1. The Thigh, Hip, Groin, and Pelvis
© 2007 McGraw-Hill Higher Education. All rights reserved.

2. Anatomy:

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 (compare bilaterally)

11. Special Tests Thomas test Straight Leg Raise Test for hip contractures
-Permanent fixation of the hip in primary positions, with limited passive or active motion at the hip joint. Locomotion is difficult and pain is sometimes present when the hip is in motion. It may be caused by trauma, infection, or poliomyelitis. 
Straight Leg Raise
Test for hip extensor tightness
Can also be used to assess low back or SI joint dysfunction

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
Direct blow to the Thigh
Constantly exposed to traumatic blows
Signs of Injury
Pain, transitory loss of function, immediate bleeding of affected muscles
Ecchymosis
Swelling
Palpable knot
Early detection and avoidance of internal bleeding are vital – increases recovery rate and prevents muscle scarring

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

16. 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

18. 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
Superficial 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
Palpable divot or lump/‘ball of muscle’
Care
Rest, ice and compression to control internal bleeding
Determine extent of injury early
Neoprene sleeve may provide some added support

19. 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, etc
Signs of Injury
Muscle belly or point of attachment pain
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

20. 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
Rehab
Restrict activity until soreness has subsided
Ballistic stretching and explosive sprinting should be avoided
Lengthy return to play 6-8 weeks

22. Acute Femoral Fractures
Cause of Injury
Generally involving shaft and requiring great 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 and medical referral

24. Femoral Stress Fractures Cause of Injury
Overuse
Females who are amenorrheic are more vulnerable to stress fx
Signs of Injury
Persistent pain in thigh
X-ray or bone scan will reveal fracture
Commonly seen in the femoral neck
Management
Analgesics, NSAID’s RICE
ROM exercises are carried out w/ pain free ROM
Rest, limited weight bearing 4-6 respectively

25. 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 early in the 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
Point tenderness

26. Groin Strain (continued)
Care
RICE, NSAID’s and analgesics for 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

28. 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

29. Piriformis Syndrome Cause of Condition Signs of Injury Care
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
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

31. Dislocated Hip Cause of Injury Signs of Injury Care
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
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

33. 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

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

36. 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
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

38. 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

39. 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

40. Acute Fracture of Pelvis Cause of Injury Signs of Injury Care
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

41. 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

42. 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

43. Pelvic Avulsion Fracture