1. Chapter 8
The Pelvis and Thigh

2. Introduction
Pelvic girdle forms structural base of support between lower extremity and trunk
Hip articulation – strongest and most stable joint in the body
This benefit gained at the expense of ROM

3. Clinical Anatomy Bones and Bony Landmarks Figures 8-1 and 8-2 Ilium,
Ischium
Pubis
Sacrum
Acetabulum
Labrum

4. Clinical Anatomy Bones and Bony Landmarks cont. Femoral head and neck
Angle of inclination
Head is angled at 125 degrees in frontal plane
Angle of torsion
Relationship between head and shaft, 15 degrees
Figures 8-3, 8-4, 8-5
Greater trochanter
Lesser trochanter

5. Clinical Anatomy Articulations and Ligamentous Support Pubic symphysis
Fibrocartilaginous interpubic disc
Small degree of spreading, compression and rotation between halves of girdle
Sacroiliac joint (SI joint)
Very study, limited ROM

6. Coxofemoral joint (hip joint)
Ball-and-socket
3 degrees of freedom
Flexion and extension
Abduction and adduction
Internal and external rotation
Rom supported by depth of acetabulum, strength of ligaments, strong muscular support
Joint capsule
Dense synovial capsule from acetabular rim to distal femoral neck

7. Iliofemoral ligament (Y ligament of Bigelow)
Figure 8-6
AIIS to distal and proximal intertrochanteric line
Reinforces anterior jt capsule and limits hyperextension
Allows us to stand upright with minimal muscular activity
Pubofemoral ligament
Also reinforces anterior capsule
Pubis ramus to intertrochanteric fossa

8. Ligamentum teres (ligament of the head of the femur)
Conduit for medial and lateral circumflex arteries
Little function in stabilizing hip
Figure 8-7
Inguinal ligament
ASIS to pubic symphysis
Serves to contain soft tissues as they course anteriorly from trunk to lower extremity
Superior border of femoral triangle

9. Muscular Anatomy Table 8-1, pages 276-277 Anterior Musculature
Quadriceps
Iliopsoas group
Psoas major, psoas minor, iliacus
Primary hip flexors when knee extended
Figure 8-8
Medial Musculature
Adductor group
Gracilis
Figure 8-9

10. Lateral Musculature Gluteus medius Tensor fascia latae Figure 8-10
Trendelenburg’s gait pattern
Intrinsic muscles form cuff around femoral head and externally rotate hip
Piriformis, quadratus femoris, obturator internus, obturator externus, gemellus superior, gemellus inferior
Figure 8-11

11. Posterior Musculature
Gluteus maximus
hamstrings

12. Femoral Triangle Figure 8-12 Formed by: Landmark for:
Inguinal ligament (superiorly)
Sartorius (laterally)
Adductor longus (medially)
Landmark for:
Femoral nerve, artery and vein
Femoral pulse
Lymph nodes

13. Bursae
3 bursa to decrease friction between gluteus maximus and adjacent bony structures
Trochanteric bursa
Gluteus max – greater trochanter
Gluteofemoral bursa
Gluteus max – vastus lateralis
Ischial bursa
Gluteus max – ischial tuberosity

14. Clinical Evaluation of Pelvis and Thigh
May necessitate evaluation of lower extremity, spinal column, and posture
Patient preparedness
Clinician preparedness
Gender issues
Evaluation Map
Page 280

15. History Location of symptoms Onset Training techniques
Table 8-2, page 281
Onset
Training techniques
Mechanism of injury
Prior medical conditions
Legg-Calve-Perthes Disease
Slipped capital femoral epiphysis

16. Inspection Most trauma to area cannot be visualized
Inspection of Hip Angulations
Angle of inclination
Relationship of femoral head and shaft
Coxa valga
Increase in angle, may lead to genu varum or lateral patella
Coxa vara
Decrease in angle, may lead to genu valgum or squinting patella
Mechanical advantage of glut medius is reduced

17. Angle of torsion Measured through radiograph Box 8-1 Anteverted hips
Increases greater than 15 degrees result in internal femoral rotation, squinting patellae and a toe-in gait
Retroverted hips
Angle less than 15 degrees, femur externally rotates, resulting in a toe-out position, laterally positioned patellae

18. Inspection of Medial Structures Inspection of Anterior Structures
Adductor group
Inspection of Anterior Structures
Hip flexors
Inspection of Lateral Structures
Iliac crest (figure 8-13)
Nelaton’s line
ASIS to ischial tuberosity
Figure 8-14

19. Inspection of Posterior Structures
PSIS
Gluteus maximus
Hamstring muscle group (figure 8-15)
Median sacral crests
Inspection of Leg Length Discrepancy

20. Palpation Refer to list of Clinical Proficiencies
Utilize pages

21. Range of Motion Testing
Limited by bony and soft tissue restraints
Position of knee
Flexed vs. extended
Table 8-3, page 286 (Muscle actions)
Box 8-2, page 287 (Goniometry)

22. Active Range of Motion Flexion and Extension Adduction and Abduction
Figure 8-17
degrees (range, knee flexed)
Majority occurs during flexion
Extending knee limits hip flexion
Adduction and Abduction
Figure 8-18
Abduction – 45 degrees
Adduction – degrees

23. Active Range of Motion Internal and External Rotation Figure 8-19
ER – degrees
IR – 45 degrees
Hip flexed vs. extended

24. Passive Range of Motion
Flexion and Extension
Flexion
Figure 8-20
End-feel: soft w/knee flexed; firm w/knee extended
Thomas Test
Box 8-3, page 289
Extension
Figure 8-21
End-feel: firm w/knee extended and flexed but due to different structures

25. Passive Range of Motion
Adduction and abduction
Figure 8-22
End-feel: firm
Adduction – due to tension in lateral structures
Abduction – due to tension in medial structures
Internal and external rotation
Figure 8-23
IR – due to tension in posterior capsule and external hip rotators
ER – due to tension in anterior capsule and ligament support
Anteverted vs. retroverted hips

26. Resisted Range of Motion
Box 8-4, pages
Trendelenburg’s Test for Gluteus Medius Weakness
Box 8-5, page 293

27. Ligamentous Testing No specific tests for hip ligaments
Dysfunction is determined through passive testing of movement
Hyperextension places iliofemoral, pubofemoral, and ischiofemoral ligaments on stretch

28. Neurologic Testing
Complete lower quarter screening should be performed
Pathology involving femoral or sciatic nerve
Piriformis Syndrome
Impingement of sciatic nerve from spasm of piriformis muscle

29. Pathologies and Related Special Tests
Acute
Contusions or strains
Chronic
Improper biomechanics from poor posture, leg length discrepancies, overuse syndromes
Injury to hip joint is rare
Potential medical emergency

30. Muscle Strains Table 8-4, page 294
Occur secondary to dynamic overload during eccentric muscle contraction
Commonly injured
Iliopsoas, quadriceps, adductors, hamstrings
Signs and Symptoms

31. Bursitis
Onset related to biomechanical factors, congenital influences, or environmental conditions, such as prolonged periods of sitting
Septic infection may be a cause

32. Bursitis Trochanteric Bursitis
Evaluative Findings - Table 8-5, page 295
May result from a single blow or friction from IT band
History of training changes or increased Q angle may be predisposing factors
“Snapping Hip” syndrome

33. Bursitis Ischial Bursitis Evaluative Findings - Table 8-6, page 296
Movement of buttocks while patient is weight-bearing in seated position can irritate this bursa
Also irritated by prolonged sitting
Need to rule out hamstring strain or avulsion of its attachment
Doughnut padding may help

34. Bursitis Iliopsoas Bursitis
Associated with rheumatoid arthritis or osteoarthritis of hip
Signs and symptoms
Pain in anterior hip
Palpable mass in groin or inguinal ligament
“snapping hip” syndrome
Treatment includes strengthening hip rotators

35. Degenerative Hip Changes
Due to age, repetitive trauma, acute trauma, or improper arrangements of hip
Degeneration of articular surfaces of femur and acetabulum
Arthritis, osteochondritis dissecans, acetabular labrum tears, avascular necrosis
Signs and symptoms
Pain, referred to low back, anterior thigh, knee
Loss of motion in all planes, decrease strength
Hip Scouring, Box 8-6, page 297
Radiographic evaluation

36. Piriformis Syndrome
Sciatic nerve passes under or through the piriformis muscle as nerve travels across posterior pelvis
Spasm or hypertrophy of muscle places pressure on sciatic nerve
Six times more common in women
Relatively undefined and confusing
Mimics lumbar nerve root impingement and intervertebral disk disease

37. Piriformis Syndrome Evaluative Findings
Table 8-7, page 298
Straight leg raise, passive hip internal rotation resisted external rotation with patient seated, and resisted hip abduction may produce symptoms
Figure 8-24
Treatment includes stretching and strengthening or surgical release

38. On-Field Evaluation of Pelvis and Thigh Injuries
Trauma to coxofemoral joint is rare
Protection from padding
More commonly, strains, contusions, sprains of SI joint
Note position of athlete
If leg is moving, rule out dislocation
Fixed, immobile awkward position may indicate dislocation

39. On-Field Evaluation of Pelvis and Thigh Injuries
After ruling out dislocation or subluxation and femoral fracture – AROM
Weight-bearing status
Removal from field

40. Initial Evaluation and Management of On-Field Injuries
Iliac Crest Contusion (hip pointer)
Evaluative Findings, Table 8-8, page 299
Disproportionate amount of pain, swelling, and loss of function
Recognition and immediate management of pain reduces time lost due to injury
Treatment
Ice, padding, reduced activity, crutches, if necessary

41. Initial Evaluation and Management of On-Field Injuries
Quadriceps Contusion
As severity of impact increases, so does the proportion of muscle fiber death
Can result in decreased force during knee extension
Associated pain and spasm may limit flexion
Gross discoloration, painful to touch, intramuscular hematoma gives hardened feel, increase in girth of muscle
Overtime, atrophy may occur

42. First 24 hours following injury are critical
Risk of myositis ossificans is increased when effusion of knee joint occurs
Figure 8-25
First 24 hours following injury are critical
Pain during AROM, or weakness during MMT = removal from activity
Ice applied in flexion
Maintaining ROM decrease possibility of myositis ossificans formation
Figure 8-26

43. Hip Dislocation Rare Medical emergency
Majority involve posterior displacement of femoral head
Fractures to femoral neck and acetabulum
Most occur when hip is in flexion and adduction and axial force is placed on femur, displacing it posteriorly and causing head to be driven through posterior capsule

44. Signs and Symptoms Immediate pain within joint and buttocks
Sensation of “giving out”
Femur and lower leg positioned in internal rotation and adduction
Figure 8-27
AROM is impossible
No attempt to reduce
Sensory and vascular check

45. Immediate immobilization and transportation to emergency facility
Reduction under anesthesia

46. Femoral Fracture Torsional or shear force to shaft Relatively rare
“weak link” principle
Immediate loss of function, pain, deformity, easily recognizable
Stress fracture
Shaft and neck, difficult to diagnosis
Similar s/s to hip flexor strain or tendinitis
Treatment