© 2009 McGraw-Hill Higher Education. All rights reserved. Chapter 21: The Thigh, Hip, Groin, and Pelvis

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Text of © 2009 McGraw-Hill Higher Education. All rights reserved. Chapter 21: The Thigh, Hip, Groin,...

  • Chapter 21: The Thigh, Hip, Groin, and Pelvis

    * 2009 McGraw-Hill Higher Education. All rights reserved.

  • Anatomy of the Thigh

    * 2009 McGraw-Hill Higher Education. All rights reserved.

  • Figure 21-1

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  • Figure 21-2

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  • Nerve and Blood SupplyTibial and common peroneal are given rise from the sacral plexus which form the largest nerve in the body the sciatic nerve complexThe main arteries of the thigh are the deep circumflex femoral, deep femoral, and femoral arteryThe two main veins are the superficial great saphenous and the femoral vein

    * 2009 McGraw-Hill Higher Education. All rights reserved.

  • FasciaThe fascia lata femoris is part of the deep fascia that invests the thigh musculatureThick anteriorly, laterally and posteriorly but thin on the medial sideIliotibial track (IT-band) is located laterally serving as the attachment for the tensor fascia lata and greater aspect of the gluteus maximum

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  • Functional Anatomy of the ThighQuadriceps insert in a common tendon to the proximal patellaRectus femoris is the only quad muscle that crosses the hipExtends knee and flexes the hipImportant to distinguish between hip flexors relative to injury for both treatment and rehab programs

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  • Hamstrings cross the knee joint posteriorly and all except the short of head of the biceps crosses the hipBi-articulate muscles produce forces dependent upon position of both knee and hipPosition of the knee and hip during movement and MOI play important roles and provide information to utilize w/ rehab and prevention of hamstring injuries

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  • Assessment of the ThighHistoryOnset (sudden or slow?)Previous history?Mechanism of injury?Pain description, intensity, quality, duration, type and location?ObservationSymmetry?Size, deformity, swelling, discoloration?Skin color and texture?Is patient in obvious pain?Is the patient willing to move the thigh?

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  • Palpation: Bony and Soft TissueMedial and lateral femoral condylesGreater trochanterLesser trochanterAnterior superior iliac spine (ASIS)SartoriusRectus femorisVastus lateralisVastus medialisVastus intermediusSemimembranosusSemitendinosusBiceps femorisAdductor brevis, longus and magnusGracilisSartorius

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  • Palpation: Soft Tissue (continued)PectineusIliotibial Band (IT-band)Gluteus mediusTensor fasciae latae

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  • Special TestsIf a fracture is suspected the following tests are not performedBeginning 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 strainWeak and pain free may indicate 3rd degree or partial ruptureMuscle weakness against an isometric resistance may indicate nerve injury

    * 2009 McGraw-Hill Higher Education. All rights reserved.

  • Prevention of Thigh, Hip, Groin & Pelvic InjuriesThigh must have maximum strength, endurance, and extensibility to withstand strainWhile muscle function is critical to perform dynamic activities, also critical in providing a base of support with pelvis for whole body motionDue to demands of both dynamic force production and core stability, this region is vulnerable to injury

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  • Maintaining strength and flexibility in this region is criticalConcentrate on dynamic stretching of quadriceps, hamstrings, groin musclesWell designed strengthening program is also criticalWould include squats, lunges, leg presses and core stability work

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  • Recognition and Management of Thigh Injuries Quadriceps ContusionsEtiologyConstantly exposed to traumatic blunt blowContusions usually develop as a result of severe impactExtent of force and degree of thigh relaxation determine depth and functional disruption that occursSigns and SymptomsPain, transitory loss of function, immediate effusion with palpable swollen areaGraded 1-4 = superficial to deep with increasing loss of function (decreased ROM, strength)

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  • Quad ContusionFigure 21-3

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  • ManagementRICE, NSAIDs and analgesicsCrutches for more severe casesAspiration of hematoma is possibleFollowing exercise or re-injury, continued use of iceFollow-up care consists of ROM, and PRE w/in pain free rangeHeat, massage and ultrasound to prevent myositis ossificansFigure 21-4

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  • General rehab should be conservativeIce w/ gentle stretching w/ a gradual transition to heat following acute stagesElastic wrap should be used for supportExercises should be graduated from stretching to swimming and then jogging and runningRestrict exercise if pain occursMay require surgery of herniated muscle or aspirationOnce an patient has sustained a severe contusion, great care must be taken to avoid another

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  • Myositis Ossificans TraumaticaEtiologyFormation of ectopic bone following repeated blunt trauma (disruption of muscle fibers, capillaries, fibrous connective tissue, and periosteum)Gradual deposit of calcium and bone formationMay be the result of improper thigh contusion treatment (too aggressive)Signs and SymptomsX-ray shows calcium deposit 2-6 weeks following injuryPain, weakness, swelling, decreased ROMTissue tension and point tenderness w/ ManagementTreatment must be conservativeMay require surgical removal due to pain and decreased ROM

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  • Quadriceps Muscle StrainEtiologySudden stretch, violent forceful contraction of hip and knee into flexionOverstretching of quadricepsCan be very disablingSigns and SymptomsPeripheral tear causes fewer symptoms than deeper tearPain, point tenderness, spasm, loss of function (decreased knee flexion) and little discolorationComplete tear may leave patient w/ little disability and discomfort but with some deformity

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  • Signs & SymptomsGrade 1: Complain of tightness in front of thigh; near normal ambulation; swelling may be limited; mild discomfort during palpationGrade 2: Abnormal gait cycle; may be splinted in extension; swelling may be noticeable with pain on palpation; possible defect in muscle; resistive knee extension will reproduce painGrade 3: Possibly unable to ambulate; pain with palpation; may be unable to perform knee extension; isometric contractions may produce defect or bulging in muscle belly

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  • ManagementRICE, NSAIDs and analgesicsManage swelling, compression, crutchesWith increased healing, progress to isometrics and stretchingGrade 1: Neoprene sleeve may provide some added supportGrade 2: Ice and compression for 3-5 days with gradual increase in isometric exercises and pain free knee ROM exercisesLimit passive stretching until later phasesGrade 3: Crutch use for 7-14 days; restore normal gait; compression for support; may require 12 weeks until returning to full activity

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  • Hamstring Muscle Strains(most common thigh injury)EtiologyMultiple theories of injuryHamstring and quad contract togetherChange in role from hip extender to knee flexorFatigue, posture, leg length discrepancy, lack of flexibility, strength imbalances,Signs and SymptomsMuscle belly or point of attachment painCapillary hemorrhage, pain, loss of function and possible discolorationGrade 1 - soreness during movement and point tenderness (
  • 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, NSAIDs and analgesicsGrade I - dont resume full activity until complete function restoredGrade 2 and 3 should be treated conservatively w/ gradual return to stretching and strengthening in later stages of healing

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  • Management (continued)Modalities and isometrics need to gradually be introduced during healing processWhen soreness is eliminated, isotonic leg curls can be introduced (focus on eccentrics)Recovery may require months to a full yearGreater scaring = greater recurrence of injury

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  • Acute Femoral FracturesEtiologyGenerally involving shaft and requiring a great deal of forceOccurs in middle third due to structure and point of contactSigns and SymptomsPain, swelling, deformityMuscle guarding, hip is adducted and ERLeg with fx may also be shorterManagementTreat for shock, verify neurovascular status, splint before moving, reduce following X-rayAnalgesics and iceExtensive soft tissue damage will also occur as bones will displace due to muscle force

    * 2009 McGraw-Hill Higher Education. All rights reserved.

  • Femoral Stress FracturesEtiologyOver