Nerve and Blood Supply · Nerve and Blood Supply Tibial and common peroneal are given rise from the...

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

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

Semimembranosis

Semitendinosis

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

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

Quad Contusion – Grade 1 Superficial

Intramuscular hematoma

Mild hemorrhage

Little Pain

No Swelling

Mild Point Tenderness

No restriction in Movement (FLEXION)

Quad Contusion – Grade 2 Signs and Symptoms

Deeper than grade 1

Mild pain

Mild swelling

Point tenderness

Flex NO MORE than 90 Degrees

Quad Contusion – Grade 3 Signs and Symptoms

Moderate Intensity

Swelling

Painful

ROM from 45 to 90 flexed

Obvious limp

Quad Contusion – Grade 4 Signs and Symptoms

MAJOR DISABILITY

Split the Fascia (Muscle Herniation)

Deep Intramuscular Hematoma

Severe Pain

Swelling

Hematoma

ROM is LESS than 45 Degreed flexed

LIMP

Quad Contusion -- Treatment Immediately placed into FLEXION with ice pack

applied to avoid muscle contracture (shortening)

RICE, NSAID’s & analgesics

Non-weight bearing (grade 2 and / or 3)

ROM exercises

PRE (Progressive Resistive Exercise)

Conservative

Gentle Stretching as able

Compression

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, decreased ROM Tissue tension and point tenderness w/

Management 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)

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 leave athlete w/ little disability and discomfort

but with some deformity Management

RICE, NSAID’s and analgesics Manage swelling, compression, crutches Move into isometrics and stretching as healing progresses 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 (modalities and isometrics)

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

Hamstring Strain

Acute Femoral Fractures Etiology

Generally involving shaft and requiring great force

Occurs in middle third due to structure and point of contact

Signs and Symptoms

Pain, swelling, deformity

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 Compression or distraction fracture generally occur

Signs and Symptoms Persistent pain in thigh X-ray or bone scan will reveal fracture 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 Complete stress fracture may require pins

Anatomy of the Hip, Groin and Pelvic Region

Extra StructuresHip Capsule

Hip Labrum (like meniscus)

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

•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 – more at end too…

Functional Evaluation

ROM, strength tests

Hip adduction, abduction, flexion, extension, internal and external rotation

Leg Length Difference

Leg Length Difference Anatomical – Leg is shorter

Functional – Leg is ok, appears shorter

Not Physically Active – over 1/2 inch may produce symptoms

Physically Active – 1/8 inch may produce symptoms

Cumulative stresses to lower limbs, hip, and pelvis or low back

Measure –

X-Ray best to determine due to soft tissue

Anatomical –lateral malleolus & ASIS

Functional – belly button & medial malleolus

Leg LengthApparent = Functional Difference – Measure from belly button to medial malleolus

True = Anatomical Difference – Measure from ASIS to medial malleolus

“Typically” – Anatomical = Functional, but Functional does NOT = Anatomical

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

Hip flexor vs Groin strain…

Pull up to assist hip flexor strain, pull

down to assist groin strain

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 injectionRecovery lasts 1-3 weeks

Trochanteric Bursitis Etiology

Inflammation at the site where the gluteus medius ties into the IT-band

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

Look at biomechanics and Q-angle

Avoid inclined surfaces;

Dislocated Hip Etiology

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

Result of temporary or permanent loss of blood supply to proximal femur

Can be caused by traumatic conditions (hip dislocation), 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 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

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

Osteitis Pubis

Etiology

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

•Special Tests

Functional Evaluation

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

`

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

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

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

Early treatment and head may reossify and revascularize

Complication

If not treated early, will result in ill-shaping and 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 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 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

Stress Fractures

Etiology 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

Intense interval or competitive racing may cause

Stress Fractures (continued)

Management Rest for 2-5 months

Crutch walking for ischium and pubis fractures

X-ray normal 6-10 weeks and bone scan will be required

Swimming can be used -- breast stroke 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