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Chapter 21: The Thigh, Hip, Groin, and Pelvis

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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



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 IT-band
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 Hamstrings 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

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 Special Tests 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

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 1 - 4 Decreased ROM 1 - 4 Decreased strength 1 - 4

15 Thigh Injuries: Quadriceps Contusions
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

16 Thigh Injuries: Myositis Ossificans Traumatica
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

17 Thigh Injuries: Quadriceps Muscle Strain
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

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

19 Thigh Injuries: Hamstring Muscle Strains
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

20 Thigh Injuries: Hamstring Muscle Strains
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 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 Thigh Injuries: Acute Femoral Fractures
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

23 Thigh Injuries: Femoral Stress Fractures
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

24 Anatomy of the Hip, Groin, and Pelvic Region







31 Functional Anatomy Hip Joint Pelvis 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 Assessment of the Hip and Pelvis
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

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

44 Special Tests: Tensor Fasciae Latae and Iliotibial Band
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 Special Tests: Leg Length Discrepancy
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

47 Leg Length Discrepancy Measures

48 Hip and Groin Injuries Groin Strain Etiology Signs and Symptoms
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 Hip and Groin Injuries 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

50 Hip and Groin Injuries 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

51 Hip and Groin Injuries 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

52 Hip and Groin Injuries 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

53 Hip and Groin Injuries 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

54 Hip and Groin Injuries Dislocated Hip Etiology Signs and Symptoms
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

55 Hip and Groin Injuries 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

56 Hip and Groin Injuries Avascular Necrosis Etiology Signs and Symptoms
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

57 Hip and Groin Injuries 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

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 Hip Problems in the Young Athlete
Slipped Capital Femoral Epiphysis Etiology Found mostly in tall boys between ages 10-17 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

61 Hip Problems in the Young Athlete
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

62 Hip Problems in the Young Athlete
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

63 Hip Problems in the Young Athlete
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

64 Pelvic Injuries Contusion (hip pointer) Etiology Signs and Symptoms
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

65 Pelvic Injuries 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

66 Pelvic Injuries Osteitis Pubis Etiology Signs and Symptoms Management
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

67 Pelvic Injuries Athletic Pubalgia Etiology Signs and Symptoms
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

68 Pelvic Injuries 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

69 Pelvic Injuries Stress Fractures Etiology Signs and Symptoms
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

70 Pelvic Injuries 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

71 Pelvic Injuries 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

72 Pelvic Injuries 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

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


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



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


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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