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

2. Anatomy of the Thigh

5. Nerve and Blood Supply
Tibial and common peroneal are given rise from the sacral plexus which form the largest nerve in the body the sciatic nerve complex
The main arteries of the thigh are the deep circumflex femoral, deep femoral, and femoral artery
The two main veins are the superficial great saphenous and the femoral vein

6. Fascia
The fascia lata femoris is part of the deep fascia that invests the thigh musculature
Thick anteriorly, laterally and posteriorly but thin on the medial side
Iliotibial track (IT-band) is located laterally serving as the attachment for the tensor fascia lata and greater aspect of the gluteus maximum

7. Functional Anatomy of the Thigh
Quadriceps insert in a common tendon to the proximal patella
Rectus femoris is the only quad muscle that crosses the hip
Extends knee and flexes the hip
Important to distinguish between hip flexors relative to injury for both treatment and rehab programs

8. Hamstrings cross the knee joint posteriorly and all except the short of head of the biceps crosses the hip
Bi-articulate muscles produce forces dependent upon position of both knee and hip
Position of the knee and hip during movement and MOI play important roles and provide information to utilize w/ rehab and prevention of hamstring injuries

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 athlete in obvious pain?
Is the athlete willing to move the thigh?

10. Palpation: Bony and Soft Tissue
Medial and lateral femoral condyles
Greater trochanter
Lesser trochanter
Anterior superior iliac spine (ASIS)
Sartorius
Rectus femoris
Vastus lateralis
Vastus medialis
Vastus intermedius
Semimembranosus
Semitendinosus
Biceps femoris
Adductor brevis, longus and magnus
Gracilis
Sartorius

11. Palpation: Soft Tissue (continued)
Pectineus
Iliotibial Band (IT-band)
Gluteus medius
Tensor fasciae latae

12. Special Tests
If a fracture is suspected the following tests are not performed
Beginning in extension, the knee is passively flexed
A normal muscle will elicit full range of motion pain free (one w/ swelling or spasm will have restricted motion)
Active movement from flexion to extension
Strong and painful may indicate muscle strain
Weak and pain free may indicate 3rd degree or partial rupture
Muscle weakness against an isometric resistance may indicate nerve injury

13. Prevention of Thigh Injuries
Thigh must have maximum strength, endurance, and extensibility to withstand strain
In collision sports thigh guards are mandatory to prevent injuries

14. Recognition and Management of Thigh Injuries
Quadriceps Contusions
Etiology
Constantly exposed to traumatic blunt blow
Contusions usually develop as a result of severe impact
Extent of force and degree of thigh relaxation determine depth and functional disruption that occurs
Signs and Symptoms
Pain, transitory loss of function, immediate effusion with palpable swollen area
Graded 1-4 = superficial to deep with increasing loss of function (decreased ROM, strength)

15. Quad Contusion

16. Management RICE, NSAID’s and analgesics Crutches for more severe cases
Aspiration of hematoma is possible
Following exercise or re-injury, continued use of ice
Follow-up care consists of ROM, and PRE w/in pain free range
Heat, massage and ultrasound to prevent myositis ossificans

17. General rehab should be conservative
Ice w/ gentle stretching w/ a gradual transition to heat following acute stages
Elastic wrap should be used for support
Exercises should be graduated from stretching to swimming and then jogging and running
Restrict exercise if pain occurs
May require surgery of herniated muscle or aspiration
Once an athlete has sustained a severe contusion, great care must be taken to avoid another

18. Myositis Ossificans Traumatica
Etiology
Formation of ectopic bone following repeated blunt trauma (disruption of muscle fibers, capillaries, fibrous connective tissue, and periosteum)
Gradual deposit of calcium and bone formation
May be the result of improper thigh contusion treatment (too aggressive)
Signs and Symptoms
X-ray shows calcium deposit 2-6 weeks following injury
Pain, weakness, swelling, tissue tension and point tenderness w/ decreased ROM
Management
Treatment must be conservative
May require surgical removal due to pain and decreased ROM

19. Quadriceps Muscle Strain
Etiology
Sudden stretch when athlete falls on bent knee or experiences sudden contraction
Associated with weakened or over constricted muscle
Signs and Symptoms
Peripheral tear causes fewer symptoms than deeper tear
Pain, point tenderness, spasm, loss of function and little discoloration
Complete tear may live athlete w/ little disability and discomfort but with some deformity

20. Management RICE, NSAID’s and analgesics
Manage swelling, compression, crutches
With increased healing, progress to isometrics and stretching
Neoprene sleeve may provide some added support

21. Hamstring Muscle Strains
(second most common thigh injury)
Etiology
Multiple theories of injury
Hamstring and quad contract together
Change in role from hip extender to knee flexor
Fatigue, posture, leg length discrepancy, lack of flexibility, strength imbalances
Signs and Symptoms
Muscle belly or point of attachment pain
Capillary hemorrhage, pain, loss of function and possible discoloration
Grade 1 - soreness during movement and point tenderness (<20% of fibers torn)
Grade 2 - partial tear, identified by sharp snap or tear, severe pain, and loss of function (<70% of fiber torn)

22. Signs and Symptoms (continued)
Grade 3 - Rupturing of tendinous or muscular tissue, involving major hemorrhage and disability, edema, loss of function, ecchymosis, palpable mass or gap
>70% muscle fiber tearing
Management
RICE, NSAID’s and analgesics
Grade I - don’t resume full activity until complete function restored
Grade 2 and 3 should be treated conservatively w/ gradual return to stretching and strengthening in later stages of healing

23. Management (continued)
Modalities and isometrics need to gradually be introduced during healing process
When soreness is eliminated, isotonic leg curls can be introduced (focus on eccentrics)
Recovery may require months to a full year
Greater scaring = greater recurrence of injury

24. Acute Femoral Fractures
Etiology
Generally involving shaft and requiring a great deal of force
Occurs in middle third due to structure and point of contact
Signs and Symptoms
Pain, swelling, deformity
Muscle guarding, hip is adducted and ER
Leg with fx may also be shorter
Management
Treat for shock, verify neurovascular status, splint before moving, reduce following X-ray
Analgesics and ice
Extensive soft tissue damage will also occur as bones will displace due to muscle force

25. Femoral Stress Fractures
Etiology
Overuse (10-25% of all stress fractures)
Excessive downhill running or jumping activities
Often seen in endurance athletes
Signs and Symptoms
Persistent pain in thigh/groin
X-ray or bone scan will reveal fracture
Walk with antalgic gait (abduction lurch)
Positive Trendelenburg’s sign
Management
Prognosis will vary depending on location
Fx lateral to femoral neck tend to be more complicated
Shaft and medially located fractures tend to heal well with conservative management

26. Anatomy of the Hip, Groin and Pelvic Region

33. Functional Anatomy
Pelvis moves in three planes through muscle function
Anterior tilting changes degree of lumbar lordosis, lateral tilting changes degree of hip abduction
Hip is a true ball and socket joint w/ intrinsic stability
Hip also moves in all three planes, particularly during gait (body’s relative center of gravity)

34. Tremendous forces occur at the hip during varying degrees of locomotion
Muscles are most commonly injured in this region
Numerous injuries attach in this region and therefore injury to one can be very disabling and difficult to distinguish

35. Assessment of the Hip and Pelvis

36. Body’s center of gravity is located just anterior to the sacrum
Injuries to the hip or pelvis cause major disability in the lower limbs, trunk or both
Low back may also become involved due to proximity
History
Onset (sudden or slow?)
Previous history?
Mechanism of injury?
Pain description, intensity, quality, duration, type and location?

37. 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 on one side
Ambulation
Walking, sitting - pain will result in movement distortion

38. Palpation: Bony 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

39. 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, lymph nodes

40. Special Tests Functional Evaluation Tests for Hip Flexor Tightness
ROM, strength tests
Hip adduction, abduction, flexion, extension, internal and external rotation
Tests for Hip Flexor Tightness
Kendall test
Test for rectus femoris tightness
Thomas test
Test for hip contractures

41. Kendall’s Test

42. Thomas Test

43. Femoral Anteversion (A) and Retroversion (B)
Relationship between neck and shaft of femur
Normal angle is 15 degrees anterior to the long axis of the femur and condyles
Internal rotation in excess of 35 degrees is indicative of anteversion, 45 degrees of external rotation is an indicator of retroversion

44. Test for 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

45. Gaenslen’s Test Test works to push SI joint into extension
Test is positive if hyperextension on affected side increases pain

46. Testing the Tensor Fasciae Latae and Iliotibial Band
Renne’s test
Athlete stands w/ knee bent at degrees
Positive response of TFL tightness occurs when pain is felt at lateral femoral condyle

47. Nobel’s Test Lying supine the athlete’s knee is flexed to 90 degrees
Pressure is applied to lateral femoral condyle while knee is extended
Pain at 30 degrees at lateral femoral condyle indicates a positive test

48. Ober’s Test Used to determine presence of contracted TFL or IT-band
Thigh will remain in abducted position, not falling into adduction

49. Trendelenburg’s Test - Iliac crest on unaffected side should be higher when standing on one leg - Test is positive when affected side is higher indicating weak abductors (glut medius)

50. Piriformis Test Hip is internally rotated
Tightness or pain is indicative of piriformis tightness

51. Measuring Leg Length Discrepancy
Ely’s Test
Used to assess tightness of rectus femoris
Athlete is prone, w/ pelvis stabilized and knee on the affected side is flexed
If hip on that side extends as the knee is flexed, rectus femoris is tight
Measuring Leg Length Discrepancy
With inactive individual, difference of more that 1” may produce symptoms
Active individuals may experience problems w/ as little 3mm (1/8”) difference
Can cause cumulative stresses to lower limbs, hips, pelvis or low back

52. Apparent or functional
True or anatomical
Shortening may be equal throughout limb or localized w/in femur or lower leg
Measurement taken from medial malleolus to ASIS
Apparent or functional
Result of lateral pelvic tilt or from a flexion or adduction deformity
Measurement is taken from umbilicus to medial malleolus

53. Leg Length Discrepancy Measures

54. Recognition and Management of Specific Hip, Groin, and Pelvic Injuries
Groin Strain
Etiology
One of the more difficult problems to diagnose
Injury to one of the muscles in the regions (generally adductor longus)
Occurs from running , jumping, twisting w/ hip external rotation or severe stretch
Signs and Symptoms
Sudden twinge or tearing during active movement
Produce pain, weakness, and internal hemorrhaging

55. Groin Strain (continued)
Management
RICE, NSAID’s and analgesics for hours
Determine exact muscle or muscles involved
Rest is critical; daily whirlpool and cryotherapy, moving into ultrasound
Delay exercise until pain free
Restore normal ROM and strength -- provide support w/ wrap

56. Trochanteric Bursitis
Etiology
Inflammation at the site where the gluteus medius inserts or the IT-band passes over the trochanter
Signs and Symptoms
Complaint of lateral hip pain that may radiate down the leg
Palpation reveals tenderness over lateral aspect of greater trochanter
IT-band and TFL tests should be performed

57. Management RICE, NSAID’s and analgesics
ROM and PRE directed toward hip abductors and external rotators
Phonophoresis if pain doesn’t respond in 3-4 days
Must look at biomechanics and Q-angle
Runners should avoid inclined surfaces

58. Sprains of the Hip Joint
Etiology
Due to substantial support, any unusual movement exceeding normal ROM may result in damage
Force from opponent/object or trunk forced over planted foot in opposite direction
Signs and Symptoms
Signs of acute injury and inability to circumduct hip
Similar S & S to stress fracture
Pain in hip region, w/ hip rotation increasing pain

59. Management X-rays or MRI should be performed to rule out fx
RICE, NSAID’s and analgesics
Depending on severity, crutches may be required
ROM and PRE are delayed until hip is pain free

60. Dislocated Hip Etiology Signs and Symptoms Management
Rarely occurs in sport
Result of traumatic force directed along the long axis of the femur (posterior dislocation w/ hip flexed and adducted and knee flexed)
Signs and Symptoms
Flexed, adducted and internally rotated hip
Palpation reveals displaced femoral head posteriorly
Serious pathology
Soft tissue, neurological damage and possible fx
Management
Immediate medical care (blood and nerve supply may be compromised)
Contractures may further complicate reduction
2 weeks immobilization and crutch use for at least one month

61. Avascular Necrosis Etiology Signs and Symptoms
Result of temporary or permanent loss of blood supply to proximal femur
Can be caused by traumatic conditions (hip dislocation – disruption of circumflex artery), or non-traumatic circumstances (steroids, blood coagulation disorders, excessive alcohol use compromising blood vessels)
Signs and Symptoms
Early stages - possibly no S&S
Joint pain w/ weight bearing progressing to pain at times of rest
Pain gradually increases (mild to severe) particularly as bone collapse occurs
May limit ROM
Osteoarthritis may develop
Progression of S&S can develop over the course of months to a year

62. Avascular Necrosis (continued)
Management
Must be referred for X-ray, MRI or CT scan
Must work to improve use of joint, stop further damage and ensure survival of bone and joint
Most cases will ultimately require surgery to repair joint permanently
Conservative treatment involves ROM exercises to maintain ROM; electric stim for bone growth; non-weight bearing if caught early
Medication to treat pain, reduce fatty substances reacting w/ corticosteroids or limit blood clotting in the presence of clotting disorders may limit necrosis

63. Hip Problems in the Young Athlete
Legg Calve’-Perthes Disease (Coxa Plana)
Etiology
Avascular necrosis of the femoral head in child ages 4-10
Trauma accounts for 25% of cases
Articular cartilage becomes necrotic and flattens
Signs and Symptoms
Pain in groin that can be referred to the abdomen or knee
Limping is also typical
Varying onsets and may exhibit limited ROM

64. Legg-Calve’-Perthes Disease (continued)
Management
Bed rest to alleviate synovitis
Brace to avoid direct weight bearing
With early treatment and the head may re-ossify and revascularize
Complication
If not treated early, will result in ill-shaping and develop into osteoarthritis in later life

65. Slipped Capital Femoral Epiphysis
Etiology
Found mostly in boys ages who are characteristically tall and thin or obese
May be growth hormone related
25% of cases are seen in both hips, trauma accounts for 25%
Head slippage on X-ray appears posterior and inferior

66. Signs and Symptoms Management
Pain in groin that comes on over weeks or months
Hip and knee pain during passive and active motion
Limitations of abduction, flexion, medial rotation and presents with a limp
Management
W/ minor slippage, rest and non-weight bearing may prevent further slippage
Major displacement requires surgery
If undetected or surgery fails severe problems will result

67. The Snapping Hip Phenomenon
Etiology
Common in young female dancers, gymnasts, hurdlers
Habitual movement predispose muscles around hip to become imbalanced (lateral rotation and flexion)
Related to structurally narrow pelvis, increased hip abduction and limited lateral rotation
Hip stability is compromised
Signs and Symptoms
Pain w/ balancing on one leg, possible inflammation
Management
Focus on cryotherapy and ultrasound to stretch musculature and strengthen weak musculature in hip region

68. Pelvic Conditions
Athletes can suffer serious, acute and chronic injuries to the pelvic region
Pelvis rotates along longitudinal axis when running, proportionate to the amount of arm swing
Also tilts as legs engage support and nonsupport
Combination of motion causes shearing and changes in lordosis throughout activity

69. Contusion (hip pointer)
Etiology
Contusion of iliac crest or abdominal musculature
Result of direct blow (same MOI for iliac crest fx and epiphyseal separation
Signs and Symptoms
Pain, spasm, and transitory paralysis of soft structures
Decreased rotation of trunk or thigh/hip flexion due to pain
Management
RICE for at least 48 hours, NSAID’s,
Bed rest 1-2 days
Referral must be made, X-ray
Ice massage, ultrasound, occasionally steroid injection Recovery lasts 1-3 weeks

70. Osteitis Pubis Etiology Signs and Symptoms Management
Seen in distance runners
Repetitive stress on pubic symphysis and adjacent muscles
Signs and Symptoms
Chronic pain and inflammation of groin
Point tenderness on pubic tubercle
Pain w/ running, sit-ups and squats
Acute case may be the result of bicycle seat
Management
Rest, NSAID’s and gradual return to activity

71. Athletic Pubalgia Etiology Signs and Symptoms
Chronic pubic region pain caused by repetitive stress to pubic symphysis from kicking, twisting, or cutting
Forced adduction, from hyperextended position, creates shearing forces that are transmitted through pubic symphysis to insertion of rectus abdominus, hip adductors and conjoined tendon
Result in microtears of tranversalis abdominis fascia, aponeurosis of obliques, or conjoined tightness
Create weakening of anterior wall and inguinal canal
Signs and Symptoms
No presence of hernia
Chronic pain during exertion, sharp and burning that laterally radiates into adductors and testicles

72. Signs and Symptoms (continued)
Point tenderness on pubic tubercle
Pain increased w/ resisted hip flexion, internal rotation, abdominal contraction, resisted hip adduction (adductors not painful = adductor strain)
Management
Conservative treatment (even though rarely effective)
Massage, stretching after 1 week of surrounding musculature
2 weeks, strengthening of abs and hip flexors and adductors
3-4 weeks begin running progression
Aggressive treatment involves cortisone injection or tightening of pelvic wall surgically

73. Stress Fractures Etiology Signs and Symptoms
Seen in distance runners - repetitive cyclical forces from ground reaction force
More common in women than men
Common site include inferior pubic ramus, femoral neck and subtrochanteric area of femur
Signs and Symptoms
Groin pain, w/ aching sensation in thigh that increases w/ activity and decreases w/ rest
Standing on one leg may be impossible
Deep palpation results in point tenderness
May be caused by intense interval or competitive racing

74. Stress Fractures (continued)
Management
Rest for 2-5 months
Crutch walking for ischium and pubis fractures
X-ray are usually normal for 6-10 weeks and bone scan will be required
Swimming can be used for training -- breast stroke should be avoided

75. Avulsion Fractures and Apophysitis
Etiology
Traction epiphysis (bone outgrowth)
Common sites include ischial tuberosity, AIIS, and ASIS
Avulsions seen in sports w/ sudden accelerations and decelerations
Signs and Symptoms
Sudden localized pain w/ limited movement
Pain, swelling, point tenderness
Muscle testing increases pain

76. Avulsion Fractures and Apophysitis
Management
X-ray
If uncomplicated, RICE, NSAID’s, crutch toe-touch walking
After control pain and inflammation, 2-3 weeks of gradual stretching
When 80 degrees of ROM have been regained a PRE program should be instituted.
With full return of ROM and strength athlete can return to play

77. Thigh and Hip 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

79. Mobilization
Will be necessary if injury and subsequent limitation is caused by tightness of ligaments and capsule surrounding the joint
Use to re-establish appropriate arthrokinematics
Series of glides (anterior and posterior) and rotations can be used to restore motion

81. Strength
Progression should move from isometric exercises until muscle can be fully contracted to isotonic strengthening PRE’s and on into isokinetics
PNF strengthening should then be incorporated to enhance functional activity

82. Strength (Continued)
Active exercise should occur in pain free ranges -- in an effort not to aggravate condition
Exercises for the core must also be included
Develop optimal levels of functional strength and dynamic stabilization

85. Neuromuscular Control
Establish through combination of appropriate 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

86. Balance Shoe for Neuromuscular Control

87. Functional Progression and Return to Activity
Begin in pool, non-weight bearing
Depending on activity, progression of walking, to jogging, to running and more difficult agility tasks can occur
Before returning to play, athlete should demonstrate pain free function, full ROM, strength, balance and agility