1. Pelvis/hip/thigh injuries

3. Hip Pointers Mechanism – direct blow to the iliac crest
Occurs most often in contact/collision sports like football because of improperly fitting (or absent) hip pads
One of the most handicapping injuries in sports

4. Hip Pointers Signs and symptoms include…
Point tenderness, swelling, ecchymosis
Antalgic gain with shortened swing phase
Immediate pain
Muscle spasms
Transitory paralysis of the soft tissue structures - Athlete may not be able to rotate trunk or flex their thigh without pain

5. Hip Pointers Management/Care and treatment by the ATC
Immediate application of ice and compression (as tolerated by the athlete)
In severe cases, bed rest may be necessary for hours after injury
Referral to a physician if you suspect a fracture
Ice massage and ultrasound after the acute phase
Protective, hard-shell padding upon return to activity in 1-3 weeks

6. Thigh Contusion (Quadriceps)
Mechanism – Direct Blow, usually develop as the result of being hit by someone or something, while thigh muscles were relaxed forcing the soft tissues against the hard surface of the femur – helmets, pads, elbows
The extent of the force and the degree of thigh relaxation usually determines the depth of the injury and amount of structural and functional disruption that occurs

7. Thigh Contusion
Early detection is essential to a quick recovery for the athlete
Signs and Symptoms
weakness with muscle testing
Transitory paralysis or loss of function (dead leg)
A circular, swollen area at the location of the injury with point tenderness
Limited AROM due to pain;

8. Thigh Contusion
Care and treatment for contusions by the ATC includes management in 3 stages…
Stage 1
Application of ice, compression, and elevation
Isometric quad contractions
Crutches for 2nd and 3rd degree cases
Gentle passive stretching w/cold application
Stage 2
Recovery of ROM through the use of warm whirlpool or moist heat packs, ultrasound, ice, and stretching
Stage 3
Recovering full function through PRE’s and gradual return to activity

9. Thigh contusions
Care and rehabilitation of thigh contusions should be handled relatively conservatively
Exercises should not be used if pain is present
Never use deep, penetrating therapies and manual therapies until you are convinced swelling and bleeding have stopped
Once an athlete has suffered an injury like this, care should be taken to insure that the athlete is not re-injured by providing protective padding, etc.

10. Myositis Ossificans What is it : Mechanism of Injury:
An inflammation of muscle leading to bone formation
Mechanism of Injury:
Severe and repeated blows to the same area of the thigh can result in ECTOPIC BONE FORMATION
Usually occurs after bleeding into the quadriceps/thigh and formation of a hematoma (blood tumor)
This causes a disruption in the tissues, which may result in inflammation
This irritation, in turn, cause tissue formation resembling cartilage or bone

11. Myositis Ossificans

12. Myositis Ossificans S/S Warm, firm, swollen thigh; 2-4 cm larger
Hard lump in muscle tissue
Limited ROM - Palpable, painful mass may limit passive knee flexion to 20 – 30 degrees
Previous quadriceps contusion

13. Myositis Ossificans Management
The most common cause of this condition is improper care of a thigh contusion
The following are classic ways in which this condition can be caused or aggravated… or Attempting to “run off” the quad contusion
Management
Limit the swelling and bleeding – compression wrap
Preserve elasticity – gentle stretching
Physical therapy
Donut padding to prevent repeated blows to the area
Referral to physician:
In most cases the bony growth will have to be surgically removed, after which a recovery of up to one year can be expected

14. Myositis Ossificans
Examples of ossified tissues removed from patients suffering from Myositis Ossificans

15. Thigh Strains - Quadriceps
Quadriceps muscle strains
Mechanism of Injury
The quad is often strained with a sudden contraction or stretching of the muscle
A tear of the rectus femoris muscle (the most commonly torn muscle) may cause partial or complete disruption of the muscle fibers
These tears can occur in the belly of the muscle or at the ends of the muscle, most typically towards the distal aspects at the muscle-tendon junction

16. Thigh Strains - Quadriceps
Quadriceps muscle strains
S/S
swelling
Pain when muscle is used or the inability to use the muscle
Bruising
Popping
Indentation in the muscle

17. Thigh Strains - Quadriceps
Quad contusion

18. Thigh Strains – Quadriceps
Care & Treatment of Quad Strains
Immediately application of ice, compression, and elevation
Crutches (if necessary)
After swelling and inflammation have ended, whirlpool and/or ultrasound may be used
Isometric muscle contraction as tolerated, progressing to PRE’s to restore muscle strength
Gentle stretching as tolerated
Elastic wrapping for support

20. Thigh Strains - Hamstring
Hamstring strains
Hamstrings are the muscles most likely to be injured in the thigh
Mechanism of Injury
The exact cause of hamstring strains is unknown
It is believed that it most often has to do with a quick change in the functions of the muscle from that of a knee stabilizer to a hip flexor
This thought stems from the fact that most hamstring injuries are the result of “explosive starts”
Hamstrings should be 60-70% as strong as the quadriceps muscles
A greater difference may also play a role in causing hamstring injury

21. Thigh Strains - Hamstring
Hamstring strains
As with the quads, strains about the hamstring can occur in the belly of the muscle or more distally towards the muscle attachments or muscle-tendon junctions
The extent of the injury can very from a simple tearing of a few muscle fibers to a complete rupture of the muscle or tendons
General signs and symptoms include…
Bleeding or bruising
Pain and point tenderness
Immediate loss of function
All of these will vary depending on severity

22. Thigh Strains - Hamstring

23. Thigh strains – hamstring
Degrees of hamstring strains
1st Degree
Muscle soreness with movement
Point tenderness
Sometimes difficult to detect because symptoms often do not appear until well after the athlete has cooled down
2nd Degree
Partial tearing of the muscle fibers
Identified by a sudden snap or tear accompanied by severe pain and loss of strength with knee flexion
3rd Degree
A complete rupture of the tendon or muscle
Major disability and bleeding

24. Thigh strains - hamstring
Care and Treatment by the ATC…
Immediate application of ice, compression, and elevation
Decreased or stopped activity until soreness subsides
NO ballistic stretching or explosive sprinting
Whirlpools, ultrasound, e-stim, massage, etc, after inflammation and bleeding have subsided
Gentle stretching, either passive or active
Isometric muscle exercise progressing to PRE’s as tolerated
Gradual return to activity with jogging, etc.
Elastic wrapping for support

25. Thigh strains - hamstring
Remember…
Hamstring strains often recur in athletes
Care must be taken in instructing the athlete about daily warm-ups and stretching to prevent recurring injury
The psychological factors of this injury must also be considered by the ATC
Often athletes who suffer hamstring strains develop concerns and “worries” about re-injury which may affect their future performance

26. Hip sprains/strains Mechanism of Injury
Usually seen as a result of a violent twisting of the hip
Involves the various ligaments that hold the hip in place
Professional athletes with this injury:
Derek Jeter, Kobe Bryant, Greg Norman

27. Hip Sprains/Strains S/S Management Pain Swelling Decrease ROM
Ecchymosis –discoloration
Felt/heard pop
inability to circumduct the thigh
Management
RICE
Crutches
Gentle stretching
Physical therapy – for electrical stim, ultrasound, etc
Referral to physician if symptoms do not resolve

29. Hip strains - groin Mechanism of injury
Usually caused by an overstretching of the muscles within the groin area
Activities such as running, jumping, and twisting with external rotation can cause these types of injuries
Runners, jumpers (soccer, football)

30. Hip strains - groin
These injuries are often some of the most difficult to care for in athletics
They can occur suddenly or appear gradually over time
Signs & symptoms include…
Pain
Weakness
Popping or snapping felt
Decrease in motion – adduction, external rotation
Internal hemorrhage (discoloration)

31. Hip strains - groin Care and treatment by the ATC should include…
Ice, compression, elevation, and rest for the first hours after the injury is discovered
Warm whirlpools, moist heat packs, and/or ultrasound (after initial 2-3 days)
Reduced participation until athlete is pain free
Rehab should emphasize flexibility with graduated stretching and range of motion exercises
Groin should be wrapped for support using a hip spica

32. Hip strains - groin Special Note…
Care should be taken if a distance runner presents in the athletic training room complaining of severe groin pain
Pelvic stress fractures often first appear as groin strains and exhibit similar signs and symptoms
If there is no logical cause or explanation for their injury and pain, they should be referred to a physician for evaluation

33. Bursitis Iliopsoas Ischial bursitis
Pain medial and anterior to joint; cannot be easily palpated
Increase pain with passive hip rotation; resisted hip flexion, abduction, adduction and external rotation
Ischial bursitis
Pain aggravated by prolonged sitting and uphill running
Point tenderness directly over ischial tuberosity
Increase pain with passive and resisted hip extension
Management: Standard acute; deep friction massage, NSAIDS, stretching program for involved muscles, ongoing prevention, biomechanical analysis

34. Trochanteric bursitis
Relatively common condition involving the greater trochanter of the femur, surrounding muscles, and ligaments
Most commonly seen in female runners

35. Trochanteric bursitis
Trochanteric Bursitis, continued…
Care and treatment by the ATC should include…
Elimination of running on inclined surfaces
Correction of leg-length discrepancies and faulty running form
Cold packs/ice massage in combination with rest
Anti-inflammatory medications with physician approval or direction

36. Hip Stress fracture MOI
Once most commonly affected military personnel who marched and ran all day after day. Now hip stress fx are more common in athletes. Esp distance runners.
a) Femoral neck stress fracture
primarily in endurance athletes, overuse injury

37. Hip stress fracture S/S
Management:
RICE, Referral to Physician
Plain radiographs taken early may be negative- Further imaging may be required- (i.e.) MRI/ Bone Scan. 
If suspected, keep on crutches nonweight bearing until diagnosis confirmed
nondisplaced fracture on the compression (inferior) side consists of non-weightbearing/modified bed rest until the patient is completely pain free
displaced fractures and nondisplaced tension  side fractures - ORIF
S/S
presence with groin or anterior thigh pain, often a deep ache relived with cessation of activity.
antalgic gait, painful ROM, especially with internal and external rotation

38. Fractures - femur Femoral Fractures
In athletics, most often occur in the shaft of the femur
Usually caused by an outside force like falling from a height, being hit, etc
Shock generally accompanies a femur fracture as a result of the extreme pain and bleeding associated with the injury
This is a TRUE medical emergency
There will usually be deformity and displacement of the bone ends as a result of the quad muscles contracting
This can also cause internal lacerations to muscle tissues

39. Fracture - femur

40. Fractures - femur Signs and Symptoms of Femoral Fractures include…
Deformity with the thigh turned inward
Shortening of the thigh
Loss of function
Severe pain and point tenderness
Swelling of the soft tissues

41. Fractures - femur Care & Treatment by the ATC…
Immediate application of manual traction
Activation of EMS system
Splinting with a TRACTION SPLINT
If a traction splint is not available, then manual traction should be maintained until EMS arrives
Application of ice to the area of fracture
Treatment for shock
Monitoring of vital signs

42. Hip dislocations Mechanism: Rarely seen in athletics
When they do occur, it is usually the result of massive traumatic forces along the long axis of the femur
Generally hip dislocations occur with the knee in a flexed position
Displacement will occur posteriorly with the femoral shaft adducted and in a flexed position
This is a very serious injury, requiring emergency care, because of the severe damage that can be caused to surrounding soft tissues in the hip

43. Hip dislocations Dislocation of the Hip Joint, continued…
Bi-lateral hip dislocation with x-ray image

44. Hip dislocations Managment S/S Intense pain Inability to move hip
Immediate request for EMS assistance
Monitor vital signs especially distal vascular integrity
treat for shock
Stabilization of the hip and athlete in the position found. Best way to splint this type of injury is by placing the athlete on a backboard and then stabilizing the hip in the position found with pillows, blankets, etc.
S/S
Intense pain
Inability to move hip

45. Hip dislocations
After reduction the athlete will usually be confined to bed rest for approximately 2 weeks, followed by 1-2 months of assisted ambulation with a crutch or cane
Also during this time the athlete will probably receive physical therapy to restore the hip to normal function
Complications that can arise from this injury include…
Muscle paralysis as a result of damage to various nerves including the sciatic nerve
Osteoarthritis in the hip joint

46. Legg- Calve’-Perthes Disease
Legg-Perthes Disease (Coxa Plana)
Definition:
An avascular necrosis of the femoral head
Caused by a loss or disruption of blood flow to femoral head
Osteochondrosis of femoral head
Occurs more often in boys than in girls and is generally seen between the ages of 3 and 12

47. Legg-Perthes Disease Management S/S
Gradual onset of limp and mild hip or knee pain of several months in duration
Pain is activity related
Decrease ROM in hip abduction, extension, and external rotation due to spasm in hip flexors and adductors
Pain in the groin area, often referred to the abdomen
Management
Complete bed rest
Special bracing to avoid direct weight bearing on the hip
Complications related to this condition include…
Improper formation of the femur leading to osteoarthritis later in life

50. Avascular Necrosis Avascular Necrosis of the Femoral Head
Rarely seen in athletics but can occur as the result of a severe blow to the hip joint
Lack of blood flow to the femoral head, causing bone death
Most famous case was that of Bo Jackson
Usually results in hip replacement surgery

51. Snapping Hip Snapping Hip Phenomenon
Commonly seen among dancers, gymnasts, and hurdlers
Caused by habitual movements which cause certain muscles surrounding the hip to become unbalanced in terms of strength
Usually occurs when the athlete laterally rotates and flexes the hip

52. Snapping hip Snapping Hip Phenomenon
The athlete will complain of snapping, mainly when balancing on one leg
Care and treatment by the ATC should include….
Encouraging the athlete to avoid activities that cause the snapping
Stretching
Muscle strengthening
If there is associated pain, the athlete may need to be referred to a physician for evaluation

53. Osteitis pubis Osteitis Pubis
Most often seen in long distance runners, but can also be seen in football, soccer, and wrestling athletes

54. Osteitis pubis Osteitis Pubis, continued…
Chronic inflammatory condition of the pubic symphysis as a result of muscle pulling and repetitive stress on the bony structures of the pelvis

55. Osteitis pubis Osteitis Pubis, continued… Signs and symptoms include…
Pain in the groin area and over the pubic symphysis
Pain with movements such as running, sit-ups, and squats
Care and treatment by the ATC includes…
Rest and anti-inflammatory medications per physician orders
Gradual return to activity as tolerated

56. Thrombosis Other thigh conditions Thrombosis
Blood clot in a vein or artery in the thigh
Disrupts blood flow to the leg
Needs to be referred to the emergency room or a physician for immediate treatment
Signs & Symptoms may include…
Swelling
Pain
Loss of function
Loss of sensation

57. Thrombosis
Deep thrombosis to the thigh

58. Thrombosis of the thigh
Other thigh conditions
Very similar to compartment syndrome in the lower leg
Swelling in the thigh compartment that leads to loss of sensation, loss of blood flow, etc.
Signs and Symptoms include thigh swelling, severe pain, loss of function, loss of sensation, etc.
This condition needs to be referred to a physician for evaluation and treatment, which may involve surgical intervention

59. Thigh compartment syndrome

60. Done with injuries