1. Chapter 21: The Thigh, Hip, Groin, and Pelvis
Jennifer Doherty-Restrepo, MS, LAT, ATC
Academic Program Director, Entry-Level ATEP
Florida International University
Acute Care and Injury Prevention

2. Anatomy of the Thigh
Review

5. Nerve and Blood Supply Tibial and common peroneal nerves
Arise from the sacral plexus to form the largest nerve in the body, the sciatic nerve
The main arteries of the thigh include:
Deep circumflex, deep femoral, and femoral
The two main veins of the thigh include:
Great saphenous and femoral

6. Muscles Fascia lata femoris IT-band
Deep fascia that surrounds thigh musculature
Thick anteriorly, laterally, and posteriorly
Thin on the medial side
IT-band
Attachment site for the tensor fascia lata and gluteus maximum

7. 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

8. 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

9. Assessment of the Thigh
History
Onset (sudden or slow?)
Previous history?
Mechanism of injury?
Pain description, intensity, quality, duration, type, and location?
Observation
Symmetry?
Size, deformity, swelling, discoloration?
Skin color and texture?
Is the athlete in obvious pain?
Is the athlete willing to move the thigh?

10. Palpation: Bony Tissue
Medial and lateral femoral condyles
Greater trochanter
Lesser trochanter
Anterior superior iliac spine (ASIS)

11. Palpation: Soft Tissue
Sartorius
Rectus femoris
Vastus lateralis
Vastus medialis
Vastus intermedius
Semimembranosus
Semitendinosus
Biceps femoris
Adductor brevis, longus, and magnus
Gracilis
Sartorius
Pectineus
Iliotibial Band (IT-band)
Gluteus medius
Tensor fasciae latae

12. Special Tests Not performed if a fracture is suspected!!!
Passive knee flexion
Normal = full, pain-free ROM
Injury = swelling or spasm restricting ROM
Active knee extension
Muscle strain = strong and painful ROM
3rd degree strain or partial rupture = weak and pain free ROM
Resistive knee extension
Nerve injury = muscle weakness against an isometric resistance

13. Prevention of Thigh Injuries
Maximum strength
Endurance
Flexibility
In collision sports, thigh guards are mandatory to prevent injuries

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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

23. 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

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

31. 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

32. 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?

33. 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

34. Palpation: Bony Tissue
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 (PIIS)

35. 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, and lymph nodes

36. Special Tests Functional Evaluation PROM, AROM, RROM
Hip adduction and abduction
Hip flexion and extension
Hip internal and external rotation

37. Special Tests: Hip Flexor Tightness
Kendall test
Test for rectus femoris tightness

38. Special Tests: Hip Flexor Tightness
Thomas test
Test for hip contractures

39. Special Tests: 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

40. Special Tests: Hip and Sacroiliac Joint
Gaenslen’s Test
Test forces SI joint into extension
Hyperextension on the affected side increases pain

41. Special Tests: Tensor Fasciae Latae and Iliotibial Band
Renne’s test
Athlete stands with knee bent at degrees
Pain at lateral femoral condyle indicates tensor fasciae latae tightness

42. Special Tests: Tensor Fasciae Latae and Iliotibial Band
Nobel’s Test
Lying supine, knee is flexed to 90 degrees
Pressure is applied to lateral femoral condyle while knee is extended
Pain at 30 degrees of knee flexion in the area of the lateral femoral condyle indicates IT band irritation

43. Special Tests: Tensor Fasciae Latae and Iliotibial Band
Ober’s Test
Used to determine presence of contracted TFL or IT-band
Thigh will remain in abducted position

44. Special Tests: Tensor Fasciae Latae and Iliotibial Band
Trendelenburg’s Test
Stand on one leg and compare level of PSIS and iliac crests bilaterally
Test is positive when affected side is higher
Indicates weak hip abductors (gluteus medius)

45. Special Tests: Piriformis
Piriformis Test
Hip is internally rotated
Tightness or pain is indicative of piriformis tightness

46. 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

47. Leg Length Discrepancy Measures

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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

60. 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

61. 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

62. 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

63. 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

64. 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

65. 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

66. Pelvic Injuries Osteitis Pubis Etiology Signs and Symptoms Management
Often seen in distance runners
MOI = repetitive stress
Signs and Symptoms
Chronic pain and inflammation of groin
Point tenderness on pubic tubercle
Pain with running, sit-ups, and squats
Management
Rest, NSAID’s, and gradual return to activity

67. Pelvic Injuries Athletic Pubalgia Etiology Signs and Symptoms
Chronic pubic region pain
MOI = repetitive stress to pubic symphysis from kicking, twisting, or cutting
Signs and Symptoms
No presence of hernia
Chronic pain during exertion
Sharp and burning pain that radiates into adductors and testicles

68. Pelvic Injuries Athletic Pubalgia (continued)
Signs and Symptoms (continued)
Point tenderness on pubic tubercle
Increased pain with resisted hip flexion, internal rotation, abdominal contraction, and hip adduction
Management
Conservative treatment (rarely effective): rest, ROM exercises, and PRE exercises
Aggressive treatment: cortisone injection or surgical tightening of pelvic wall

69. 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

70. 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

71. 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

72. 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

73. Rehabilitation Techniques
General Body Conditioning
Must maintain cardiovascular fitness, muscle endurance, and strength of total body
Avoid weight bearing activities if painful
Flexibility
Regaining pain free ROM is a primary concern
Progress from passive to PNF stretching

75. Rehabilitation Techniques
Strength
Progression from isometric exercises to isotonic strengthening PREs
Isokinetic exercises may be utilized
PNF strengthening could be incorporated to enhance functional activity
Active exercise should occur in pain free ranges
Avoid re-aggravating the injury
Exercises for the core must also be included
Develop functional strength and dynamic stabilization

78. Rehabilitation Techniques
Neuromuscular Control
Established through postural alignment and stability strength
As neuromuscular control is enhanced, the ability of the kinetic chain to maintain appropriate forces and dynamic stabilization increases
Focus on balance and closed kinetic chain activities

80. Functional Progression and Return to Activity
Begin in pool, non-weight bearing
Progression of walking, to jogging, to running, and to more difficult agility tasks
Before returning to play, athlete should demonstrate pain free function, full ROM, strength, balance, and agility