1. Chapter 17: The Thigh, Hip, Groin, and Pelvis

2. Anatomy of the Pelvis, Thigh, and Hip

9. 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?

10. 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

11. Special Tests Thomas test Straight Leg Raise Test for hip contractures
Test for hip extensor tightness
Can also be used to assess low back, SI joint dysfunction, sciatic nerve pain

12. 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

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

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

15. 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

17. 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
Peripheral 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
Care
Rest, ice and compression to control internal bleeding
Determine extent of injury early
Neoprene sleeve may provide some added support

18. 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,
Signs of Injury
Muscle belly or point of attachment pain
Capillary 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

19. 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
Restrict activity until soreness has subsided
Ballistic stretching and explosive sprinting should be avoided initially

20. Femoral Fractures Cause of Injury Signs of Injury Care
More common in auto accidents; less common in sports
Involves significant 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

21. 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 in early part of 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

22. Groin Strain 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

23. 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

24. Dislocated Hip Cause of Injury Signs of Injury 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

25. Dislocated Hip
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

26. Hip Labral Tears Cause of Condition Signs of Injury Care
Result of repetitive overuse (i.e. running or pivoting)
May occur due to acute trauma (i.e. dislocation)
Signs of Injury
Often present as asymptomatic
Causes clicking, locking, or catching
Pain in the groin; stiffness; limited motion
Care
Exercises to maintain ROM, strength & stability
Avoid aggravating activities
NSAID’s, corticosteroids
Surgical repair

27. Piriformis Syndrome Cause of Condition Signs of Injury
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

28. 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

29. 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

31. Legg-Calve’-Perthes Disease (continued)
Care
Bed rest to reduce chance of chronic condition
Brace to avoid direct weight bearing
Early treatment and head may reossify and revascularize
Complication
If not treated early, will result in ill-shaping and osteoarthritis in later life

32. 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

33. Slipped Capital Femoral Epiphysis
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

34. 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

35. 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

36. Acute Fracture of Pelvis
Cause of Injury
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

37. 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

38. 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