1. Injuries to the Hip and Pelvis

2. We will discuss a basic overview of the anatomy in the region of the hip and pelvis We will have a brief description of movements by the joints and actions of the musculature in the area We will target more common hip and pelvis injuries incurred in sports and outlines emergency procedures We will also talk about injuries that aren’t common in sports The chapter reviews injuries to the male genitalia, including both testicular contusion and torsion It also covers hernia and nerve problems and discusses proper referral http://www.youtube.com/watch?v=7VpS0T_kt2w http://www.nbcolympics.com/video/gracie-gold-confident- after-outstanding-performance-team-event?ctx=olympic- journey http://www.nbcolympics.com/video/gracie-gold-confident- after-outstanding-performance-team-event?ctx=olympic- journey

3. Anatomy Review… The hip and pelvis form a square in the way they are constructed This area comprises the two large, irregularly shaped pelvic bones on the lateral sides, the sacrum and coccyx posteriorly, and the articulation of the pubic bones anteriorly

4. Anatomy Review… The pelvic bones are also known as the innominate bones and are made up three distinct parts: ◦ The ilium ◦ The ischium ◦ And pubis

5. Anatomy Review… In the adult, the three parts are fused and come together at a lateral point called the acetabulum, which is where the head of the femur articulates with the hip to form the hip joint

6. Anatomy Review… The bony pelvis has several functions in the body: ◦ The lower extremities attach here ◦ Muscle attachments are prevalent ◦ It provides substantial protection for the entire pelvic region

7. Anatomy Review… The major articulations of the bony pelvis include the hip joint, the sacroiliac joints, and the symphysis pubis The hip joint is the articulation of the head of the femur and the acetabulum in the hip bone; it is a true ball-and-socket joint that is well supported by strong ligaments

8. Anatomy Review The sacroiliac joints are formed by the sacral bones and the iliac portion of the hip bones The symphysis pubis is formed by the two pubic bones meeting in anterior portion of the bony pelvis All of these joints have strong ligamentous support that assist in joint stability

9. Anatomy Review… Several nerves and blood vessels course through the bony pelvis Some of the more important nerves that course down the lower extremity are subdivisions of the make up of the cauda equina

10. Anatomy Review… The spinal cord ends at L2 level, and the cauda equina exits the spinal cord beginning at L2 and proceeding inferiorly (Gray, 1974) Nerves exiting the spinal cord below the L1 level typically pass through the bony pelvis

11. Anatomy Review… These nerves include the formation of the lumbar plexus, the sacral plexus, the coccygeal plexus and other individual nerves Probably the most well known of these is the sciatic nerve, which is the largest in the body and is made up of nerve roots L4 – S3

12. Anatomy Review… The sciatic nerve passes through the posterior portion of the bony pelvis and down the posterior aspect of the leg The blood vessels of the area include both arteries and veins that supply the pelvis and lower extremities The more well known of these vessels include the iliac artery and vein

13. Anatomy Review Many of the muscles that attach to the bony pelvis are ones that move the lower extremities The smaller muscles consist of the medial and lateral rotators of the femur Some of the medial rotators include the tensor fasciae latae and gluetus minimus These muscles are quite active in many movements of the lower extremity

14. Anatomy Review… The lateral rotators of the hip are small muscles located deep within the hip area that are also quite active in many movements of the lower extremity Some of those muscles more commonly injured include the piriformis ◦ Which attaches to the anterior surface of the sacrum and to the greater trochanter of the femur

15. Anatomy Review… The piriformis is a lateral rotator of the thigh; the sciatic nerve runs directly beneath the piriformis and can be irritated by the overuse of this muscle

16. Anatomy Review… Other external rotators of the thigh include the gemelli (superior and inferior), which attach on the ischium and run to the greater trochanter of the femur

17. Anatomy Review… All of these muscles are small in comparison with the surrounding muscles, but they play an important part in the proper functioning of the hip and leg Many muscles attach on the pelvis and provide musculature for the leg, back, and abdomen These muscles responsible for many of the large movements at the hip joint include flexors, extensors, adductors, and abductors

18. Anatomy Review… The main hip flexors include the rectus femoris, the iliopsoas group, the tensor fasciae latae, and the sartorius The rectus femoris attaches at the ASIS and runs down the front of the leg to the common attachment of the quadriceps group at the patellar tendon

19. Anatomy Review… The iliopsoas group is a combination of the iliacus and psoas muscles, which attach on the anterior lumbar spine and iliac crest and come together as they run down to the lesser trochanter of the femur

20. Anatomy Review… The tensor fasciae latae and sartorius attach on the anterior iliac spine The tensor fasciae latae runs to the lateraly condyle of the tibia, whereas the sartoris runs across the anterior thigh and attaches to the anterior medial aspect of the tibia The sartorius becomes one of the muscles of the pes anserinus group

21. Anatomy Review… The main muscles of hip extension are the gluteals and the hamstrings The gluteus maximus is the main hip extensor of the gluteals Attaches on the posterior surface of the ilium and runs inferiorly to the femur

22. Anatomy Review… The hamstrings attach mainly on the ischial tuberosity; then, two of the muscles, the semitendinosus and semimembranosus, run more medially on the posterior leg and attach near the sartorius and on the posterior/medial condyle of the tibia The biceps femoris runs more laterally on the posterior leg and attaches to the lateral aspect of the tibia and head of the fibula

23. Anatomy Review… The muscles that adduct the hip are located on the medial portion of the leg are commonly called the groin area Main muscles included in this group are the three adductors (brevis, longus, magnus) as well as the pectineus and gracilis

24. Anatomy Review… The adductors attach on the pubis and run to the femur The pectineus also attaches at the pubis and runs to the femur The gracilis attaches on the inferior portion of the pubis and runs medially down the leg to the anterior medial portion of the tibia

25. Anatomy Review The sartoris, gracilis and the semitendinosus compose the pes anserinus group Say grace before tea ◦ How to remember them in order http://www.youtube.com /watch?v=PHttidEwqz8 http://www.youtube.com /watch?v=PHttidEwqz8 ◦ (MMG, 2008)

26. Common Sports Injuries… The hip and pelvic regions are well designed anatomically Sports-related injuries to the skeletal structures of the hip and pelvis are not common Injuries to the soft tissues in the region are more common and can be quite debilitating to the athlete Injuries commonly involve collision sports or forceful movements pursuant to an activity that requires power and speed of the lower extremities Overuse injuries may also be associated wit hthe hip and pelvis

27. Skeletal Injuries…FX of the Pelvis One of the most devastating injuries to the pelvic region is the fracture of one of the pelvic bones Typically, a great deal of force is necessary to cause a fracture of this type This is not a common injury related to sports participation Still, it can occur in sports such as hockey, pole-vaulting, or football in which there is the possibility of direct compression from another athlete, a fall from a height, or being twisted and hit by another player

28. Skeletal Injuries…FX of the Pelvis Skeletal injuries to the pelvis in the adolescent population can be extremely serious, especially if the injury involves an open epiphysis Any suspected skeletal injury to this area should be referred to a physician as quickly as possible

29. Skeletal Injuries…FX of the Pelvis S&S: ◦ Abdominal pain in the pelvic region after the injury ◦ There might be swelling at the site, with the rare occurrence of a visual or palpable deformity at the injury ◦ Pain is elicited when the iliac crests are pressed together ◦ Associated injuries to internal organs such as the bladder are possible and should be ruled out TX: ◦ Treat for possible shock and internal bleeding ◦ Monitor the athlete’s vital signs regularly ◦ Transport the athlete to the hospital on a long spine board with the foot of the board elevated to eliminate pooling of blood in the lower extremities

30. Skeletal Injuries…FX of the pelvis A fracture of the pelvis is a serious injury and should be evaluated by a physician ASAP Treatment depends on the severity of the injury and should be complete before the athlete returns to practice or competition Under NO circumstances should an athlete with a suspected FX of the pelvis return to competition before seeing a physician

31. Femoral Neck Stress Fracture This injury occurs more commonly in the thin amenorrhea athlete involved in running or an endurance sport The femoral neck stress fracture is a result of a loss in shock-absorbing capacity of the fatigued muscles in the hip area

32. Femoral Neck Stress Fracture This problem can also be a partial result of poor footwear, hard running surface, or hip deformities (Lacroix, 2000) Typically, athletes c/o severe anterior thigh or groin pain when they have a possible femoral neck stress fracture The athlete will be able to walk but will experience pain during ambulation Seeing a physician is necessary to get radiographs

33. Slipped Capital Femoral Epiphysis This problem occurs most commonly in 10 to 15 year old boys Typically, it occurs in boys who are tall and have recently experienced a rapid growth period, or in boys who are overweight The boy exhibits a flexed hip, thigh or knee Any child younger than the age of 12 who complains of knee pain should have a thorough hip evaluation by the physician to r/o any one of a number of hip pathologies that may exist in this population

34. Hip Pointer Probably the most common injury to the region is a contusion to the superior/anterior portion of the iliac crest, which is commonly referred to as a hip pointer Typically, with this injury the athlete receives a direct blow to the area from an opponent’s helmet or falls to the ground with great force

35. Hip Pointer This can be an extremely painful and debilitating injury for the athlete, but it is not one that requires emergency attention or causes major complications if further activity is necessary

36. Hip Pointer S&S: ◦ Swelling at the site of injury ◦ Discoloration at the site of injury ◦ Pain and discomfort at the site of injury ◦ The athlete may walk with a slight limp on the affected side  Coughing, sneezing, and laughing may also produce pain at the site of injury TX: ◦ Immediately apply ice to the injured area ◦ Have the athlete rest and avoid activity that involves the lower extremities ◦ If the injury is severe, walking with crutches may be necessary for a few days

37. Hip Pointer Long-term care for this type of injury is rather simple The contusion has in most cases caused minimal damage to an area where several muscles attach directly to bone tissue The muscular attachments in the abdominal region are the cause of pain when the athlete coughs, sneezes, or laughs The player will usually be able to participate on a limited basis within 1 to 2 weeks, depending on the severity

38. Hip Pointer It is important to note that if an athlete wishes to continue participation in sports while recovering from a hip pointer, the area should be padded well so that further damage can not occur if a similar incident happens before recovery is complete

39. Other Hip Problems Athletes who participate in excessive running as a part of their sport can experience what is known as “snapping hip syndrome” Snapping hip syndrome is a sensation that occurs when the athlete moves the hip in a specific direction Usually, there is little if any pain associated with snapping hip This problem is attributed to one of the muscles in the lateral hip riding over the top of the greater trochanter of the femur

40. Other Hip Problems… The structures that could be involved include the iliotibial band, tensor fascia lata, and the gluteus medius There could be subluxation of the hip or labral tears that induce extra movement of the femur during locomotion Typically, treatment consist of stretching tightened muscles that may contribute to the snapping sensation and correcting any biomechanical deviations of the area Anti-inflammatory medications may help

41. Other Hip Problems… Trochanteric bursitis is another rare problem experienced by some athletes It is a problem seen most often in middle- aged people, but athletes, especially runners, are becoming more prone to trochanteric bursitis This bursitis is usually a result of either acute trauma to the specific area or repeated microtrauma to the tendon attachments with secondary inflammation of the bursae in the area

42. Other Hip Problems.. The iliotibial band can be a source of the problem if it is tight and the athlete continues to run when he/she is experiencing S&S of trochanteric bursitis When an athlete is experiencing the onset of trochanteric bursitis, he/she will initially c/o pain over the greater trochanter followed by pain radiating down the anterior/lateral thigh to the buttock region

43. Other Hip Problems.. Most athletes benefit from stretching the iliotibial band and the low back area in the proximity of the sacroiliac joints, and taking an NSAID For some athletes, it may be necessary to pad the area if there is a chance of external trauma such as falling or being hit by another athlete in the hip On rare occurrences, athletes do not respond to conservative treatment and benefit from surgical management http://www.youtube.com/watch?v=ZDBLdEpsvvk

44. Osteitis Pubis Another type of skeletal injury to the pelvic area is osteitis pubis, a condition resulting from continued stress and possibly some degeneration in the symphsis pubis joint This injury is commonly a result of overuse and chronic strain on the joint Long-distance runners, basketball and soccer players, and other athletes who experience repetitive pelvic movements in sports may c/o this condition

45. Osteitis Pubis Athletes who produce repetitive shearing forces of the pelvis and have increased stresses on the lower abdominal structures during their sport participation are more susceptible to this problem Osteitis pubis is a difficult injury to diagnose because the many muscles and structures in the pelvic area, resulting in a delayed diagnosis or a non-diagnosed problem

46. Osteitis Pubis S&S ◦ c/o an insidious onset of pain that worsens progressively ◦ May indicate that the pain is in the groin area TX: ◦ Should be referred to the appropriate doctor for complete evaluation ◦ Because this is a chronic problem, first aid is typically not necessary ◦ Athlete may benefit from RICES

47. Osteitis Pubis The athlete typically responds well to therapy, with very few if any long-term side effects An athlete may take anywhere from 3 months to a year to return to preinjury functioning levels

48. Injury of the Sacroiliac Joint… The sacroiliac (SI) joint, which is the articulation between the sacrum and pelvis, is a common site of pain in the posterior aspect of the pelvis Movement of this joint is limited because of the configuration of the bones and numerous ligaments

49. Injury of the Sacroiliac Joint… This joint can present problems for the athlete if it becomes completely immobile or if it becomes inflamed from an injury or other problem Injuries resulting in an immobile SI joint require specific movement techniques by a trained professional to restore the normal motion in the joint Problems with inflammation in the SI joint can be treated by a certified athletic trainer or physical therapist under the direction of a physician

50. Hip Dislocation… Infinitely more serious is a hip dislocation This injury is actually quite rare in athletic events; however, it may occur to an athlete participating in contact sports If a violent collision occurs between two players or between a player and another object (for example, the boards surrounding a hockey rink), this type of injury can happen Typically, when the injury occurs the hip joint is in flexion, and the force is applied through the femur Most often the hip dislocates posteriorly, and the athlete experiences extreme pain and loss of movement in the affected extremity

51. Hip Dislocation S&S: ◦ Abnormal pain at the site of injury ◦ Swelling at the site of injury, with a palpable defect ◦ Knee of the involved extremity is angled toward the opposite leg ◦ This injury is typically quite visible to the observer TX: ◦ Treat for possible shock ◦ Immobilize the athlete and transport to the nearest medical center ◦ Care should be given to monitor blood flow to the leg at all times

52. Soft-tissue Injuries… Because of the size and functions of the musculature in the hip and pelvic region, soft-tissue injures are not very common in sport The ligamentous support of the hip, sacrum, and other structures in the area is very strong; as a result, sprains rarely occur here however, several muscles attach in the area of the pelvis, including the musculature on both the anterior and posterior aspects of the thigh, and these are subject to avulsion

53. Avulsion Fractures… The possibility of muscle avulsions during forceful activity always exists Skeletally immature athletes are more prone to avulsion fractures around the hip because their tendons are stronger than their cartilaginous growth centers The MOI is a sudden near maximal muscle contraction This results in the tendon pulling off a piece of bone at the attachment site

54. Avulsion Fracture In a skeletally mature adult, this action usually results in a torn muscle or tendon because the bone is stronger than the tendon In the adolescent, the tendon is stronger than the bone, so the result is an avulsion fracture

55. Avulsion Fracture Avulsion fractures occur more commonly in adolescents who participate in sports requiring short bursts of maximal muscle contraction, such as soccer, tennis, sprinting, or jumping The injured athlete will c/o severe localized pain and ecchymosis at the site of injury

56. Avulsion Fracture Common sites of injury in adolescents are ASIS where the rectus femoris attaches, and the ischial tuberosity where the hamstrings attach

57. Avulsion Fracture S&S: ◦ Pain and swelling at the site of injury ◦ Inability to produce specific movement that is usually accomplished easily ◦ Point tenderness over the affected area ◦ Movement of the muscle closer to its opposite attachment when contracted ◦ May have felt or heard a snap or pop at the time of injury TX: ◦ Immediately apply ice and require the athlete to rest ◦ Limit motion as much as possible ◦ Have the athlete evaluated by a physician ASAP to determine the extent of the injury

58. Avulsion Fracture.. Are debilitating and should be treated conservatively to reduce the amount of scar tissue Without proper treatment and rehabilitation, this type of injury can be a problem in an athlete’s future career

59. Hernias… A hernia is the protrusion of abdominal viscera through the abdominal wall; this typically occurs in the groin area In males, inguinal hernias are more common Femoral hernias are more prevalent among female athletes (Crowley, 2010) Most hernias are detected during a preparticipation physical evaluation

60. Hernias However, an athlete who is suffering from a hernia most likely has an abnormal protrusion in the groin area and experiences pain in the groin and/or testicles The area should seek proper medical advice promptly to discern how soon the hernia will have to be repaired

61. Hernia… Athletes can experience “sports hernias” in which the posterior inguinal wall is weakened w/o any protrusion of abdominal contents through the abdominal wall In this situation, no palpable hernia is discovered during a routine physical examination, yet the athlete c/o continuing pain in the groin and lower abdominal regions

62. Hernia… The sports hernia is difficult to diagnose for the physician and usually exhibits diffuse, deep groin that does not have a specific onset and gradually gets worse as the days pass The athlete may c/o pain along the inguinal ligament and into the rectus muscles It has been suggested that sports hernias may be a common cause of chronic groin pain in athletes

63. Hernias… In any case, groin pain must be addressed with proper treatment and the course of action taken needs to follow a predetermined timeline Conservative treatment of rest, ice, stretching, and a change in kicking biomechanics may be all that is needed to relieve groin pain in a soccer player If the symptoms do not resolve over a 2-week period, it is time to see the team physician Athletes need to understand that many different techniques for surgical repair exist and new ideas are being reported

64. Nerve Problems… A common complaint among many athletes is a burning or tingling sensation radiating from the hip and buttocks area and going down the back of the leg These symptoms are often the result if irritation of the sciatic nerve Typically, if an athlete continues to pursue the activity that has caused the irritation, the pain will radiate farther down the leg to the foot and become more debilitating over time Strengthening and stretching exercises will help depending on the situation

65. Prevention… Many of these injuries can be prevented by the use of proper conditioning and strengthening of the associated musculature Rest is important for the body to repair micro damages incurred by stresses of training The use of proper shoes for each activity can be helpful in preventing slipping or sliding by the athlete that might result in overstretch or tearing of muscles

66. Prevention Soccer players or similar types of athletes slipping on a wet field can sustain severe groin injury Even though injuries to the hip and pelvis are relatively uncommon as a result of sports participation, it is important to realize that injuries to this area do occur and that they can be debilitating to the athlete