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Chapter 14 Pelvis, Hip, and Thigh Conditions

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Presentation on theme: "Chapter 14 Pelvis, Hip, and Thigh Conditions"— Presentation transcript:

1 Chapter 14 Pelvis, Hip, and Thigh Conditions

2 Skeletal features of the pelvis, hip, and thigh
Anatomy Skeletal features of the pelvis, hip, and thigh

3 Anatomy (cont’d) Pelvis Function Protects organs
Transmits loads between trunk and lower extremity Provides site for muscle attachments

4 Anatomy (cont’d) Pelvis (cont’d) 4 fused bones Sacrum Coccyx
Innominate bones Ilium, ischium, and pubis

5 Anatomy (cont’d) Pelvis (cont’d) SI joint
Critical link between the two pelvic bones Strong ligamentous support Sacrococcygeal joint Fused line symphysis united by a fibrocartilaginous disc

6 Anatomy (cont’d) Pelvis (cont’d) Pubic symphysis
Interpubic disc located between the two joint surfaces Femur Weakest at femoral neck

7 Anatomy (cont’d) Hip Joint Head of femur and acetabulum of pelvis
Ball and socket joint Very stable

8 Anatomy (cont’d) Hip Joint (cont’d) Strong ligament support
Iliofemoral ligament Limits hyperextension Pubofemoral ligament Limits abduction and hyperextension

9 Ligaments of the pelvis and hip
Anatomy (cont’d) Hip Joint (cont’d) Strong ligament support (cont’d) Ischiofemoral ligament Limits extension Ligaments of the pelvis and hip

10 Anatomy (cont’d) Femoral Triangle Borders Inguinal ligament—superior
Sartorius—lateral Adductor longus—medial

11 Anatomy (cont’d) Femoral Triangle (cont’d) Contents Femoral nerve
Femoral artery Femoral vein

12 Anatomy (cont’d) Bursae Iliopsoas
Reduces friction between iliopsoas and articular capsule Deep trochanteric bursa Provides cushion between greater trochanter and gluteus maximus at its attachment to iliotibial tract

13 Anatomy (cont’d) Bursae (cont’d) Gluteofemoral bursa
Separates gluteus maximus from origin of vastus lateralis Ischial bursa Weight-bearing structure during sitting Cushions ischial tuberosity where it passes over gluteus maximus

14 Anatomy (cont’d) Nerves Lumbar plexus Femoral nerve Obturator nerve
Sacral plexus Sciatic nerve

15 Anatomy (cont’d) Blood Vessels External iliac Femoral Deep femoral
Femoral circumflex

16 Kinematics and Major Muscle Actions
Muscles of the pelvis, hip, and thigh. Anterior view

17 Kinematics and Major Muscle Actions (cont’d)
Muscles of the pelvis, hip, and thigh. Lateral view

18 Kinematics and Major Muscle Actions (cont’d)
Muscles of the pelvis, hip, and thigh. Posterior view

19 Kinematics and Major Muscle Actions (cont’d)
Hip flexors Iliopsoas, pectineus, rectus femoris, sartorius, and tensor fascia latae Two-joint muscles Rectus femoris—active during hip flexion and knee extension Sartorius—active during hip flexion and knee extension

20 Kinematics and Major Muscle Actions (cont’d)
Hip extensors Gluteus maximus and hamstrings (biceps femoris, semitendinosus, and semimembranosus) Hamstrings—two-joint; hip extension and knee flexion

21 Kinematics and Major Muscle Actions (cont’d)
Hip abductors Gluteus medius, gluteus minimus Active in stabilizing pelvis during single-leg support and during support phase of walking and running Hip adductors Adductor longus, adductor brevis, and adductor magnus

22 Kinematics and Major Muscle Actions (cont’d)
Lateral rotators Piriformis, gemellus superior, gemellus inferior, obturator internus, obturator externus, and quadratus femoris Lateral rotation of femur of swinging leg accommodates lateral rotation of pelvis during stride

23 Kinematics and Major Muscle Actions (cont’d)
Medial rotators Gluteus minimus Tensor fascia latae, semitendinosus, semimembranosus, gluteus medius, and adductors

24 Kinematics and Major Muscle Actions (cont’d)
PRIMARY ACTION MUSCLES Flexion Iliopsoas; rectus femoris; pectineus; sartorius; tensor fasciae latae Extension Gluteus maximus; biceps femoris; semitendinosus; semimembranosus; adductor magnus Abduction Gluteus medius; gluteus minimus Adduction Adductor brevis; adductor magnus; adductor longus; adductor magnus; gracilis Medial rotation Gluteus minimus; gluteus medius; tensor fasciae latae; semitendinosus; semimembranosus; adductor muscles Lateral rotation Piriformis; obturator internus; obturator externus; superior gemelli; inferior gemelli; quadratus femoris; gluteus maximus

25 Kinematics and Major Muscle Actions (cont’d)
Hip joint – movement in 3 planes Sagittal Flexion and extension Frontal Abduction and adduction Transverse Medial rotation and lateral rotation of the femur

26 Injury Prevention Physical conditioning Flexibility Strength
Protective equipment Hip joint well protected but iliac and pelvis need protection Thigh Shoe selection Cushion forces

27 Contusions Hip pointer MOI: direct blow to iliac crest S&S
Any trunk movement is painful (incl. coughing, laughing, & breathing) Immediate pain, discoloration, spasm, and loss of function Unable to rotate trunk or laterally flex the trunk toward injured side.

28 Contusions (cont’d) Hip pointer (cont’d) S&S (cont’d)
Any trunk movement is painful Extreme tenderness Abdominal muscle spasm may be present Severe injury – unable to walk or bear weight, even with crutches

29 Contusions (cont’d) Hip pointer (cont’d) Management
Standard acute; rest; protect with hard-shell pad for return to activity Severe pain over iliac crest – physician referral

30 Contusions (cont’d) Quadriceps contusion MOI: direct blow
Common – anterolateral thigh S&S Pain may be extensive immediately after impact

31 Contusions (cont’d) Quadriceps contusion (cont’d) S&S (cont’d) Grade I
Mild pain and swelling Able to walk without a limp Passive flexion beyond 90° – painful; resisted knee extension may cause less discomfort.

32 Contusions (cont’d) Quadriceps contusion (cont’d) S&S (cont’d)
Grade II Can flex the knee between 45 and 90° Walks with a noticeable limp Grade III Unable to bear weight or fully flex the knee.

33 Contusions (cont’d) Quadriceps Contusion (cont’d) Management:
Standard acute; with knee in maximum flexion Hard-shell pad for return to activity Physician referral if S&S persist >48 hours

34 Management of a quadriceps contusion
Contusions (cont’d) Quadriceps contusion (cont’d) Management of a quadriceps contusion

35 Contusions (cont’d) Myositis ossificans
Develops secondary to single significant blow or repetitive blows to same area Evident on radiograph 3–4 weeks after injury Myositis ossificans

36 Contusions (cont’d) Myositis ossificans (cont’d) S&S
Warm, firm, swollen thigh; 2–4 cm larger Palpable, painful mass may limit passive knee flexion to 20–30° Active quadriceps contractions and straight leg raises—difficult Management: standard acute; physician referral

37 Bursitis MOI Excessive friction or shear forces due to overuse
Greater trochanteric bursitis Influence of Q-angle Bursa of the hips

38 Bursitis (cont’d) Greater trochanteric bursitis S&S
Burning or aching over or posterior to greater trochanter Aggravated with: Hip abduction against resistance Hip flexion and extension on weight bearing

39 Bursitis (cont’d) Iliopsoas bursitis
Pain medial and anterior to joint; cannot be easily palpated  pain with passive hip rotation; resisted hip flexion, abduction, and external rotation

40 Bursitis (cont’d) Ischial bursitis
Pain aggravated by prolonged sitting and uphill running, Point tenderness directly over ischial tuberosity  pain with passive and resisted hip extension

41 Bursitis (cont’d) Bursitis management
Do not permit to continue activity until seen by a physician Suggest cold to decrease pain and inflammation

42 Bursitis (cont’d) Snapping hip syndrome
Can result from chronic bursitis S&S Snapping sensation heard or felt during hip motion, especially with lateral rotation and flexion while balancing on one leg Iliopsoas bursa affected—snapping in medial groin

43 Bursitis (cont’d) Snapping hip syndrome (cont’d) Management
Do not permit to continue activity until seen by a physician Suggest cold to decrease pain and inflammation

44 Hip Sprains and Dislocations
MOI Violent twisting actions With hip and knee flexed to 90°, force through shaft of femur S&S Mild/moderate: pain with internal rotation Severe: intense pain; inability to move hip Position of flexion and internal rotation

45 Hip Sprains and Dislocations (cont’d)
Management Mild/moderate—standard acute; physician referral Severe—activate EMS; immobilize in position found – do not move; monitor and treat for shock

46 Hip Dislocations Hip dislocations

47 Strains Quadriceps Typically rectus femoris S&S Grade I
Normal gait, but tightness in the anterior thigh Pain with passive knee flexion beyond 90°

48 Strains (cont’d) Quadriceps (cont’d) S&S (cont’d) Grade II
Snapping or tearing sensation, followed by immediate pain and loss of function. Knee held in extension – protection Pain with passive knee flexion; Pain & weakness with knee extension

49 Strains (cont’d) Quadriceps (cont’d) S&S (cont’d) Grade III strains
Extreme pain Ambulation not possible Defect in the muscle may be visible Resisted knee extension not possible; ROM is severely limited

50 Strains (cont’d) Hamstrings
Initial swing—flex knee; late swing— eccentrically contract to decelerate knee extension and re-extend hip in prep for stance phase Overemphasis on stretching without strengthening Additional risk factors (Box 14.2) Strength imbalance

51 Strains (cont’d) Hamstrings (cont’d) S&S Grade 1 Tightness and tension
Pain with passive stretching

52 Strains (cont’d) Hamstrings (cont’d) S&S (cont’d) Grade II
Tearing sensation or feeling a “pop,” leading to immediate pain and weakness in knee flexion.

53 Strains (cont’d) Hamstrings (cont’d) S&S (cont’d) Grade III
Sharp pain may occur during midstride Limps; unable to do heel-strike or fully extend the knee. Pain and muscle weakness with active knee flexion

54 Strains (cont’d) Adductors
Quick changes of direction, and explosive propulsion and acceleration Strength imbalance

55 Strains (cont’d) Adductors (cont’d) S&S
An initial “twinge” or “pull” of the groin muscles, and is unable to walk because of the intense, sharp pain As the condition worsens, increased pain, stiffness, and weakness in hip adduction and flexion

56 Strains (cont’d) Adductors (cont’d) S&S (cont’d)
Running straight ahead or backward may be tolerable, but any side-to-side movement leads to more discomfort and pain Pain with passive stretching with the hip extended, abducted, and externally rotated Pain with resisted hip adduction

57 Strains (cont’d) Predisposing factors
Beginning of season – too much too soon Fatigue History of strains; reinjury common Restricted flexibility of involved muscle group

58 Strains (cont’d) Management:
Grade 1 – standard acute; If symptoms persist > 2-3 days, physician referral Grade 2 or 3 – standard acute; physician referral

59 Vascular and Neural Disorders
Legg-Calvé-Perthes disease Avascular necrosis of proximal femoral epiphysis Seen especially in males ages 3–8 Osteochondrosis of femoral head

60 Vascular and Neural Disorders
Legg-Calvé-Perthes disease (cont’d) S&S Gradual onset of limp and mild hip or knee pain of several months in duration Pain is generally activity related  ROM in hip abduction, extension, and external rotation due to spasm in hip flexors and adductors

61 Vascular and Neural Disorders (cont’d)
Legg-Calvé-Perthes disease Management Do not permit to continue activity until seen by a physician

62 Hip Fractures Avulsion fractures
Due to rapid, sudden acceleration and deceleration Apophyseal sites ASIS with displacement of sartorius AIIS with rectus femoris displacement Ischial tuberosity with hamstrings displacement Lesser trochanter with iliopsoas displacement

63 Hip Fractures (cont’d)
Avulsion fractures (cont’d) S&S Sudden, acute, localized pain—may radiate down muscle Swelling and discoloration Palpable gap between tendon attachment and bone  pain with AROM, PROM, RROM of involved muscle

64 Hip Fractures (cont’d)
Avulsion fractures (cont’d) Management: fit with crutches; immediate physician referral

65 Hip Fractures (cont’d)
Slipped capital femoral epiphysis Boys ages 12–15 Femoral head slips at epiphyseal plate— displaces inferiorly and posteriorly Slipped capital femoral epiphysis

66 Hip Fractures (cont’d)
Slipped capital femoral epiphysis (cont’d) S&S Early S&S often undetected other than diffuse knee pain Later stages More comfortable holding leg in slight flexion

67 Hip Fractures (cont’d)
Slipped capital femoral epiphysis (cont’d) Later stages Unable to touch the abdomen with the thigh because the hip externally rotates with flexion Unable to rotate the femur internally or stand on one leg. Management: Do not permit to continue activity until seen by a physician

68 Hip Fractures (cont’d)
Stress fractures Pubis, femoral neck, and proximal one-third of femur Risk factors

69 Hip Fractures (cont’d)
Stress fractures (cont’d) S&S Diffuse or localized aching pain in anterior groin or thigh during weight-bearing activity, relieved with rest Night pain Antalgic gait may be present

70 Hip Fractures (cont’d)
Stress fractures (cont’d) S&S (cont’d) ↑ pain on extremes of hip rotation, abduction lurch Inability to stand on involved leg Management: Do not permit to continue activity until seen by a physician

71 Sacral and Coccygeal Fractures
Rare in sports Direct blow to area due to fall on buttock S&S: extremely painful; unable to sit Management: immediate referral to a physician

72 Femoral Shaft Fracture
MOI Tremendous impact forces Direct compressive forces Potential for neurovascular damage

73 Femoral Shaft Fracture (cont’d)
S&S Severe pain and a total loss of functions Swelling at fracture site Present with the thigh externally rotated Shortened limb deformity

74 Femoral Shaft Fracture (cont’d)
Management Activate emergency plan, including summoning of EMS Do not attempt to immobilize Assess and treat for shock as necessary

75 Femoral Fractures (cont’d)
S&S Previous history of femoral stress fracture ↑ risk of complete fracture Extreme pain and inability/unwillingness to move involved side Shock

76 Femoral Fractures (cont’d)
S&S (cont’d) Neck Individual supine, lower extremity in external rotation and abduction; appears shortened compared with other side Shaft Limb appears shortened; thigh appears externally rotated

77 Femoral Fractures (cont’d)
Management Activate EMS Assess distal vascular integrity Monitor and treat for shock Defer immobilization until emergency medical personnel arrive (traction splint will typically be applied) NPO—possible surgical intervention

78 Coach and Onsite Assessment
S &S that require activation of emergency plan, including summoning EMS Obvious deformity suggesting a dislocation or fracture Significant loss of motion or loss of function Palpable defect in a muscle Severe joint disability that may be evident by a noticeable limp

79 Coach and Onsite Assessment (cont’d)
S &S that require activation of emergency plan, including summoning EMS Excessive soft tissue swelling, particularly in the quadriceps Abnormal cutaneous sensations or an absent or weak pulse Refer to Application Strategy 14.2


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