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

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Chapter 21: The Thigh, Hip, Groin, and Pelvis. Anatomy of the Thigh. 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 - PowerPoint PPT Presentation

Text of Chapter 21: The Thigh, Hip, Groin, and Pelvis

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

  • Anatomy of the Thigh

  • 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

  • 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

  • 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

  • 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 hip jointsPosition of the knee and hip during movement and MOI play important roles and provide information to utilize w/ rehab and prevention of hamstring injuries

  • 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 athlete in obvious pain?Is the athlete willing to move the thigh?

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

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

  • 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

  • Prevention of Thigh InjuriesThigh must have maximum strength, endurance, and extensibility to withstand strainIn collision sports thigh guards are mandatory to prevent injuries

  • 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)

  • Quad Contusion

  • 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 ossificans

  • 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 athlete has sustained a severe contusion, great care must be taken to avoid another

  • 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 if too painful and restricts motion (after one year - remove too early and it may come back)

  • Quadriceps Muscle StrainEtiologySudden stretch when athlete falls on bent knee or experiences sudden contractionAssociated with weakened or over constricted muscleSigns and SymptomsPeripheral tear causes fewer symptoms than deeper tearPain, point tenderness, spasm, loss of function and little discolorationComplete tear may live athlete w/ little disability and discomfort but with some deformityManagementRICE, NSAIDs and analgesicsManage swelling, compression, crutchesMove into isometrics and stretching as healing progressesNeoprene sleeve may provide some added support

  • Hamstring Muscle Strains(second 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 tearingManagement 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 (modalities and isometrics)When 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

  • Acute Femoral FracturesEtiologyGenerally involving shaft and requiring great forceOccurs in middle third due to structure and point of contactSigns and SymptomsPain, swelling, deformityManagementTreat 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

  • Femoral Stress FracturesEtiologyOveruse (10-25% of all stress fractures)Excessive downhill running or jumping activitiesCompression or distraction fracture generally occurSigns and SymptomsPersistent pain in thighX-ray or bone scan will reveal fractureCommonly seen in femoral neckManagementAnalgesics, NSAIDs RICEROM and PRE exercises are carried out w/ pain free ROMRest, limited weight bearingComplete stress fracture may require pins

  • Anatomy of the Hip, Groin and Pelvic Region

  • Functional AnatomyPelvis moves in three planes through muscle functionAnterior tilting changes degree of lumbar lordosis, lateral tilting changes degree of hip abductionHip is a true ball and socket joint w/ intrinsic stabilityHip also moves in all three planes, particularly during gait (bodys relative center of gravity)Tremendous forces occur at the hip during varying degrees of locomotion Muscles are most commonly injured in this regionNumerous injuries attach in this region and therefore injury to one can be very disabling and difficult to distinguish

  • Assessment of the Hip and PelvisBodys center of gravity is located just anterior to the sacrumInjuries to the hip or pelvis cause major disability in the lower limbs, trunk or bothLow back may also become involved due to proximity

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

  • ObservationSymmetry- hips, pelvis tilt (anterior/posterior)Lordosis or flat backLower limb alignment Knees, patella, feetPelvic landmarks (ASIS, PSIS, iliac crest)Standing on one legPubic symphysis pain or drop on one side AmbulationWalking, sitting - pain will result in movement distortion

  • Palpation: Bony Iliac crestAnterior superior iliac spine (ASIS)Anterior inferior iliac spin (AIIS)Posterior superior iliac spine (PSIS)Pubic symphysisIschial tuberosityGreater trochanterFemoral neck

  • Palpation: Soft TissueRectus femorisSartoriusIliopsoasInguinal ligamentGracilisAdductor magnus, longus & brevisPectineusGluteus maximus, medius & minimusPiriformisHamstringsTensor fasciae lataeIliotibial Band

    - Major regions of concern are the groin, femoral triangle, sciatic nerve, lymph nodes

  • Special TestsFunctional EvaluationROM, strength testsHip adduction, abduction, flexion, extension, internal and external rotationTests for Hip Flexor TightnessKendall test Test for rectus femoris tightnessThomas testTest for hip contractures

  • Kendalls Test

  • Thomas Test

  • Femoral Anteversion (A) and Retroversion (B)Relationship between neck and shaft of femurNormal angle is 15 degrees anterior to the long axis of the femur and condylesInternal 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 JointPatrick Test (FABER)Detects pathological conditions of the hip and SI jointPain may be felt in the hip or SI joint

  • Gaenslens TestTest works to push SI joint into extensionTest