1. © 2010 McGraw-Hill Higher Education. All rights reserved. Chapter 17: The Thigh, Hip, Groin, and Pelvis

2. © 2010 McGraw-Hill Higher Education. All rights reserved. Anatomy of the Pelvis, Thigh, and Hip

3. © 2010 McGraw-Hill Higher Education. All rights reserved.

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. © 2010 McGraw-Hill Higher Education. All rights reserved. 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. © 2010 McGraw-Hill Higher Education. All rights reserved. Special Tests –Thomas test Test for hip contractures –Straight Leg Raise Test for hip extensor tightness Can also be used to assess low back or SI joint dysfunction

12. © 2010 McGraw-Hill Higher Education. All rights reserved. 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. © 2010 McGraw-Hill Higher Education. All rights reserved. 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. © 2010 McGraw-Hill Higher Education. All rights reserved. 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. © 2010 McGraw-Hill Higher Education. All rights reserved. Myositis Ossificans –Cause of Injury 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

16. © 2010 McGraw-Hill Higher Education. All rights reserved.

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. © 2010 McGraw-Hill Higher Education. All rights reserved. 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. © 2010 McGraw-Hill Higher Education. All rights reserved. –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. © 2010 McGraw-Hill Higher Education. All rights reserved. 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

21. © 2010 McGraw-Hill Higher Education. All rights reserved. Femoral Stress Fractures –Cause of Injury Overuse Uncommon injury – tends to occur in endurance athletes –Females > Males –Signs of Injury Pain occurs weeks after increasing workout intensity Persistent pain in thigh, groin, especially after activity Referred pain to knee X-ray or bone scan will reveal fracture Commonly seen in femoral neck –Management Initial treatment involves rest While most head with conservative management, fracture may result –May require surgical repair

22. © 2010 McGraw-Hill Higher Education. All rights reserved. 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

23. © 2010 McGraw-Hill Higher Education. All rights reserved. Groin Strain (continued) –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

24. © 2010 McGraw-Hill Higher Education. All rights reserved. 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 fracture RICE, NSAID’s and analgesics Depending on severity, crutches may be required ROM and PRE are delayed until hip is pain free

25. © 2010 McGraw-Hill Higher Education. All rights reserved. Dislocated Hip: –Cause 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 fracture

26. © 2010 McGraw-Hill Higher Education. All rights reserved. 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

27. © 2010 McGraw-Hill Higher Education. All rights reserved. Hip Labral Tears –Cause of Condition 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 Insert 17-14

28. © 2010 McGraw-Hill Higher Education. All rights reserved. –Cause of Condition 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 Result of trauma tic force directe d along the long axis of the femur –Signs of Injury Flexed, adduct ed and interna lly rotated hip Palpati on reveal s displac ed femora l head, posteri orly Seriou s pathol ogy –Soft tiss ue, neu rolo gica l dam age and pos sibl e fract ure –Care Immed iate medic al care (blood and nerve supply may be compr omise d) Contra ctures may further compli cate reducti on 2 weeks immob ilizatio n and crutch use for at least one month Piriformis Syndrome

29. © 2010 McGraw-Hill Higher Education. All rights reserved. Piriformis Syndrome con’t –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

30. © 2010 McGraw-Hill Higher Education. All rights reserved. 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. © 2010 McGraw-Hill Higher Education. All rights reserved.

32. 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

33. © 2010 McGraw-Hill Higher Education. All rights reserved. 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

34. © 2010 McGraw-Hill Higher Education. All rights reserved.

35. 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

36. © 2010 McGraw-Hill Higher Education. All rights reserved. Osteitis Pubis –Cause of Injury 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

37. © 2010 McGraw-Hill Higher Education. All rights reserved. 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

38. © 2010 McGraw-Hill Higher Education. All rights reserved. Stress Fractures –Cause of injury 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

39. © 2010 McGraw-Hill Higher Education. All rights reserved. Avulsion Fractures –Cause of Injury 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