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

Anatomy of the Thigh

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

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

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

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

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?

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

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

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

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

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)

Quad Contusion

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

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

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

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

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

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)

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

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

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

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

Anatomy of the Hip, Groin and Pelvic Region

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)

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

Assessment of the Hip and Pelvis

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?

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

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

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

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

Kendall’s Test

Thomas Test

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

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

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

Testing the Tensor Fasciae Latae and Iliotibial Band Renne’s test Athlete stands w/ knee bent at 30 - 40 degrees Positive response of TFL tightness occurs when pain is felt at lateral femoral condyle

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

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

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)

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

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

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

Leg Length Discrepancy Measures

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

Groin Strain (continued) Management RICE, NSAID’s and analgesics for 48-72 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

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

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

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

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

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

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

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

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

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

Slipped Capital Femoral Epiphysis Etiology Found mostly in boys ages 10-17 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Balance Shoe for Neuromuscular Control

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