1. Pelvis, Hip, and Thigh Conditions
Chapter 17

2. Skeletal Features of Pelvis, Hip, and Thigh

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

4. Pelvis (cont.) SI joint Critical link between the two pelvic bones
Strong ligamentous support
Sacrococcygeal joint
Fused line symphysis united by a fibrocartilaginous disc
Pubic symphysis
Interpubic disc located between the two joint surfaces

5. Bony Structure of Thigh
Femur
Weakest at femoral neck
Angle of inclination
Angle of depression formed by a line drawn through the shaft of femur and a line passing through the long axis of femoral neck
Approximately 125 in the frontal plane
125 coxa valga
125 coxa vara

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

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

10. Hip Joint Capsule
Completely surrounds joint, attaching to the labrum of the acetabular socket
Passes over a fat pad internally to join to the distal aspect of femoral neck
Zona orbicularis

11. Ligaments of Hip Joint Iliofemoral ligament Limits hyperextension
Pubofemoral ligament
Limits abduction and hyperextension
Ischiofemoral ligament
Limits extension

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

13. Bursae
Iliopsoas
Reduces friction between iliopsoas and articular capsule
Deep trochanteric bursa
Provides cushion between greater trochanter and gluteus maximus at its attachment to iliotibial tract
Gluteofemoral bursa
Separates gluteus maximus from origin of vastus lateralis
Ischial bursa
Weight-bearing structure during sitting
Cushions ischial tuberosity where it passes over gluteus maximus

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

15. Muscles

16. Muscles (cont.)

17. Muscles (cont.)

18. Nerves Lumbar plexus Femoral nerve Obturator nerve Sacral plexus
Sciatic nerve

19. Blood Vessels External iliac Femoral Deep femoral Femoral circumflex

20. Kinematics Pelvis positioning
Pelvis “tilts” to facilitate movement in hip
Posterior tilt—assists hip flexion
Anterior tilt—assists hip extension
Lateral tilt—assists hip abduction

21. Kinematics (cont.) Hip flexors
Iliopsoas, pectineus, rectus femoris, sartorius, and tensor fascia latae
Two-joint muscles
Rectus femoris—active during hip flexion and knee extension
Sartorius—active during hip flexion and knee extension
Hip extensors
Gluteus maximus and hamstrings (biceps femoris, semitendinosus, and semimembranosus)
Hamstrings—two-joint; hip extension and knee flexion

22. Kinematics (cont.) Hip abductors Gluteus medius, gluteus minimus
Active in stabilizing pelvis during single-leg support and during support phase of walking and running
Hip adductors
Adductor longus, adductor brevis, and adductor magnus

23. Kinematics (cont.) Lateral rotators
Piriformis, gemellus superior, gemellus inferior, obturator internus, obturator externus, and quadratus femoris
Lateral rotation of femur of swinging leg accommodates lateral rotation of pelvis during stride
Medial rotators
Gluteus minimus
Tensor fascia latae, semitendinosus, semimembranosus, gluteus medius, and adductors

24. Kinetics
Body weight places compression on hip, as does tension in hip muscles
Forces are less during standing than with running and walking
Forces translated through the lower extremity; result ↑ compression on hip

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

26. Contusions Hip pointer Mechanism: direct blow to iliac crest
Common—anterior or lateral portion of crest
Often from improperly fitting (or absent) hip pads

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

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

29. Contusions (cont.) Management:
Standard acute; with knee in maximum flexion
Hard-shell pad for return to activity
Physician referral if myositis ossificans or compartment syndrome is suspected

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

32. Contusions (cont.) S&S Warm, firm, swollen thigh; 2–4 cm larger
Palpable, painful mass may limit passive knee flexion to 20–30°
Active quadriceps contractions and straight leg raises— difficult
Management: standard acute; physician referral
Self-limiting injury
Maturation—6–12 months

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

34. Bursitis Mechanism Excessive friction or shear forces due to overuse
Posttraumatic bursitis from direct blows that cause bleeding in the bursa
Greater trochanteric bursitis
Influence of Q-angle

35. Bursitis (cont.)
S&S
Burning or aching over or posterior to greater trochanter
Aggravated with:
Hip abduction against resistance
Hip flexion and extension on weight bearing
Referred pain—lateral aspect of the thigh

36. Bursitis (cont.) Iliopsoas bursitis
Pain medial and anterior to joint; cannot be easily palpated
 pain with passive hip rotation; resisted hip flexion, abduction, and external rotation
Ischial bursitis
Pain aggravated by prolonged sitting and uphill running,
Point tenderness directly over ischial tuberosity
 pain with passive and resisted hip extension

37. Bursitis (cont.) Bursitis management
Standard acute; deep friction massage; NSAIDs; stretching program for involved muscle
On-going prevention: biomechanical analysis; technique analysis

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

39. Bursitis (cont.)
S&S
Snapping sensation heard or felt during hip motion, especially with lateral rotation and flexion while balancing on one leg
Iliopsoas bursa affected—snapping in medial groin
Management: NSAIDs; rehabilitation program to address specific deficits

40. Hip Sprains and Dislocations
Mechanism
Violent twisting actions
With hip and knee flexed to 90°, force through shaft of femur

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

42. Hip Dislocation

43. Strains Mechanism Explosive movements
Tensile stress from overstretching
Muscles
Quadriceps
Typically rectus femoris

44. Strains (cont.) Hamstrings
Initial swing—flex knee; late swing—eccentrically contract to decelerate knee extension and re-extend hip in prep for stance phase
Overemphasis on stretching without strengthening
Strength imbalance
Adductors
Common with quick change of direction and explosive propulsion and acceleration

45. Strains (cont.) S&S Point tender with palpable spasm
Possible palpable defect/divot
Ecchymosis may or may not be present
Pain with AROM; pain with PROM (muscles placed on stretch)

46. Strains (cont.) Piriformis strain
In some individuals, sciatic nerve passes through or above piriformis, subjecting nerve to compression from trauma, hemorrhage, or spasm

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

48. Strains (cont.) Predisposing factors
Beginning of season – too much too soon
Fatigue
History of strains; reinjury common
Restricted flexibility of involved muscle group
Management: standard acute; restrict weight bearing if unable to assume normal gait

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

50. Vascular and Neural Disorders (cont.)
Venous disorders
Direct blow may damage a vein causing
Thrombophlebitis
Superficial thrombophlebitis (ST)
Deep venous thrombosis (DVT)
Phlebothrombosis

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

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

53. Hip Fractures Avulsion fractures Apophyseal sites
ASIS with displacement of sartorius
AIIS with rectus femoris displacement
Ischial tuberosity with hamstrings displacement
Lesser trochanter with iliopsoas displacement
Due to rapid, sudden acceleration and deceleration

54. Hip Fractures (cont.) S&S
Sudden, acute, localized pain—may radiate down muscle
Swelling and discoloration
Palpable gap between tendon attachment and bone
 pain with AROM, PROM, RROM of involved muscle
Management: immobilize with elastic bandage; fit with crutches; immediate physician referral

55. Hip Fractures (cont.) Slipped capital femoral epiphysis
Boys ages 12–15
Femoral head slips at epiphyseal plate— displaces inferiorly and posteriorly relative to femoral neck

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

57. Hip Fractures (cont.) Stress fractures
Pubis, femoral neck, and proximal one-third of femur
Risk factors

58. Hip Fractures (cont.) S&S
Diffuse or localized aching pain in anterior groin or thigh during weight-bearing activity, relieved with rest
Night pain
Antalgic gait may be present
Pain with deep palpation in inguinal
↑ pain on extremes of hip rotation
+ Trendelenburg sign
Management: physician referral

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

60. Sacral and Coccygeal Fractures
Rare in sports
Direct blow to area due to fall on buttock
S&S: extremely painful; unable to sit
Management: immediate referral to a physician

61. Femoral Fractures Mechanism Tremendous impact forces
Direct compressive forces
Potential for neurovascular damage

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

63. Femoral Fractures (cont.)
Management
Activate EMS
Assess distal vascular integrity
Monitor and treat for shock
Defer immobilization until emergency medical personnel arrive (traction splint will typically be applied)
NPO—possible surgical intervention

64. Assessment History Observation/inspection Contranutation and nutation
Palpation
Physical examination tests

65. Observation Contranutation at the SI joint
Indicates anterior torsion of joint, or posterior rotation of sacrum on ilium on one side
Nutation
Backward rotation of ilium on sacrum

66. Range of Motion (ROM) Active range of motion (AROM) Hip Flexion
Extension
Abduction
Adduction
Lateral rotation
Medial rotation

67. ROM (cont.)
Knee
Flexion
Extension

68. ROM (cont.) Normal ranges Hip flexion (110–120°) with knee flexed
Hip extension (10–15°)
Abduction (30–50°)
Adduction (30°)
Lateral rotation (40–60°)
Medial rotation (30–40°)
Knee flexion (0–135°)
Knee extension (0–15°)

69. ROM (cont.)

70. ROM (cont.) Passive range of motion (PROM) Normal end feel
Hip flexion and adduction—tissue approximation
Hip extension, abduction, and medial and lateral rotation—tissue stretch
Passive movements at pelvic joint also stress the ligamentous structures
Sacroiliac compression and distraction test

71. ROM (cont.)
RROM

72. ROM (cont.)

73. ROM (cont.)

74. Stress Tests Sacroiliac compression and distraction test “Squish” test
Sacroiliac rocking test

75. Stress Tests
Approximation test
Patrick’s (FABER) test

76. Special Tests
Leg length measurement
Anatomic
Apparent

77. Special Tests (cont.)
Thomas Test for flexion contractures

78. Special Tests (cont.)
Gaenslen’s test

79. Special Tests (cont.) Kendall test for rectus femoris contracture
Hamstring contracture test
90° – 90° straight leg raising test

80. Special Tests (cont.) Straight leg raising (Lasegue's) test
Trendelenburg test

81. Special Tests (cont.)
Piriformis test
Long sitting test
Ober’s test

82. Special Tests (cont.)
Sign of the buttock test

83. Neurologic Tests Myotomes Hip flexion—L1, L2 Knee extension—L3
Ankle dorsiflexion—L4
Toe extension—L5
Ankle plantarflexion, foot eversion, or hip extension—S1
Knee flexion—S2
Reflexes
No specific reflexes to test the pelvic or hip area
Lower extremity reflexes
Patella—L3, L4
Achilles tendon—S1

84. Neurologic Tests (cont.)
Dermatomes
F16.35

85. Neurologic Tests (cont.)
Cutaneous patterns

86. Rehabilitation Restoration of motion
Refer to Field Strategies 16.1 and 17.1
Restoration of proprioception and balance
Closed-chain exercises
Muscular strength, endurance, and power
Open-chain exercises
PNF-resisted exercises
Cardiovascular fitness