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Chapter 10 Hip Injuries.

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1 Chapter 10 Hip Injuries

2 Bones of the Pelvic Girdle
Pelvis (right and left) Parts to know: Sacrum Pubic Symphysis Coccyx Sacroiliac Joint (p. 45 in Anatomy Coloring Workbook) The pelvic girdle consists of the Pelvis (right and left), the sacrum, and the coccyx. Although the pelvis is deep to surrounding muscles, organs and adipose tissue, aspects of it are easily palpable. Pubic Symphysis – Anterior joint (Amphiarthrodial Joint – cartilaginous joint) between the two pelvic bones with cartilage in between the bones. Sacroiliac Joint - is the joint in the bony pelvis between the sacrum and the ilium of the pelvis, which are joined by strong ligaments. In humans, the sacrum supports the spine and is supported in turn by an ilium on each side. Sacroiliac joints are paired C-shaped or L-shaped joints capable of a small amount of movement (2–18 degrees, which is debatable at this time) that are formed between the articular surfaces of the sacrum and the ilium bones. The joints are covered by two different kinds of cartilage; the sacral surface has hyaline cartilage and the ilial surface has fibrocartilage. The SIJ's stability is maintained mainly through a combination of only some bony structure and very strong intrinsic and extrinsic ligaments.

3 Pelvis Bones of the Pelvis Ilium Ischium Pubis
After birth and during early childhood, the pelvis consists of three separate bones: ilium, ischium and the pubis. By the adult years, these bones have fused firmly together and their boundaries cannot be distinguished. However, their names are retained for reference to different portions of the pelvic bones. Processes therefore include the names of the three bones. Each of the three bones form a cuplike acetabulum seen in the lateral view which helps form the receiving end for the head of the femur which creates the hip joint.

4 Parts of the Pelvis Parts of the Pelvis to know:
Anterior Inferior Iliac Spine (AIIS) Anterior Superior Iliac Spine (ASIS) Iliac Crest Posterior Superior Iliac Spine (PSIS) Posterior Inferior Iliac Spine (PIIS) Greater Sciatic Notch Ischial Spine Lesser Sciatic Notch Ischial Tuberosity Ramus of the Ischium Pubic Tubercle Superior Ramus Inferior Ramus Body of the Pubis Obturator Foramen Acetabulum Parts of the Pelvis to know: Anterior Inferior Iliac Spine (AIIS) – is a bony eminence on the anterior border of the hip bone, or, more precisely, the wing of the ilium (i.e. the upper lateral parts of the pelvis). Anterior Superior Iliac Spine (ASIS) – is a bony projection of the iliac bone and an important landmark of surface anatomy. It refers to the anterior extremity of the iliac crest of the pelvis, which provides attachment for the inguinal ligament, and the sartorius muscle. Iliac Crest – is the curved superior border of the ilium, the largest of the three bones that merge to form the os coxa, or hip bone. It is located on the superior and lateral edge of the ilium very close to the surface of the skin in the hip region. Posterior Superior Iliac Spine (PSIS) – the posterior extremity of the iliac crest, the uppermost point of attachment of the sacrotuberous and posterior sacroiliac ligaments; a readily apparent dimple occurs in the skin overlying the posterior superior iliac spine that is clinically useful as an indication of the level of the S2 vertebra, the level of the inferior limit of the subarachnoid space. Posterior Inferior Iliac Spine (PIIS) – projection on the posterior margin of the ilium that is situated below the posterior superior iliac spine and is separated from it by a notch Greater Sciatic Notch – the deep indentation in the posterior border of the hip bone at the point of union of the ilium and ischium. Ischial Spine – thin pointed triangular eminence that projects from the dorsal border of the ischium and gives attachment to the several muscles. Lesser Sciatic Notch – Below the ischial spine is a small notch, the lesser sciatic notch; it is smooth, coated in the recent state with cartilage, the surface of which presents two or three ridges corresponding to the subdivisions of the tendon of the Obturator internus, which winds over it. Ischial Tuberosity - is a large swelling posteriorly on the superior ramus of the ischium. It marks the lateral boundary of the pelvic outlet. When sitting the body’s weight is placed on the ischial tuberosity, the strongest part of the pelvic girdle. Ramus of the Ischium – the portion of the bone that passes forward from the ischial tuberosity to join the inferior ramus of the pubic bone, thus forming the ischiopubic ramus. Pubic Tubercle – is a prominent forward-projecting tubercle on the upper border of the medial portion of the superior ramus of the pubis. The inguinal ligament attaches to it. The pubic spine is a rough ridge that extend from the pubic tubercle to the upper border of pubic symphysis. Superior Ramus – is a part of the pubic bone which forms a portion of the obturator foramen. It extends from the body to the median plane where it articulates with its fellow of the opposite side. Inferior Ramus – is a part of the pelvis and is thin and flat. It passes laterally and downward from the medial end of the superior ramus; it becomes narrower as it descends and joins with the inferior ramus of the ischium below the obturator foramen. Body of the Pubis – forms the wide, strong, medial and flat portion of the pubic bone which unite in the pubic symphysis. The rough superior edge of the corpus, the pubic crest, ends laterally in the pubic tubercle. Obturator Foramen – a large opening in the hipbone between the pubis and the ischium. Acetabulum - the socket of the hipbone, into which the head of the femur fits.

5 Sacrum & Coccyx Parts to Know: Sacrum Base of the Sacrum Sacral Canal
Median Sacral Crest Sacral Cornua Sacral Hiatus Sacral Foramen Ala Lateral Sacral Crest Apex of the Sacrum Coccyx Coccygeal Vertebrae Coccygeal Cornu Transverse Processes Parts to Know: Sacrum Base of the Sacrum - is broad and expanded, is directed upward and forward. In the middle is a large oval articular surface, the upper surface of the body of the first sacral vertebra, which is connected with the under surface of the body of the last lumbar vertebra by an intervertebral fibrocartilage. Sacral Canal - is a continuation of the vertebral canal and runs throughout the greater part of the sacral bone. Above the sacrum, it is triangular in form and below its posterior wall is incomplete, from the non-development of the laminae and spinous processes. Median Sacral Crest – an unpaired crest formed by the fused spinous processes of the upper four sacral vertebrae. Sacral Cornu – Sacral Cornu (singular); Sacral Cornua (plural); rounded process on each side of the fifth sacral vertebra that projects downward and represents an inferior articular process of the vertebra. Sacral Hiatus – normally occurring gap at the lower end of the sacrum, exposing the vertebral canal, due to failure of the laminae of the last sacral segment to coalesce. Sacral Foramen – any of 16 openings in the sacrum of which there are four on each side of the dorsal surface giving passage to the posterior branches of the sacral nerves and four on each side of the pelvic surface giving passage to the anterior branches of the sacral nerves. Ala – the upper surface of the lateral part of the sacrum adjacent to the body. Lateral Sacral Crest – crests that are rough ridges lying lateral to the sacral foramina; they represent the fused transverse processes of sacral vertebrae. Apex of the Sacrum – the tapering lower end of the sacrum that articulates with the coccyx. Coccyx Coccygeal Vertebrae – is the final segment of the vertebral column in humans and apes. Comprising three to five separate or fused coccygeal vertebrae below the sacrum. Coccygeal Cornua – two processes that project upward from the dorsum of the base of the coccyx to articulate with the sacral cornua. Transverse Processes - a lateral process of a vertebra; the transverse processes are most prominent and noticeable on the first coccygeal segment.

6 Bones of the Hip Pelvis Femur Parts to know: Greater Trochanter
Head of the Femur Neck of the Femur Lesser Trochanter Shaft of the Femur Linea Aspera Lateral Condyle of the Femur Lateral Epicondyle of the Femur Medial Condyle of the Femur Medial Epicondyle of the Femur Patellar Surface Popliteal Surface Intercondylar Fossa Review from Ch. 9 Anterior view Posterior view

7 Muscles of the Hip Rectus Femoris Origin
Anterior Inferior Iliac Spine (AIIS) Insertion Tibial Tuberosity via the patellar tendon Action Extend the knee Flex the hip Two –joint muscle so will have actions at both joints. Large muscle over the femur The rectus femoris muscle (/ˈrɛktəs ˈfɛmərɨs/) is one of the four quadriceps muscles of the human body. The others are the vastus medialis, the vastus intermedius (deep to the rectus femoris), and the vastus lateralis. All four parts of the quadriceps muscle attach to the patella (knee cap) via the quadriceps tendon.

8 Muscles of the Hip Vastus Lateralis Origin
Lateral lip of linea aspera, gluteal tuberosity, and greater trochanter. Insertion Tibial tuberosity via the patellar tendon. Action Extend the knee. Vastus = Large Lateralis = Lateral side The Vastus lateralis (/ˈvæstəsˌlætəˈreɪlɨs/ or /ˈvæstəsˌlætəˈrælɨs/); (vastus externus) is the largest part of the quadriceps femoris.

9 Muscles of the Hip Vastus Lateralis (posterior view)

10 Muscles of the Hip Vastus Intermedius Origin
Anterior and lateral shaft of the femur. Insertion Tibial tuberosity via the patellar tendon. Action Extend the knee. Only visible on the deep view because it lies under the Rectus Femoris muscle. Vastus = Large muscle Intermedius = in the middle the division of the quadriceps muscle that arises from and covers the front of the shaft of the femur.

11 Muscles of the Hip Vastus Medialis Origin
Medial lip of the linea aspera. Insertion Tibial tuberosity via the patellar tendon. Action Extend the knee. Vastus = Large muscle Medialis = Medial side Rectus Femoris, Vastus Lateralis, Vastus Intermedius and Vastus Medialis for the Quadriceps group. Quad = 4 ceps = heads. is a muscle present in the anterior compartment of thigh, and is one of the four muscles that make up the quadriceps muscle. It is the most medial of the "vastus" group of muscles, the others being vastus intermedius and vastus lateralis.

12 Muscles of the Hip Sartorius Origin
Anterior Superior Iliac Spine (ASIS) Insertion Proximal, medial shaft of the tibia at the pes anserinus Action Flex the hip, laterally rotate the hip, abduct the hip, flex the knee, medially rotate the flexed knee a long, narrow muscle running obliquely across the front of each thigh from the hipbone to the inside of the leg below the knee. Longest muscle in the human body.

13 Muscles of the Hip Sartorius (posterior view)

14 Muscles of the Hip Gracilis Origin Inferior ramus of the pubis
Insertion Proximal, medial shaft of the tibia at pes anserinus Action Adduct hip, medially rotate hip, flex the knee, medially rotate the flexed knee a slender superficial muscle of the inner thigh.

15 Muscles of the Hip Gracilis (posterior view)

16 Muscles of the Hip Pectineus Origin Insertion Action
Superior ramus of the pubis. Insertion Pectineal line of the femur. Action Adduct the hip, medially rotate the hip, assist to flex the hip. The pectineus muscle (from the Latin word pecten, meaning comb) is a flat, quadrangular muscle, situated at the anterior (front) part of the upper and medial (inner) aspect of the thigh. The pectineus muscle is the most anterior adductor of the hip.

17 Muscles of the Hip Adductor Longus Origin Pubic tubercle. Insertion
Medial lip of the linea aspera. Action Adduct the hip, medially rotate the hip, flex the hip. In the human body, the adductor longus is a skeletal muscle located in the thigh. One of the adductor muscles of the hip, its main function is to adduct the thigh and it is innervated by the obturator nerve. It forms the medial wall of the femoral triangle.

18 Muscles of the Hip Adductor Magnus Origin
Inferior ramus of the pubis, ramus of the ischium and ischial tuberosity. Insertion Medial lip of the linea aspera and adductor tubercle. Action Adduct the hip, medially rotate the hip, flex the hip. Posterior fibers of the Adductor Magnus also help to extend the hip. The adductor magnus is a large triangular muscle, situated on the medial side of the thigh.

19 Muscles of the Hip Adductor Magnus (posterior view)

20 Muscles of the Hip Adductor Brevis Origin Inferior ramus of the pubis.
Insertion Pectineal line and medial lip of the linea aspera. Action Adduct the hip, medially rotate the hip, flex the hip. The adductor brevis is a muscle in the thigh situated immediately deep to the pectineus and adductor longus.

21 Muscles of the Hip Tensor Fascia Latae and the Iliotibial Band Origin
Iliac crest, posterior to the ASIS Insertion Iliotibial tract (which then inserts on the tibial tubercle on the lateral aspect of the proximal tibia) Action Flex the hip, medially rotate the hip, abduct the hip Tensor = a stretcher Fascia = connective tissue Latae = broad

22 Muscles of the Hip Iliacus Origin Insertion Action Iliac fossa.
Lesser trochanter of the femur. Action Flex the hip, laterally rotate the hip, flex the trunk toward the thigh, tilt the pelvis anteriorly. The iliacus and the psoas major muscle are commonly referred to as the iliopsoas muscles. Located deep to the abdomen in the iliac fossa.

23 Muscles of the Hip Psoas Major Origin Insertion Action
Bodies and transverse processes of lumbar vertebrae. Insertion Lesser trochanter of the femur. Action Flex the hip, laterally rotate the hip, flex the trunk towards the thigh, tilt the pelvis anteriorly, assist in laterally flexing the lumbar spine. Best known to your local butcher as the “tenderloin” or “filet mignon,” the long slender psoas major is located deep to the abdominal contents. It stretches from the lumbar vertebrae, underneath the inguinal ligament, to the lesser trochanter of the femur.

24 Muscles of the Hip Psoas Minor Origin Insertion Action
Body and transverse process of first lumbar vertebra. Insertion Superior ramus of the pubis. Action Helps to create lordotic curvature in the lumbar spine, tilt the pelvis posteriorly. Roughly 40% of the population has a psoas minor muscle. It is a small muscle which extends from the lumbar vertebrae to the superior ramus of the pubis. When present, the psoas minor assists in posterior tilt (upward rotation) of the pelvis – the opposite of the psoas major. The psoas minor is important to locomotion of a dog or cat, but is relatively insignificant in the human.

25 Muscles of the Hip Quadratus Lumborum Origin Insertion Action
Posterior iliac crest. Insertion Last rib and transverse processes of first through fourth lumbar vertebrae. Action Laterally tilt pelvis (elevate side), laterally flex the vertebral column to the same side, assist in extension of the vertebral column, fix the last rib during forced inhalation and exhalation. Although it would seem to be the deepest muscle of the low back, the quadratus lumborum is the deepest muscle of the abdomen. Stretching from the posterior ilium to the transverse processes of the lumbar vertebrae and the 12th rib, this squat muscle is simply an abdominal muscle located on the posterior surface of the thorax. While the medial portion of the quadratus lumborum is buried beneath the thoracolumbar aponeurosis and the thick erector spinae, its lateral edge is accessible from the side of the torso.

26 Muscles of the Hip Semimembranosus Origin Ischial tuberosity.
Insertion Posterior aspect of medial condyle of tibia. Action Flex the knee, medially rotate the flexed knee, extend the hip, assist in medially rotating the hip, tilt the pelvis posteriorly Sits under the Semitendinosus muscle.

27 Muscles of the Hip Semitendinosus Origin Ischial tuberosity. Insertion
Proximal, medial shaft of the tibia at pes anserinus. Action Flex the knee, medially rotate the flexed knee, extend the hip, assist to medially rotate the hip, tilt the pelvis posteriorly. Sits over the Semimembranosus muscle.

28 Muscles of the Hip Biceps Femoris Origin
Long head: Ischial tuberosity. Short head: Lateral lip of the linea aspera. Insertion Head of the fibula. Action Flex the knee, laterally rotate the flexed knee, Long head: extend the hip and assist to laterally rotate the hip, tilt the pelvis posteriorly.

29 Muscles of the Hip Quadratus Femoris Origin Insertion Action
Lateral border of the ischial tuberosity. Insertion Intertrochanteric crest, between the greater and lesser trochanters. Action Laterally rotate the hip.

30 Muscles of the Hip Obturator Externus Origin Insertion Action
Rami of pubis and ischium, obturator membrane. Insertion Trochanteric fossa of the femur. Action Laterally rotate the hip.

31 Muscles of the Hip Obturator Internus Origin Insertion Action
Obturator membrane and inferior surface of the obturator foramen. Insertion Medial surface of the greater trochanter. Action Laterally rotate the hip.

32 Muscles of the Hip Inferior Gemellus Origin Insertion Action
Ischial tuberosity. Insertion Medial surface of the greater trochanter. Action Laterally rotate the hip.

33 Muscles of the Hip Superior Gemellus Origin Insertion Action
Ischial spine. Insertion Medial surface of the greater trochanter. Action Laterally rotate the hip.

34 Muscles of the Hip Piriformis Origin Insertion Action
Anterior surface of sacrum. Insertion Superior aspect of the greater trochanter. Action Laterally rotate the hip and abduct the hip when the hip is flexed.

35 Muscles of the Hip Gluteus Minimus Origin Insertion Action
Gluteal surface of the ilium between the anterior and inferior gluteal lines. Insertion Anterior aspect of the greater trochanter. Action Abduct the hip, medially rotate the hip, and flex the hip.

36 Muscles of the Hip Gluteus Medius Origin Insertion Action
Gluteal surface of the ilium, between the posterior and anterior gluteal lines, just below the iliac crest. Insertion Lateral aspect of the greater trochanter. Action Abduct the hip, flex the hip (anterior fibers), medially rotate the hip (anterior fibers), extend the hip (posterior fibers) and laterally rotate the hip (posterior fibers).

37 Muscles of the Hip Gluteus Maximus Origin Insertion Action
Coccyx, edge of sacrum, posterior iliac crest, sacrotuberous and sacroiliac ligaments. Insertion Iliotibial tract (upper fibers) and gluteal tuberosity (lower fibers). Action Extend the hip (all fibers), laterally rotate the hip (all fibers), abduct the hip (all fibers), adduct the hip (lower fibers).

38 ROM of the Hip Joint Adduction Abduction Flexion Extension
Internal Rotation External Rotation Torso Flexion Torso Extension Lateral Flexion Lateral Rotation Circumduction

39 Muscle Groups of the Hip
Hip flexors Psoas Major Psoas Minor Iliacus Rectus Femoris Tensor Fascia Latae Sartorius Hip Extensors Gluteus Maximus Biceps Femoris Semimembranosus Semitendinosus Piriformis Hip Adductors Adductor Longus Adductor Magnus Adductor Brevis Gracilis Pectineus Hip Abductors Gluteus Medius Gluteus Minimus Piriformis

40 Muscles Groups of the Hip
Medial Rotators Gluteus medius Gluteus Minimus Tensor Fascia Latae Lateral Rotators Gluteus maximus Piriformis Superior Gemellus Inferior Gemellus Obturator Internus Obturator Externus Quadratus Femoris

41 Common Injuries Groin strains Trochanteric Bursitis
Testicular Contusion Hip Pointer (contusion) Hip Dislocation Avascular Necrosis Femur Fracture Thigh Contusion Myositis Ossificans Avulsion Fractures/Apophysitis Osteitis Pubis Piriformis Syndrome Legg-Calve’-Perthes Disease (Coxa Plana) Slipped Capital Femoral Epiphysis

42 Groin Strain Etiology Groin strain Pathology Treatment
Etiology - The groin is the region that lies on the medial and anterior aspect of the upper thigh. The musculature of this area includes the iliopsoas, the rectus femoris, and the adductor group (gracilis, pectineus, adductor brevis, adductor longus, and adductor magnus). Groin pain is one of the more difficult problems to diagnose, especially if it is chronic. Any one of the muscles in the region of the groin can be injured during sports activity and elicit what is commonly considered a groin strain. The adductor longus muscle is most often strained. Running, jumping, or twisting with external rotation can produce such injuries. Pathology – The groin is one of the most difficult injuries to care for in sports. The strain can be felt in a sudden twinge or feeling of tearing during an active movement, or the athlete may not notice it until after the termination of the activity. Like most tears, the groin strain produces pain, weakness, and internal hemorrhage. Treatment – If it is detected immediately after it occurs, the strain should be treated by PRICE, NSAIDs, and analgesics as needed for 48 – 72 hours. Passive, active, and resistive muscle tests should be given to determine the exact muscle or muscles involved. The ATC frequently encounters difficulty when attempting to care for a groin strain. Rest has been the best treatment. Daily whirlpool therapy or cryotherapy are palliative ( (of a treatment or medicine) relieving pain or alleviating a problem without dealing with the underlying cause.); ultrasound offers a more definite approach. Exercise should be delayed until the groin is pain free. Exercise rehabilitation should emphasize gradual stretching and restoration of the normal ROM. Until normal flexibility and strength are developed, a protective spice bandage or commercial brace should be applied.

43 Trochanteric Bursitis
Etiology Pathology Treatment Injection procedure Etiology - Trochanteric bursitis is a relatively common condition of the greater trochanter of the femur. Although commonly called bursitis, the condition also could be an inflammation at the site where the gluteus medius muscle inserts or the iliotibial band passes over the trochanter. Pathology – The athlete complains of pain in the lateral hip. Pain may radiate down to the knee, causing a limp. Palpation reveals tenderness over the lateral aspect of the great trochanter. The ATC should perform tests for tensor fascia latae and iliotibial band tightness. Treatment – Therapy includes PRICE, NSAIDs, and analgesics as needed. ROM exercises and progressive resistance exercises (PREs) directed toward the hip adductors and external rotators should follow. Phonophoresis (is the use of ultrasound to enhance the delivery of topically applied drugs. Phonophoresis has been used in an effort to enhance the absorption of topically applied analgesics and anti-inflammatory agents through the therapeutic application of ultrasound) may be added if the athlete does not respond in three to four days. The athlete’s return to running should be cautious; the athlete should avoid running on inclined surfaces. Faulty running form, leg-length discrepancy, and faulty foot biomechanics must be taken into consideration. The condition is most common among women runners who have increased Q-angle or a leg-length discrepancy.

44 Testicular Contusion Etiology Pathology Treatment
Etiology - A testicular contusion is when an accident injures blood vessels in the testicle, it can cause a contusion, which involves bleeding and bruising. Blunt trauma (a strike) causes about 75% of testicular injuries. Examples include: •Getting kicked •Getting hit by a baseball •Motorcycle accident •Bicycle accident Pathology – As many men and boys know all too well, a testicular injury typically causes substantial pain in the scrotum. There is sometimes pain in the abdomen, as well. Other symptoms can include: •Nausea (especially common with testicular torsion) •Bruising or discoloration of the scrotum •Swelling of the scrotum •Blood in the urine •Difficulty urinating •Fever Treatment - Treatments for some types of testicular trauma include: •Placing an ice pack against your scrotum •Resting and avoiding strenuous activity •Medication to treat pain and inflammation •Antibiotics to prevent or treat infection •Wearing a jockstrap to support your testicles

45 Hip Pointer (Contusion)
Etiology Hip pointer Pathology Treatment Etiology - Iliac crest contusion and contusion of the abdominal musculature, commonly known as a hip pointer, occurs most often in contact and collision sports. The hip pointer results from a blow to an inadequately protected iliac crest. The hip pointer is considered one of the most handicapping injuries in sports and one that is difficult to manage. A direct force to the unprotected iliac crest causes severe pinching action to the soft tissue of that region. Pathology – A hip pointer produces immediate pain, spasms, and transitory paralysis of the soft structures. As a result, the athlete is unable to rotate the trunk or to flex the thigh without pain. Treatment – PRICE should be applied immediately after the injury occurs and should be maintained for at least 48 hours. In severe cases, bed rest for one to two days will speed recovery. The mechanism for the hip pointer injury is either a direct blow or fall on the iliac crest. The athlete must be referred to a physician, and an X-ray must be performed to rule out an iliac crest fracture or epiphyseal separation. A variety of treatment procedures can be used for this injury. Ice massage and ultrasound have been found to be beneficial. Initially the injury may be injected with a steroid to reduce inflammation. Later, an oral anti-inflammatory agent may be used. When returning to participation the body part should be padded properly to prevent re-injury and offer more protection. Recovery time usually ranges from one to three weeks.

46 Hip Dislocation Etiology Hip Dislocation Pathology Treatment
Etiology - Dislocation of the hip joint rarely occurs in sports and then usually only as the end result of traumatic force directed along the axis of the femur. Such dislocations are produced when the knee is bent. The most common displacement is one posterior to the acetabulum, with the femoral shaft adducted and flexed. Pathology – The injury presents a picture of a flexed, adducted, and internally rotated thigh (posterior displacement). Palpation will reveal that the head of the femur has moved to a position posterior to the acetabulum. A hip dislocation causes serious pathology by tearing capsular and ligamentous tissue. A fracture is often associated with this injury, accompanied by possible damage to the sciatic nerve. If the injury presents with a abducted, flexed and externally rotated thigh the you should suspect an anterior displacement, but this is much less common than the posterior displacement. Treatment – Splint/stabilize the body part in the position they are found in. May need to use rolled towels or pillows to provide support for the athlete’s injured leg. Should be backboarded and immediately transported to the ER for medical attention. Muscle contractures may complicate the reduction of the joint. Immobilization usually consists of two weeks of bed rest and the use of crutches for walking a month or longer. Complications – Complication of the posterior hip dislocation is likely, with such possibilities as a palsy of the sciatic nerve and later the development of osteoarthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward. It causes pain and stiffness, especially in the hip, knee, and thumb joints). Hip dislocations also can lead to disruption of the blood supply to the head of the femur which eventually leads to the degenerative condition known as avascular necrosis.

47 Avascular Necrosis Etiology Pathology Treatment
Etiology - Avascular necrosis is a condition that results from the temporary or permanent loss of blood supply to the proximal femur. Without blood, the bone tissue dies and causes collapse of the joint surface. Avascular necrosis has several causes. Loss of blood to the bone can be caused by an injury such as a hip dislocation (trauma related avascular necrosis) in which the blood vessels may be damaged, thus interfering with the circulation to the bone. In a hip dislocation, the lateral circumflex artery, which supplies most of the blood to the femoral head, can be compromised, thus interfering with circulation. If this condition is not quickly rectified the chances of developing avascular necrosis are greatly increased. Certain other risk factors (nontraumatic avascular necrosis), such as use of some medications (steroids), blood coagulation disorders, or excessive alcohol use, can create increased pressure within the bone, causing the blood vessels to narrow making it hard for the vessels to deliver enough blood to the bone cells. Pathology – In the early stages of avascular necrosis, the athlete may not have any symptoms. As the disease progresses, however, most individuals experience joint pain – at first, only when weight bearing on the affected joint, and then even when resting. Pain usually develops gradually and may be mild or severe. If avascular necrosis progresses and the bone and surrounding joint surface collapse, pain may develop or increase dramatically. Pain may be severe enough to limit the athlete’s ROM in the affected joint. In some cases, osteoarthritis may develop. The period of time between the first symptoms and loss of joint function is different for each individual, ranging from several months to more than a year. Treatment – In cases of suspected avascular necrosis, the athlete should be referred to a physician for an MRI, X-ray, or CT scan. The goal in treating avascular necrosis is to improve the athlete’s use of the affected joint, stop further damage to the bone, and ensure bone and joint survival. Several conservative treatments are available that can help prevent further bone and joint damage and reduce pain. ROM exercises may be used to maintain or improve joint ROM. Electric stimulation has been recommended to induce bone growth. If avascular necrosis is diagnosed early, the physician may begin treatment by having the athlete be non-weight bearing. When combined with medication to reduce pain, reduced weight bearing can be an effective way to avoid or delay surgery. The use of medications to reduced fatty substances (lipids) that increased with corticosteroid treatment or to reduce blood clotting in the presence of clotting disorders is also recommended. In most cases the athlete will eventually require surgery to repair the joint permanently.

48 Femur Fracture Etiology Pathology Treatment
Etiology - A femoral neck fracture is a condition characterized by a break in the neck of the femur (thigh bone). The femur is the anatomical name given to the long bone of the thigh (figure 1). It is the largest and strongest bone in the body. The neck of the femur refers to the part of the bone which connects the round headed ball of the hip joint to the long shaft of the femur. Following a fall or due to a direct blow to the hip or thigh, stress is placed on the femur. If these forces are excessive and beyond what the femur can withstand, a break in the neck of the bone may occur. When this occurs the condition is known as a femoral neck fracture and can vary from a small undisplaced fracture to a severe displaced (and / or comminuted) fracture with obvious deformity. Femoral neck fractures are particularly common in elderly patients who have poor balance (i.e. are prone to falls) and have reduced bone density due to osteoporosis. Due to the strength of the femoral bone, a femoral neck fracture usually requires a large amount of force in healthy young adults. This typically occurs due to a fall (usually from a height, and often onto a hard surface) or due to a direct blow to the femur such as a motor vehicle accident. The most common clinical presentation of a femoral neck fracture is in older patients (greater than 60) who have weakened bones due to conditions such as osteoporosis, or sometimes, malignancy. In these cases, the injury may occur with minimal force such as a trip, stumble or fall. Pathology – Patients with a femoral neck fracture typically experience a sudden onset of sharp, intense pain in the hip, groin, buttock or thigh at the time of injury. In severe cases, particularly involving a displaced fracture of the femur, weight bearing will be impossible with the patient often unable to get up off the floor without help. In less severe cases, patients may be able to walk (typically with a limp) and may experience symptoms that settle quickly with rest, leaving the patient with an ache at the site of injury which may be particularly prominent at night or first thing in the morning. Occasionally patients may also experience symptoms in the lower back, knee, lower leg, ankle or foot. Patients with a femoral neck fracture may also experience swelling, bruising and pain on firmly touching the hip region. Pain usually increases with certain movements of the hip or knee, when sitting or when attempting to stand or walk (particularly up hills or on uneven surfaces). Often the patient's leg will present in a "turned-out" position and will appear to be shorter compared to the unaffected leg. In severe femoral fractures (with bony displacement), an obvious deformity may be noticeable. Occasionally patients may also experience pins and needles or numbness in the hip, groin, thigh, knee, lower leg, ankle or foot. A thorough subjective and objective examination from a physiotherapist is essential to assist with diagnosis of a femoral neck fracture. An X-ray is usually required to confirm diagnosis and assess the severity. Further investigations such as an MRI, CT scan or bone scan may be required, in some cases, to assist with diagnosis and assess the severity of the injury. Treatment - For those femoral neck fractures that are displaced (which is usually the most common presentation), treatment typically involves anatomical reduction (i.e. re-alignment of the fracture via careful manipulation under anesthetic) followed by surgical internal fixation to stabilize the fracture (using rods, plates, pins or screws). This may be followed by a period of rest and the use of walking aids or crutches for a number of weeks. In elderly patients (particularly those with osteoarthritis affecting the hip joint), prosthetic replacement of the hip joint may be indicated. This may be followed by the use of crutches or a walking frame for weeks to months. For those less common, non-displaced fractures, treatment may involve the use of crutches and/or bed rest for a number of weeks. The orthopedic specialist will advise the patient as to which management is most appropriate based on a number of factors, including the location, severity and type of femoral neck fracture. For those patients who are not managed with hip joint replacement, evaluation of the fracture with follow up X-rays is important to ensure the fracture is healing in an ideal position. This is particularly important as blood supply to the femoral head may be damaged during a fracture resulting in significant complications with fracture healing (e.g. delayed healing, non-healing or death of the femoral head due to lack of blood supply, known as avascular necrosis). Once healing is confirmed, rehabilitation and mobilization can progress as guided by the orthopedic surgeon and the treating ATC or PT. One of the most important components of rehabilitation following a femoral neck fracture is that the patient progresses their rehabilitation with exercises and activities which do not increase their pain (crutches are often required). Activities which place large amounts of stress through the femur should also be avoided, particularly excessive weight bearing activities such as running, jumping, standing or walking excessively (especially up hills or on uneven surfaces), lifting or carrying, or, sitting excessively. Rest from aggravating activities allows the healing process to take place in the absence of further damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms. This should take place over a period of weeks to months with direction from the treating ATC/PT. Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to cause further damage and may slow healing or prevent healing of the femoral neck fracture altogether. Patients with a fractured femur should perform pain free flexibility, strengthening and balance exercises as part of their rehabilitation to ensure an optimal outcome. This is particularly important, as balance, soft tissue flexibility and strength are quickly lost with inactivity. Hydrotherapy exercises are also often indicated. The treating ATC/PT can advise which exercises are most appropriate for the patient and when they should be commenced. In the stages following confirmation of fracture healing, manual "hands-on" treatment from a ATC/PT, such as massage, trigger point release techniques, dry needling, joint mobilization, stretches and electrotherapy, can assist with improving range of movement, pain and function, and assist with hastening return to activity. In the final stages of rehabilitation for a femoral neck fracture, a gradual return to activity can occur as guided by the treating ATC/PT provided there is no increase in symptoms. In younger patients, this may involve a gradual return to running program followed by acceleration, deceleration and change of direction drills, before commencing training and eventually match play. Most patients with a non-displaced femoral neck fracture make a full recovery with appropriate management. Patients with a displaced femoral neck fracture that requires surgical internal fixation or hip joint replacement are unlikely to return to high level sporting activity. Depending on the severity of the fracture (and the type of activity), return to activity or some sports usually occurs between 3-12 months. This should be guided by the treating ATC/PT. In patients with severe injuries involving structural deformity or damage to other bones, soft tissue, nerves or blood vessels, recovery time may be significantly prolonged.

49 Thigh Contusion Etiology Pathology Treatment
Etiology - The quadriceps group is usually the muscles involved. They are continually exposed to traumatic blunt blows in a variety of vigorous sports. Contusions usually develop as the result of a severe impact to the relaxed thigh that compresses the muscle against the femur. The extent of the force and the degree of thigh relaxation determine the depth of the injury and the amount of structural and functional disruption that take place. Pathology – Contusions of the quadriceps display all of the classic symptoms for most bruises. Pain, temporary loss of function, and immediate capillary effusion usually occur at the instant of trauma. The athlete usually describes having been hit by a sharp blow to the thigh, which produces intense pain and weakness. Early detection and avoidance of profuse internal hemorrhage are vital, both in effecting a fast recovery and in preventing widespread scarring. Palpation may reveal a circumscribed swollen area that is painful to the touch. Grade 1 contusion – superficial intramuscular bruise that produces mild hemorrhage, little pain, no swelling, and mild point tenderness at the site of trauma. There is no restriction of ROM. Grade 2 contusion – deeper than grade 1 and produces mild pain, mild swelling, and point tenderness, with the athlete unable to flex the knee more than 90 degrees. Grade 3 contusion – moderate pain, moderate swelling, and point tenderness. The athlete can only flex the knee between degrees and has an obvious limp when walking. Grade 4 contusion – The blow may have split the fascia latae, allowing the muscle to protrude (muscle herniation). A characteristic deep intramuscular hematoma (a solid swelling of clotted blood within the tissues) with an intermuscular spread is present. Pain is severe, and swelling may lead to hematoma. Movement of the knee is severely restricted with 45 degrees or less of flexion and a decided limp. Treatment – The leg should be immediately placed in flexion with an ice pack to avoid muscle shortening. PRICE, NSAIDs, and analgesics are given as needed. Crutches may be warranted for 2nd – 4th degree contusions. A hematoma that develops may have to be aspirated. One or two units of blood may be lost into the anterior thigh. After exercise or re-injury, PRICE must be routinely applied to the thigh. Follow-up care consists of ROM exercises, Progressive Resistive Exercises (PREs) within a pain-free limitation. Heat, massage, and ultrasound should be avoided to prevent the possibility of myositis ossificans. Generally, the rehabilitation of a thigh contusion should be handled conservatively. PRICE combined with gentle stretching may be the preferred treatment. If heat therapy is used, it should not be initiated until the acute phase of the injury has clearly passed. An elastic bandage or thigh sleeve should be worn to provide constant pressure and mild support to the quadriceps area. Exercise should be graduated from mild stretching, to swimming (if possible), to jogging, then finally running. Exercises should not be conducted if it produces pain. Medical care of a thigh contusion may include surgical repair of a herniated muscle or aspiration of a hematoma. Some physicians administer enzymes either orally or though injection for the dissolution of the hematoma. Once an athlete has sustained a thigh contusion, he or she must take great care to avoid sustaining another. The athlete should routinely wear a protective pad held in place by an elastic wrap while engaged in sports activities.

50 Myositis Ossificans Etiology Pathology Treatment
Etiology - A severe blow or repeated blows to the thigh, usually the quadriceps muscles, can lead to ectopic bone production, or myositis ossificans. This condition commonly follows bleeding in to the quadriceps muscles and a hematoma. The contusion to the muscle causes disruption of the muscle fibers, capillaries, fibrous connective tissue, and periosteum (a dense layer of vascular connective tissue enveloping the bones except at the surfaces of the joints) of the femur. Acute inflammation follows the resolution of hemorrhage. The irritated tissues may then produce calcified formations that resemble cartilage or bone. Particles of bone may be noted during x-ray examination two to six weeks after the injury. If the injury is to the muscle belly, complete absorption or decrease in size of the formation may occur. This decrease is less likely, however, is calcification is at a muscle origin or insertion. In terms of bone attachment, some formations are completely free of the femur, some are stalk-like (coming off the femur), and some are broadly attached. Improper care of a thigh contusion can also lead to myositis ossificans. The following can initially cause the condition or, once present, can aggravate it, causing it to become more pronounced: Attempts to “run off” a quad contusion Too vigorous treatment of a contusion – for example, massage directly over the contusion, ultrasound therapy, or superficial heat to the thigh. Pathology – The athlete complains of pain, muscle weakness, soreness, swelling, and decreased muscle function. On examination there is tissue tension and point tenderness along with decreased ROM. Treatment – Once myositis ossificans is apparent, treatment should be extremely conservative. If the condition is painful and restrict motion, the formation may be surgically removed after one year with much less likelihood of its return. Too early removal of the formation may cause it to return. Recurrent myositis ossificans may indicate a blood-clotting problem such as hemophilia, which is a rare condition.

51 Avulsion Fractures/Apophysitis
Etiology Pathology Treatment Etiology - The pelvis has a number of apophyses where major muscles make their attachments. An apophysis, or traction epiphysis, is a bony outgrowth and is contrasted to pressure epiphysis, which are the growth plates of long bones. The three most common sites for avulsion fractures and apophysitis (inflammation of an apophysis) in the pelvic region are: The ischial tuberosity - hamstring attachment site Anterior superior iliac spine (ASIS) – sartorius attachment site Anterior inferior iliac spine (AIIS) – rectus femoris attachment site Sports having sudden acceleration or deceleration, such as football, soccer, and basketball, can cause a convulsion, fracture, or an apophysitis. Pathology – The athlete complains of a sudden localized pain within limit of movement. There is swelling and point tenderness. Muscle testing increases pain. Treatment – X-ray examination is routinely given with apophysical pain. Uncomplicated conditions can be treated with PRICE and crutches, with toe-touch weight bearing for one to two months. After the control of pain and inflammation (two to three weeks), a gradual stretch program should begin. When 80 degrees of ROM have returned, a PRE program should be instituted. When full ROM and strength have been regained, the athlete can return to competition.

52 Osteitis Pubis Etiology Pathology Treatment
Etiology - Because the popularity of distance running has increased, a condition known as osteitis pubis has become more prevalent. It is also caused by the sports of soccer, football, and wrestling. Repetitive stress on the pubic symphysis and adjacent bony structures caused by the pull of muscles in the area creates a chronic inflammatory condition. Pathology – The athlete has pain in the groin region and in the area of the symphysis pubis. There is point tenderness on the pubic tubercle, and the athlete experiences pain while running, doing sit-ups, and doing squats. Acute osteitis pubis may occur as a result of pressure from a bicycle seat. Treatment – Follow-up care consists of rest, an oral anti-inflammatory agent, and a gradual return to activity.

53 Piriformis Syndrome Etiology Pathology Treatment Piriformis Test
Piriformis Release Etiology - Piriformis syndrome is an uncommon neuromuscular disorder that is caused when the piriformis muscle compresses the sciatic nerve. The piriformis muscle is a flat, band-like muscle located in the buttocks near the top of the hip joint. This muscle is important in lower body movement because it stabilizes the hip joint and lifts and rotates the thigh away from the body. This enables us to walk, shift our weight from one foot to another, and maintain balance. It is also used in sports that involve lifting and rotating the thighs -- in short, in almost every motion of the hips and legs. The sciatic nerve is a thick and long nerve in the body. It passes alongside or goes through the piriformis muscle, goes down the back of the leg, and eventually branches off into smaller nerves that end in the feet. Nerve compression can be caused by spasm of the piriformis muscle. Pathology – Piriformis syndrome usually starts with pain, tingling, or numbness in the buttocks. Pain can be severe and extend down the length of the sciatic nerve (called sciatica). The pain is due to the piriformis muscle compressing the sciatic nerve, such as while sitting on a car seat or running. Pain may also be triggered while climbing stairs, applying firm pressure directly over the piriformis muscle, or sitting for long periods of time. Most cases of sciatica, however, are not due to piriformis syndrome. There is no definitive test for piriformis syndrome. In many cases, there is a history of trauma to the area, repetitive, vigorous activity such as long-distance running, or prolonged sitting. Diagnosis of piriformis syndrome is made by the patient’s report of symptoms and by physical exam using a variety of movements to elicit pain to the piriformis muscle. In some cases, a contracted or tender piriformis muscle can be found on physical exam. Because symptoms can be similar in other conditions, radiologic tests such as MRIs may be required to rule out other causes of sciatic nerve compression, such as a herniated disc. Treatment - If pain is caused by sitting or certain activities, try to avoid positions that trigger pain. Rest, ice, and heat may help relieve symptoms. A doctor or physical therapist can suggest a program of exercises and stretches to help reduce sciatic nerve compression. Some health care providers may recommend anti-inflammatory medications, muscle relaxants, or injections with a corticosteroid or anesthetic. Other therapies such as iontophoresis, which uses a mild electric current, and injection with botulinum toxin (botox) may be used. Using the paralytic properties of the botulinum toxin, botox injections can relieve muscle tightness and sciatic nerve compression to minimize pain. Some studies have found Botox to be more effective than corticosteroids. Surgery may be recommended as a last resort. Since piriformis syndrome is usually caused by sports or movement that repeatedly stresses the piriformis muscle, such as running or lunging, prevention is often related to good form. Avoid running or exercising on hills or uneven surfaces. Warm up properly before activity and increase intensity gradually. Use good posture while running, walking, or exercising. If pain occurs, stop the activity and rest until pain subsides. See a health care provider as needed.

54 Legg-Calve’-Perthes Disease (Coxa Plana)
Etiology Pathology Treatment Etiology - Legg-Calve’-Perthes disease is avascular necrosis of the femoral head. It occurs in children ages four to ten and in boys more often than girls. For the most part this condition is not clearly understood. Trauma accounts for only 25% of the cases seen. It is listed under the broad heading of osteocondrosis (is a family of orthopedic diseases of the joint that occur in children and adolescents and in rapidly growing animals, particularly pigs, horses, and dogs). Because of a disruption of circulation at the head of the femur, articular cartilage becomes necrotic and flattens. Pathology – The young athlete complains of pain in the groin that sometimes is referred to the abdomen or the knee. Limping is also typical. The condition can have a rapid onset, but more often it comes on slowly over a number of months. Examination may show limited hip movement and pain. Treatment – Care of this condition could mean complete bed rest to alleviate synovitis (inflammation of a synovial membrane). The athlete may have to wear a special brace to avoid direct weight bearing on the hip. If treated in time, the head of the femur will revascularize and reossify. Complications – If the condition is not treated early enough, the head of the femur will become ill shaped, creating problems of osteoarthritis in later life.

55 Slipped Capital Femoral Epiphysis
Etiology Pathology Treatment Etiology - The problem of a slipped capital femoral epiphysis (SCFE) is found mostly in boys between the ages of 10 and 17 who are characteristically tall and either extremely thin or extremely obese. Although idiopathic (relating to or denoting any disease or condition that arises spontaneously or for which the cause is unknown), it may be related to the effects of a growth hormone. ¼ of the cases seen have the condition in both hips. Trauma only accounts for 25% of the cases seen. X-ray examination may show femoral head slippage posteriorly or inferiorly. Pathology – Like Legg-Calve’-Perthes disease, a slipped capital femoral epiphysis causes the athlete pain in the groin that comes on suddenly as a result of trauma or over weeks or months as a result of prolonged stress. In the early stages of this condition, signs may be minimal. In it most advanced stage, however, there is hip and knee pain during passive and active ROM; limitations of abduction, flexion and medial rotation; and a limp. Treatment – In minor slippage, rest and non-weight bearing may prevent further slipping. Major displacement usually requires corrective surgery. Complications – If the slippage goes undetected or if surgery fails to properly restore normal hip mechanics, severe hip problems may occur later in life.

56 For your quizzes: Students should be able to:
Identify the different parts of the bones of the hip on a labeling quiz. Identify the different muscles of the hip on a labeling quiz. Identify the different bones on a practical exam. Identify the different hip injuries and conditions and be able to define them.

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