1. Pelvis, Hip and Thigh

2. Skeletal Features of Pelvis, Hip, and Thigh

3. Pelvis Function 4 fused bones Protects organs
Transmits loads between trunk and lower extremity
Provides site for muscle attachments
4 fused bones
Sacrum
Coccyx
Innominate bones (Bilateral)
Ilium, ischium, and pubis 3

4. Pelvis (cont.) SI joint Sacrococcygeal joint Pubic symphysis
Critical link between the two pelvic bones
Strong ligamentous support
Sacrococcygeal joint
Fused line symphysis united by a fibrocartilaginous disc
Pubic symphysis
Interpubic disc located between the two joint surfaces
Sacroiliac (SI) joint
working with pubic symphysis—helps transfer the weight of the torso and skull to the lower limbs, provide elasticity to the pelvic ring, and conversely, act as a buffer to decrease impact forces from the foot as they are transmitted to the spine and upper body
Sacrococcygeal joint
freely movable and synovial, but with advanced age, the joint may fuse and be obliterated
Pubic symphysis
cartilaginous joint
small degree of spreading, compression, and rotation occurs between the halves of pelvic girdle 4

5. Bony Structure of Thigh
Femur
Weakest at femoral neck

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

7. Femoral Triangle Borders Contents Inguinal ligament—superior
Sartorius—lateral
Adductor longus—medial
Contents
Femoral nerves
Femoral artery
Femoral vein

8. Q-Angle
Angle between line of resultant force produced by quadriceps and line of patellar tendon
Males 13°; females 18°

12. Nerve and Blood Supply Blood Supply Nerves Lumbar plexus Sacral plexus
Femoral nerve
Obturator nerve
Sacral plexus
Sciatic nerve
Blood Supply
External iliac
Femoral
Deep femoral
Femoral circumflex

13. Kinematics
ROM
Hip Flexion
Hip Extension
Hip Abduction
Hip Adduction
Medial Rotation
Lateral Rotation
Body weight places compression on hip, as does tension in hip muscles
Forces are less during standing than with running and walking
Forces translated through the lower extremity; result ↑ compression on hip

14. Prevention Protective equipment Physical conditioning Shoes
Hip joint well protected but iliac and pelvis need protection
Thigh
Physical conditioning
Shoes
Cushion forces

15. Contusions Hip pointer Mechanism: direct blow to iliac crest
Common—anterior or lateral portion of crest
Often from improperly fitting (or absent) hip pads
S&S
Point tenderness; swelling; ecchymosis
Individual prefers slightly forward flexed position to relieve tension of abdominals and iliopsoas
Antalgic gait with shortened swing phase
↑ pain with active trunk flexion and active hip flexion
Pain with coughing, laughing, breathing
Abdominal muscle spasm
Management: standard acute; rest; protect with hard-shell pad for return to activity

16. Contusions (Cont’d) Quadriceps contusion Management:
Mechanism: direct blow
Common – anterolateral thigh
S&S
Transitory loss of function
With continued play, progressively stiffer and unresponsive
↑ pain with active knee extension and hip flexion
Limited AROM due to pain; knee flexion limited actively and passively
Management:
Standard acute; with knee in maximum flexion
Hard-shell pad for return to activity
Physician referral if myositis ossificans or compartment syndrome is suspected

18. Bursitis Greater trochanteric bursitis Bursitis management
Influence of Q-angle
Effect of IT Band
S&S
Burning or aching over or posterior to greater trochanter
Aggravated with:
Hip abduction against resistance
Hip flexion and extension on weight bearing
Referred pain—lateral aspect of the thigh
Bursitis management
Standard acute; deep friction massage; NSAIDs; stretching program for involved muscle
On-going prevention: biomechanical analysis; technique analysis

19. Hip Sprains and Dislocations
Mechanism
Violent twisting actions
With hip and knee flexed to 90°, force through shaft of femur
S&S
Mild/moderate: pain with internal rotation
Severe: intense pain; inability to move hip
Position of flexion and internal rotation
Management
Mild/moderate—standard acute
Severe—activate EMS; immobilize in position found; assess distal vascular integrity; monitor and treat for shock; NPO

21. Strains Mechanism Muscles S&S Explosive movements
Tensile stress from overstretching
Muscles
Quadriceps
Typically rectus femoris
Hamstrings
Initial swing—flex knee; late swing—eccentrically contract to decelerate knee extension and re-extend hip in prep for stance phase
Overemphasis on stretching without strengthening
Strength imbalance
S&S
Point tender with palpable spasm
Possible palpable defect/divot
Ecchymosis may or may not be present
Pain with AROM; pain with PROM (muscles placed on stretch)

22. Strains (Cont’d.) Piriformis strain
In some individuals, sciatic nerve passes through or above piriformis, subjecting nerve to compression from trauma, hemorrhage, or spasm
S&S
History of prolonged sitting, overuse, recent ↑ in activity, or buttock trauma
Dull ache in midbuttock—worse at night
Numbness or weakness may extend down posterior leg
Predisposing factors
Beginning of season – too much too soon
Fatigue
History of strains; reinjury common
Restricted flexibility of involved muscle group
Management: standard acute; restrict weight bearing if unable to assume normal gait

23. Venous disorders Direct blow may damage a vein causing
Thrombophlebitis
Superficial thrombophlebitis (ST)
Deep venous thrombosis (DVT)
S&S
ST—acute, red, hot, palpable, tender cord in course of a superficial vein
Extension of ST to deep veins—via proximal long and short saphenous veins to common femoral and popliteal veins, respectively
Management: anticoagulant therapy; external support (e.g., compression stockings); therapeutic exercise

24. Femoral Fracture Mechanism Potential for neurovascular damage
Tremendous impact forces
Direct compressive forces
Potential for neurovascular damage
S&S
Previous history of femoral stress fracture ↑ risk of complete fracture
Extreme pain and inability/unwillingness to move involved side
Shock
Neck
Individual supine, lower extremity in external rotation and abduction; appears shortened compared with other side
Shaft
appears shortened; thigh appears externally rotated
Management
Activate EMS
Assess distal vascular integrity
Monitor and treat for shock
Defer immobilization until emergency medical personnel arrive (traction splint will typically be applied)

25. Assessment History Observation/inspection Palpation
Physical examination tests

26. ROM
AROM
AAROM
PROM
RROM

27. ROM (cont.) 27

28. ROM (cont.)

29. ROM (cont.)

30. Stress Tests Sacroiliac compression and distraction test “Squish” test
Sacroiliac rocking test
Sacroiliac compression and distraction test
Patient (pt) is supine
Examiner applies a cross-arm pressure down and outward to ASIS with the thumbs
Repeat with pressure applied down through the anterior portion of the ilium, spreading the SI joint
If test is +, unilateral gluteal or posterior leg = a sprain to the anterior SI ligaments
Sharp pain elsewhere along the pelvic ring with outward pressure or with bilateral compression of the iliac crests may indicate a pelvic fracture
“Squish” test
Pt is supine
Examiner pushes both ASISs downward and inward at a 45° angle (stresses the posterior SI ligaments)
If test is +, pain is present = sprain of posterior SI ligaments
Sacroiliac rocking (knee-to-shoulder) test (sacrotuberous ligament stress test)
Examiner fully flexes the pt’s knee and hip toward the opposite shoulder and adducts the hip
SI joint is rocked by flexion and adduction of the hip
If test is + when bringing single knee to chest, pain in the posterolateral thigh = irritation of the sacrotuberous ligament
If test is + when pulling leg toward opposite shoulder, pain produced in the area around the PSIS = SI ligament irritation 30

31. Stress Tests Approximation test Patrick’s (FABER) test
Approximation (transverse posterior stress) test
Pt is side lying
Examiner exerts a downward force over the iliac crest
If test is +, pain or a feeling of pressure on the SI joints = a sprain of the posterior SI ligaments or an SI lesion, or both
Patrick’s (FABER) test
Pt is supine with the foot and ankle of the involved leg resting on the contralateral knee; pt slowly lowers flexed leg into abduction
Final position of flexion, abduction, and external rotation (FABER) at the hip should place the involved leg on the table or at least near a horizontal position with the opposite leg
If test is +, leg unable to relax; remains above opposite leg = iliopsoas spasm or hip joint contracture 31

32. Special Tests Leg length measurement Anatomic Apparent
Anatomic (true) leg length discrepancy (LLD)
Pt is supine, with legs extended
Examiner measures distance between ASIS and medial malleoli
If test is +, unequal distances when compared bilaterally; due to length of bones
To determine location of length discrepancy (i.e., tibia or femur), flex pt’s knees to 90° and examine height from anterior (tibia) and lateral (femur) views
Apparent LLD
Examiner must first establish that there is not a true LLD
Examiner measures distance between umbilicus and medial malleoli
If test is +, unequal distances when compared bilaterally; examine for pelvic obliquity of ADD/flex deformity at hip 32

33. Special Tests (cont.) Thomas Test for flexion contractures Thomas test
Pt is supine with legs extended
Pt is instructed to passively flex hip and knee of the uninvolved leg to chest and hold the position
If test is +, straight leg (involved) raises up off table = iliopsoas tightness; straight leg (involved) moves into extension = tight rectus femoris 33

34. Special Tests (cont.) Straight leg raising (Lasegue's) test
Trendelenburg test
Straight leg raising (Lasegue’s) test
Pt is supine
Examiner maintains the knee in extension while flexing the hip until pt complains of tightness or pain
Examiner then slowly lowers the leg until the pain or tightness disappears; next, examiner dorsiflexes the ankle and instructs pt to flex the neck
If test is +, pain does not increase with dorsiflexion or neck flexion = tight hamstrings
If both legs are passively raised simultaneously, and pain occurs prior to 70° of flexion = SI joint problems
Trendelenburg test
Examiner stands behind patient at level of PSIS
Pt bears weight on one (involved) leg
If test is +, pelvis drops on opposite side = stance leg weakness 34

35. Special Tests (cont.) Piriformis test Ober’s test Piriformis test
Pt lies on uninvolved side; involved side ~60° hip flexion and knee flexion
Examiner stabilizes the involved hip with one hand and applies a downward pressure to the knee
If test is +, tightness or pain in hip/buttock = piriformis tightness; pain in buttock/anterior thigh = sciatic impingement due to tightness
Long sitting test
Pt is supine with legs straight
Examiner places thumbs over medial malleoli, ensuring malleoli are level
Pt is asked to sit; examiner observes whether one leg moves from a long position to a short position (moves proximally)
If test is +, one leg moves up farther than other = functional leg length difference resulting from pelvic dysfunction caused by pelvic torsion or rotation
If the reverse occurs (i.e., the leg moves from a shorter to a longer position) = posterior rotation of the ilium on the sacrum
Ober’s test
Pt is side lying with involved leg up; hip and knees extended
Examiner
Stabilizes pelvis from rotating with one hand
Other hand abducts and extends hip (brings iliotibial band posterior to greater trochanter)
Slowly lowers upper leg
If test is +, the leg remains in the abducted position = tight tensor fascia latae or iliotibial band 35