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Chapter 17: The Thigh, Hip,
Groin, and Pelvis
Anatomy of the Pelvis, Thigh,
and Hip
Bony Anatomy
• Pelvic Girdle
– Ilium
• Iliac crest
• Anterior superior iliac spine
• Posterior superior iliac spine
• Anterior inferior iliac spine
• Ischium
– Ischial tuberosity
– Hamstring or bursa problems
– Should sit on this area of pelvis
• Pubis
– Pubic symphysis
• Acetabulum
• Femur
– Head
– Neck
– Greater trochanter
– Lesser trochanter
– Shaft
– Medial condyle
– Lateral condyle
Ligaments - Major source of strength
– Ligamentum teres-head of femur
– Iliofemoral ligament
• Y ligament
• Strongest in the body
• Prevents hyperextension, external
rotation, abduction
• Pubofemoral ligament
– Prevents abduction
• Ischiofemoral ligament
– Prevents medial rotation
Bursa
• 18 in hip
• Ischial bursa
• Greater trochanteric bursa
– Found at attachment of gluteus
maximus and IT band
• Iliopsoas
Muscles
• Flexors
– Iliopsoas
– Rectus femoris (quad)
– Sartorius
• Anterior thigh (quads)
– Vastus medialis
– Vastus lateralis
– Vastus intermedialis
• Extensors
– Gluteus maximus
– Semitendonosis (hamstring)
– Semimembranosis (hamstring)
– Biceps femoris (hamstring)
• Abductors
– Gluteus medius
– Gluteus minimus
– Tensor fascia latae (Iliotibial band)
• Adductors
– Adductor magnus
– Adductor brevis
– Adductor longus
– Pectineus
– Gracilis
• External Rotators
– Oburator externus
– Obturator internus
– Quadratus femoris
– Piriformis – sciatic nerve goes
through it.
– Gamellus superior
– Gamellus inferior
– Gluteus maximus
• Internal Rotators
– Gluteus minimus
– Tensor fascia Latae
– Gluteus medius
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?
• 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
• Special Tests
– Thomas test
• Test for hip
contractures
– Straight Leg Raise
• Test for hip extensor
tightness
• Can also be used to assess
low back or SI joint
dysfunction
Thomas Test
• Trendelenburg Test
– Gluteus medius
• Ober’s/Noble Test
– IT Band
• Fulcrum
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
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
Quad
Contusion
• 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
• Myositis Ossificans Traumatica
– 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
• If condition is recurrent it may indicate problem with blood clotting
– 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)
• Quadriceps Muscle Strain
– Cause of Injury
• Sudden stretch-falls on bent knee or experiences sudden contraction
• Weakness or over constricted muscle
– Signs of Injury
• Peripheral tear causes fewer sx than deeper tear
• Pain, pt tenderness, spasm, loss of function and little discoloration
• Complete tear may leave athlete w/ little disability/discomfort but with some deformity
– Care
• RICE to control internal bleeding
• Determine extent of injury early
• Neoprene sleeve may provide some
added support
• 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
• Grade 2 - partial tear, identified by
sharp snap or tear, severe pain, and
loss of function
– 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
– 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
• Acute Femoral Fractures
– Cause of Injury
• Generally involves shaft, requires great
force
• Occurs in middle 1/3 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
and medical referral
8 foot fall
• Femoral Stress Fractures
– Cause of Injury
• Overuse
• Females who are amenorrheic are more vulnerable to stress fx
– Signs of Injury
• Persistent pain in thigh
• X-ray or bone scan
• Commonly seen in femoral neck
– Management
• Analgesics, NSAID’s RICE
• ROM and PRE exercises are carried out w/ pain free ROM
Hip, Groin, and Pelvic Injuries
• Groin Strain
– Cause of Injury
• One of the more difficult problems to
diagnose
• Early part of season due to poor
strength and flexibility
• 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
• Groin Strain (continued)
– 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
• 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
• 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
– 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
7 y/o posterior hip dislocation
skate board fall
Anterior Hip Dislocation
• Notice leg position
Hip Problems in the Young
Athlete
• Legg-Perthes Disease (Coxa Plana)
– Cause of Condition
• Avascular necrosis of femoral head: children 4-
10 y/o
• Articular cartilage becomes necrotic, flattens
– Signs of Condition
• Pain in groin, can refer to abdomen or knee
• Limping is also typical
• Varying onsets and may exhibit limited ROM
•Legg-Perthes Disease (continued)
• Care
– Bed rest-reduce chance of chronic
condition
– Brace to avoid direct weight bearing
– Early treatment-head may reossify and
revascularize
• Complication
– If not treated early, will result in ill-
shaping and osteoarthritis in later life
• Slipped Capital Femoral Epiphysis
– Cause of Condition
• May be growth hormone related
• 25% of cases are seen in both hips
– Signs of Condition
• Pain in groin over weeks or months
• Hip/knee pain during PROM,AROM; limited abd, flex,med. rotation and limp
– Management
• W/ minor slippage, rest and non-weight bearing may prevent further slippage
• Major displacement requires surgery
• If undetected/surgery fails severe problems
• 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
• Osteitis Pubis
– Cause of Injury
• Seen in distance runners
• Repetitive stress on pubic symphysis
and adjacent muscles
– Signs of Injury
• Chronic pain, inflam. of groin
• Pt tenderness on pubic tubercle
• Pain w/ running, sit-ups and squats
– Management
• Rest, NSAID’s and gradual RTP
• 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
• 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
• Avulsion Fractures– Cause of Injury
• Avulsions seen in sports w/ sudden accelerations and decelerations
– What muscles can cause avulsion fx?
– Signs of Injury• Sudden localized pain w/ limited movement
• Pain, swelling, point tenderness
– Care• Rest, limited activity and graduated exercise
