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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pelvis, Hip, and Thigh Conditions Chapter 17.

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Presentation on theme: "Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pelvis, Hip, and Thigh Conditions Chapter 17."— Presentation transcript:

1 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pelvis, Hip, and Thigh Conditions Chapter 17

2 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Skeletal Features of Pelvis, Hip, and Thigh

3 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pelvis Function –Protects organs –Transmits loads between trunk and lower extremity –Provides site for muscle attachments 4 fused bones –Sacrum –Coccyx –Innominate bones Ilium, ischium, and pubis

4 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pelvis (cont.) SI joint –Critical link between the two pelvic bones –Strong ligamentous support Sacrococcygeal joint –Fused line symphysis united by a fibrocartilaginous disc Pubic symphysis –Interpubic disc located between the two joint surfaces

5 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bony Structure of Thigh Femur –Weakest at femoral neck –Angle of inclination Angle of depression formed by a line drawn through the shaft of femur and a line passing through the long axis of femoral neck Approximately 125 in the frontal plane 125 coxa valga 125 coxa vara

6 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

7 Bony Structure of Thigh (cont.) Femur –Angle of torsion Relationship between femoral head and femoral shaft in transverse plane Approximately 12 12 anteversion 12 retroversion

8 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

9 Hip Joint Head of femur and acetabulum of pelvis Ball and socket joint Very stable

10 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Joint Capsule Completely surrounds joint, attaching to the labrum of the acetabular socket Passes over a fat pad internally to join to the distal aspect of femoral neck Zona orbicularis

11 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Ligaments of Hip Joint Iliofemoral ligament –Limits hyperextension Pubofemoral ligament –Limits abduction and hyperextension Ischiofemoral ligament –Limits extension

12 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Femoral Triangle Borders –Inguinal ligament— superior –Sartorius—lateral –Adductor longus—medial Contents –Femoral nerves –Femoral artery –Femoral vein

13 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Q-Angle Angle between line of resultant force produced by quadriceps and line of patellar tendon Males 13°; females 18°

15 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Muscles

16 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Muscles (cont.)

17 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Muscles (cont.)

18 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerves Lumbar plexus –Femoral nerve –Obturator nerve Sacral plexus –Sciatic nerve

19 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Blood Vessels External iliac –Femoral Deep femoral Femoral circumflex F16.10

20 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics Pelvis positioning –Pelvis “tilts” to facilitate movement in hip Posterior tilt—assists hip flexion Anterior tilt—assists hip extension Lateral tilt—assists hip abduction

21 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics (cont.) 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 Hip extensors –Gluteus maximus and hamstrings (biceps femoris, semitendinosus, and semimembranosus) Hamstrings—two-joint; hip extension and knee flexion

22 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics (cont.) 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

23 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics (cont.) 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 Medial rotators –Gluteus minimus –Tensor fascia latae, semitendinosus, semimembranosus, gluteus medius, and adductors

24 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinetics Body weight places compression on hip, as does tension in hip muscles Forces are less during standing than with running and walking –Forces translated through the lower extremity; result ↑ compression on hip

25 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Prevention Protective equipment –Hip joint well protected but iliac and pelvis need protection –Thigh Physical conditioning Shoes –Cushion forces

26 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions Hip pointer –Mechanism: direct blow to iliac crest Common—anterior or lateral portion of crest Often from improperly fitting (or absent) hip pads

27 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont.) –S&S Point tenderness; swelling; ecchymosis Individual prefers slightly forward flexed position to relieve tension of abdominals and iliopsoas Antalgic gait with shortened swing phase ↑ pain with active trunk flexion and active hip flexion Pain with coughing, laughing, breathing Abdominal muscle spasm –Management: standard acute; rest; protect with hard-shell pad for return to activity

28 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont.) Quadriceps contusion –Mechanism: direct blow –Common – anterolateral thigh –S&S Transitory loss of function With continued play, progressively stiffer and unresponsive ↑ pain with active knee extension and hip flexion Limited AROM due to pain; knee flexion limited actively and passively

29 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont.) –Management: Standard acute; with knee in maximum flexion Hard-shell pad for return to activity Physician referral if myositis ossificans or compartment syndrome is suspected

30 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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

32 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont.) –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 –Self-limiting injury –Maturation—6–12 months

33 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont.) Compartment syndrome –Neurovascular compression –Due to uncontrolled internal bleeding and swelling –S&S Progressive, severe pain with passive motion and isometric contraction of quadriceps  pressure → ↓ femoral sensation and motor weakness; distal pulse and capillary refill may be normal –Management: ice (no compression); immediate physician referral

34 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis Mechanism –Excessive friction or shear forces due to overuse –Posttraumatic bursitis from direct blows that cause bleeding in the bursa Greater trochanteric bursitis –Influence of Q-angle

35 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont.) –S&S Burning or aching over or posterior to greater trochanter Aggravated with: Hip abduction against resistance Hip flexion and extension on weight bearing Referred pain—lateral aspect of the thigh

36 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont.) Iliopsoas bursitis –Pain medial and anterior to joint; cannot be easily palpated – pain with passive hip rotation; resisted hip flexion, abduction, and external rotation Ischial bursitis –Pain aggravated by prolonged sitting and uphill running, –Point tenderness directly over ischial tuberosity – pain with passive and resisted hip extension

37 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont.) Bursitis management –Standard acute; deep friction massage; NSAIDs; stretching program for involved muscle –On-going prevention: biomechanical analysis; technique analysis

38 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont.) Snapping hip syndrome –Causes: intra- and extra-articular (refer to Box 15.2) –Types External—IT band or gluteus maximus snapping over greater trochanter during hip flexion → trochanteric bursitis Internal—iliopsoas snaps over structures deep to musculotendinous unit (e.g., iliopsoas bursa) Intra-articular—lesions of the joint (e.g., labral tear)

39 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont.) –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 –Management: NSAIDs; rehabilitation program to address specific deficits

40 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Sprains and Dislocations Mechanism –Violent twisting actions –With hip and knee flexed to 90°, force through shaft of femur

41 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Sprains and Dislocations (cont.) S&S –Mild/moderate: pain with internal rotation –Severe: intense pain; inability to move hip –Position of flexion and internal rotation Management –Mild/moderate—standard acute –Severe—activate EMS; immobilize in position found; assess distal vascular integrity; monitor and treat for shock; NPO

42 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Dislocation

43 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains Mechanism –Explosive movements –Tensile stress from overstretching Muscles –Quadriceps Typically rectus femoris

44 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont.) –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 Strength imbalance –Adductors Common with quick change of direction and explosive propulsion and acceleration Strength imbalance

45 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont.) S&S –Point tender with palpable spasm –Possible palpable defect/divot –Ecchymosis may or may not be present –Pain with AROM; pain with PROM (muscles placed on stretch)

46 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont.) Piriformis strain –In some individuals, sciatic nerve passes through or above piriformis, subjecting nerve to compression from trauma, hemorrhage, or spasm

47 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont.) –S&S History of prolonged sitting, overuse, recent ↑ in activity, or buttock trauma Dull ache in midbuttock—worse at night Numbness or weakness may extend down posterior leg ↑ pain or weakness during: Passive hip flexion, adduction, and internal rotation Active hip external rotation Resisted hip external rotation

48 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont.) Predisposing factors –Beginning of season – too much too soon –Fatigue –History of strains; reinjury common –Restricted flexibility of involved muscle group Management: standard acute; restrict weight bearing if unable to assume normal gait

49 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Vascular and Neural Disorders Legg-Calvé-Perthes disease –Avascular necrosis of proximal femoral epiphysis –Seen esp in males ages 3–8 –Osteochondrosis - femoral head –S&S Gradual onset of limp and mild hip or knee pain of several months in duration Pain -activity related  ROM in hip abduction, extension, and external rotation due to spasm in hip flexors and adductors

50 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Vascular and Neural Disorders (cont.) Venous disorders –Direct blow may damage a vein causing Thrombophlebitis  Superficial thrombophlebitis (ST)  Deep venous thrombosis (DVT) Phlebothrombosis

51 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Vascular and Neural Disorders (cont.) –S&S ST—acute, red, hot, palpable, tender cord in course of a superficial vein Extension of ST to deep veins—via proximal long and short saphenous veins to common femoral and popliteal veins, respectively –Management: anticoagulant therapy; external support (e.g., compression stockings); therapeutic exercise

52 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Vascular and Neural Disorders (cont.) Toxic synovitis of hip –Transient inflammatory condition –Painful hip joint with an antalgic gait –Management: physician referral Obturator nerve entrapment –Possible causes: pelvic tumors, obturator hernias, or pelvic and proximal femoral fractures –S&S: exercise-induced medial thigh pain; described as vague groin or medial knee pain –Management: physician referral

53 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures Avulsion fractures –Apophyseal sites ASIS with displacement of sartorius AIIS with rectus femoris displacement Ischial tuberosity with hamstrings displacement Lesser trochanter with iliopsoas displacement –Due to rapid, sudden acceleration and deceleration

54 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont.) –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 –Management: immobilize with elastic bandage; fit with crutches; immediate physician referral

55 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont.) Slipped capital femoral epiphysis –Boys ages 12–15 –Femoral head slips at epiphyseal plate— displaces inferiorly and posteriorly relative to femoral neck

56 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont.) –S&S Early stages—diffuse knee pain Later stages More comfortable holding leg in slight flexion Unable to touch abdomen with thigh because hip externally rotates with flexion Unable to rotate femur internally or stand on one leg –Management: fit with crutches; physician referral

57 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont.) Stress fractures –Pubis, femoral neck, and proximal one-third of femur –Risk factors

58 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont.) –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 Pain with deep palpation in inguinal ↑ pain on extremes of hip rotation + Trendelenburg sign –Management: physician referral

59 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont.) Osteitis pubis –Continued stress on pubic symphysis From repeated overload of the adductor muscles From repetitive running activities –S&S Gradual onset of pain in the adductor musculature, aggravated by kicking, running, and pivoting on one leg  pain with sit-ups and abdominal strengthening exercises Pain may radiate distally into groin or medial thigh –Management: standard acute—treat symptoms

60 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

61 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Femoral Fractures Mechanism –Tremendous impact forces –Direct compressive forces Potential for neurovascular damage

62 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Femoral Fractures (cont.) S&S –Previous history of femoral stress fracture ↑ risk of complete fracture –Extreme pain and inability/unwillingness to move involved side –Shock –Neck Individual supine, lower extremity in external rotation and abduction; appears shortened compared with other side –Shaft Limb appears shortened; thigh appears externally rotated

63 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Femoral Fractures (cont.) 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

64 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment History Observation/inspection –Contranutation and nutation Palpation Physical examination tests

65 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Observation Contranutation at the SI joint –Indicates anterior torsion of joint, or posterior rotation of sacrum on ilium on one side Nutation –Backward rotation of ilium on sacrum

66 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Range of Motion (ROM) Active range of motion (AROM) –Hip Flexion Extension Abduction Adduction Lateral rotation Medial rotation

67 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.) –Knee Flexion Extension

68 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.) Normal ranges –Hip flexion (110–120°) with knee flexed –Hip extension (10–15°) –Abduction (30–50°) –Adduction (30°) –Lateral rotation (40–60°) –Medial rotation (30–40°) –Knee flexion (0–135°) –Knee extension (0–15°)

69 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.)

70 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.) Passive range of motion (PROM) –Normal end feel Hip flexion and adduction—tissue approximation Hip extension, abduction, and medial and lateral rotation—tissue stretch –Passive movements at pelvic joint also stress the ligamentous structures Sacroiliac compression and distraction test

71 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.) RROM

72 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.)

73 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.)

74 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Stress Tests Sacroiliac compression and distraction test “Squish” test Sacroiliac rocking test

75 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Stress Tests Approximation test Patrick’s (FABER) test

76 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests Leg length measurement –Anatomic –Apparent

77 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests (cont.) Thomas Test for flexion contractures

78 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests (cont.) Gaenslen’s test

79 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests (cont.) Kendall test for rectus femoris contracture Hamstring contracture test 90° – 90° straight leg raising test

80 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests (cont.) Straight leg raising (Lasegue's) test Trendelenburg test

81 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests (cont.) Piriformis test Long sitting test Ober’s test

82 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests (cont.) Sign of the buttock test

83 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests Myotomes –Hip flexion—L1, L2 –Knee extension—L3 –Ankle dorsiflexion—L4 –Toe extension—L5 –Ankle plantarflexion, foot eversion, or hip extension—S1 –Knee flexion—S2 Reflexes –No specific reflexes to test the pelvic or hip area –Lower extremity reflexes Patella—L3, L4 Achilles tendon—S1

84 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests (cont.) Dermatomes F16.35

85 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests (cont.) Cutaneous patterns

86 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Rehabilitation Restoration of motion –Refer to Field Strategies 16.1 and 17.1 Restoration of proprioception and balance –Closed-chain exercises Muscular strength, endurance, and power –Open-chain exercises –PNF-resisted exercises Cardiovascular fitness


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