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

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Presentation on theme: "Chapter 21: The Thigh, Hip, Groin, and Pelvis Jennifer Doherty-Restrepo, MS, LAT, ATC Academic Program Director, Entry-Level ATEP Florida International."— Presentation transcript:

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

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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 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 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 Hamstrings

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 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 Special Tests

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 Decreased ROM Decreased strength 1 - 4

15 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 Thigh Injuries: Quadriceps Contusions

16 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 Thigh Injuries: Myositis Ossificans Traumatica

17 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 Thigh Injuries: Quadriceps Muscle Strain

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

19 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 Thigh Injuries: Hamstring Muscle Strains

20 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 Loss of function 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 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 Thigh Injuries: Acute Femoral Fractures

23 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 Thigh Injuries: Femoral Stress Fractures

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

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31 Functional Anatomy Hip Joint 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 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 Assessment of the Hip and Pelvis

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

44 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 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 Special Tests: Leg Length Discrepancy

47 Leg Length Discrepancy Measures

48 Hip and Groin Injuries Groin Strain Etiology 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 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 Hip and Groin Injuries

50 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 Hip and Groin Injuries

51 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 Hip and Groin Injuries

52 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 Hip and Groin Injuries

53 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 Hip and Groin Injuries

54 Dislocated Hip Etiology 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 Hip and Groin Injuries

55 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 Hip and Groin Injuries

56 Avascular Necrosis Etiology 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 Hip and Groin Injuries

57 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 Hip and Groin Injuries

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 Slipped Capital Femoral Epiphysis Etiology Found mostly in tall boys between ages 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 Hip Problems in the Young Athlete

61 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 Hip Problems in the Young Athlete

62 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 Hip Problems in the Young Athlete

63 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 Hip Problems in the Young Athlete

64 Contusion (hip pointer) Etiology 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 Pelvic Injuries

65 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 Pelvic Injuries

66 Osteitis Pubis Etiology 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 Pelvic Injuries

67 Athletic Pubalgia Etiology 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 Pelvic Injuries

68 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 Pelvic Injuries

69 Stress Fractures Etiology 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 Pelvic Injuries

70 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 Pelvic Injuries

71 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 Pelvic Injuries

72 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 Pelvic Injuries

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

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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

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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

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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


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