McGraw-Hill/Irwin © 2013 McGraw-Hill Companies. All Rights Reserved.

Chapter 17: The Thigh, Hip, Groin, and Pelvis

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Anatomy of the Pelvis, Thigh, and Hip

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Assessment of the Thigh• History

– Onset (sudden or slow?)– Previous history?– Mechanism of injury?– Pain description, intensity, quality, duration, type and

location?

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

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• 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

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• Special Tests– Thomas test

• Test for hip contractures

– Straight Leg Raise• Test for hip extensor

tightness• Can also be used to

assess low back, SI joint dysfunction, sciatic nerve pain

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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– Squats, lunges, leg press– Core strengthening

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Recognition and Management of Thigh Injuries

• Quadriceps Contusions– Cause 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

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• 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

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• Myositis Ossificans– 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

– 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)• If condition is recurrent it may indicate problem with blood

clotting

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• Quadriceps Muscle Strain– Cause of Injury

• Sudden stretch when athlete falls on bent knee or experiences sudden contraction

• Associated with weakened or over constricted muscle

– Signs of Injury• 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

– Care• Rest, ice and compression to control internal bleeding• Determine extent of injury early• Neoprene sleeve may provide some added support

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• 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,

– 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 - partial tear, identified by sharp snap or tear, severe pain,

and loss of function

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– Signs of Injury (continued)• Grade 3 - Rupturing of

tendinous or muscular tissue, involving major hemorrhage and disability, edema, loss of function, ecchymosis, palpable mass or gap

– Care• RICE • Restrict activity until soreness

has subsided• Ballistic stretching and

explosive sprinting should be avoided initially

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• Femoral Fractures– Cause of Injury

• More common in auto accidents; less common in sports

• Involves significant force

• Occurs in middle third 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

– Care• Treat for shock, verify neurovascular status, splint before moving, reduce

following X-ray• Secure immediate emergency assistance

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Recognition and Management of Specific Hip, Groin, and

Pelvic Injuries• Groin Strain

– Cause of Injury • One of the more difficult problems to diagnose• Often seen in early part of season due to poor strength

and flexibility• Occurs from running , jumping, twisting w/ hip external

rotation or severe stretch

– Signs of Injury• Sudden twinge or tearing during active movement• Produce pain, weakness, and internal hemorrhaging

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• Groin Strain– Care

• RICE, NSAID’s and analgesics for 48-72 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

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• 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

– 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

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• Dislocated Hip– Cause 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

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• Dislocated Hip– 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

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• Hip Labral Tears– Cause of Condition

• Result of repetitive overuse (i.e. running or pivoting)

• May occur due to acute trauma (i.e. dislocation)

– Signs of Injury• Often present as

asymptomatic• Causes clicking, locking, or

catching• Pain in the groin; stiffness;

limited motion

– Care• Exercises to maintain ROM,

strength & stability• Avoid aggravating activities• NSAID’s, corticosteroids• Surgical repair

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• Piriformis Syndrome – Cause of Condition

• Compression of sciatic nerve; irritation due to tightness or spasm of muscle

• May mimic sciatica

– Signs of Injury• Pain, numbness and tingling in butt – may

extend below knee and into foot• Pain may increase following periods of

sitting, climbing stairs, walking or running

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– Care• Stretching and

massage• NSAID’s may be

prescribed• Cessation of

aggravating activities will be prescribed

• Corticosteroid injection may also be suggested

• Surgery is sometimes an option as well

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Hip Problems in Adolescent Athletes

• Legg Calve’-Perthes Disease (Coxa Plana)– Cause of Condition

• Avascular necrosis of the femoral head in child ages 4-10• Articular cartilage becomes necrotic and flattens

– Signs of Condition• Pain in groin that can be referred to the abdomen or knee• Limping is also typical• Varying onsets and may exhibit limited ROM

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•Legg-Calve’-Perthes Disease (continued)

• Care– Bed rest to reduce chance of chronic condition– 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

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• Slipped Capital Femoral Epiphysis– Cause of Condition

• May be growth hormone related• 25% of cases are seen in both hips• Epiphysis slips from femoral head in backwards direction

due to weakness in growth plate• May occur during periods of elevated growth

– Signs of Condition• 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

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• Slipped Capital Femoral Epiphysis– 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

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• 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

– Care• RICE for at least 48 hours, NSAID’s, • Bed rest 1-2 days in severe cases• Referral must be made, X-ray• Padding should be used upon return to minimize chance of

added injury

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• Osteitis Pubis– Cause of Injury

• Seen in distance runners• Repetitive stress on pubic symphysis and adjacent muscles

– Signs of Injury• Chronic pain and inflammation of groin• Point tenderness on pubic tubercle• Pain w/ running, sit-ups and squats

– Management• Rest, NSAID’s and gradual return to activity

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• 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

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• Stress Fractures– Cause of injury

• 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

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• Avulsion Fractures– Cause of Injury

• Avulsions seen in sports w/ sudden accelerations and decelerations

• Pulling of tendon away and off of bony insertion• Common sites include ASIS (sartorius), AIIS (rectus

femoris attachment), ischial tuberosity (hamstring

– Signs of Injury• Sudden localized pain w/ limited movement• Pain, swelling, point tenderness

– Care• Rest, limited activity and graduated exercise