Chapter 21: The Thigh, Hip, Groin, and Pelvis. Anatomy of the Thigh

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

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  • Chapter 21: The Thigh, Hip, Groin, and Pelvis
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  • Anatomy of the Thigh
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  • 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
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  • Fascia The fascia lata femoris is part of the deep fascia that invests the thigh musculature Thick anteriorly, laterally and posteriorly but thin on the medial side Iliotibial 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 Thigh Quadriceps insert in a common tendon to the proximal patella Rectus femoris is the only quad muscle that crosses the hip Extends knee and flexes the hip Important 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 hip Bi-articulate muscles produce forces dependent upon position of both knee and hip joints Position 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 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?
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  • 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
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  • Palpation: Soft Tissue (continued) Pectineus Iliotibial Band (IT- band) Gluteus medius Tensor fasciae latae
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  • 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
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  • Prevention of Thigh Injuries Thigh must have maximum strength, endurance, and extensibility to withstand strain In collision sports thigh guards are mandatory to prevent injuries
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  • 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)
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  • Quad Contusion
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  • Management RICE, NSAIDs 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
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  • 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
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  • 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)
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  • 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 live athlete w/ little disability and discomfort but with some deformity Management RICE, NSAIDs and analgesics Manage swelling, compression, crutches Move into isometrics and stretching as healing progresses Neoprene sleeve may provide some added support
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  • 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 (70% muscle fiber tearing Management RICE, NSAIDs and analgesics Grade I - dont 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
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  • 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
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  • 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, NSAIDs RICE ROM and PRE exercises are carried out w/ pain free ROM Rest, limited weight bearing Complete stress fracture may require pins
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  • Anatomy of the Hip, Groin and Pelvic Region
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  • Functional Anatomy Pelvis moves in three planes through muscle function Anterior tilting changes degree of lumbar lordosis, lateral tilting changes degree of hip abduction Hip is a true ball and socket joint w/ intrinsic stability Hip 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 region Numerous injuries attach in this region and therefore injury to one can be very disabling and difficult to distinguish
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  • Assessment of the Hip and Pelvis Bodys 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?
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  • 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
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  • 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
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  • Palpation: Soft Tissue Rectus femoris Sartorius Iliopsoas Inguinal ligament Gracilis Adductor magnus, longus & brevis Pectineus Gluteus maximus, medius & minimus Piriformis Hamstrings Tensor fasciae latae Ilio