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

2. Anatomy of the Pelvis, Thigh, and Hip

5. Bony Anatomy Pelvic Girdle Ilium Iliac crest
Anterior superior iliac spine
Posterior superior iliac spine
Anterior inferior iliac spine

6. Ischium Pubis Acetabulum Ischial tuberosity
Hamstring or bursa problems
Should sit on this area of pelvis
Pubis
Pubic symphysis
Acetabulum

8. Femur Head Neck Greater trochanter Lesser trochanter Shaft
Medial condyle
Lateral condyle

10. Ligaments - Major source of strength
Ligamentum teres-head of femur
Iliofemoral ligament
Y ligament
Strongest in the body
Prevents hyperextension, external rotation, abduction

11. Ischiofemoral ligament
Pubofemoral ligament
Prevents abduction
Ischiofemoral ligament
Prevents medial rotation

12. Bursa 18 in hip Ischial bursa Greater trochanteric bursa Iliopsoas
Found at attachment of gluteus maximus and IT band
Iliopsoas

14. Muscles Flexors Anterior thigh (quads) Iliopsoas Rectus femoris (quad)
Sartorius
Anterior thigh (quads)
Vastus medialis
Vastus lateralis
Vastus intermedialis

15. Extensors Abductors Gluteus maximus Semitendonosis (hamstring)
Semimembranosis (hamstring)
Biceps femoris (hamstring)
Abductors
Gluteus medius
Gluteus minimus
Tensor fascia latae (Iliotibial band)

16. Adductors Adductor magnus Adductor brevis Adductor longus Pectineus
Gracilis

18. External Rotators Oburator externus Obturator internus
Quadratus femoris
Piriformis – sciatic nerve goes through it.
Gamellus superior
Gamellus inferior
Gluteus maximus

19. Internal Rotators
Gluteus minimus
Tensor fascia Latae
Gluteus medius

20. Assessment of the Thigh
History
Onset (sudden or slow?)
Previous history?
Mechanism of injury?
Pain description, intensity, quality, duration, type and location?

21. Observation Postural symmetry?
Size, deformity, swelling, discoloration?
Skin color and texture?
Is athlete in obvious pain?
Is the athlete willing to move the thigh?

22. Palpation
Soft tissue of the thigh (anterior, posterior, medial, lateral) should be palpated for pain and tenderness
Bony palpation should also be performed to locate areas of pain/discomfort
Utilize palpation to assess body symmetry

23. Special Tests Thomas Test Thomas test Straight Leg Raise
Test for hip contractures
Straight Leg Raise
Test for hip extensor tightness
Can also be used to assess low back or SI joint dysfunction
Thomas Test

24. Trendelenburg Test
Gluteus medius
Ober’s/Noble Test
IT Band
Fulcrum

25. Prevention of Thigh Injuries
Thigh must have maximum strength, endurance, and extensibility to withstand strain
Dynamic stretching programs may aid in muscle preparation for activity
Strengthen programs can also help in preventing injuries

26. Thigh Injuries Quadriceps Contusions Cause of Injury Signs of Injury
Constantly exposed to traumatic blows
Signs of Injury
Pain, transitory loss of function, immediate bleeding of affected muscles
Early detection and avoidance of internal bleeding are vital – increases recovery rate and prevents muscle scarring

27. Quad Contusion

28. Care RICE and NSAID’s Crutches for more severe cases
Isometric quadriceps contractions should begin as soon as tolerated
Heat, massage and ultrasound to prevent myositis ossificans
Padding may be worn for additional protection upon return to play

29. Myositis Ossificans Traumatica
Cause of Injury
Formation of ectopic bone following repeated blunt trauma
Signs of Injury
X-ray shows calcium deposit 2-6 weeks following injury
Pain, weakness, swelling, decreased ROM
Tissue tension and point tenderness
If condition is recurrent it may indicate problem with blood clotting

30. Care Treatment must be conservative
May require surgical removal if too painful and restricts motion (after one year - remove too early and it may come back)

32. Quadriceps Muscle Strain
Cause of Injury
Sudden stretch-falls on bent knee or experiences sudden contraction
Weakness or over constricted muscle
Signs of Injury
Peripheral tear causes fewer sx than deeper tear
Pain, pt tenderness, spasm, loss of function and little discoloration
Complete tear may leave athlete w/ little disability/discomfort but with some deformity

33. Care RICE to control internal bleeding
Determine extent of injury early
Neoprene sleeve may provide some added support

35. Hamstring Muscle Strains
Cause of Injury
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
Grade 2 - partial tear, identified by sharp snap or tear, severe pain, and loss of function

36. Signs of Injury Muscle belly or point of attachment pain
Capillary hemorrhage, pain, loss of function, and possible discoloration
Grade 1 - soreness during movement and point tenderness
Grade 2 – increase pain, swelling, palpable swelling/defect?
Grade 3 - Rupturing of tendinous or muscular tissue, involving major hemorrhage and disability, edema, loss of function, ecchymosis, palpable mass or gap

37. Care RICE Restrict activity until soreness has subsided
Ballistic stretching and explosive sprinting should be avoided initially

39. Acute Femoral Fractures
Cause of Injury
Generally involves shaft, requires great force
Occurs in middle 1/3 due to structure and point of contact
Signs of Injury
Shock, pain, swelling, deformity
Must be aware of bone displacement and gross deformity
Loss of function

40. Care
Treat for shock, verify neurovascular status, splint before moving, reduce following X-ray
Secure immediate emergency assistance and medical referral

41. 8 foot fall

42. Femoral Stress Fractures
Cause of Injury
Overuse
Females who are amenorrheic are more vulnerable to stress fx
Signs of Injury
Persistent pain in thigh
X-ray or bone scan
Commonly seen in femoral neck
Management
Analgesics, NSAID’s RICE
ROM and PRE exercises are carried out w/ pain free ROM
Rest, limited weight bearing

44. Hip, Groin, and Pelvic Injuries
Groin Strain
Cause of Injury
One of the more difficult problems to diagnose
Early part of season due to poor strength and flexibility
Running, jumping, twisting w/ hip external rotation or severe stretch

45. Signs of Injury Care Sudden twinge or tearing during active movement
Produce pain, weakness, and internal hemorrhaging
Care
RICE, NSAID’s and analgesics for hours
Determine exact muscle or muscles involved
Rest is critical
Restore normal ROM and strength -- provide support w/ wrap
Refer to physician if severe groin pain is experienced

46. Sprains of the Hip Joint
Cause of Injury
Result of violent twist due to forceful contact
Force from opponent/object or trunk forced over planted foot in opposite direction
Signs of Injury
Signs of acute injury and inability to circumduct hip
Pain in hip region, w/ hip rotation increasing pain

47. Care 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

48. Dislocated Hip Cause of Injury Signs of Injury Rarely occurs in sport
Result of traumatic force directed along the long axis of the femur
Signs of Injury
Flexed, adducted and internally rotated hip
Palpation reveals displaced femoral head, posteriorly
Serious pathology
Soft tissue, neurological damage and possible fx

49. Care
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

50. 7 y/o posterior hip dislocation skate board fall

51. Posterior Hip Dislocation
injury footage

52. Anterior Hip Dislocation
Notice leg position

53. Hip Problems in the Young Athlete
Legg-Perthes Disease (Coxa Plana)
Cause of Condition
Avascular necrosis of femoral head: children 4-10 y/o
Articular cartilage becomes necrotic, flattens
Signs of Condition
Pain in groin, can refer to abdomen or knee
Limping is also typical
Varying onsets and may exhibit limited ROM

54. Legg-Perthes Disease (continued)
Care
Bed rest-reduce chance of chronic condition
Brace to avoid direct weight bearing
Early treatment-head may reossify and revascularize
Complication
If not treated early, will result in ill-shaping and osteoarthritis in later life

55. Slipped Capital Femoral Epiphysis
Cause of Condition
May be growth hormone related
25% of cases are seen in both hips
Signs of Condition
Pain in groin over weeks or months
Hip/knee pain during PROM,AROM; limited abd, flex,med. rotation and limp
Management
W/ minor slippage, rest and non-weight bearing may prevent further slippage
Major displacement requires surgery
If undetected/surgery fails severe problems

56. Iliac Crest Contusion (hip pointer)
Cause of Injury
Contusion of iliac crest or abdominal musculature
Result of direct blow
Signs of Injury
Pain, spasm, and transitory paralysis of soft structures
Decreased rotation of trunk or thigh/hip flexion due to pain

57. Care RICE for at least 48 hours, NSAID’s,
Bed rest 1-2 days in severe cases
Referral must be made, X-ray

58. Osteitis Pubis Cause of Injury Signs of Injury Management
Seen in distance runners
Repetitive stress on pubic symphysis and adjacent muscles
Signs of Injury
Chronic pain, inflam. of groin
Pt tenderness on pubic tubercle
Pain w/ running, sit-ups and squats
Management
Rest, NSAID’s and gradual RTP

59. Acute Fracture of Pelvis
Cause of Injury
Result of direct blow or blunt trauma
Signs of Injury
Severe pain, loss of function, shock
Care
Immediately treat for shock
Refer to physician
Seriousness of injury dependent on extent of shock and possibility of internal injury

60. Stress Fractures Cause of injury Signs of Injury Care
Repetitive abnormal overused forces
Signs of Injury
Groin pain, w/ aching sensation in thigh that increases w/ activity and decreases w/ rest
Discomfort increases with activity and subsides during rest
Care
Refer to physician for assessment and X-ray
Rest for 2-5 months

61. Avulsion Fractures Cause of Injury What muscles can cause avulsion fx?
Avulsions seen in sports w/ sudden accelerations and decelerations
What muscles can cause avulsion fx?
Signs of Injury
Sudden localized pain w/ limited movement
Pain, swelling, point tenderness
Care
Rest, limited activity and graduated exercise