs and Symptoms
Pain in muscle belly or point of attachment
Capillary hemorrhage
Ecchymosis
Grade 1
Pain with movement
Point tenderness
<20% of fibers torn
Grade 2
Partial tear
<70% of fibers torn
Sharp snap or tear
Severe pain
Loss of function
Grade 3
Rupture of tendinous or muscular tissue
>70% muscle fiber tearing
Severe hemorrhage
Disability
Edema
Ecchymosis
Palpable mass or gap

14. Thigh Injuries: Hamstring Muscle Strains
Management
RICE,
NSAID’s and analgesics
Modalities
PRE exercises
When soreness is eliminated, focus on eccentrics strengthening
Recovery may require months to a full year
Scaring increases risk of injury recurrence of
Grade I
Do not resume full activity until complete function restored
Grade 2 and 3
Should treat conservatively
Gradual return to stretching and strengthening in later stages of healing

15. Thigh Injuries: Acute Femoral Fractures
Etiology
Fracture in middle third of femoral shaft
MOI = great deal of force
Signs and Symptoms
Pain, swelling, deformity, muscle guarding
Leg with fx positioned in hip adduction and ER
Leg with fx may appear shorter
Management
Medical emergency!
Treat for shock, splint, refer
Analgesics and ice

16. Thigh Injuries: Femoral Stress Fractures
Etiology
Overuse (10-25% of all stress fractures)
MOI = excessive downhill running or jumping
Often seen in endurance athletes
Signs and Symptoms
Persistent pain in thigh/groin region
X-ray or bone scan will reveal fracture
Positive Trendelenburg’s sign
Management
Prognosis will vary depending on location
Fx in shaft and medial to femoral neck heal well with conservative management
Fx lateral to femoral neck are more complicated

17. Anatomy of the Hip, Groin, and Pelvic Region
Review

24. Functional Anatomy Hip Joint Pelvis True ball and socket joint
Intrinsic stability
Moves in all three planes, particularly during gait
Pelvis
Moves in all three planes
Anterior tilting
Changes degree of lumbar lordosis
Lateral tilting
Changes degree of hip abduction

25. Assessment of the Hip and Pelvis
Injuries to the hip or pelvis cause major disability in the lower limbs, trunk, or both
Low back may also become involved
History
Onset (sudden or slow?)
Previous history?
Mechanism of injury?
Pain description, intensity, quality, duration, type, and location?

26. Assessment of the Hip and Pelvis
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 to one side
Ambulation

27. Special Tests: Leg Length Discrepancy
True or anatomical
Shortening may be equal throughout limb or localized in femur or lower leg
Measure from ASIS to medial malleolus
Apparent or functional
May result due to lateral pelvic tilt, flexion, or adduction deformity
Measure from umbilicus to medial malleolus

28. Leg Length Discrepancy Measures

29. Hip and Groin Injuries Groin Strain Etiology Signs and Symptoms
Injury usually occurs to the adductor longus
MOI = running, jumping, or twisting with hip external rotation; over-stretching; or too forceful contraction
Signs and Symptoms
Sudden twinge or tearing during movement
Pain, weakness, and internal hemorrhaging

30. Hip and Groin Injuries Groin Strain (continued) Management RICE
NSAID’s and analgesics
Rest is critical
Modalities
Daily whirlpool and cryotherapy
Ultrasound
Delay exercise until pain free
Restore normal ROM and strength
Provide support with elastic wrap

31. Hip and Groin Injuries Trochanteric Bursitis Etiology
Inflammation of bursa at greater trochanter
Insertion site for gluteus medius and where IT-band passes over the greater trochanter
Signs and Symptoms
Lateral hip pain that may radiate down the leg
Point tenderness over greater trochanter
IT-band and TFL tests should be performed

32. Hip and Groin Injuries Trochanteric Bursitis (continued Management
RICE
NSAID’s and analgesics
ROM and PRE exercises for hip abductors and external rotators
Phonophoresis
Evaluate biomechanics and Q-angle
Runners should avoid inclined surfaces

33. Hip and Groin Injuries Sprains of the Hip Joint Etiology
Unusual movement exceeding normal ROM
MOI = force from opponent/object, or, trunk forced over planted foot in opposite direction
Signs and Symptoms
Pain, which increases with hip rotation
Inability to circumduct hip
Similar S&S to stress fracture

34. Hip and Groin Injuries Sprains of the Hip Joint (continued) Management
RICE
NSAID’s and analgesics
Depending on severity, crutches may be required
ROM and PRE are delayed until hip is pain-free
X-rays or MRI should be performed to rule out a possible fracture

35. Hip and Groin Injuries Dislocated Hip Etiology Signs and Symptoms
Result of traumatic force directed along the long axis of the femur
Posterior dislocation more common
Hip flexed, adducted, and internally rotated
Knee flexed
Rarely occurs in sport
Signs and Symptoms
Flexed, adducted, and internally rotated hip
Palpation reveals displaced femoral head
Medical emergency
Compications include soft tissue damage, neurological damage, and possible fracture

36. Hip and Groin Injuries Dislocated Hip (continued) Management
Immediate medical care
Blood and nerve supply may be compromised
Contractures may further complicate reduction
2 weeks immobilization
Crutch use for at least one month

37. Hip and Groin Injuries Avascular Necrosis Etiology Signs and Symptoms
Temporary or permanent loss of blood supply to the proximal femur
MOI = traumatic conditions (ie: hip dislocation) or non-traumatic conditions (ie: steroids, blood coagulation disorders)
Signs and Symptoms
Possibly no S&S in early stages
Develop over the course of months to a year
Joint pain with weight bearing, progressing to pain at rest
Limited ROM
Osteoarthritis may develop

38. Hip and Groin Injuries Avascular Necrosis (continued) Management
Must be referred for X-ray, MRI, or CT scan
Most cases will ultimately require surgery
Conservative treatment
Non-weight bearing;ROM exercises; e-stim for bone growth; medication to treat pain
Limit necrosis
Reduce fatty substances, which react with corticosteroids
Limit blood clotting in the presence of clotting disorders

39. Hip Problems in the Young Athlete
Legg Calve’-Perthes Disease (Coxa Plana)
Etiology
Avascular necrosis of the femoral head in child ages 4-10
MOI = trauma (accounts for 25% of cases)
Signs and Symptoms
Pain in groin
Referred pain to the abdomen or knee
Limping
may exhibit limited ROM

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

41. Hip Problems in the Young Athlete
Slipped Capital Femoral Epiphysis
Etiology
Found mostly in tall boys between ages 10-17
May be growth hormone related
MOI = trauma (accounts for 25% of cases)
25% of cases are seen in both hips
Femoral head slippage on X-ray appears in posterior and inferior direction

42. Hip Problems in the Young Athlete
Slipped Capital Femoral Epiphysis (continued)
Signs and Symptoms
Pain in groin that progresses over weeks or months
Hip and knee pain during passive and active motion
Limitations of hip abduction, flexion, and medial rotation
Limp
Management
Minor slippage
Rest and non-weight bearing may prevent further slippage
Major slippage results in displacement
Requires surgery
If condition goes undetected or if surgery fails, severe problems will result

43. Hip Problems in the Young Athlete
The Snapping Hip Phenomenon
Etiology
Common in young female dancers, gymnasts, and hurdlers
MOI = repetitive movement that leads to muscle imbalance
Related to narrow pelvis, increased hip abduction, and limited lateral rotation
Hip stability is compromised

44. Hip Problems in the Young Athlete
The Snapping Hip Phenomenon (continued)
Signs and Symptoms
Pain while balancing on one leg
Possible inflammation
Management
ROM exercises to increase flexibility
Flexion and lateral rotation
Cryotherapy and ultrasound may be utilized
PRE exercises to strengthen weak muscles

45. Pelvic Injuries Contusion (hip pointer) Etiology Signs and Symptoms
Contusion of iliac crest or abdominal musculature
MOI = direct blow
Signs and Symptoms
Pain, spasm, and transitory paralysis
Decreased ROM due to pain
Rotation of trunk, thigh/hip flexion

46. Pelvic Injuries Contusion (hip pointer) continued Management
RICE for at least 48 hours
NSAID’s,
Bed rest days
Referral must be made for X-ray
Modailities
Ice massage, ultrasound, occasionally steroid injection
Recovery lasts weeks

47. Pelvic Injuries Stress Fractures Etiology Signs and Symptoms
Seen in distance runners – more common in women than men
MOI = repetitive cyclical forces from ground reaction forces
Common sites include inferior pubic ramus, femoral neck, and subtrochanteric area of the femur
Signs and Symptoms
Groin pain
Aching sensation in thigh that increases with activity and decreases with rest
Standing on one leg may be impossible
Deep palpation results in point tenderness

48. Pelvic Injuries Stress Fractures (continued) Management
Rest for months
Crutch walking
Especially for ischium and pubis stress fractures
X-rays are usually normal for weeks, therefore a bone scan will be required to detect the stress fracture
Swimming can be used to maintain CV fitness
Breast stroke should be avoided

49. Pelvic Injuries Avulsion Fractures and Apophysitis Etiology
Common sites include ischial tuberosity, AIIS, and ASIS
MOI = sudden accelerations and decelerations
Signs and Symptoms
Sudden localized pain
Limited ROM
Pain, swelling, point tenderness
Muscle testing increases pain

50. Pelvic Injuries Avulsion Fractures and Apophysitis (continued)
Management
X-ray required for diagnosis
RICE, NSAID’s, crutch “toe-touch” walking
ROM exercises
PRE exercises
When 80 degrees of ROM have been regained
Return to play when full ROM and strength are restored

51. Anatomy Review https://www.youtube.com/watch?v=qlCvKEOZtpo
And he’s even southern!!!

52. Greater Trochanter PSIS

53. ASIS Iliac Crest

54. Lumbar Spine Thoracic Spine

55. Ribs Cervical Spine

56. Occipital protuberance

57. Hip Flexion Hip Extension

58. Hip ABD Hip ADD

59. Trunk SB, Flex., Ext

60. Trunk rotation

61. Head and neck rom
Flexion
Extension
Rotation
Lateral Side Bending

62. Special Tests https://www.youtube.com/watch?v=MZuPBL_rTns
Trendelenburg's Test
Steps
Athlete stands with the feet evenly distributed (i.e. approximately shoulder–width apart from each other)
Examiner sits or kneels behind the athlete
Examiner slightly lowers the athlete's shorts so that the examiner may palpate the right & left PSIS and/or iliac crests
Examiner instructs the athlete to flex the hip thereby lifting the right (and then the left knee) while observing the pelvis
Positive Test
The PSIS or iliac crest on the same side as the leg lifted will drop in relation to the contralateral side
Positive Test Implications
Contralateral (i.e., stance leg) gluteus medius weakness

63. https://www.youtube.com/watch?v=vPPp1wEEQFQ Gaenslen's Test Steps
Athlete is supine, lying close to the side of the table
Examiner allows the near leg to hang over the side edge of the table
Examiner instructs the athlete to actively flex the other leg to his/her chest & hold
Examiner stabilizes the athlete & applies pressure to the near leg, forcing it into hyperextension
Positive Test
Pain in the SI region
Positive Test Implications
SI joint dysfunction

64. Babinski Test
Steps
Run metal edge of neurlogic hammer, or fingernail along the tplantar surface of the foot from the calcaneus, along the lateral border of the foot to the forefoot
Positive Test
Great toe extension with flexion and splaying of the lateral four toes
Positive Test Implications
Upper motor neuron lesion

65. Piriformis Tightness Test
Steps
Athlete is side–lying with the test leg being the uppermost leg
Athlete's test leg is flexed at the hip to about 60° & the knee flexed
Examiner stabilizes the hip with one hand & applies a downward pressure to the knee
Positive Test
Piriformis muscle pain; buttock pain; sciatica pain
Positive Test Implications
Piriformis tightness (piriformis muscle pain); piriformis muscle pinching the sciatic nerve (buttock pain and sciatica pain)

66. 90–90 Straight Leg Raising Test
Steps
Athlete lies supine with the hips and knees flexed to 90°
Athlete grasps behind both of his/her thighs to stabilize the hip joints
Athlete actively extends each knee in turn
Positive Test
Unable to extend the knee to within 20° of full knee extension
Positive Test Implications
Hamstring muscle tightness

67. Thomas Test
Steps
Athlete is supine with his/her knees bent at the end of the table
Examiner places one hand between the lumbar lordotic curve & the tabletop
Examiner passively flexes one of the athlete's legs to his/her chest, allowing the knee to flex during the movement
Examiner observes the involved leg for movement
Positive Test
The knee of the leg on the table cannot flex past 90° (i.e. the knee of the leg on the table will extend as the examiner flexes the contralateral hip); the involved leg (i.e. the leg on the table) rises up off the table (i.e. the contralateral hip to the one being moved will flex)
Positive Test Implications
Rectus femoris tightness (the knee extends as the examiner flexes the hip); iliopsoas tightness (the leg on the table will rise off of the table)

68. Pelvis Anatomy